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VOLUME 4/ISSUE 9 - AUGUST 2017

JUST FOR YOU. Because every patient is an individual.

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whether they want to Relax their lines, Restore their youthful appearance, Enhance their facial features or Refresh their skin quality. Contact your local Galderma representative for more information.

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Treatments in Pregnancy CPD Practitioners review literature for the delivery of aesthetic procedures during pregnancy

Date of Preparation: April 2017 Code: RES17-04-0129

Special Feature: Rhinoplasty

The Epidermal Barrier

Marketing Planning

Practitioners discuss their preferred methods for nonsurgical rhinoplasty

Dr Daniel Chang reviews how aesthetic treatments impact the epidermal barrier

Julia Kendrick provides her top 5 tips for effective marketing


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Contents • August 2017 06 News The latest product and industry news 15 On the Scene

Out and about in the industry this month

19 News Special: Social Media and Appearance Anxiety

Aesthetics asks what practitioners can do to restrict social media’s influence on appearance anxiety

Special Feature Non-surgical Rhinoplasty Page 23

CLINICAL PRACTICE 23 Special Feature: Non-surgical Rhinoplasty

Practitioners discuss methods for non-surgical rhinoplasty using hyaluronic acid dermal filler

28 CPD: Aesthetic Procedures During Pregnancy

Mr Nihull Jakharia-Shah, Miss Priyanka Chadha and Miss Lara Watson review literature for the delivery of aesthetic procedures during pregnancy

32 Beautifying the Young Face Dr Rupert Critchley presents his technique for refining the young female face 36 Spotlight On: Biofibre

Aesthetics learns more about the new Biofibre artificial hair implantation device

38 Treating the Brow

Dr Victoria Manning and Dr Charlotte Woodward outline their techniques for performing a non-surgical brow lift using threads

42 The Epidermal Barrier

Dr Daniel Chang provides an overview of how the epidermal barrier is affected by different aesthetic treatments

49 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 51 Marketing Planning to Maximise Success

PR and communications consultant Julia Kendrick advises on how to create a successful clinic marketing approach

55 Seven Tips for Expanding Your Business

Multiple clinic owner Lucy Xu provides considerations for opening additional practices

59 Training in Waste Management and Infection Control Clinic waste technical manager Luke Rutterford discusses the

importance of waste management and infection control training

63 In Profile: Dr Daniel Sister

Dr Daniel Sister explains how he developed an interest for trying new antiageing treatments as he reflects on his career journey

65 The Last Word

Aesthetic journalist Gina Clarke provides patients’ perspective of vaginal rejuvenation treatments and discusses how procedures are affecting lives

NEXT MONTH • IN FOCUS: Complication Management • Filler Infection • PDO Threads • The Benefits of Mentoring • Aesthetics Awards 2017 Finalists Announced

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In Practice Improving Marketing Planning Page 51

Clinical Contributors Mr Nihull Jakharia-Shah is a final year medical student at King’s College London. He has completed a BSc degree in Regenerative Medicine and Innovation Technology where he studied biomaterials including aesthetic skin grafting products. Miss Priyanka Chadha is co-director of Acquisition Aesthetics training academy and currently works as a plastic surgery registrar in London. Her academic CV comprises national and international prizes and higher degrees in surgical education and training. Miss Lara Watson is co-director of Acquisition Aesthetics and is pursuing a career in maxillofacial surgery. She is currently in the final year of the Dentistry Entry Programme for Medical Graduates (DPMG) at King’s College, London. Dr Rupert Critchley is the director of Viva Skin Clinics and its sister training faculty, the Viva Academy. After qualifying as a medical doctor in 2009, he has completed an array of courses in advanced non-surgical aesthetics and is also a fully qualified GP. Dr Victoria Manning is an aesthetic practitioner and GP, with more than 20 years’ clinical experience. She is the co-founder of River Aesthetics in New Forest and London and is a national threads trainer. Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience, as well as the co-founder of River Aesthetics. She was one of the first in the UK to offer non-surgical breast lifting using PDO threads and is a national trainer. Dr Daniel Chang specialises in aesthetic medicine and is a KOL and trainer for injectables and threadlifting. Dr Chang founded Asia Aesthetic Academy in 2015 and has developed a number of signature treatments.

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Editor’s letter Well, we are in the great month of August when it’s holiday time! Maybe you have taken the journal away with you to read; if you have, please send us a photo of wherever you are reading and we will share on social media! Amanda Cameron August tends to be the month many have a Editor rest and slow down, however some clinics are busier than ever, so whether you are open for business or away, we hope this journal will entertain, educate and delight you as usual. At Aesthetics, we have been very busy planning for the Aesthetics Awards and are excited by the prospect of another fabulous occasion on December 2. We take the judging process extremely seriously with the most stringent shortlisting methods in place so you can be assured of high levels of integrity and scrutiny. Remember, finalists will be announced in our next issue, which comes out on September 1. In this issue, we focus on injectables. It’s amazing how their use

has changed procedures over the years; there was a time when surgery was the only option – now, however, you can read about practitioners’ approaches to non-surgical rhinoplasty in our Special Feature on p.23. On a different note, have you ever wondered what treatments can be performed in pregnancy? Well, have a read of this month’s CPD article (p.28) where three practitioners explore the studies behind aesthetic procedures and pregnancy, while sharing their advice for approaching treatment. Don’t forget to increase your business knowledge by reading our In Practice section, where you can learn how best to plan marketing campaigns, with advice from PR consultant Julia Kendrick on p.51, as well as discover multiple clinic owner Lucy Xu’s top tips for opening more than one clinic on p.55. You can also read advice from technical waste manager Luke Rutterford on training staff for infection control on p.59. We hope you enjoy our injectables issue; be sure to post your pictures and thoughts on Twitter, Facebook, Instagram and LinkedIn.

Editorial advisory board

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

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

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

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 17 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

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

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

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

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

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

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

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DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Teenage treatment

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Training MATA Courses @MATACourses Busy day at @MATACourses #jointinjection course accredited by @rcgp, @ApulParikh @drbawaaesthetic #generalpractitioners #Dermatology BCDG @BritishCosmDerm A truly excellent talk on #vitiligo and #melasma from our Fellowship winner Dr Faisal Ali thank you! @BritishCosmDerm @HealthySkin4All #ClinicEvent Marc Pacifico @MarcPacifico Final preparation for this evening’s open evening @PurityBridgeTW with @NHTWH #collaboration #plasticsurgery #LiveShow Dr Raj Acquilla @RajAcquilla Amazing live show by satellite in #Tbilisi hosting doctors from #Russia #Ukraine and #Turkey @Allergan #Botox #Juvéderm #NewClinic Dr Daniel Sister @DrDanielSister We have exciting news! After 13 years in Notting Hill, Dr Sister is moving to a new clinic in Westminster this coming September! More soon! #Achievement Nigel Mercer @NigelMercer I’m honoured to have been elected as President of the #FederationOfSurgicalSpecialistAssociations representing surgeons in the British Isles #Conference Healthxchange @HealthxchangeUK Gareth Cartman from Clever Little Designs discussing Digital Marketing for your clinic #AAE2017

Allergan CEO calls on aesthetic stakeholders to build a consensus for treating teenagers Brent Saunders, the CEO of global pharmaceutical company Allergan, has issued a statement asking aesthetic professionals to join a discussion on how the specialty can support teenagers seeking aesthetic treatments. He said, “I’m asking all stakeholders in this industry – medical aesthetic product manufacturers, plastic surgeons, dermatologists, aestheticians, owners of medical spas, mental health professionals and others – to join in a conversation to tackle this question: How can we appropriately manage and counsel teenage patients who want medical aesthetic treatments?” As the father of two high school age girls, Saunders said he is sensitive to the societal pressures they face – to look a certain way or meet a certain standard. He added that as the leader of Allergan, he appreciates how medical aesthetic technologies can provide safe, effective treatments for patients who seek the benefits of improving their appearance. However, he noted, “When these two worlds intersect – through the inappropriate use of medical aesthetic procedures among minors – it is time to speak up.” Emphasising that Allergan’s medical aesthetic products are only approved for adults, Saunders cited the fact that there is growing interest from younger patients, often teenagers under the age of 18, wanting to try aesthetic treatments. Calling on aesthetic professionals to join the discussion, Saunders emphasised, “Regardless of whether you agree with me, it’s clear that we need to begin a dialogue about this issue before it becomes a major challenge. Unless we do something to address this issue directly, we risk harming a vulnerable part of our society.” He concluded, “I look forward to gathering our community to address this question head on. My hope is that together we can come to a shared, common sense position, and ensure we are doing what is best for patients.” Industry

Cosmedic Pharmacy becomes UK distributor for Intraline Medical aesthetics company Intraline has partnered with Cosmedic Pharmacy to distribute its range of dermal fillers, PDO threads and skincare in the UK. Katrina Ellison, who has recently been appointed as UK country manager for Intraline said, “I am very happy to be in partnership with Cosmedic Pharmacy because our company values are aligned. I feel it’s very important that we work with the best suppliers in the industry to ensure that we have accessibility to our customers and offer them exceptional service, support and quality.” Iain Ashby, director of Cosmedic Pharmacy, added, “I am very excited to be working with Intraline, their dermal filler and threads will be very well received by our customers and I am looking forward to working closely with them to increase brand awareness and drive sales in the UK.”

