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t ke s tic tic ay ur the od yo es 4 T ok e A 01 Bo Th s 2 to ard Aw

VOLUME 1/ISSUE 9 - AUGUST 2014

Nutraceuticals CPD Article Dr Raina Zarb Adami examines the literature surrounding nutraceuticals

Neck & Jaw Tightening A discussion of nonsurgical options for tightening the jaw and smoothing the neck

Skin Health

Clinic Design

Practitioners share advice on how to effectively prepare the skin for aesthetic procedures

From traditional to modern, we take a look at four compelling clinic designs


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Contents • August 2014 INSIDER 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month 16 The future of the industry An insight into the BACN’s role in the HEE Expert Reference Group

CLINICAL PRACTICE Nutraceuticals Page 24

CLINICAL PRACTICE 18 Special Feature: Neck & Jaw Tightening Practitioners discuss non-surgical options for tightening the jaw and smoothing the neck 24 CPD Clinical Article Dr Raina Zarb Adami examines the literature surrounding nutraceuticals 30 Techniques Dr Sarah Tonks explores mesobotox as an alternative use of botulinum toxin 34 Clinical Focus A discussion of the importance of primed skin prior to a procedure and the best ways this can be achieved 38 Treatment Focus Dr Jenna Burton examines how cheek fillers can provide an all-in- one anti-ageing procedure 42 Clinical Focus Micheal Pugliese explores the role of peptides in cosmeceuticals 46 Spotlight On Dermatologists discuss prescribing Mirvaso gel for the treatment of rosacea 50 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 52 Design We take a look at four compelling clinic designs 58 Business Process Annalouise Kenny offers advice on building a successful clinic 60 Marketing Dan Travis highlights the effective outcomes of email marketing 62 In Profile Karen Betts shares her experiences as a medical tattooist 64 The Last Word Roseanne Aitken argues for the importance of product traceability

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

IN PRACTICE Clinic Design Page 52

Clinical contributors Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. She practices cosmetic injectables and hormonal based therapies. Dr Jenna Burton is an aesthetic physician working between the UK and Dubai. After founding her company ‘Prescribing Beauty’ in 2012, she is now working towards her American Medical Board Specialist Status. Dr Raina Zarb Adami is a surgeon whose private practice, Aesthetic Virtue, is dedicated to non-invasive facial aesthetic medicine. She is the medical director of The Academy of Aesthetic Excellence, which provides foundation and advanced training courses. Michael Pugliese is a skincare specialist and CEO of skincare company, Circadia. He is a member of the Society of Cosmetic Chemists and regularly attends their education events to stay on the cutting edge of new product development.

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Editor’s letter Here we are in August already: a time for some to take a break and for others to maintain the on-going business and develop new ways of retaining and attracting clients through the warmer months. Amanda Cameron As we move towards the awards season Editor (watch this space for finalists of The Aesthetics Awards), I’ve become reflective about our industry. I have been involved in this profession since its inception and have seen many changes, none more so than in recent years as the market grows at an exponential rate. I first became involved in the aesthetics industry in 1989 as a territory and training manager for Collagen Corporation. This was a time when when dermal fillers were a virtually unknown concept and the thought of putting a bovine tissue in human skin to improve the appearance of wrinkles was thought of as strange to say the least. It is no surprise that, at the time, the industry was viewed as taboo by many, yet nowadays treatment modalities are in the nation’s daily vocabulary. My early years were spent training plastic surgeons and cosmetic doctors to chase lines by injecting a prescription medicine into the dermis: injectable collagen was a POM! So have we come full circle in the evolution of the aesthetics

market? Over the years many new treatment modalities have come and gone and large organisations have attempted to apply pharmaceutical principles to this highly skilled area of medicine. Needless to say those companies who invest in novel, innovative and safe products whilst ensuring competence amongst the healthcare professionals who use them, grow from strength to strength and set a benchmark for new entrants to aspire to. We now live in an aesthetics world where we have many events and many resources for learning – none of which existed in the early 90’s. At the journal we pride ourselves on offering the best we can in education to help to grow both your clinical knowledge and your business. This month we discuss the topical issue of nutraceuticals in our CPD article, how to achieve optimum skin health for treatment and injection techniques and methods for lifting and tightening the neck and jawline. We also take a look at the design of some stunning clinics and provide advice on email marketing and opening a new clinic. I hope this issue offers some useful information to support you during the holiday season. Have a great summer and let us know what topics and articles are of interest to you – get in touch with us on twitter @aestheticsgroup

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.

Dr Mike Comins is president and Fellow of the British

Mr Dalvi Humzah is a consultant plastic, reconstructive and

College of Aesthetic Medicine. He is part of the cosmetic interventions working group, and is on the faculty for the European College of Aesthetic Medicine. Dr Comins is also an accredited trainer for advanced Vaser liposuction, having performed over 3000 Vaser liposuction treatments.

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

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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 Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

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.

maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0203 096 1228 | M: 07867 974 121 chris@aestheticsjournal.com Suzy Allinson • Associate Publisher T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com Amanda Cameron • Editor T: 0207 148 1292 M: 07810 758 401 mandy@aestheticsjournal.com Betsan Jones • Journalist T: 0207 148 1292 | M: 07741 312 463 betsan@aestheticsjournal.com Chloé Gronow • Journalist T: 0207 148 1292 M: 07788 712 615 chloe@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com Craig Christie • Administration and Production T: 0203 096 1228 | support@aestheticsjournal.com MARKETING Laura Weir • Marketing Manager T. 0203 096 1228 laura@aestheticsjournal.com Claire Simpson • Events Manager T: 0203 096 1228 | claire@aestheticsjournal.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

FOLLOW US @aestheticsgroup Aesthetics Journal Aesthetics ARTICLE PDFs AND REPRO

Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Craig Christie; support@aestheticsjournal.com © Copyright 2013 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240

DISCLAIMER: The editor and the publishers do not necessarily agree with the views

expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


Insider News

Talk Aesthetics Dermatology Times / @DermTimesNow “The goal of #aesthetic medicine is not necessarily to be beautiful, but to feel beautiful.” ow.ly/yXoYr #dermatology InjectAbility Beauty / @InjectAbility Have you heard of “Brotox”?!? Women aren’t the only ones who want to “throwback” time. #tbt #Botox #Men #FrownLines Anne-Marie Sharman / @IAMAesthetics Have just realised that my friends spend more on #alcohol than looking after their #skin hmmm…feel a blog coming on Dr Harold Lancer / @DrLancerRx Having a consistent workout regime isn’t just good for your body, but it’s also great for your skin! #skincare #beautytips Safetyinbeauty / @safetyinbeauty If you know of any public exhibitions or events selling Botox or Dermal Fillers please contact us urgently we are trying to ban them To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com Nursing

BACN respond to NMC public consultation The second part of a public consultation on the revision of the Nursing and Midwifery standard of good practice will close on August 11. In part one, the Nursing and Midwifery Council (NMC) focused on how the proposed model of revalidation could be implemented in different employment settings. Andrew Rankin, BACN representative on the HEE board, said, “It is important that all nurses have their say. The BACN encourage our members to respond to NMC matters in the same way that we encouraged them to contribute to the Keogh report.” Part two will concentrate on the draft Code and focused engagement. Focus groups will take place and any interested parties can complete an online survey. Rankin outlined that, from the BACN’s perspective, there were no particular issues that need be addressed, and said it is important that the Code reflects the principles of nursing. “As cosmetic nurses it is important that we remember these underlying principles, which apply in any and every environment,” he said. 6

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Industry

Merz to acquire Ulthera for $600m International pharmaceutical company Merz will buy US-based medical device company Ulthera for $600 million in upfront cash and milestone payments. Founded in 2004, Ulthera focuses on developing and commercializing technology for aesthetic and medical applications. Using ultrasound technology, The Ulthera System is the only lifting and tightening device to receive FDA clearance. Merz Pharma Group’s CEO, Philip Burchard said, “We have a vision to be the most innovative company in aesthetics, and expanding into the rapidly growing field of energy devices will position us for long-term success in this area.” The company said the acquisition is an important milestone that will aid their expansion of treatment options. The transaction is expected to close in the third quarter of 2014. Distribution

Galderma gains full rights to US distribution of Restylane, Emervel, Sculptra and Dysport Galderma has gained full rights to distribute Restylane, Emervel, Sculptra and Dysport in the US, from Valeant Pharmaceuticals International. Humberto C. Antunes, CEO of Galderma worldwide, said, “We at Galderma are delighted to bring Restylane, Perlane, Emervel, and Dysport home to the US. Adding Sculptra to our global portfolio allows us to bring additional indications to our broad range of medical solutions.” Restylane Silk, a new formulation to smooth perioral lines and enhance lips, recently received FDA clearance. It is an injectable gel composed of a non-animal-based formulation of hyaluronic acid and 0.3% lidocaine. Journal

Aesthetics journal appoints Dr Christopher Rowland Payne to Editorial Advisory Board Aesthetics journal has announced the addition of a new member to their editorial advisory board, consultant dermatologist, Dr Christopher Rowland Payne. Based at The London Clinic, Dr Rowland Payne has worked in dermatology for the past 23 years. An internationally recognised expert in cosmetic dermatology and a co-founder of the European Society for Cosmetic and Aesthetic Dermatology, Dr Rowland Payne has contributed to numerous publications, delivered plenary lectures, and taught students across the globe. Along with these achievements, Dr Rowland Payne is the Founding Editor-in-Chief of the Journal of Cosmetic Dermatology and has been widely recognised for his contribution to the field. He is active in all areas of clinical and surgical dermatology, especially the treatment of skin cancer and, in 2005, was instrumental in establishing the mole-mapping service, MoleMonitor. Dr Rowland Payne was also a co-author of the first paper in world literature to describe skin manifestations of AIDS and HIV. Along with the other leading figures in the medical aesthetic community on the Aesthetics journal Editorial Advisory Board, his wealth of experience will help steer the direction of educational, clinical and business content. Aesthetics | August 2014


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Awards

Finalist countdown has begun for The Aesthetics Awards 2014 After receiving hundreds of entries, The Aesthetics Awards are now closed and the finalists are being decided. The overwhelming response is even more impressive given the stricter entry criteria for the 2014 Awards. Entrants were required to provide detailed information, studies and testimonials to support their entry, meaning that those chosen as finalists and, eventually, winners truly represent the highest standards in medical aesthetics. Following the success of last year’s glamorous celebration, the 2014 event is sure to be another night not to be missed. To be held at the four star Park Plaza Westminster Bridge Hotel in Central London, the awards will feature finalists in 20 categories and the winner of the special Lifetime Achievement Award, along with entertainment and a delicious sit down dinner. Tickets for The Aesthetics Awards 2014 are available now at www.aestheticsawards.com.

Aesthetics

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Insider News

Standards

CEN aesthetic standards update By Sharon Bennett Last month the CEN aesthetic surgery draft standard was approved for publication as a European standard. Sharon Bennett, the UK lead on BSI/CEN non-surgical medical cosmetic standards gives us an update on the latest developments. What does this mean to us as cosmetic medical practitioners? Essentially not much – the standard only addresses surgical procedures, as the non-surgical content has been removed in anticipation of a separate draft standard. For those who do carry out cosmetic surgical procedures, these standards are guidelines on which to base safe practice, not only protecting the patient but the surgeon as well. The standard represents the minimum expectations required in Europe, so is not something practitioners must aspire to, but it does provide a sound benchmark to map best practices against. The approval of the surgical standard was not without contention; there was heavy lobbying from the Netherlands against the document and the CEN voting procedure. In some countries, notably Germany, there are A-deviations in place where legislation conflicts with the standard’s recommendations. The CEN only allows these deviations in exceptional circumstances. The UK has been granted an A-deviation to allow relevantly qualified dentists and nurse prescribers to be recognised as ‘practitioners’, and another deviation allows the use of lasers and IPL by non-healthcare practitioners, such as beauty therapists, who have relevant qualifications in this area. All aspects of the patient and practitioner journey are covered by the standard. It includes guidelines on operating facilities, qualifications, legal advice, staffing, consultations, care of the patient, and commercial aspects such as advertising and promotion. The non-surgical draft standard will include minimally invasive surgical treatments that may not have been included in the surgical standard. There will not be an exhaustive list of nonsurgical and minimally invasive surgical cosmetic treatments; instead they will be grouped into sections such as cosmetic injectables, laser and IPL. Like the surgical standard it is meant to be a benchmark of good, safe practice and will cover all aspects of cosmetic medical treatments, including facilities and qualifications – subject to national legislation. Last month the outline of the non-surgical standard was presented for approval as a working draft item, however it was rejected by the CEN. It could require revision and expansion but ultimately, this means that there might not even be a CEN non-surgical aesthetic standard. CEN delegates will meet in Vienna in September to discuss its future. The decision will be based on an electoral procedure, which can be confusing as the process is focused on consensus rather than voting. As with all things that rely on this method, there can be many surprises so, at the moment, I am reluctant to hazard a guess as to what will happen.

Industry

Ackman criticizes Allergan in open letter William Ackman, the CEO of Allergan’s largest shareholder, Pershing Square Capital Management, has sent an open letter to Allergan criticising their attitude towards Valeant and urging them to not delay a shareholders meeting. It is likely that Mr Ackman would replace six of the nine Allergan directors in the board meeting, opening the door for cash and stock offers to proceed. Allergan can delay the meeting until November. “We, on behalf of Allergan’s other shareholders, ask that you do not delay the inevitable any further,” Mr Ackman wrote in the letter. “What legitimate board of directors

attempts to silence or otherwise delay hearing what its own shareholders have to say?” He also called Allergan’s criticism of Valeant a “scorched earth response”, and claimed that Allergan were guilty of “market manipulation” for spreading what he described as “false and misleading information”. Mr Ackman said Allergan directors had breached their fiduciary of care and urged them to first apologize and then negotiate. In its response Allergan said, “Pershing Square’s letter to the Allergan board is not based on facts, and is rooted in selfinterest and innuendo.” Allergan claim that Mr Ackman is trying to distract their stockholders and says the Aesthetics | August 2014

Valeant proposal is “grossly inadequate and substantially undervalues Allergan.” With a 9.7% stake in Allergan, Ackman is attempting to gain support of other shareholders. The hedge fund billionaire has teamed up with Valeant CEO J. Michael Pearson in their bid to acquire the Botox manufacturing company. They believe the takeover would create a platform for growth and value creation in healthcare. Valeant’s current bid stands at $72 billion USD, an increase of $19 billion USD from its original offer of $53 billion USD. Allergan has rejected all offers and says Valeant’s business model is unsustainable and would cripple its future. 7


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Hair

Aesthetics

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Distribution

Arthritis drug allows alopecia patient to grow full head of hair

Dermatologists at Yale University say tofacitinib citrate, an oral rheumatoid arthritis drug, allowed an alopecia patient to grow a full head of hair. The 25-year-old male patient, who had never been treated for alopecia before, was referred to the dermatology department for psoriasis treatment. (Researchers have recently discovered that the drug was also an effective method for treating psoriasis – with patients noticing a 75% reduction in the disease after taking tofacitinib twice daily.) There, the patient was diagnosed with alopecia universalis, leaving him hairless everywhere but in the psoriasis plagues on his head. Assistant professor of dermatology, Dr Brett King, decided to treat him with tofacitinib, knowing it had also been used successfully in trials to treat mice with alopecia. Initially the patient was given 10mg daily for two months that improved his psoriasis. After an additional three months of 15mg daily treatments, the patient had regrown hair on his head, eyebrows, eyelashes and armpits – all of which he lacked before the treatment began. It is thought that tofacitinib blocks immune system attacks on hair follicles, prompted by alopecia, to encourage hair growth. Dr King said he hoped to duplicate the results in other alopecia patients and, along with his colleagues, is proposing a clinical trial to test a tofacitinib-based cream to treat the hair loss disease. Acne

Can Ultherapy be used to treat acne? In a presentation to the delegates at Vegas Cosmetic Surgery 2014 on June 20, Dr Michael Gold discussed the potential for Ultherapy, an ultrasound-based skin tightening system, to be used for the treatment of acne. According to Dr Gold, Ulthera – the manufacturers of the product – have recently submitted a clinical article for publication describing study results for acne treatment. In the study, 22 patients with moderate to severe acne were treated with Ultherapy, using the 1mm transducer (Amplify tip) for superficial skin treatment. At the three and six-month follow-up, a significant number of participants (80% to 90%) noticed improvement. Patient satisfaction was around 80%. Despite these positive results, pain control continues to be an issue, with most patients in the study reporting moderate pain during treatment.

Rosmetics to distribute Stylage, Cebelia and Revitacare Rosmetics Ltd has announced it is the exclusive UK distributor for French products Stylage, Cebelia peptide skincare and Revitacare. Stylage, manufactured by Vivacy Laboratories, is the first hyaluronic acid dermal filler that uses local anaesthetic and an antioxidant within one product. Injected into the dermis using mesotherapy techniques, Stylage claims to offer longlasting hydration, improved skin tone and optimized restructuring of the skin, delaying skin-ageing. According to Rosmetics, volume is restored to the subcutaneous tissues and deep skin depressions are immediately corrected, lasting 12-18 months. Cebelia and Revitacare claim to support the skin after treatment and compliment aesthetic results. Clive Shotton, sales director at Rosmetics, said, “Cebelia and Revitacare have fitted in to our own clinics successfully, increased our range of effective treatments and helped our practitioners work excel.” Cebelia’s products aim to aid the skins recovery while prolonging results of aesthetic treatments, while Revitacare is a mesotherapy range that claims to rehydrate the skin, help smooth fine lines and improve skin elasticity. Managing Director of Rosmetics, Ros Bown, said, “The addition of these prestigious products come at a great time for Rosmetics. They sit well within our current product offering and will assist us in our efforts to be among the UK’s leading aesthetic distributors.”

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Vital Statistics

Awards

New sponsors announced for The Aesthetics Awards 2014

Syneron Candela, Sinclair IS Pharma and Rosmetics are the latest sponsors to be announced for The Aesthetics Awards 2014. Syneron Candela will be supporting the ‘Best Clinic Scotland’ category at the awards, to be held on Saturday 6th December at the Park Plaza Westminster Hotel in London. General manager at Syneron Candela, Michaela Barker, said, “As a company we value aesthetics clinics who are raising standards in patient experience and safety, and therefore we are pleased to be able to promote this through such a prestigious event. As a previous sponsor of The Aesthetics Awards, we have found it a great opportunity to celebrate the best of medical aesthetics and we are looking forward to another night to remember this year!” Sinclair IS Pharma has announced that they will be supporting the category for Best Clinic Wales. Andrew Morrison, country operations director, commented, “At Sinclair we understand that practitioners and clinics play a crucial role in our aim to provide patients with safe, effective treatments and great outcomes. Therefore we are very proud to be involved in The Aesthetics Awards 2014 by celebrating the clinics who demonstrate their commitment to offering outstanding service and care to their patients.” Ros Bown, managing director of Rosmetics who will sponsor Best Clinic North England, said, “We are always keen to be involved in prestigious events that recognise the best in the industry and this is a fantastic opportunity to show clinics how much we value their hard work and achievement. We look forward to presenting the winner with their trophy in December!” Finalists for The Aesthetics Awards 2014 will be announced in the September issue of the Aesthetics journal. Tickets for the event are available now at www.aestheticsawards.com.

Insider News

50%

of 50-year-old men are affected by hair loss Hair Restoration Blackrock

The European market for cosmetic surgery, facial aesthetics and medical lasers will grow to an estimated $1.18 billion by 2019 ReportsnReports

Acne affects more than three-quarters (80%) of 11 to 30-year-olds Acne Academy

In 2013 the Botox market in the UK was worth £18m Transform

384,672 men in America had botulinum toxin injections in 2013 American Society for Aesthetic Plastic Surgery

Legal

Pollution and the sun causes 90% of visible ageing

Lawsuit against Clinipro rejected The Provincial High Court in Barcelona has rejected a two-year lawsuit against Spanish aesthetic manufacturer Clinipro. Zeltiq Aesthetics, another medical technology company specialising in fat reduction, prompted the lawsuit for an alleged infringement of patents. Clinipro’s arguments have been agreed, confirming that the patents of Zeltiq Aesthetics are nullified, due to the lack of inventive activity (the procedure patent) and to the lack of new items (the device patent). Philippe Plan, Clinipro CEO, said, “The confirmation of Zeltiq-MGH patents’ invalidity, added to the worldwide success of LipoCryo and the new lipocryolysis evolution system, LipoContrast, definitively encourages us to focus our next input to the American market.” Founder of NUA Aesthetics, the UK distributors of LipoContrast, DonnaMarie McBride said, “This is a positive result as it will give the UK market great confidence in purchasing other Cryo machines that are more affordable in a tough climate. It gives the opportunity for new technologies like LipoContrast to grow and develop.”

The Skin Cancer Foundation

1.4m

Aesthetics | August 2014

in 2007

Laser hair removal procedures declined 38% from 1.4m procedures in 2007 to 883k in 2012

883k in 2012

Medical Insight Survey

An estimated 400,000 cases of skin cancer each year are related to indoor tanning Centers for Disease Control and Prevention

9


Insider News

Events diary 12th - 13th September 2014 F.A.C.E.2f@ce Conference, Cannes www.face2facecongress.com/en 20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014, London www.bcam.ac.uk 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London www.meetings.baaps.org.uk 3rd-4th October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org 6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com Social media

FDA drafts social media guidelines for pharmaceutical companies The American Food and Drug Administration (FDA) has released a draft of guidelines for pharmaceutical companies to adhere to when using social media. In the draft, the FDA said that companies must be sure to disclose the “most serious risks” when discussing the benefits of their products on social media sites, as well as specifying the most precise indications for each product. The FDA acknowledged that, “For some products, particularly those with complex indications or extensive serious risks, character space limitations imposed by platform providers may not enable meaningful presentations of both benefit and risk.” If this is the case, the agency said companies should provide hyperlinks to sites where more complete information can be found. 10

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Cryotherapy

NUA Aesthetics launch new cryotherapy technology A cryotherapy product to remove warts, skin tags and other skin problems has been launched by NUA Aesthetics this week. NUA claim that CryoPen transforms cryotherapy into a quick outpatient procedure that does not need preparation or follow-up care. Dr Robert Barot from Paris, has used the technology and said, “CryoPen instruments have added to our efficiency. We are impressed by the instruments ease of use and by the positive reactions of our patients.” CryoPen claims to penetrate the skin tissue at approximately 1mm per five seconds and takes only ten seconds to treat a 2mm lesion, with no anaesthesia necessary. According to NUA, the high-pressure cryogen jet means all lesions can be treated regardless of size, including those that would normally have been referred – increasing practitioner’s patient numbers. CryoPen has been successful abroad and is available in the UK now. Government

Jeremy Hunt says cosmetic surgery should not be available on the NHS Health secretary, Jeremy Hunt has said cosmetic surgery such as tummy tucks and breast enlargements should no longer be available on the NHS. Speaking at a lunch for political journalists, it was reported that he said he was “purely against cosmetic work” being carried out for free by the health service. His views come in light of official figures, released in a parliamentary answer at the end of last year, that stated in the last six years, nearly 8,000 people have had tummy tucks on the NHS, at an estimated cost of £50 million to the taxpayer. “We should not be doing cosmetic work on the NHS,” he said. “The decisions are taken on the basis of clinical need, but I have made it very clear that I am against purely cosmetic work.” Mr Hunt did however agree that in some circumstances mental-health needs call for state-funded surgery, when deemed appropriate by a local doctor. “But I do completely understand people’s reservations about some of the things that happen,” he said. Industry

Red Dot Award for Restylane Skinboosters system Galderma’s Restylane Skinboosters SmartClick delivery system has won the Red Dot Award for High Design Quality 2014. The Restylane Skinbooster syringe uses the SmartClick system to provide built-in dosage control, dispensing ~10 microlitres of product with every audible click. The Red Dot Design award panel consisted of 40 international design experts, and the SmartClick system faced competition from over 1,800 international entrants. Aesthetics | August 2014


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Mesotherapy

Mesoestetic launch treatment kits for transcutaneous use Two new lines of mesotherapy solutions have been developed by mesoestetic to treat a range of aesthetic concerns. c.prof and m.prof belong to meso.prof, a range of solutions and specific active substances in sterile ampoules for transcutaneous use. The c.prof line consists of highly concentrated cocktail formulas, designed to treat ageing, dark spots, cellulite, facial and body flaccidity and fluid retention. Facial, figure and capillary aesthetic concerns can be treated with the m.prof range. The range consists of six treatment kits; antiox, mesolift, hair loss, hard cellulite and soft cellulite. The products can be used with transcutaneous penetration equipment and devices such as rollers, microneedling, electroporation, iontophoresis, ultrasound, cavitation and IR thermotherapy. They are available in the UK now.

