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VOLUME 2/ISSUE 9 - AUGUST 2015

Nasolabial Folds CPD Dr Souphiyeh Samizadeh offers her insight into treating the nasolabial folds

Filler Retrospective Practitioners discuss the evolution and modern-day portfolio of fillers

Eczema Dr Sadequr Rahman on the aetiology and treatment of this common skin condition

Discovering SEO Gavin Griffiths explains how to enhance your online presence


Contents • August 2015 06 News

The latest product and industry news

14 On the Scene

Out and about in the industry this month

16 News Special: New Technology

Special Feature Filler Retrospective Page 21

We discover the latest apps and gadgets for patient wellbeing

CLINICAL PRACTICE 21 Special Feature: Filler Retrospective

An investigation into the evolution and modern-day portfolio of fillers

27 CPD Clinical Article

Dr Souphiyeh Samizadeh provides insight into her technique for treating the nasolabial folds

33 Bell’s Palsy Dr Nestor Demosthenous presents a case study of using threads to

In Practice Media Profile Page 56

improve the appearance of a Bell’s Palsy patient

37 Sun Protection

Balsam Alabassi and Lorna Bowes explain how suncreen is best used to protect skin from UV radiation

40 Non-Surgical Rhinoplasty

Clinical Contributors

Dr Simon Ravichandran outlines the use of hyaluronic acid to treat nasal deformities

Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine.

44 The ‘H-Lift’

Mr Dalvi Humzah and Anna Baker share their technique for rejuvenating the mandibular region

Dr Nestor Demosthenous obtained his medical degree and BSc Hons Neuro from the University of Edinburgh in 2006. He is an experienced aesthetic practitioner and has completed advanced and masterclass training in aesthetic medicine.

47 Eczema

Dr Sadequr Rahman highlights effective treatment options for this common skin condition

50 Advertorial: Lumenis

Dr Firas Al-Niaimi invites you to find out why the Lumenis UltraPulse® is his laser of choice

52 Advertorial: Skinade

Dr Amanda Wong-Powell explains why she recommends this collagen drink for rejuvenation from within

53 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 54 Discovering SEO

Gavin Griffiths on how to master the basics of search engine optimisation

56 Media Profile Julia Kendrick provides key tips to help you develop your profile as a spokesperson

58 Mixed Marketing

Amanda Cameron outlines how to stay one step ahead when developing your business

61 Advertorial: Observ UK

Observ offers you the chance to discover more about its visual imaging system

62 In Profile: Dr Roy Saleh

Aesthetics Awards Lifetime Achievement winner Dr Roy Saleh reflects on his career in aesthetics

64 The Last Word: Sun Awareness

Mr Apul Parikh argues for the importance of public health awareness campaigns around sun safety

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Lorna Bowes is an aesthetic nurse and trainer with an interest in dermatology. She was formerly a committee member of the Royal College of Nursing Aesthetic Nurse Forum and a founding member of the British Association of Cosmetic Nurses. Balsam Alabassi is a pharmacist with degrees in both pharmacy and pharmacology. With qualifications in advanced skincare and skin rejuvenation, she writes blog posts on maintaining health and wellbeing. She is currently studying for a cosmetic science diploma. Dr Simon Ravichandran is as an ear, nose and throat surgeon. He established the Scottish Advanced Aesthetic Training Programme with Glasgow University, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners. Mr Dalvi Humzah is a consultant plastic reconstructive and aesthetic surgeon, with a BSc in anatomy. He is the lead tutor for the award-winning anatomy teaching programme, Facial Anatomy Teaching. Anna Baker is a dermatology and cosmetic nurse practitioner. She runs the nurse-led Medicos Rx Skin Clinic at The Nuffield Health Hospital in Cheltenham, and is the coordinator for Facial Anatomy Teaching. Dr Sadequr Rahman studied medicine at King’s College London. He has a special interest in dermatology, and offers patient advice on nutrition, weight management and confidence building.

NEXT MONTH • IN FOCUS: Rejuvenation • CPD: Using pulsed dye lasers • Aesthetics Awards finalists announced • Building a women’s health clinic

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Editor’s letter The eighth month of the year is upon us already and many aesthetic professionals will be taking some time to relax and enjoy a well deserved break; I wonder if any of you are reading this issue while you’re away? If so, tweet us a picture Amanda Cameron via @aestheticsgroup and you could see yourself Editor in next month’s journal! We tend to think of August as a month to slow down while many of our patients are away on holiday; yet, August is usually the precursor to our season beginning. Conferences and launches start to take place in September and we begin to see new trends for the coming months making their name. We always enjoy hearing about what our readers are doing in the industry, so remember to keep us up-to-date with any events you’re planning over the next few months. During the summer, I tend to walk rather than use public transport in London, so, lately, I have appreciated not only the beautiful open spaces, but some of the great architecture we so often miss in the rush. Good structure and form are of course extremely relevant to aesthetic practice and good practitioners are often referred to as ‘artists’ or ‘architects’ thanks to their abilities to augment and construct beautiful features. This notion is particularly relevant in August’s issue, in which

our focus is augmentation. To complement this we have produced an informative Special Feature on the history of dermal fillers (p. 21), while Dr Souphiyeh Samizadeh has written a comprehensive and engaging CPD article on treating nasolabial folds (p. 27). Although the summer will sadly come to an end this month, it is vital that we continue to advise patients of how to manage the dangers of the sun. As such, independent nurse prescriber Lorna Bowes and pharmacist Balsam Alabassi have put together an excellent article on using sunscreen, while Mr Apul Parikh argues for more sun awareness in the UK. It never ceases to amaze me that a considerable proportion of the London population take their clothes off at the mere glimpse of sunlight, while in hotter countries this habit does not seem to exist. Are we really less well-educated about the dangers of the sun, despite all the rise in skin cancers? Perhaps we should take Mr Parikh’s advice and look to adopt a similar awareness campaign to that used in Australia – to find out more turn to p. 64. Last, but certainly not least, I hope you’re all looking forward to the Aesthetics Awards 2015. Finalists will be announced in next month’s issue, so make sure you don’t miss it. As always, we love to hear your latest news, so don’t forget to tweet us @aestheticsgroup or email editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. 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).

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 and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Awards

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Launch Dr Askari Townshend @Dr_AskariT First day of trading at @ASKINOLOGY! Had our first journalist and more in the diary. #collagencocktails went down a treat.

#Training Souphiyeh Samizadeh @drssamizadeh Thank you @drtapanp for an excellent day of training at the lovely Phi clinic #allergan

#Hyperpigmentation BJD @BrJDermatol BAD Annual Meeting – Comprehensive overview of mechanisms and treatment of hyperpigmentation from Dr Tamara Griffiths and colleagues #BJD

#Industry Nigel Mercer @NigelMercer Scottish Cosmetic Interventions Expert Group Report published today. Some fresh air from north of the border. Well done Scotland!

#Advice Petra Boynton @DrPetra Really enjoying #tipsfornewdocs. From a patient perspective – say #hellomynameis. Be kind. Be tolerant. Be clear. Be prepared to change things.

#Education Dr Kannan Athreya @drathreya Postgraduate Diploma in Dermatology Graduation @drathreya #skinsmart #Essex #skinhealth #PrivateGP #CosmeticDoctor

#PatientService Sharonbennettskin @sharonbennettuk In clinic people forget what you said or did but never forget how you made them feel! #aesthetics #skinhealth @BACNurses #customerservice

#Women Dr Stefanie Williams @DrStefanieW The most common inspirations for Women to improve their appearance. #beauty #aesthetics #dermatology #confidence

Simon Evans to entertain at the Aesthetics Awards It has been confirmed that British comedian Simon Evans will entertain guests with a comedy set at the Aesthetics Awards 2015. Evans, who has performed at comedy festivals across the UK and appeared on numerous television shows, including the Michael McIntyre Roadshow, will perform his set before hosting the presentation of the awards, after guests have enjoyed a three-course sit down dinner. It has also been announced that voiceover artist Peter Dickson, best known for his work as the X-Factor announcer, will once again delight guests by compering the ceremony. Of last year’s Aesthetics Awards, aesthetic business consultant Wendy Lewis said, “The whole Aesthetics team did a fantastic job organising the evening and a good time was had by all. The entire event has elevated the UK medical aesthetics industry to a new level, and the winners should be very proud of the honour bestowed on them.” This year’s event will take place on December 5 at the Park Plaza Westminster Bridge Hotel in central London, where guests will enjoy a networking reception, threecourse dinner and entertainment. The presentations of the awards will then begin, before guests have the chance to enjoy music and dancing late into the night. To book your ticket, visit www.aestheticsawards.com Industry

AestheticSource adds Skin Tech range to its product portfolio Skincare product range Skin Tech has been acquired by AestheticSource after its previous management, Euromedical Systems, retired from the aesthetic industry. Skin Tech offers a full range of peeling depths, from epidermal up to reticular dermis peels. Easy TCA, the brand’s most well-known product and a medium-depth chemical peel, is claimed by Skin Tech to be the safest and most effective chemical peel. The range of products is composed of two main groups; peels aimed at medical professionals and daily care creams for patients to apply after peeling treatments. “Skin Tech has been leading the way in medium and deep peeling since its launch in 1996. With a full range of peels from superficial to deep, and supporting home-care products, Skin Tech represents an excellent and appropriate addition to the AestheticSource portfolio – innovation in aesthetics delivered to you.” Bowes added, “Over the next few months we will re-launch the Skin Tech brand in the UK and introduce a series of exciting new additions to the range.”

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Aesthetics

Regulation

Conference

Westminster Briefing on the Duty of Candour to be held later this year An opportunity to discuss the new guidelines on maintaining the Duty of Candour is set to take place on November 12. Earlier this year, the Care Quality Commission (CQC) published an update to its Duty of Candour, stating that medical professionals are responsible for being honest and transparent with patients and their families when mistakes occur. Medical professionals have been invited to engage with a panel of experts and peers from across the NHS and private medical sector in order to explore how to fulfil new responsibilities under the Duty of Candour, improve communication with patients and create an open and honest working environment. Additional key issues to be addressed in the briefing include the legal implications of the new duty, understanding what the Duty of Candour will mean for your organisation, and how to put effective systems in place to detect failings early. Statistics

ISAPS announces more than 20 million cosmetic procedures were performed in 2014 The International Society of Aesthetic Plastic Surgery (ISAPS) has released figures stating that more than 20 million surgical and non-surgical procedures were performed in 2014. The organisation, which has more than 2,700 board-certified aesthetic plastic surgeon members in 95 countries, conducted the report to determine countries where most procedures were performed throughout the year. The top most common non-surgical procedures performed were botulinum toxin treatments, with 4,830,911 treatments recorded, followed by hyaluronic acid (2,690,633 treatments) hair removal (1,277,581), chemical peels (493,043) and laser skin resurfacing (480,271). The US ranked first for most procedures performed, out of the top five countries, with 24.4% of non-surgical procedures performed. Training

Courthouse Clinics and Harley Academy launch partnership The Harley Academy and treatment provider Courthouse Clinics have established a nationwide training initiative to strengthen standards in cosmetic treatments. The partnership will enable students to undergo intensive training at the Harley Academy before embarking on a practical placement with the clinic. The academy, which was established by the British College of Aesthetic Medicine (BCAM) educational executives Dr Kam Singh and Dr Tristan Mehta, is a training organisation for aspiring aesthetic and medical professionals to further refine their skills and abilities. Speaking of the initiative, medical director of Courthouse Clinics Dr Robin Stones, said, “Courthouse Clinics have agreed to link to the new academy and will offer theoretical training based in our training suites. It will provide practical support by allowing candidates to observe toxin and filler treatments and then supervise the candidates as they perform the treatments. This is another important step towards improving standards in the industry.” The initiative comes as new regulations recommend for students to undergo a placement supervised by an experienced professional in a Care Quality Commission (CQC) approved clinic.

Registration now open for BCAM conference The British College of Aesthetic Medicine (BCAM) has announced that online registration for its annual conference is now open. To be held on September 26 at the Church House Conference Centre in Westminster, the event will consist of lectures and live demonstrations from both national and international guest speakers, including aesthetic practitioners Dr Nick Lowe, Dr Amanda Wong-Powell and Dr Ravi Jain. “I am thrilled to be invited to speak at the upcoming BCAM Conference,” said Dr Amanda Wong-Powell, who will be talking about body contouring at the event. “I am looking forward to be able to talk about the latest developments in body contouring; it is one of the most dynamically changing areas in aesthetic medicine. It will be a great opportunity to share my experiences with my peers and colleagues.” Other topics to be covered during the conference will include cosmeceuticals with cosmetic surgeon Mr Paul Banwell, a discussion on the use of injectable fillers for anti-ageing with former British Association of Aesthetic Plastic Surgeons president Mr Rajiv Grover, and live demonstrations of injection techniques using a cadaver with Mr Philippe Kestemont and Dr Beatriz Molina. Speaking of the conference, Dr Molina, who is also BCAM’s director of conferences and host of the conference, said, “I’m thrilled and honoured to be asked to host this event – it’s a privilege to play a pivotal role in this conference. I’m looking forward to sharing further information about the exciting speakers and workshops which will be offered to delegates.” The annual conference caters for aesthetic practitioners across the industry, offering delegates the chance to attend both clinical and business lectures, catering for numerous industry areas across the board. The aim of the event is to advance the effective, safe and ethical practice of aesthetic medicine, with a focus on leadership, continued education, support, professional development and maintaining of high standards. Dr Molina continued, “This will be a fantastic opportunity for practitioners to meet, share experience and enjoy hearing from experts in various fields of relevance to our profession and our businesses.” The conference will close with a networking drinks reception in the evening, following a final question and answer session with various conference speakers. Visit www.bcam.ac.uk for more information.

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Business

3D-lipo announced as ACE 2016 networking sponsor Aesthetic device manufacturer 3D-lipo has been announced as the Aesthetics Conference and Exhibition (ACE) 2016 networking sponsor. On the Friday evening of the two-day event, to be held at the Business Design Centre, Islington, on April 15-16, attendees will be invited to a drinks reception to network with a variety of aesthetic professionals in the industry and build key connections. Roy Cowley, managing director of 3D-lipo, said, “3D-lipo is thrilled to be sponsoring the networking reception at the Aesthetics Conference and Exhibition in 2016. This will be an ideal opportunity for delegates to network and make those connections which are so vital to our industry, and we look forward to meeting those who are new to the industry, as well as old friends and fellow colleagues.” The conference, which last year received more than 1,800 delegate visits, is an excellent opportunity for aesthetic professionals to meet fellow practitioners, suppliers and trainers in one place, with the chance to attend a huge range of innovative and educational lectures, masterclasses, expert clinics and business sessions.

Transform bought out of administration German-listed investment company Aurelius Group has acquired cosmetic surgery specialist Transform after it went into administration in June 2015. Transform has 26 clinics and two hospitals across the UK. Former managing director Patricia Dunion left her post in November 2014, with business consultant Thorsten Sprank stepping in as the company’s sole active director. A spokesperson, who has confirmed the acquisition, said, “Transform remains committed to its patients and these changes will see the new legal entity TFHC Ltd, which trades as Transform, honour all existing aftercare commitments, extended warranties and ensure deposit protection. Transform will continue to deliver its marketleading surgical and non-surgical cosmetic procedures to patients across the UK.”

Education

Radiofrequency

TLC to launch training courses The Lovely Clinic (TLC) in London is to launch training courses for practitioners, covering a wide range of aesthetic treatments. Led by aesthetic practitioner Dr Sarah Tonks, sessions will be targeted at practitioners from beginners to advanced in areas such as dermal fillers, thread lifting and toxins, as well as incorporating skincare and anti-ageing seminars and wellness medicine tutorials. Practitioners will have the opportunity to tailor a selection of modules to suit their needs, and the option to combine modules for an assessed certification. Courses will begin at the end of September. Regulation

Private clinics in Scotland to be regulated next year The Scottish Government has announced new legislation which will regulate all private healthcare services and non-surgical cosmetic interventions. The step for regulation has been taken following recommendations from the Scottish Cosmetic Interventions Expert Group which was set up by Scottish ministers at the beginning of 2014. The group proposes that professionals must keep up to date with latest training, all providers must have sufficient insurance and that a transparent complaints systems must be in place. It’s hoped that by introducing a sound system of regulation and inspection, there will be fewer instances of complications after procedures – particularly those which can potentially leave the patient with lasting injuries. Sharon Bennett, chair of the British Association of Cosmetic Nurses, said she “fully supported” the moves to develop frameworks and standards for the delivery of non-surgical cosmetic procedures.“We believe that patient safety should be at the centre of any proposals agreed, and that patients are assured at all times of the best medical care that is available from medical professionals who are accountable to their own governing councils.” The news comes amid new research by YouGov that shows that only 23% of Scots have a fair amount of confidence in non-surgical cosmetic procedures. Maureen Watt, Scottish minister for public health, said, “Cosmetic procedures, both surgical and non-surgical, have increased massively in popularity over the last few years. As this research shows, many people are not aware that there is no regulation of independent clinics who provide non-surgical cosmetics procedures.”

BTL Vanquish receives FDA clearance for circumferential reduction Global device manufacturer BTL Aesthetics has announced that its Vanquish device has been cleared by the Food and Drug Administration (FDA) for non-surgical circumferential reduction of the abdomen. Of the announcement, Dr David McDaniel, dermatologist and investigator of high-tech devices for non-invasive body contouring, said, “FDA clearance of Vanquish is a significant step forward in providing the newest treatment option for body slimming and shaping.” The system, which has been FDA-cleared for deep-tissue heating, uses a panel array that emits selective radiofrequency energy with a larger spot size to treat the core in one application. The high-frequency energy field created by the technology aims to target the thermal effects into the fat layer for contouring and waistline reduction, while protecting the surrounding tissue. Andrea Morrison, BTL’s director of clinical development, said, “FDA clearance of BTL Vanquish marks a defining moment in our journey to provide physicians and their patients an elegant treatment option to target fat cells and bring about a reduction in the waist circumference.”

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Topical

Lynton presents new post-laser serum Lynton Lasers has introduced its new post-laser skincare range in the UK. The skincare range aims to provide effective recovery for those patients who have undertaken laser or intense pulsed light (IPL) treatments, and consists of two products, LIGHT SOOTHE and LIGHT PROTECT. LIGHT SOOTHE is a recovery serum to be used post-treatment, aiming to cool, moisturise and stimulate cell regeneration for optimum results. This is then followed with LIGHT PROTECT, an SPF, to ensure optimal dermal protection from UV radiation, which the company claims is crucial after any laser intense pulsed light treatment. “LIGHT SOOTHE is exactly what we and all other laser practitioners around the world have been waiting for,” said Lynton Clinic clinical manager Kirsty Turnbull. She continued, “Our clients love feeling like they are doing something pro-active post-treatment to enhance results and aid healing, and, as an added benefit, it’s also become an additional revenue generator for all our aesthetic treatments.” Sun protection

Murad launches Invisiblur Perfecting Shield SPF30 Professional skincare range Murad has added a new noncomedogenic formula to its collection that utilises invisible sunscreen technology. Invisiblur Perfecting Shield SPF30 aims to offer protection from both UVA and UVB rays, as well as treat the visible signs of ageing, blurs and imperfections. According to the company, ingredients, such as barley, aim to lock in moisture for optimal hydration. The combination of ingredients, which include shiitake mushroom peptides and sunflower extracts, aims to reduce the appearance of fine lines and wrinkles. Dr Howard Murad, founder of the company, said, “It’s imperative to have a daily skincare routine which consists of treating, moisturising and protecting the skin. We developed Invisiblur Perfecting Shield SPF30 to save time for the busy person and give them the benefits of all these in one step.”

Aesthetics

Vital Statistics Psoriasis most commonly appears between the ages of 15 and 35 (National Psoriasis Foundation)

9.4%

Acne

is estimated to affect 9.4% of the global population (British Journal of Dermatology)

75% of women do not believe that their body responds positively to exercise (Bausch + Lomb)

When surveyed, only 2% of people feared being judged negatively for having plastic surgery (RealSelf)

More than 85% of patients treated with Botox reported looking younger than their actual age (Dermatologic Surgery)

Light

Body Boost Bed receives CE mark A light-based therapy that aims to treat a range of aesthetic concerns has been granted a CE mark. The Body Boost Bed, which uses LED lights to emit a range of frequencies with no heat, was designed in Australia to be used in clinics for, amongst other patient concerns, skin firming, treating cellulite, encouraging vitamin D production and boosting collagen. Following four years of development, the Body Boost Bed’s creators claim that the device is most effective for treating muscle and tissue disorders by promoting regenerative metabolism at a cellular level. The Body Boost Bed is available now via Beam Supreme.

30%

of women named love handles as a key troublesome area of the body (Bausch + Lomb)

1,277,581

hair removal treatments were performed worldwide in 2014 (International Society of Aesthetic Plastic Surgery)

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Events diary 19th – 23rd August 2015 American Academy of Dermatology Summer Meeting, New York www.aad.org/meetings/2015-annualmeeting/general-information

17th – 18th September 2015 Beyond Aesthetics, Manchester www.beyondaesthetics.org.uk

25th – 26th September 2015 F.A.C.E2F@ce conference 2015, Cannes www.face2facecongress.com/en

26th September 2015 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

3rd October 2015 British Association of Cosmetic Nurses Conference, Birmingham www.bacn.org.uk/events/bacn-annualconference-exhibition

5th December 2015 The Aesthetics Awards 2015, London www.aestheticsawards.com Industry

Practitioners divided over GMC’s recommendation A survey conducted by Hamilton Fraser has indicated that there is a clear division on the General Medical Council’s (GMC) proposed four week cooling-off period before undergoing surgery. Of Hamilton Fraser’s customers surveyed, slightly more practitioners disagreed with the GMC’s recommendation that patients should spend time thinking about whether or not to undergo surgery, with 53% saying ‘no’ compared to 47% who said ‘yes’. It is hoped that the recommendation will help patients who are unsure about having treatment, as well as protect them from hard-pressure sales tactics. According to Hamilton Fraser, however, some practitioners feel that the cooling-off period wouldn’t work for all types of procedures; fearing that non-surgical clinics would become obsolete in such circumstances. Other practitioners argued that patients will have spent a significant amount of time considering treatment options so a cooling-off period was unneccesary. The company claimed that the consensus indicated that a cooling-off period was necessary for more invasive treatments, but not for simple cosmetic ones.

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Clinic

New clinic to offer advanced aesthetic skin treatments New clinic ASKINOLOGY has opened its doors to patients in Leadenhall Market, London, for advanced aesthetic treatments and skincare. The new clinic, set over four floors, has been launched by aesthetic practitioner Dr Askari Townshend following his previous experience of owning a clinic and working with one of the largest clinic chains in the UK, sk:n. “I’ve felt ready to open a larger London clinic for some time,” said Dr Townshend. “I’ve seen the way people view and want to access aesthetic services slowly change over my 10 years in the industry, and wanted to ensure that I responded to that with something completely new. After two years in the planning, I’m really excited to have finally opened the doors to ASKINOLOGY.” The clinic is what Dr Townshend describes as the UK’s “first premium facial and makeup bar”, offering a designer cosmeceutical boutique, an aesthetic and laser clinic, and training space, each dedicated to the improvement of skin health. Acne

Phototherapy cream claimed to kill acne at the root Startup company Sebacia has created a photosensitive cream that can be used in conjunction with hair removal lasers to potentially kill acne at its root. The cream contains gold and silica-based microparticles that are activated by the light during hair removal laser treatment, which penetrates the follicles and reduces the activity in the oil-producing sebaceous glands in the skin. CEO Anthony Lando said, “It’s a quick procedure that can be done by a mid-level healthcare worker or physician’s assistant. Clinical trials in Europe have shown 60% to 70% improvement in acne six months after the therapy.” The topical cream uses photothermal particles and the therapy involves three half-hour procedures over the course of 10 days. The US startup company now plans to move its acne treatment through clinical trials and is hoping for Food and Drug Administration (FDA) approval by the second half of 2016, as well as a CE mark by the fourth quarter this year. Décolletage

FDA clears non-invasive décolletage treatment The Food and Drug Administration (FDA) has approved the nonsurgical ultrasound treatment Ultherapy for the treatment of lines and wrinkles on the chest. It comes as a poll, consisting of 2,000 women in the UK, indicated that 40% agreed that the décolletage is the most noticeable sign of ageing, followed by wrinkles (29%), jowls (15%) and loss of collagen and firmness of the skin (14%). Dr Tracy Mountford of Cosmetic Skin Clinic and founding member of the British College of Aesthetic Medicine, said of the treatment, “Ultherapy gives a really swift and impressive lifting and tightening effect which smoothes the wrinkling in the chest.” She continued, “We can combine Ultherapy with laser technology for people who are significantly sun-damaged to give optimum results in both lift, firmness and skin quality.”