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Conference

ACE 2018 dates announced

Vital Statistics The total sales value of the UK cosmetics market in December 2016 was estimated at £9.4 billion (GBP) (Statista, 2017)

Delegates from throughout the UK will meet at the Business Design Centre in London for the esteemed Aesthetics Conference and Exhibition (ACE) on April 27 and 28. ACE 2018 will feature presentations from top experts who will share their latest techniques and developments to support practitioners in their professional development in four agendas over two days. Delegates will also have the unique opportunity to discover the newest and most innovative products on the 2,500m2 Exhibition Floor, which will feature more than 80 aesthetic companies. Aesthetics journal editor and ACE 2018 conference organiser, Amanda Cameron said next year’s event will be one not to miss, “ACE is the number one place to be if you are involved in the aesthetics specialty and there is something for everyone. Last year we had 2,118 visitors attend and what stood out to them was the exceptional standard of top-quality educational clinical and business content. I am really looking forward to exceeding delegates’ expectations yet again in 2018, with some exciting announcements to come soon.” New sponsors have been announced for the Expert Clinic agenda, including skincare manufacturers AesthetiCare and mesoestetic. Adam Birtwistle, managing director of mesoestetic UK distributor, Wellness Trading said, “We are so excited to be able to showcase the latest offerings from mesoestetic in the Facing Pigmentation: Options and Outcomes Expert Clinic session, which is sure to demonstrate how innovative the mesoestetic products really are.” Free registration for ACE 2018 will open in October. To stay updated with the latest news and developments subscribe to the ACE website www.aestheticsconference.com Industry

Syneron Candela launches new operation in Ireland Global aesthetic device company Syneron Candela has set up new business operations in Ireland. The company, known for its devices for body contouring, hair removal, wrinkle reduction, tattoo removal and more, has also appointed a new dedicated regional manager for the Irish market, Grace McCormack. The manager of UK and Ireland at Syneron Candela, Scott Julian, said, “Syneron Candela is delighted to have a direct operation in Ireland; for many years Ireland has been an important market with a large and loyal established customer base. There has been considerable growth in the Irish aesthetic market, we have listened to our customers and believe that as a direct operation we can better support their needs by providing a world class service, marketing and clinical support.” He added, “Grace McCormack is our dedicated regional manager for the Irish market, she brings with her considerable experience as both an aesthetic practitioner and sales professional. Grace looks forward to working with new and existing customers to help them achieve outstanding results and growing their aesthetic business with Syneron Candela.”

In a survey of 1,001 women between the ages of 18-44 in the US, 40% admitted to editing a picture to cover a blemish before posting on social media (Google Consumer Surveys, 2017)

Research by Statistic Britain suggests 60% of hair loss sufferers would rather have more hair than money or friends (Statistic Britain, 2016)

According to global information services group Experian PLC, emails with personalised subject lines are 26% more likely to be opened (Experian, 2015)

Americans spent more than $15 billion dollars on combined surgical and non-surgical aesthetic procedures in 2016, accounting for an 11% increase over the past year alone (The American Society for Aesthetic Plastic Surgery, 2017)

There were 1.36 million chemical peel procedures in the US in 2016, up 4% from 2015 (plasticsurgery.org, 2016)

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Events diary 15th - 16th September 2017 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

23rd September 2017 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

2nd December 2017 The Aesthetics Awards 2017, London www.aestheticsawards.com

27th - 28th April 2018 The Aesthetics Conference 2018, London www.aestheticsconference.com

Marketing training

Kendrick PR launches the E.L.I.T.E Reputation Programme Business strategy and communications specialist Julia Kendrick has launched a new programme aimed at training aesthetic practitioners in PR and marketing to further enhance their business. The E.L.I.T.E Reputation Programme utilises an online platform, which contains 24 modules, and can be tailor-made to suit practitioners’ needs, time and budget. Users can learn how to develop their clinic’s unique selling point (USP), create newsletters, blogs and press releases, through a host of training videos, PowerPoint presentations and downloadable templates. “In today’s hyper-competitive aesthetics industry, many new clinics are struggling to manage their own PR and marketing on top of business management and clinical work,” said Kendrick, adding, “This is why I created the E.L.I.T.E. Reputation Programme – it is the ideal flexible solution for anyone looking to get their PR and marketing working for them, rather than sapping precious time, energy and budget.” The programme aims to create a strong, reputable name for practitioners and their clinics by helping them to establish powerful messaging, leverage compelling content, initiate positive relationships, target key audiences and rise above competitors. 

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Tattoo removal

PICOCARE receives FDA clearance for tattoo removal A picosecond laser device has received Food and Drug Administration (FDA) approval for tattoo removal. The device, which is available in the UK through Novus Medical, is a picosecond Nd:YAG laser and is designed to remove tattoos of various colours using wavelengths 1064 nm, 532 nm, 595 nm and 660 nm. According to the company, it can selectively remove pigment particles to minimise damage to skin tissue. Reno Kim, CEO of the device’s manufacturer WONTECH said, “PICOCARE has received a lot of praise for successfully competing with the products of dominant global brands in the Korean market, which possesses strong interest and demand for lasers. As the performance and stability have already been verified through many procedures since its launch in Korea, we are looking forward to seeing rapid market penetration in the US market as well.” Recognition

Paul Burgess receives MBE The CEO of the British Association of Cosmetic Nurses (BACN) has been formally appointed a Member of the Order of the British Empire (MBE) in the Queen’s Birthday Honours List 2017. Paul Burgess, who has been the CEO of the BACN since 2014, has received the honour for his services to people with disabilities and the community in Birmingham. Burgess has spent more than 35 years working in a voluntary capacity in the West Midlands, where he has worked with hundreds of community groups. His recognised work includes being chair at Focus Birmingham – a specialist charity providing support and advice to people in Birmingham affected by sight loss or disability, and representing Birmingham Royal Institute for the Blind for 12 years. Burgess said, “It was a huge surprise to be awarded the MBE and I hope that it will be seen as recognition of those vulnerable people in society that need our help and the countless people who on a daily basis give selflessly to improve their lives.” Multi-platform

New radiofrequency and LED device released Aesthetic company mesoestetic Pharma Group has introduced the new Genesis radiofrequency and LED device for customisable facial and body treatments. According to the company, Genesis is a multi-factorial, multi-level and multi-zone equipment that comes with 44 pre-set programmes to treat a range of indications such as ageing, wrinkles, sensitive skin with redness, double chins, and remodelling. mesoestetic states that the device aims to achieve results that are painless and long-lasting. The device is also user friendly according to the company, with a touch screen and compact size and it can also be upgraded through USB insertion to add new programmes and solutions. The Genesis device is available in the UK through aesthetic distributor Wellness Trading.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


Aesthetics Skincare

Clinisept+ launches in the UK UK aesthetic distributor AestheticSource has introduced the Clinisept+ range of skin cleansers and disinfectants to the UK. Clinisept+ is a new bactericidal, fungicidal, virucidal and sporicidal skin disinfectant technology, which has a neutral pH and does not contain any alcohol or irritants. According to AestheticSource, the products are non-cytotoxic to re-growing skin cells, so aims to kill the micro-organisms that inhibit the wound-healing process without damaging re-growing skin. Within the product range is ‘Prep & Procedure’ for use before, during and after procedures and ‘Aftercare’, which is a take-home product for use by patients who have had procedures that require protection from infection whilst the skin heals. Consultant ENT and facial plastic surgeon at Beacon Face and Dermatology, Mr Kambiz Golchin, said of the products, “Effective disinfection is a fundamental and absolute necessity of any aesthetic procedure. Thanks to Clinisept’s unique new skin neutral pH formulation, enhanced skin antisepsis is constantly achieved with a superior safety profile.” Director of AestheticSource, Lorna Bowes, said, “Put simply, Clinisept+ is a game-changer in the field of skin disinfection. This phrase ‘gamechanger’ was repeated to me and the team at AestheticSource constantly by both our key opinion leaders who have been using Clinisept+ over the past weeks and months, and experts in aesthetics reading the data about the product for the first time. Despite the fact that it is breakthrough technology, it is also cost effective so it can be adopted for all aesthetic procedures.” Dermatology

Study suggests laser effective for xanthelasma The Q-switched Nd:YAG laser has shown positive results in the treatment of xanthelasma palpebrarum in Asian patients, according to a recent study published in the Journal of the American Academy of Dermatology. In a retrospective review of data from January 2012 through to August 2015, the device was used on 46 Asian patients with a total of 103 xanthelasma palpebrarum lesions, which present as yellowish deposits of fat underneath the skin, usually on or around the eyelids. The patients, who had a mean age of 49.2 years and of whom 67% were female, received between one to five treatment sessions, with 50% of patients receiving only one treatment session. Four treatment sessions were found to give ‘optimum results’. They were consecutively treated with a 1064 nm, Q-switched Nd:YAG laser. The study found ‘noticeable improvement’ in 93.2% of lesions after a single treatment session, with 52.5% of lesions displaying at least fair clearance. Jun Khee Heng, who conducted the study, said, “Future randomised controlled trials would be useful to compare Nd:YAG lasers to CO2 lasers or surgery.”