Conference

Inaugural ACE 2015 Steering Committee meeting held in London The first official Aesthetics Conference and Exhibition 2015 Steering Committee meeting was held in London on July 17. Members of the Aesthetics team and the Steering Committee, including Mr Dalvi Humzah, Dr Raj Acquilla, Dr Tapan Patel were in attendance. During the meeting, the Committee discussed the main conference agenda, presentation topics and innovations designed to maintain ACE’s status as the leading non-surgical medical aesthetics conference in the UK. Dr Raj Acquilla said, “I’m delighted to be part of the expert committee helping to put together a world class programme for ACE 2015. Last year it was the biggest UK medical aesthetic conference and exhibition and our exciting new plans for the dynamic live anatomy/injection symposium for this year will ensure that once again ACE is the event not to be missed for any professional in the industry.” Encompassing all areas of the profession through the huge exhibition and education programme, ACE 2015 will be held in London on 7 and 8 March next year and will feature even more live clinical demonstrations, expert presentations and the extremely popular business track. More details about the conference and updates on the agenda can be found at www.aestheticsconference.com. Aesthetics | August 2014

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Eddie Hooker, managing director at Hamilton Fraser Insurance With regards to cosmetic insurance, what changes have occurred recently? A significant change, which may potentially affect many nurses and aesthetic practitioners, is the withdrawal of indemnity cover for elective aesthetic procedures from the Royal College of Nursing’s membership package. The change took place on the 1st of July 2014, and whilst unconfirmed, is more than likely due to the high risk of claims associated with this area of medicine. The removal of this cover requires nurses for the most part to source external insurance protection. What does this mean for aesthetic practitioners? The RCN withdrawal leaves nurses exposed, and has knock on effects for other practitioners in the sector. There is now clear evidence that malpractice claims are rising and insurance premiums are coming under pressure, especially for higher risk procedures. It is vital that nurses, and the wider cosmetic industry, ensure they check their cover as to what they are actually covered for, and whether past treatments carried out are also covered. What advice can Hamilton Fraser offer to practitioners concerned about the situation? Hamilton Fraser Cosmetic is able to offer reassuring advice to practitioners who are potentially concerned about their defence body coverage. This advice and expertise comes from 20 years of experience in dealing with aesthetic practitioners. Our advice is to check what cover defence bodies are offering you – never assume. Are you protected for all the procedures that you practice? This is important. Practitioners are able to arrange standalone cover with us to be covered for specific treatments. If you are not receiving the right answers from your defence body it is advisable to take out a stand-alone cover, for guaranteed protection. But it’s important not to be hasty and cancel your defence body membership. Hamilton Fraser Cosmetic Insurance and defence body protection often goes hand in hand, providing cover for both your general practice and your aesthetic practice you can simply downgrade your membership level and create a package of covers that will ensure complete protection.

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News in Brief

Acne

FDA warns of risks associated with over-the-counter acne products The Food and Drugs Administration (FDA) has warned consumers of the risk of over-the-counter acne treatments that could cause potentially lifethreatening allergic reaction or severe irritation. Topical products, sold globally under well-known brand names, often contain benzoyl peroxide or salicylic acid, which have been linked to serious cases of hypersensitive reactions. At the moment the Drug Safety Communication (DSC) cannot determine if the reactions were triggered by the acne products’ active ingredients, benzoyl peroxide or salicylic acid, the inactive ingredients, or by a combination of both. From 1969 to January 2013 the FDA received 131 cases of hypersensitivity reactions with serious outcomes. The majority of the cases were reported since 2012. Manufacturers of over-the-counter topical acne products have the option to add label directions for sensitivity testing. They are encouraged to add these directions and consumers are advised to follow them. The FDA said they are continuing to monitor and evaluate the safety issue, and will work with manufacturers regarding any future label changes that would address the risk of severe hypersensitivity reactions. Technology

Evidence-based health apps are “promising tools” for practitioners Chicago-based researchers claim mobile apps are an effective method of distributing medical information. After creating a free app that conveyed evidence-based content on diet and acne, the team found it was downloaded to 5507 devices in 98 countries. In a report published in JAMA Dermatology in June, the researchers, Dr Diane Cohen and colleagues, said, “Well-designed apps remain promising tools for collection of data from large populations and for dissemination of health information, particularly the predominantly adolescent and young adult acne population that increasingly use smartphones.” The researchers added an optional survey to the app that was completed by 110 people. Results showed 37.3% of respondents had not seen a doctor for their acne and 87.3% reported acne duration greater than one year. The data demonstrates that people are frequently seeking medical information online, supporting practitioners’ views that the underutilization of online resources for providing information qualifies as a practice gap. Dermatologist, Dr Ashish Bhatia, said in the invited commentary, “This gap can be closed by creating a credible resource that uses this format compiled and produced by medical societies, speciality thought leaders, or journal task forces.” With annual downloads for health apps set to reach 142 million by 2016, he said the information must be updated regularly, be easy to understand and provided to the patients freely or inexpensively. “As our patients’ preferences for the way they seek information evolve, we need to adapt to these changes to ensure that credible information is easily available. Not only will this help avoid patients searching for and finding incorrect or poorquality information on their condition, it will also help reinforce the information we provide at the point of care,” said Bhatia. 12

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Aesthetics | August 2014

Sinclair recruiting aesthetic account managers International pharmaceutical company, Sinclair IS Pharma is recruiting nationwide aesthetic account managers. Country operations director, Andrew Morris said, “Due to rapid extension, after acquiring many new products over the last few months, we are actively looking to recruit aesthetic account managers for various sales roles – experience of the industry is essential.” Spectra’s Gold Handpiece launches in the US Following a successful launch in Europe, the Middle East and Asia, Lutronic Spectra’s Gold Handpiece is now for sale in the US. Lutronic claim that studies prove that the laser device allows practitioners to get a superior reduction in the redness that often remains after acne has been treated. The gold 585nm handpiece is now available on the Spectra Q-switched laser. Facial aesthetics report launched Market research company Research and Markets has announced the launch of Facial Aesthetics Market to 2020. The report predicts that the global facial aesthetics market will be valued at $5.4 billion by 2020. It claims that this growth is fuelled by an increasing awareness among consumers of the various facial injectable products available, as well as sustained economic recovery in developed countries. RSM to hold dermal filler course The Royal Society of Medicine (RSM) will hold a fully accredited dermal filler course on December 2. A certificate of attendance will be provided to those who pass the assessment at the end of the training day. This is the first time the RSM have run the course and there are still spaces available. Duration of US acne antibiotic use decreasing A study, published in the Journal of the American Academy of Dermatology, found that the mean antibiotic course duration was 129 days, a decrease compared to previous data. Among the 31,634 courses assessed, 93% lasted fewer than nine months, but 17.53% of courses exceeded six months. Researchers said if these were shortened to six months, $580.99 could be saved per person.


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The British Association of Dermatologists Annual Conference, Glasgow

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PelleFirm launch, London

The 94th annual meeting of The British Association of Dermatologists (BAD) was held in Glasgow between 1-3 July. With 1, 125 delegates in attendance at the Scottish Exhibition and Convention Centre, the conference was host to an international audience. Attendees included Dr Rachael Clark from Boston, USA, and Professor Robert Moots from Liverpool, Professors Vijay Sharma and Amrinder Kanwar, both from India. Chris Garrett of the British Association of Dermatologists said, “The annual meeting committee worked hard to provide a blend of new scientific presentations with updates from experts in various fields, covering a huge range of skin conditions. A particular highlight from this year’s event was the first ever ‘Dermatology Question Time’. Open and free to all members of the public and chaired by Martyn Lewis (CBE), the session gave the public the opportunity to ask questions about any aspect of dermatology. It proved to be a big success with over 110 attendees and plenty of very interesting and varied questions.”

Dr Rita Rakus hosted a launch of the PelleFirm system on Tuesday June 24 at her Knightsbridge clinic. The new FDA-approved PelleFirm system is a non-invasive treatment for the tightening of the skin on the body, which the manufacturers claim results in a firmer, more toned appearance. Use of the small spheres on the device’s massage head aims to reduce the appearance of cellulite by encouraging movement of underlying fluids into areas where they can be naturally excreted via the body’s lymphatic system. Dr Rakus is titled the The World’s Biggest User of Pellevé-GlideSafe and winner of the first Premier Pellevé Partner Award, having treated over 3,000 patients to date. Demonstrations of the system using the Pellevé machine were accompanied by presentations of other treatments offered at Dr Rakus’ clinic including Coolsculpting, Aqualyx, Mesogun U225 and Cellulaze.

Facial Aesthetics Conference and Exhibition, London The annual Facial Aesthetics Conference and Exhibition (FACE) took place at the Queen Elizabeth II Conference Centre in London on June 20-22. The three-day event included agendas devoted to hair, skin, facial injectables, lasers, radio frequency and other facial rejuvenation devices, as well as business and marketing. The exhibitor workshops agenda saw a host of industry names present on the latest products and services. On the first day of the conference, Dr Sabrina Fabi and Dr Tapan Patel ran an Ultherapy workshop on lifting and tightening of the neck area. Dr Michael Kane played host to a Merz symposium, spanning subjects such as ageing of the temple, the effect of pollution on the skin and facial attractiveness. Meanwhile as part of the Equipment agenda, Dr David Eccleston gave a detailed presentation on fractional radiofrequency for the rejuvenation of the eye, sponsored by Syneron Candela. Saturday saw Dr Linda Eve and Dr Askari Townshend present on Sculptra, and Dr Christoph Martschin hold a session on Restylane Skinboosters for Galderma, exploring the ways in which the treatment is able to rejuvenate the face, neck, decolletage and hands. Practitioners in attendance included Dr Beatriz Molina, who said, in a session on the importance of improving skin quality in an aesthetic procedure, that she believed, “Ageing cannot be corrected, we must [instead] age gracefully.”

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Andrew Rankin gives an insight into the BACN’s role in the HEE Expert Reference Group

The Future of the Industry The BACN is privileged to be involved in the work of Health Education England (HEE) in reviewing education and qualifications within the medical aesthetics industry. We have, in the past several months, led the project’s phase 1 work on assessing the education and training requirements for delivering the treatment modalities of botulinum toxins and dermal fillers. This project will undoubtedly shape the future of the cosmetic medical industry and will have an impact on all those yet to be involved. Most of all, it will have an impact on the patient – the end user who forms the focus of our every objective. Transparency at every level, user involvement, informed consent, standards; these are but a few of the buzz words which signal the drive towards a new, cohesive, patient-centred industry. From the perspective of the BACN, work began as early as November 2013 when we presented our report (Medical aesthetics. An educational framework. A Review of the Industry for the purpose of regulation (2013)) to HEE. This 6,000-word report complemented the BACN competencies framework, and provided significant detail for nonexperts (i.e. HEE) in terms of outlining the industry. It described the various problems and concerns evident to those familiar with the industry, and made recommendations that would close loopholes and promote a secure future for the industry. The Expert Reference Group (ERG), set up by Health Education England to advise and work with them to create a formal framework of education for the non-surgical cosmetic industry, is broad. Representatives include nurses, doctors, dentists, surgeons, pharmacists, beauty and industry spokespersons and experts from laser and hair transplant fields. Importantly, the table at which we sit is, metaphorically speaking, round. That is to say, all have an equal opportunity to present their perspective, and decisions made are a consensus reflecting the breadth and depth of the group. It is perhaps the first time the industry has been so unified and working in this way is hugely rewarding. This unified approach is important on several

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levels. We are able to more readily agree on (and therefore influence) the issues where there is such strength of feeling. Phase 1 The remit of phase 1 has been to agree the framework of education which will lead to a formal qualification, and then to populate it with the relevant indicative content. The framework, set out in the table, describes a process for medics and non-medics alike, enabling them to achieve minimum standards at various levels for specific treatment modalities. With regard to botulinum toxins and dermal fillers, Levels 4 and 5 represent theoretical knowledge only, developing to the point where at level 6, practical experience can begin. The principle of Accreditation of Prior Experiential Learning (APEL) is key and it is anticipated that as nurses, we can demonstrate many of the prerequisites required for levels 4 and 5. During phase 1 the Department of Health (DoH) have also signalled their intent to support this work with legislation. The form this will take will not involve a prescription status for dermal fillers, as anticipated. Instead, legislation is aimed at a requirement for all dermal filler treatments (in the first instance, and other treatments later) to require a face to face consultation with a (statutory) regulated (e.g. NMC, GMC) practitioner who holds the above qualification. They would then be able to delegate treatment administration to any practitioner who also holds the appropriate qualification. Further work is still required on what this will mean in practice and any ‘supervision’ requirements. Phase 2 Following our report to HEE, the BACN sought to agree the principles it contained with the British College of Aesthetic Medicine and the British Association of Dermatologists, thereby setting the foundation for the close working relationship we currently enjoy. As mentioned above, supervision will be one of a number of factors to consider during this second phase. Who can supervise – doctors, dentists and nurses only, or are there others? What does supervision entail? Will it be open to abuse? These have to remain questions at the moment, rather than answers, but it is important to consider the factors involved in reaching an eventual decision. As part of our initial recommendation for HEE, BACN defined supervision as the following:

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Aesthetics | August 2014


• Under supervision Under supervision means to work within the same legal entity as the supervisor, that the supervisor is in-house at the time of treatment, able to assist where required and respond to emergency situations. • Independent practice Holistic management of a patient’s assessment, treatment and intervention in complication and emergency - without immediate recourse to peers or superiors. These definitions should give a flavour of what we wish to achieve. Further, the ERG will make recommendations to close loopholes where we see a potential for abuse of the system. From experience so far, it is fair to say that Expert Reference Group recommendations are given the merit they deserve by HEE and the Department of Health.

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Regulation The DoH has been actively considering options for governance within the industry. The prospect of a voluntary register is a real one, as is an overarching “competent authority” to provide industry oversight. The BACN has made recommendations to HEE and the DoH, suggesting the format that a new industry structure might take. Such potential change affects everyone. However, the fact that we have been able to work so closely with our medical colleagues to agree on this direction is testament to a developing, cohesive industry, as described earlier. The BACN have also been advising a new organisation — Save Face – of the requirements of a voluntary register. They are committed to providing both a voluntary register, and significantly adding value to patients and members alike. We have described to them what such a register should look like, providing them with the insight necessary to achieve these patient-centred aims. Finally, the position of nurse prescribers holding prescription medicines as stock will need to be addressed as the project moves forward. Of the developments, HEE performance and delivery manager Carol Jollie, said, “It is clear that there is genuine and unanimous stakeholder desire for greater consistency in training standards to contribute to improved patient/user safety in the non-surgical cosmetics industry. HEE will shortly be publishing its report on phase 1 of its project reviewing the qualifications required for non-surgical cosmetic interventions, and we look forward to continuing to lead this important and challenging programme.” Phase 2, due to be completed in April 2015, will provide more answers, and result in a picture of the industry emerging with greater clarity. Contrary to various criticisms, concerns and uninformed opinions, I am confident the medical nature of our industry will not be compromised. To my mind, the future is bright. It may not be faultless, but nevertheless a single, unified industry, based on a formal qualification and designed around both the patient and the principle of professional, statutory responsibility is a significant stride in the right direction. Importantly, the voluntary professional bodies have demonstrated that they can work together to achieve a common objective. A process of continuous improvement is feasible, and should go a long way towards securing the future of the industry. Andrew Rankin was the original consultant editor for the Journal of Aesthetic Nursing and is currently chair of the BACN Education Committee and a member of the board. Andrew was invited by HEE to be one of the final members of the Expert Advisory Group in the UK and was leading the group on toxins and dermal fillers.

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Clinical Practice Special Feature

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with a list of procedures and [I] just agree to do them. Patients need our expertise to recommend what is going to have the most impact on their problem – they have a choice, but it must be an informed choice,” says Mr Karidis.

When is surgery the best option?

Jaw and neck rejuvenation Many women aged 40-60 want a tighter jaw line and a smoother neck. Surgery is certainly one option, but what else is available to patients who don’t want to opt for such an invasive procedure? Kathryn Senior speaks to practitioners about their recommendations. Who can benefit from jaw and neck lifting? Aesthetic practitioners and cosmetic surgeons report that enquiries for neck and jaw work are made mainly by women aged 40 to 60. According to the aesthetic practitioners interviewed for this article, between 80% and 90% of this demographic is female, but this does not mean that the procedures available do not work in men. Surgical and non-surgical techniques have similar effects and satisfaction rates in both sexes. “The treatments that boost collagen production and lift the skin through dermal heating can in fact work better in men as they tend to have thicker skin and more collagen than women of the same age,” comments Dr Patrick Bowler, founder of the Courthouse Clinics, who offers predominantly non-surgical options in his ten clinics throughout the UK.

Making informed decisions The ageing process varies between individuals. An important first step in advising a patient of the options most suitable for them is to assess both the patient’s physical appearance and their expectations. Mr Alex Karidis, lead cosmetic surgeon at the Karidis Clinic, based in The Hospital of St John & St Elizabeth in St Johns Wood, London, offers both surgical and non-surgical options. “When a patient first comes to see me I ask them to describe what they want. Those first 5-10 minutes are the key to establishing how the patient views their face and neck, and their expectations,” he says. Mr Karidis does this by asking patients to look at themselves in a mirror and demonstrate how they would like to look. The response varies. “It’s usually clear very quickly if the patient needs surgery – they pull their skin back to demonstrate their need for a drastic change.” Some patients are happy with the recommendation and opt for a surgical procedure, but others do not want to go anywhere near an operating theatre. “Someone who is not keen to follow a surgical path needs to understand what can and can’t be achieved with non-surgical treatments. We don’t want them to spend money on non-invasive treatments if they are not going to be happy with the results,” he adds. Although patients are important in the decision making process, the aesthetic practitioner is there to provide expert input and direction. “I spend a lot of time asking the patient what they want to achieve, but I don’t expect them to come 18

Aesthetics | August 2014

Cosmetic surgeon, Mr Jan Stanek, is convinced that surgery is the only option for men and women with advanced signs of ageing. “One of the most common complaints is of sagging in the cheeks, jowls and some degree of fullness and sagging under the chin. As the platysma muscle in the neck relaxes, this also causes sagging of the skin down towards the chest,” he explains. “Non-surgical treatments can have only minor effects; if you want significant improvements, surgery is the way forward,” he says. The jaw and neck are intimately associated with the face, and patients who may think they just need a facelift, are advised to have a combination procedure for a more pleasing effect. “If you tighten up the face without paying any attention to the neck, the result can look very odd because you are treating only one part of the problem. It’s really not worth doing as far as I’m concerned,” stresses Mr Stanek. “I will always be honest with a patient and explain to them what can be achieved with surgery.” Mr Karidis agrees, as does Dr Bowler, who confirms that some patients are beyond the scope of what he can provide. “Even the best techniques that make use of radiofrequency, dermal fillers, Botox, ultrasound or laser therapy, or any combination of these techniques, have their limitations. If a patient has a neck with a lot of loose skin, very little collagen structure and advanced ageing, we recommend they have surgery,” he confirms. In his practice, he regularly turns away patients who want non-surgical treatments but whose expectations are unlikely to be met.

The non-surgical approach Cosmetic surgery may provide the most drastic reversal in the signs of severe ageing in the neck and jawline but a surgical procedure is not right for everyone. “Some patients just don’t want surgery,” says Dr Bowler, “But they want to achieve some improvements and accept the limitations. We also see many middle-aged women who want to be told they look ‘well’, rather than receive questions about who has done their cosmetic work,” he says. The gradual improvements that can be achieved by non-surgical techniques suit this demographic very well. Following a programme of non-surgical jaw and neck tightening procedures, over months or even years, can keep the skin and underlying tissues in good condition, delaying the ageing process. “But you only get the maximum effect if you are persistent, attending for regular treatments,” says


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Mr Karidis. Non-surgical interventions are less invasive and in many cases patients do not have downtime. Many procedures can be done as ‘lunchtime’ appointments and produce no visible adverse effects. “This is a significant advantage to many of the women I see, who don’t want to be out of action and certainly don’t want swelling, bruising or scars,” notes Dr Sam Robson, medical director

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at the Temple Medical clinic in Aberdeen. Appearance is not the only factor that is important. “Patients that have the Harmony Clear Lift treatment often report that the feel of their skin has improved noticeably, and this is one of the aspects that they are most pleased with. Feeling better and looking better are intimately linked,” says Dr Bowler.