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Aesthetics

Research

New non-invasive skin rejuvenation treatment could avoid scarring A new approach to skin rejuvenation that uses pulsed electrical fields (PEF) aims to reduce the chance of undesired side effects when rejuvenating skin. The non-invasive technology, developed at Massachusetts General Hospital (MGH), aims to avoid scarring and altered pigmentation by only affecting cells, rather than the whole tissue during treatment. During recent trials using an animal model, MGH reported that PEF removed skin cells without affecting the supporting extracellular matrix, eventually leading to renewal of the skin surface. Up to two months after treatment, PEF induced changes in skin thickness and blood supply, and collagen density had returned to the pre-treatment characteristics of healthy young skin. Dr Martin Yarmush, director of the MGH Center for Engineering in Medicine, said, “Our results show that the procedure is safe, does not lead to scarring and increases skin metabolism and cell proliferation.” Sun protection

Skin specialists warn against #SunburnArt online trend Skin specialists are warning the public to avoid participating in the new #SunburntArt trend on social media. “The sunburn art trend is an incredibly dangerous practice,” said consultant dermatologist Dr Anjali Mahto, adding, “Reddening of the skin is a sign of damage to skin cells or keratinocytes.” The new trend, which features social media users posting images of their bodies with artistic designs created using sunscreen, and evident burning around the area, has been condemned as dangerous, with the potential to increase the risk of skin cancer. Dr Mahto continued, “There is enough evidence to show that a person’s risk of skin cancer increases with sunburn and there is no doubt these individuals are putting their health at risk.” Industry

Victims of faulty breast implants ordered to pay back compensation More than 1,000 women worldwide who received compensation following the PIP breast implant scandal in 2010 have been ordered by a French appeals court to pay back the money. The court ruled that German product-testing firm Technischer Überwachungs-Verein (TUV), that was sued as a result of the issue, is not liable for the faulty products. Around 100 British women suffered health problems due to the faulty implants leaking industrial-grade silicon into their bodies. An interim payment was paid to the women in 2013 of £2,500, pending a full assessment of their condition. Jan Spivey, one of the British women who sued TUV, said, “It’s so cruel to put this pressure on us after what we’ve been through. We have received no help or support from anyone. We’ve just been abandoned and we have had to fight every step of the way.” The French appeals court said the firm had “committed no error engaging their criminal responsibility” in certifying the implants as safe while they were later found to be faulty. TUV maintains its job was not to test the actual implants as they were only tasked with inspecting the manufacturing process.

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Dr Sarah Tonks, Medical Director Why have you decided to start training individual practitioners? I was getting a lot of requests for thread lifting training, so I decided to start running my own sessions. Current training for threads often just covers the very basic process, but getting great results with threads requires a combination of different gauges and designs. There is little knowledge of this in the UK, so I wanted to bring something to the market that would equip practitioners with the confidence to select the appropriate tools for the job and expand their current practice.   What type of course will you be offering? We will be offering a wide range of in-depth sessions from beginner to advanced training in toxins, dermal fillers and thread lifting, including all new techniques; through to dermatology days, chemical peel overviews, skincare ingredient seminars, anti-ageing and wellness medicine tutorials. We aim to provide practitioners with a comprehensive choice of modules covering all aspects of aesthetic medicine and health and wellness so they can tailor their selection to their individual learning needs. What makes your courses different? The sessions will be modular, meaning it will be possible to combine them together to gain an assessed certification. Delegates will be confident that they have all the necessary knowledge and tools to tackle tricky aesthetic cases.   What else is new for TLC? I am aware that it can be confusing to differentiate the thread brands on the market, and there are products of mixed quality. We are now offering an exciting portfolio of branded threads making the choice of product much easier for the clinician and more accessible for the patient. We also carry a range of materials and provide comprehensive training on how to use them. Thread lifting can have more complications than basic injectables, so it is important to ensure one is properly trained. Thankfully, awareness of thread lifting is growing in the public domain and is becoming a real growth area at the moment.   Courses will commence at the end of September in London. This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Dermal filler

Restylane Lyft receives FDA approval for cheek augmentation The Food and Drug Administration (FDA) has approved Restylane Lyft with lidocaine for cheek augmentation. The injectable gel aims to increase volume and smooth facial wrinkles, as well as correct age-related mid-face contour deficiencies. In a recent study, researchers observed that almost 90% of the 200 patients treated with Restylane Lyft displayed improvement in fullness in the right and left mid-face areas at two months into the clinical trial. More than half of the patients maintained improvement for over 12 months. Common adverse side effects to the product included tenderness, redness, bruising, swelling and itching, with most of these resolving themselves within two weeks. “Achieving natural-looking lift in the cheek area is one of the most common requests that I receive from my patients,” said clinical trial investigator Dr Robert Weiss of MD Laser, Skin and Vein Dermatology in Maryland, US. “The results of this clinical trial show that Restylane Lyft can provide an effective option for patients when they desire lift – not just volume – in their cheeks.” Scarring

Science of Skin to launch natural scar cream with green tea extract Skincare manufacturer Science of Skin is to launch a natural-based anti-scarring cream later this month which utilises green tea extract. Solution for Scars is a fragrance and paraben-free product that has been designed for application once the wound has been closed, and aims to minimise the appearance of scars before they establish. Research on the green tea extract was led by scientist Dr Ardeshir Bayat and Mr Douglas McGeorge, former president of the British Association of Plastic Surgeons. Dr Bayat, who wanted to formulate a solution that combines the best of science with natural ingredients, said, “In contrast to the treatment options on the market, our formula induces a completely new outcome for the appearance of scars”. The company states that the cream is best adapted for surgery scars, stretch marks and post-laser surgery scars. Sun protection

Survey suggests that sunscreen labels may confuse consumers A survey conducted by the Journal of the American Medical Association (JAMA) has suggested that despite recent labelling changes mandated by the US Food and Drug Administration (FDA), more than half of participants still do not understand sunscreen terminology. The study, which surveyed 114 people in the US over three months, explored sunscreen behaviour and the understanding of language commonly used on sunscreen labels. It was found that more than half of participants (51%) did not understand the definition of SPF value, and just 55.3% were able to correctly identify the amount of sunscreen needed to cover the entire body in order to achieve the advertised level of sun protection. Other results indicated that although 81.6% understood that sun avoidance is superior to sun protection in preventing skin cancer, participants who cited a higher SPF value as an important factor in sunscreen protection were less likely to answer this question correctly. Of the terminology, less than 40% were able to identify the correct terminology that indicated how well a sunscreen protected against skin cancer, with 22.8% understanding terminology for sunburn protection and 7% for photoageing. The study concluded, “There is an ongoing need for physicians to educate their patients about the need for protection against both UVA and UVB radiation in preventing skin cancer and sunburns.”

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News in Brief Unilever set to acquire Dermalogica Multinational consumer goods company Unilever is to acquire professional skincare brand Dermalogica. Dermalogica offers both a range of home-use products, as well as a specialist offering for professional skin therapists. Its products aim to address hyperpigmentation, acne, ageing and sensitive skin, as well as other skin problems. proto-col introduces Collagen Shot British skincare brand proto-col has launched a new oral collagen shot claiming to visibly reduce wrinkles and increase skin elasticity in four weeks. Taken daily, Collagen Shot uses 5000mg of VERISOL Bioactive collagen peptide – the closest match to human DNA. The company states it is the only source of collagen hydrolysate scientifically proven to repair and restore collagen within the body, and has been approved by the World Health Organisation as safe for consumption. Lumenis to be acquired by XIO Group Energy-based technology manufacturer Lumenis has entered into a definitive agreement with XIO Group for its acquisition, agreed at approximately $510 million ($14.00 per share in cash). The prospective transaction is expected to close in September 2015, subject to customary closing conditions, the approval of Lumenis’ shareholders and receipt of certain regulatory approvals. “This acquisition is a strong recognition and vote of confidence in Lumenis’ achievements and its employees, and I am excited about the future prospects of Lumenis,” said Tzipi Ozer-Armon, CEO. New acne charity launched A charity has been launched that aims to help sufferers of acne and rosacea. Professor Tony Chu, a consultant in dermatology, launched the Acne and Rosacea Association to administer better information and education to pharmacists and clinics, as well as encourage sufferers to seek advice sooner. Professor Chu said, “By providing training to pharmacies we will improve the advice they give, and certification will allow sufferers to identify trained pharmacies. There is a real need to provide information on the new treatments available for acne, rosacea, acne scarring and telangiectasia.”

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Acne

5 Squirrels chosen for Entrepreneurial Spark programme

FDA approves topical gel treatment for acne

Private label cosmeceutical supplier 5 Squirrels has been selected to participate in the Entrepreneurial Spark business accelerator programme. Developed by aesthetic business consultants Gary Conroy and Amanda Cameron, the company has been approached to join the growing ventures programme that is in partnership with the Royal Bank of Scotland, NatWest and KPMG. Conroy said, “We are delighted to have been selected for this programme and it is an honour to be recognised as a high-growth-potential, early-stage company.” He continued, “This will enable us to implement our business plan faster, so that our customers can continue to grow their own brand offering. Our short-term goal is to widen our product ranges, offer more flexible packaging options and enhance our marketing support tools to help the brands we are working with grow faster too!” The company will further develop its range to meet the needs of both patients and business owners seeking high-quality, medically-proven skincare from qualified healthcare professionals.

The Food and Drug Administration (FDA) has approved pharmaceutical company Galderma’s Epiduo Fortel Gel (0.3%/2.5%) for the treatment of acne vulgaris. President and general manager of Galderma Laboratories Todd Zavodnick said, “The FDA approval of Epiduo Forte Gel has helped us deliver a safe, effective and antibiotic-free treatment to patients in need.” The treatment, available for prescription from September, was approved based on a phase III, 12-week study of 217 patients, where the gel was rated as superior in the last week, compared to the opposing vehicle gel. 50.5% of patients treated with Epiduo Fortel Gel went from ‘severe’ to ‘clear’ or ‘almost clear’. The once daily topical treatment combines benzyl peroxide, adapalene and retinoid, and is recommended for patients with moderate to severe acne.

On the Scene

On the Scene

O Shot and P Shot training, Royale Academy of Aesthetic Medicine Practitioners were invited to attend training for the O Shot and P Shot procedure with platelet rich plasma (PRP) from July 1-2 at the Royale Academy of Aesthetic Medicine in London, hosted by Dr Sherif Wakil. At the first European workshops for the procedures, delegates were able to learn the theory and background behind the techniques. The first day focused on the O Shot, with in-depth theory and demonstrations from Dr Wakil, following an emphasis on the P Shot procedure for day two. Dr Charles Runels, pioneer of the O and P Shot procedures, attended the event as a special guest. Presenters from PRP device manufacturer Magellan also attended to talk to delegates about PRP technology. Dr Kannan Athreya, attendee and aesthetic practitioner, said, “I was thrilled to be a part of the very first European training organised and hosted by Dr Sherif Wakil, and we were all honoured with having the originator of the treatment, Dr Charles Runels, in attendance for this inaugural event.” He added, “I am greatly looking forward to contributing to the experience of the worldwide group of O and P Shot physicians.”

Ethos clinic launch, London

The launch for the new Ethos Centre of Excellence for Medical & Cosmetic Dermatology took place at the Chelsea Bridge Clinic on June 24. Guests including patients, friends, media and industry colleagues were invited to an evening on the Chelsea Bridge Wharf riverfront to celebrate with a drinks reception and live music. The new clinic offers treatments in areas of weight management and skin health, and hosts a team of medical and complementary specialists working together across these areas to address face and body concerns. James Bird, founder and director of Chelsea Bridge Clinic, said, “We were absolutely delighted with the enthusiasm with which our new Ethos Centre of Excellence for Medical & Cosmetic Dermatology and Weight Management were received by the media and guests!”

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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The Health Tech Revolution: The rise of gadgets and apps for patient wellbeing in 2015 Aesthetics explores the latest technology that aims to help consumers protect their skin from sun damage, reduce the signs of ageing and improve overall wellbeing A report recently published by the International Longevity Centre UK has claimed that tech innovation is vital to help us adapt to ageing and keep good skinhealth. It states that without new technology, future health costs in the UK could become higher than currently projected by the Office of Budget Responsibility (OBR) within the next decade. The report, Opportunity Knocks, argues that the government and technology designers must work together to break down the barriers to innovation, claiming there is significant potential for wearable technologies to respond to the challenges associated with ageing. As such, companies around the world are developing gadgets and applications that aim to help us take better care of our skin and inhibit ageing. To look after your patients’ skin requires a conscious effort to find the best products, provide the most innovative treatments and acquire an abundance of knowledge – but could any of these new technologies help you do this and make a difference to patients’ skin health? And are they really a safe option?

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UV protection Last year, consumer electronic company Netatamo launched an ultraviolet (UV)-monitoring bracelet named JUNE. The bracelet aims to help the wearer better manage their exposure to sun, whilst doubling up as a fashion accessory. Boasting a ‘jewel’ containing UV sensors, it connects wirelessly to the wearer’s smartphone, where the companion app monitors UV exposure to provide tailored suncare information. The app then prompts the user to apply sunscreen, sit in the shade or wear a hat. It also tracks the total amount of exposure to the sun throughout the day and, depending on the user’s skin type, calculates the maximum recommended exposure for that individual. Fred Potter, CEO and founder of Netatmo, said, “Our goal at Netatmo is to develop devices that measure the environment to help people better understand their surroundings, adapt their behaviour accordingly and improve their daily lives. JUNE was created with this vision.” French swimsuit design company Spinali Design similarly launched a device in May of this year that also claims to help users monitor their sun exposure. The new technology, which aims to prevent sunburn and comes in the form of a bikini, alerts the wearer when it is time to re-apply sunscreen or seek shade. The swimwear is embedded with a two-centimetre UV sensor that can be connected to a smartphone, and, like JUNE, will recognise when a person has had too much sun and send an alert via the app. Marie Spinali, CEO of the startup company, came up with the idea when she saw a girl with “skin like a lobster” and wondered why she hadn’t protected herself with sun cream. “It can only make a conscious person think about taking better care of their skin,” Spinali said. “It’s not a medical swimsuit – its aim is to make someone take care and pay attention.” The technology, dubbed Connected Bikini, also comes in the form of towels and children’s swimwear. Continuing with the suncare technology trend, scientists at Klein Buendal, the National Oceanic and Atmospheric Administration, and the University of New Mexico developed a mobile app called sunZapp. The app, which is available for download in the UK, takes details of user’s skin type, location, environmental conditions, clothing and sunscreen to offer sun protection advice, while providing users with alerts when UV levels are high. “We wanted sunZapp to give all the information you need to stay safe in the sun,” said Dr David Buller, senior scientist at Klein Buendel and lead investigator on the sunZapp project. “sunZapp can personalise advice for you and your family when and where you need it – whether you are sitting outside for lunch or on vacation at the beach.” There are a few apps on the market that aim

“Technology alone is not a silver bullet for health and social care, but it is an enabler that should not be overlooked” Karen Taylor, director of Deloitte’s Centre for Health Solutions

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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to help you avoid too much UV exposure but one that is particularly noteworthy is the UV app created by the British Association of Dermatologists (BAD) in collaboration with the Met Office. The app provides daily UV forecasts for more than 10,000 locations worldwide. The forecast alerts the user to the peak strength of the UV radiation from the sun, suggests steps that should be taken to protect you and provides information about individual skin types. Dr Alexis Granite, a dermatologist at the Cadogan Clinic in London, supports the use of UV apps, providing they are used alongside conventional suncare methods. She said, “There are a variety of new, innovative skin care technologies available to the public that provide users with information about local weather and UV conditions and send reminders based on skin type about sun protection. While these should not replace more traditional practices of avoiding sun at peak hours and regular application of a broad spectrum sunscreen, I do think these devices could be helpful as another tool for patients, especially ones at high risk of skin cancer, to stay skin safe outdoors.” Monitoring One key way in which technology, particularly in smartphones, is developing is through the use of apps that allow the user to track and monitor their health. SkinVision is a CE-certified melanoma app that allows the user to investigate skin issues. The user takes a picture of a spot or mole they may be particularly concerned about and the app will then analyse the indication and recommend what steps to take next; whether this is seeing a practitioner or seeking over-the-counter treatment. Users can also track how their moles evolve by taking a series of photographs over time. The app uses an online algorithm, which has taken two years to develop, to determine potentially unnatural growths of pigmented moles on the skin. A team of boardcertified dermatologists developed the app in the US, before it was scientifically tested in Ludwig-Maximilians-Universitat Clinic in Munich, Germany. “SkinVision does not intend to provide medical advice or replace a dermatologist’s opinion,” said app developer Dr Kostas Konstantinos. He continued, “SkinVision offers tools that allow users to better understand and track their skin health, bring more fact-based information to their next GP or dermatologist visit and make healthy skin part of their day-to-day lifestyle.”3 Matt Gass, communications officer for the British Association of Dermatologists (BAD) said anything that encourages people to examine their skin is welcome, but also warned that users should be cautious. “Apps purporting to provide a treatment or diagnosis should be looked at with a high degree of caution. There is a real danger that not only will unevaluated mole screening apps over-diagnose, but that they may also under-diagnose and falsely reassure the customer, who then does not seek referral for a changing mole,” he said. “Any commercial mole-checking devices, particularly those as accessible as apps, must be scientifically evaluated before they can be considered safe. The danger is that commercial incentives will get in the way of patient safety and good medicine.” Another device that claims to cater for skin concerns is WAY, a small, doughnut-shaped device that monitors and recommends what the user needs for optimum skin health. Created by Korean startup company WayWearables, the device is aimed purely at women. Users touch the device onto their skin once a day and the biometric sensors in the device collect information about their skin and surrounding environment, before sending alerts to their smartphone. According to the company, WAY aims to be the watchdog of consumers’ skin; diagnosing and informing them

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“Any commercial molechecking devices, particularly those as accessible as apps, must be scientifically evaluated before they can be considered safe” Matt Gass, communications officer for the British Association of Dermatologists

of their skin condition, and suggesting products it thinks would improve skin health. For example, the device would highlight the fact that current humidity levels are low and a moisturiser should be applied. Although currently only available in Korea, the company hopes to extend the technology globally, including to the UK. The future of digital healthcare Connected Health, the latest report from the Deloitte UK Centre for Health Solutions, provides a current view of the ways in which digital technology could enhance health. It discovered that the UK adoption of digital health remains slow but found that technologies can empower patients and carers by giving them more control over their own health.4 Karen Taylor, director of Deloitte’s Centre for Health Solutions, said, “Technology alone is not a silver bullet for health and social care, but it is an enabler that should not be overlooked. Its success lies in the convergence of technology and human interaction. Effective adoption of technology-enabled care relies on developing partnerships that harness patient education, easy-to-use technology and the support of staff, aided by the protection of patient data. There is a real opportunity here for the UK that we cannot afford to miss.”5 Yet despite the advancements and effectiveness of many consumer-driven technologies, it remains imperative that your patients understand when it is time to see a medical professional and get face-to-face specialist advice. While gadgets and apps may be useful in prompting and reminding patients to take better care of themselves, it seems that the general consensus is that they can not represent a substitute for face-to-face consultation and practitioner expertise. REFERENCES 1. David Sinclair and Helen Creighton, Opportunity knocks: Designing solutions for an ageing society, (UK: International Longevity Centre, 2015) <http://www.ilcuk.org.uk/index.php/publications/ publication_details/opportunity_knocks_designing_solutions_for_an_ageing_society> 2. James Perdue, Anti-aging Market (Anti-wrinkle products, Hair Color, Hair restoration treatment, Breast augmentation and Radio frequency devices) Global Industry Analysis, Size, Share, Growth, Trends and Forecast, 2013 – 2019 (US: Transparency Market Research, 2014) < http://www. transparencymarketresearch.com/anti-aging-market.html> 3. Victoria Woollaston, Should you get that mole checked out? £2.99 dermatologist-designed app scans skin for signs of cancer - and does it with up to 90% accuracy (UK: MailOnline, 2014) < http:// www.dailymail.co.uk/sciencetech/article-2831557/Should-mole-checked-2-99-dermatologistdesigned-app-scans-skin-signs-cancer-does-90-accuracy.html> 4. Connected health: How digital technology is transforming health and social care (UK: Deloitte, 2015) < http://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/connectedhealth.html> 5. Connected health: How digital technology is transforming health and social care (UK: Deloitte, 2015) < http://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/connectedhealth.html>

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Aesthetics

Filling in the blanks: a retrospective view of dermal fillers From the conception of the earliest collagen-filled syringes through to the modern-day portfolio of injectables, Allie Anderson traces the development of the dermal filler One of the most popular treatments offered in aesthetics clinics is the dermal filler. According to statistics from WhatClinic.com, more enquiries were made about dermal fillers in the UK in 2014 than any other non-surgical aesthetic procedure, and the number of filler treatments carried out increased by 131% last year alone.1 These days, it seems consumers are more willing than ever before to have substances injected into their faces to smooth the appearance of lines and wrinkles in the pursuit of eternal youth. However, this kind of procedure is not a recent advancement. Records of patients having fat removed from their arm and grafted to their face date back as far as the 1890s, and injectable fat grafts have been performed since the 1920s.2 Paraffin was used as a skin filler in the early part of the 20th century, when a Viennese surgeon developed the technique of injecting a product that becomes semi-liquid when heated and solidifies when it cools. The procedure was adopted for treating cosmetic indications – such as filling cheeks, augmenting breasts, nasal defects and facial wrinkles – but soon resulted in complications that rendered it unfit for purpose.3 The collagen era Since the first modern-era dermal fillers were approved by the Food and Drug Administration (FDA) for cosmetic use in the US in 1981,4 the idea of using injectable substances to fill out and smooth wrinkles in the face has gradually become so commonplace, it’s almost part of modern-day collective conscious. But it wasn’t always that way. “The whole idea of injecting something into your face to make you look better was very alien back then,” explains aesthetic business consultant and Aesthetics editor Amanda

Cameron. “It came to the UK a few years later, but the market was tiny and it was only available in little pockets, like London’s Harley Street, and parts of central and northern England.” This first-generation filler was in the form of bovine collagen and was brought to the international marketplace by US-based Collagen Corporation. It became popular as an aesthetic treatment and in its most primitive form – branded Zyderm I – was found to be highly effective in minimising fine lines and shallow scars, with results lasting around three months. However, as a filler for deeper wrinkles, nasolabial folds and marionette lines, results were both less convincing and shorter lasting.5 So while overall demand for this procedure in UK clinics through the 1980s and 90s was comparatively small, patients who wanted a sustained result would have to return to have the treatment several times a year. Working as a UK trainer for Collagen Corporation, Cameron witnessed first-hand how the UK market developed in those early years. “We were selling around 5-6,000 syringes a year, which isn’t a lot in the grand scheme of things, especially when you consider that they didn’t last long, so patients would have to have more than one,” she recalls. “For several years, we had a monopoly in a small market, so the only way to make money was to put the price up. It was unique, and people were prepared to pay for it.” Patients also had to undergo a skin test four weeks before the treatment, so it didn’t provide the instant gratification that consumers crave nowadays. Aesthetic nurse Marie Duckett, of Fiona and Marie Aesthetics, was introduced to dermal fillers when she, too, worked at Collagen Corporation’s UK arm, and began injecting when fillers were in their infancy. She remembers bovine collagen as “a nice product to use” – albeit with its

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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disadvantages. “Apart from the fact that it didn’t last very long, a high percentage of patients were allergic,” Duckett comments. “There was a 3% allergy rate with bovine collagen, even among patients whose skin tests showed no allergic reaction. In terms of the hundreds of thousands of patients who walk into clinics today, that would be unacceptable.” In addition, the high viscosity of the fillers meant they had to be injected through large-gauge devices (although, the needles used were no bigger than those used today) causing pain, bruising and swelling – and with no comparable alternative, patients had to tolerate it. A breakthrough came a few years later with the introduction of Zyderm II and Zyplast: the former is a similar preparation to Zyderm I, but with 65mg/ml rather than 35mg/ml of bovine collagen (with 0.3 per cent lidocaine), injected into the superficial dermis; while the latter contains the same 35mg/ml of collagen cross-linked with glutaraldehyde to form a more viscous substance that is more resistant to degradation, and therefore lasted longer. Zyplast was injected into the mid-dermis, and was especially effective in treating deep wrinkles and skin folds, atrophic scars and to define the vermillion border of the lips.6 Hyaluronic acid – a new dawn Bovine collagen enjoyed a monopoly as a filler in the UK until the mid-1990s, when a new development was to revolutionise the market. A naturally occurring substance found in cell and tissue fluids, hyaluronic acid (HA) is a significant factor in keeping the skin moisturised.7 Since the skin’s high water content is partly responsible for the properties associated with young and youthful-looking skin – pliability, resilience and plumpness – the emergence of HA fillers was a significant advancement in the development of anti-ageing solutions, providing very effective results.8,9 First came Hylaform, a HA filler made from rooster combs that was gradually absorbed by the body. This was closely followed by Restylane, one of the first dermal fillers that wasn’t derived from animal sources. The new-style treatments could be used straight from the box and had a far lower reaction rate, thereby spelling the end for collagen fillers. “When Restylane suddenly appeared, it was a shock. It had a significant impact on the industry and took most of the collagen market overnight,” Cameron explains. “First, there wasn’t the same risk of allergies as with collagen fillers, and second, you didn’t have to have a skin test, so you could just walk in and, after a consultation, have the treatment there and then.” HA fillers remain one of the primary treatments for the correction of wrinkles, folds and loss of volume that develop with age, and are a popular choice among practitioners and patients alike. However, scientific developments in the way HA fillers work together with how they are placed – have meant that for some, Restylane, which is now classed as one of the original HAs, isn’t always practitioners’ first choice of filler to use. “It had its place at the time, but it’s superseded by products with better advancements in biotechnology,” says Dr Raj Acquilla. He uses fillers containing Vycross technology, which combines 90% low- and 10% high-molecular-weight hyaluronic acid that enables better cross-linking. The result, says Dr Acquilla, is smoother and longer lasting with minimal swelling. Dr Kate Goldie explains that this cross-linking – whereby chains of molecules are bonded together – improves the functionality of the product. “The crosslinking process means the substance is able to integrate with the tissue unusually well. When the particles are cross-linked, they’re

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able to move into small spaces and the product blends. The other thing is that these gels are highly cohesive, so the molecules stay together. Low viscosity and high cohesivity equals a product that is constant in its result.” Other filler ingredients have been developed, each with varying degrees of permanence and with their own functionality. One example is Poly L lactic acid (PLLA), a semi-permanent filler belonging to the class of substances known as collagen stimulators. Rather than ‘fill’ wrinkles, folds and deflated areas directly, the injected material promotes the production and deposition of collagen where it is required in the face. Another biocompatible substance, calcium hydroxylapatite, contains small particles suspended in a water-based gel, which form a scaffold over which the collagen produced by the body can grow. Advancements of fillers since the early 2000s has resulted in products with varying degrees of thickness, which determines how deeply the substances can be injected, and hence, their indications. “This has changed placement of fillers tremendously,” comments Dr Ravi Jain. “Most of the fillers I perform are either on the bone, under the muscle or in the fat – anywhere but the dermis.” As such, it is now considered by many to be a misnomer to refer to these treatments as ‘dermal’ fillers, but rather ‘soft tissue’ fillers. Dr Goldie goes further, suggesting that the word ‘filler’ is “misleading” when describing modern-day products. “The way fillers are going now, they have the ability to do lots of things. It’s not just about occupying a space, it’s about becoming part of the tissue,” she says. “We want the product to occupy space, but we also want them to make the tissues lie in a smooth, even way, as well as to volumise. Practitioners used to use volumisers superperiosteally, but the modern gels can be used subdermally as well.” Great knowledge, great responsibility The evolution of dermal fillers has also had a significant impact on both the level of skill and the knowledge required to be able to inject them competently. Training in injectables has historically been somewhat hit and miss, with many practitioners having only been required to undertake the bare minimum before being let loose with a syringe. “In the early days, we were mainly training doctors and plastic surgeons, so they already had a strong core knowledge of anatomy and physiology, but they needed guidance in filler placement,” Cameron recalls. “Now, people are coming in to the industry from different backgrounds, so the entry level knowledge is very different.” The reclassification of fillers from prescription-only medications (POMs) to ‘medical devices’ under the Medical Devices Directive has opened up the market to practitioners from non-medical backgrounds, further increasing the need for more in-depth training. Arguably, one of the biggest changes in fillers within the last 20 years has not been developments in products themselves, but in the level of anatomical knowledge required to be able to use them most effectively. “We knew absolutely nothing; we looked at the face in a 2D approach, so when we placed a needle into the skin exactly, we didn’t understand what depths certain structures were located,” says Dr Acquilla. “We were causing risk and unnecessary side effects to the patient. We were also not injecting at the right level for optimum effect and best results, which were pretty primitive.” With training gradually incorporating more advanced understanding of facial anatomy and physiology – and focusing on a three-dimensional approach to injecting

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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– practitioners are employing more refined techniques and generating better results for the patient. “Anyone who’s injecting nowadays should have a knowledge of where the needle tip is to the nearest 1mm3 in the face, and what that structure represents,” Dr Acquilla adds. “Placement and technique are paramount; absolute accuracy and precision dictates the result and the safety of the treatment.”

that has been a big breakthrough; it’s more comfortable for the patient as well.” She adds that ergonomics also come into play, when it comes to syringes, “The distance from the flanges to the end of the plunger can be longer in one 1cc syringe than another, making it more difficult to inject.” With needles becoming ever-thinner and syringes more ergonomically pleasing, the filler experience is much improved both for the patient and for the practitioner.