Radiant Skin, Radiant Patients A progressive approach to improved skin condition

Restylane Skinboosters and Galderma are trademarks owned by Galderma S.A RES/020/0316d Date of preparation March 2016

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Vitamin D

Study suggests differences in nutritional value for vitamins D2 and D3 A study published in the American Journal of Clinical Nutrition has indicated that vitamin D2 and D3 do not have the same nutritional value. Researchers from the University of Surrey examined the vitamin D levels of 335 South Asian and white European women aged between 20 and 64 years over two consecutive winter periods. The women were split into five groups and randomly assigned to either receive a placebo, a juice containing 15g of vitamin D2 or D3, or a biscuit containing 15g of vitamin D2 or D3 daily for 12 weeks. The results showed that vitamin D levels in women who received vitamin D3 via juice increased by 75%, while vitamin D levels in those who ate the biscuit increased by 74%. Those given D2 saw an increase of 33% and 34%, respectively. Lead author of the study, Dr Laura Tripkovic from the University of Surrey, said, “Our findings show that vitamin D3 is twice as effective as D2 in raising vitamin D levels in the body, which turns current thinking about the two types of vitamin D on its head.” Professor Susan Lanham-New, head of the Department of Nutritional Sciences at the University of Surrey and principal investigator, said, “This is a very exciting discovery, which will revolutionise how the health and retail sector views vitamin D. Vitamin D deficiency is a serious matter, but this will help people make a more informed choice about what they can eat or drink to raise their levels through their diet.”

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Skincare

Cosmetic Courses Level 7 certificate launches Aesthetic training provider Cosmetic Courses now provides an Ofqual accredited Level 7 qualification in injectable treatments. The Level 7 Certificate in Injectables for Aesthetic Medicine aims to provide medical practitioners with the relevant knowledge and practical skills to safely and competently perform a range of botulinum toxin and dermal filler treatments independently. The certificate is said to be suitable for both new practitioners entering the aesthetics profession, as well as established practitioners looking to obtain formal recognition of their skills. The qualification comprises eight mandatory botulinum toxin and dermal filler treatments, including: pharmacology, understanding patients, anatomy and ageing, managing possible complications and effective treatment administration. To gain the certificate, delegates will undertake a combination of online learning modules, clinical observation sessions, practical hands-on teaching and assessments to provide 277 hours of comprehensive learning. Clinical director and consultant plastic surgeon Mr Adrian Richards, who is leading the course, said, “The non-surgical cosmetic industry has, up until now, been highly unregulated. The introduction of a Level 7 qualification is a necessary movement towards a more standardised level of training for medical professionals.” He continued, “We have invested a lot of time in creating a qualification that our delegates can be proud to achieve, offering a challenging but engaging learning experience. I’m also fully aware of how difficult it can be to study alongside full-time work and family life, so we decided to offer a bespoke Level 7 programme designed to fit in with our delegates’ time, schedule and budget.”

Medik8 introduces new SPF Global skincare brand Medik8 has added the Physical Sunscreen Broad Spectrum Physical SPF 30 to its product portfolio. According to the company, the formulation contains anti-pollution, anti-infrared and antiglycation technology to protect against environmental aggressors, while correcting existing lines and wrinkles. Medik8 states that it is also fast-absorbing and does not contain nanoparticles. The ingredients include a blend of zinc oxide and titanium dioxide that aim to work together to reflect the sun’s radiation without inducing redness or clogging pores. Medik8 recommends using the product on the face, neck and décolletage after a regular moisturiser, avoiding the upper and lower eyelids and lips, and reapplying throughout the day. The company also advises to use it after laser, microneedling and chemical peel procedures. Microneedling

Bellus Medical gains certification through the ISO Microneedling company Bellus Medical has become certified through the International Organization for Standardization’s (ISO) 13485:2016 Certification. Adopting ISO certification is a voluntary and internationally-accepted model that a manufacturer can implement to help demonstrate compliance with laws and regulations. It is accepted as the basis for CE marking for medical devices. According to the company, which manufactures the SkinPen device, this certification allows Bellus Medical to get to market faster with new products, enhance trust with clients and patients and secure global business because the standards meet most international regulatory agencies. Bellus Medical president and CEO Joe Proctor, said, “The ISO 13485:2016 certification is the best professionally accepted model a medical device provider can implement to show compliance with laws and regulations in the medical device industry. The ability to comply with the 2016 version of the standard shows a concentrated focus on mitigating patient risks and delivering the highest quality of products to our customers. By voluntarily going through this process, we have demonstrated the strength of our organisation, our commitment to quality and to continue to build confidence in Bellus Medical as a trusted partner.” Bellus Medical products are distributed in the UK through BioActiveAesthetics.

Sexual aesthetics

First IAAGSW conference to take place in October The International Association of Aesthetic Gynaecology and Sexual Wellbeing’s (IAAGSW) first conference will take place this year on October 27-28 at the Royal Society of Medicine, London. 
 The conference will have four agendas over the two days; delegates will learn about aesthetic gynaecology in the female sexual rejuvenation agenda on day one, along with developments in regenerative medicine for male and female sexual rejuvenation. On the second day, male sexual rejuvenation and bioidentical hormones will be on the agenda. In the bioidentical hormones session, there will be discussion on how to factor in the concern of hormone imbalances alongside treatment.

Chair of the conference and founder of the IAAGSW, Dr Sherif Wakil said, “A lot of practitioners are becoming interested in non-surgical sexual rejuvenation. This is the first congress of its kind in the UK and globally, because it incorporates both male and female sexual solutions as well as regenerative medicine and bioidentical hormones all under one umbrella, so we hope that we can help share information and allow others to offer these treatments to their patients.” Following the conference, delegates will also have the option to attend a bioidentical hormone workshop on October 29, where they will receive hands-on teaching in how to treat patients using bioidentical hormones and how to incorporate them into their practice.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Nutraceuticals

Aesthetics Training 


MINERVA Research Labs announces ‘positive results’ for GOLD COLLAGEN FORTE clinical trial Aesthetic supplement manufacturer MINERVA Research Labs has announced ‘positive results’ for its latest clinical trial on GOLD COLLAGEN FORTE. The double-blind, randomised, placebo-controlled clinical trial, in collaboration with independent clinic MedicalSpa Roma in Italy, studied the photo-protective benefits and effects related to the daily consumption of the oral liquid nutricosmeceutical. The trial was conducted on 120 healthy volunteer subjects, who were divided into two groups: 60 subjects drank one bottle of GOLD COLLAGEN FORTE daily and the other 60 subjects consumed one bottle of the placebo. Outcome measures were related to skin elasticity and skin architecture. In addition, the subjects recruited in this study underwent observational assessments through self-assessment questionnaires. “Through histological examinations, we demonstrated a significant increase in skin elasticity and an improvement in skin texture after daily oral consumption of GOLD COLLAGEN FORTE, while in the placebo group we recorded a reduction in the elasticity due to the deterioration of skin condition caused by sun damage,” said professor Andrea Corbo of MedicalSpa Roma, who led the study. He added, “We also obtained positive patient feedback through the self-assessment questionnaires and the compliance throughout the study was excellent. Taken together, these results indicate that GOLD COLLAGEN FORTE has photo-protective effects that helps to improve skin health.” According to patient feedback through the self-assessment questionnaires, 95% felt their skin was more hydrated, 91% felt their hair was stronger, 96% of subjects felt their nails were stronger, 93% would recommend it to a friend and 68% of subjects felt they had less wrinkles. The study has been peer-reviewed and published in Skin Pharmacology and Physiology and is also available also through PubMed.