Non-surgical procedures available for the jaw and neck Devices Local heating of the dermis causes contraction of the collagen fibres already in the skin at the time of treatment. This causes a contraction of the underlying tissue, which pulls the surface skin. When treatment is targeted carefully, the overall effect is to lift the skin, removing fine lines, making the skin look smoother and more toned. The heat also stimulates fibroblasts in the dermis to produce more collagen; over the course of several treatments this thickens the skin and provides more collagen to work on, so the effects build over several weeks. Different technologies are available to cause sub-dermal heating: • Radiofrequency, eg the Endymed RF system used by Dr Robson, or the Exilis by BTL • Ultrasound, eg Ultherapy, favoured by Mr Karidis • Laser, eg the Harmony Clear Lift system used by Dr Bowler Microneedling causes minor physical damage to the dermis, which also stimulates fibroblast activity. Injectables Botulinum toxin injections carefully placed in the muscles of the neck, around the jaw and in the lower face, can inhibit contractions of the muscles that pull the skin down. Botulinum toxin works in a completely different way to techniques that cause heating, so can be used concurrently and can accentuate the non-surgical lifting

Combination treatments Different practitioners have their own views on what works best for which patient, but most incorporate some type of energy device. “Radio-frequency, ultrasound or deep laser treatments heat the underlying tissues, stimulating the formation of new collagen, which leads to shrinkage and tightening of the skin. That’s the basic premise on which these energy devices work,” explains Mr Karidis. Like any interventional process, a balance between sufficient heating to have a positive effect and too much heating that could cause burning, is essential. “Today’s technology can target the tissues in a very precise manner but even so you can get burning, so you have to accept shorter treatment times and lower settings for the maximum therapeutic effect without damage,” he adds. The field certainly seems to be moving in the direction of combining multiple treatments, either concurrently, or over a period of months. The techniques work in different ways, targeting different tissues and processes, so do appear to have a cumulative effect. Mr Karidis personally avoids radiofrequency because of what he deems its ‘scattergun’ approach, and favours Ultherapy. “I prefer ultrasound because of its precision. You can focus exactly on the depth and area that you want to target and you can use fewer 20

effect. Dermal fillers add volume underneath the skin, and can reduce the appearance of jowls and smooth folds around the mouth and creases around the lip line. Threads Absorbable ‘threads’ are used to lift and realign sagging tissue and work to support the neck. The surrounding tissues hold the threads in place, eliminating visible scars. French cosmetic doctor Dr Jean-Louis Sebagh, who uses Silhouette Soft to perform this treatment, says, “There are a number of benefits to the patient when using Silhouette Soft to lift and tighten the neck and jaw area. It does not require a general anaesthetic and the treatment itself can be performed in 30 to 60 minutes. In addition, as the procedure requires no incisions to be made, the downtime and recovery is minimal, with the patient feeling well immediately after treatment and any potential downtime is limited to a week or so – unlike surgery which comes with a recovery time of six weeks plus. “The results last for up to 18 months – thanks to the threads being made of polysaccharide, they gradually dissolve over a 12-18 month period but the collagen that is created after the treatment is carried out helps to extend the period of lifting and tightening. For some patients, Silhouette Soft will allow them to delay or even avoid the need for cosmetic surgery, which is excellent news. If carried out correctly by an experienced doctor, the results are remarkable and rewarding.”

treatments. It is very useful for sculpting the jawline and neck area,” he comments. Ultherapy is used in combination with other treatments in patients who don’t want surgery and also in those who have had a surgical face and neck lift. “It’s not all about just lifting the skin. That’s where Botox and fillers and skin peels go hand-in-hand. I use the non-surgical treatments after surgery for maintenance in the years following. It’s an on-going process,” he explains. In Dr Bowler’s practice, the emphasis is on a bespoke treatment plan for each patient, which can involve injections of botulinum toxin, dermal fillers based on hyaluronic acid as well as the Harmony Clear Lift laser system that he favours. “The Harmony Clear Lift system is fairly new technology but we have treated many patients now and we are impressed,” he comments. “Not all patients are suitable; the laser used within the system causes a targeted heating effect that stimulates fibroblasts to produce more collagen, but if a patient has very little collagen left in their neck, it is unlikely to achieve very much,” adds Dr Bowler. Dr Robson’s preferred treatment for tightening up the jawline is to use the Endymed RF system but within a combination protocol that also offers fractional resurfacing, microneedling, Skinboosters, Ominlux, botulinum toxin, dermal fillers, PRP and surface skincare. “We are currently devising a complete non-surgical facelift that

Aesthetics | August 2014


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Duo Cryolipolysis (New) Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months. Two areas can now be treated simultaneously.

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. no pain as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology RF (New) The new 3D-lipomed incorporates 3D Dermology RF with the stand alone benefits of automated vacuum skin rolling and radio frequency.

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After

“I am so pleased to be given the opportunity to have the first medical version of the award winning 3D Lipo machine in my new clinic. This multi-platform technology offers a powerful non-surgical alternative to lipo suction with the addition of skin tightening and cellulite reduction modalities. I’m so proud to be able to offer my clients the very latest result driven technology.” Dr Leah Totton - Winner of The Apprentice 2013

For further information or a demonstration call: 01788 550 440

www.3d-lipo.com www.3d-skintech.com


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can be applied to anyone, but predominantly aimed at women aged 40 to 60. The treatments are done over several months and everyone will see at least some improvement since we are stimulating collagen production, restoring lost volume and improving skin health,” she reports.

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Robson is confident that all patients can benefit from non-surgical treatments, even those with marked signs of ageing. “If someone does not want surgery, there is still plenty that can be done. It is a matter of expectation,” she notes. “Patients need to understand that improvements will be gradual and that there are limitations.”

Case study: example combination systems Although aesthetic practitioners are devising their own bespoke combination treatment protocols, some manufacturers have also developed treatment systems that combine different modalities.

Alma’s Accent Ultra V Technology involved: Combines cavitational ultrasound with high power radio frequency for deep thermal heating. Treatment details: Cold ultrasound sheer waves are applied to the neck and jawline. This breaks down fat cells, which are large (50150 microns) and so easily shocked by the vibration, but leaves the smaller cells that make up blood vessels and nerves (5-15 microns) undamaged. This is followed by an application of radiofrequency for deep heating, which increases the metabolism and stimulates collagen production. How long does it take? Approximately 30 minutes. How many treatments? Four to six sessions, each two weeks apart. Advantages and benefits: Can be combined with other treatments. Can be adjusted to the individual needs of the patient.

Harmony Clear Lift Technology involved: Deep thermal non-ablative laser that targets the layer of skin up to 3mm below the surface. It leaves no surface effects. Treatment details: A Pixel Q-switched laser targets the deep dermis using multiple fractions of energy. This encourages collagen production, which has a tightening effect. How long does it take? Approximately 30 minutes. How many treatments? Three to six sessions, each two weeks apart. Advantages and benefits Can be done as a lunchtime treatment and effects can be noticeable immediately and then build over the weeks of treatment. Most practitioners advise a follow-up treatment six to twelve months later for maintenance. Improves skin texture and reduces pigmentation.

Sygmalift Technology involved: A combination of high frequency ultrasound and a 635nm laser. Treatment details: The HIFU line probe remodels fat effectively while the Trimicro focal ultrasound probe produces local heating in the dermis to stimulate collagen production. The LLLT probe stimulates deeper skin layers. How long does it take? Approximately 30 minutes. How many treatments? Three to six sessions, each two weeks apart. Advantages and benefits A treatment that can be done at lunchtime with no visible adverse effects. The coupling of the laser and ultrasound produces a glow to the complexion, as well as underlying changes in collagen.

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Aesthetics | August 2014


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3D-skintech peels and clinical skincare A compact range of medical grade peels and cosmeceutical skincare products complete the Skintech’s unique offering and enables you to both use as a “stand-alone” service or combine with equipment protocols. ‘To compliment our core injectable business the 3D-skintech has added an array of new result driven facial services to our clinic’s menu as well as the combination services for our more curative patients. We recognized that this device offered the stand alone quality of each technology in a unique machine that will ensure that we both deliver the results but equally can make money from the start due its affordability. As a clinician too many times in the past we have invested huge sums of money in a single concept that has proven difficult to profit from. In my opinion this type of system represents the future in our industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic

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From Mouth to Dermis Dr Raina Zarb Adami discusses the literature surrounding nutraceuticals The notion of improving the condition of skin through the ingestion of nutrients has longstanding roots in history. A food or food product that imparts medical or health benefits, other than its primary nutritive purpose, is considered a nutracuetical.

literature of the science pertaining to the employment of nutrients for the improvement of the dermis and the skin as a whole, and their anti-ageing properties.

THE AGEING TRAJECTORY OF THE SKIN The term is a combination of the words nutrition and pharmaceutical, initially coined by Dr. Stephen L. DeFelice1, founder and chairman of the Foundation of Innovation Medicine (FIM), Crawford, New Jersey. Nutraceuticals are not subject to the same testing and regulations as pharmaceutical drugs nor are they classified as medical devices. The human integument is continuously exposed to fluctuations in internal and external environments that may influence its anatomy and physiology. These may include photo-ageing, inflammatory processes, immune dysfunction, imbalanced epidermal homeostasis, and a whole plethora of other skin disorders.2 Advances in nutritional science scrutinise the relation between food intake and subsequent health, and impacts ingredients that may have cause to be biologically relevant at a cellular level for optimising skin conditions. Nutraceuticals refer to medicinal foods whose role is to partake in the maintenance of well-being, immune modulation and disease prevention, as well as treatment.3

HISTORY Since the time of the Sumerians, Chinese, Indians and Egyptians, food has been employed for its medicinal purposes.4 It is well documented that even Hippocrates, the ancient Greek physician and ‘father’ of medicine, said, “Let food be thy Medicine”. Recent years have seen a trend towards more natural remedies and plenty of research has been devoted to understandingthe development of dietary supplements, isolated nutrients, genetically engineered foods and their absorption and translation at a cellular level. Dietary supplements are receiving increasing recognition as being beneficial in various conditions such as ischaemic heart disease, malignancy, osteoporosis and chronic and degenerative diseases such as diabetes, Alzheimer’s or Parkinson’s.5 The industry has met with considerable monetary success, partly owing to the increasing momentum in popularity of all things natural pertaining to health and wellbeing, and the trend away from traditional medicinal products by much of the Western and Asian worlds.6 The US, Japan and India are responsible for the vast majority of nutracuetical consumption and this mammoth industry is continuing to gain momentum, growing at 7-12% per annum.7 There is an abundance of skepticism among medical professionals surrounding this concept as these foods are not classified as drugs or medical devices and minimal regulation governs their use. The research studies supporting these claims are somewhat limited.8 This article is a succinct review of the 24

The ageing trajectory of the skin’s dermis and epidermis could be roughly divided into two broad categories: intrinsic chronological ageing and extrinsic ageing, often referred to as photo-ageing, the latter term coined by Kligman in 1986.9 Chronological ageing occurs over time – in sun-protected skin – independent of environmental insults. These are unpreventable changes that are mainly dependent on the hormonal changes throughout life. Increasing age presents a progressive decline of a response to growth factors in keratinocytes and fibroblasts, resulting in a compromise to their synthetic capacity.10 The macroscopic appearance of such skin is saggy, but smooth and unblemished. The epidermis is thinner with a normal stratum corneum and loss of the undulation of the rete ridges, with increased prominence in vasculatory and fragility.11 The dermis shows irregularly stored elastin. The collagen synthetic capacity of the fibroblast is much lower compared to young (sun-protected) individuals.12 Skin that has suffered the prolonged subjection to environmental insults, such as UVA and UVB damage, pollution and smoking, among others, is leathery, rough, wrinkled and exhibits a variegation of pigment.13 The sratum corneum has thicker acanthotic epidermal cells and basal keratinocyte irregularity.10 The dermis shows a depletion of hyaluronic acid,14 and a reduction and improper orientation of collagen and elastin fibres. In 1995 Bernstein and Uitto described, contradictorily, an increase in hyaluronic acid and glycosaminoglycans in the skin. However, these compounds are not stored in the papillary dermis.15 The abnormal storage of such proteins in the dermal extracellular matrix, termed elastosis,16 disallows them to impart their elastic properties. Hyaluronic acid is hygroscopic, therefore its depletion results in a more dehydrated skin and thinner dermis. Oxidative stress plays a significant role in both types of skin ageing, through the potentiation of matrix metalloproteinases, which accelerate the degradation11,13 and impede the fibroblast’s synthesis of collagen, elastin and hyaluronic acid, leading to abnormal matrix degradation and the accumulation of nonfunctional matrix components in the dermis and epidermis.17 In 1998, Campisi stated that cellular attrition of replicative senescence is a powerfully protective, albeit imperfect, mechanism of mitotically active cells against the development of cancer, also known as tumorigenesis.18 The ageing effect of sugars (fructose and glucose) on the skin is due to the covalent cross-linking of the amino acids in collagen and elastin fibres, in an irreversible process termed glycation.19

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These advanced glycation end products disallow the compounds to impart their innate properties to the skin.

OBJECTIVES FOR THE USE OF NUTRACEUTICALS FOR THE IMPROVEMENT OF THE SKIN Condition Anti-ageing strategies aim to reduce further damage and restore the key molecules to the dermis. Prevention of reactive oxygen species derived damage is achieved through the employment of various anti-oxidant substances. Evidence surrounding anti-oxidant theories, their role in the inhibition of matrix metalloproteinase activity and DNA renewal capability potentiation is well documented in literature. Replenishment of the building blocks of the dermal extracellular matrix, i.e collagen, and glycosaminoglycans through ingested nutrients is more complex. Skin improvement may be difficult to assess through discrete objective measurements. An increase in dermal thickness, skin lustre improvement, increased skin hydration and a decrease in the depth of fine lines and wrinkles are among the variables assessed. Patient improvement scales are also taken into consideration. In vivo studies in rodents examined the breakdown and absorbance in the gut versus the amounts of compounds excreted using radiolabelled isotopes, as well as histological examination of the soft tissues with various staining methods for the individual compounds under scrutiny.20 The availability of scientific evidence surrounding nutraceuticals is rapidly improving, however, there remain concerns surrounding the validation of these products. These include the security of the composition of such food products, together with the market of ‘other substances’. Security in composition is also a concern, along with supply chain, production, storage and sale, definition and quantification of influence of metabolic aspects, and regulatory aspects such as the claims definition.21

COMMON NUTRACEUTICAL COMPONENTS FOR DERMAL PRODUCTS The skin requires replacement of its components lost through the ageing trajectory, namely collagen, elastin, hyaluronic acid and the nutrients to prevent further damage and to halt or stall further attrition. This latter group includes trace elements, fatty acids, fish oils and anti-oxidants. Ongoing research provides evidence of improvement in the skin secondary to the oral ingestion of nutrients.22 Evidence suggests that the mechanism of action of such natural compounds exert influence on a wide array of biological processes, the activation of antioxidant defence pathways, signal transduction pathways, gene expression associated with cellular attrition, proliferation and differentiation.5 Collagen Collagen is a very large molecule, which if ingested in its natural form, is broken down and its 3-dimensional helical structure denatured in the gut, hence compromising its bioavailability. The individual amino acids generated as a by-product of this process would not be absorbed.23 In order to be absorbed intact, a smaller molecular moiety is required. Hydrolysed bovine collagen, at 3kDa per molecule, is an FDA approved food product. Collagen hydrolysate ingestion stimulates a statistically significant increase in synthesis of extracellular matrix macromolecules.24 This is marketed as Arthred. Its

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initial indication was for osteo arthritis and rheumatoid arthritis sufferers, to increase their intra-articular collagen content. Bovine hydrolysed collagen peptides more closely resemble those of human collagen, with the predominant amino acids being glycine, proline, hydroxylysine, lysine and especially hydroxyproline. In 1993, Beuker et al conducted a double-blind, placebo controlled trial involving 52 athletes to investigate hydroxyproline serum levels over a four month period. Hydroxyproline was used as a marker in blood serum to quantify absorption of Arthred. It was continuously and significantly elevated during supplementation with Arthred compared to the placebo group, and by week 10 hydroxyproline levels were 200% higher in serum blood tests.25 Bioavailability of Arthred is superior to free form amino acids or other conventional collagen products due to its low molecular weight.26 An 11 day study showed that once Arthred is absorbed it is transported to cartilage, i.e. collagen containing tissue, and positively stimulates collagen biosynthesis.26 Oesser et al20 compared the time course of hydrolyzed collagen absorption, as well as its subsequent distribution in various tissues and organs in mice, via 14C radiolabeled Arthred hydrolysed collagen, to a control group. Plasma and tissue radioactivity was measured over 192 hours. 95% of orally administered Arthred hydrolysed collagen was absorbed within 12 hours. Distribution of Arthred hydrolysed collagen, compared to the control group, shows double the accumulation of Arthred hydrolysed collagen in collagen containing tissue such as cartilage.20 Proksch et al27 conducted another double blind placebo controlled trial with 114 women aged 45-65 years old with Bovine hydrolysed collagen or placebo for eight weeks. After this time the bovine hydrolysed collagen group significantly reduced eye wrinkle volume between 20-49.9%. Pro-collagen type I increased by 65% while elastin increased by 18%. A positive long-lasting effect was also observed four weeks after the last bovine hydrolysed collagen administration. Hyaluronic acid Hyaluronic acid (HA) is a mucopolysaccharide comprised of tandem repeats of D-glucuronic acid and N-acetyl glucosamine.28 Benefits of exogenous HA are limited due to its high molecular weight and generally positive results are via injectable form only.28 Synovoderma is formulated via a proprietary, patented enzymatic process that reduces the molecular weight of HA from 1200–1500 kDa to 50-200 kDa, making Synovoderma hyaluronic acid highly absorbable and bio-absorbable, and is available in oral form.29 Sato et al have found that ingested HA supplementation identical to Synovoderma is directly correlated to measured increases in skin moisture, increased skin smoothness, and amelioration of wrinkles. A double blind study was carried out wherein 35 subjects, who frequently suffer from dry, rough skin were given either a dietary HA supplement or a placebo over a four week period. The results showed that the group who had ingested HA had a significant increase in skin moisture. Microscopic skin surface analysis also showed an increase in skin smoothness and lessening of wrinkles. 30 Anti-oxidants Dietary anti-oxidants such as grape seed proanthocyanidins, resveratrol, apigenin, curcumin, silymarin, and green tea polyphenols, protect against free radical damage. Flavonoids and ellagic acid have been shown to attentuate the action

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of metalloproteinases and improve the appearance of wrinkles.31 They have also been proven to play a role against photocarcinogenesis in in vitro and in vivo systems.32 Grape seed extract in particular, derived from unfermented chardonnay, merlot and muscadine grapes,33 has been found to be instrumental in the inhibition of carcinogenesis through a reduction in UVB-induced oxidative damage and tissue fat content in mice.34 The antioxidant power of these flavonoids – oligomeric proanthocyanidins – is 20 times greater than vitamin E and 50 times greater than vitamin C. Abundant research supports the theory that grape seed extract is beneficial to skin health because of its capability of bonding with collagen, promoting youthful skin, cell health, elasticity, and flexibility.35 Phenolic compounds which include catechins, epicatechin and some dimers and trimers are also found in abundance in grape seeds.36 Peroxyl radical scavenging activities of phenolics present in grape seeds or skins, in decreasing order, were resveratrol, catechin, epicatechin, gallocatechin, gallic acid and ellagic acid. The results indicated that dimeric, trimeric, oligomeric, or polymeric procyanidins account for most of the superior antioxidant capacity of grape seeds.31 Resveratrol (3,5,40-trihydroxystilbene), a polyphenol also derived from grape skin (Vitis vinifera) and in a variety of berries, peanuts, and medicinal plants, such as Japanese knotweed, has recently been on the receiving end of a plethora of attention.37 In vitro studies show resveratrol’s protective properties towards normal human fibroblasts, from the damaging effects of hydrogen peroxide, in a dose-dependent manner.38 A 12-week, doubleblind, placebo controlled study of 60 women found that green tea catechins (active polyphenol, found in green tea extract) are able to improve skin characteristics, including elasticity, roughness, scaling, density, and water content. Additionally, less UV radiation damage was seen in the group that was supplemented with green tea catechins. The study also showed that after 12 weeks, oral green tea extract boosted oxygen flow to the skin.39 In vitro and in vivo studies suggest that green tea polyphenols (particularly epigallocatechin-3-gallate) are photo-protective in nature and, in the future, may be employed as pharmacological agents for the prevention of UVB light-induced skin disorders, such as photo-aging, melanoma and non-melanoma skin cancers.40 Alpha lipoic acid is a water and fat-soluble antioxidant that is capable of regenerating other antioxidants, such as vitamins C and E.41 In vitro research on humans in cell-culture systems show that following oral ingestion, the acid helps to prevent cellular damage. By protecting fibroblasts this helps to slow down the ageing process in the skin and stimulate repair. Ascorbic acid (vitamin C) appears capable of overcoming the reduced proliferative capacity of elderly dermal fibroblasts, as well as increasing collagen synthesis in elderly cells.42 It is an essential cofactor for hydroxylases needed for collagen biosynthesis, as it stimulates collagen specific mRNA for collagen synthesis. Trace elements The synthesis of mature elastin and collagen take place and is controlled by the availability of copper. A dietary deficiency can induce defective crosslinking of collagen and elastin, which in turn can cause problems such as premature ageing and wrinkling of the skin. It is an essential cofactor for activation and synthesis of lysyl oxidase, which is the only enzyme involved in healthy collagen crosslinking.43 Manganese is required for the 26

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activation of prolidase, an enzyme that functions to provide the amino acid, proline, for collagen formation in human skin cells. It is an essential cofactor for the glycosylation of hydroxylysine. This process strengthens newly formed collagen molecules and influences its fibril size. The highest glycosylation enzymes are found in the young and decrease with age.44 Manganese superoxide dismutase is integral to the mitochondrial reactive oxygen species formation and has been proven to be instrumental in skin ageing.45 Zinc is a cofactor for procollagen N-Proteinase & procollagen C-Proteinase, whose role is to produce procollagen, the precursor to collagen. The rate of collagen breakdown is decreased by the administration of zinc.46 Zinc deficiency results in significant reduction of collagen synthesis and turnover, and thus poor wound healing due to poor quality collagen formation. It is a useful nutrient for combatting intrinsic and extrinsic skin ageing factors by enabling superoxide dismutase, an antioxidant enzyme, to help protect against oxidative stress.47 Fatty acids Fish oils have long been known for their beneficial effects. A pilot study carried out by Segger et al48 found that a dietary supplement rich in fish oils, known as the Eskimo Skin Care, examined the hypothesis that supplementation with an oral oil formulation rich in natural stable fish oil can alter skin elasticity, transepidermal water loss (TEWL), and skin roughness in healthy women. This single-blind randomised trial revealed an improvement in skin elasticity but no change in texture. A mild increase in skin hydration was noted.