Complementary treatments Just as fillers and their ingredients have evolved over time, so have other, related treatments – as well as consumers’ attitude towards aesthetic procedures in general – which have impacted both the use of fillers and the results that are achievable. “With the advent of technology, we now have more advanced lasers and skin tightening and lifting treatments,” explains Dr Tracey Mountford. “The effect is that we have a more extensive portfolio of products to call upon, which yields much better results. I don’t believe these other treatments have affected our use of fillers in terms of numbers, but they have certainly made dermal fillers look better, as we are delivering a total package.” Dr Linda Eve likens the practitioner’s choice of different, complementary treatments to artistry. “We’re much more into combination therapy now. We’re artists; we have many colours on our palette of paint and we have many products in our toolbox,” she says. “We can safely mix and match products from different companies these days. For example, we may use PLLA to give a contoured scaffold lift to the face, then use the HA filler to address the nasolabial lines or marionette lines. You can use more products, with confidence, to get lift and shaping that you want to achieve.” As Duckett points out, equipment has also undergone development since the advent of the first collagen filler, which has in turn had an effect on the injector’s technique. “New technology has come about with needles. You can pick up a standard 30-gauge needle where the outer diameter of the needle is 30-gauge, but another 30-gauge needle will have the same outer diameter, but the inner bore is larger,” she comments. “So as you push the plunger, there is less resistance. Wide bore needles have come about in the last four or five years, and

Botulinum toxin – a game changer Back in the late 1980s when collagen fillers were a dominant force in an as-yet largely unchartered industry, a discovery was about to be unearthed that would later be described as “one of the most successful symbioses in late-20th century cosmetic medicine”.10 Having been successfully used to treat blepharospasm (eye twitching) and strabismus (squinting), a dilution of botulinum toxin injected into muscles around the eyes was found to have the unusual side effect of smoothing fine lines and wrinkles. Several years of studies and trials followed before the cosmetic and aesthetic worlds began to realise the benefits of what soon became widely known by its brand name Botox, and consumers became drawn to this new treatment. Although Botox was only granted approval for the treatment of glabellar lines in 200211 – and for crows’ feet as recently as 201312 – practitioners across the world had been performing the procedure ‘off-label’ for years. As well as having a strong media presence, which hadn’t been seen before in the aesthetics industry, many users reported that with botulinum toxin they were able to produce more desirable treatment outcomes. As such, it had a significant impact on the industry as a whole, as well as the filler market. Cameron suggests that in the year-long period botulinum toxin began appearing in UK clinics, the aesthetics industry more or less doubled in size. “Things changed dramatically. The PR botulinum toxin had was phenomenal, and at around the same time it became fashionable to have cosmetic treatments,” she recalls. Dr Jain concurs that as it became more available and accepted, it had the knock-on effect of opening up aesthetic medicine to wider audiences. “Today, I would say that botulinum toxin is probably the first thing people come into my clinic for, with fillers second.” Unlike dermal fillers, the formulation of botulinum toxin has changed little over the years, and its effects have similarly remained constant. However, some practitioners report that demand for the treatment fluctuates depending on trends. “Sometimes, it’s really on everyone’s lips and then interest fades away again,” comments Duckett. “Every now and then there seems to be a flurry of patients who are tired of the ‘Botox look’ and want to look less frozen, so they go back to the fillers again.” Notwithstanding, the global botulinum toxin market is expected to be worth almost $3bn in just three years’ time.13

With training gradually incorporating more advanced understanding of facial anatomy and physiology – and focusing on a three-dimensional approach to injecting – practitioners are employing more refined techniques and generating better results for the patient

Driving change in fillers The evolution of filler treatments can be attributed to a number of influences, a significant factor being the way we understand the ageing process and its effects on the appearance of the skin. “Going back 18 years, you didn’t inject the body of the lip, you only did the lip border. You mainly treated lipstick lines, nasolabial lines, marionette lines, perioral lines, periorbital lines and frown lines,” says Duckett. “Now, we still treat lines and wrinkles but we also look at volume. That has been one of the biggest changes – the recognition that lines and wrinkles occur because the face becomes like a slowly deflating balloon over time; that volume is lacking and you need to restore the volume in order to restore the proportions and take the pressure off lines and wrinkles.”

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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From the early days of ‘chasing lines’ with collagen fillers, and as understanding of the anatomical structures underlying injection sites developed, so did the substances used and the devices through which they were delivered. “Consumers and patients know what aesthetic result they want – usually that means a procedure that gives a natural-looking and un-spottable look,” says Dr Eve. “Now, practitioners are innovating more in how to use dermal fillers, and they go to the companies and say ‘I need something that can do this and has these specific properties’, and that feeds back into the system. We’re also getting really good research and development in the companies who understand and can achieve products that are much more compatible with the results the patients want.” As such, developments thus far, and those that are yet to occur, are brought about by close working between progressive injectors and state-ofthe-art manufacturing. “That’s how you get really clever products,” Dr Eve adds. The popularity of injectable treatments shows no signs of ebbing in the coming years, as long as it remains a comparatively affordable option. Raw material prices have seemingly plateaued, having changed only marginally in the 30-or-so years since collagen fillers emerged – a consequence of the ever-expanding and competitive market. But the price to the consumer has, in many clinics, risen to reflect the advanced skills and knowledge of the practitioner and the improved results that fillers can now achieve. “The results that I could give 15 years ago deserved the low prices fillers were being charged at,” comments Dr Acquilla. “But the results we can now generate, because of our understanding of anatomy and the technical application, as well as the sophisticated

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science of the products we inject, are so superior that the value of that to the patient is disproportionately higher than it used to be.” Cost implications aside, Cameron believes we’ve reached a point where we can offer optimum product choice for optimum effects, for lifting, volumising and filling. “The next big milestone will be if someone manages to do all this without using a needle,” she concludes, “but I think that’s a long way off.” REFERENCES: 1. WhatClinic.com, Thread lifts’ revealed as top cosmetic trend of 2014, while ‘fat filler’ destined to be big in 2015, (Ireland: WhatClinic.com, 2014) <http://www.whatclinic.com/about/press/> 2. Hendy Amgad, ‘Facial Re-Contouring Using Autologous Fat Transfer’, J Plast Reconstr Surg, 34(1) (2010), pp. 65-69 3. J Glicenstein, ‘The first ‘fillers’, Vaseline and paraffin. From miracle to disaster’, Ann Chir Plast Esthet, 52(2) (2007), pp. 157-61. 4. K Cockerham and VJ Hsu, ‘Collagen-based dermal fillers: past, present, future’, Facial Plast Surg, 25(2) (2009) pp. 106-13 5. Dr Robert S Bader, Dermal Fillers: Overview, (US: Medscape, 2015), <http://emedicine.medscape. com/article/1125066-overview> 6. Dr Robert S Bader, Dermal Fillers: Collagen, (US: Medscape, 2015), <http://emedicine.medscape. com/article/1125066-overview#a2> 7. E Papakonstantinou et al, ‘Hyaluronic acid: A key molecule in skin aging’, Dermatoendocrinol, 4(3) (2012) pp. 253–258 8. MP Lupo, ‘Hyaluronic acid fillers in facial rejuvenation’, Semin Cutan Med Surg, 25(3) (2006), pp. 122-6 9. H Sundaram et al, ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications’, Plast Reconstr Surg 132 (2013) 10. Katherine Ashenburg, The birth of Botox, (Canada: Reader’s Digest, 2011), <http://www. readersdigest.ca/health/beauty/birth-botox/#R6Byf58CjaMh1S8B.97> 11. Allergan, Botox history and development, (UK: Allergan Inc., 2010), <http://www.allergan.jp/ Assets/pdf/botox_history_and_development.pdf.> 12. Marie-Louise Olson, Doctors have been doing it ‘off the books’ for years but now they finally have the go-ahead to inject BOTOX into those unwanted ‘crow’s feet’ wrinkles, (UK: Daily Mail, 2013) <http://www.dailymail.co.uk/news/article-2418738/Botox-legally-approved-lines-wrinklescrows-feet-despite-Drs-doing-years.html> 13. Eva Wiseman, Is Botox starting to show its age? (UK: The Guardian, 2014), <http://www. theguardian.com/lifeandstyle/2014/mar/23/botox-starting-to-show-age-eva-wiseman>

The first resilient hyaluronic acid dedicated to facial dynamism www.lifestyleaesthetics.com T: +44 (0)1793 784459

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015

** RE RS EISLIILEIN EN T TB E BA EA UU TY TY

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LESS INTACT COLLAGEN

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LOSS OF FIBROBLAST ACTIVITY

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Treating Nasolabial Folds Dr Souphiyeh Samizadeh details the multifactorial formation of nasolabial folds and argues for an increased use of indirect nasolabial treatment Introduction Although nasolabial folds (NLFs) are evident in youth and upon smiling, they often deepen with age and can give the face a tired and sagging appearance.1, 2 Prominent NLFs are one of the early visual signs of ageing and, in my experience, a very common concern for patients. NLFs are creases that extend from the ala (wing) of the nose to the corners of the mouth, and separate the cheeks from the upper lip. Different varieties of NLFs include convex, concave and straight, with varied lengths from short, extended Figure 1: Anatomic variations of the nasolabial fold, from the top: convex, and continuous (Figure 1).1,3Although straight and concave. Adapted from ageing is variable in each patient Zufferey, 1991 we treat, some features occur in a predictable fashion. NLFs are a prime example, as they often become more prominent with age and distort the youthful contour of the mid-face. Facial ageing is a multifactorial and threedimensional process where there is an interrelationship between all facial tissues. Age-related changes include primary bony changes and skeletal remodeling, diminution of muscular and skeletal support and changes of the soft-tissue envelope, which result in changes in proportions of the face.4 Traditionally in aesthetic practice, NLFs are filled with dermal filler to ease the depth of the line and produce a more youthful appearance. In my opinion, however, this approach simply treats the symptoms rather than the cause of the problem. Adopting this approach could result in disharmony of the face and 1

Figure 2: Facial fat compartments adapted from Rohrich and Pessa.11,12

produce undesirable results for the patient, because NLFs contribute to facial expression and play a role in facial animation.1 Filling the NLFs to rejuvenate the lower face, without addressing the ageing mid-face may result in facial disharmony. The wrong injection technique may result in worsening the appearance and prominence of NLFs by adding volume laterally to the folds, resulting in further cheek ptosis5 and inadvertently changing your patientâ&#x20AC;&#x2122;s smile characteristics. The distribution of the facial artery and its relation to the NLFs should be kept in mind when treating this area; understanding the anatomy of NLFs, facial fat distribution and its changes during ageing is essential for successful facial rejuvenation. Other non-surgical methods for improving the appearance of facial ageing and nasolabial folds include non-ablative radiofrequency,6 injection of botulinum toxin A,7 and the use of threads.8 Threads can be used for mid-face and jowl tightness, firmness and, to some extent, tissue elevation â&#x20AC;&#x201C; depending on the type of thread used.9 Dr Michael Kane demonstrated use of botulinum toxin A for treatment of NLFs in patients where the fold is primarily caused by muscular action.7 As described by Dr Kane in his paper published in 2003, formation of NLFs is multifactorial and is caused by skin, fat, muscles and bone, therefore, there is no single approach for the treatment of NLFs.7 This also highlights the importance of proper diagnosis of what is causing the NLF. In this paper, I will focus on the use of dermal fillers for the rejuvenation and reduction of prominence of NLFs.

The formation of nasolabial folds The formation of a prominent nasolabial fold is multifactorial. Ageing results in progressive and selective ptosis of the cheek tissues with relatively little change in the position of upper lip tissues.10 The selective hypertrophy and ptosis of the cheek fat pads have a direct effect on the formation of NLFs.1, 3, 11, 12,7

Figure 3: Loss of volume and projection of the medial cheek fat pad results in pseudoptosis and contributes to prominence of NLFs.7

1. 2. 3.

Malar Fat

Malar Fat

4. 5. 6. 7.

1. Middle forehead 2. Superior orbital 3. Interior orbital 4. Lateral Temporal Descent 5. Middle-Malar (Atrophy/Flattening) 6. Medial-Malar (Inferio-medial descent) 7. Buccal (Prolapse/Descent)

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015

Figure 4: Loss of volume and ptosis of the medial cheek fat pad (light blue arrows on the top image). Augmentation of the deep medial cheek fat pad will enhance the anterior projection and reduce/ eliminate NLF (dark blue arrows on the bottom image indicate aims of rejuvenation: volumising and lifting)


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A combination of the following factors can also contribute to a prominent NLF:2,4,6,7 • Reduced skin thickness over the folds • Excess ptotic skin lateral to the NLF • Excessive fat deposits lateral to the folds that are fixed in place by retaining ligaments • Ptosis of the malar and submalar fat compartments13

Fat compartments The anatomic position of facial fat is a key factor for determining facial shape. With ageing, there are qualitative and quantitative changes in facial fat. A youthful face is full of well-supported fat with intact support of retaining ligaments.14 In the ageing face, facial fat descends and therefore the shape of the face changes.11, 12, 14 Facial fat is highly compartmentalised, and the independent fat compartments are separated by vascularised boundaries.15 Morphologic changes of these compartments play a significant role in ageing and the formation of NLFs. It has been shown that different fat compartments behave differently during the ageing process, and there is a general redistribution of fat with ageing (Figure 2).16,12 Superficial fat compartments are: the nasolabial fat, the medial cheek fat, the middle cheek fat, the lateral temporal cheek compartment, and three orbital compartments. Deep mid-face fat compartments consist of the suborbicularis oculi fat and the deep medial cheek fat.12, 15 With ageing there is an inferior migration of the fat compartments as well as an inferior volume shift within these fat compartments.15 Rohrich and Pessa reported that nasolabial fat is positioned anterior to the medial cheek fat, and intersects with the jowl fat.12 The superior border of the nasolabial fat compartment is the orbicularis retaining ligament, and the lower border of the zygomaticus major muscle is adherent to this compartment.5 Their study of 10 hemifaces of male and female cadavers showed no volume changes of this compartment between cadavers, regardless of age or sex.12 However, a computer tomography study of the mid-face fat compartments carried out by Gierloff et al reported an inferior migration of fat compartments and inferior volume shift within the nasolabial fat compartment during ageing.15 This volume increase in the inferior segment of nasolabial fat will lead to a pronounced NLF.15 In three separate studies, Gosain and his colleagues analysed photographic and direct facial measurements of surface landmarks with ageing, studied high resolution Magnetic Resonance Imaging (MRI) scans of nasolabial fold changes during ageing, and carried out a volumetric analysis of facial soft tissue compartments. All studies reported soft tissue changes, ptosis of cutaneous and subcutaneous components of the cheek mass, and selective hypertrophy within the subcutaneous component.1, 16,17 There are three cheek fat compartments: the medial, middle, and lateral temporal. Immediately lateral to the nasolabial fold is the medial cheek fat.12 Loss of volume in the medial cheek fat pad results in pseudoptosis (resembling ptosis due to loss of projection of the superficial medial and middle cheek fat pads) and contributes to the prominence of NLFs.7 Gosain et al reported selective hypertrophy of the upper portion of the cheek fat pad in addition to ptosis. Maximum hypertrophy of the cheek fat pad was found to occur in the upper portion of the mid-face with gradually less hypertrophy toward the nasolabial fold. In an upright position, the ptotic and hypertrophied cheek mass descend inferiorly and overhang the nasolabial fold.16 In addition, deflation of the buccal fat pad leads to lack of support for middle and medial cheek fat pads,

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aggregating ptosis of these compartments.15 The loss of volume and the normal anatomic subcutaneous facial fat compartments gives the illusion of increased skin laxity and prominent perioral folds such as the nasolabial region, periorbital region and jowl. 18 Knowledge of the fat compartments of the face and localised injections into distinct compartments, such as the deep medial fat pads, has reformed the approach to facial rejuvenation. Volume replacement and recontouring of the soft tissues into an anatomically more youthful position can be achieved through a systematic approach.18 Musculature The muscles associated with facial expression have extensions which extend to the skin overlying the NLFs. The mimetic muscles of the upper lip insert in the orbicularis oris at the level of the NLFs. The folds are on the peripheral border of the orbicular oris muscle at the fusion of levator labii superioris medially and the zygomatic major muscle laterally.19 Gosain et al reported no significant changes in the length or position or fat density of the underlying mimetic muscles with age,16 however, Le Louarn has reported that ageing muscles of the mid-face shorten and straighten.20 A combination of any one of the mid-face mimetic muscles are responsible for elevating the upper lip and producing a smile:13 • The zygomatic complex • The central upper lip levators • The levator anguli oris • Risorius These muscles individually, or as a group, contribute to the formation and deepening of the NLFs and play a role in facial expression.13 Ligaments Mendelson reported that ligamentous laxity occurs during ageing due to continuous muscular activity and intrinsic ageing, resulting in ptosis of the soft tissues of the face.2, 21 Zygomatic and mandibular ligaments originate from the periosteum and insert directly into the dermis.22 The subcutaneous fat compartments are limited by septa that originate from the underlying fascia and insert into the dermis of the skin.23 The zygomatic ligament suspends malar soft tissue over the zygomatic eminence.22 The attenuated retaining ligaments act as a hammock to the atrophied fat compartments and facial soft tissues.18 Laxity and loss of zygomatic ligament support results in inferior descent and ptosis of malar fat pad, and downward orientation of nasolabial fat influencing prominence of the NLF.14, 22, 23 Therefore, prominent and ageing NFLs should be primarily addressed by restoring the malar soft tissue by repositioning the tissue to its previous position.22 Skeleton Skeletal remodelling and bony changes of the mid-face during ageing include:2 • Remodelling of the inferior orbital rim and loss of its anterior projection • The mid-face loses vertical height • The pyriform aperture recesses posteriorly In a paper titled ‘Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging’, Pessa et al reported that as ageing progresses there is shortening of the maxilla vertically in proportion

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Aesthetics Figure 5: This patient was treated through indirect treatment of NLFs and a combination of direct and indirect treatment of the perioral region. Volume loss in mid-face was addressed first using dermal fillers. This was followed by subtle volume restoration of the lips and perioral region and was carried out using dermal fillers. The results can be improved on subsequent appointments.

to the orbit, and retrusion of maxillary skeleton at the pyriform which results in reduced surface area available in the mid-face to support the overlying soft tissues.2, 4, 24 These changes therefore contribute to the prominence of the NLFs. Tooth loss results in irreversible and continuous alveolar bone resorption25, 26 and microstructural changes in the cortical bone such as reduced thickness.27 Loss of dentition affects the mandible more than the maxilla, also more bone loss is seen in women than in men.28, 29 These changes to the bony scaffolding results in reduced lowerface height and loss of support for the soft tissue curtain. The soft tissue changes due to the progressive atrophy of the edentulous jaws are as follows:30 • The narrowing of the mouth due to collapse of the circumoral musculature • Loss of lip support • Inversion of the lips • Contraction of the cheeks Pessa et al also reported that young patients with skeletal deficiency of maxilla, such as maxillary retrusion, displayed prominent NLFs.24

Complications associated with a direct approach to NLF treatment Direct correction of NLFs may be inevitable in some cases. If practitioners wish to employ a direct approach to treatment and augment NLFs with dermal fillers, it is important to keep in mind the course of the facial artery (Figure 6). Understanding the anatomical blood supply of the perioral region is essential for preventing vascular complications. Although uncommon, vascular injury can lead to detrimental complications such as tissue necrosis,33 brain infarction34 (following autologous fat injection into the nasolabial groove),35 or, in some cases, blindness.34, 35 A systematic review of the available literature with regard to the occurrence of iatrogenic blindness caused by cosmetic injection of the face was carried out by Lazzeri et al,36 in which they identified 29 articles describing 32 patients. Blindness was reported to occur in 15 patients following injection of adipose tissue in the NLFs (two cases) lower-third of the face (three cases), the upper-mid of the face (seven cases), and the mid-third of the face (three cases).36 In all of these reported cases, signs and symptoms of visual adverse effects (severe pain and a sudden blackout of the involved eye) happened immediately following the injection and were permanent.3 Furthermore, the literature identified 17 patients who suffered transitory (three cases) or permanent (14 cases) of blindness following injections of other materials

Treatment Taking into account the various ageing patterns discussed above, an aesthetic practitioner should address the following points during treatment: • The mid-facial volume loss, pesudoptosis and ptosis • The inferior nasolabial volume excess • The tethering effect of ligamentous insertions at the nasolabial crease • Skin texture and laxity

The deep medial fat pad underlies the superficial middle fat pad.2 Rohrich et al demonstrated that augmentation of the deep medial cheek fat pad would: • Enhance anterior projection of the mid-face11, 15, 31 • Reduce/eliminate depth of NLFs11, 15, 31 • Improve/eliminate the V-deformity (a hollow in the centromedial cheek below the tear trough2) and reduce the appearance of the tear trough11, 31 • Recreate a youthful cheek12, 31 An elevation and reduction of the nasolabial fold can therefore be achieved by an augmentation of the: 2, 11, 12 • Deep medial cheek fat pad • Deepest fat compartment in the paranasal region, a triangular fat pad (Ristow’s space: space between the periosteum of the maxilla and the deep medial fat) For very deep and prominent NLFs, an indirect approach of enhancement may need to be complemented by mild direct correction of the NLFs (injection of dermal fillers). In addition, inferior nasolabial volume excess and mid-face ptosis may also need to be addressed.32

(corticosteroids, filler materials: paraffin, silicone oil, bovine collagen, polymethylmethacrylate, hyaluronic acid, and calcium hydroxyapatite). The transitory sight loss was reported in three patients; one who received corticosteroids for alopecia areata, another patient following injection of hyaluronic acid in the glabellar area and in the cheeks, whose vision recovered completely after prompt administration of acetazolamide, and, in the third patient, there was complete recovery of visual acuity, following injection of calcium hydroxyapatite for nose augmentation,

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Aesthetics aestheticsjournal.com Figure 6: The facial artery is one of the branches of the external carotid artery. It supplies blood to the structures of the face. The location of the facial artery and its course are extremely important with respect to dermal filler injection for the removal of nasolabial creases. Detailed understanding of vascular anatomy of the facial artery will encourage safe clinical administrations during injectable treatments to the nasolabial fold and nasojugal groove.

in addition to other symptoms, (intraocular inflammation, oculomotor nerve palsy and skin necrosis), except dilated pupils, after treatment with oral and topical corticosteroid tapers.36 The upper and lower lips, the perioral region and the nasolabial folds have been noted as areas that were injected when visual impairment occurred.34, 36-38 Park et al studied iatrogenic retinal artery occlusion caused by cosmetic facial filler injections. The study included 12 patients with retinal artery occlusion associated with cosmetic facial filler injection. All the patients reported to have immediate sudden visual loss after the injections. It is worth noting that all patients were healthy apart from one patient who had hypertension. In seven cases autologous fat was injected, in four cases hyaluronic acid was injected and in one case collagen was injected. The injection sites included the glabellar region in seven cases, the nasolabial fold in four cases and both regions in one case.34 As Park et al described, while attempting to inject the NLFs, an injection into either of the following can cause retrograde embolism:34 • Anastomosis of the dorsal nasal artery from the ophthalmic artery • Angular artery • Lateral nasal artery from the facial artery Tissue necrosis can happen as the result of interruption of the vascular supply to the area by any of the following: 33, 39 • Compression of the area around the vessel • Obstruction of the vessel by the filler material

Symptoms of tissue necrosis include prolonged blanching and possibly pain at the site of injection, followed by a dusky, purple discolouration.33 When suspecting vascular compromise, injection should be discontinued and hyaluronidase injected,40 in addition to application heat and nitroglycerin paste (at the clinic and at home by the patient) to induce vasodilation, and the affected area should be massaged.33, 39 In addition to sound knowledge of anatomy, tips and techniques suggested by Lazzeri et al can be employed to reduce the risk of intravascular injection include:36 • Aspiration recommended, however limited efficacy has been noticed • Slow injections with the least amount of pressure possible • Avoid single deposits, the tip of the needle should be moved slightly, recommended to deliver the filler at different points along a line to minimise the chance of depositing a large amount of

material into an artery • Fractionated incremental injections, limiting to 0.1ml of filler regardless of the filler type used • Use of small syringes in attempt to reduce speed and pressure • Repeated treatments with smaller volumes • When possible, use of blunt, flexible micro-cannulas and nontraumatic flexible blunt-tip needles

Conclusion Other non-surgical methods for improving the appearance of a patient’s NLFs include non-ablative radiofrequency, injection of botulinum toxin A and the use of threads.6-8, 41 With all of these options, the patient’s smile pattern and nasolabial fold in animation should be carefully analysed during treatment planning to prevent interference with facial expression. The key to successful correction of NLFs and achieving patient satisfaction is a combination of correct diagnosis of what is causing the folds and careful patient selection. Understanding the primary processes in an ageing mid-face, such as skeletal remodelling and the ptosis of the subcutaneous and cutaneous components of the cheek mass, results in better patient education and a more systematic treatment planning. In addition, knowledge of the age-dependent changes of the fat compartments will lead to natural volume redistribution and a more precise consumption of filler product with accurate application. While the NLFs can of course continue to be treated directly with dermal fillers, this only introduces padding between the dermis of the lip and the superolateral border of the orbiculari oris muscle. This results in a softening, but could also result in a medialisation (movement to the middle) of the fold, which can potentially worsen the appearance of the NLFs. In my opinion, an ideal treatment approach involves the elevation and suspension of the ptotic fat pads, with support of the attenuated facial ligaments, and augmentation of lost volume. The correction of the volume loss and ptosis should therefore be the primary aim of rejuvenation. This may involve use of multiple treatment options, techniques and treatment sessions. The appearance of youth is directly correlated to contours, proportions and the quality of the soft tissues and skin. With a correct knowledge of anatomy, ageing process and changes, as well as product characteristics, practitioners can combine direct and indirect approaches to achieve a desirable aesthetic outcome. Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine.