UK nurses become first in the world to train in Plexr Aesthetic distributor Fusion GT and its training provider Soft Surgery Academy have announced that they will now provide training to non-prescribing nurses for its plasma generator device, Plexr. According to Fusion GT, the decision to train non-prescribing nurses has come following a realisation that some practitioners were delegating Plexr treatments to the nurses in their clinic without proper training and insurance coverage. Fusion GT director and European trainer for Plexr, Tiziana Giovanelli, said that all medical practitioners should have the opportunity to offer the plasma treatment and be properly trained to maintain patient safety. She said, “We are proud to announce that after many years of conversations with our manufacturer, we are now licensed to sell and train nurses in Plexr, opening up this innovative technology to all medical practitioners. The UK will be the first country where Plexr is available for nurses.” Key opinion leader and trainer for Plexr, Ruth Eaton added, “I am immensely looking forward to training both prescribing and non-prescribing nurses, because it is a gateway gift from Fusion GT to open the pathway of the future of plasma medicine to all nurses working under the umbrella of aesthetics. Having Plexr at our disposal will allow us to improve patients’ choices and the quality of the treatments that we give.” Clinic

EF MEDISPA Bristol celebrates one year anniversary

Dermal fillers

83% of survey participants think dermal filler should be a POM An overwhelming majority of participants in a recent survey conducted by The British Medical Journal (BMJ) believe that dermal filler treatments should only be available with prescription.    There were 1,054 votes cast in the online poll and, of these BMJ website users, 877 voted ‘yes’ for dermal fillers to be a prescription only medication (POM). Independent nurse prescriber and chair of the BACN Sharon Bennett said she wasn’t surprised by the results of this survey, but added, “I have mixed views about dermal fillers being either prescription medicines or devices, as I don’t think making them POMs will solve all of our concerns. I think it would be better to have definitive limitations put in place on who can administer them.” She continued, “I see many cases of poor treatment delivery, even from the medical fraternity, and being able to write a prescription for a drug or a device is not the ticket to ensuring a safe treatment or good outcome.”

Aesthetic clinic EF MEDISPA in Bristol has celebrated its first anniversary, following the launch of its clinic last summer. The team has expanded from six to nine staff members, which now includes two front-of-house staff, two aesthetic therapists, two treatment coordinators, a prescribing nurse, and a marketing executive, as well as owner of EF MEDISPA Bristol, Elena Hunt. The clinic offers multiple treatments including LED light therapy, microneedling and chemical facial peels. Hunt said, “The past 12 months have been such a whirlwind but I couldn’t be more proud of where we stand now. When we brought EF MEDISPA to Bristol, we knew that the city would be welcoming; however, nothing could have prepared us for just how warm the welcome would be.” She added, “It has been such a great year and beating our targets has been the best way to celebrate all that we have achieved.”

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Industry

Aesthetics welcomes Dr Souphiyeh Samizadeh to journal Editorial Board

Filorga appoints MedivaPharma as new distributor

Dental surgeon and aesthetic practitioner Dr Souphiyeh Samizadeh has joined other leading experts in the specialty by becoming the 10th Aesthetics journal Editorial Board member. Dr Samizadeh is a King’s College London graduate, dental surgeon and the clinical director of Revivify London clinics. She has a Master’s degree in Aesthetic Medicine and is a regular speaker at UK conferences, such as the Aesthetics Conference and Exhibition (ACE), as well as events in Asia. As a valued member of the Aesthetics journal Editorial Board, Dr Samizadeh will share her experience and expertise to assist with the continuing development of the journal, steering the direction of educational clinical and business content. She said, “I am absolutely thrilled to be joining the Aesthetics journal Editorial Board. I am really looking forward to bringing some of my ideas to the table to further the learning of other medical aesthetic professionals.” Aesthetics journal Editor, Amanda Cameron, said, “With Dr Samizadeh’s experience in teaching and speaking in Asia, she is going to be a huge asset to our team. We are excited to learn about her work and share her knowledge to benefit our readers.”

Aesthetic pharmacy MedivaPharma has formed a partnership with Filorga Laboratoires to distribute its products in the UK. MedivaPharma specialises in the supply of dermal fillers, PDO threads and skincare products, and is said to have ‘enjoyed significant growth’ over the last four years. Gary Wilson, commercial manager for MedivaPharma, said, “MedivaPharma welcomes new customers to our pharmacy every day, our product deals and support services are known to many in our industry and we look forward to demonstrating our quality customer support services to Filorga and its customers.” Rebecca Denham, national business development manager in the UK for Filorga, said, “I’m very excited to be launching the brand with MedivaPharma. After nearly a year of presence within the UK, Filorga’s popularity is growing at great speed so it’s important for us to work with the industry’s best suppliers to be accessible to our aesthetic practitioners who are attending our training and conferences, learning about the unique innovations coming from France.”

Qualifications

Social media

Sydney hospital bans surgeons from using Snapchat Westmead Private Hospital in Sydney has banned surgeons from using Snapchat during surgical procedures, due to fears they could be sued by patients over privacy or negligence issues. Snapchat, the mobile app that allows users to capture videos and pictures that disappear after a few seconds, has become a popular marketing tool and has been used by some practitioners to showcase treatments to potential patients. Plastic surgeon Mr Laith Barnouti from Westmead Private Hospital, said the risk to both patients and surgeons was too high, claiming one Australian hospital and one of its surgeons are being taken to court by a former patient over privacy concerns involving the app. “There are privacy issues, because even if the patients does consent to being filmed beforehand, which doesn’t always happen, they can’t approve every live video that’s being sent,” Dr Barnouti told Australian website, news.com.au. He added, “Even if the patient consented for their photo to be taken, they might not consent for their pubic hair or their genitalia or their nipples or their face to be in it. They probably didn’t know their whole face would be shown.” A spokeswoman for the Royal Australian College of Surgeons said the industry body recommends its members refrain from ‘posting images (whether identifiable or not) or information’ about patients, as well as posting comments or information which ‘may breach any obligations to their employers’.

First practitioners receive regulated Level 7 qualification in aesthetic medicine Industry Qualifications (IQ), which provides certification of people and organisations to national and international standards, has awarded the first Ofqual regulated qualifications for Injectables in Aesthetic Medicine at Level 7. The qualification has been awarded to Dr Emily Macgregor, Dr Harriet Bradley and Dr Kim Booysen following their course at the Harley Academy. The IQ qualification was developed following the Review of Regulation of Cosmetic Interventions led by Sir Bruce Keogh in 2013, and incorporates subsequent guidelines published by Health Education England in 2015, and the General Medical Council in 2016. Professor David Sines, chair of the Joint Council for Cosmetic Procedures (JCCP), which is due to launch a register of approved practitioners in November 2017, said, “The JCCP wishes to congratulate Emily, Harriet and Kim in achieving the first Ofqual regulated Level 7 qualifications for the injectables sector. The announcement provides a significant step on the path to raising standards within the sector as a whole.” Raymond Clarke, chief executive of IQ said, “The qualification is demanding, even for those that have been medically trained, and sets a new benchmark for professionals working in the sector. I would particularly like to acknowledge the work of the Harley Academy and in particular, Dr Tristan Mehta, for his support in the development of this qualification.” IQ has reported that five centres are now approved to provide the course and around 100 people are currently registered in the programme, with IQ expecting this to significantly increase as the launch of the JCCP nears.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


Aesthetics SPF

DMK launches new sunscreen Skincare manufacturer Danné MontagueKing (DMK) has introduced the new DMK Nutrascreen Replenish & Protect Day Cream. According to DMK, the product is a water resistant and perspiration resistant SPF that contains amino acids and antioxidants. The product is formulated using phosphatidylcholine, zinc oxide, cyclohexasiloxane, hydrolysed rice protein, polygonum aviculare extract, alteromonas ferment extract and helianthus annuus seed oil. DMK claims that the main benefits of the product are that it has regenerative and age management properties, prevents trans epidermal water loss, keeps the surface of the skin supple and moist, and has a high protection SPF 30+ and a broad-spectrum UVA protection. Conference

Great British Academy of Aesthetic Medicine to hold two conferences The Great British Academy of Aesthetic Medicine (BAAMed) will be holding an international conference in Shanghai on August 15 and a botulinum toxin A symposium in London on September 29. The one-day Shanghai conference will focus on 3D treatment and rejuvenation of the Asian face. Speakers will include the founder of the academy, Dr Souphiyeh Samizadeh, as well as plastic surgeons Dr Hong Ki Lee, Dr Daru Wang and Dr Peter Peng. The facial anatomy will be discussed in detail and safe rejuvenation techniques, complications prevention, and management will be taught and discussed to help raise standards of clinical practice. The five-hour symposium on the clinical pharmacology of botulinum toxin A in London will discuss the important aspects of toxin that is relevant in day-to-day practice, focusing on duration of action, doseeffect curves, product differences, dilution, spread and antigenicity. Speaking at the symposium will be professor of neurology at Hannover Medical School, Professor Dirk Dressler and Professor Andy Pickett, who has worked with botulinum toxin for nearly 30 years. BAAMed Founder, Dr Souphiyeh Samizadeh said, “There is an increase in training opportunities available on the aesthetic applications of botulinum toxin A, however, much-needed knowledge of the pharmacology of botulinum toxin is missing.” She added, “We are proud to organise and host this symposium with two of the truly world leading experts on the topic, to enable better understanding of the products available, improve clinical practice and patient safety.” The symposium will take place at the Royal Society of Medicine and booking is open now.