NUTRACEUTICALS Nutraceuticals often contain a variety of such compounds. Various studies on different combinations are underway to determine optimal synergistic combinations of compounds to yield the maximal restorative and preventative benefits to the dermis and epidermis. Udompataikul et al8 studied the impact of a nutraceutical containing minerals, antioxidants, and glycosamino-glycans on cutaneous ageing. This was a double-blind, placebo-controlled trial involving 60 women between the ages of 35 to 60 years, over 12 weeks. It showed a statistically significant improvement in the skin smoothness and fine wrinkles in the treatment group, with a 21.2% improvement versus a 1.7% improvement in the placebo group. Similarly patients reported a statistically significant reduction in pore size and improvement in texture and rhytids, however they noted there was no change in pigment. An earlier preliminary study in 2001 showed that oral supplementation of a combination of glucosamine, amino acids, minerals and anti-oxidants had the potential to improve visible wrinkles. However, it did not have any effect on the epidermal hydration.49 In 2004 Segger and Schönlau studied the effects of Evelle, a nutritional supplement containing vitamins E and C, carotenoids, selenium, zinc, amino acids and glycosaminoglycans, blueberry extract and pycnogenol on 62 women in a double-blinded, randomised placebo-controlled trial. It was found that skin roughness decreased and skin elasticity increased significantly.50 DermaVite, a preparation containing marine proteins, alpha-lipoic acid, pine bark extract, vitamins and minerals was studied in 40 women with symptoms of ageing skin in 2005.51 Objective measurements included skin thickness, elasticity wrinkles, roughness and teleangiectasia. Changes were

Aesthetics | August 2014


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evaluated after two, four and six months’ treatment. A statistically significant improvement was seen when compared to placebo, and it was concluded that it was a useful oral supplement to combat cutaneous ageing.51 A six month double blind, placebo controlled, randomised study on healthy post-menopausal females was performed, examining the cutaneous changes following the ingestion of a dietary supplement that contained soy extract, fish protein polysaccharides, extracts from white tea, grape seed and tomato, vitamins C and E as well as zinc and chamomile extract – Imedeen Prime Renewal. Photo evaluation and ultra-sound evaluation showed a statistically significant improvement in proved condition, structure and firmness of the skin in the facial, peri-orbital, neck and décolletage areas.52

LIMITATIONS Nutraceuticals still face many challenges until their efficacy is proven further. Generally, these products are safe and well tolerated, however interpretation of the collective results tend to be heterogenous and inconsistent, and reconcile an apparent structural benefit with absence or modest effect on symptoms remains a conundrum.53 With regard to anti-oxidant needs, the normal blood oxidative stress parameters in a given individual have not yet been objectively established. Hence antioxidant or other dietary supplementation dosaging remains a rather grey area.22 Nutritional factors are certainly instrumental in exerting promising actions on the skin, however clinical evidence pertaining to the effects of low-to-moderate doses of nutrients, consumed long term by healthy individuals, is lacking in the literature available, as is data on direct effects on basal skin properties, including hydration, sebum production, and elasticity.2 Due to a relative lack of hard evidence and an absence of regulation, consumers are given little direction to objectively assess the vast array of health claims that adorn most nutraceuticals’ packaging and marketing schemes.54 As the fields relating to nutritional skin care further expand their scope into the beauty sector and the age reversal phenomenon, the introduction of regulatory agencies will become warranted. A multi-disciplinary approach combining medical, nutritional and dietary professional input is needed in order to treat and prevent the ageing integument. REFERENCES: 1. Kalra E, ‘Nutraceutical--definition and introduction’, AAPS Pharmaceutical Science, 5 (2003), p.25. 2. Boelsma E, Hendriks H, Roza L, ‘Nutritional skin care: health effects of micronutrients and fatty acids’, American Journal of Clinical Nutrition, 73 (2001), 853-864. 3. Ramaa C, Shirode A, Mundada A, Kadam V, ‘Nutraceuticals – an emerging era in the treatment and prevention of cardiovascular diseases’, Current Pharmaceutical Biotechnology, 7 (2006), 15-23. 4. Misra L, ‘Traditional Phytomedicinal Systems, Scientific Validations and Current Popularity as Nutraceuticals’, International Journal of Traditional and Natural Medicines, 2 (2013), 27-75. 5. Mandel S, Packer L, Youdim M, Weinreb O, ‘Proceedings from the “Third International Conference on Mechanism of Action of Nutraceuticals”’, Journal of Nutritional Biochemistry, 16 (2005), 513-520. 6. McFadden K, Hernández T, Ito T, ‘Attitudes Towards Complementary and Alternative Medicine Influence Its Use’, Explore New York, 6 (2010), 380-388. 7. Pandey M, Rastogi S, Raway A, ‘Indian Traditional Ayurvedic System of Medicine and Nutritional Supplementation’, Evidence Based Alternative Complementary Medicine, 1 (2013) 8. Udompataikul M, Sripiroj P, Palungwachira P, ‘An oral nutraceutical containing antioxidants, minerals and glycosaminoglycans improves skin roughness and fine wrinkles’, International Journal of Cosmetic Science, 31 (2009), 427-437. 9. Kligman L, Kligman A, ‘The nature of photoageing: its prevention and repair’, Photodermatology, 3 (1986), 215–227. 10. Gilchrest B, ‘A review of skin aging and its medical therapy’, British Journal of Dermatology, 135 (1996) 867–875. 11. Mukherjee S, Date A, Patravale V, Korting H,Roeder A, Weindl G, ‘Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety’, Clinical Interventional Ageing, 1 (2006), 327-348. 12. Varani J, Dame M, Rittie L, Fligiel S,Kang S,Fisher G,Voorhees J, ‘Decreased Collagen Production in Chronologically Aged Skin’, American Journal of Pathology, 168 (2006), 1861-1868. 13. Kang S, Fisher G, Voorhees J, ‘Photoaging: Pathogenesis, prevention and treatment’, Clinical Geriatric Medicine, 17 (2001), 643–659.

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FUTURE DIRECTIONS As research into the science of nutraceuticals progresses, efforts appear to be concentrating on nutrigenomic concepts. Nutritional interventional studies are underway on a large scale. They aim to provide individuals who are genetically at risk of developing metabolic or degenerative disease the opportunity to practice preventative health through nutraceauticals.55 This concept will in no doubt be applied to the anti-ageing milieu. Metabolomics is another novel concept in the prevention or stalling of the skin’s ageing trajectory. This science seeks to provide direction for intervention and nutrition through the examination of blood and tissue metabolite under defined conditions.56 Dietary antioxidant vitamins, minerals, and phytochemicals in addition to n-3 polyunsaturated fatty acids, n-9 monounsaturated fatty acids, and low pro-inflammatory n-6 polyunsaturated fatty acids, have demonstrated protective properties against UV radiation.57 Harnessing this phenomenon to provide ingestible sun protection is an avenue currently under intense exploration. The development of an orally-administered systemic agent, that could reduce the effects of UV exposure on skin, could potentially modulate the photo-ageing trajectory, as well as play a pivotal role in the prevention of skin malignancies.58

CONCLUSION The demand for preventative and curative anti-ageing skin treatments, both traditional and non-traditional, will continue to grow. A growing body of evidence provides a rationale for the use of nutraceuticals for this indication. It would appear that ingesting specific ingredients really can create anti-ageing solutions ‘from within’. Ongoing and future research will provide the necessary data for nutraceuticals to be more specific, of optimal quality and high purity in order to ensure therapeutic levels are bioavailable for body utilisation within the skin. Dr Raina Zarb Adami is a Maltese surgeon whose private practice, Aesthetic Virtue, is dedicated to non-invasive facial aesthetic medicine. She is the medical director of The Academy of Aesthetic Excellence, which provides foundation and advanced training courses in Aesthetic Medicine to medical professionals.

14. Dai G, Freudenberger T, Zipper P, Melchior A, Grether-Beck S, Rabausch B, de Groot J, Twarock S, Hanenberg H, Homey B, Krutmann J, Reifenberger J, Fischer JW, ‘Chronic ultraviolet B irradiation causes loss of hyaluronic acid from mouse dermis because of down-regulation of hyaluronic acid synthases, American Journal of Pathology, 171 (2007), 1451-1461. 15. Bernstein E, Uitto J, ‘Connective tissue alterations in photoaged skin and the effects of alphahydroxy acids’, Journal of Geriatric Dermatology, 3 (1995), 7-18. 16. Laga A, Murphy G, ‘The Translational Basis of Human Cutaneous Photoaging’, American Journal of Pathology, 174 (2009), 357-360. 17. Pillai S, Oresajo C, Hayward J, ‘Ultraviolet radiation and skin aging: roles of reactive oxygen species, inflammation and protease activation, and strategies for prevention of inflammation-induced matrix degradation’, International Journal of Cosmetic Science, 27 (2005), 17-34. 18. Campisi J, ‘The Role of Cellular Senescence in Skin Aging’, Journal of Investigative Dermatology Symposium Proceedings, 3 (1998), 1-5. 19. Danby F, ‘Nutrition and aging skin: sugar and glycation’, Clinics in Dermatology, 28 (2010), 409-411. 20. Oesser S, Adam M, Babel W, Seifert J, ‘Oral Administration of 14C Labeled Gelatin Hydrolysate Leads to an Accumulation of Radioactivity in Cartilage of Mice (C57/BL)’, The Journal of Nutrition, 129 (1999), 1891-1895. 21. Nicoletti M, (2012) ‘Nutraceuticals and botanicals: overview and perspectives’, International Journal of Food, Science and Nutrition, 63 (2012), 2-6. 22. Ravi Subbiah M, ‘Application of Nutrigenomics in Skin Health Nutraceutical or Cosmeceutical?’, Journal of Clinical Aesthetic Dermatology, 3 (2010), 44-46. 23. Mullen W, Edwards C, Serafini M, Crozier A, ‘Bioavailability of pelargonidin-3-O-glucoside and its metabolites in humans following the ingestion of strawberries with and without cream’, Journal of Agricultural Food Chemistry, 56 (2008) 713-719. 24. Bello A, Oesser S, ‘Collagen hydrolysate for the treatment of osteoarthritis and other joint disorders: a review of the literature’, Current medical Research and Opinion, 22 (2006), 2221-2232.

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25. Beuker F, Stehle P, Ritsch M, Theel H, ‘The influence of regular gelatin substitution at the amino acid levels in blood plasma’, Ernährungs-Umschau, 5 (1993), 40-64. 26. Oesser S, Seifert J, ‘Stimulation of type II collagen biosynthesis and secretion in bovine chondrocytes cultured with degraded collagen’, Cell and Tissue Research, 311 (2003), 393-399. 27. Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser S, ‘Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study’, Skin Pharmacology and Physiology, 271 (2014), 47-55. 28. Tashiro T, Seino S, Sato T, Matsuoka R, Masuda Y, Fukui N, ‘Oral Administration of Polymer Hyaluronic Acid Alleviates Symptoms of Knee Osteoarthritis: A Double-Blind, Placebo-Controlled Study over a 12-Month Period’, Scientific World Journal, 1 (2012). 29. SynovoDerma 150 Softgels (Allergan Research Group, 2014) http://www.allergyresearchgroup.com/ SynovoDerma-150-Softgels-p-236.html [15/7/14]. 30. Sato T, Sakamoto W, Odanka W, Yoshida K, Urishibata O, ‘Clinical Effects of Dietary Hyaluronic Acid on dry, rough skin’ Aesthetic Dermatology, 12 (2002), 109-120. 31. Bae J, Choi J, Kang S, ‘Dietary compound ellagic acid alleviates skin wrinkle and inflammation induced by UV-B irradiation,’ Experimental dermatology, 19 (2010), 182-190. 32. Baliga M, Katiyar S, ‘Chemoprevention of photocarcinogenesis by selected dietary botanicals’, Photochemical and Photobiological Sciences: Official Journal of the European Photochemical Association and the European Society for Photobiology, 5 (2006), 243-253. 33. Yilmaz Y, Toledo R, ‘Major flavonoids in grape seeds and skins: antioxidant capacity of catechin, epicatechin, and gallic acid’, Journal of Agricultural and Food Chemistry, 52 (2004), 255-260. 34. Mittal A, Elmets C, Katiyar S, ‘Dietary feeding of proanthocyanidins from grape seeds prevents photocarcinogenesis in SKH-1 hairless mice: relationship to decreased fat and lipid peroxidation’, Carcinogenesis, 24 (2003), 1379-1388. 35. Shi J, Yu J, Pohorly J, Kakuda Y, ‘Polyphenolics in grape seeds-biochemistry and functionality’, Journal of Medicinal Food, 6 (2003), 291-299. 36. Xia E, Deng G, Guo Y, Li H, ‘Biological Activities of Polyphenols from Grapes’, International Journal of Molecular Science, 11 (2010), 622-646. 37. Buonocore D, Lazzeretti A, Tocabens P, Vincenzo Nobile V, Cestone E, Santin G, Bottone M, Marzatico F, ‘Resveratrol-procyanidin blend: nutraceutical and antiaging efficacy evaluated in a placebo controlled, double-blind studY’, Clinical Cosmetic Investigative Dermatology, 5 (2012), 159-165. 38. Jagdeo J, Adams L, Lev Tov H, ‘Dose-dependent antioxidant function of resveratrol demonstrated via modulation of reactive oxygen species in normal human skin fibroblast in vitro’, Journal of Drugs and Dermatology, 9 (2010), 1523-1526. 39. Heinrich U, Moore C, De Spirt S, Tronnier H, Stahl W, ‘Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women’, The Journal of Nutrition, 141 (2011), 1202-1208. 40. Katiyar S, ‘Skin photoprotection by green tea: antioxidant and immunomodulatory effects’, Current Drug Targets. Immune, Endocrine and Metabolic Disorders, 3 (2003), 234-242. 41. Roy S, Packer L, ‘Redox regulation of cell functions by alpha-lipoate: biochemical and molecular

Clinical Practice CPD Clinical Article

aspects’, Biofactors, 7 (1998), 263-267. 42. Phillips C, Combs S, Pinnell S, ‘Effects of ascorbic acid on proliferation and collagen synthesis in relation to the donor age of human dermal fibroblasts’, Journal of Investigative Dermatology, 103 (1994), 228-232. 43. Romero-Chapman N, Lee J, Tinker D, Uriu-Hare JY, Keen CL, Rucker RR, ‘Purification, properties and influence of dietary copper on accumulation and functional activity of lysyl oxidase in rat skin’, Biochemistry Journal, 275 (1991), 657-662. 44. Anttinen H, Oikarinen A, Kivirikko K, ‘Age-related changes in human skin collagen galactosyltransferase and collagen glucosyltransferase activities’, Clinical Chim Acta, 76 (1977) 95-101. 45. Treiber N, Maity P, Singh K, Ferchiu F, Wlaschek M, Scharffetter-Kochanek K, ‘The role of manganese superoxide dismutase in skin aging’, Dermatoendocrinology, 4 (2012), 232-235. 46. Tengrup I, Ahonen J, Zederfeldt B, ‘Influence of zinc on synthesis and the accumulation of collagen in early granulation tissue’, Surgery, Gynaecology and Obstetrics. 152 (1981), 323-326. 47. Aricioglu A, Bozkurt M, Balabanli B, Kilinç M, Nazaroglu N, Türközkan N, ‘Changes in zinc levels and superoxide dismutase activities in the skin of acute, ultraviolet-B-irradiated mice after treatment with ginkgo biloba extract’, Biological Trace Element Research, 80 (2001), 175-179. 48. Segger D, Matthies A, Saldeen T, ‘Supplementation with Eskimo Skin Care improves skin elasticity in women. A pilot study’, Journal of Dermatological Treatments, 19 (2008), 275-283. 49. Murad H, Tabibian M, ‘The effect of an oral supplement containing glucosamine, amino acids, minerals, and antioxidants on cutaneous aging: a preliminary study’, Journal of Dermatological Treatments, 12 (2001), 47-51. 50. Segger D, Schönlau F . ‘Supplementation with Evelle improves skin smoothness and elasticity in a double-blind, placebo-controlled study with 62 women’, Journal of Dermatological Treatments, 15 (2004), 222-226. 51. Thorn E, ‘A randomized, double-blind, placebo-controlled study on the clinical efficacy of oral treatment with DermaVite on ageing symptoms of the skin’, Journal of International Medical Research, 33 (2005), 267-272. 52. Skovgaard G, Jensen A, Sigler M, (2006), ‘Effect of a novel dietary supplement on skin aging in post- menopausal women’, European Journal of Clinical Nutrition. 60 (2006), 1201-1206. 53. McAlindon T, ‘Nutraceuticals: do they work and when should we use them?’, Best Practice and Research: Clinical Rheumatology, 20 (2006), 99-115. 54. Brower V, ‘A Neutraceutical a Day may keep the doctor away’, European Molecular Biology Organization Report, 5 (2005), 708-711. 55. Kaput J, ‘Developing the promise of nutrigenomics through complete science and international collaborations’, Nutrition, 60 (2007), 209-223. 56. Goodacre R, ‘Metabolomics of a Superorganism’, Journal of Nutritional, 137 (2007), 259-266. 57. Shapira N, ‘Nutritional approach to sun protection: a suggested complement to external strategies’, Nutritional Review, 68 (2010), 75-86. 58. Jackson M, Jackson M, McArdle F, Storey A, Jones S, McArdle A, Rhodes L, ‘Effects of micronutrient supplements on u.v.-induced skin damage’, The Proceedings of the Nutrition Society, 61 (2002), 187- 189.


Clinical Practice Techniques

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Aesthetics Journal

Mesobotox Dr Sarah Tonks explores the alternative use of botulinum toxin to achieve whole-face rejuvenation Botulinum toxin has been widely used for facial rejuvenation. Today it is common for practitioners to treat the whole face with the toxin, rather than confining it to individual areas. The traditional discord seen when the upper face is successfully treated and the hyperkinetic lower is left untreated is now increasingly recognised as a failure of aesthetic result — the disharmony of the face is a certain giveaway of cosmetic intervention. It is our job to educate patients about the use of toxins and other rejuvenation procedures in the mid-face, lower-face, neck and décolletage, as this is something not often covered in the media and patients may be unaware of the options. In order to achieve this whole-face, global change we can use a technique of dilute botulinum toxin, judiciously placed in specific areas. Mesotherapy was introduced as a medical procedure by Pistor in 1958. It consists of intradermal injection of pharmacologic substances that have been diluted, with the aim of restoring healthy texture of the skin. Material used can include vitamins, minerals, enzymes and other reagents. Mesotherapy promotes rejuvenation by increasing hydration and activating fibroblasts.1 Hyaluronic acid injected into the skin can cause fibroblasts to produce collagen type 1, matrix metalloprotease 1 and tissue inhibitor matrix metalloprotease 1.1 An additional study suggested dermal injection of vitamins causes stimulation of collagen production.2 30

Mesobotox “Mesobotox” is a term coined for the application of botulinum toxin by papule needle injection into the dermis of the skin. Often these toxins are more dilute than those traditionally used for treating areas such as the glabellar, and in some cases mesotherapy products such as hyaluronic acid, are added to the mixture. It is the injection not of specific muscles, but the treatment of large areas of dermis with dilute botulinum toxin. Mesobotox has four advantages and can be used successfully in people of all skin types. Botulinum toxin has been shown to decrease sebum production and improve acne, so can be used in oily and sebaceous skins.3,4 Botulinum toxin can be used to improve older skins with fine lines and wrinkles by diminishing the pull of the facial depressors, resulting in an improvement of the facial contour.5 Botulinum toxin blocks production of eccrine sweat glands which can give a smoother appearance of the skin.6 The addition of mesotherapy products can produce an additional benefit to the health of the skin.1,2 The facial muscles are classified into levators (frontalis, zygomaticus major and minor, levator labii superioris, alequai nasi, anguli oris) and depressors (procerus, corrugator supercilii, orbicularis oculi, platysma, depressor anguli oris, depressor labii inferioris). Levators and depressors Aesthetics | August 2014

Aesthetics

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are balanced in younger people but with ageing, this balance shifts towards the depressors. By injecting into the dermis, rather than a muscle, we can reduce the strength of the depressors. This works because the facial muscles insert onto the skin rather than onto bone, so when toxin is injected into the dermis it blocks the superficial fibres of the muscle inserted into the skin. Intradermal injection is suitable for flat, sheet like muscles rather than muscle bundles. It can be used where the skin is lax with poor tone. A flat, thin muscle, like platysma, has a medium motor endplate concentration whilst a short, thick muscle, such as corrugator, has a high concentration of motor endplates near the point of injection, influencing the choice of concentration used for the injections.6 In a study of 275 patients selected for cheek droop and mid-cheek groove, 24.9% attained high improvement with the cheeklift, softening of the nasolabial folds and redefining of the facial contour.5 The pattern of injection can be seen in figure 1 with the results in figure 2 and 3. An alternative pattern of injection, more suitable for oily skin, can be seen in figure 4. Mesotherapy can be used as an alternative to the Nefertiti lift, performed by injecting botulinum toxin into the platysma and posterior bands to release the downward pull of the platysma. Those with poorly defined posterior bands or skin laxity might not be good candidates, so the intradermal technique may be useful. Botulinum toxin blocks eccrine sweat glands innervated by cholinergic sympathetic nerve fibres. Apocrine sweat glands are unaffected, innervated by adrenergic sympathetic nerve fibres. This can result in smoother skin after injection.6 Some patients suffer from excessive facial sweating and use of botulinum toxin for nasal hyperhidrosis has been reported.7 Some physicians have claimed that intradermal botulinum toxin injections can cause collagenesis, although, to date, no placebo-controlled trial has been conducted that supports this.8 However the acetylcholine receptor is present on the surface of melanocytes, keratinocytes and other dermal tissue so it is possible that it may give a wider effect than initially thought.9 One of the most compelling studies, a split face study of nine patients, noted a global improvement in skin texture in six of the patients, and moderate improvement in resting and dynamic facial lines, with


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Clinical Practice Techniques

maximal effect lasting two months.10 Interestingly, histologic samples taken from this study showed no significant difference in haematoxylin and eosin staining with the exception of increased

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Aesthetics Journal

staining density of procollagen. For those with oily skin, botulinum toxin can offer relief. Extraneuronal acetylcholine plays a role in sebum production and sebocyte differentiation.9 In a study of 25 patients,

aestheticsjournal.com

91% reported a 50-75% improvement in the oil production.3 In a separate study of 20 patients, 17 noted an improvement in sebum production and decrease in pore size.4

Figure 1. Reproduced from

Technique Injection pattern and reconstitution vary according to the issue needing treatment and a practitioner’s clinical judgement. To prepare the skin, it is first cleaned with chlorhexidine while anatomical landmarks and injection points are marked up, if lifting the mid-face. For oily skin I use Azzalure, reconstituted with 130 Speywood units bacteriostatic saline, mixed with 1 ml Filorga NCTF 135HA, applied via a bevel up superficial nappage technique to the dermis using a 32g, 6mm (TSK) needle, causing a blanching effect in the skin. Points are placed approximately 5mm apart and areas with excessive oiliness, such as the T-zone, are targeted. For drier areas of skin on the oily face, the remaining 2ml mesotherapy product is used plain, without the addition of toxin unless facial sculpting is indicated. Areas such as the cheeks, neck, hands and décolletage can be targeted. The patient is reviewed at two weeks and the treatment can be repeated if indicated. If not, the patient undergoes a further four mesotherapy treatments using the Filorga NCTF 125HA alone, in order to derive the maximum benefits from mesotherapy. For patients with mid-face droop, the skin can be assessed by pulling it in the direction of the contraction of platysma to determine the strength of the depressor muscles and points of injection. Here I use Azzalure reconstituted with bacteriostatic saline and applied to the dermis with a 34g, 8mm needle (Japan Bio Products), into predetermined injection points, causing blanching. For the platysma the first row starts from the TMJ down the mandibular joint at 1cm intervals. The second row is placed 1cm superiorly to this with the injection points between the ones beneath. The lateral orbicularis oculi injections are made across the lateral border of the muscle in the temporal area, as seen in figure 1. Each injection placed in the superficial dermis should cause blanching of approximately 3-4mm diameter. For these patients I use Azzalure reconstituted with 130 Speywood units. Bacteriostatic saline is mixed with Filorga 135HA in a 1:1 ratio and is applied to the remaining skin, as seen in figure 4. Practitioners’ should use their clinical judgement to decide which areas of the patient’s face would benefit from treatment. The most common areas are the cheeks and forehead. The remaining Filorga is used plain in other areas such as the hands and décolletage. The patient is then reviewed at two weeks and a further four sessions of mesotherapy are carried out. A clinical judgement should be made to decide whether to add more toxin at the follow up or not. “Mesobotox” is a safe way of improving the texture and tone of the skin, often giving a subtler and more global result compared with using botulinum toxin in the upper face alone. It is a way of bridging the gap for patients who are not ready to make the jump into having traditional dermal fillers and botulinum toxin.