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


103428 DermaluxTrade Ad 2:Layout 1 02/07/2015 17:45 Page 1

REFERENCES 1. Gosain AK, Amarante MT, Hyde JS, et al, ‘A dynamic analysis of changes in the nasolabial fold using magnetic resonance imaging: implications for facial rejuvenation and facial animation surgery’, Plast Reconstr Surg, (1996) 98(4) p.622-636. 2. Wulc AE, Sharma P, Czyz CN, ‘The anatomic basis of midfacial aging. Midfacial Rejuvenation’, Springer, (2012) p.15-28. 3. Zufferey J, ‘Anatomic variations of the nasolabial fold’, Plast Reconstr Surg, (1992) 89(2) p.225-231; discussion p.232-223. 4. Pessa JE, Zadoo VP, Yuan C, et al, ‘Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls,’ Plast Reconstr Surg, (1999) 103(2) p.635-644. 5. Monheit GD, Coleman KM, ‘Hyaluronic acid fillers’, Dermatologic therapy, (2006) 19(3) p.141-150. 6. Jacobson LG, Alexiades-Armenakas M, Bernstein L, et al, ‘Treatment of nasolabial folds and jowls with a noninvasive radiofrequency device’, Archives of dermatology, (2003) 139(10) p.1371. 7. Kane MA, ‘The effect of botulinum toxin injections on the nasolabial fold’, Plastic and reconstructive surgery, (2003) 112(5) p.66S-72S. 8. Sulamanidze MA, Fournier PF, Paikidze TG, et al, ‘Removal of Facial Soft Tissue Ptosis With Special Threads’, Dermatologic Surgery (2002) 28(5) p.367-371. 9. Wu WTL, ‘Barbed Sutures in Facial Rejuvenation’ 2004. 10. Ducic Y, Hilger PA, ‘The aesthetic challenges of the nasolabial fold’. 11. Rohrich RJ, Pessa JE, Ristow B, ‘The youthful cheek and the deep medial fat compartment’, Plast Reconstr Surg, (2008) 121(6):2 p.107-2112. 12. Rohrich RJ, Pessa JE, ‘The fat compartments of the face: anatomy and clinical implications for cosmetic surgery’, Plast Reconstr Surg (2007) 119(7) p/2219-2227; discussion p.2228-2231. 13. Benedetto A, ‘Botulinum Toxins in Clinical Aesthetic Practice’, CRC Press (2011). 14. Ozdemir R, Kilinc H, Unlu RE, et al, ‘Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication’, Plastic and reconstructive surgery, (2002) 110(4) p.1134-1147; discussion p.1148-1139. 15. Gierloff M, Stohring C, Buder T, et al., ‘Aging changes of the midfacial fat compartments: a computed tomographic study’, Plast Reconstr Surg, (2012) 129(1) p.263-273. 16. Gosain AK, Klein MH, Sudhakar PV, et al, ‘A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation’, Plast Reconstr Surg. (2005) 115(4) p.1143-1152; discussion p.1153-1145. 17. Yousif NJ, Gosain A, Sanger JR, et al., ‘The nasolabial fold: a photogrammetric analysis’, Plast Reconstr Surg (1994) 93(1) p.70-77. 18. Farkas JP, Pessa JE, Hubbard B, et al. ‘The Science and Theory behind Facial Aging’, Plastic and Reconstructive Surgery Global Open, (2013) 1(1) e8-e15. 19. Barton Jr FE, Gyimesi IM, ‘Anatomy of the nasolabial fold’, Plastic and reconstructive surgery, (1997) 100(5) p.1276-1280. 20. Le Louarn C, ‘Muscular aging and its involvement in facial aging: the Face Recurve concept’, Ann Dermatol Venereol, (2009) 136 Suppl 4 p.S67-72. 21. Mendelson BC, ‘Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation’, Plast Reconstr Surg, (2001) 107(6) p.1545-1552; discussion 1553-1545, 15561547, 1558-1561. 22. Rossell-Perry P, ‘The zygomatic ligament of the face: a critical review’, OA Anatomy (2013) 1(3). 23. Rohrich RJ, Pessa JE, ‘The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments’, Plastic and reconstructive surgery, (2008) 121(5) p.1804-1809. 24. Pessa JE, Zadoo VP, Mutimer KL, et al., ‘Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging’, Plast Reconstr Surg, (1998) 102(1) p.205-212. 25. Bodic F, Hamel L, Lerouxel E, et al., ‘Bone loss and teeth’, Joint Bone Spine, (2005) 72(3) p.215221. 26. Jahangiri L, Devlin H, Ting K, et al., ‘Current perspectives in residual ridge remodeling and its clinical implications: A review’, The Journal of Prosthetic Dentistry, (1998) 80(2) p.224-237. 27. Schwartz-Dabney CL, Dechow PC, ‘Edentulation alters material properties of cortical bone in the human mandible’, J Dent Res, (2002) 81(9) p.613-617. 28. Sofat A, Galhotra V, Gambhir RS, et al., ‘An Analysis of the Vertical Bone Loss in Edentulous Mandibles by Using the Mental Foramen as a Reference: A Radiographic Study’, Journal of Clinical and Diagnostic Research : JCDR, (2013) 7(7) p.1508-1510. 29. Xie Q, Ainamo A, Tilvis R, ‘Association of residual ridge resorption with systemic factors in homeliving elderly subjects’, Acta Odontol Scand, (1997) 55(5) p.299-305. 30. Sutton DN, Lewis BRK, Patel M, et al., ‘Changes in facial form relative to progressive atrophy of the edentulous jaws’, International Journal of Oral and Maxillofacial Surgery, (2004) 33(7) p.676-682. 31. Nahai F, ‘The Art of Aesthetic Surgery: Principles and Techniques’, CRC Press (2010). 32. Gierloff M, Stöhring C, Buder T, et al., ‘The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides’, Journal of Plastic, Reconstructive & Aesthetic Surgery, (2012) 65(10) p.1292-1297. 33. Grunebaum LD, Bogdan Allemann I, Dayan S, et al, ‘The risk of alar necrosis associated with dermal filler injection’, Dermatol Surg, (2009) 35 Suppl 2:1635-1640. 34. Park SW, Woo SJ, Park KH, et al, ‘Iatrogenic retinal artery occlusion caused by cosmetic facial filler injections’, Am J Ophthalmol, (2012) 154(4) p.653-662.e651. 35. Lee DH, Yang HN, Kim JC, et al., ‘Sudden unilateral visual loss and brain infarction after autologous fat injection into nasolabial groove’, The British Journal of Ophthalmology, (1996) 80(11) p.1026-1027. 36. Lazzeri D, Agostini T, Figus M, et al., ‘Blindness following cosmetic injections of the face’, Plast Reconstr Surg, (2012) 129(4) p.995-1012. 37. Al-Hoqail RA, Meguid EM, ‘Anatomic dissection of the arterial supply of the lips: an anatomical and analytical approach’, J Craniofac Surg, (2008) 19(3) p.785-794. 38. Tansatit T, Apinuntrum P, Phetudom T, ‘A typical pattern of the labial arteries with implication for lip augmentation with injectable fillers’, Aesthetic Plast Surg (2014) 38(6) p.1083-1089. 39. Cohen JL, ‘Understanding, Avoiding, and Managing Dermal Filler Complications’, Dermatologic Surgery, (2008) 34:S92-S99. 40. Hirsch RJ, Cohen JL, Carruthers JD, ‘Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase’, Dermatologic surgery, (2007) 33(3) p.357-360. 41. Paul MD, ‘Using barbed sutures in open/subperiosteal midface lifting’, Aesthetic Surgery Journal, (2006) 26(6) p.725-732.

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Treating a Bell’s Palsy Patient Dr Nestor Demosthenous discusses the use of botulinum toxin, dermal filler and threads to improve a Bell’s Palsy patient’s facial asymmetry Aetiology Bell’s Palsy is an acute, unilateral, peripheral, lower motor-neuron facial nerve paralysis, and the most common cause of unilateral facial paralysis worldwide.1 It affects 60-70% of unilateral facial paralysis sufferers,1 and in 80-90% of cases gradually resolves over time.1 The aetiology and pathophysiology of Bell’s Palsy is unclear. It is thought to be a polyneuritis disorder with possible viral, inflammatory, autoimmune, and ischaemic influences. Good evidence suggests that herpes simplex type I and herpes zoster virus reactivation from cranial-nerve ganglia play a role in its development.2 The facial nerve courses through the temporal bone at the facial canal. Oedema and ischaemia may result in compression of the facial nerve at this point (peripheral to the nerve’s nucleus). This compression has been seen in MRI scans with facial nerve enhancement.3 Bell’s Palsy affects between 20-40 people for every 100,000 in the UK each year.4 Peitersen et al2 found that one third of patients had an incomplete paralysis, while the remaining two thirds suffered from complete paralysis. Of these patients, 85% showed signs of recovery within three weeks of developing Bell’s Palsy, 71% had complete recovery, 13% had slight sequelae, and 16% had residual weakness, synkinesis and/or contracture. Patients with incomplete lesions had a 94% rate of return to normal function, while only 60% of those with clinically complete lesions returned to normal function. Diagnosis The diagnosis of Bell’s Palsy must be made on the basis of a thorough history and physical examination, as well as the use of diagnostic testing when necessary. It is a diagnosis of exclusion. Onset is typically sudden, with symptoms peaking in less than 48 hours. These include the acute onset of unilateral upper- and lower-facial paralysis, auricular pain, decreased tearing and blurred vision, as well as taste disturbances.5 Paralysis can take place on the forehead and lower aspect of the face. Late manifestations include mild, generalised mass contracture of the facial muscles, rendering the affected palpebral fissure narrower than the opposite one, aberrant regeneration of the facial nerve with motor synkinesis, reversed jaw winking (i.e. contracture of the facial muscles with twitching of the corner of the mouth or dimpling of

Aesthetics

the chin occurring simultaneously with each blink).2 Facial spasm is a very rare complication of Bell’s Palsy and occurs as tonic contraction of one side of the face.2 To objectively describe facial function, the House-Brackmann facial nerve grading system is most commonly used. It is a widely accepted system, which, in my opinion, is simple, sensitive, accurate and reliable. It grades facial function in six steps from normal (HB I) to total paralysis (HB VI).6 Treatment options Treatment of Bell’s Palsy should be supportive and guided by the severity and probable prognosis in each particular case. Studies have shown the benefit of high-dose corticosteroids for acute cases.7 Rehabilitative treatment includes eye care (eye drops for lubrication) and physiotherapy (incorporating facial muscle exercises to improve muscle tone and strength).8,9 Botulinum toxin injections can be used to treat either the affected or the unaffected side of the face in some people with long-term Bell’s Palsy, by relaxing any facial muscles that have become tight, or to reduce muscle activity of the unaffected side and balance the movement of the face.8 In cases where the palsy is prolonged, surgical management is best. Procedures are aimed at protecting the cornea from exposure, and achieving facial symmetry. These include crossfacial nerve grafts, nerve transfers and muscle and tendon transfers.8 Nerve function cannot be restored, but surgery serves to reduce the need for constant use of lubrication drops, improve the position of the mouth, and help with speech, eating, drinking and facial symmetry.10,11 Side effects There are currently no published studies regarding risks and complications following the use of Silhouette Soft threads. Risks of both thread treatment and dermal fillers include, more commonly, bruising and swelling, and far less commonly, haematoma and infection. As advised by Sinclair Pharma, there have only ever been three reported cases of infection following treatment with Silhouette Soft, all of which were treated with a course of oral antibiotics. Further risks from using threads are anecdotal, based on my personal and colleagues’ experience, and include puckering and dimpling of the skin, which almost always resolves within the first few days. There is a theoretical risk of sensory nerve injury, as would be expected with any procedure using an instrument in the subcutaneous layer, however, I have not seen this in my practice or heard of it amongst colleagues.

The aetiology and pathophysiology of Bell’s Palsy is unclear. It is thought to be a polyneuritis disorder with possible viral, inflammatory, autoimmune, and ischaemic influences

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


Case Study Bell’s Palsy

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Figure 1: Configuration of Silhouette Soft 12 cone threads

Aesthetics Journal

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Figure 2: Configuration of Silhouette Soft 12 cone threads

Number of cones in images do not represent the actual number of cones used

Case study Patient A Patient A is a 58-year-old female with an eight-year history of Bell’s Palsy. She had developed sudden onset, complete right-sided idiopathetic facial paralysis, which was diagnosed as Bell’s Palsy following neurologist-led investigations. Patient A is in the minority of cases where the condition did not spontaneously resolve. Although she received supportive treatment, it was decided that she was not a candidate for surgical correction to improve the residual asymmetry, and had therefore been actively seeking non-surgical correction. Patient A was offered supportive treatment for her condition, which included eye drops and physiotherapy on behalf of the NHS. Surgical intervention was considered to carry too high a risk of bilateral manifestation of her palsy, thus she sought a non-surgical procedure to help correct her profound facial asymmetry. Presentation of Bell’s Palsy On inspection, Patient A had obvious facial asymmetry at rest. There was a question of contracture of the zygomaticus major and/or minor. This was associated with malar fat

Before treatment

34

Two weeks after Silhouette Soft threads, dermal fillers and botulinum toxin treatment

atrophy, resulting in descended right cheek tissue and a deep right-sided nasolabial fold. Right-sided brow ptosis was present, including upper and lower lip asymmetry at rest. On examination, right-sided frontalis and depressor anguli oris activity was absent, with only weak orbicularis occuli and oris activity on maximal effort (House-Brackman V). Evidence of muscle synkinesis was present – when the patient closed her eyes, the right corner of her mouth pulled laterally with hyperactivity of the right belly of the mentalis. On her left unaffected side, inspection and examination revealed normal muscle activity, with normal facial ageing, resulting in facial fat pad atrophy with resultant tissue descent. Patient A’s concerns were predominantly cosmetic. They related to mid-face and lower-face asymmetries at rest. Midfacial asymmetry was largely due to a profound right-sided nasolabial fold and volume depletion in the malar and lateral cheek area. It was felt that dermal filler treatment alone was not adequate to re-volumise the depletion and soften the nasolabial fold, therefore soft tissue transposition would form the cornerstone of correction. This would be achieved through non-surgical means as much as possible, using threads. Brow ptosis, lip and chin-dimpling asymmetry was felt to be the result of both altered muscle activity and volume loss. Dermal fillers and targeted botulinum toxin injections would therefore comprise the treatment for these.

Three months after Silhouette Soft threads, dermal fillers and botulinum toxin treatment

Aesthetics | August 2015

The treatment process I corresponded with Patient A’s GP to confirm her diagnosis, discuss previous investigations, treatments and consultations from the relevant specialties (and to exclude any potential contraindications to treatment), as well as discuss the patient’s wishes and my treatment plan for her. Patient A’s treatment was carried out in three stages.


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The first phase comprised the administration of botulinum toxin. This included injections into her left orbicularis occuli (below the right lateral eyebrow) to weaken any depressor function that was remaining to achieve some lift. Further injections were administered into the left depressor anguli oris to elevate the patient’s left corner of her mouth. Finally, botulinum toxin was injected into her mentalis muscles bilaterally. Six threads (12 cone, three on each side) were sited in phase two of treatment (week one), in the directions illustrated in Figures 1 and 2. This procedure is not carried out sterile, and it does not require to be as it is a minimally invasive procedure siting a biodegradable, non-permanent device – however, 0.5% chlorhexidine gluconate was used for skin antisepsis, three times. The drapes, gloves, instrument pack and threads used were all opened sterile. The products used are absorbable poly-lactic acid threads that are sited in the subcutaneous fatty tissue with small lactide-glycolide cones. The cones provide traction to soft tissue, allowing instant mechanical transposition of soft tissue in the sited vector. Twelve weeks after the treatment, thread resorption stimulates fibroblast activity, which results in collagenosis of structured Type I collagen, which, in turn, creates a biological lift. Once entry and exit holes of the threads had epithelialised, and any bruising had subsided, phase three (week two) of the treatment was carried out. This consisted of hyaluronic acid dermal filler treatment as follows: • • •

0.5ml of a medium thickness dermal filler was sited with a cannula below the lateral aspect of the right eyebrow. 0.5ml of the same filler was sited into the left temple area (1cm above and 1cm lateral to the temporal ridge). 1ml of a soft, medium thickness filler was used to volumise

Conclusion Bell’s Palsy is an idiopathic facial paralysis that spontaneously resolves in the vast majority of cases. It can, however, be life altering to the few it persists, affecting patients’ confidence and quality of life. Patient A was forced to take early retirement three years after onset as she became very self-conscious and aware of what she felt was a ‘disfigurement’. The NHS offers many supportive treatments, and even surgical interventions to improve the cosmetic appearance of these patients, however, it is not always possible to offer all patients these procedures. In my experience, I have found that threads offering a mechanical lift are an effective way of addressing some of the soft tissue facial asymmetry, combined with dermal filler to restore volume in key areas, and, finally, targeted botulinum toxin to weaken depressor muscles and improve appearance. The threads used offer an instant mechanical lift and delayed biological lift. Patient A is not a typical candidate for thread treatment due to the extent of facial fatty tissue, however it was felt that with enough threads, vectored in a specific configuration, this treatment could provide her with a better result than she currently had, following the onset of her facial palsy.

Case Study Bell’s Palsy

predominantly the left section of the upper and lower lips, redefine the ‘cupid’s bow’ and achieve vertical projection. • 1ml of a thick volumising filler was used to achieve greater symmetry as well as projection and elongation of the chin. • 1ml of a very thin, soft filler was used to improve transition of the lid cheek junction bilaterally. • Finally, 0.5ml of dermal filler was used to further soften the left nasolabial fold and 0.5ml was used in the left marionette line. At this point, Patient A was keen to undergo botulinum toxin injections in the glabella area, so this treatment was also carried out. The final result after dermal filler treatment at week two and follow-up pictures at three months post procedure can be seen in Figure 3. Post-procedure care Patient A was followed up seven days after botulinum toxin treatment, four days after her thread treatment, and then weekly for a month following this. She was seen again in clinic three months following her initial treatment. Patient A will continue to be seen at six, nine and 12 months post-treatment. Post-procedure advice and care was given both verbally and in writing following treatment. This included strict instructions to avoid strenuous facial activity (e.g forceful chewing), as well as avoiding facial massage or sleeping on her side. Antibiotic ointment (Fucidin 2%) was given to Patient A to apply twice a day on entry and exit points of the threads for four days post procedure. Although there is little evidence that topical antibiotic application a number of days after treatment is of greater benefit than immediate post-treatment application on the first day, it was felt that this was appropriate in Patient A’s case given the extent of treatment she underwent. Dr Nestor Demosthenous obtained his medical degree and BSc Hons Neuro from the University of Edinburgh in 2006. He has completed core surgical training followed by four years as a clinical fellow in Trauma and Orthopaedic Surgery. Dr Demosthenous is an experienced aesthetic practitioner and has completed advanced and masterclass training in aesthetic medicine. Disclosure Dr Demosthenous is a UK trainer for Silhouette Soft non-surgical facial thread lifting for Sinclair Pharma, and is the lead trainer in Scotland. REFERENCES 1. Peitersen E, ‘Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies’, Acta Otolaryngol Suppl, (2002) pp. 4-30. 2. Peitersen E, ‘The natural history of Bell’s palsy’, Am J Otol, 4(2) (1982) pp. 107-11. 3. Seiff SR, Chang J, ‘Management of ophthalmic complications of facial nerve palsy’, Otolaryngol Clin North Am, 25(3) (1992) pp. 669-90. 6. Bell’s Palsy: What is Bell’s palsy (UK: Facial Palsy, 2015) <http://www.facialpalsy.org.uk/aboutfacial-palsy/causes-diagnoses/bells-palsy/37> 6. Danette C, Taylor Bells Palsy clinical presentation, (Medscape, 2015) <http://emedicine. medscape.com/article/1146903-clinical> 7. Yen TL1, Driscoll CL, ‘Significance of House-Brackmann facial nerve grading global score in the setting of differential facial nerve function’, Otol Neurotol, 24(1) (2003), pp. 118-22. 8. Sullivan FM, Swan IR, Donnan PT, Morrison JM, Smith BH, McKinstry B, ‘Early treatment with prednisolone or acyclovir in Bell’s palsy’, N Engl J Med, 18. 357(16) (2007) pp. 1598-607. 9. Bell’s Palsy: Treatment (NHS Choices, 2014) <http://www.nhs.uk/Conditions/Bells-palsy/Pages/ Treatment.aspx> (accessed 21st May 2015) 10. Cardoso JR, Teixeira EC, Moreira MD, Fávero FM, Fontes SV, Bulle de Oliveira AS, ‘Effects of exercises on Bell’s palsy: systematic review of randomized controlled trials’. Otol Neurotol. Jun. 29(4) (2008), pp. 557-60. 11. Olver JM, ‘Raising the suborbicularis oculi fat (SOOF): its role in chronic facial palsy’, Br J Ophthalmol, 84(12) (2000) pp.1401-6. 12. Facial Palsy: Surgery (UK: British Association of Plastic Reconstructive and Aesthetic Surgeons, 2015) <http://www.bapras.org.uk/public/patient-information/surgery-guides/facialpalsy#What surgery is available?>

Aesthetics | August 2015

35


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skin laxity.2 Long- term exposure to UV radiation is also associated with an increased risk of skin cancer – most commonly squamous cell carcinoma and basal cell carcinoma – due to the creation of free radicals.2

Sun Protection: The Facts Balsam Alabassi and Lorna Bowes explain how sunscreen works to protect skin from UV radiation Consumers are becoming increasingly aware of the differences between UVA and UVB radiation and the varying effects that environmental factors such as UV and pollution have on the skin. Aesthetic practitioners need to ensure that they are giving their patients the right information and advice on sun and skin protection. When discussing sun protection as it relates to aesthetic practice, there are a number of different topics that need to be covered: what is ultraviolet radiation and what effect does it have on the skin; what skin conditions can be exacerbated by exposure to UV rays (a subject not covered in this article); what ingredients can provide adequate protection from the sun; ingredients that are also photoprotective; and what amount of sunscreen should be applied and how frequently. UV radiation – what is it? Ultraviolet (UV) radiation is categorised by wavelength as UVA, UVB and UVC. UVC radiation (wavelength 320-400) is absorbed by the ozone layer and has no effect on the skin,1 so this article is concerned only with UVA and UVB rays. Even on a cloudy day, more than 80% of UV radiation makes it through the clouds, and exposure can be increased by other factors – both sand and snow reflect the rays, causing an increase in UV exposure of 20% and 80% respectively.1 What does UV radiation do to the skin? UV radiation is an oxidative process that stimulates the production of free radicals (unstable oxygen molecules that have lost one of their two electrons), which cause cellular damage. It has both immediate and long-term effects on the skin.2 Some of the immediate effects of the sun on the skin are DNA damage, immunosuppression and sunburn. Sunburn is caused by UVB radiation2 and is a physiological reaction to over-exposure to the sun. This process, known as apoptosis, is a form of cell suicide, where the keratinocytes – the cells that form a barrier to protect the skin from environmental damage – are broken down in an attempt to minimise the risk of skin cancer.3 Both UVA and UVB rays can cause long-term damage to the skin, although UVA is the root cause of accelerated ageing, as UVA rays can penetrate the dermis and be absorbed by fibroblasts and stimulate matrix metalloproteinases (MMPs).4 This reduces fibrillin and collagens I, III and VII, and increases elastotic material, all of which contribute to the visible effects of ageing: lines, wrinkles, volume loss and