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Distribution

Vida Aesthetics launches new products is the solution you’re looking for!

Restore your beauty. UK distributor Vida Aesthetics has introduced Plenhyage, Jalucomplex, TANNIC [CF] SERUM, the UNIQ-WHITE system and the Automatic Patting System (APS) to its product portfolio. The Plenhyage injectable product is a deep tissue regeneration polymerised polynucleotide-based gel, manufactured by Italian company Bioformula. Plenhyage aims to encourage cell turnover, improve skin elasticity and hydration, and can be used for sun damaged skin or scars. It can also be used for skin preparation prior to other cosmetic procedures. Also new to the UK from Bioformula is Jalucomplex, which is a high molecular weight hyaluronic acid that aims to fill, hydrate and revitalise the face, neck, décolleté and hands. Vida Aesthetics has also introduced an antioxidant, the TANNIC [CF] SERUM, which aims to treat the signs of skin ageing such as wrinkles, brown spots and loss of firmness caused by environmental and biological stressors. According to its French manufacturer, ALPHASCIENCE, the formula contains 2% tannic acid, 0.5% ferulic acid, 10% l-ascorbic acid and ginkgo biloba concentrate. Also new is the three-step patented system UNIQ-WHITE by French biomedical research laboratory nunii Laboratoire. The product aims to reduce lentigo, melasma and dark spots on the skin through its: EXPERT PIGMENT CORRECTOR, REVITACTIV ENERGIZING DAY CREAM and the INRECOV SOOTH & PROTECT SPF 15. The APS has also been introduced to the UK by Vida Aesthetics. It is an Italian patented device for face and body cosmetic treatments and combines seven different actions on the skin, which aims to make it smoother, more elastic and more receptive to active ingredients. According to the company, the device does this by increasing the microcirculation in the treated areas with a consequent tissue oxygenation, stimulation of cell metabolism of the tissue and stimulation of fibroblasts to increase collagen and elastin production. The products are available in the UK now through Vida Aesthetics.

Aesthetics aestheticsjournal.com

News in Brief Hamilton Fraser announces business development conference date Cosmetic insurance firm Hamilton Fraser will hold the Aesthetics Business Conference (ABC) on September 25 to equip practitioners with knowledge for running a successful practice. Educational sessions and panel discussions will be hosted by Hamilton Fraser Cosmetic Insurance, Galderma, Church Pharmacy, AestheticSource and the Joint Council for Cosmetic Practitioners. The event will be held at the Royal Society in London and tickets are now available.

is a trademark of Bioformula Srl

Appointment

AestheticSource announces new business development manager Aesthetic distributor AestheticSource has welcomed Samantha Gibbons as business development manager for London and the surrounding area. Gibbons brings 10 years’ experience from working within the aesthetic industry as a product specialist and business development manager. Her achievements include winning ‘product specialist for the UK’ when working with Allergan and introducing Regen PRP to the UK whilst working with Schuco. “We are absolutely delighted with the experience and knowledge Sam brings to the team. Our excitement has only been increased by spending time with her! It’s so pleasing to have so many customers thank us for bringing Sam into the AestheticSource family,” said Lorna Bowes, director of AestheticSource. Gibbons will be working with new and existing AestheticSource customers and will help grow the business with tailored treatment protocols, maximising retail sales through education and training. She said about her new career move, “As I have worked within the aesthetics industry in different sectors, this will enable me to help my clinics with combination treatments, so not only does it help maximise their retail sales, it will also help maximise the other treatments they may offer.”

Aesthetics raises £1k for Jo’s Cervical Cancer Trust  The Aesthetics team took part in a 5K walk to raise money for a charity dedicated to women affected by cervical cancer and cervical abnormalities. ‘Steps for Jo’ took place at the Queen Elizabeth Olympic Park in London and involves an annual sponsored 5km walk and also a 10km run, which takes place during cervical screening awareness week in June. Jo’s Cervical Cancer Trust is one of Aesthetics’ chosen charities for 2017, with more fundraising planned for the rest of the year. Survey suggests over 50s feel pressures to look young Financial services company SunLife has conducted a study that suggests there is an increasing number of Britons over the age of 50 who are feeling under pressure to look young. SunLife’s Big 50 study, which surveyed 50,000 people aged 50 and over about their lives and attitudes, found that 45% felt pressure to look young, almost nine in ten said they have actively done something to try and stay fit, healthy and younger, and one in 100 admitted to having cosmetic surgery in a bid to stay young. New aesthetic publication released The Five Layers Simple Anatomy book which aims to provide advice for safe aesthetic and regenerative medicine is now available. The book, written by cosmetic surgeon and clinical researcher Mr Mario Goisis, aims to increase the reader’s knowledge of anatomy for the use of non-surgical treatments. It covers a range of topics including the prevention of complications such as necrosis or blindness, SMAS and muscles, medical rhinoplasty and nasolabial fold correction. The publication is available now through medical scientific book and resources supplier, Archidemia.

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EVA UK launch, London On June 16, distributer Q Medical invited practitioners to The Cinnamon Club in London for the UK launch of vaginal rejuvenation device EVA. Guests received cocktails on arrival and were treated to a dinner while they networked with other medical professionals, doctors and women’s health specialists. Research coordinator, Dr David Bosoni, provided a presentation on the energy-based device, which was followed by a question and answer session. He explained that the system of EVA employs a proprietary version of radiofrequency that aims to address vaginal atrophy and laxity, external vulvar rejuvenation, genitourinary syndrome of menopause and mild stress urinary incontinence. Dr Bosoni said that one of the positive aspects of EVA is the extensive research and multiple scientific studies the product has undergone. Charlie Pillans, managing director of Q Medical Technologies said after the event, “I hope that practitioners will consider taking on these type of technologies, look at the scientific data, make certain that the product they are using is effective and use their own clinical judgement with the individual patient concern to choose the right cause of action.”

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Aesthetics

Insider On the Scene

sk:n Harley Street VIP launch, London The media, internal stakeholders and VIP guests were among those who attended the launch of the new sk:n clinic on Harley Street on June 22. The purpose of the event was to showcase the new dermatology clinic chain’s flagship practice, which is situated on London’s Harley Street, which is renowned for private specialists in medicine and surgery. The afternoon event began with a ‘roundtable’ discussion with medical director of sk:n, Dr Daron Seukeran and chief operating director, Tim Foster. Dr Seukeran said, “The roundtable discussed burgeoning issues facing our industry today and in the future. With a growing population, an ever-growing rise in the demand of treatments and the increasing demands on the NHS, we’re seeing more people turn to the private sector for solutions to their skin issues, many of which are complex. The question remains – which of these should be deemed as cosmetic, and which should be deemed medical?” The three core areas discussed were aesthetics, lasers and dermatology. Following the discussion, guests were treated to canapés and refreshments and Foster delivered a speech that highlighted sk:n’s medical expertise and heritage. This was followed by a tour of the new clinic space, live treatment demonstrations and networking opportunities.

Harpar Grace iS Clinical brand day, London International distributor Harpar Grace hosted its first iS Clinical brand day at Chandos House, London on June 15. The event offered clinical lectures, PR, marketing and business optimisation sessions to educate practitioners and clinics on how to transform their current performance and drive growth within their clinic. Dr Charlene DeHaven, a board-certified physician in both Internal Medicine and Emergency Medicine, presented talks on the theories of ageing, post-procedure treatments, as well as skin conditions and treatments, which was followed by a question and answer session. The event also included business content from director of Harpar Grace, Alana Chalmers, who advised delegates on how to optimise a treatment portfolio through ‘Fusion’ opportunities, including clinical education, business training, brand engagement and networking.