32

Aesthetics

‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.

Figure 2. Reproduced from ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.

Figure 3. Reproduced from ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology 2009;8:312-6. C Petchnagaovilai.

Figure 4. Reproduced from ‘The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A’, International Journal of Dermatology 2008; 47:12871294. SH Chang, HH Tsai, WY Chen, WR Lee, PL Chen. REFERENCES 1. F Gao, Y Liu, Y He, Y Wang, X Shi, G Wei, ‘Hyaluronan oligosaccharides promote excisional wound healing through enhanced angiogenesis.’ Matrix Biologu 29 (2010), 107-116. 2. JC Geesin, LJ Hendricks, PA Falkenstein, JS Gordon, RA Berg. ‘Regulation of collagen synthesis by ascorbic acid: Characterization of the role of ascorbate- stimulated lipid peroxidation.’ Archives of Biochemisty and biophysics 290 (1991), 127-132. 3. Rose, DJ Goldberg, ‘Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin’ Dermatological Surgery, 39 (2013), 443-448. 4. AR Shah, ‘Use of intradermal botulinum toxin to reduce sebum production and facial pore size’, Journal of Drugs in Dermatology, 7 (2008), 847-850. 5. C Petchnagaovilai, ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology, 8 (2009), 312-316. 6. C Le Louarn. ‘Botulinum toxin A and facial lines: The variable concentration’, Aesthetic Plastic Surgery, 25 (2001), 73-84. 7. MI Tammi, AJ Day, EA Turley, ‘Hyaluronan and homeostasis: A balancing act’, Journal of Biological Chemistry, 277 (2002), 4581-4594. 8. H Kurzen, KU Schallreuter. ‘Novel aspects in cutaneous biology of acetylcholine synthesis and acetylcholine receptors’, Experimental Dermatology, 13 (2004, 27-30. H Kurzen, KU Schallreuter. 9. E Geddoa, AK Balakumar, TRF Paes, ‘The successful use of botulinum toxin for the treatment of nasal hyperhidrosis’, International Journal of Dermatology 47 (2008) 1079-1080. 10. SH Chang, HH Tsai, WU Chen, WR Lee, PL Chen, TH Tsai. ‘The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A’, International Journal of Dermatology 47 (2008), 1287-1294. SH Chang, HH Tsai, WU Chen, WR Lee, PL Chen, TH Tsai.

Aesthetics | August 2014

Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. She practises cosmetic injectables and hormonal based therapies.


ELEGANT • FULFILLED • MY TIME

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. 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. 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 observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or

rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013. Full prescribing information and further information is 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 medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1139/BOC/NOV/2013/LD Date of preparation: March 2014


Clinical Practice Clinical Focus

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Allie Anderson speaks to practitioners about the role of primed skin in the run up to an aesthetic procedure

Optimised skin health: preparing the skin before a procedure

It’s said that beauty is only skin-deep, but when it comes to medical aesthetics it seems the two are irrevocably entwined. Beauty – in the aesthetic sense at least – fundamentally entails healthy skin, and there is an ever-increasing appreciation, by both practitioners and patients, of the association between inner health and outer beauty. No wonder, then, that optimum skin condition, both on the surface and from the inside, is fundamental in performing a successful aesthetic treatment. “When patients come to you, they have to appreciate that they have a certain canvas, and there’s only so much fillers and Botox can do for you,” says consultant dermatologist Dr Sandeep Cliff. “People seem to think that these treatments are a panacea for complete skin rejuvenation. But if you’re given a poor canvas, then while you can make some improvements, you’re not going to get the ‘wow factor’ that many patients are hoping for.” Dr Cliff highlights the importance of looking after the skin, not just in the run-up to a treatment, but as a preventative measure from a young age. This maximises the quality of the facial canvas should a patient decide to undergo a procedure to improve or enhance their appearance later in life. PREPARATION IS PARAMOUNT Practitioners employ different protocols to boost skin health in the weeks and months leading up to an aesthetic treatment. Some less intensive treatments, such as fillers, botulinum toxin and superficial peels, require very little preparation at home according to Dr Cliff. Although he sometimes recommends a topical solution six to eight weeks before the planned treatment to even out the skin’s 34

Aesthetics Journal

Aesthetics

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texture. “I tend to use a range which includes antioxidant-containing cleansers to improve texture. By using topical antioxidants in combination with fillers and Botox, you’ll have the best of both worlds, enhancing the deeper structures of the skin and its superficial texture.” Preparation for the application of chemicals, on the other hand, is generally aimed at acclimatising the skin to the active ingredients, says Dr Rabia Malik, a specialist in chemical peels. “There’s a whole spectrum of different concentrations and various depths of penetration depending on the type of treatment,” she comments. “Anything more than a superficial peel requires a minimum of two weeks’ preparation.” This typically involves patients using vitamins A and C topically, as well as, in some cases, including a form of alpha hydroxy acid in their homecare regime. “Using the peel in the homecare regime conditions the skin for the stronger in-clinic treatment,” says Dr Malik. KNOWING YOUR PATIENTS As the benefits of a holistic approach to medical aesthetics are becoming more widely acknowledged, practitioners are increasingly promoting a ‘whole-patient’ approach to treatment. Rather than simply employing a quick-fix solution to an aesthetic symptom, says consultant nurse practitioner Constance Campion, the focus ought to be on delivering a “patient-orientated symphony of care”, with the skin at its core. “The skin is the mirror of the mind, body and soul,” Constance says, “so it’s a key indicator to what’s going on with a patient.” A thorough assessment, including an in-depth skin analysis and comprehensive consultation, is therefore the first step in preparing for a treatment. Not only does this process reveal whether additional skin enhancement or skin health restoration is indicated, it can also bring to the fore more fundamental issues in a patient’s life, such as unhealthy diet, lack of sleep, and poor mental (and sometimes physical) health – all of which need to be addressed before a treatment can be undertaken. “As a nurse, I’m responsible for the physical, spiritual and emotional needs of my patients,” Constance adds. “Does care go out of the window because we’re in aesthetics? I don’t think so.” Getting to know your patients will also help guide the nature of the skincare regime you recommend for them to carry out at home, in the run-up to a treatment. Generally speaking, patients who are spending a lot of money in clinic are keen to take on board a practitioner’s advice and do whatever they can to optimise the results of their procedure, however onerous the regime. For Dr Cliff, keeping things simple is essential. “Gone are the days when patients expect to apply one cream and then another; nobody wants anything too complicated,” he says. “I advise patients to use an emollient moisturiser that contains sun block in the morning, and some sort of topical antioxidant with added retinoid in the evening, to allow the skin to rehydrate and rejuvenate.” Dr Charlene DeHaven, clinical director of California-based Innovative Skincare, believes that aligning a patient’s regime with their existing skincare preferences is crucial. “Some patients are ‘minimalists’ and will not take the time to apply a large number of products. Multi-tasking products will be recommended for them,” she says. “Others are ‘power users’ and are quite willing to spend a great deal of time on skin regimes and are willing to use multiple products.” According to Dr DeHaven, reputable products with a proven track record, the quality of which can be backed up by extensive

Aesthetics | August 2014


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Post 1 CO2RE Treatment

Before

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Post 1 CO2RE Treatment Photos: Alain Braun, M.D. Photos: Alain Braun, M.D.

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experience and training, are essential. Most notable is a good, thorough yet gentle cleanser to exfoliate whilst also cleaning pores, alongside one or more other topical products such as serums, gels and creams that contain various cosmeceutical ‘actives’. Dr DeHaven adds that, in general, “the regime should address and achieve optimising epithelial turnover to physiologically more youthful values. It should improve Skin preparation with Innovative Skincare skin cell metabolism, internal hydration and surface dryness. Improving fine lines and wrinkles as much as possible is also important so that further gains may be achieved via the procedure, lessening uneven pigmentation, decreasing pore size, and improving skin texture.” Equally important is making sure patients know what to avoid. At the top of the list is excess sun exposure, which as well as increasing the risk of skin cancer, will also thin the skin, causing inflammation and discolouration – giving the skin a mottled and rough texture. “Patients should also avoid abrasive treatments, such as microdermabrasion and other types of peels,” says Dr Malik. “Some patients use bleach to lighten the hair on their face, but the chemicals in bleach can affect how the active ingredients in their treatment penetrate the skin, increasing the risk of interaction and side effects.” FROM THE INSIDE OUT Healthy skin relies not just on what we do to it on the outside, but also how we treat it from the inside. “I believe the skin is an organ, not a face, and it’s connected to every organ in the body, so every organ in the body can affect how skin functions,” says Constance, highlighting the importance of addressing the nutritional needs of a patient in relation to their skin health, and the treatment they are undertaking. “Our dietary choices dramatically affect the health of our skin, as well as ageing processes,” says nutritionist Kim Pearson. “Optimising skin health through diet will mean getting the most out of any aesthetic treatment and its results. It also potentially helps with healing time and recovery.” There is a great deal of focus on topical antioxidants to prevent and combat premature ageing. But increasing the intake of antioxidants in the diet – by eating more vegetables and lowsugar fruits – can also help to protect the skin’s cells from free radical damage, noticeably improving skin health. “Fried, burnt and processed foods, as well as sugars, create free radicals so eliminating these in the diet in the first place is important,” Kim says. 36

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Patients seeking treatments to fill wrinkles and plump the skin may be surprised to learn that collagen can be boosted through diet too. “Collagen is protein, whether it’s from the skin, or from chicken, eggs and tofu. Once in the digestive system it’s broken down into amino acids and distributed throughout the body for different uses, including maintaining a healthy skin structure,” Kim explains. She adds that, despite the current trend for collagencontaining drinks to improve skin density and enhance the effects of medical aesthetic treatments, she believes most people would see equally good results by increasing their dietary intake of protein. Constance also highlights the role of advanced glycation endproducts (AGEs) in causing stiffening, weakening and noticeable ageing of the skin. AGEs are created through a process called glycation, whereby sugar molecules bind to the skin’s collagen. Reducing sugar in the form of refined carbohydrates is thus very important to skin health. Oily fish, particularly wild salmon, according to Kim, is a good source of the essential nutrient omega 3, which has anti-inflammatory properties and can help combat dry skin and maintain a supple complexion. “Supplementing certain nutrients can also be beneficial,” says Kim. “There are combinations available that boost a number of skin nutrients, including vitamins A, C and E, B-vitamins and zinc. Patients should also look out for supplementary sources of antioxidants, such as green tea catechins, anthocyanins from dark berries, citrus bioflavonoids, carotenoids such as lycopene and lutein from tomatoes, resveratrol from red wine and genistein from soy – all of which can offer potent protection to the skin.” Nutrition and diet must be addressed up to several months before an aesthetic procedure, in order for it to impact its success. In the shorter term, practitioners should advise patients to maintain hydration and ensure they are fully recovered from any illness or recent surgery before placing the body through the stress of additional treatments. “Rapid weight loss should also be avoided as this

But if you’re given a poor canvas, then while you can make some improvements, you’re not going to get the ‘wow factor’ that many patients are hoping for.

Aesthetics | August 2014


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IN THE CLINIC While the success of most procedures relies upon the patient having adhered to the advice and prescribed regime in the months and weeks beforehand, there is still room for some eleventh-hour prepping in the clinic immediately prior to the procedure. For the likes of botulinum toxin or a volumising treatment, this usually involves applying a thorough yet gentle cleanser. “My protocol also includes some light exfoliation, and I use a device called a Foreo, which uses sonic pulsations to lift debris from the surface of the skin,” says Dr Malik. “It’s a similar concept to other cleansing devices, but it’s less abrasive and more hygienic because it doesn’t use a brush. With peels, preparation can involve using a degreasing solution to remove any sebum from the skin.” In the event that a patient has not been following a practitioner’s advice, all is not necessarily lost. “Things can still be done to help, such as extra cleansing, resurfacing or applying antioxidant serums and anti-inflammatories, as well as wound healers,” comments Dr DeHaven. “However, in all medical disciplines, prevention is always better than attempts at last-minute treatment.” Oral medication, though not typically necessary except in the case of pre- or post-treatment infection, is sometimes indicated. “Arnica in tablet form can be given a few days before dermal fillers and volumisers, and post-treatment, to prevent bruising,” says Dr Cliff. “I’d also tell patients to avoid taking aspirin-containing products that are more likely to make you bleed.” Dr DeHaven adds that, since the outer layers of skin have very few blood vessels, medication taken orally tends to have difficulty reaching these areas. “There are no blood vessels in the epithelial layer of skin and nutrients must reach epithelium by the process of diffusion only. In the dermis, capillaries become much less dense progressing up from deep to superficial dermis. Orally ingested supplements are delivered from the gastrointestinal tract to target organ using the blood vessels. For these reasons, delivery of orally ingested nutrients is quite small in skin’s outer layers, and so topical products are essential in optimising results.” Similarly, Constance takes the view that with the advancement of more natural, biological solutions one should rarely need to resort to medication to improve skin health. “For example if we didn’t use antibiotics in the treatment of acne and instead used the alternatives that are now available to us, we’d make a huge contribution in the aesthetics and cosmetic dermatology arena to reducing antibiotic resistance,” she says. Skin is an integral part both of a medical aesthetic treatment itself, and of its result. Adopting a multi-pronged approach to skin health ultimately means patients will leave the clinic looking and feeling their best, for as long as possible.

Skin Regeneration

Photographs Courtesy of V. Gurvits, DO

impairs protein synthesis, which is required for good healing and tissue regeneration,” comments Dr DeHaven. Skinpolluting agents such as those from traffic fumes and tobacco smoke can negatively affect skin health. Kim points out that smoke creates free radicals – unstable molecules that cause damage to cells and catalyse ageing – and is one of the main reasons that smokers’ skin ages significantly faster than that of non-smokers. Patients should therefore consider cutting down or stopping smoking to encourage healthier skin, as well as for general well-being.


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Aesthetics Journal

Cheek Fillers: Anti-Aging All in One? Dr Jenna Burton discusses the use of hyaluronic acid malar enhancement in substituting direct correction of deepened nasolabial folds, evening out of jowl formation and lifting of the infra orbital tear trough deformity through adoption of the deep ‘bolus technique’. Migration of Our Cheeks in Aging As a child our cheeks were high and full of life, spawning “chubby cheek” taunts, references to ‘puppy fat’ and squeezes from aunts. Gravity however is unselective. The inverted, bright ‘triangle of youth’ becomes the weary, tired ‘triangle of old age.’ Increasing age brings about lipoatrophy, bone reabsorption and laxity of ageing membranes. This, in turn, leads to a pseudo herniation of facial fat over the zygoma and maxilla. As the fat pad migrates downwards and more medially, skin loses its full supporting framework. It sags and collects, without structure, around the eyes, cheeks, and mouth. It also gathers bilaterally in a mass along the mandibular border in the form of jowls. The tone, elasticity and hydration of the skin obviously plays a large part in how dramatic the downward migration of facial fat is realised for each particular individual. Despite this, there is little doubt as to its significant contribution to facial ageing and attractiveness. 70% of women injected with 1.0cc of hyaluronic acid into each cheek felt more attractive post-procedure than pre-procedure.1 Aesthetic practitioners appreciated this link between cheek fullness and perceived attractiveness back in the 16th and 17th century. Artificial cheek implants were adopted to lift and enhance a woman’s ogee curve in profile. Silver, gold, bone and leather were trialled to produce crude implants, leading to much complication and infection. Following many years of research, practitioners these days no longer need to encourage patients to undergo surgery to create the same enhanced look in their cheeks.2 Hyaluronic acid is now widely used in place of more artificial substances. This glycosaminoglycan is distributed widely throughout connective, epithelial and neural tissue within our anatomy. As a major component of the ground substance within the reticular dermis, it adds like-for-like and allows for natural movement of the face, post injection. However in my experience, few practitioners presently choose to inject cheek fillers into their patients as a first line treatment. If the loss of voluminous cheeks

Developing tear trough deformity and nasojugal groove, deepend nasolabial fold, jowl formation and hollowing of the mid face.

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over the zygomatic arch plays such a significant role in facial ageing, and injections of hyaluronic acid are easy, safe and effective substitutes, this should certainly be an area addressed more readily during consultations.

Addressing The Cause, Not The Wrinkle Patients often present complaining of specific aesthetic concerns. They complain of their tear trough deformities, their jowls, lines running along the side of their cheeks and, most frequently, of their nasolabial folds. In order to please the patient, we reach for what they are expecting. If they hate their nasolabial folds, we want to ensure they are filled before they leave. If not, we will have dissatisfied customers. We have stopped thinking about why they have nasolabial folds and what more we can do for the patient other than just fill in the area they do not like. Filling in the cheeks is an alternative solution to filling in the nasolabial folds. Tackling the cause of the problem itself should ensure longer lasting and more natural results, and lifting of the overall face. A randomised comparison of the efficacy of low volume deep placement cheek injection versus mid to deep dermal nasolabial fold injection technique for the correction of nasolabial folds was carried out and published in June 2014.3 The study, published in Cosmetic Dermatology, concluded that neither patients nor physicians involved noted a difference in improvement between correction of nasolabial folds with either method. Sadly, the study does not mention whether there were any further benefits gained from having cheek injections versus direct injection of the nasolabial folds themselves.

Safety and Anatomy Subcutaneous fat compartments have been studied by Rorich and Pessa.4 They confirmed that deep fat is compartmentalised into discrete anatomical compartments which are not equally affected by ageing. The malar fat pad is split into three compartments; medial, middle and lateral. These deep fat compartments show greater atrophy with age than superficial fat, such as the nasolabial and jowl fat compartments, which can actually increase in volume as we get older. Sagging of the arcus marginalis and the orbital septum allows the aponeurotic fat to bulge. The malar bag, nasojugal groove and tear trough deformity that results is not considered aesthetically pleasing and is associated with an ageing face. Previous treatments have included cannula or needle injections of permanent and semi-permanent fillers in the infra-orbital region. Dr Riekie Smit, president of the Aesthetic and Anti-Ageing Congress of South Africa, has commented that filling of the deep cheek compartments is not only more natural than direct correction of tear trough deformities via infraorbital injections, but can also be much safer.


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Dr Reikie Smit - injection of 0.5ml of hyaluronic acid to both cheeks to improve the nasolabial folds and beginning of tear trough deformity.

Tackling the cause of the problem itself should ensure longer lasting and more natural results, and lifting of the overall face. Although there have been many instances of success, complications for the semi-permanent filler range include risk of permanent oedema and loss of sight5. Use of permanent fillers to this area has been largely discontinued, and the FDA now only approves permanent fillers made of polymethylmethacrylate beads, limited to correction of the nasolabial fold5. Intricate vasculature surrounding the eye increases the chance of arterial occlusion and ECM (‘Embolia Cutis Medicamentosa’ or full thickness necrosis).6 Further complications can be caused by inadvertent injection of, even a tiny amount, of filler behind the septum, according to Dr DeLorenzi, who has a private practice in Kitchener-Waterloo, Ontario. She says, “this can cause persistent oedema in the lower lids.” Although potentially corrected with hyaluronase, it raises questions as to whether the same effect can be had without such risks of vascular occlusion and infra-orbital oedema. Again, the answer could lie within deep dermal cheek fillers. I believe that the periosteal layer is a much safer region in which to inject as it contains fewer arteries and veins, and when combined with aspiration prior to injection, it reduces risk of arterial occlusion. Injecting a bolus of hyaluronic acid deep to the zygoma stretches the skin from below the orbital rim and pulls the tissues tight. Whilst previous fillers over the malar eminence have concentrated on lateral injections to highlight the cheekbones, practitioners may forget about injecting the medial aspect of the cheek. This becomes more important in later years, secondary to lipoatrophy and bone reabsorption of the mid-face. Therefore, we should aim to fill the entire cheek. Doing so should pull the excess skin from around the eyes outwards to look much tighter and reduce sagging.

Technique To achieve mid face enhancement for improvement of nasolabial folds, jowls and tear trough deformity, along with improving the overall general appearance of the face, there are many techniques that can be adopted. Professor Alessio Redaelli, cosmetic medical author7 and faculty member of the American Academy of Aesthetic 40

Medicine recommends the ‘deep bolus technique’. His approach adopts the theory that your own tissue moves more naturally than anything that is injected. He recommends injecting deep, just above the periosteum of the zygoma. This will allow the hyaluronic acid to sit below the muscle and hence the patient’s own tissues. Smiling and laughing will recruit movement of their own muscle and dermal layers without interruption from foreign products. However, bruising can be common with this technique and it will often require more hyaluronic acid to achieve noticeable results. If the needle is inserted right to the depth of the bone, although not painful, the sensation is not always well tolerated by patients. An infra-orbital block may be used prior to injection for pain relief, but it will have little to no effect on this needle to bone sensation. Many practitioners still believe this is a minor trade off for a safer procedure, as injections are below major vasculature which avoids risk of the tyndall effect and gives a much more natural appearance.