Ingredients to look for Broadly speaking, sunscreen ingredients can be divided into physical and chemical sun blocks. The most common physical blocks are zinc oxide, titanium dioxide and iron oxide, all of which physically block the sun’s rays from entering the skin.5 Chemical sunscreens, however, such as phenylbenzimadole sulfonic acid, avobenzone and octyl methoxycinnamate, work by absorbing the UV radiation themselves.6 Both physical and chemical sunscreens have their disadvantages; historically it has been almost impossible to find a physical block that doesn’t leave a tint on the skin, which can be frustrating for those with darker skin. New techniques are allowing products to be formulated with far smaller particles of physical filters such as titanium dioxide and zinc oxide.7 As such lightweight, photostable, virtually transparent, fluid, broad spectrum, mineral sun protection at SPF50 is a reality. Chemical sunscreens, whilst previously preferable on an aesthetic basis, can cause dermatitis or photocontact allergy.8 Antioxidants Antioxidants can fight the effect of free radicals, and it has been proven that a combination of both oral and topical antioxidants provides antioxidative activity in different structures, and can inhibit the effects of UV radiation and prevent skin damage.9,10 Potent antioxidants include vitamins C and E, and more recently polypodium leucotomos, a tropical fern extract known to have significant antioxidant properties.9 One specific effect of UV exposure is lipid peroxidation in cell membranes and mitochondria leading to cell damage.11 In addition, the ingredient maltobionic acid has been shown to reduce the production of malondialdheyhde, an oxidative degradation product, as well as inhibit UVinduced lipid peroxidation.12 Lactobionic, another bionic polyhydroxyacid, is a powerful metal chelator, and additionally has been shown to improve barrier function12 and prevent inflammation.13 A further study reviewed lactobionic acid looking specifically at capacity for MMP inhibition and lipid peroxidation. The study demonstrated strong in vitro MMP inhibition as well as the capacity to block collagen degradation, helping to preserve the skin matrix in photoaged and naturally ageing skin.14 The polyhydroxyacid, gluconolactone is a cell nutrient and antioxidant15 that also exhibits MMP inhibition, increased viable epidermal thickness and increased glycosaminoglycans.16 Reducing unwanted pigmentation There are many ingredients shown to reduce hyperpigmentation, of those already discussed above,

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The vitamin D debate Vitamin D deficiency is becoming an increasing problem, as we become more aware of the risks of exposure to the sun. In a 2008 study, Holick showed that sunlight is the main source of vitamin D for humans, as it is very difficult to derive adequate vitamin D from food, and we rely on UVB photons to synthesise vitamin D3.22 Sadly, the use of sunscreens does have a negative impact on vitamin D3 synthesis, and it is important to be aware of the importance of vitamin D when advising patients on sun protection. Vitamin D deficiency is associated with rickets, growth retardation and osteoporosis, as well as increasing the risk of certain cancers and autoimmune diseases.2 To avoid this, it may be advisable to recommend that patients take a daily supplement of vitamin D.

maltobionic acid inhibits MSH-stimulated melanogenesis and so as well as being a powerful antioxidant, it is also a pigment-evening agent.17 Likewise, lactobionic acid has been shown to effectively inhibit UV-triggered melanin synthesis helping to prevent hyperpigmentation in sun-exposed skin.18 How can we advise patients on sun protection? In general, patients can work out how frequently they need to reapply their chosen sunscreen by multiplying the SPF by the length of time it takes for their skin to burn without sunscreen – for example, if they usually burn in ten minutes and they are using a product with an SPF of 10, their skin will be protected for 100 minutes, after which they will need to apply more sunscreen.19 If your patient has been undergoing treatment that is likely to affect the natural barrier provided by the skin – a chemical peel or laser treatment, for example – then it is essential to recommend a higher, broad-spectrum SPF.

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will only provide protection against UVB radiation. Whilst this will prevent burning, and offer some protection against skin cancer, it will not affect UVA radiation, which is the main culprit when it comes to accelerated ageing and other skin concerns.20 It is also important to note that no sun protection product is truly waterproof – products are now described only as ‘water resistant’ and should be reapplied after contact with water – and that use-by-dates are as important for sunscreens as for any other product. If a sunscreen has exceeded its expiry date, it may well be ineffective. Conclusion A broad-spectrum sunscreen, with an absolute minimum SPF of 15+ should be used daily, throughout the year, regardless of the weather for exposed skin. However, as an aesthetic practitioner, it is vital that you take into account any procedures your patient has undergone that may necessitate a higher SPF, and that you advise on the manner of application – a minimum of 30ml should be used to cover the whole body, and this should be reapplied at least every two hours, more often if the patient comes into contact with water, unless the product is one of a new breed of ‘all-day-wear’ sun protection. Ensure that your patient is aware of the importance of checking the expiry date on their sunscreen, and suggest the use of oral and topical antioxidants, as well as ingredients to support barrier functions and reduce the risk of pigmentary disorders, alongside or even within sun product application to maximise skin protection. Aesthetic practitioners can and should play a vital role in helping patients to protect their skin from the sun, as this can have a dramatic effect on the need for future treatments, as well as preventing cancer and other sun-induced skin conditions such as photodamage and associated aesthetic changes. Balsam Alabassi is a pharmacist with degrees in both pharmacy and pharmacology. She has qualifications in advanced skincare and skin rejuvenation, and writes regular blog posts on maintaining health and wellbeing. Alabassi will begin a diploma in cosmetic science in October of this year.

Why broad spectrum? SPF 15 protects against more than 93% of UVB rays, and there is only a slight increase in that protection to 97% with an SPF of 30+, and 98% for SPF 50+.20 In fact, the level of SPF is less important than the amount of product applied and exposure to water or sweat. NICE guidelines now state that provided it is applied properly, SPF 15+ is sufficient to protect the skin from the sun, however, a higher, broad spectrum SPF is recommended by most dermatologists.21 Unless the sunscreen used is broad spectrum, covering a wide range of wavelengths, it

Lorna Bowes is an aesthetic nurse and trainer with an interest in dermatology. She is formerly a committee member of the Royal College of Nursing Aesthetic Nurse Forum and a founding member of the British Association of Cosmetic Nurses. With extensive experience of delivering aesthetic procedures, Bowes trains and lectures regularly on procedures and business management in aesthetics. Lorna is director of Aesthetic Source.

REFERENCES 1. Office of Air and Radiation, UV Radiation (United States: Environmental Protection Agency, 2010) <http://www.epa.gov/sunwise/doc/uvradiation.html> 2. Health effects of UV radiation (World Health Organization, 2015) <http://www.who.int/uv/health/en/> 3. Alberts B et al, Programmed Cell Death (Apoptosis), (US, Molecular Biology of the Cell, 2002) http:// www.ncbi.nlm.nih.gov/books/NBK26873/ 4. Fisher GJ et al, ‘Molecular basis of sun-induced premature skin aging and retinoid antagonism’, Nature, 379(3653) (1996), pp.335-9. 5. Fallick H, A Guide to Light Protection, (US, Dermascope, 2015) < http://www.dermascope.com/sun/aguide-to-light-protection#.Vagj-3jIbHg> 6. Physical vs Chemical Suncreen, (US, Skinacea, 2015) <http://www.skinacea.com/sunscreen/ physical-vs-chemical-sunscreen.html#.VagleXjIbHg> 7. UV Filter Chart: Suncreen Active Ingredients, (US, Skinacea, 2015) <http://www.skinacea.com/ sunscreen/uv-filters-chart.html#.VagmNXjIbHg> 8. Dean SW et al, ‘Development of assays for the detection of photomutagenicity of chemicals during exposure to UV light—1. Assay development’, Mutagenesis, 6(5) (1991), p.335. 9. Middlekamp-Hup MA et al, ‘Orally administered polypodium leucotomos extract decreases psoralen-UVA-induced phototoxicity, pigmentation and damage of human skin’, Journal of the American Academy of Dermatology, 50(1) (2004) pp.74-82. 10. Passi S et al, ‘The combined use of oral and topical lipophilic antioxidants increases their levels both in sebum and stratum corneum’, Biofactors, 18(1-4) (2003), pp,289-97. 11. Ganesh N et al, UV-Induced Cell Death In Plants, (US, Int J Mol Sci, 2013) http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3565337/< 12. Hachem JP et al, ‘Acute acidification of stratum corneum membrane domains using polyhydroxyl

acids improves lipid processing and inhibits degradation of corneodesmosomes’, J Invest Dermatol, (2009); doi:10.1038/jid.2009.249. 13. Hatano Y et al, ‘Maintenance of an acidic stratum corneum prevents emergence of murine atopic dermatitis’, J Invest Dermatol, (2009) pp.1824-35. 14. Upadhya GA, Strasberg SM, ‘Glutathione, lactobionate, and histidine: cryptic inhibitors of matrix metalloproteinases contained in University of Wisconsin and histidine/tryptophan/ketoglutarate liver preservation solution’, Hepatology. 2000 31(5) pp.1115-22. 15. Bernstein EF et al, ‘The polyhydroxy acid gluconolactone protects against ultraviolet radiation in an in vitro model of cutaneous photoaging’, Dermatol Surg, 30(2 Pt 1) pp.189-95. 16. Grimes PE et al, ‘The use of polyhydroxy acids (PHAs) in photoaged skin’, Cutis 73(2 Suppl) pp. 3-13. 17. Brouda I et al, ‘Matobionic Acid, a powerful yet gently skincare ingredient with multiple benefits to protect skin and reverse the visible signs of ageing’, Poster Exhibit at the Summer Academy Meeting of the American Academy of Dermatology, Chicago, IL, August 4-8, 2010. 18. Brouda I et al, ‘Lactobionic acid anti-ageing mechanisms: antioxidant activity, MMP inhibiton, and reduction of melanogensis’, Poster Exhibit at the Summer Academy Meeting of the American Academy of Dermatology, Chicago, IL, August 4-8, 2010. 19. Barber J, ‘The Forever Factor’, New Horizons Communications, 2003, p94. 20. Reiche L, Ngan V, How to choose and use sunscreens (New Zealand, DermNet NZ, 2005 [updated 2012]) <http://www.dermnetnz.org/treatments/which-sunscreen.html> 21. National Institute for Health and Clinical Excellence, Skin cancer prevention: information, resources and environmental changes (United Kingdom, Nice.org.uk, 2011). 22. Holick MF, ‘Sunlight, UV-R radiation, vitamin D and skin cancer: how much sunlight do we need?’, Advances in Experimental Medicine and Biology, 624 (2008), pp1-15.

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Injection Rhinoplasty Dr Simon Ravichandran offers his advice on using hyaluronic acid to treat nasal deformities Introduction Rhinoplasty is a procedure for altering the structure, improving the function, and aesthetically enhancing the nose. Currently, the most common method of achieving this is with a surgical rhinoplasty. This article discusses a developing method of altering the shape of the nose non-surgically and provides anatomical advice for practitioners looking to incorporate this treatment into their clinic. Three groups of patients are suitable for consideration of injection rhinoplasty. These include those with small deformities that can easily be addressed in the clinic; patients who have defects that would benefit from formal rhinoplasty but are not ready to commit to a surgical procedure; and finally, post-rhinoplasty patients who can have an injection procedure to smooth out any residual roughness or depressions. Modern rhinoplasty Rhinoplasty is usually performed in one of two ways: the closed or open approach. The closed approach involves making incisions on the inside of the nose and manipulating the bones and cartilages from within. The closed technique has the advantage of no scarring to the external skin and a shorter post-operative recovery time.1 The external, open techniques involve exposing the bones and cartilage of the nose by lifting the skin through an incision in the columella. This has the advantage of creating a direct visualisation of the structures, allowing an anatomical correction of deformity, as well as allowing the use of tip-suturing techniques to restore the structure of the nasal tip with a greater degree of anatomical certainty. It has the disadvantage of creating a small external scar, and a slightly longer recovery time. Whichever method is employed, there are two main approaches to the correction of nasal deformity, and most surgeons will employ a degree of overlap between the two. The first will involve a restoration of the normal nasal anatomy, and the second will aim to camouflage the nasal defects. Camouflage involves the use of graft to fill any defects,1 which could include a supratip depression, a splayed tip or a depressed bony dorsum. The graft can be autologous using cartilage or fat; or exogenous using, for example, porous polyethylene implants or, more recently, hyaluronic acids (HAs).1

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HA use in rhinoplasty The evolution of modern injectable HAs has provided a novel material for the use in the camouflage of minor defects, either as part of a rhinoplasty procedure, or as a stand alone clinic procedure. HAs have four distinct advantages over other materials:  • The biodegradability of HAs allows them to be used as a pre-surgical treatment to enable a patient to visualise the result prior to proceeding to surgery. This is a useful tool for patients who may benefit from surgery, but are not quite ready to take the step.   • The ability of hyaluronidases to break down HAs allows for the product to be easily removed from patients who could be dissatisfied with the outcome.2 • The cost of HAs is considerably less than the cost of surgery, allowing treatment for the more budgetconscious patients. • As HAs can be injected with either no anaethesia, or simple topical anaesthesia, the procedures can be carried out quickly and safely in a clinic environment. As bleeding and bruising is minimal, the downtime is negligible. Disadvantages of HAs stem mainly from the properties that make it desirable: • The duration of action is from 12 to 18 months, whereas some patients may request longerlasting results.  • While HAs can be used to camouflage defects, they cannot correct structural anatomical abnormalities. Defects addressed with injection techniques The simplest deformities to address with injection rhinoplasty are the dorsal depressions. They may be congenital or acquired, and they may be primary, or secondary as a result of another deformity – for example, a dorsal hump giving the appearance of depression either above or below. In addition, dorsal nasal deformities are also common sequelae of previous surgical rhinoplasty.3 The two areas where dorsal depressions can occur are the supratip and the nasion. Both depressions may occur as a result of the natural ageing process, i.e. loss of glabella soft tissue volume leading to a nasion depression, and an agerelated laxity of the cartilaginous tip complex, resulting in dislocation of the crural cartridges from the upper lateral / bony dorsal complex.4 It is important to note that a dislocation may also present with tip elongation and tip ptosis. This is a result of age-related connective tissue weakness, as well as loss of inferior support that comes with maxillary resorption. Nasal tip deformities when mild may be treated with injection techniques in experienced hands, but would preferably be treated with rhinoplasty or tipplasty. The difference between the two is that rhinoplasty concerns the nasal bones, while tipplasty concerns reshaping the delicate cartilaginous structures that give shape and structure to the nasal tip. Other deformities that can be addressed are bony complex deviations, and depressed bony fractures that may be camouflaged, some mild nasal tip deformities, such as a box tip and mild nasal tip ptosis.5,6

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Nasal Anatomy When assessing the nasal deformity it is important to understand the underlying anatomy of the area in order to appreciate the effect the alteration may have on the function of the nose, as well as to appreciate the mechanism of potential complications.

Bones and cartilage The nasal skeleton is divided into subunits; there is a bony upper-third consisting of the frontal processes of the maxilla laterally, and the left and right nasal bones medially. Both frontal processes of maxilla and the nasal bones articulate with the frontal bone superiorly.7 The lower two-thirds of the nose have dorsal projection provided by the septal cartilage and lateral support provided superiorly by the upper lateral cartridges. Lateral support and tip shape is provided by the lower lateral cartridges, which are further subdivided into medial, intermediate and lateral crura.7

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horizontal rhytid forming over the upperthird of the nose.8 Levator labii superioris alaeque nasi runs laterally along the nose, attaching to the frontal process of the maxilla superiorly, and inserting into the skin of the nostril inferiorly. It is responsible for flaring of the nostrils as well as assisting with lip elevation. The other muscles are depressor septi nasi, the transverse nasalis and the dilator nares. Depressor septi nasi inserts into the skin in the upper lip, and is responsible for the ‘dancing’ nasal tip that is occasionally an aesthetic concern. Transverse nasalis compresses the nares and dilator nares, which dilates the nares. The muscles are all contained within the submucosal musculoaponeurotic system.

Blood supply and venous drainage

The skin on the nose is also divided into three vertical subunits. Superiorly the skin is thick, rapidly thinning towards skin overlying the dorsum of the nose in the middle-third, and thickening at the lower-third over the tip as the skin becomes sebaceous.7

The blood supply of the external nose stems from the facial artery. This divides near the angle of the mouth to give a superficial labial branch that gives rise to the columella branch, which runs under the skin of the columella in the body of depressor septi nasi. At the angle of the mouth, the main facial artery continues superiorly medially to the alar sulcus, where it runs up along the lateral wall of the nose to become the angular artery at the medial canthus. The venous drainage follows the arterial supply.9

Muscles

Sensory nerve supply to the nose

The nasal muscle lies deep to the skin and comprises the procerus muscle, which arises from the fascia overlying the inferior part of the nasal bones, and inserts to the skin between the eyebrows. The procerus muscle assists in pulling the eyebrows downwards in the frown or anger gesture. Prolonged use of procerus is causative of a

The ophthalmic and maxillary divisions of the trigeminal nerve supply the external part of the nose. Anaesthesia can therefore easily be achieved by a blockade of these nerves as they exit the skull from the infraorbital and supraorbital foramina. It is also very easy to achieve sufficient anaesthesia using topical anaesthetic creams, such as EMLA or LMX 4.9

Skin

Techniques Injection of HAs into the nasion area can correct volume depletion and camouflage a pseudo-depression caused by an osteocartilagenous dorsal hump. By increasing the profile and volume of the nasion area the base can appear narrowed, as loose deflated skin gets re-draped. It can also affect the horizontal rhytids caused by contraction of the procerus, as well as the nasal scrunch lines caused by contraction of nasalis and the medial fibres of obicularis oculi. I tend to use topical anaesthetic or no anaesthetic at all, depending on patient preference. Local infiltrations make the correction harder to judge as a result of their own volumising effect. In addition, the combination of supratrochlear and infraorbital nerve blocks can provide good regional anaesthesia, however, they can be uncomfortable for many patients.

Special considerations

The nasal valve The nasal valve area is the angle subtended by the cartilaginous septum and the upper lateral cartilage at the osteocartilaginous junction. A reduction in the angle of the nasal valve area will result in decreased nasal airflow.9 Any procedure that narrows the nasal valve has the potential to reduce nasal airflow and increase the sensation of nasal obstruction.10

The soft nasal cartilage The upper lateral and lower lateral cartilages of the nose provide the structural rigidity to the non-bony caudal two thirds of the external nose. They also provide resistance to in-drawing on nasal inspiration. The upper lateral cartilages are responsible for the rigidity of the nasal walls, and the lower lateral cartilages provide structure to the nasal tip and nostrils.9 The cartilages are paper thin and potentially susceptible to damage due to pressure necrosis from inappropriately placed implants.11  

The skin The skin of the nose has three distinct subunits. The skin is thicker over the nasion and superior bony dorsum, and thins over the bony pyramid of the middle - third of the nose and becomes thicker again over the tip.9 Injections under the thin skin of the middle-third can easily result in lumpiness or discolouration if placed too superficially. This is of specific concern when attempting to camouflage a deviation of the bony pyramid with contralateral lateral nasal wall volumisation.11

I use either EMLA or LMX 4 on skin cleaned with chlorhexidine. The patient should be sitting upright or semi-reclined. I prefer to inject from above the patient with the needle pointing towards the nasal tip as it is the easiest place to view the brow-tip aesthetic line. Injections can be performed using either needle or blunt cannula. Pinching loose skin between thumb and forefinger of my left hand, I hold the syringe in my right hand and inject into the midline with the needle entering slightly superior to the nasion at an angle, aimed towards the area of greatest volume deficiency. The needle is advanced until contact is made with the nasal bone. I inject a single depot injection of anywhere between 0.05 and 0.3cc, depending on the volume correction required. To prevent migration of the product during injection, it is important to inject slowly, and I also apply concurrent pressure laterally to the

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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After

Female in her early 30s with a congenital osteocartilaginous hump. She was treated with 0.3cc Belotero Intense at the nasion, 0.1cc Intense at the supratip, 0.05cc at the nasal tip, 0.1cc at the columella and 0.2cc at the maxillary crest. The outcome is reduced appearance to the hump, together with an increase tip projection and the appearance of a slightly elevated tip.

injection site with my left finger and thumb. After initial injection the product can be moulded and the nose re-assessed. Further injections can be performed if the initial treatment is sub-optimal.  Supratip depression Several techniques of supratip augmentation have been described. Injections can be performed via a needle directly through the skin at the point of deficiency, or via a cannula entering the skin from a distal point, either the nasion or the tip. I prefer to use a blunt cannula for augmentation of the supratip for two reasons. Firstly, supratip depressions may require larger volumes of product to be injected, and having a distally-based injection point may potentially reduce the risk of implant infection. Secondly, as the supratip area is made-up entirely of soft tissues, a blunt cannula inserted distally into the correct plane is less likely to cause perforations through the various tissue planes, through which product can bleed. In the absence of a significant dorsal hump, I prefer to inject from the nasion down. I place my cannula in the superperiosteal or deep subcutaneous plane and slide the tip down to the defect. The tip of the cannula should be in the deep soft tissue in the midline, superior to the dorsal septal cartilage and superior medial to the upper laterals. It is important to note that inadvertent trauma to the upper lateral cartilages can have long-term implications in both nasal valve function and nasal cosmesis. Using the same technique as described for the nasion augmentation, namely, injecting small volumes slowly with pressure applied laterally to prevent product migration, the defect is filled. After injection, I withdraw the cannula and apply pressure to the tissues with a gauze swab soaked in saline. Pressure is kept on for at least three minutes as haematoma in this area can be catastrophic for the soft cartilage and result in cosmetic and functional deficit.12 Nasal tip augmentation The simplest nasal tip technique involves the placement of an implant vertically through the columellar. This single technique can provide subtle alteration to the shape of the tip through more than one mechanism. Firstly, provision of columellar support can reduce mild tip ptosis and lift the tip. Secondly, it can lengthen the appearance of a short columellar and increase tip projection. Thirdly, with a mild box-tip deformity, the soft tissue at the mid-portion of the nasal tip between the intermediate and superior parts of the two medial crura can be filled, which provides a more rounded and aesthetically pleasing appearance. The improvement occurs as a result of the primary filling of defect, but also due to the skin re-draping over an increased projection, which exerts a small medialising force on the splayed cartridges.