Venus Concept workshop, London Developer and manufacturer of noninvasive aesthetic devices Venus Concept held a workshop at Chandos House in London on June 19. Current and prospective customers were invited to watch demonstrations, learn tips and tricks for new treatments, and to engage with other clinic owners as well as watch presentations from Meon Face practice manager Joanna Koussertari and skin therapist Abigail James. Koussertari gave a talk on how to run a successful clinic while James ran a discussion on how to perform a consultation and spoke about her book ‘Love Your Skin,’ which features the Venus Viva treatment. Sophie Goodman, Venus Concept marketing specialist, said of the day, “The event went really well and we have had excellent feedback. The purpose of the event was to educate our clients on how to use our machines in innovative ways, with new treatment ideas, parameters and tips and tricks. We also wanted our clients to learn how to run an aesthetic consultation and how to run a successful practice to help make their clinics as successful as they can be.” According to Goodman, more events are currently being planned for the north of England and in Ireland.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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

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

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

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Aesthetics

mesoestetic factory visit, Barcelona Selected representatives from aesthetic clinics in the UK were invited to travel to Barcelona on June 25-26 to visit mesoestetic’s headquarters.The one-day trip, which was arranged by UK distributor Wellness Trading to coincide with the launch of mesoestetic’s Genesis machine, aimed to show visitors how its products are manufactured and to teach them more about the company. After arriving in Spain, the group travelled to mesoestetic’s 8,500m2 manufacturing facility, where they were taken on a tour by export manager Carles Font Martin and shown products being made and packaged. They also toured the research and development labs, where products are formulated and tested on human cells such as adipose and fibroblast cells. The group then learnt about the new Genesis machine by international trainer Oksana Shadrina. She explained that the Genesis is a multi-technology device for skin rejuvenation that aims to stimulate collagen and elastin, among other things, over the face and body. Dr Sotirios Foutsizoglou, who attended the trip said, “I had a lovely time and was very impressed by the mesoestetic facilities in Barcelona and their high standards. I was able to witness mesoestetic’s quest for excellence in product development, research and manufacturing processes that brings the company to the forefront of the advances in the field of mesotherapy and aesthetic medical science.” Managing director of UK distributor Wellness Trading, Adam Birtwistle said, “We thoroughly enjoy being able to take our customers to meet the team and experience the facilities of mesoestetic in Barcelona. It is a great opportunity for us to spend time with our customers, to thank them for working with us and to reassure them that the products they are using are produced to exacting standards. We hope that everyone enjoys their time and feels energised with full confidence in the brand they have chosen to put their name to.”

RejuvaMed Skin Clinic and Vein Centre official opening, Lancashire On July 1, the RejuvaMed Skin Clinic and Vein Centre opened its doors to guests to celebrate its official opening and to showcase the facilities and services that are on offer in Holmes Mill, Clitheroe. Staff welcomed guests who arrived throughout the day to explore both clinics and enjoy refreshments during their tours. Demonstrations of 3D-lipo and HydraFacial were arranged over the course of the day and guests had the opportunity to undergo mini consultations with medical and managing director Dr Grant McKeating and vascular surgeon Mr Rob Salaman. The clinic was officially opened by the Mayor of the Ribble Valley, Richard Bennett, Mayoress Marilyn Davies and the town crier Roland Hailwood. Dr McKeating said of the day, “The opening was a huge success. We had a fantastic day showcasing our fantastic premises and the many treatments that we offer.”

Insider On the Scene

Achieving Aesthetic Excellence 2017, London

On June 29, Achieving Aesthetic Excellence took place in central London, showcasing products and providing CPD-certified education to practitioners. The event, which was organised and supported by UK distributor Healthxchange Pharmacy, featured eight hours of presentations by clinical speakers including Dr Tapan Patel, Dr Uliana Gout and Dr Leah Totton. Dr Patel presented on advanced upper facial rejuvenation with dermal fillers and provided a live demonstration on a patient, advising on Allergan’s MD Codes when treating the full face. Speaking after his presentation, Dr Patel said, “I hope my demonstration has expanded people’s treatment knowledge. There are a lot of practitioners who might just have one, two or three techniques that they do, but now, hopefully they will get access to many more treatment protocols.” Other sessions included topics on the latest HIFU and RF technology by Dr Mike Comins, a sponsored Allergan presentation on seven steps to centric consultation with senior business developer Marcus Haycock, and a skin cell revitalisation workshop with Dr Julien Levy. There was also a speaking corner where question and answer sessions were held. Additionally, the event featured an exhibition, with companies such as Allergan, Consentz, SmartMed, Obagi Medical and Healthxchange showcasing their latest products. Marketing director of Healthxchange Pharmacy, Steve Joyce, said of the day, “I’m certainly hoping that people can take some practical experience of what they can do in their clinic. Hopefully they can consider some of the new treatments that are on offer and take something away so they can make an improvement to their business and give better treatments to their patients.”

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Social Media and Appearance Anxiety Aesthetics looks at the findings from the Nuffield Council on Bioethics report and asks what can be done to stop social media’s influence on appearance anxiety The Nuffield Council on Bioethics, an independent body that examines and reports on ethical issues in biology and medicine, has published a new report: Cosmetic procedures: ethical issues.1 The report makes a series of recommendations that aim to address areas of concern for aesthetic practice and the promotion of cosmetic procedures in the UK. One of these recommendations is that social media companies should collaborate with each other to carry out independent research, to better understand how social media contributes to anxiety about one’s appearance, and to ‘act on the findings’. Jeanette Edwards, professor of Social Anthropology from the University of Manchester, who chaired the Council’s inquiry, says in the report, “There is a daily bombardment from advertising and through social media channels like Facebook, Instagram and Snapchat that relentlessly promote unrealistic and often discriminatory messages on how people, especially girls and women, ‘should’ look.”1  While the Nuffield Council on Bioethics is still in talks with social media providers to see how they can help towards this issue, we ask: how much of an issue is this and what can the aesthetics specialty do to curb the problem? The report The task that the Nuffield Council on Bioethics set itself was to investigate the

use and provision of invasive and nonreconstructive cosmetic procedures following the Keogh report. Through people spoken to by the council’s Working Party and a review of literature, it found that there was an increasing availability of cosmetic procedures and that this could potentially pose social and communal harms. These harms included: encouraging a focus on appearance and adding to levels of appearance anxiety; shifting perceptions of what is ‘normal’ and reinforcing discriminatory attitudes; constructing ideals that can only be met through invasive means; and adding to the pressures on those who might like to, but cannot, meet these ideals. Some of the

News Special Appearance Anxiety

council’s subsequent recommendations included: a ban on offering ‘walk-in’ cosmetic procedures to under 18s, more data and improved testing for unproven products and procedures, and a more responsible approach from social and broadcast media platforms.1 Aesthetic nurse prescriber Sharron Brown, who was on the Working Party panel for the committee, explains, “We looked at the ethics around cosmetic treatment, both surgical and non-surgical, and one area we looked at was the psychological impact social media has on people; the drivers that push these people down the route of appearance-related treatment.” The council spent more than a year putting together its recommendations, seeking advice and the opinions of a range of professionals. Brown adds, “We had so many people come and speak to us; women affected by the PIP implants, advertising regulators, industry professionals, people from social media companies – a wide range of groups.” Social media and appearance Existing research has demonstrated a positive correlation between Facebook usage and body dissatisfaction. In a study by Fardouly et al. in 2015, 112 female participants aged between 17-25 years old were randomly assigned to spend 10 minutes browsing either their Facebook account, a magazine website, or an appearance-neutral control website. Afterwards, computer-based visual analogue scales (VAS) were used to measure their mood, body dissatisfaction, and appearance discrepancies, which were weight-related, as well as face, hair, and skinrelated. It was found that participants who spent time on Facebook reported being in a more ‘negative mood’ than those who spent

Pressure on children Anxiety caused by social media is very apparent in young girls, with the National Society for the Prevention of Cruelty to Children (NSPCC)’s ChildLine last year revealing girls as young as nine are worried about body image and ‘looking perfect’. Mounting pressures to ‘look good’ resulted in the service receiving 1,595 contacts from girls worried about body image last year (2015/16), up 17% on the previous year. One young person contacting the service was quoted as saying, “It has been getting worse for a while now. There are so many pictures of perfect women on social media and I want to look like them. I just don’t feel like I can compete.”3 The majority of girls who contacted ChildLine about body image were aged between 12 and 15. However, there were also 77 counselling sessions given to girls aged 11 and under. “Young people face intense pressures, often bombarded by society’s unhealthy obsession with appearance and unrealistic images of the ‘norm’,” says NSPCC CEO Peter Wanless, adding, “It’s important to remind them that the images they see online are often heavily edited. Chasing these airbrushed ideals can result in the destruction of body image and confidence.”3