Deep Bolus Injection Important points to note when carrying out a deep bolus injection for cheek enhancement: • Counsel patients in how they will look following the procedure, and manage expectations. To demonstrate how the cheeks will look, push their current cheek pad upwards from underneath. • As with all treatments, take oral and written consent. • Apply local anaesthetic prior to the procedure. This can include infra-orbital blocks/ice application/Emla cream or nothing at all. Assess patients individually to determine tolerance. • Redaelli8 recommends making three to six injections in the cheek, depending on the patient’s needs. • Draw a curved line along the malar eminence, approximately 2cm below the infraorbital rim. Along this line, mark three appropriate points for injection. • A second line can be drawn 1cm below and parallel to this, again with three appropriate injection points (usually directly below the points marked on the line above). • Using high viscosity hyaluronic acid, inject at 90° to the bone, just above the periosteum. ‘Grabbing’ and gently squeezing the tissue to be injected can aid in pain relief as well as assisting with the direction of the needle. • Inject an appropriately sized bolus below the muscle layer and withdraw the needle. • Mould the material to create a gentle contour along the face. • Approximately one syringe per cheek (1ml) of high viscosity filler should be used (shared between the three to six marked

Aesthetics | August 2014


points.) This again will depend on the individual patient’s needs. Most filler is usually distributed over the most lateral point of malar eminence, then secondly the most medial point towards the nose. Use the least filler in between the two extremities, as this area will include some overlap. Remember that men’s faces have different contours, and caution is needed not to feminise a male face (unless this is the desired effect).

Conclusion Use of the deep bolus technique for lifting of nasolabial folds, tear trough deformity and overall improved, youthful appearance is safe, effective and simple to perform. Little research has been published regarding how jowls can be affected by this mid-face enhancement. However, many aesthetic practitioners are already marketing its use to help even out the mandibular border, suggesting their success with such a technique. Whilst there is little we can do about the increasing volume of superficial facial fat as patients age, such as for nasolabial folds and jowls without the use of cosmetic surgery, we can consider how we can affect these areas by correcting the loss of deeper, superior fat compartments In the cheeks. As hyaluronic acid injections of the mid face are also associated with an increased feeling of attractiveness1, patients should not only look younger, but also experience an increase in self-esteem. Overall it appears that the approach to dermal fillers may slowly be changing. Practitioners are attempting medical facelifts rather than simply filling in lines. Yet it is important to remember that patients do have budgets, and enhancing the mid-face contours successfully will usually be a heavier financial burden compared to simply filling in the infraorbital rim/nasolabial fold or premature jowls. Patient education is needed to appreciate the cost-effectiveness of enhancing the face in this way, and to communicate its virtues as a safe and efficacious treatment. REFERENCE 1. Amy Forman Taub, ‘Cheek Augmentation Improves Feelings of Facial Attractiveness,’ Journal of Drugs in Dermatology, Volume 11 issue 9 (2012) 2. Dr Neal Handel, Dr Steven Dresner, Dr Randal Howarth, ‘Online Surgery’ (California; www.onlinesurgery.com) <www.onlinesurgery.com/article/history-of-cheek-implants. html>[accessed 26/6/14] (page 1) 3. Goodie M, Elm K, Wallander I, Zelickson B, Schram S, ‘A randomized Comparison of the efficacy of low volume deep placement cheek injection technique for the correction of nasolabial folds’, Journal of Cosmetic Dermatology, 13(2) (2014), pp. 91-8. 4. Rod J Rohrich, Joel E. Pessa, ‘The Individualised Compartments of the Face. Anatomy and Clinical Indications for Cosmetic Surgery.’ Plastic and Reconstructive Surgery. Volume 121 Issue 3 (2008) 5. FDA US Food and Drug Administration. ‘Wrinkle Fillers’ New Hampshire, Silver Spring MD, http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ cosmeticdevices/wrinklefillers/default.htm> published 2014, [Accessed 15/07/15] (1) 6. Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK, ‘Iatrogenic Retinal Artery Occlusion Caused by Cosmetic Facial Filler Injections.’ American Journal of Opthalmology, Volume 155 Issue 2, (2013) 7. Redaelli A.: Facial Aging: medical, surgical and odontostomatological solutions. OEO Firenze, Italy, 2012 8. Redaelli A.: medical Rhinoplasty: basic principles and clinical practice. OEO Firenze, Italy, 2010

Dr Jenna Burton is an aesthetic physician, medical writer and is involved heavily with the population health promotion (focusing particularly on the promotion of chronic eating disorder management.) Presently Dr Jenna works between the United Kingdom and Dubai, UAE. Dr Jenna has obtained a diploma from the American Academy of Aesthetic Medicine, whilst working towards her American Medical Board Specialist Status.


Clinincal Practice Clinincal Focus

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Peptide Technology Michael Q. Pugliese, L.E. explores the dynamic role of peptides in cosmeceuticals In nearly 15 years since making their introduction to the cosmetic market place as effective clinical ingredients, peptides have gone from being buzzwords to recognised as industry staples. While many practitioners and patients have heard of them, few fully understand the dramatic benefits that can be achieved by these high-performance ingredients, and what they hold for the future of professional skincare. In this article we will review the structure and function of cosmetic peptides, and take a look at some family classifications. We will also highlight several proven commercially available peptides for the practitioner to offer to the patient.

Figure 1

What are peptides? Peptides can be defined as short chains of amino acids linked together in whatâ&#x20AC;&#x2122;s known as the amine or peptide bond. Amino acids are primarily composed of four elements: carbon, oxygen, nitrogen, and hydrogen, with a few exceptions. There are 22 essential amino acids playing various roles in skin health, which can be found functioning throughout the many layers of the skin. These include lysine, proline, valine, glycine, tyrosine, glutamine and several others. These individual amino acids can be found in many cosmetic formulations serving their own unique individual purposes. It is when we see these amino acids hooked together in precise sequences, that we open up a new world of high-performance ingredients with these very special bonds. When properly formulated, 42

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peptides have the ability to help us effectively address almost every issue that we associate with skin irregularities including wrinkles, hyperpigmentation, acne, rosacea, cellulite and many more. Each amino acid has a portion of its structure that is positive (amine group) and a portion that is negative (carboxyl group). This is the key to understanding how peptides are made. In this case as in many others, opposites attract. The positive of one amino acid will conjoin with the negative of another, creating what is referred to as the peptide bond. During this bond water is produced as a byproduct. See Figure 1 which shows two amino acids bonded together. No matter how many amino acids are hooked together, they will always link the positive of one to the negative of another. Typically, the key difference between peptides and proteins is the number of amino acids. Proteins are recognised as 50 or more amino acids in a single chain, but this is a relatively arbitrary classification as there are many exceptions to this rule. Most commercial peptides that are used as skincare ingredients are between two and ten amino acids. Where do peptides come from? Peptides are made by the body in vast amounts every day. They help regulate a variety of body functions in various systems. The glycoprotein hormones are the most chemically complex family of the peptide hormones. Three members of this family include FSH (follicle stimulating hormone), LH (luteinizing hormone) and HCG (human chorionic gonadotropin). The synthesis of FSH and LH occurs in the same cells of the anterior pituitary, but their secretion is controlled by the hypothalamic portion of the brain through a third peptide hormone called GnRH, or gonadotropin releasing hormone. These hormones have receptors on their target cells, which are mainly the ovaries, and are used to regulate ovulation and the menstrual cycle. TSH or thyroid stimulating hormone, is stimulated by thyrotropin-releasing hormone (TRH) from the hypothalamus. TRH, a tripeptide, is synthesised by neurons in the hypothalamus and is secreted in a pulsatile manner, with peak secretion being exerted between midnight and 4am, producing a biphasic delivery of thyroid stimulating hormone. In turn, TSH stimulates the thyroid gland to produce thyroid hormone, which is essential for every cell in the body. The Pro-Opiomelanocortin (POMC) family is a complex of peptides having a wide range of function in the body. Actually, it is a precursor of several other hormones, including ACTH- like (adrenocorticotrophic hormone) compounds that stimulate the adrenal gland to produce cortisol type compounds. The major hormone produced from POMC is Alpha MSH, which stimulates the production of melanin in the melanocyte. Finally, this versatile complex peptide also produces endorphins which have a profound effect on the central nervous system. With a basic understanding of these primary hormones, it is important to clarify that the peptides we use as skincare ingredients are very different from those

Aesthetics | August 2014


Clinincal Practice Clinincal Focus

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made and utilised by the body. Primarily, peptides used for formulating topical products have been engineered. Specific sequences of selected amino acids are designed to have an influence on a particular cell or group of cells. There are a number of ingredient supply companies which have made the technology of engineering peptides big business and have reshaped the skincare industry. How do peptides work? Typically, cosmetic peptides are designed to engage a particular cell, or group of cells, resulting in a specific function that will vary, depending on the peptide and the target cells. They do this by binding to various receptors on the surface of these cells, and targeting messages to the nucleus via transcription factors. Once the nucleus has received the messages, they will be directed to produce the action that the peptide dictates. Practitioners can communicate this action to their patients by stating that peptides are meant to tell certain cells what to do. Two notable properties of peptides are that they are primarily water soluble, and they are relatively large molecules. This combination makes it impossible for peptides to penetrate cell membranes and affect cell activity. In contrast, vitamin A, in its many forms, is lipid soluble and able to move through the membrane and interact directly with cellular DNA. It is for these reasons that commercial peptides are often formulated with “built in” and/or additional delivery systems and penetration enhancers, enabling them to reach targeted cells and receptors. Carrier peptides. The first commercialised peptides were carrier peptides. Introduced in the early 1990’s, these peptides were designed to hook to another ingredient and facilitate transportation of the agent to the active site. The first carrier peptide was designed to deliver copper, a trace element necessary for wound healing. From a wound healing application, a peptide known as GHK-Cu was commercialised into a line of skin care products to minimize the appearance of fine lines and wrinkles. GHK-Cu is composed of glycine and histidyl and lysine

Signal Peptides Preventhelia is a tetrapeptide, born from preventive cosmetics, that protects skin cells from UVA-induced DNA damage and is able to promote the DNA repair system capacity, providing skin protection of intrinsic and extrinsic ageing. Liporeductyl is a tripeptide and acts as a scavenger for by-products of lipid peroxidation, enhancing the effectiveness of the other components to fight cellulite and prevent adipocyte maturation.

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hooked to copper and was found to induce dermal keratinocyte proliferation. GHK was originally isolated from human plasma and then synthetically engineered. Copper peptides lost their popularity mainly due to potentially harmful properties of copper itself. While critical to collagen formation, copper is a transition metal associated with free radical damage. Copper also has the ability to create AGEs (advanced glycation endproducts) via the Fenton reaction, which can damage collagen and other essential dermal proteins. That said, however, everything old becomes new again. Copper is now available once again in an ingredient launched in 2013, under the trade name Neodermyl. The manufacturer claims this new version of the ingredient, while not technically a peptide, contains two amino acids, proline and lysine, hooked to either end of the copper, ensuring a safe delivery of the ingredient while virtually eliminating the risk of free radical damage and glycation. Signal peptides. The largest peptide family currently used in marketed cosmeceuticals is made of the signal peptides. Signal peptides provide a multitude of actions, most notably stimulating collagen, elastin, fibronectin, proteoglycan and glycosaminoglycans. The most popular signal peptide, palmitoyl pentapeptide-4, was released in 1999, commercially known as Matrixyl. Palmitoyl pentapeptide-4 is composed of the amino acids lysine, threonine, lysine and serine. It is demonstrated to stimulate the production of collagen I, III, and IV.1 Several newer, and seemingly more effective, versions of this early technology have been launched over the years by the ingredient manufacturer. Matrixyl 3000 was introduced in 2003, and Matrixyl synthe’ 6 in 2010. Both achieved ready acceptance and exposure because of their efficacy. Matrixyl sythe’ 6 has enjoyed a meteoric rise in use in the industry, because of its ability to stimulate certain types of collagen as well as fibronectin and lamanin-5, proteins responsible for helping to strengthen the dermo-epidermal junction. A few of the many signal peptides and their functions are listed below.

encapsulated in a liposome vehicle. It differentiates itself from other traditional whitening agents with its unique inhibitory action on the MITF cellular pathway to decrease constitutive and facultative pigmentation, allowing optimal whitening and lightening effect with an excellent safety profile.

dGlyage prevents DNA structure changes triggered by transition metals. It chelates such ion metals that catalyse different reactions producing several DNA lesions.

Progeline is a 3 amino acids peptide biomimetic of Elafin, an enzyme inhibitor that regulates the integrity of the extracellular matrix. Progeline decreases progerin synthesis, a new ageing biomarker involved in skin cellular senescence. By acting directly on a senescence marker it clinically improves the appearance of signs associated with skin maturation: sagging, slackness and wrinkles.

ß-White is a TGF-ß biomimetic peptide

Telangyn helps to decrease facial redness

Aesthetics | August 2014

and other skin disorders caused by LL-37 activation and subsequent release of IL. It also provides a photo-protective effect, lowering cell damage and skin inflammation negative effects. Bodyfensine, designed through a combinatorial chemistry approach, stimulates human-β-defensin -2 and -3, enhancing the skin’s natural defence system, therefore maintaining the balance between commensal microbes and pathogens in the skin. Diffuporine enhances AQP3 expression levels in keratinocytes, which are inherently reduced due to chronologic ageing and photo-ageing. In addition, this peptide presents further properties that contribute to maintaining skin barrier integrity and a youthful appearance.


Neurotransmitter peptides Neurotransmitter peptides function by inhibiting the release of acetylcholine at the neuromuscular junction. They are similar to botulinum toxin in that they both selectively modulate synaptosome-associated protein of 25,000 Daltons, more commonly known as Snap-25. Botulinum toxin A proteolytically degrades SNAP-25. Acetyl hexapeptide-3, trade name Argireline, is a neurotransmitter peptide, which mimics the N terminal end of the SNAP-25 protein that inhibits the SNARE (soluble N-ethyl-maleimidesensitive attachment protein receptor) complex formation. Acetyl hexapeptide-3 functions topically to relax muscles by inhibiting vesicle docking through prevention of the SNARE complex formation. This muscle relaxation reduces the appearance of facial wrinkles. Much like the Matrixyl family of peptides, the manufacturer of Argireline has since improved its initial technology. Snap-8, (Acetyl Octapeptide-3), a similar functioning peptide, has been shown to reduce wrinkle depth by 63% in 28 days.2 This provides nearly twice the wrinkle reducing power of Argireline. Enzyme modulating peptides. Enzyme modulating peptides directly or indirectly inhibit the function of a key enzyme in some metabolic processes. Many of the enzyme modulating peptides are extracted from botanical sources rather than engineered through chemistry. Soy proteins, already used in cosmeceuticals for the reduction of pigmentation and the inhibition of hair growth, possess another peptide that inhibits the formation of proteases that break down collagen and elastin. Rice proteins possess a peptide that inhibits MMP (matrix metalloproteinase) activity. These naturally occurring peptides are used in cosmeceutical facial moisturisers in combination with the previously discussed synthesised peptides.3 The use of peptides in a skin treatment product is percentage dependent, thus responsible manufacturers provide a formulary range, low to high, of the effective dose concentration. Using a higher concentration than recommended adds only to the cost, not to the effectiveness, of a product. It follows that skimping below the minimum percentage, when adding peptides simply for labelling and advertising purposes, will do nothing to contribute to the product, nor the patients’ results. Bear in mind that the sophistication of peptide technology does not require the professional to become a molecular biologist in order to serve our patients. As in all new things, the goal is to keep learning, and absorbing a little bit at a time. Be aware that new discoveries in skin science allow us to address evermore specific skin care concerns with professional skin care treatments and products, with the intention of safely effecting a positive change in the health and appearance of human skin at all stages. Michael Pugliese is a skincare specialist and CEO of skincare company, Circadia. He is a member of the Society of Cosmetic Chemists and regularly attends their education events to stay on the cutting edge of new product development. REFERENCES 1. Sederma, ‘The Messenger Peptide for Dermal Matrix Repair: An Alternative to Retinol and Vitamin C,’ (www.doctstoc.com, 2011) http://www.docstoc.com/docs/92616994/MatrixylTM 2. Lipotec Group, ‘Snap-8: An octapeptide to express yourself at ease’ (www.docstoc.com, 2011) http://www.docstoc.com/docs/84112127/An-octapeptide-to-express-yourself-at-ease 3. Physiology of the Skin, Third Edition, by Peter T. Pugliese, MD and Zoe Diana Draelos, MD (Allured Business Media, 2011) pp 233-234

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Clinical Practice Spotlight On

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Spotlight On: Mirvaso Galderma’s Mirvaso gel for the treatment of the redness of rosacea was officially launched in the UK in March this year. Here we ask leading dermatologists to discuss patient selection, and to share their advice on prescribing. Galderma’s Mirvaso 3 mg/g gel is an alpha-2adrenergic receptor agonist that acts rapidly to reduce the persistent facial erythema (redness) of rosacea in adult patients. The active ingredient is brimonidine, an ingredient that has been used to treat the eye disease glaucoma since 1997. While not a cure, symptomatic relief can last for up to 12 hours. The ability of Mirvaso to constrict blood vessels in the skin was discovered by accident, when patients with glaucoma and rosacea found the skin underneath the eye developed pallor when they spilled some of their glaucoma drops on the skin. At the end of February 2014, Mirvaso was granted marketing authorisation in Europe by the European Commission. The EC authorisation is based on data from 553 patients in two one-month phase 3 clinical trials, showing that patients who used Mirvaso saw significantly greater reduction of facial redness than those who used the vehicle gel alone. In a US, long-term, multi-centre study, 449 patients with moderate-to-severe erythema of rosacea applied Mirvaso once daily for up to 12 months.1 Mirvaso was shown to be effective in reducing persistent facial erythema of rosacea from the first day of treatment and throughout the 12-month study. The study, published in the Journal of Drugs in Dermatology, the study saw no evidence of tachyphylaxis and so Mirvaso remained effective. No new safety issues or side effects emerged. The most common adverse reactions (incidence ≥ 1%) included erythema, flushing, skin burning sensation, and contact dermatitis. In the long-term study, the most common adverse events (≥ 2% of subjects) included flushing (9.1%), worsening of erythema (6.5%), worsening of rosacea (3.6%), skin-burning sensation (3.3%), increased intraocular pressure (4%), and headache (4%). Dr Anthony Bewley, consultant dermatologist at Bart’s Health NHS Trust in London, recently conducted UK trials on Mirvaso with ten patients. He found they all responded well to the treatment. “Rosacea sufferers often find the facial redness very disfiguring and even disabling,” he says. “Patients often also suffer a burning sensation at the same time. It makes them feel wretched and out of control. Some become depressed and a few even feel suicidal. Until now there hasn’t been much that effectively treated the redness and flushing. Even 46

Before

After

if patients have expensive laser treatments, the redness tends to come back. To have this is helpful not just for my patients’ skin, but their self-worth too.” A recent awareness programme, launched in June 2014 by Galderma and fronted by actress Cynthia Nixon, is working to urge rosacea sufferers to seek help for their condition. New research data from the ‘Face Values: Global Perceptions Survey’ showed that facial redness affects sufferers emotionally (77%), socially (67%), at work (63%) and in their relationships/dating behaviour (53%). The survey also showed that respondents also formed judgements about sufferers’ personalities: those with facial redness were less frequently perceived as intelligent, reliable, successful and trustworthy compared to people without redness.2

Treatment Dr Bewley says that although Mirvaso can take up to 30 minutes (or longer) to work, he has found that redness cleared within a few minutes in some patients. “The patients all liked it very much and told me how much better they felt when using it. It made a big difference to their skin, taking away the redness. Redness and flushing can lead to full blown rosacea with papules and pustules and even rhinophyma, or skin thickening of the nose. Treating the disease early could prevent progression.” However, as with all drugs,

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Aesthetics | August 2014

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Clinical Practice Spotlight On

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Aesthetics Journal

patient selection is vital. For grade 1 improvement, studies suggest Mirvaso may be effective at reducing visible redness in 71% of patients.3 For a grade 2 improvement, the result was 31.5%. The studies were rigorous: for a successful outcome both patients and assessors had to agree that the patients had a two-grade reduction in redness at each time point assessed. If Mirvaso is applied patchily, the face will have red areas where the cream was missed. Consultant dermatologist Dr Nick Lowe says, “I have been interested in brimonidine for some time now, and think Mirvaso is going to be very helpful when treating rosacea. It seems it can be used in conjunction with other medications such as antibiotics, for example metronidazole, and devices such as IPL and lasers, such as the new Nd:YAG vascular lasers. However, I would like to see more safety testing of Mirvaso in combination with

Baseline

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9 Hours

other prescription drugs. I would be wary of prescribing it with tretinoin or isotretinoin and in sensitive skin patients.” He adds, “It is vital to diagnose rosacea correctly in the first place as there are other causes of rosacea-like redness, including facial eczemas.” Dr Bewley advises that, as it constricts blood vessels, Mirvaso might not be suitable for people who suffer from migraines. Dr Daron Seukeran, consultant dermatologist and medical director of the sk:n laser unit, suggests caution in patients with coronary or cerebral insufficiency, Reynaud’s phenomenon. Alpha-2-adrenergic agents can lower blood pressure so patients with hypotension may not be suitable. Galderma suggests Mirvaso should also be used with caution in patients with depression, orthostatic hypotension, thromboangiitis obliterans, scleroderma, or Sjögren’s syndrome or severe or unstable or uncontrolled cardiovascular disease. Adverse reactions following accidental ingestion of Mirvaso gel by children have been reported, though both children made a full recovery within 24 hours.4 Some contributors to internet sites have complained of side effects, of which the worst seems to be worsening of redness that they believe is worse than before they tried Mirvaso.5 And Dr Lowe says, “Some of my patients who have used Mirvaso in the US say they have experienced stinging and increased redness. However, the complaints may also arise because the contrast with their new pallor could make patients believe that when the redness returns after 12 hours, it is worse than they remembered. They may find that papules, which are disguised by diffuse redness, become more obvious when the redness fades, as Mirvaso does not reduce these.” Dr Alison Layton, consultant dermatologist at Harrogate District Hospital, agrees. “It is important to warn patients that Mirvaso does not treat lesions. In addition, some patients note that some of the small red vessels on their skin are more prominent. Again it is important to inform patients that any dilated vessels which we call telangiectasia (sometimes referred to as small thread veins) will not clear with the Mirvaso and may look more prominent. These telangiectasia are amenable to laser treatment.” Patients may also be less vigilant about avoiding triggers such as alcohol, spicy food, extreme temperatures and stress while the Mirvaso is active, and, warns Dr Bewley, the skin may show a delayed reaction to these triggers when the effect of Mirvaso wears off. Dermatologist and medical therapeutic area specialist for Galderma, Dr Gregor Schäfer, says, “The vast majority of patients have been very satisfied with Mirvaso. But it’s important to set clear expectations: Mirvaso is a symptomatic treatment for facial erythema of rosacea and the patients’ erythema 48

Aesthetics | August 2014

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will return as the effect of the drug/brimonidine wears off. Therefore it is of crucial importance to set the patients expectations right, to ensure they have a good knowledge of the potential side effects and understand the limitations of the treatment. The term rebound, as defined in the clinical development programme, refers to worsening of erythema after the end of a 29 day study (at week two and four visits following cessation of treatment) as compared to baseline assessment. However, no substantial numerical difference in ‘rebound’ was observed between Mirvaso (brimonidine) and vehicle groups, in either of the two pivotal Phase III trials. However, in these studies, during the treatment period, some patients reported a flare of their redness, sometimes worse than baseline, occurring a few hours after Mirvaso application. This was reflected in the US PI in the ‘warning and precaution’ section as worsening of erythema and in the European Label as worsening of rosacea and skin redness. Intermittent flushing is also reported. These adverse events occurred intermittently in some patients or on a daily basis in others, but were not defined as rebound in these studies.”3 Good clinical photography and counselling is of crucial importance when prescribing Mirvaso. Dr Lowe adds, “As patients can be allergic or irritated by any ingredient, I would suggest patients first apply a small amount of Mirvaso in an inconspicuous area of skin before applying it to their entire face.” Health trusts will now have to decide whether to offer Mirvaso to patients in their area – it is expected to cost the NHS as little as 50p a day per patient. However, Mirvaso will also be available privately. Galderma originally assumed patients would use around 1g a day which contains 5mg of brimonidine tartrate, but in studies they found participants used an average of .53g meaning a 30g tube will last up to 60 days and will cost less than £35.