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This is also useful in the management of the bifid tip deformity caused by splayed intermediate crura. Finally, the effects of columellar lengthening and increased tip projection will pull the entire tip structure forward from the face. This results in a medial pull on the soft tissue of the lateral alar region, resulting in an apparent alar base reduction. In my practice, I use a topical anaesthetic cream to numb the skin after thorough cleansing with chlorhexidine. I identify the landmarks of the alar cartilage, specifically the domes, medial crura and the medial footplates. I make a preliminary stab incision through the skin of the nasal tip in the midline and then insert a blunt cannula directly downwards to the maxillary crest, taking great care to remain in the midline and avoid the cartilages. Injecting slowly, I carefully withdraw the cannula, leaving a ribbon of implant in the midline. Whilst injecting, I keep a thumb and forefinger on either side of the columellar skin and also the anterior vertical septal cartilage to prevent accidental bleeding of product. I observe for signs of blanching of the nasal tip that may indicate pressure on or transection of the columellar nasal artery. If volume is required in the nasal tip, a small depot can be placed superiorly on the column. Gentle pressure is applied for a minimum of three minutes. Summary The techniques described allow correction of a wide range of nasal deformities without the cost, complications and downtime of surgery, providing an attractive alternative for patients. With appropriate experience of using injectable fillers, and a thorough appreciation of nasal anatomy, complications are unlikely. Dissatisfaction with cosmesis is easily addressed with the use of hyaluronidase. Injection rhinoplasty is a new technique that surgeons can utilise to compliment their practice and increase patient satisfaction. Dr Simon Ravichandran is as an ear, nose and throat surgeon, specialising in rhinology. He trained in aesthetic medicine in 2007 and co-founded Clinetix Medispa in 2010. Dr Ravichandran has established the Scottish Advanced Aesthetic Training Programme with Glasgow University, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners. REFERENCES 1. H Berholm, ME Tardy, Essentials of septorhinoplasty. Philosophy - approaches – techniques, (New York: Thieme, 2004) 2. DW Kim, ES Yoon, YH Ji, SH Pasrk, ES Lee Bi Dhong, ‘Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management’, J Plast Recontr Aesthet Surg, 64(12) (2011), pp. 1590-5 3. Koen JAO Ingles and Rene MJ Middelweerd, ‘Nasal Dorsal Management’, Facial Plastic and Reconstructive Surgery, ed. by Hade Vuyk (Florida: CRC Press, 2012), pp. 231-246. 4. Manavpreet Kaur, Rakesh K. Garg, Sanjeev Singla, ‘Analysis of facial soft tissue changes with aging and their efferct on facial morphology: A forensic perspective’, Egyptian Journal of Forensic Sciences, 5(2) (2015), pp. 46-56 5. C Chestnut, J Hsiao, J Kim, D Beynet, ‘New uses for Fillers’, Cosmetic Dermatology, 25(4) (2012) 6. D Bray, C Hopkins, DN Roberts, ‘Injection rhinoplasty: non-surgical nasal augmentation and correction of post-rhinoplasty contour asymmetries with hyaluronic acid: how we do it’ Clin Otol, 35 (2010), pp. 220-237 7. ME Tardy and RJ Brown, Surgical anatomy of the nose, (New York: Raven Press, 1990) 8. MR MacDonald, Jeffrey H. Spiegel, Raymond B. Raven, Shledon S. Kabaker, Corey S Maas, ‘An Anatomical Approach to Glabellar Rhytids’, Arh Otolaryngol Head Neck Surg, 124(12) (1998), pp. 1315-1320 9. WF Larrabee, KH Makielski, JL Henderson, Surgical Anatomy of the Face, (Philadelphia: Lippincott Williams and Wilkins , 2004) 10. Balaji N, Ravichandran S ‘Assessment of Nasal Valve Obstruction: a new nasal ‘wall’ sub-unit concept’, ENT and Audiology News, 21 (2012), pp. 4111-113 11. Clinton D. Hymphrey, John P Arkins, Steven Dayan, ‘Soft Tissue Fillers in the Nose’, Aesthetic Surgery Journal, 29(6) (2009), pp. 478-84 12. MA Leon MA, L Cardenas-Camarena, ‘Deforming posttraumatic hematoma of the nasal tip: an infrequent lesion’, Plastic and Reconstructive Surgery, 113(2) (2004), pp. 641-4

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The ‘H-Lift’: The Hammock Principle of Lower Facial Rejuvenation and Contouring Mr Dalvi Humzah and Anna Baker share their techniques for rejuvenating the mandibular region When considering rejuvenating the lower face (mandibular region) there are several concepts to keep in mind. Many of the changes associated with this area originate with changes in the mid-face; descent of the facial skin and mid-face fat pads result in the appearance of the jowl and soft tissue disproportion. As a consequence, there is commonly a change in the shape of the lower third of the face – often referred to as the inverted triangle (of youth) to the Pyramid (of ageing). Therefore, minor lower facial rejuvenation can be achieved through addressing the mid-face changes by lifting and re-contouring the mid-face. With progressive changes, however, the lower mandibular region has to be addressed directly due to changes in that area. The main concept to consider with a non-surgical procedure is combining the ‘3R’ techniques to: Rebuild, Reposition and Revolumise the area. To apply this technique, which I have developed to achieve effective results while performing the ‘H-Lift’ procedure, the specific tissues that will need to be treated are the bone (mandible), soft tissues, fat pads and skin. Ageing of the mandibular region We are aware that, with age, maxillary and zygomatic retrusion results in loss of soft tissue support and descent of the superficial fat pads of the mid-face.1 The jowl fat increases in volume inferiorly2 with sagging, resulting in it ‘folding over’ and forming the marionette line. The labiomandibular fat pad (medial to the marionette line) undergoes a loss of volume along the lateral edge (adjacent to the marionette fold) thus accentuating the line. Although the bigonial width is thought to undergo minimal senescent changes,3 further bone-related changes accentuate this appearance of jowling. The height of the body of the mandible reduces; with a concomitant Before

Two weeks post procedure

loss of the width of the bone. The protrusion of the chin is also reducing (anterior and posterior) by approximately three to four millimeters by the age of about 60.3 Finally, the ramus angle changes from approximately 90/94 degrees to roughly 120 degrees.3 The mentolabial crease (below lower lip) is also pronounced as the area of attachment of the mentalis reduces, causing the mentalis to contract and ‘cobblestone’ the skin attachments.4 The two fat pads in this area are the superficial chin fat and the deep submentalis fat, which is located supraperiosteally and underlies the mentolabial sulcus. The inferior part of this fat overlies the mentum and shapes the inferior chin.4 The soft tissue sagging appears worse as the mandible size reduces and the jowls now represent the hanging, the angle of the ramus and the chin protuberance representing the fixed points. The ‘3Rs’ in practice The principles of rejuvenation and recontouring in the mandibular region that the practitioner has to consider include: 1. Rebuilding the bone changes 2. Revolumising the marionette area 3. Repositioning the soft-tissues This is tailored to the individual patient’s requirements and, having understood the changes in the soft tissues, the mandible is recontoured to effectively elongate the angle and chin protuberance. This tightens the soft tissue between the two distal points, with additional volume to the inferior border of the mandible body to reshape the underlying bony support and reduce the sagging; effectively producing what we refer to as the ‘H-Lift’. The lengthening and reshaping effect will relax the mentalis muscle, and further relaxation may be obtained by botulinum toxin treatment Three months post procedure

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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to relax the muscle and revolumise the deep fat pad in the crease. The superficial subcutaneous chin fat pad, which lies inferior to the labiomental sulcus, should not be revolumised, as it will result in the deepening of the sulcus.4 The marionette line is approached in a layered manner; the cephalic part of the fold (superior to the buccal sulcus) requires revolumisation around the lateral side of the labiomandibular fat in the subcutaneous plane, with a deep supra periosteal revolumisation of the superior-lateral extension of the deep submentalis fat pad. Further repositioning can be achieved by vectoring the soft tissues to cause fibrous contraction and further tighten and reposition the soft tissues. The H-Lift procedure The patient is appropriately examined and informed of the details regarding the procedure prior to treatment. Complications of soft tissue fillers are discussed (Figure 1) and, if required, a period of reflection is advised. Having received patient consent for treatment and photographed the area for documentation, the face is thoroughly cleaned and disinfected from the zygomatic arch to the neck with an antiseptic solution (e.g. 2% chlorhexidine in 70% alcohol). The product used in this case is Radiesse 1.5ml, mixed with 0.1 ml 1% Lidocaine, however, practitioners could also use other products with a high-lifting capacity. Additional local anaesthetic may be used to infiltrate from skin entry points to the periosteum, with a further 0.1-0.2ml along the periosteum of the ramus and body supraperiosteally. A dental syringe with a 27G is used to provide the anaesthetic and infiltration around the inferior dental nerve, and completes the anaesthesia of the area. The entry points are located at the angle of the mandible posteriorly and anterior-inferiorly at the mentum. We use a TSK Steriglide 25G x 50mm or 22G x 50mm which allows easy gliding in the soft tissue and accurate placement in the supraperiosteal plane. Having made an entry point, the cannula is ‘screwed’ to place the tip at the supra periosteal layer. The cannula is then steered along the inferior border of the mandible towards the area where the facial artery crosses the mandible. Although it is possible to steer the cannula behind the artery, we would recommend that until one is proficient in the use of cannulas, and has treated this area extensively, not to go beyond this area. Linear retrograde placement of the product is performed (0.4-0.6ml) and, from the same entry point, the cannula is introduced into the supraperiosteal layer along the ascending ramus. A bolus technique is used to place a right-angle triangle shape on the posterior border and recreate the 90/94 degree angle (0.4-0.6ml). Figure 1 Potential complications include:1 • • • • • • • • •

Injection site reactions Infection Erythema Oedema Pain/tenderness Bruising Itching Nodule Systemic responses to infection • Granulomatous inflammation • Erythema varying from subclinical

• • • • • • • • •

Disfiguring nodules Hypersensitivity Migration of filler Aseptic abscess Discoloration Redness Whiteness Hyperpigmentation Local tissue necrosis caused by vascular occlusion • Potential blindness

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The anterior point is approached in a similar manner, the cannula is steered along the inferior border along to the area of the facial artery and no further. The linear threads are, therefore, away from the area of the facial artery and prevent compression of the vessels. A further 0.4-0.6ml can be placed in this plane. The cannula is then turned superiorly to place an additional bolus 0.2-0.3ml on the supraperosteal region of the protuberance of the mandible. If required, a further superior placement in line with the labiomental crease can be performed carefully, as this may be close to the oral sulcus in an elderly patient. The volumes stated are approximate amounts and are tailored to the patient’s requirements. If larger volumes are required, this is performed in a staged approach over a two-week period. Other ancillary procedures can also be performed with the anterior entry point, the marionette fold area can be revolumised in the supraperiosteal plane inferiorly, and then subcutaneously superiorly. Both entry points may be used to place threads to vector the soft tissue. Finally, in those patients who request an enhancement of the bigonial distance (masseter enhancement), the posterior entry point can be used to place the product as multiple threads around the masseter region in the subcutaneous region, and deep to the masseter to produce the ‘masculine’ jaw. The injected areas are gently moulded and the patient is advised to avoid manipulating the area. Analgesia is advised as required and plans are made for a review of the patient after a period of two weeks. Further recontouring and top-ups may be performed at this review. Conclusion The ‘H-Lift’ technique is based on the dynamic anatomical changes that are associated with ageing. The foundation of this rebuilds the bony tissue and then revolumises and repositions the soft tissues. This technique addresses the changes in the mandibular region and allows recontouring to be performed as an evidencebased technique in a safe plane, in order to reduce potential complications in a highly mobile area. The use of high volumising fillers produces the recontouring with low product volumes and results in a natural-looking appearance. The ‘H-Lift’ procedure is an advanced technique that requires specific anatomical knowledge and training to perform safely. Anna Baker runs a nurse-led cosmetic and dermatology clinic at Nuffield Health Hospital Cheltenham. With a special interest in photodynamic therapy, she holds two specialist clinics and is currently undertaking postgraduate study in applied clinical anatomy, specialising in head and neck anatomy at Keele University. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director at Plastic and Dermatological Surgery. A consultant plastic surgeon in the NHS for 10 years, he is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons. Mr Humzah teaches and lectures and is an examiner nationally and internationally. REFERENCES 1. Rohrich R.J., Pessa J.E. ‘The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery’, Plastic And Reconstructive Surgery, 119(7) (2007), pp. 2219-2227. 2. Gierloff M., Stohring C., Buder T., Gassling V., Acil Y., Wiltfang J., ‘Aging Changes of the Midfacial Fat Compartments: A Computed Tomographic Study’, Plastic And Reconstructive Surgery, 129(1) (2012), pp. 263-273. 3. Shaw R.B., Katzel E.B., Koltz P.F., Yaremchuk M.J., Girotto J.A., Kahn D.M., Langstein H.N. ‘Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies’, Plastic And Reconstructive Surgery, 127(1) (2011), pp. 374-383. 4. Gierloff M., Stohring C., Buder T., Wiltfang J., ‘The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 65 (2012), pp. 1292-129 5. Lowe N.J., Maxwell C.A., Patnail R., ‘Adverse reactions to dermal fillers:Review’, Dermatological Surgery, 31 (2005) , pp.1616-1625.

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Eczema: Scratching the Surface Dr Sadequr Rahman details the aetiology and treatment options for this common dermatologic condition In the world of dermatology and skin health, we, as practitioners, need to have a working understanding of the most common skin diseases and complaints that affect our patients. It is believed that 10% of the population at any one time suffer some form of eczema.1 Eczema and dermatitis refer to the same disease pathology, and the terminologies are used interchangeably; for simplicity I will refer to the former to indicate either condition. The most common form of eczema is known as ‘atopic eczema’, which is most prevalent in younger patients, and accounts for up to half of all eczema conditions seen in the UK.2 Atopy defines those with an inherited tendency to develop asthma, eczema and other allergic conditions.2 Eczema is an inflammatory skin condition showing itching, redness and scaling. While some attempt to classify eczema into categories of exogenous (contact, irritant) or endogenous (internal factors), this has proven extremely difficult due to the similar characteristics occurring in both categories. Many patients will attempt to identify an external source for the eczema by requesting or undertaking allergy testing – some online resources claim to offer accurate predictive tests of irritants for affected individuals. Due to the multifactorial nature of the condition, however, these often have a poor predictive value. Aetiology Current research of atopic eczema suggests an initial selective activation of Th2type CD4 lymphocytes in the skin, part of the body’s immune response against infection. This activation drives the excessive inflammatory process.1 In at least 80% of cases there is a raised serum Immunoglobulin E level (indicating an increased propensity to generate an allergic response) and commonly a strong family predisposition to allergic conditions.1

Strong detergents and chemicals have also been linked to eczema, and there is a current trend towards the development of cleaning products with a lower chemical count. It has been suggested that lower chemical counts may decrease the frequency of eczema and allergies – indeed, several companies have sprung up offering products to cater for this need. However, the evidence for this is still uncertain, with ongoing trials suggesting that while particular chemicals are indeed more irritant than others, the concentration of such chemicals are extremely low, and even prolonged usage has not conclusively shown a causal link to allergy formation.3 The most commonly observed clinical features of eczema are itchy erythematous patches, especially in the flexures of the arms and legs, and around the neck.1 Repeated rubbing and scratching can lead to lichenification (i.e. thickening of the skin with exaggerated skin markings).1 In people with pigmented skin, eczema often shows a reverse pattern of extensor involvement, and hyper- or hypo-pigmentation has been noted following a flare of eczema, leading to often cosmetically undesirable results. The prognosis for eczema is good, in that more than 80% of children will spontaneously resolve, or ‘grow-out of’ the condition by their teenage years.1 Treatment Avoidance of known allergens is key in the treatment of eczema. Nickel sensitivity is the most common contact allergy (10% of women, 1% of men).2 Where eczema is suspected, usually in the hands, face or feet, patch testing may be carried out. For this, a supply of the potential irritants needs to be supplied to the dermatologist ahead of the test, particularly if cosmetic or industrial ingredients are suspected. I usually test for around 40 common irritants. The ingredients are applied to the back and remain on the skin for several days until the skin response is noted for each ingredient. It should be mentioned that due to the complex and often multifactorial triggers of eczema, locating a specific irritant is difficult, time consuming, and often of limited value, as further allergies may develop at any time in a sensitive patient. Positive test results may occur in up to 10% of individuals.1 Patients, and sometimes parents, need a thorough consultation, education and time to absorb these explanations, as treatment may be a long-term proposition with periods of more serious flare-ups. Regular emollient remains the backbone of topical therapy, and compliance with these needs to be confirmed and reinforced. As there are many emollients available to the prescribing practitioner, the selection process will be a matter of personal preference for the patient. Note that many formulations are available in cream and ointment form, and while the latter is more adherent to the skin, the greasy texture is often less favoured than

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the cream for many patients. The emollients are provided in quantities of up to 500ml for most preparations, and it is notable that a young child will often require two such jars over a month period when extensive eczema is involved, and it is vital to ensure that sufficient quantities are provided to ensure that treatment is adhered to. In fact, the NICE guideline suggests that in some cases, 250-500ml of emollient may be required weekly.4 The add-on treatment to emollient is the topical steroid, which has frequently been underused due to fears of skin thinning in the patient. However, it has been shown that topical steroids can be used for long-term intermittent courses quite safely and their usage should be encouraged where emollients alone are not controlling the condition.1 The mildest steroid should be used on the face, while the body can be treated with stronger steroids – this is because the face has thinner skin than elsewhere and is more sensitive to pigmentation effects with steroids. In general, the older the patient, the thicker the skin, and the stronger the treatment needed. Tacrolimus ointment is a topical immune-modulator, which can be a useful alternative where potent steroids are not tolerated or undesirable. In more severe cases, oral antihistamine and antibiotics may be required for infected eczema, and in uncontrolled cases admission for body bandaging and wraps have been used.5 The skin is wrapped in bandages that have emollients and sometimes steroids built in, which allows prolonged adherence to the skin and prevents scratching. Carers may be taught to apply these at home if required and are generally well tolerated. Hand eczema may present with itchy blisters or vesicles along the sides of the fingers, and this is known as pompholyx. Scaling and peeling of the skin may be noted at the fingertips. Issues relating to the aesthetic practitioner Most eczema cases will be treated effectively in primary care, and the practitioner should ensure they make notes in the patient’s medical history of any usage of topical treatments for eczema/dermatitis conditions. The presence of such conditions on the face may alter the use of certain treatments and cosmetics. For example, a patient with prior sensitivity to paraffin will be unable to tolerate creams or ointments with a paraffin base. One should also consider that chemical peels and other topical treatments that are designed to be irritant could likely worsen an eczema condition. Allergy can often present as sensitive skin for the patient, and they will often indicate that they have tried several different cosmetic or makeup products until finding a regime that suits. A patient will certainly remember if a product you prescribe or administer causes a flare-up on their skin. While it may be possible to patch test for certain products, careful history taking will reveal a past history of sensitivity to soap or products. These patients should avoid alkaline soaps and products that cause frothing or ‘bubbling’ on the skin. It is also worth bearing in mind that eczema can commonly be triggered by stress factors, either emotional or physical. A clinical intervention in the form of injectable or topical treatment can certainly be classified as a stress trigger, and it is not unheard of for a reactive eczema to occur following an aesthetic treatment. This may then be classified as an allergy, when in fact a stress reaction may have occurred. Where possible, and especially if abrasive treatments are to be used, administration on a non-cosmetic area of the skin, for example, the arm, can be useful in determining the skin sensitivity to such products. Red faces are not a good look for either the patient or practitioner. Sun protection is also vital for the sensitive skin patient. Untreated eczema will become further dried and irritated in the

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We must be ever more vigilant in our usage of cosmetic treatments and cosmeceuticals in patients suffering from eczema and the challenges they present to our practice presence of strong sunlight. An emollient with good sun protection, preferably SPF 15-30 depending on skin pigmentation, should be recommended for the patient. Bear in mind, when performing any kind of cosmetic treatment in the summer months, sun protection should be foremost in your mind and, if the patient is not already on board, emphasise the importance of protecting their skin from sun damage. Thirdly, the itch-scratch cycle of eczema has been shown to lead to significantly lower quality of life (QOL) scores in individuals.6 This manifests as poor sleep, itch distress, cosmetic appearance and the frequent requirement of medical attention in more serious cases. A patient, therefore, may already have issues with mood and selfesteem at the time of presentation in the presence of eczema, and these issues should be taken into account when assessing suitability for treatment. Finally, the practitioner should be mindful of the fact that eczema is primarily a pathology stemming from loss of skin barrier function,2 and that any cosmetic treatment that compromises that barrier may well negatively impact the quality of the skin. One must ensure that the patient is made fully aware, via verbal or, ideally, written consent, that skin that is prone to eczema has a higher likelihood of flare-up. If the patient wishes to proceed with an aesthetic treatment, they should be told to avail themselves of preventative measures such as emollient, antihistamine treatment and protection for the face. Recorded incidence and lifetime prevalence of eczema in England continues to increase.7 Similar increases have also been observed in the estimated number of eczema prescriptions issued to the English population.7 Noting this, we must be ever more vigilant in our usage of cosmetic treatments and cosmeceuticals in patients suffering from eczema and the challenges they present to our practice. Dr Sadequr Rahman studied medicine at King’s College London. He has been a practicing GP since 2003 and has run his own cosmetic medicine clinic, Doctor-SR Beauty Clinics, in South Wales since 2010. Dr Rahman has a special interest in dermatology, and offers patient advice on nutrition, weight management and confidence building. REFERENCES 1. Kumar and Clark Pgs 1203-7. Clinical Medicine 8th ed 2012. Written by D G Paige. Chapter 21 ‘Skin Disease’ (London : Saunders Ltd, 2012) 2. Gawkrodger and Ardern-Jones, ‘Dermatology, an illustrated colour text 5th ed’, Publ Churchill Livingstone (2012), pp.34-7. 3. D. Basketter et al, ‘Skin sensitisation to fragrance ingredients: is there a role for household cleaning/maintenance products?’, European Journal of Dermatology, 24 (2015). 4. NICE guideline CG57, ‘Atopic eczema in children’, (2007) <https://www.nice.org.uk/guidance/ cg57/chapter/Key-priorities-for-implementation> 5. Atopic (UK, National Eczema Society, 2015) <,http://www.eczema.org/atopic-eczema for picture reference> 6. A Ganemo et al, ‘Quality of life in Swedish children with eczema. Acta Dermato Venereologica’, 87(4) (2007), pp.345-9. 7. Simpson et al, ‘Trends in the epidemiology and prescribing of medication for eczema in England’, Journal Royal Society of Medicine’, 102(3) (2009), pp. 108-117.

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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THE LUMENIS ULTRAPULSE® CARBON DIOXIDE LASER TECHNOLOGY: POWER AND VERSATILITY Dr Firas Al-Niaimi, group medical director of sk:n clinics, is an honorary consultant dermatologist at Guy’s and St Thomas’ Hospitals, and runs a weekly CO2 tertiary referral NHS laser clinic using the Lumenis UltraPulse® machine. He explains why it is his product of choice for a range of medical and aesthetic concerns

INTRODUCTION: Ablative lasers have been used in dermatologic and aesthetic procedures for more than two decades. The mechanism relies on effects on the tissue through ablation and coagulation using tissue water as chromophore. This article will highlight the key principles of carbon dioxide laser (CO2) focusing in particular on the UltraPulse® technology by Lumenis.

ABLATIVE LASER PHYSICS: The mid and far infrared wavelengths beyond 2000nm are used in current ablative laser technology as these higher wavelengths target water as chromophore. Currently there are three wavelengths used: 2940nm Erbium:YAG (Er:YAG), 2790nm Yttrium Scandium  Gallium  Garnet (YSGG), and the 10.600nm CO2 laser. The water absorption affinity is the highest with Er:YAG and lowest with CO2 with the YSGG sitting in between. Work performed by American laser dermatologist Rox Anderson showed that with the CO2 laser, the tissue requires a minimum ablation threshold energy of 5 joules per cm2 and ideally in less than one ms (generally considered the thermal relaxation time of the skin) to have an ablation characteristic with minimal collateral thermal damage. The changes to the tissue as a result of the incoming ablative laser beam depend on the tissue temperature reached. A temperature of 100 degree Celsius will lead to “vaporisation” of tissue, clinically observed as ablation. A temperature higher than 150 degrees leads to carbonisation, clinically evident as charring and is an unwanted clinical endpoint. A temperature of around 65 degrees is the desired temperature required for protein denaturation that clinically gives before

after

Images courtesy of Joseph Niamtu III DMD

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the tightening effect and stimulates the process of new collagen formation. Scientific studies have shown that this temperature gradient observed in the dermis is responsible for a cascade of important molecular pathways, mainly through the induction of heat shock proteins that play an important role in collagen remodelling. Understanding the tissue interaction with the CO2 laser is important in determining how to use this laser efficiently. Depending on the clinical goal a practitioner desires to achieve, the ideal setting would be to reach the ablation threshold with a controlled zone of thermal injury for collagen remodelling with minimal to no charring. In other words, optimal safety and efficacy dictates a favourable and consistently reproducible ablation to coagulation ratio.

CO2 – FROM FULL FIELD TO FRACTIONAL: The CO2 laser in its original non-fractional use was widely considered the gold standard in the treatment of wrinkles and scarring in the 1990s, a process referred to as “full field resurfacing”. Though the results were clinically impressive, this was achieved at the cost of prolonged wound healing and downtime. In order to reduce the risk of side-effects with the procedure, the principle of fractional photothermolysis was pioneered. The first concept of the fractional photothermolysis was described in 2003, however it wasn’t until a year later when this technology was first introduced in clinical practice with the Lumenis UltraPulse® having the first fractional ablative machine. The technology involves the production of an injury pattern to the skin with “ablated” columns of tissue called microthermal zones (MTZs) with intervening uninvolved areas of skin. In practice this will allow for rapid wound healing through migration of cells from the neighbouring uninvolved areas with less risk of longterm complications. The MTZs vary greatly in their diameter and depth as well as the amount of coagulation around them, referred to as the “coagulative zone”. These characteristics are important and one that Lumenis has particularly advanced due to their pulse structure and power. The non-ablative fractional lasers – wavelengths below 2000nm – create non-ablative MTZs and rely on the generated heat in the dermis to stimulate collagen formation. Whilst this technology has certainly been shown to improve wrinkles and scarring; it is widely accepted that the ablative technology results in superior results. There are numerous studies confirming this fact, including a split-face study using the Lumenis UltraPulse® device. There are currently several CO2 machines in the market and, to the novice laser user, the key important differences may not be apparent. The differences relate to key principles such as pulse duration, peak power, fluence, handpieces (with or without scanning technology), fractional cover and versatility of applications. The Lumenis UltraPulse® is currently the most powerful CO2 in the market with a maximum power of 240 Watts (W), six times more powerful than most of the other available CO2 machines.

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before

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after

Images courtesy of Dr Jill S. Waibel

PULSE STRUCTURE AND WIDTH: One of the key core components of success and safety is the UltraPulse® structure mode this machine has. Traditional CO2 machines have either a continuous wave pattern or a “pulsed” pattern. In the majority of CO2 lasers the pulse structure in the pulsed pattern consists of the so-called “superpulse” structure. This means that the pulse has a peak power but tails off at the end of the pulse with some residual unwanted energy that increases the risk of collateral damage. The residual thermal zone is much wider in the continuous mode pulse which is clinically evident in prolonged erythema and a higher complications rate. The UltraPulse® structure that is used in Lumenis differs in that it resembles a top hat profile beam with a rapid peak that does not tail off and therefore has a narrower coagulative zone. The advantage of this technology, coupled with a pulse duration of less than one millisecond (shorter than 0.8ms and made possible due to the high power of the machine), is the excellent ablation to coagulation ratio with minimal charring and unwanted thermal damage. This consistent and predictive ablation to coagulation ratio has been replicated in numerous histological studies. The aforementioned concept of pulse duration (also referred to as dwell time) is of crucial importance. A pulse duration greater than one ms will lead to more of the given energy to be conducted, in other words a lower ablation to coagulation ratio, thus giving rise to a broader zone of thermal damage. A low-powered CO2 machine will have to extend the pulse duration over one ms and use higher energy in order to get a deeper penetration compared to a highpowered CO2 such as Lumenis UltraPulse®; this in turn leads to a greater zone of thermal damage and possible complications.

INCISIONAL HANDPIECES: The Lumenis UltraPulse® comes with several incisional handpieces in 0.2 and 1.0mm non-collimated and a 2.0mm collimated handpiece, referred to as the “true spot”. The power of the machine (240 W) allows for a very rapid and powerful incision which gives a great versatility in surgical procedures, requiring incision and coagulation. In a defocused mode these handpieces allow for a high “power irradiance” that can allow for rapid vaporisation of tissue or superficial coagulation and contraction dependent on the chosen power setting.