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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time on the magazine and control website. Furthermore, participants reported more facial, hair, and skin-related discrepancies after Facebook exposure than exposure to the other websites.2 “We are well-aware of the impact social media has on people’s perception of their appearance,” says Brown, “When you look at celebrities on social media such as Kylie Jenner, who famously had lip fillers at the age of 16, she has millions of young followers and a lot of them are going to be pretty impressionable. Having this procedure could be seen by them as ‘normal’.” Aesthetic nurse prescriber and clinic director of Aspire Clinic, Jenny O’Neill, who avidly uses social media to market her clinic, says, “The media has caused appearance anxiety for decades, from stick-thin fashion models used in advertising campaigns, to celebrities being air-brushed.” She adds, “However, with the popularity of sharing one’s life on social media and showing the world how great one is, social media causes a false sense of reality, which in turn exacerbates appearance anxiety.” Who’s at fault? When asked if the issue of social media and appearance is linked to the posts of certain people, groups or organisations, Brown says, “I think it is a bit of both celebrity endorsement and some aesthetic clinics being misleading with their advertising. There are some very good cosmetic clinics that stick within the advertising boundaries and guidelines4 and then there are others that will promote irresponsible offers on injectable treatments. When taking up these offers, patients are often not being properly consulted and these treatments are trivialised and made to sound the same as having your eyebrows or nails done. They should be seen as medical procedures and it should be known that there is a chance you could react to the substances being injected and there is a potential for harm.” However, O’Neill believes that clinics have a much smaller reach than most, often limited to their patients and business associates. She says, “The risk of communicating potentially damaging messages is much lower. I firmly believe ethical clinics wouldn’t use their social media channels to push misleading messages in order to increase sales. For instance, at Aspire Clinic we aim for our messages to be educational in order to give our patients an informed choice.” She adds, “With their huge followings – sometimes in the millions – celebrities are reaching the masses, therefore the potential for causing

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feelings of inadequacy or people wanting to replicate their look is far higher.” The recommendation The recommendation from the Nuffield Council on Bioethics regarding social media states: ‘We recommend that the social media industry (including Facebook, Instagram, Snapchat, Twitter and YouTube) collaborate to establish and fund an independent programme of work, in order to understand better how social media contributes to appearance anxiety, and how this can be minimised; and to take action accordingly’. The report ‘welcomes the fact’ that social media companies such as Facebook and Instagram have informed them that they are beginning to include concerns about body image in the campaigning and educational work they undertake among adolescents. However, the council believes ‘much more needs to be done’.1 Resolving the issue In the UK, the Advertising Standards Authority (ASA) enforces and regulates the Committee of Advertising Practice (CAP), which includes commercial advertising online and on social media, but it does not cover unsolicited endorsements in tweets or blogs, or images shared by social media users.1 As well as this, the ASA only investigates claims brought to it, and does not actively police sites.5 According to O’Neill, aesthetic clinics can play their part by ensuring that what they share on social media is ethical and responsible. She says, “It is essential that clinics follow the General Medical Council (GMC) guidelines6 and adhere to the CAP code7 when marketing any products and services, and this should extend to social media practises.” As well as the GMC guidelines, dentists and nurses have guidelines through the General Dental Council (GDC)8 and the Nursing and Midwifery Council (NMC).9 Brown adds, “When speaking with representatives from social media companies, they said this sort of advertising is difficult to monitor and that there is nothing they can do until something has actually been posted. It’s like waiting for the horse to bolt before closing the door, instead of closing the door before the horse has bolted.” The Nuffield Council on Bioethics believes that an essential element in empowering users to make choices that are right for them is access to ‘high quality information’. There is much concern that vigorous marketing of cosmetic procedures by the commercial sector has led to aesthetic

treatments being seen as trivial or potential risks downplayed. Therefore, the council suggests that the major providers (suppliers) of cosmetic procedures collaborate with both the relevant professional bodies, and practitioners who offer cosmetic procedures, to fund the independent development and wide dissemination of detailed information for users about both surgical and nonsurgical procedures. A representative of the council said that a meeting with Facebook and Instagram was held in the run up to the publication of the report and that they are currently organising a second one. Since the report was published, the Nuffield Council on Bioethics has also written to these companies, as well as Snapchat and Twitter, to discuss how they can work together to implement the recommendations, however they are yet to receive a response. Summary Brown believes that the publication of these recommendations will hopefully raise awareness of the issue amongst the medical aesthetic community and ensure they are acting responsibly on social media. She says, “This report has got us thinking about not only what we do, but why we do it, who we do it to and how best we can protect the vulnerable from being exploited and not cared for in the right way.” Assistant director of the Nuffield Council on Bioethics, Katharine Wright concludes, “Our report makes a series of recommendations that highlight areas of concern for the practice and promotion of invasive cosmetic procedures in the UK. We want everyone to consider how they can contribute solutions including practitioners and commercial providers of procedures.” REFERENCES 1. Nuffield Council on Bioethics, Cosmetic procedures: ethical issues (2017) <http://nuffieldbioethics.org/wp-content/uploads/ Cosmetic-procedures-full-report.pdf> 2. Fardouly J, Diedrichs PC, Vartanian LR, Halliwell E, Social comparisons on social media: the impact of Facebook on young women’s body image concerns and mood. (2015) <https://www. ncbi.nlm.nih.gov/pubmed/25615425> 3. NSPCC, Modern pressures leaving girls with crippling fears about how they look, (2016) <https://www.nspcc.org.uk/what-we-do/ news-opinion/girls-body-image-concerns> 4. Advertising Standards Agency. Our Purpose & Strategy. 2015. Available from: <https://www.asa. org.uk/About-ASA/Strategy. aspx> 5. ASA, The work we do, (2017) <https://www.asa.org.uk/about-asaand-cap/the-work-we-do/how-we-handle-complaints.html> 6. General Medical Council, Guidance for doctors who offer cosmetic interventions (April 2016) <http://www.gmc-uk.org/ guidance/ethical_guidance/28687.asp> 7. Committee of Advertising Practice, ‘Cosmetic interventions’, <https://www.cap.org.uk/~/media/Files/ CAP/Help%20notes%20 new/CosmeticSurgeryMarketingHelpNote.ashx> 8. General Dental Council, Principles of Ethical Advertising, (2012) <http://www.gdc-uk.org/ Dentalprofessionals/Standards/ Documents/Ethical%20advertising%20statement%20Jan%20 2012.pdf> 9. Nursing and Midwifery Council, ‘Guidance’, (2015) <https://www. nmc.org.uk/standards/guidance/>

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information:M-BOCUK-0067. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the Xseverity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 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. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients

may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with Botulinum neurotoxin products. Upper Facial Lines: very common: Headache. Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: February 2017. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

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Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50 units Summary of Product Characteristics (SmPC). March 2016. Available from: https://www.medicines.org.uk/emc/ medicine/23251. 2. Bocouture® 100 units Summary of Product Characteristics (SmPC). September 2016. Available from: https://www.medicines.org.uk/ emc/medicine/32426 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomized, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0085 Date of Preparation June 2017


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normal.” While over the years, rhinoplasty protocols have developed, since the introduction of dermal filler treatments a whole new option for patients has arisen. Mr Ravichandran explains, “We use dermal filler as a camouflage in the place of grafts and the advantage is that it can take away the need for a surgical procedure.” Independent nurse prescriber Emma Chan, adds, “Non-surgical rhinoplasty (NSR) usually produces quite dramatic results and it can resolve problems that patients probably deemed as surgical because in the past only surgery could fix their concerns. The big selling points are that it’s a minimally-invasive treatment with reduced downtime and you can see the results immediately, without having to wait for the swelling and bruising to subside. Although there are risks involved and practitioners performing it will need to be very experienced, the risks are much lower than surgery.”

Non-surgical Rhinoplasty Aesthetics speaks to practitioners about their preferred methods for performing a non-surgical rhinoplasty using hyaluronic acid dermal filler When you assess a face, what is it that you notice first? Research has suggested that the nose, which has a prominent and central facial position, has a direct effect on our evaluation of attractiveness,1 and when one has a prominent nose, or a small nasal deformity of some kind, then it is something that is often noticed, especially by the individual affected. It is therefore no surprise that there is a large market for cosmetic alterations of the nose, with rhinoplasty being among the top 10 cosmetic surgical procedures in the UK in 2016.2 Rhinoplasty Rhinoplasty, derived from two Greek words, rhino (nose) and plastikos (to shape or mould),3,4 has been a surgical option for patients for some time. In fact, its early descriptions date back to ancient Egypt and India.3,4 Ear, Nose and Throat (ENT) surgeon and aesthetic practitioner Mr Simon Ravichandran explains that there are two general aims of surgical procedures, “One is reconstructive, to create a functioning working nose that is also aesthetically pleasing, while the other approach is purely to camouflage deformities, where you can insert grafts into the nose to smooth things out, which doesn’t actually affect the function of the nose in any way or restore the anatomy, it camouflages it to make it look Figure 1: The eyebrow tip aesthetic line