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REFERENCES 1. Moore A, Kemper S, Murakawa G et al. ‘Long-term safety and efficacy of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of a 1-year open- label study’, J Drugs Dermatol, 13 (1) (2014), pp. 56–61. 2. Galderma S.A. Face Values: Global Perceptions Survey. 2013. 3. Fowler J, Jackson JM, Moore A et al. ‘Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies’, J Drugs Dermatol, 12 (2013), pp. 650–656. 4. Galderma, Mivaso 3mg/g SPC (www.medicines.org.uk, 2014) <www. medicines.org.uk/emc/medicine/28682/SPC/Mirvaso+3mg+g+Gel> 5. David Pascoe, Mirvaso User Reviews (http://rosacea-support.org, 2013) <http://rosacea-support.org/mirvaso-user-reviews.html>


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Clinical Practice Abstracts

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A summary of the latest clinical studies Title: Diet and acne update: carbohydrates emerge as the main culprit Authors: SN Mahmood, WP Bowe Published: Journal of Drugs in Dermatology, 2014 April Keywords: Acne, Carbohydrates, Diet, Dermatology Abstract: ‘The prevalence of adult acne in the US appears to be increasing over the last few decades. But what’s behind the rise: is it nature or nurture? We are well aware that genetics can strongly influence a patient’s risk of developing acne. However, significant changes in germline genetic variants are unlikely to have occurred over the last 20 years. Consequently, we are forced to examine environmental variables, including diet. This review article presents the most updated evidence supporting a link between refined carbohydrates and acne. Based on the data summarized here, dermatologists should encourage their acne patients to minimize their intake of high glycemic index foods.’ Title: Influence of skin ageing features on Chinese women’s perception of facial age and attractiveness Authors: A Porcheron, J Latreille, R Jdid, E Tschachler, F Morizot Published: International Journal of Cosmetic Science, 2014 May Keywords: Ageing, Wrinkles, Chinese, Caucasian Abstract: ‘Ageing leads to characteristic changes in the appearance of facial skin. Among these changes, we can distinguish the skin topographic cues (skin sagging and wrinkles), the dark spots and the dark circles around the eyes. Although skin changes are similar in Caucasian and Chinese faces, the age of occurrence and the severity of age-related features differ between the two populations. The aim of this study is to evaluate the contribution of the different age-related skin features to the perception of age and attractiveness in Chinese women. Facial images of Caucasian women and Chinese women in their 60s were manipulated separately to reduce the following skin features: skin sagging and wrinkles, dark spots and dark circles. Finally, all signs were reduced simultaneously. Female Chinese participants were asked to estimate the age difference between the modified and original images and evaluate the attractiveness of modified and original faces. Chinese women perceived the Chinese faces as younger after the manipulation of dark spots than after the reduction in wrinkles/ sagging, whereas they perceived the Caucasian faces as the youngest after the manipulation of wrinkles/sagging. Interestingly, Chinese women evaluated faces with reduced dark spots as being the most attractive whatever the origin of the face.’ Title: Severe androgenetic alopecia as a proxy of metabolic syndrome in male psoriatic patients older than 59 years Authors: V Descamps, E Mahé, F Maccari et al Published: European Journal of Dermatology, 2014 June Keywords: Androgenetic alopecia, Psoriasis, Hypertension Abstract: ‘Whereas several studies have underlined the association between severe psoriasis and metabolic syndrome (MetS), the association of androgenetic alopecia (AGA) and MetS have yielded inconsistent results. We investigated the relationship between AGA and the components of MetS in psoriatic male 50

patients. A non-interventional, cross-sectional, multicenter study was conducted in France. A standardized questionnaire was completed, including information on components of MetS and other possible risk factors. MetS was defined in this study as a combination of three or more of the four components of MetS: waist circumference, hyperlipidemia, diabetes mellitus and hypertension. A standardized simplified Norwood classification limited into 5 grades (0-4) was used. In a total of 1073 male patients, hypertension, high waist circumference, diabetes mellitus and hyperlipidemia were observed in 28%, 59%, 11%, and 31%, respectively. In age-adjusted multivariate analysis, severe AGA (grade 3-4 versus grade 0) was associated with the presence of at least one component of MetS. By groups of age, a statistically significant association of severe AGA and MetS was demonstrated in patients over 59 years. Severe AGA was also associated with a first-degree familial history of major cardiovascular event in patients older than 59. Our study, based on a simplified but stringent definition of MetS, confirmed the link between severe AGA and individual components of MetS in psoriatic patients. This argues for careful follow-up with regular screening in male psoriatic patients with severe AGA in order to early detect determinants of MetS.’ Title: Complications after facial injections with permanent fillers: Important limitations and considerations of MRI evaluation Authors: J Kadouch, C Tutein Nolthenius, D Kadouch et al Published: The Aesthetic Surgery Journal, 2014 June Keywords: Filler migration, Filler complication, Magnetic resonance imaging Abstract: ‘Soft-tissue fillers have become more prevalent for facial augmentation in the last 2 decades, even though complications of permanent fillers can be challenging to treat. An investigative imaging tool could aid in assessing the nature and extent of these complications when clinical findings are ambiguous. The authors analyzed the value of magnetic resonance imaging (MRI) in the assessment of delayed-onset complications. Thirty-two patients with complications related to facial fillers were evaluated in this prospective cohort study. Their medical history was documented, and MRI was conducted before treatment. Radiologists were informed of the injection sites but were blinded to the results of other clinical evaluations. Levels of agreement between clinical and radiologic findings were calculated with the Jaccard similarity coefficient. A total of 107 site-specific clinicoradiologic evaluations were analyzed. The level of agreement was assessed as strong for deposits without complications and noninflammatory nodules (combined 85%), moderate for abscesses (60%), fair for low-grade inflammations (32%), and slight for migrations (9%). Results from the MRI examinations aided in subsequent treatment decisions in 11% of cases. Results show that MRI may be useful for diagnosing complications associated with fillers that have migratory potential, for depiction of the extent of deposits before treatment, and for follow-up of low-grade inflammation and abscesses after surgery.’

Aesthetics | August 2014


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Aesthetics Journal

Aesthetics

Don’t miss your chance to attend The Aesthetics Awards 2014, book your ticket today! With entry closed and the finalists being chosen, plans are coming together for the most prestigious celebration in medical aesthetics. The Aesthetics Awards 2014 will be held on Saturday 6th December at the Park Plaza Westminster Bridge Hotel in Central London and will play host to the best in the profession. Alongside the presentations honouring winners and highly commended finalists, the evening will also feature fantastic entertainment, a formal sit down dinner and a great opportunity to network with colleagues and peers. Individual ticket: £200 plus VAT Table of 10: £1,900 plus VAT To book your tickets visit www.aestheticsawards.com, call 0203 096 1228 or email bookings@aestheticsawards.com

This year the Janeé Parsons Award for Sales Representative of the Year is sponsored by Healthxchange Pharmacy

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Aesthetics Awards Special Focus

Finalists will be announced in next month’s issue of Aesthetics journal on 1st September whereby voting/judging will commence. How will winners be selected? Once the finalists have been selected and announced in September, voting and judging will take place to select the winners. Via the Aesthetics Awards website you will be able to vote for the winner in the following categories: • Cosmeceutical Range/Product of the Year • Injectable Product of the Year • Treatment of the Year • Equipment Supplier of the Year • The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy • Best Customer Service by a Manufacturer/Supplier • Distributor of the Year • The Neocosmedix Award for Association/Industry Body of the Year An expert judging panel will consider the nomination forms submitted by the finalists for the following categories: • The Pinnell Award for Product Innovation • Training Initiative of the Year • The 3D-lipomed Award for Best New Clinic, UK and Ireland • The Syneron Candela Award for Best Clinic Scotland • The Rosmetics Award forBest Clinic North England • The Dermalux Award for Best Clinic South England • The Oxygenetix Award for Best Clinic London • The Sinclair IS Pharma Award for Best Clinic Wales • Best Clinic Ireland • The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year • The Merz Aesthetics Award for Aesthetic Medical Practitioner of the Year • The Church Pharmacy Award for Clinic Reception Team of the Year The winner for The Aesthetic Source Award for Lifetime Achievement will be selected by the Aesthetics team and announced on the night. Winners in all categories will be announced at The Aesthetics Awards on Saturday 6 December 2014. Where appropriate, judges may also choose to commend or highly commend particular finalists. These commendations will also be announced at The Aesthetics Awards.

Gemma Knowler, voted winner of the Janeé Parsons Award for Sales Representative of the Year, shares her experience of being honoured at The Aesthetics Awards 2013. “Winning Sales Rep of the Year at The Aesthetics Awards was the biggest achievement of my career to date. I had set myself a personal goal two years ago to make the shortlist in 2013 or 2014 so to win went beyond my goals and made me feel very proud of all my hard work since joining the industry seven years ago. I am thankful to all of my customers and colleagues that both nominated and voted for me. It was a wonderful feeling to win and know my work was recognised and that all those who voted for me care for me as much as I do them. Knowing all this is a lovely feeling!”

Aesthetics | August 2014

51


In Practice Design

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Aesthetics Journal

Clinic design Dr Tapan Patel details his journey from construction site to design excellence, recounting his clinic development project, which began in March 2013 Essentially, my practice had outgrown my clinic in North London and we decided that it was time to find something in Harley Street. The site I chose was an empty shell that would need to be built up almost entirely from scratch. In my first clinic, the facial aesthetic procedures on offer were purely non-surgical, and with the new clinic I decided that I wanted to provide a wider range of aesthetic treatments for my patients. The first steps were to consider the name and concept for the clinic, and what I wanted to do architecturally with the space. The name I decided upon was the Greek letter PHI, the 21st letter of the Greek alphabet, pronounced ‘Fy’. The clinic takes its inspiration from Ancient Greek scholars, artisans and the notion of the golden ratio with its aesthetically pleasing proportions. The design for the clinic wasn’t based on any practice that I had previously seen. I wanted to reinvent how cosmetic-based practices were presented and perceived. The idea was to make it a combination of traditional but modern, clinical and professional. Initially, this seemed to be a mass of conflicting themes but I felt that there was a way for me to bring all these disparate notions together. I met with an architectural design specialist, Roger Gullidge, and very early on he was able to explain to me what could be done with the space. I already had some design concepts that I had been working on, and when I shared my ideas and vision for 52

the clinic these began to be transposed into the foundations of a plan. During the development I was on site a lot; I wanted to be there as often possible, and it meant that I could be involved in all of the day-today decisions. I also employed a project manager and a building company, which meant that I didn’t have to carry out the actual running of the site myself. Considering the rebranding of the practice was a very different process to the construction of the site, it was carried out through working with a specialist website and graphic design team who were able to come up with specifically tailored branding

Aesthetics | August 2014

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that suited the new clinic. In the new clinic, patients are offered both non-surgical and surgical solutions for all indications, and I wanted this to be reflected in the image of the practice, especially as previously the clinic’s provision was purely non-surgical. Amazingly, we didn’t come across any significant obstacles or problems during the build or design; in fact we were very lucky throughout the entire project. When I originally selected the site I was aware that it was a listed building and knew about the relevant controls and regulations, but I wasn’t overly concerned about these issues. Fortunately, having a specialist architectural design company on board able to deal with these factors, and who had experience managing this kind of build previously, meant that this was not a problem. Now that the project is complete and has become a fully working practice, I am particularly pleased with the clinic’s overall impression. For me, it really does create that kind of wow-factor that we had intended, and simply managing to get it all up and running in such a short space of time is a proud achievement.. The whole team here at PHI Clinic are able to share my excitement and pride everyday when we walk in to our gleaming new clinic – it really brings a smile to all our faces. The advice I would give to other practice owners going into a similar project is to allow plenty of time from conception to conclusion, and not to be too unrealistic as to the amount of your own time that a project like this will take up. You can budget for a build or for equipment, but there will always be unforeseen factors that can add to a project, and you have to make sure that you have the


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In Practice Design

right timescale to accomplish what you want. I was fortunate in that respect. Beforehand, I had made some provisions for hidden surprises but luckily I was able to avoid any major problems. It would have only taken an issue with the wiring or the plumbing, or for the builders to find damage somewhere, to add a considerable unexpected expense. It is also worth noting what a big task it actually is to rebuild and rebrand a clinic. It requires coordinating building work with all aspects of the business; you will have to organize everything from the equipment to the staffing, the branding and the marketing strategies, as well as all of the legalities. It is very important to be under no illusion as to

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Aesthetics Journal

the huge amount of work that will be involved. Whether you are looking to rebuild or rebrand your practice to expand or improve the services you offer, I would suggest that you meet with a project manager as early into the conceptualisation of the project as possible. They will be able to use their experience to help identify what the limitations or possibilities of your project might be; if you’re not already in the field yourself you don’t always realise the potential that a building might have. From my own personal experience, I would certainly recommend getting that advice early on and working with a design service that will help you establish your artistic concepts and budgets to ensure the long term success of your business. Looking back at the project, from start to finish, there isn’t anything I would have done differently. For me, it was very important to get this project right the first time, and I think we achieved that through detailed plans and a clear vision from the start. The new clinic is just as I had envisaged it, and now I don’t anticipate myself having to go through this process again. The project began in March 2013 and took us right into January 2014. It’s difficult to say for certain so soon after its completion what affect this project has had on the success of the overall business, but it has certainly started with a bang. I have received masses of positive feedback about the clinic and its design, and I hope that patients and visitors

Aesthetics

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alike will continue to be pleased with the outcome, and that this momentum will carry on for many years to come. Dr Tapan Patel is the founder and medical director of VIVA and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning. Dr Patel gives presentations at conferences worldwide.

The power of any clinic design lies in its function for everyday practice. How your patients respond to your tailored space is key to its success. We take a look at three compelling clinic designs:

Riverbanks Clinic Dr Ravi Jain, owner

“As soon as I saw the building, I knew I wanted it for my clinic. It was previously a pub called the Leather Bottle and had to be totally gutted and rewired before any of the interior design could begin. The secluded location of the clinic allows patients privacy, with no stressful parking. We even grew the hedges around the car park so people can’t be recognised by their cars. The clinic gardens back on to a river, providing a beautiful view and constantly reaffirming the clinic’s ‘natural’ ethos. With the river running by, we came up with the name: Riverbanks. Designed by my wife, Rosalind Jain, she chose a blue-green colour scheme, as it is calming and tranquil. Getting the correct balance between clinical and homeliness was our challenge. We kept a few of the original features such as the fireplace and ceiling beams. Natural 54

Aesthetics | August 2014


In Practice Design

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wood floor was laid, and our white shutters are a great success, letting light in but providing privacy for the patient. The same colours were used in furnishings, vases and ornaments to create a calming continuity. We have rooms to accommodate all our treatment options, as well as a room dedicated purely to consultation, with no treatment chairs in sight. We wanted to make it homely and let patients feel at ease straight away. Our natural and timeless interior design reflects the treatment outcomes that we offer. We wanted our clinic to be reassuringly traditional and discreet; there are no big signs outside saying, ‘Botox here!’ Patients quite simply love our clinic. Comments include, ‘I wish I lived here’, ‘The view is beautiful’, and ‘It’s so relaxing’.”

Cosmex Clinic

John Culbert, Business Director

Our patients respond very well to our clinic design, they love the light, airy feel and tell us it is a comfortable place to come to.

“Our clinic was originally a gatehouse, and is part of a grade I building called Anstey Hall. With vaulted ceilings and hardwood flooring, we wanted to keep the original features, whilst incorporating a contemporary, modern feel. Although our colour scheme is neutral, our walls are decorated with pieces by the artist Richard Snowden, that are also for sale. When patients enter the reception they are greeted with glass and stainless steel features – a minimalist feel which lets the building speak for itself. Based in Cambridge, in the middle of a burgeoning upmarket area and adjacent to Waitrose, we are just three minutes from the M11. Being so close to the motorway has definitely increased our catchment area. Our patients can come to our clinic, have their treatment, and pop to Waitrose to do their shopping on their way home. We are also only 150 yards from a bus stop. Our patients respond very well to our clinic design, they love the light, airy feel and tell us it is a comfortable place to come to. They appreciate the space and the fact that there are no parking restrictions. The building was previously used as a laser clinic, an area we are hoping to expand into, so has already received CQC approval. In anticipation of future laser use, the clinic is already fitted with blackout blinds.”

Medikas

Dr Beatriz Molina, medical director “In Spanish ‘Medica’ means female doctor and ‘Kas’ means calm: I combined the two to create the name of my clinics: Medikas. I chose the locations as I had been working in the local area as a GP, so I was already well known. We now cover large areas of Somerset, forming a triangle of clinics in Bristol, Bath and Street. Our Bristol clinic incorporates a minimalistic, modern design, which is in line with how I like treating my patients. I normally like my patients to look very natural, only treating what is absolutely necessary and adding treatment only where it gives the best results. The building itself inspired the design of the interior, as it offered bright and spacious rooms. I took into account what would be required in each treatment room and how much space would be needed to treat our patients with the latest technology and commodities. We have a waiting room with comfortable sofas for our patients to relax on, along with a recovery room for patients to rest in after more invasive treatments. Our photography room gives a comprehensive skin analysis with sophisticated photos that use the latest 3D technology, and we have a room dedicated to laser treatments. Patients love the clinic, we always get lots of compliments – my daughter thinks we should live there!”

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Aesthetics | August 2014


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In Practice Business process

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clients, within your competency, that your competition is not offering and that is in line with what the client is willing to pay. If you are not sure, one of the best ways to find out is try out some treatments at various clinics yourself, and speak to friends and family to find out their needs.

Opening a clinic Annalouise Kenny offers helpful advice on how to successfully build a medical aesthetics clinic Although the result can be highly rewarding, opening an aesthetic practice does take a lot of hard work and careful planning. Here are some simple tips to help you with the process of launching a clinic: Location – Whether this is on a high street or in a more discreet area, location is so important. If you are looking at off-high street locations you need to take into consideration that you will have to put more effort into marketing, which then needs to be included in your budget. Clients like the privacy of an off-high street clinic, but they need to know about it first; if you advertise your services sufficiently then you will encourage patients to move away from the high street. If the clinic is on the high street there will be higher overheads, but this is countered by the walkin business. Whatever location you choose, just be aware of any extra considerations you need to make and allow for these in your planning. Competition – Before you make a decision on equipment or services, ensure that you look at what your competitors are offering; what kind of clientele they are attracting; and of course their price range. This is not to undercut them, but rather to find your own demographic. If another clinic is offering low cost services and deals, it might be preferable to offer better equipment at a higher price – otherwise it’s a race to the bottom. Equipment – Do the training FIRST. Training not only supplies you with invaluable skills but also gives you the information to know what questions to ask suppliers regarding service contracts 58

and consumables. All machines have their benefits and drawbacks. You need to find one that will suit your demographic, price, location and your business as a whole. Website – A well designed, aesthetically pleasing and functional website is one of the most important factors for any new business. It is true that you get what you pay for, so with this in mind your website needs to be built on a good platform. I have never paid for SEO for the Advance website, but we always remain at the top of the results for the search term “training courses”. If someone else builds your website, make sure they give you access to it so you can update it yourself regularly. I have seen too many cases where owners are held to ransom by their website developer because they have no control over their own site. Staff – If you are going to hire staff, develop a staff manual that includes all aspects of how you want the business to be run on a daily basis. This ensures that once they commence employment they are aware of how things should be done. It also makes hiring staff much easier. The manual needs to be as in-depth as possible and include specifics such as how to answer the phone and how to greet the clients. This ensures consistency within the business. If you are sending staff on training courses, make sure the costs are built into their contract; if they leave within a certain period of time they will have to pay back anything owed for training. Treatments – So many students I meet want to know what the best treatment is. There is no single best treatment; it is the treatment that is most suitable for your Aesthetics | August 2014

Suppliers – Nowadays, clients have researched the different treatments; they are knowledgeable so you must be knowledgeable too. When asking suppliers about machines do not be afraid to ask questions. Do not just take their word for how it works – ask them to explain why it works. All reputable suppliers will offer follow up support and this is why it is so important that the supplier is UK based. If, for example, the machine breaks down and you have a lengthy appointment list, most suppliers will be willing to make necessary repairs within a day. Training – I would advise finding someone that has extensive experience in the field. Life experience is invaluable, as well as being hugely beneficial to students. Ensure that the training company you use is accredited by an official awarding body such as BTEC VTCT or ITEC. These awarding bodies ensure that the centres are of a high standard. Social Media – Google looks for people who are Google+ account holders. If you have a Google+ account you will be ranked higher in Google searches. Clients love free advice – posting hints and tips on Facebook and Twitter on how to improve your skin and body is a good example. If you don’t have time, schedule posts to go out at a certain time every week. Competitions are also worthwhile and can be run at a low cost. When I last ran a competition, the Facebook page for Advance increased in views by 500%. Targets – Decide what your targets are for the next three years. If you do not have stringent targets, you have nothing to measure yourself against. It gives you more drive. Have a treat if you reach your target, something that drives you to reach your goals. Annalouise Kenny is managing director of Advance and company director of Fitzwilliam Transformation clinic. She has worked in the industry for 12 years, working specifically with Advanced skin treatments and laser for the last seven years in America, Europe and Africa.