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“ActiveFX®”. The ActiveFX® has a collimated spot size of 1.3mm with various choices for pattern shapes and sizes, allowing for adaptation to different clinical situations. The depth is related to the chosen fluence and extends to around 300 microns (0.3mm), allowing for superficial resurfacing of fine lines and texture. The density ranges from fractional (density 1-3) to full field with overlapping (density 4-9). The handpiece has a sophisticated method of delivering the individual spots in a non-sequential random pattern manner “coolscan technology” thus allowing for the tissue to cool in between and avoiding any “hot spots”. The microscanner device has both the “DeepFX®” and “SCAAR FX™” (Synergistic Coagulation and Ablation for Advanced Resurfacing) modes. The DeepFX® has a range of fluence up to 50mj and a spot size of 0.12mm, hence with such a great power of the laser (240 W), coupled with a very short pulse width (less than 0.8ms), this will allow for a deep penetration of up to 1.5mm. The software allows for a double pulse mode if necessary on the same spot. Different shapes and sizes are available with a range of densities allowing for precise spot or larger area coverage. The combination of the two treatment modalities with both the ActiveFX® and DeepFX® is referred to as “TotalFX®”. It is this unique feature of the Lumenis UltraPulse® machine to give the opportunity for both superficial ablation together with deep fractional treatment with variable densities that surpasses it from other currently available CO2 machines. The SCAAR FX™ mode allows for the greatest depth penetration of any CO2 laser of up to 4mm, enabling us for the first time to treat hypertrophic or deep burn scars. The density pattern ranges from 1 to 5% with a single pulse mode only. The energy starts from 60mj to a maximum of 150mj; the highest energy in any CO2 laser with a small spot size and very short pulse duration. In both handpieces the ratio of ablation to coagulation is consistent (increases with higher energy) allowing for greater safety use.

COMBINATION THERAPY: The UltraPulse® CO2 has been combined with other treatment modalities for maximum clinical efficacy. Examples include the use of pulsed dye laser for erythematous scars prior to the use of CO2. Antiageing treatments such as botulinum toxin and filler injections have also been used post CO2. More recently, the UltraPulse® CO2 has been used as a mode of drug delivery, a novel approach to delivering certain drugs or molecules through deep ablated channels. This has been particularly beneficial in the treatment of hypertrophic scars.

CONCLUSION: The Lumenis UltraPulse® is the most versatile and powerful CO2 machine in the world. The sophisticated pulse profile coupled with very short pulse duration and a high peak power allows for the greatest tissue depth penetration of any CO2 machine with a favourable ablation to coagulation ratio. The various handpieces available allow for a versatility of treatments ranging from superficial to deep resurfacing in both fractional and conventional modes. T: 020 8736 4110 E: UKAesthetics@lumenis.com W: lumenis.com

SCANNING HANDPIECES: The Lumenis UltraPulse® has two scanning devices, the UltraScan C-P-G (Computer-Pattern-Generator) and the microscanner handpiece. The UltraScan is the scanning device for a mode called

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Skinade: Better skin from within As clinical director of Courthouse Clinics, Dr Amanda Wong-Powell (Dr W) is keen to ensure both her skin and her patients’ skin remains healthy and rejuvenated. For the past two months facial rejuvenation and VASER liposuction specialist, Dr W has been drinking Skinade – an anti-ageing collagen drink. Skinade aims to boost the body’s natural production of collagen and hyaluronic acid, as well as improve the way skin looks and feels within 30 days. From her personal experience of drinking Skinade, Dr W has noticed a considerable difference to the quality of her skin, “If a patient asks me for a collagen supplement drink, I would definitely recommend Skinade,” Dr W explains. “I think it’s a very good product. I like the simplicity of it and it’s definitely had a salutary effect on my skin.” Collagen drinks have seen a boost in popularity during recent months, each claiming their ability to restore plumpness and suppleness in the face. Dr W notes that she has found that Skinade stands out amongst the other collagen drinks on offer, although she admits that she originally had concerns with how the technology worked. “I initially queried how the collagen would be digested,” she explains. “I soon learnt that with Skinade, however, the collagen has a low molecular weight which means it’s rapidly absorbed into the bloodstream – it’s a patent-pending collagen that can’t be digested through the stomach when you drink it. As such, it can actually trigger the proliferation of collagen and go where it’s needed – it actually does work!” Dr W suggests that all her patients aged 30-plus take the drink, “I think they need a little bit more help and there is only so much that ‘lotions and potions’ can do.” She continues, “Taking Skinade can help stimulate new collagen and there are other vitamins in it that are useful, such as vitamin B,C, MSM, L-lysine and essential omegas 3 and 6. I think that it’s superb to have a drink where you can get all your collagen and multivitamins from.” Skinade is peach and mangosteen flavoured, and comes in two versions: a ready-mixed 150ml bottle and a 15ml travel sachet, with both products having exactly the same efficacy. Dr W thinks the drink is beneficial for time-sensitive patients who are constantly on-the-go, “If your patients are busy and haven’t got the time to eat properly, then Skinade is a great additional help. I also recommend it to patients that I have performed liposuction on as the procedure takes quite a lot more out of their body other than fat; it removes fluids and patients commonly get urea and electrolyte imbalances. Skinade can help patients with replenishing natural resources.” Dr W’s patients using Skinade have seen a noticeable change. She explains, “Most of them have noticed their skin glows more; they have noticed their hair is better, their nails are stronger and this indicates that the collagen is getting through. The results are 52

not instant and you have to take it once a day for at least a month to notice a difference, however, within a week of taking it, you can already start to see that hydration has improved. To see more substantial results, I advise patients take it for more than a month.” Collagen regulates the activity of fibroblasts in the skin and the cells that are responsible for rebuilding the connective tissue, which play a critical role in wound healing. According to Dr W, her patients have seen these effects. She explains, “I have a patient who had minor rashes following treatment and their appearance has improved a lot. The same patient is also very prone to bruises and she has noticed that since she’s been drinking Skinade, she doesn’t get as many.” Dr W’s passion for her job is clearly evident and she is determined to provide the most valuable treatments and skincare options to her patients. “I love what I do, I enjoy it, and it doesn’t feel like work to me,” she says. “The most important thing in the medical aesthetics industry is to understand what your patients want and need. I’m glad to be able to offer them Skinade – something that I know will be beneficial for them.”

For more information email info@skinade.co.uk or call 08451 300 205

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A summary of the latest clinical studies Title: Skin Aging, Gene Expression and Calcium Authors: M Rinnerthaler, MK Streubel, J Bischof, K Richter Published: Experimental Gerontology, August 2015 Keywords: Skin ageing, atopic dermatitis, calcium, psoriasis Abstract: The human epidermis provides a very effective barrier function against chemical, physical and microbial insults from the environment. This is only possible as the epidermis renews itself constantly. Stem cells located at the basal lamina which forms the dermoepidermal junction provide an almost inexhaustible source of keratinocytes which differentiate and die during their journey to the surface where they are shed off as scales. Despite the continuous renewal of the epidermis, it nevertheless succumbs to aging as the turnover rate of the keratinocytes is slowing down dramatically. Aging is associated with such hallmarks as thinning of the epidermis, elastosis, loss of melanocytes associated with an increased paleness and lucency of the skin and a decreased barrier function. As the differentiation of keratinocytes is strictly calcium dependent, calcium also plays an important role in the aging epidermis. Just recently it was shown that the epidermal calcium gradient in the skin that facilitates the proliferation of keratinocytes in the stratum basale and enables differentiation in the stratum granulosum is lost in the process of skin aging. In the course of this review, we try to explain how this calcium gradient is built up on the one hand and is lost during aging on the other hand. How this disturbed calcium homeostasis is affecting the gene expression in aged skin and is leading to dramatic changes in the composition of the cornified envelope will also be discussed. This loss of the epidermal calcium gradient is not only specific for skin aging but can also be found in skin diseases such as Darier disease, HaileyHailey disease, psoriasis and atopic dermatitis.

the success of surgery. In addition, regardless of initial demand and type of surgery, rhinoplasty provides improvement in nasal obstruction, and a positive impact on QoL in most of the patients undergoing rhinoplasty.

Title: The effect of rhinoplasty on psychosocial distress level and quality of life Authors: C Günel, IK Omurlu Published: European Archives of Oto-Rhino-Laryngology, August 2015 Keywords: Rhinoplasty, psychological distress, cosmetic surgery Abstract: The aim of this study was to evaluate psychosocial distress and improvement in quality of life (QoL) of patients undergoing rhinoplasty and compare the level of distress associated with the types of rhinoplasty. Patients were grouped due to primary, secondary, functional and cosmetic rhinoplasty, and evaluated four times: preoperative evaluation, 4th, 12th, and 24th weeks postoperatively and completed questionnaires including the rhinoplasty outcome evaluation (ROE) scale, nasal obstruction symptom evaluation (NOSE) scale, and Derriford Appearance Scale 24 (DAS24) every four visits. The revision cases and patients with cosmetic indication have more emotional distress than others at the preoperative and early postoperative period (p < 0.005). However, the distress level equalize and return baseline values beyond 12 weeks. The ROE and NOSE scores of all patients were very significantly improved by the rhinoplasty (p < 0.001). The psychosocial distress has a significant impact on quality of life and, therefore, it is an important factor to assess

Title: A Survey Comparing Delegation of Cosmetic Procedures Between Dermatologists and Nondermatologists Authors: MB Austin, D Srivastava, IH Bernstein, JS Dover Published: Dermatologic Surgery, July 2015 Keywords: Dermatology, cosmetic procedures, specialities, Abstract: This study looked at how delegation of procedures varies among cosmetic specialties in the United States is not well described. The objective was to better describe current practices in delegation of procedures to nonphysicians among physicians of different cosmetic specialties in the United States. It was found when delegation occurred, dermatologists were more likely than non-dermatologists to delegate the following procedures to higher level non-physician providers (NPP): chemical peels, neuromodulator and filler injections, laser hair removal, pulsed dye laser, tattoo removal, intense pulsed light, nonablative fractional laser and sclerotherapy. No difference in delegation rate was noted between dermatologists and non-dermatologist physicians with respect to microdermabrasion, ablative fractional laser, cryolipolysis, radiofrequency skin tightening, focused ultrasound skin tightening and focused ultrasound fat reduction. Dermatologists delegate procedures to NPP less frequently than non-dermatologist physicians, and when they do, it is typically to higher level NPP.

Title: Blood Aspiration Test for Cosmetic Fillers to Prevent Accidental Intravascular Injection in the Face Authors: G Casabona Published: Dermatologic Surgery, July 2015 Keywords: Facial fillers, injection, adverse reaction, skin necrosis Abstract: Filler injection for cosmetic treatment of the aging face may be complicated by visual impairment, skin necrosis, or anaphylaxis because of accidental intravascular injection. Blood aspiration test (withdrawal of blood by the syringe plunger before injection) may decrease the risk of intravascular injection. The objective of this study was to evaluate the reliability of the aspiration test. A red ink solution was withdrawn from a cup using a syringe containing 0.1 mL filler (17 different filler products); where there was no aspiration. Retesting was performed with larger-gauge needles until aspiration was observed. In a white rabbit, aspiration was attempted after puncturing the ear vein and withdrawing the syringe plunger (5 different filler products). The aspiration test with an ink solution in vitro was negative with 8 filler products (47%) and positive with 9 filler products (53%); for all products that had a negative aspiration test, the test became positive when a largergauge needle was used. All 5 products tested with the rabbit ear aspiration test were positive. The aspiration test was reliable with 53% syringes and needles tested. Fillers that have a negative aspiration test may be applied when the needle gauge is adjusted.

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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expensive, and most of the SEO firms who built these links have seen their business model ruined and are long gone.

The Truth About SEO Gavin Griffiths shares his advice on making the most of search engine optimisation “Would you like to be number one on Google?” trumpets the email, the fourth such one sent to me this week alone. Of course I would! Who wouldn’t want to be at the top of Google? Being the top position on Google for your area of expertise would be a game changer for many businesses. People who search key words of the treatments that you offer at your clinic are the perfect customers. They are actively seeking your service; they want what you’ve got and they want it now. On the basis that the top position gets approximately 40% of the clicks on the page,1 then you’re looking at thousands of potential patients visiting your site each month. Only it won’t happen. What most search engine optimisation (SEO) companies won’t tell you, is that getting ranked on Google isn’t just what you do as an individual. It’s as much about what everyone else is doing and it’s almost impossible to ascertain exactly what this is without studying the market sector in some depth. For you to go up, someone else needs to go down, and the ‘someone else’ is a key component here. Anyone promising to do this for you without a comprehensive knowledge of the sector is unlikely to make this happen. The number one incumbent on Google may have thousands of links, been around for decades and updates their site twice a day and, unless you have huge resources at your fingertips (and possibly a time machine), you’re never going to leap above them. Although there are some honourable companies offering

web-marketing services out there, it’s important to be wary of scammers in the SEO sector. There is no immediate result, no guarantees and a degree of faith is required to sign up to an SEO provider. Furthermore, there is also an almost limitless supply of companies prepared to sign up to it, meaning there is even more competition for the higher rankings on Google. The SEO providers suggest that it takes three to six months before you see anything happening, but to really see a benefit can take some deeper investment. Google now seems to be making a concerted effort to make the SEO industry honest. Historically, you could programme the software and get a website to rank by posting links from thousands of unrelated third-party sites.2 Your website link would be posted onto these unrelated, just-for-links websites, meaning that your site would then appear higher up on Google’s search results page, as the SEO process ranks those with more external websites linking their website higher up. The more your link was posted onto external websites, the better your SEO. Not only does this no longer work, those clients that have links pointing to them from untrustworthy websites will get penalised. In fact, we have many clients who had innocently paid for SEO work in the past and are now seeing the damage wrought by these dishonest practices. I work with one practitioner who offers Vibration Amplification of Sound Energy at Resonance (VASER) liposuction, and he doesn’t appear in the top 100 pages of Google for this procedure due to penalties on his site. The work required to clean up the damage is time consuming and

Getting ranked on Google The simple truth of SEO is that there are so many factors at play that, for a new or relatively unknown site, getting to the top is difficult for highly competitive keywords in the immediate future. You need to understand that you’ve got to be in it for the long haul. Google ranks sites according to an algorithm,3 which it applies to every single website that exists. The exact details of the ‘algo’ is secret and known only to a few select employees of Google, and has some 200 points of measurement.2 However, some smart people have been able to ascertain what the most important are by trial and error. Here are some of the main ones, not ranked in order of importance: • • • • • • • • • • • •

Site age The software it’s built on The way it’s built Load speed Server efficiency Mobile optimisation Onsite content; how much and how relevant Offsite mentions and articles with links from quality websites Listings in online directories such as Yell Reviews on Google and other sites Social media connections (LinkedIn, Twitter, Facebook, Pinterest) Updating your site on a regular basis

Be honest Many people think that it’s complicated to get ranked. Pseudo-technical terms and acronyms fly about the place making it seem baffling, but it’s entirely possible to do it yourself by putting aside a couple of hours a week. If you are going to manage your SEO, then I would adopt one key philosophy: be honest. If someone is offering to get you ranked for a small amount of money then it’s more than likely that you are paying a small amount of money for nothing. If there is some software that claims to get you ranked, then it won’t, because if it worked then everyone would be doing it. More alarmingly, you may even be paying someone who will actually damage your site and online reputation. If it feels like a shortcut, then it almost certainly is, so avoid it. Google wants to reward those that engage with the internet in an honest way. SEO isn’t

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something that can be done in isolation as a stand-alone function. It can’t be forged and there isn’t a shortcut, it needs to be knitted into the fabric of your business. What next? I’ve listed some of the key components of the Google algorithm. Some, like site longevity, can’t be addressed, but here’s my advice on your first steps towards SEO nirvana: 1. Check what platform your site is built on: WordPress is deemed highly ‘Googlefriendly’,4 but we have also heard good things about the latest version of Squarespace. 2. If you don’t already have Google Analytics installed on your site, then do so straightaway so you can start analysing your traffic – it can fast become addictive. 3. If you think you’ve been penalised for past SEO activities, then get a friendly webmaster to check inbound links to your site – they’ll have software that can highlight any spam sites and be able to upload a ‘Disavow File’ which basically

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asks Google’s forgiveness for past sins. 4. Avoid the big keywords where competition can be intense. Go for niche phrases and keywords, which are known in the trade as ‘long tail’. You can do this onsite by writing blog posts (weekly, if possible). Not sure what to write? Tell the world what you’re up to, where you’ve been and what you’ve learned. Find out what common questions your patients are asking and write short articles (FAQs) answering those questions. Be useful. Be the source of information on your particular area of expertise. 5. Local listings – make sure your site is listed with the various local free listing services that are available. This can include Google+, Yell, Thomson Directory and many more local directory and listing sites. In time, you will find yourself getting traffic from dozens of different sources, you will rank for a hundred niche keywords and, if you do it well, you may even rank for some of your bigger keywords. But you can’t

just turn it off and on. Getting ranked on Google in the natural listings is the result of lots and lots of relatively small activity over time that builds up your credibility. It can’t be done quickly and anyone who promises you this isn’t telling the truth. In fact, if you want to get to the top of Google by the end of the week, you will need to get your cheque book out and load up your AdWords account. Gavin Griffiths is a healthcare marketing professional who, with his wife, runs BHM Media – a specialist healthcare and medical marketing firm based in Leamington Spa. Gavin has a 20-year background in digital marketing and publishing. REFERENCES 1. Danny Goodwin, Top Google Result Gets 36.4% of Clicks [Study] (London: ClickZ Group Limited, 2011) <http:// searchenginewatch.com/sew/news/2049695/top-googleresult-gets-364-clicks-study> 2. Unnatural Links to Your Site, (US: Google, 2015) <https:// support.google.com/webmasters/answer/2700611?hl=en> 3. Algorithms (US: Google, 2015) <http://www.google.com/ insidesearch/howsearchworks/algorithms.html> 4. 24 Steps To Rank Your Blog On Google’s 1st Page, (US: HOWTOMAKEMYBLOG, 2015)<http://howtomakemyblog.com/ googles-matt-cutts-wordpress-the-best-blogging-platformfor-seo/>

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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journalists will be wary of sources who are too closely linked with any one particular company. The perceived danger is that the spokesperson may be acting as a mouthpiece for opinions that directly benefit a particular company or product. 2. Knowledgeable: Your training, years of experience and thorough understanding of treatments, processes and the wider industry are what journalists want to see here. 3. Professional: This is about keeping a calm, collected approach in the face of divided opinions and not getting drawn into speculation or a ‘gossiping’ style – keeping yourself above the media fray. 4. Instantly quotable: Good spokespeople have the inherent ability to drill complex issues down to interesting ‘soundbites’ – messages that hold the audience’s attention and get to the point quickly and effectively.

Building Your Brand as a Spokesperson Julia Kendrick explains how developing your skills as a spokesperson can unlock business potential Introduction We can all picture those well-known spokespeople within our industry who have struck that golden balance of repeated media exposure, but without losing their integrity or falling into the age-old temptation of self-promotion. How did they do it? Is being a spokesperson only achievable for those very select few? Do you need a big, expensive media plan in order to get going? As you may have guessed, the answer is no – becoming a credible, trusted media spokesperson is within your reach and you don’t need a public relations (PR) team to get started. This article provides practical, step-by-step advice for building your own personal spokesperson brand and leveraging this to benefit your business. So why go down this route in the first place? Becoming an expert source for the media not only provides significant advantages for your own personal ‘brand’, it also gives a ‘halo effect’ to your business by driving patient awareness, trust and engagement. Spokespeople enjoy increased visibility and credibility among a broad group of audiences, using the media as an engaging platform to highlight their ideas and insights. Whilst journalists will not be interested in directly promoting your business, they will be interested in securing a fuller understanding of a topic, or getting a different point of view in exchange for access to their readers, viewers or listeners. What makes a good spokesperson? Before delving in, it’s worth examining what makes a good spokesperson in the first place. These key characteristics will need to become the foundation for your own spokesperson brand: 1. Independent and credible: For our industry, this particularly relates to relationships with pharma companies, suppliers and manufacturers. The key here is a clear declaration of interest –

Where to start? Identifying your strengths and target media Who do you want to increase your visibility among? Over the years, I have worked with clients that have a broad range of personal spokesperson goals; some wanted to be on the TV chat-show sofa, discussing latest treatment trends and celebrity looks, and, at the other end of the spectrum, some wanted to focus purely on increasing their industry and clinical prestige via congresses and trade publications. Consider what you believe to be your communication strengths – are you good at translating scientific advances into layman’s terms? Do you enjoy outlining complex points of medical practice or providing clear counsel in the face of an industry crisis? Begin by identifying these strengths alongside your own personal goals for being a spokesperson and think about what type of media will provide you with the best opportunities to achieve these goals. Would it be ‘consumer’ press, such as women’s magazines, newspapers, TV and radio, or are industry-focused trade journals, medical publications and online portals more suitable? Maximising the ‘Halo Effect’ for your business Whilst the media aren’t interested in directly plugging your clinic, by crafting your responses carefully you can raise awareness of yourself and your clinic in a credible way. This is primarily achieved by incorporating the clinic mention within the context of a relevant example in your interview; directing the audience to your clinic experiences, trends you have seen in clinical practice, treatments you offer, regulations you follow – you can give a clear picture of your business – but in a way that is relevant and interesting for the media. Keep these kinds of examples to one or two mentions per interview – if you constantly refer back to yourself it will appear promotional and reduce your credibility. In addition, always ensure that the journalist includes your name, title and clinic alongside your quote – this is an easy win for more visibility and awareness! Once you have started engaging with the media, there are several ways you can share your successes through your clinic marketing to further enhance your profile and raise visibility: • Update your website: Add an ‘as seen in’ page to your website with coverage examples or media logos in which you have appeared. This gives prestige and credibility to potential patients browsing your site. • In-clinic tools: Maximise your waiting room by including ‘as seen in’ coverage examples in display frames and on your reading table. • Twitter signposting: Alert your followers to upcoming coverage, or thank a journalist for a recent interview. Don’t forget to include

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the media outlet or journalist’s twitter handle in your tweet – hopefully, they will retweet your comment, thus raising your visibility among their followers as well. Conclusion The main benefits to your business from being a spokesperson will be increased loyalty, trust and retention of existing patients, along with expanded visibility for new patients – those who will make the move from consideration to action after seeing or hearing about you in the press. Ensure your clinic is fully optimised online and by phone to capture these new potential patients in the immediate aftermath of any high-profile media interviews. By now you will hopefully feel better equipped to pursue opportunities as a media spokesperson in your chosen area of expertise. With solid preparation and training under your belt, you will feel more confident about engaging directly with journalists and providing that much needed expert opinion just when they need you.

In Practice “Building your reputation with key media outlets takes time and it won’t happen overnight. Work towards developing long-term relationships with a wide range of media professionals including beauty editors, freelancers, bloggers, producers and researchers. A big mistake practitioners often make is to dismiss a blogger or beauty assistant as not being worthy of their time. The beauty assistant of today is the beauty director of tomorrow. If you treat media professionals with respect and help with their stories (even if you don’t end up being quoted), they will come back to you again when they have something better for you. The operative word is credibility; it’s okay to say, “I don’t know” if you are not sure, but go the extra mile and point them in the direction of someone who does know. That strategy will really pay off in the end.” Wendy Lewis, president of Wendy Lewis & Co Ltd and editor in chief of Beautyinthebag.com Julia Kendrick has 10 years of experience in public relations and communications, and is the founder of new start-up Kendrick PR Consulting, a consultancy service specialising in medical aesthetics and healthcare PR. A previous winner of the Communiqué Young Achiever Award, Julia is passionate about delivering award-winning client campaigns and high-calibre results.

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The four key steps to spokesperson success Once you have a clear idea about your strengths, goals and target media channels, you can implement the four key steps. 1. Training and preparation • Media training: Nobody starts off feeling completely comfortable talking to journalists; this confidence comes through the development of specific techniques, a solid understanding of how the media work and lots of practice! Consider hiring a media trainer to put you through your paces – they will be able to help you build and adapt your style, to better anticipate what the media are looking for and how to cope under pressure. That pivotal skill of talking in ‘soundbites’ takes time and preparation to acquire, so it’s also well worth familiarising yourself with the different demands for TV, radio, print or online press, all of which require a slightly different approach. • Industry partnerships: If you have strong relationships with a particular company (such as a pharma/device company or manufacturer) you may wish to reach out to them for help and support in finding spokesperson opportunities. In return for speaking on behalf of their companies, they may offer to provide media training in return for pointing interview opportunities your way – just remember the points about credibility and transparency and ensure you strike a balance between giving your professional opinion versus promoting particular products, services or companies. • Do your homework: Successful media interaction means understanding how stories are told. Read, listen, and watch news reports with an eye toward issues you might contribute something to. Watch how the experts are used to move a story forward and how concisely they can frame a point. 2. Build media relationships • Introduce yourself: Start by calling specific reporters in your target media category and introduce yourself with a few specific suggestions about stories or angles on which you are qualified to offer expert opinion. The more specific your suggestion, the better. Pay attention to who has been writing about what and include this information in your call – you are more likely to get a positive reception if the journalist feels you have taken the time to familiarise yourself with what they have written about specifically. • Become a key contact: Your ultimate aim is to introduce yourself and get on the reporters’ contact list as an expert source to be called at the next opportunity. You can usually find most reporter’s contact details online – if you can’t find the specific reporter, try going through the news desk and asking for the most appropriate person to speak to. 3. Capitalise on news and trends • Offer advice: Have you read or heard something you disagree with? Track down the reporter and suggest a follow-up story from a different angle, or, if the facts in the story are wrong, offer the correct ones in a polite, respectful way. • Be contactable: If you’re going to interact with the media, you’ll have to expect short-notice requests and ever-changing deadlines – it is essential to be contactable for that all-important interview request. You might have the most expertise on a given topic, but if you’re not accessible to reporters on deadline, you won’t be called next time! 4. Adopt best practice • Resist the rumour mill: Resist the temptation, even when pushed, to speculate or comment on a rumour. Instead, offer the reporter some alternatives such as other ways of finding the information so you continue to prove your value as a source. • Never mention patient names – even celebrities: Besides betraying doctorpatient confidentiality and trust, this can land you in serious legal trouble. • Don’t spin: Don’t lie to a reporter, or stretch the truth – ever. Nothing is more important to a reporter than their reputation, because this means job security. Damage their credibility and you won’t get a second chance to become a source.

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Applying the Marketing Mix Aesthetics editor Amanda Cameron outlines how to stay ahead when developing your business The medical aesthetics market has become extremely competitive over the past few years; we all know that improving patients’ self-esteem brings emotional rewards as well as those of a financial nature. With a rapidly expanding number of clinics setting up to cater for the increasing demand for cosmetic improvement, comes increased choice for the patient. So how can you stand out from the crowd? Unsurprisingly, marketing your company effectively is key. Strategic marketing planning and analysis is an evolving process and anyone who has studied it will have been taught about the ‘marketing mix’. This was originally defined as the ‘4 Ps’ – Product, Price, Promotion, and Place.1 Since then, three more ‘Ps’ have been introduced: People, Packaging and Positioning.2 To apply the marketing mix directly to your practice is where the challenge begins. You will have written your marketing plan at the beginning of your business journey, but not everyone reviews and evaluates the plan as time goes on – which is critical in order to stay competitive and attractive to your customers. The correct ‘mix’ will vary depending on your aims, and there are different methods that exist to achieve this. You will be utilising alternative long and short-term strategies until you reach your goals. So, let’s take a look at the ‘Ps’ and how exactly to apply them: Product What are you selling? Step back and try to look at your business as a consultant would. Ask yourself, “Is my business appropriate and suitable for current patients?” Are you promoting anything that you would change if you started the business today? How do you compare with your competitors, and, if you are not superior, what do you need to do to become so? Presenting the correct product (goods and/or services) with values that meet or exceed the needs and expectations of the target market is crucial. The primary determinant is in knowing that customers perceive and receive value and satisfaction by way of your clinic. So, get to know your potential patients, research the market, ask questions, and, if necessary, engage a marketing consultant to help you with appropriate questionnaires and analysis that will deliver the results tailored to you. Price This is the amount paid in exchange for the value received. Price must be competitive and lead to profit, but may vary within promotional and/or bundle purchase options. It is important to regularly evaluate your pricing to ensure it is still relevant and appropriate for the current market, and do not be afraid to raise or lower if necessary. Are you spending too much

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on the wrong products or services? It is vital to be open-minded and unafraid of change; price is generally associated with a product, but cosmetic procedures should be looked at in a different way, as you need to include your time and expertise, as well as that of your team, on top of the cost of the raw material or system cost. Take a serious look at those areas where there is flexibility, and be open to adjusting prices. These are some key ways to work out your price range: • Look at the competition: Do not out-price yourself so customers go to other clinics, however you should avoid undervaluing your services – make sure your pricing reflects what you offer. • Talk to the manufacturer to get the idea of market value: The manufacturer can tell you how other clinics price that product, and offer their own price recommendations. • How has price changed? Utilise data and make an informed assessment of what prices should be in the current climate. • Is there a way of packaging any products together to make treatment bundles? Treatment bundles are very attractive to customers and also provide the chance to market less sought-after products or services. Promotion / Communication How you promote your business to your target audience is crucial, and very small changes can lead to big results. Don’t be afraid to re-evaluate your advertising – even a change of copy can have a dramatic effect.3 How you promote your clinic will not always be current and relevant, so evaluate your strategy regularly. If you are not already using sophisticated marketing software to help you profile and target your patients, it is well worth the investment. Review your current advertising with any public relations activity and marketing materials, and be sure it portrays you as the prime choice for your chosen audience. Ensure you have all your contact details printed clearly on all of your promotional material so people can easily find you both online and when visiting – this sounds so obvious, but you would be surprised how often it’s missed. Look at your long and short-term marketing strategies. Long-term strategy is all about building your brand, and this will be apparent in your marketing materials and the appearance of the clinic. You will have identified where you

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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started, where you want to be and how you plan to get there. Shortterm strategies can create a temporary boost by offering incentives or timed promotions, so a good mix is essential here. You then need to develop the tactics to fit with the strategy. A good marketing handbook will be invaluable in order to establish your strategy, but there are many forms of communicating with your target audience to inspire action, such as online and through social media. Some years ago, websites or social media would not have been included when creating and executing a marketing strategy, but now you must be online to compete in the marketplace on a level playing field. Social media must be fully utilised, and it is well worth speaking to an expert in this field, as well as researching key online strategies to maximise your business. Place This is where your products are actually sold – usually, this will be in your clinic, but don’t disregard other avenues to reach potential customers. You make the key decisions about the very best location for you, so optimise these opportunities by exploring the best way for your customers to receive essential information in the right place and at the right time. Place can also refer to your marketplace demographics, or even globally if you provide online services. What’s the ideal place or location to offer or provide your services? Do different locations require different approaches? Think about how the end-user gets the necessary information to reach a buying decision, and if there are additional places to offer your services. Talk to your existing patients for their preferences, or conduct a well-structured market research study. It is also worth contacting people that enquire but then do not proceed – find out the reasons why they didn’t go ahead with your clinic and, if possible, use their feedback to offer a better service next time. Packaging Be sure to look at every visual element in the packaging of your product or service. Remember, it takes just one-tenth of a second for us to judge someone and make a first impression.4 Small improvements in the look or the external appearance of your clinic can often lead to completely different reactions from your patients. Put yourself in the shoes of a potential patient – what would a secret shopper discover? Remember that packaging also refers to your staff and their appearance, as well as the overall look of the clinic, such as the waiting room and consultation rooms. Other aspects of your business’ ‘appearance’ also include brochures and information packs. Some clinic owners and staff never walk through the front door of their own clinic. Try it. You might be surprised to see what patients are seeing as they form their first impressions. You want your patient to feel they will be looked after in a clinical and professional environment; ensure your team are wellinformed and make sure the entrance of the clinic is welcoming. Positioning Spend some time thinking about how you are positioned in the minds of your patients. Consider how people think of your clinic and what words they would use to describe you and your business. Would they use words that reflect your marketing message? You need to decide how you want to be seen – whether this is as an innovator, the best at a certain technique,

Aesthetics

or the best at treating a certain body area. Decide what position you would like to have, work out what would be ideal to bring in more business and identify any changes that need to be made to do this. Patient testimonials and photographs will reinforce this image, and provide prospective patients with some third party endorsement. People The final ‘P’ of the marketing mix is crucial – people. The right people performing the right tasks in your business is often underestimated. It is vital to spend time and effort recruiting the team that will execute your plans and have the correct skillset. Regular training and routine reviews are then key to keep everything current, as well as making sure all staff are well informed of all procedures. It’s important not to forget your patients in this mix, and a good place to start is by defining your chosen patients to create an all-crucial targeted marketing approach. Consider your strengths and your top treatments (products) on offer. Work out your preferred patient profile by evaluating your existing patients and analysing their needs, then target your messaging to that demographic to avoid wasting money by sending the message to everyone. Finding your target patient: • Analyse current patients: Build up a profile – who is your typical patient according to your database? What is their age/gender/ treatment preference? • Market research: Much under-utlised in the aesthetics industry due to expense and time, however this is actually a good investment – if you spend time opening a new clinic, you should spend time building it. Use a good mix of both qualitative and quantitative research in order to gain a broad and detailed overview of the patients you should be targeting. This ‘P’ looks at the patients, clients, customers, prospective patients, providers, staff, management – everyone involved in the practice. The people who deliver a service are a significant ingredient in the product itself. Consumers evaluate service and satisfaction based on perceptions.5 Conclusion In summary, do not be afraid of going back to basics to assess your business. Take a fresh look at everything and carry out your own market research to see how you are perceived in the eyes of others – would you want to be a patient in your clinic? Establishing and executing an efficient marketing mix, which includes both long and short-terms goals, is essential for staying one step ahead of your competitors. Amanda Cameron is a sales and marketing professional, who has pioneered and worked in the aesthetics industry for more than two decades. After initially training as a nurse, she was one of the first nurse injector trainers in the UK for dermal fillers, later progressing into sales and marketing. Her current roles include industry consultantancy and holding the position of editor of Aesthetics. REFERENCES 1. McCarthy, E. Jerome. Basic Marketing (USA: Richard D. Irwin, 1960) 2. Optimizing Headlines (Florida: Marketing Experiments, 2008) <http://www.marketingexperiments. com/improving-website-conversion/optimizing-headlines.html> 3. Willis, J and Todorov, A, ‘First impressions: Making up your mind after 100 ms exposure to a face’, Psychological Science, 17(2006) 4. Bolton, Ruth N. and Drew, James H. ‘A Multistage Model of Customers’ Assessments of Service Quality and Value’ Journal of Consumer Research 17(4) (1991), p. 375-384 5. Marketing Theories – The Marketing Mix – From 4 P’s to 7p’s (UK: Professional Academy, 2015) <http://www.professionalacademy.com/blogs-and-advice/marketing-theories---the-marketing-mix--from-4-p-s-to-7-p-s>

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


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Aesthetics

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MEDICAL AESTHETICS – AN IMAGE BUSINESS? THE IMPORTANCE OF BEFORE AND AFTER IMAGING ANALYSIS Most people who seek aesthetic treatments will do so because they are unhappy about some aspect of their appearance – they do not like something they see in the mirror or a recent photograph is not as aesthetically pleasing as they hoped it would be. For practitioners, trying to accurately convey the changes that you might want to make to a patient’s appearance can be difficult; what you see as a professional and what they see as a self-conscious patient can be very different. This miscommunication can be a source of frustration for both parties; patients can become disillusioned, lose trust in the aesthetic practitioner, and eventually take their custom elsewhere. Imagine, though, if your patient could see the underlying skin issues that you discuss with them, with their own eyes. It would certainly make it a whole lot easier for you to explain your proposed treatment plan and why it would be beneficial to them. As such, the need for a high quality and sophisticated imaging system has never been more apparent in the demand for patient satisfaction.

HOW CAN SKIN ANALYSIS HELP? A visual consultation prior to any procedure is a necessary part of any clinical practice. It is the start of building a relationship and trust with your patient – following an informative and educational skin analysis, it is likely that they will buy into your treatment plan or procedure. Taking ‘before’ photographs is an excellent first step for new or prospective patients as the aesthetic professional is able to clearly demonstrate areas recommended for treatment. Post-treatment images can then be compared with the ‘after’ images to give an accurate and visible progress report of the treatments, as well as provide an objective photographic benchmark in the event of any treatment dissatisfaction. THE 21ST CENTURY SKIN ANALYSIS MACHINE The Observ 520 is a new skin diagnostic technology. It uses patented skin fluorescence and polarised light illumination technology to expose many different skin conditions, such as pigmentation, rosacea and ageing, which originate from the deeper skin layers and are, therefore, very difficult to diagnose with the naked eye. Once the skin condition is exposed, this unique technology will enable you to create awareness and propose a targeted treatment programme, specific to each individual patient. The Observ 520 technology is slick and wonderfully 21st century; an iPad is used to present the visual data created by the machine. This means that you can easily switch between different modes to highlight different aspects of the skin, or you can even move from one session to a previous one in order to show the patient their treatment progress.

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Aesthetics | August 2015

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“You must always be safe. Never take risks with your patients, that’s the key” After almost 30 years of working in the specialty, 2014’s Aesthetics Awards Lifetime Achievement Award winner, Dr Roy Saleh, speaks to us about his journey into aesthetics Having started his career in 1983 in his home town of Manchester, Dr Roy Saleh has since specialised in a wide range of non-surgical facial rejuvenation treatments and has become an innovative leader within the field. Dr Saleh explains, “At the time, there wasn’t anything in between cosmetic surgery and beauty salon treatments, so we tried to develop treatment that was somewhere in the middle, in the hope they would gradually become popular.” Before botulinum toxin was used in the industry, Dr Saleh treated patients in a south Manchester clinic with dermal fillers and collagen treatments. “I set up on my own in 2008 and I decided to stick to the north as there’s an advantage to treating the same patients over time,” he explains, “Facial rejuvenation occurs over many years, so if you’ve got a very transient population you can never see if people are improving or not. Whereas, if you see the same people for years and years, you can then see the improvements.” Dr Saleh explains that he has always been, and is still, dedicated to helping patients achieve a natural, youthful look. “Botulinum toxin is very effective when used on the forehead and around the eyes, but this means the middle and lower part of the face is still ageing. So for the last 10 years we have concentrated on treating the middle and lower part of the face. Otherwise we would have a group of people who wouldn’t look naturally balanced.” The introduction of botulinum toxin to the aesthetics industry, he says, was a turning point, and played a big part in the boost of non-surgical treatments. “Botulinum toxin breathed life into the non-surgical industry. It meant that you could do much more and we were seeing more patients than before,” he says. Between 1997 and 2001, Dr Saleh explains, there were very few practitioners using botulinum toxin in aesthetics, and he was in fact the only practitioner doing so in Manchester. Dr Saleh has been witness to the vast scientific advances in the field of non-surgical facial rejuvenation over the past twenty years. “At one time we were injecting by following lines that had already been established, but what we’re doing now is looking at facial volume and aiming to improve the appearance by putting more volume into the face,” he explains. Dr Saleh has accrued a loyal patient base over the years, despite the increasing number of new clinics and practitioners establishing themselves in the industry. “I love my patients, and I appreciate the fact that they continue to come to me,” he says. Reasons for his patients’ loyalty seems self-evident. “You always have to treat your patients with respect, and you have to do whatever you can for them. I always try to choose the best product and the best treatments for them,” he says. Dr Saleh also takes great pride in ensuring his patients endure minimal side effects. “The clinic is quite secluded so people can come and go without feeling as if they’re being watched. We work very hard for the patients to look as good as possible when they’re leaving; we don’t

want them to look as if they are bruised. People can come and have their treatment and leave with confidence.” Dr Saleh works by the view that, “You must always be safe,” – a notion he is very ardent about. “Never take any risks with your patients, that’s the key to doing well,” he emphasises. Given the chance to do anything differently, Dr Saleh admits he might have opened his own clinic sooner. “I’ve enjoyed the last eight years such a lot,” he explains, “You can always look back and think ‘if only I had done it sooner’ – but I’m very proud of the fact that we’re busy and we remain full.” Looking back over his career, Dr Saleh says maintaining his strong team of staff, some of which have been practising with him for more than 15 years, has been one of his biggest achievements. Another was winning the Lifetime Achievement Award at last year’s Aesthetics Awards, “I was so pleased to receive it – that was a fantastic surprise, I had no idea at all! It’s been lovely for me to have recognition from the rest of the industry, and it’s been very nice for my patients to see the award, to see that they’ve been coming to somebody that’s really tried hard for the whole of their career. I’m so very proud.” Dr Saleh has no plans to slow down and is always looking ahead, “The aesthetic medicine specialty is growing rapidly and successfully and I still want to be there as it progresses.”



What technological tool best compliments your work?
 The cannula has revolutionised our treatments. I believe it’s safer, you cause less damage and there is less risk. I definitely think that the cannula has markedly changed the way that I do things. Do you have an industry ‘pet hate’? No – I love it! I love everything about it, and I hope I’m lucky enough to carry on doing it for more years to come. It’s been very satisfying for me. Is there anybody in particular that you have learnt a lot from? The man who sticks out the most in my mind is Professor Fournier; he was the person who taught me how to remove fat and to inject it into the face. In my opinion, there can be no better filler than the body’s own fat. Professor Fournier is very experienced in teaching this method and had a big influence on my career.  What aspects of aesthetics do you enjoy the most? I like the idea of helping ladies to retain their youthfulness, slowing down the ageing process, and improving their confidence. If I can carry on doing that and carry on helping people, then that would be my ultimate goal. 

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


Celebrate the best of the medical aesthetics industry An amazing night of celebration with our friends and colleagues; the Aesthetics Awards is definitely a highlight of the year! Steve Joyce, Healthxchange Pharmacy, Cosmeceutical Range/Product of the Year 2014

The 2014 Aesthetics Awards night was a spectacular evening celebrating the best in the industry and it was a great joy to be part of such a wonderful event. Dr Linda Eve, Medical Aesthetic Practitioner of the Year 2014

Book your tickets www.aestheticsawards.com Finalists will be announced in the next issue of Aesthetics journal. Donâ&#x20AC;&#x2122;t miss out.

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Aesthetics Journal

The Last Word How can we prevent skin cancer? Mr Apul Parikh shares his views on the importance of public health campaigns and why he thinks the UK should follow Australia’s approach to sun awareness How many of us living in the UK are aware of the National Sun Awareness (NSA) week? How many of us were aware that this year it ran from May 4-10? I am confident that the vast majority of us (healthcare professionals, as well as the lay public) were blissfully unaware of this. The campaign was launched in 2000 by the British Association of Dermatologists (BAD).1 It aims to create awareness about skin cancer and teach people about the dangers of sunburn and excessive tanning. We are all aware, however, that excessive exposure to Ultra Violet Rays (UVR) is the main causative factor in developing skin cancer. In fact, 80% of malignant melanomas (MM) are linked to exposure to UVR from the sun as well as sunbeds.2 At present, skin cancer is a sizeable problem in the UK; unfortunately, it is rapidly increasing in incidence, and is poised to become an even more severe predicament. Approximately, 50% of basal and squamous cell cancers (or non-melanoma skin cancers – NMSC) are unrecorded in national statistics. The data is thus more accurate when limited to MM.2 The incidence of MM in 2001 was 12/100,000, by 2011, it had soared to 17.6/100,000. During the last decade, MM was the second fastest growing cancer in males and females, with incidence rates rising by 57% and 39%, respectively. In the UK, two young adults (15-34 years old) die from MM every day.2 With soaring numbers of package holidays in the sun,3 and the explosion in sunbed usage,2 deaths from MM are predicted to escalate within the next two decades. So, are we doing enough to combat skin cancer? In 1980, Cancer Council Australia launched what is now generally regarded as one of the most successful public health campaigns to date.4 “Slip! Slop!

Slap! Slip on a shirt, slop on sunscreen and slap on a hat. Slip! Slop! Slap! You can stop skin cancer” went the jingle. Featuring Sid the cartoon seagull, the campaign was rolled out nationally to combat Australia’s soaring MM rates. Over the next few years, variations of the Slip! Slop! Slap! scheme could be found in newspapers, on the radio and on national television, as well as billboards in most public places. Public warnings were issued on days when the UV index was raised, advising the population to apply sun block and seek shade. In addition to this, a national education programme was launched in nurseries along with schools. Large-scale programmes were also launched to increase the proficiency of general practitioners to diagnose skin cancers, as well as to educate the public on how to avoid sun damage.5 Twenty-five years after the inception of Slip! Slop! Slap!, preliminary studies suggested that there was a decline in NMSC. In 2007, the campaign was updated in order to maintain the offensive against skin cancer. It was amended to “Slip! Slop! Slap! Seek! Slide!”, where ‘Seek!’ encouraged people to seek shade during peak UV hours and ‘Slide!’ to remind people to slide on sunglasses. We are now 35 years on from the original campaign launch and only recently have studies in Australia confirmed a decline in NMSC as well as MM incidence rates in those under the age of 45.6 This is consistent with evidence and trends of young people in Australia who have decreased their UVR exposure as a direct consequence of the public health campaign.7 Furthermore, economic studies demonstrated that skin cancer prevention campaigns are an eminently worthwhile investment.8 Cancer Research UK predicts a decline in mortality rates for most cancers over the next two decades. MM is one of the few cancers

Aesthetics aestheticsjournal.com

that is predicted to increase exponentially over this time period.2 The crux of the matter is that most cancers are simply not preventable (although screening programmes can potentially ensure earlier diagnosis). Yet the evidence, according to Cancer Research UK, overwhelmingly suggests that the vast majority of skin cancers are preventable. The key lies in educating the masses about sun protection. The UK Sunbeds Regulation Act of 2010 banned sunbeds in those under the age of 18.9 I propose that we take this a step further, and push for a complete ban of all sunbeds. The World Health Organisation has classified tanning beds as one of the most dangerous forms of cancer-causing radiation; they have been categorised into the same group of hazardous substances such as plutonium and radium.10 Eight million people in the UK use tanning beds every year.2 With such overwhelming evidence vilifying them, how can sunbeds still remain legal? There is no need to reinvent the wheel. It is clear that the BAD need far more support in their endeavours with NSA. A week is inadequate, and simply not good enough. What is needed is a sustained, multi-faceted national campaign to the extent that the Australians have demonstrated. For all we know, the benefits of such a multi-pronged assault on skin cancer may not become evident for 30 years. So, to answer my original question, “Are we doing enough to combat skin cancer?”, I’ll ask you another, “What do you think?” Mr Apul Parikh studied medicine at the University of Leeds, before moving to London to pursue a career in aesthetics. He is one of the lead trainers for injectables at the RSM and the Medical and Aesthetic Training Academy. REFERENCES 1. Sun Awareness Campaigns (UK: British Association of Dermatologists, 2015) <http://www.bad.org.uk/for-the-public/ sun-awareness-campagin> 2. Skin cancer statistics (UK: Cancer Research UK, 2015) <http:// www.cancerresearchuk.org/health-professional/cancerstatistics/statistics-by-cancer-type/skin-cancer> 3. No-Frills Carriers: Revolution or Evolution? (UK: Civil Aviation Authority, 2006) <https://www.caa.co.uk/docs/33/CAP770.pdf> 4. Peeraya T, Principles of Communication Management Communications Campaign Analysis, (Academia, 2014) <http://www.academia.edu/9610313/_Slip_Slop_Slap_ communication_campaign_analysis> 5. Slip Slop Slap Seek Slide (Australia: Cancer Council Australia, 2015) <http://www.cancer.org.au/preventing-cancer/sunprotection/campaigns-and-events/slip-slop-slap-seek-slide. html> 6. Erdman F et al, ‘International trends in the incidence of malignant melanoma-are recent generations at higher or lower risk’, Int J Cancer, 132(2) (2013), pp. 385-400. 7. Olsen et al, ‘Turning the tide? Changes in treatment rates for cancer in Australia’, J. AM acad Dermatol, 71 (2014) pp. 21-26. 8. Hill et al, ‘Interventions to lower UVR exposure: Education, legislation and public policy’, Asco University, (2009). 9. Sunbeds (Regulation) Act 2010, (UK: gov.uk, 2010) <http://www. legislation.gov.uk/ukpga/2010/20/section/2> 10. Sunbeds (Europe: World Health Organisation, 2015) <http:// www.who.int/uv/faq/sunbeds/en/index5.html>

Reproduced from Aesthetics | Volume 2/Issue 9 - August 2015


Annual British College of Aesthetic Medicine Conference Registration is now open via the new BCAM website

This year’s event will be held at the stunning Church House Conference Centre in Westminster, London on Saturday 26th September 2015 Our conferences are always very informative and inspiring, an event where you can acquire new knowledge and expand your development whilst networking with colleagues. This year’s programme is full of educational lectures given by some of the most innovative speakers in the industry including Mr Rajiv Grover, Dr Nick Lowe, Mr Paul Banwell, Dr Ravi Jain, Dr Patrick Treacey & Prof Bob Khanna but to name a few. There will also be live demonstrations by Dr Sam Gammell (IV Nutrition) and Dr Beatriz Molina, Dr John Quinn and Mr Philippe Kestemont presenting a joint live demonstration using the latest technologies and cadaver dissection to demonstrate a non-surgical face lift. The BCAM annual conference is open to all aesthetic doctors and shouldn’t be missed. It is also an opportunity for all BCAM members to show their ongoing support and boost their CPD.

Come and join us by registering via the events page on our brand new website www.bcam.ac.uk

Receive a free £10 credit* every time you refer a medical professional to MedivaPharma. MedivaPharma customer benefits include: • Free Account for Medical Professionals • Comprehensive Range of Dermal Fillers, Toxins and Skin Rejuvenation Products • Free Delivery** & Free Order Tracking Service • Regular Promotions & Offers on our range of Dermal Fillers • Dedicated Account Managers and first class service • PIAPA Training and Support Opportunities *Credits applied to existing and new accounts. **On orders over £250.

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

Tel: 01234 841536

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Med-fx Contact: Faye Price +44 01376 532800 sales@medfx.co.uk www.medfx.co.uk

Silhouette Soft Tel. 020 7467 6920 Contact: Emma Rothery www.silhouette-soft.com silhouettetraining@sinclairpharma.com

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

Sinclair Pharmaceuticals info@sinclairpharma.com 0207 467 6920 www.sinclairispharma.com

t Medical-Store +44 (0)20 7486 4245 +44 (0)20 7486 4246 info@medical-store.co.uk www.medical-store.co.uk

Thermavien Contact: Isobelle Panton isobelle@thermavein.com 07879 262622 www.thermavein.com

z Medico Beauty Contact Name: Andy Millward +44 (0) 844 855 2499 training@medicobeauty.com www.medicobeauty.com & www.medicobeautyblog.com

Aesthetics | August 2015

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


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Now approved for crow’s feet lines Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU 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) and lateral periorbital lines seen at maximum smile (crow’s feet 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. Glabellar Frown Lines: 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. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. 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. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually 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). Glabellar Frown Lines: 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, 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). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,

dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. 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: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August 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. 1183/BOC/DEC/2014/DS Date of preparation: December 2014

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Botulinum toxin type A free from complexing proteins


Experience all the benefits of VYCROSSâ&#x201E;˘ technology. Treat various areas of the face using only 3 products. Itâ&#x20AC;&#x2122;s that versatile.

Instructions and directions for use are available on request. Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014

Aesthetics August 2015  

Augmentation