INTRODUCING LASER TREATMENTS INTO YOUR CLINIC Laser courses available with Advance 3 day, BABTAC course. This course is for medical practitioners who do not need NVQ level 4, potential clinic owners who are looking to have an overview of information or previously experienced laser therapists who do not have NVQ level 4 qualifications.

6 day, NVQ level 4 certificate in Laser and IPL treatments. This course is suited to the person who has an NVQ level 2 qualification and experience within the beauty industry.

9 day, NVQ level 4 certificate in laser and light treatments. This course has been designed for students who have no previous requisites. Upon completing this course you will receive a certificate in anatomy & physiology NVQ level 3, core of knowledge certificate and NVQ level 4 certificate in laser and light treatments.

For more information or to book contact Advance on info@advanceclinictrainingandconsultancy.com UK: 0845 261 3714 / +44 (0) 7885 215025 IRE: +353 (0) 860640595

Conference 2014 - Saturday 20th September 2014

Autumn Conference 2012 Royal Institute of British Architects, 66 Portland Place, London W1B 1AD

Purchase a ticket to the British College of Aesthetic Medicine Main conference takes place on: Conference 2014 from just £199.

Saturday 15th September 2012 • The conference will be held at the Royal Institute of British Architects, London and will comprise a mixture of lectures and live demonstrations • from fantastic international speakers in the main conference room. This year BCAM are also delighted to feature a parallel business programme • for practice managers. Main conference speakers include Dr Russell Emerson,

9am - 5pm followed by a gala dinner

£199 per ticket for BCAM members, (includes a fabulous lunch and coffee breaks)

Tickets for guest attending business lectures £149 (includes lunch and coffee breaks) Tickets for non BCAM members are £249

Venue: Celtic Manor Resort, Newport, Wales Professor Alex Drfeature Raj Acquilla and more... TheAnstey, evening will a superb gala dinner on the River Thames boat restaurant. Tickets for this event are just £99 perPharmacy, ticket and will include 7 x workshopsevening by Healthxchange a welcome drink, four course meal and live music.

Wigmore Medical Ltd, Merz Aesthetics and more...

Don’t miss out on this year’s BCAM Autumn event, Saturday 20th September 2014... Register Now!

Visit www.bcam.ac.uk and from the membership tab click on ‘events’

Invitation open to all. Visit www.bcam.ac.uk andSaturday from the evening Drinks reception & gala dinner on the membership tab click on ‘events’

£390 (conference fee , Saturday dinner & accommodation) £250 (conference fee & Saturday dinner)

£30

per pers per works


In Practice Marketing

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2. Identify who is about to buy

Mastering Mailchimp Marketing consultant Dan Travis explains how using email marketing effectively can help your business For me, clinics are split into two groups when it comes to their approach to marketing. There are those who use mailchimp and those who don’t. Those who are not using the email campaign service are being left behind and, in my opinion, will lose out to their competition. In terms of raising new business I find mailchimp to be measurably superior to Google as your main marketing activity and urge all my clients to dedicate time and resource to utilising it as a tool. In this article I will outline four very powerful strategies that could make an immediate contribution to your clinic’s profits. The strategies are based upon close study and the online course that I run for the aesthetics industry. By starting with these basic strategies in mailchimp, the clinic owners and staff that I have worked with are always surprised and fascinated by the results of their efforts. They are even more interested in turning these results into a process for their business that will generate profit.

1. Formulate a process As a clinic owner and/or manager, I have little doubt that you are under extreme time pressure. This is why you must invest time in creating and maintaining business processes that allow your clinic to run as efficiently as possible and will ultimately save you time and unnecessary stress. By carefully forward planning your marketing strategy, you can ensure that you are making the most of any opportunities to promote your business rather than 60

The subscribers in your mailchimp account who are most likely to buy products or services are those who have opened the most emails. You can see who these subscribers are after you have sent an email campaign. Go to the report of your campaign and click ‘Opened’. Then click ‘opens’ above the numbers until the arrow points up. The important recipients are those who have opened the same email more than twice. From the close studies that the Marketing clinic has made of this strategy, we know that those who have opened three or more times are far closer to purchase than any other group. You need to contact these individuals quickly (preferably within 12 hours) and this is what you should say:

By carefully forward planning your marketing strategy, you can ensure that you are making the most of any opportunities to promote your business missing out due to time constraints. Please remember to make time in your clinic diary to take action on the strategies I am about to outline at least once a month, even better, once a week. The sooner and more frequently you take action, the better and quicker the response. A successful campaign should have long term and short term goals and you will need to think about all aspects including the optimum dates and times to send emails to your database. When do you think they will receive the best response? Do you have a launch or specific promotions planned that need to be factored in? Although it is important to keep content fresh and current, you can draft, or at least outline, a lot of this in advance to avoid a last minute rush during a busy clinic week. Whether it is yourself or your front of house staff who will be taking day to day responsibility for sending client emails, make sure that several team members are well trained in using mailchimp to ensure that momentum does not falter due to planned or unplanned staff absence. Aesthetics | August 2014

“Hi, this is XXX from the XXX Clinic. Thanks for showing an interest in the XXX product/ service, is there anything I can do to help or any more information that you require?” This message can be sent by email, SMS or you can phone them. Some will say “No thanks, I was just looking.” But some will say “Yes, can I book an appointment”. The message may seem brief and simple but it is highly effective when aimed at this particular group of potential clients.

3. Find out who is not opening You need to know who is not opening because 75% of subscribers who do not open our mailchimp emails are not aware that they have received the email. Gmail, Yahoo and hotmail have all introduced a “Promotional” inbox. This means that Google is deciding on your behalf what are “Promotional” emails and putting them into another inbox. This can include mailchimp emails and to prevent this from happening again, you need to identify the non-openers. There are two ways to identify your non-


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Aesthetics Journal

openers. Both give you different types of information about your non-opener’s activity. The first way of identifying this group is after you have sent four emails in different campaigns. Go to ‘Lists’ then single click ‘Member Rating’ to give you the list of one and two star subscribers in ascending order. You then need to run the Export process. The other way of identifying your nonopeners is to go to “Reports” and click on “View Report” for the last campaign. Below where it says “Email Subject Lines” you will see “Activity”. Click here and click “Didn’t Open”. You need to Export this group using the Export process. You then need to create a group in Gmail called ‘non-openers’ and send them a group email (using BCC) with an interesting and non-commercial headline. You need to find ways of reaching your non-openers after every email that you send out. Just by sending your email directly via Gmail, you will bypass the promotional inbox and end up in the ‘Priority’ inbox. This means that your email stands a much better chance of being read. Unfortunately there will be a percentage of people who ignore (deliberately or otherwise) your mailchimp

Aesthetics

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emails. You need to grab their attention by writing compelling headlines – think about what they would be interested in hearing about. You can send them an SMS saying that you have sent them an email (this improves the open rate dramatically for any section of your subscribers).

4. Dysfunctional Emails Surprisingly to most clinics, identifying and communicating with the group of email addresses that failed to reach the recipient is the most productive of the four strategies. It produces an immediate result and I urge you to do this on at least a monthly basis. Start by going to your first campaign and looking at your bounced emails (it will show you this next to the ‘opens’). Export these to Gmail and label them in a new group called ‘Dysfunctional Emails’. Check which of these emails you have a mobile phone number for and send them an SMS on your phone or via txt local. Most of this group will not respond but between 10% and 20% will reply. Of these, some will book an appointment with you. Those who do reply will be highly

All Things Bright ‘n’ Beautiful

“All Things Bright ‘n’ Beautiful” BACN Conference and Exhibition Friday 3rd October BACN Conference 2014 Workshops and Exhibition Saturday 4th October Hilton Brighton Metropole Join the BACN in BRIGHTON for the not-to-be-missed event of the year! Highlights: • Impressive Friprogramme 3rd of speakers • Friday evening Dinner/Dance with tribute band October • Fantastic location

Sat 4th October

See BACN website for Programme, Exhibitors, Accommodation and more.

Hilton Brighton Metropole

Open to ALL professionals within the Aesthetic Industry

t: 01749 836328 e: info@cosmeticnurses.org w: www.cosmeticnurses.org Impressive Programme of Speakers on Friday - Hot Topics • Presentations & Demonstrations on Saturday • Friday Evening Dinner/Dance with Band • Fantastic Location • Beachfront • Shopping • Nightlife • and BRIGHTON COMEDY FESTIVAL

In Practice Marketing

responsive to your communications (including email campaigns). This is for two reasons: first, they have not received an email from you before. Second, they have expressed a direct and very recent interest in receiving information about your clinic. I hope the information above is as valuable to you as it has been to many other clinics that I have been working with in the last eighteen months. This is only part of the mailchimp strategy you need to employ to make an effective process in your business. There is much more that you can do and implement in mailchimp and your clinic’s marketing as a whole, but by learning more about the benefits that mailchimp can offer with comparatively little effort, you can make a strong start on improving your customer communication marketing. Dan Travis is director of the Marketing clinic and provides business services to clinic owners. Dan specialises in providing business education programmes for the aesthetics industry. He writes and speaks on how clinics can overcome the challenges they face and thrive in the new economy.


In Practice In Profile

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“I would like to be known for being able to help people” Karen Betts shares her experience as a leading permanent cosmetic artist, medical tattooist and trainer Karen Betts began her training aged 16. Ten years later she had opened her own salon, specialising in colour analysis and wig making. Designing and styling wigs for cancer patients was always something Karen thrived on. Providing her customers with what Karen calls the “gift of confidence,” is hugely rewarding, she says. Soon after Karen opened her salon, a close friend developed cancer and confided that one of her biggest fears was losing her eyebrows. With a tattoo parlour based in the same building, Karen had an idea. “After watching the tattooist at work, my belief was that tattooing eyebrows couldn’t be much different to drawing eyebrows on with a pencil,” she explains. Knowing that conventional tattooing wouldn’t be appropriate for creating facial features, Karen began researching alternative methods. Soon she discovered micro-pigmentation and, keen to learn more, she embarked on an educational journey to the US. “I went to San Francisco on my own, absolutely scared to death,” she says. “I went to most of the states, gaining as much knowledge as possible because at the time there was no education here in the UK.” She decided there was a gap in the market and after six months of hard work, developing techniques and writing manuals — Karen opened her first training school, Nouveau Contour, in 2001. She began training people in permanent cosmetic techniques for eyebrows, lips and eyes and later expanded into medical tattooing. Karen now works alongside numerous charities, specialising in treating cancer patients, patients with alopecia, cleft lips, burns and scarring. “I see a couple of patients a week through the Katie Piper Foundation, which I really enjoy,” she says. “As much as I’m giving back people something they’ve lost, it really makes me appreciate what I’ve got in my own life.” 62

Making her work look as natural as possible is Karen’s aim. “If it is good permanent cosmetics, people don’t even realise you’ve had it,” she explains. “Having an artistic eye is extremely important,” she says. “At Noveau Couture we have a strong educational programme where we teach trainees to be more artistic. We look at face shapes; we look at bone structure; how to create and draw eyebrows for each face. As long as they’ve been trained really well you can teach people to be more artistic.” Initial consultations with patients are vital for Karen — each patient has to complete medical consent forms. “When they come into the clinic we go through all the forms again, all the treatments available, and really get to know the person and what their expectations are,” she explains. “If we don’t feel that we can reach their expectations then we definitely don’t advise the procedure.” If she knows another specialist can achieve better results then Karen would have no qualms referring them. She explains that a patient may need laser treatment before she treats them. “I don’t ever think about doing the laser treatment myself,” she says. “I send patients to practitioners who specialise in laser. I would never take anybody’s money just because they’ve walked through my door.” Strategy, planning and structure — these are the key ingredients for running a successful business says Karen. “I go home every evening making sure I’ve planned the structure for the next day, organising what the priorities of the business are and what I need to be working on.” At the moment, there is no official body governing the regulation of medical tattooing and permanent cosmetics. Instead, Karen offers her trainees Nouveau Contour qualifications, recognised in more than twenty countries. Trainees can take a range of different courses, which all involve case studies and four levels of exams. Aesthetics | August 2014

In the future Karen hopes that she can raise awareness of how permanent make-up and medical tattooing can appear very natural. “Now I’m trying to make sure people know it’s a safe procedure, carried out by safe technicians who have been trained well.” After recently winning the Beauty Guild award for best eyelashes, designed with alopecia patients in mind, Karen says, “I see myself as a business entrepreneur and would like to be known for being able to help people, and most importantly give them back the gift of confidence.”

Q&A What is your proudest moment yet?

When I tattooed eyebrows on a woman I met through the Katie Piper foundation, she burst into tears as soon as I showed her the results. She was crying with joy. What treatment do you enjoy carrying out the most?

Breasts for medical tattooing. Giving my clients back areolas and nipples after they’ve gone through breast cancer is just like the final end to their journey. What’s the most difficult procedure you do?

Treating vitiligo. The results are not as successful as you’d like them to be because the skin type can change. In bigger areas on Caucasian skin it’s not always as effective as I’d want it to be. What advice would you give to practitioners in this field?

Practice, practice, practice; that’s the only way they’re going to stay ahead of the game and gain more confidence. They need to continue training and professional development — don’t ever just think that you’re good enough or the best, things change constantly. I change my techniques yearly, there is always scope to learn.


TRAINING WORKSHOPS TRAINING WORKSHOPS WILL BE RUNNING THROUGHOUT SEPTEMBER & OCTOBER 2014 BOOK YOUR PLACE TODAY AT silhouettetraininguk@sinclairpharma.com

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In Practice The Last Word

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Aesthetics Journal

The last word How traceable is the product you are injecting into your patient? Roseanne Aitken argues the accountability of practitioners in dealing with product traceability At the heart of the 2013 Keogh report lies the person who chooses to have a cosmetic procedure. While the vast majority of non-surgical treatment providers care deeply for the safety of their patients, are a small minority overlooking an important aspect of patient care? As Dr Patrick Bowler wrote in the Huffington Post, following the release of the Keogh report, “The entire review is about putting the patient at the heart of cosmetic treatments. Every patient has the right to be protected by legislation that makes them feel confident that they will be well looked after and safe.”1 Injectable non-surgical treatments fall under the Medical Devices regulatory product group. To provide guidance, the Medicines and Healthcare products Regulatory Agency (MHRA) recently released Managing Medical Devices (April 2014), and Devices in Practice (June 2014). The latter contains checklists for using medical devices. The Record Keeping checklist emphasises the need for recording where the medical device is from, it’s serial or batch number, and expiry date. This product traceability is a critical requirement for distributors and manufacturers as well. Regular audits by Notified Bodies on ISO certified distributors and manufacturers always include a detailed check on product traceability. Product traceability however, may well be the Achilles heel of the excellent work carried out by bodies and practitioners striving to protect the patient. When your patients give signed consent for their treatment, they do so trusting that their clinician has covered all aspects necessary for their safe care. Reputable practitioners keep accurate 64

records of product LOT or serial numbers injected into patients. This information becomes meaningless if, further back in the chain of supply, there has been a break in traceability. If an adverse event occurs, if a product recall is needed, or if the manufacturer needs to highlight safety aspects of the product, there must be no break in traceability from manufacturer to patients. The patient has no protection if such a break occurs. How could such a patient-risk situation develop? It develops hand-in-hand with a so-called ‘grey market’ of product. A grey market (or parallel market) is the trade of a product through distribution channels which, while legal, are unofficial, unauthorised, or unintended by the original manufacturer. The most common type of grey market is the sale of imported goods brought in by small import companies or individuals not authorised by the manufacturer, and who have obtained these goods from third parties. The sale of grey market goods is of concern across diverse industries, ranging from snacks and drinks to clothing and cosmetics. The concern is especially acute with medical devices. Suppliers of grey market goods sold outside authorised distribution channels have no relationship with the producer of the medical device. The manufacturer is completely unaware of where their product has ended up. For the patient, there is no traceability and no protection. The medical device grey market is substantial. Sellers of grey market goods are smart and determined, and substantial money is at stake for them. They often use the EU “free Aesthetics | August 2014

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movement” of goods rationale to support their unauthorised sales. Anything that it is legal to sell in the EU can be sold anywhere in the EU. When it comes to injectable medical devices however, this blithe free movement argument shouldn’t be applied in the same way as in the grey market of chocolates, cars and other products. Often grey market suppliers tempt clinicians with an offer of a lower priced product. If clinicians take up this offer, appearing unaware of, or even not caring about the implications of a grey market product for their patients, then who does care? Apart from the patient, it is the authorised country suppliers of the product as well as the manufacturers who care. These suppliers and manufactures ensure that all medical devices they provide to you are fully traceable. Authorised country suppliers have the clinical and sales support of the manufacturer and hold product liability insurance. Grey market suppliers have none of these and are seeking to get a free ride on the manufacturer’s good name and reputation. The waters are further muddied for the clinician by the existence of private labellers. Checking whether traceability exists may not be a simple case of looking for the name of the manufacturer on the product label. How can you, as a reputable clinician or clinic, ensure you are not purchasing grey market products and that all your treatments are fully traceable and supported by the manufacturer? The answer is to ask your local supplier for a supporting letter from the manufacturer. The letter should confirm that the individual or company from whom you are purchasing is indeed the authorised distributor of the product, and that you and your patients can be assured that the product you are using is fully traceable from source. Not only will you have the full sales and clinical support of the manufacturer, but if there is ever any potential risk to your patient you will be the first to know. Roseanne Aitken is the managing director of Medira Ltd, a company specialising in biomaterials for the skin regeneration and rejuvenation market. Roseanne has more than two decades experience in the medical device industry, working closely with Regulatory Bodies, Quality Assurance and Clinical Management in the wound healing and reconstruction segments. REFERENCES 1. Dr Patrick Bowler, Huffpost Lifestyle, UK (The Huffington Post, 24/04/2013, <http://www.huffingtonpost.co.uk/dr-pat rick-bowler/cosmetic-surgery-report_b_3145470.html> [date accessed: 14/07/2014]


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Bioptica Laser Aesthetics Contact: Mike Regan +44 07917 573466 mike.regan@bla-online.co.uk www.bla-online.co.uk Services: Core of Knowledge Training and Laser Protection Adviser (LPA) Services

Sound Surgical (UK) LTD Contact: Raj Jain +44 7971 686114 rjain@soundsurgical.com www.SoundSurgical.co.uk

Medical Aesthetic Group Contact: David Gower +44 02380 676733 info@magroup.co.uk www.magroup.co.uk

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Skin Geeks Ltd +44 01865 338046 info@skingeeks.co.uk www.skingeeks.co.uk

Hamilton Fraser Contact: Suzanne Dunleavy +44 0845 3106 300 cosmetic@hamiltonfraser.co.uk www.hamiltonfraser.co.uk

t ThermaVein Contact: Catherine Fuente +44 0161 826 3404 info@thermavein.com www.thermavein.com

Merz Aesthetics +44 0333 200 4140 info@merzaesthetics.co.uk

v WELLNESS TRADING LTD â&#x20AC;&#x201C; Beautylight Technical Services Ltd Contact: Jane Myerson Contact: Ashaki Vidale UK Mesoestetic T: 0208 741 1111 T: 0208 741 1111 E: sales@ellipseipl.co.uk Contact: Adam BirtwistleW: www.ellipseipl.co.uk E: ashaki@ellipseipl.co.uk W: www.technicalsupport.ellipseipl.co.uk/ +44 01625 529 540 Services: UK distributor of IPL & Laser Services: Onsite service & repairs of systems, IPL & Laser training courses aesthetic systems. UK agent for Ellipse contact@mesoestetic.co.uk and technical support IPL & Venus Radio Frequency systems www.mesoestetic.co.uk Services: Cosmeceutical Skincare Treatment Solutions, Cosmelan, Antiagaing, Depigmentation, Anti Acne, Dermamelan TECHNICAL SUPPORT

Healthxchange Pharmacy Contact: Steve Joyce +44 01481 736837 / 01481 736677 SJ@healthxchange.com www.healthxchange.com www.obagi.uk.com

Boston Medical Group Ltd Contact: Iveta Vinklerova +44 0207 727 1110 info@boston-medical-group.co.uk www.boston-medical-group.co.uk

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l Candela UK Ltd Contact: Michaela Barker +44 0845 521 0698 michaelaB@syneron-candela.co.uk www.syneron-candela.co.uk Services: Adviser (LPA) Services

Laser Physics +44 01829773155 info@laserphysics.co.uk www.laserphysics.co.uk

Carleton Medical Ltd Contact: Nick Fitrzyk +44 01633 838 081 nf@carletonmedical.co.uk www.carletonmedical.co.uk Services: Asclepion Lasers

Lawrence Grant Contact: Alan Rajah +44 0208 861 7575 lgmail@lawrencegrant.co.uk www.lawrencegrant.co.uk/ specialist-services/doctors.htm

Chromogenex Contact: Lauren Roberts +44 01554 755444 lroberts@chromogenex.com www.chromogenex.com Service: Laser System Manufacturer

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Lifestyle Aesthetics Contact: Sue Wales +44 0845 0701 782 info@lifestyleaestheics.com www.lifestyleaesthetics.com

Intense Pulse Light (I2PL) & Laser Systems

delivering the promise Contact: Jane Myerson

Venus Freeze E: sales@ellipseipl.co.uk Contact: Jane Myerson W: www.venusconceptuk.co.uk Services: UK distributor 741 of Venus1111 +44 0208 Freeze and Swan Radio Frequency (RF) &sales@ellipseipl.co.uk Magnetic Pulse (MP) systems www.venusconceptuk.co.uk Services: Venus Freeze and Swan Radio Frequency (RF) & Magnetic Pulse (MP)2 systems T: 0208 741 1111

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n Neocosmedix Europe Contact: Vernon Otto +44 07940 374001 www.neocosmedixeurope.co.uk vernon@neocosmedixeurope.co.uk

Zanco Models Contact: Ricky Zanco +44 08453076191 info@zancomodels.co.uk www.zancomodels.co.uk

LONDON SALES REPRESENTATIVE OPPORTUNITY Join a dynamic company rapidly expanding in the UK medical aesthetic market. Work with tried and tested products all backed by published science! The successful candidate should be, proactive and have a proven track record of sales. The ideal candidate will receive a competitive basic package and excellent career prospects.

Aesthetics | August 2014

Please send your CV and covering letter to aestheticsrecruitment@gmail.com


Not all HA dermal fillers are created equal. Intelligent manufacturing technology creates a variable density gel1 resulting in... Optimal tissue integration2 Greater dermal compatibility3 Superior cosmetic results4 High patient satisfaction5 Contact Merz Aesthetics NOW and ask for Belotero .

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

OPTIMAL

TISSUE

www.belotero.uk.com

INTEGRATION

Injectable Product of the Year 2013

1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014


Profile for Aesthetics Journal

Aesthetics august 2014  

Lifting and Tightening

Aesthetics august 2014  

Lifting and Tightening