Characteristics of the nose Mr Ravichandran explains that there are certain elements which define an attractive nose, “When you are looking at the frontal profile view, the attractive nose is defined by something called the eyebrow tip aesthetic line, which is a specific unbroken curved line that’s narrow in the middle and spreads out a little towards the base of the nose (Figure 1). If there is a problem with that line and it’s broken somewhere or blunted or flattened, then you are going to have a slightly less attractive nose.”6,7 From the side view, Mr Ravichandran adds that the radix, which is the deepest part over the bridge of the nose, needs to be considered, “Lots of people like a straight nose from the radix to the nasal tip, but there should actually be a very slight, natural depression just above the tip called the supratip depression, so the radix tip line should be ever so slightly curved and should dip down then dip up ever so slightly towards the tip of the nose.”7 Some practitioners also use certain angles to guide them when assessing the nose, the scope of which is too vast to specify in this article; however, Chan notes, “When you are looking at the nose you need to consider the angles. In the nasolabial angle, which is between the lips and the nose, you want to see elevation, which varies between genders. Males tend to be a bit closer to 90 degrees and females tend to want more of an open-angled nose with a slightly elevated tip at around 105 degrees.”6 Mr Ravichandran adds, “You have to take into consideration ethnicity, culture and gender when you are looking at lines and angles of the nose and you also have to consider fashion. If you look back to the 1940s and 50s, a fashionable nose had a much higher angle and was curved more upwards – the ‘button nose’. Today, we want something different, it’s a much more natural approach that is consistent with the genetics that we have. You are looking to restore the nasal tip line and create a nice, smooth, well projected nasal dorsum, a relatively straight line to the nasal tip and a columella angle that is appropriate to each individual.” ENT surgeon Mr Ash Labib also explains that practitioners need to be aware that it might not be the nose that needs treating, “Sometimes the nose might look prominent to patients but it’s actually the chin that is precluded. So, by treating the chin you get the harmony in the face that’s requested without even touching the nose.” Patient requests Patients request NSR treatments for a variety of reasons. Mr Labib says he typically gets two types of patients, “The first are those who have a deformity or a disfigurement, who may not have had treatment before. They are feeling insecure about the shape of their nose because it is

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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anatomy extremely well, know the type of surgery they have had and how many interventions, and you have to put a minute amount of product in and carefully watch the skin rise with the filler insertion.”

Product selection Due to the threat of complications in this area, which are discussed below, the practitioners interviewed say that they all only use hyaluronic acid (HA) dermal fillers. Chan explains, “It’s a high-risk area, I want to be able to reverse the treatment in the event of any complication.” Mr Labib adds, “The product must be a HA in my opinion, because that’s safer than any other semi-permanent fillers – if something goes wrong, you can dissolve the product. My product of choice is Juvéderm Voluma because I find it has a great lifting capacity and, in my experience, it lasts longer.” Chan also uses Juvéderm, but prefers Ultra. “You want the product to be slightly stiffer because it’s got to replicate Figure 2: Patient before and after non-surgical rhinoplasty using Restylane Lyft. Images bone when you are correcting indentations and, from the courtesy of Dr Beatriz Molina. safety point of view, you want to use as little product as either out of proportion from the rest of the face, or has some sort of possible. HA tends to get broken down quicker in high movement deviation.” He says the second type of patients he sees are those areas, such as the lips, so around the nose and the eyes, where who are unhappy with surgical rhinoplasty results, explaining, “They there is very little movement, you tend to see good longevity of at may still have a slight deformity and they come to me for advice; the least 12 months,” she says. Unlike Mr Labib and Chan, Dr Molina majority of those are candidates for NSR.” prefers Restylane Lyft, “You want a high G prime product that is not Aesthetic practitioner Dr Beatriz Molina adds, “Some people have easily deformed under pressure and has lifting properties. Don’t uneven noses that are slightly deviated right or left, or have quite a use a gel that’s too soft as it’s not going to lift and will flatten and high dorsal hump in the middle or on the tip and they want to make move. Restylane Lyft has a high G prime and very good longevity it look straighter. I have a few Asian patients and they tend to want and, because of its characteristics, it lifts and stays put. If I’m treating to make their nose narrower as their noses are naturally wider than a dorsal hump, Lyft is the best product, however if I’m treating mild Caucasians.”5 deformities, I may use Restylane Refyne, which is good for tiny little For patients presenting in clinic for nose alterations, Chan says, “You deformities as it’s got good product integration.” want a uniformed, nice, straight nose with good light reflection in the Mr Ravichandran uses HAs in the Belotero range, “If I am doing centre of the nose, with the width of the nose being in proportion with significant structural work and have to revolumise the nose then I the chin and the intercanthal distance between the eyes as well. The am going to use Belotero Intense, but if I am looking at very fine soft most common complaint I see is the dorsal hump.” tissue defects, for example a post-trauma nose, where the very fine cartilage is damaged or where there are depressions in the nasal tip Patient suitability and the side of the nose, then I will use a softer product – I tend to use Practitioners interviewed for this article said that it is paramount Belotero Balance. This is because any pressure you put on the soft that patient suitability is determined before going ahead with NSR cartilage of the nose may actually erode through that cartilage and treatment. Mr Ravichandran says, “The NSR is only appropriate make any defect worse, so you have to use something that’s not too for patients who have a defect that can be corrected by a lifting, just very smooth and soft.” camouflage technique, so it has to be a structural defect not a functional defect. It also has to be able to be corrected without Treatment methods affecting the functionality of the nose, for example, if correcting it When treating, Chan mainly uses cannula after the application of is going to restrict breathing through the nose then you have to topical anaesthesia and her insertion point is in the tip of the nose. discard this treatment.” Mr Labib says it is important that patients “For dorsal hump correction, it’s important to tell patients that you understand the limitations to NSR, “I would assess the nose with are building on the depressions so you maintain the existing bone a thorough consultation and examination. There are some cases structure. The aim is to bring the depressions in line with the actual where the deformity is so severe or the size of the nose is totally hump itself to create a better transition between the two areas with disproportionate that surgery is their answer. Having said that, I the dermal filler,” she says. would say that about 90% of patients I see could actually improve Dr Molina has a similar technique, “My insertion point will be in the part of, or all of, their nasal framework without surgery.” tip of the nose; I use a 32G needle to prick the skin and insert a 25G While Mr Labib has noted that he does treat post-surgery patients cannula that is 38mm long. From there you can guide it all the way for NSR, Chan explains that if you are someone who is not surgically to the top of the nose and fill the areas where the deformity is. When trained then you need to be very wary, “I wouldn’t suggest treating you are inserting the product, you can see that the skin is lifting, so patients who have had multiple surgeries or any rhinoplasty surgery do the injections very slowly. You shouldn’t really need more than in the past because of the increased risk in the change of anatomy.”10 0.5ml for most procedures. I generally only ever use one entry point Dr Molina adds, “If you are treating a post-surgery patient you need because, with a cannula, you can reach anywhere you need.” to be seriously experienced at treating noses already and know your Mr Ravichandran says the dorsal hump and depressions are the

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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blood vessels joining other blood vessels so there is a high risk of plugging an artery that can P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS cause blindness and tip necrosis of the nose.” In 2015, a review of the world literature on all P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS reported cases of vision changes from filler (98 cases) suggested that the nasal region was the P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS second highest risk for complications, after the glabella.9,10 P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS He continues, “The other thing you have to consider is the infection rate, infections in nasal P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS tissues can be catastrophic if you don’t treat P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS them properly and can go on to cause serious cosmetic defects, which is likely to require P ROPE R T Y O F A L A ESTH ETI C S P R O P ER T Y OF AL AES T HET ICS reconstructive surgery.” Mr Labib says aftercare is simple, “I would advise patients to not wear glasses or sunglasses, no makeup and not to Figure 3: Patient before and after non-surgical rhinoplasty using Juvéderm Voluma. Images massage for 24-48 hours. I’d also tell them to courtesy of Mr Ash Labib. contact me immediately if they have any issues with skin discolouration or prolonged bruising, easiest to correct, but care must be taken to achieve natural results, and if practitioners find that the product is causing vascular occlusion, “If we are correcting the dorsal hump, generally we are injecting use hyaluronidase immediately to dissolve the product and reverse above and below the hump; when we inject above the dorsum, the potential complication. Ensure that the patient knows that it’s what we are doing is bringing the radix forward. If you bring that paramount that if their injector is not available then they should contact forward too much it looks really artificial. I use a cannula at the tip of accident and emergency.” the nose after very thoroughly cleaning the nose with chlorhexidine. I use a strict aseptic technique and my cannula slides over the septal Knowledge is paramount cartilage and over the hump. When you are in the top part of the Although, technically, any practitioner is legally allowed to perform nose you can start layering little bits of filler very slowly and gently NSR with dermal fillers, Mr Labib says, “Practitioners have to be until you achieve correction. You can do pretty much everything experienced injectors – I would say at least five years’ experience. from that one insertion point.” They also have to have a really good degree of knowledge of the Mr Labib says he prefers to use a needle, “I think it’s more precise anatomy, particularly the blood supply to the nose, and they need to and produces a greater amount of correction for the product. have theoretical and hands-on training.” My injection points tend to vary – I use my own code for noses Mr Ravichandran explains that NSR is not for everyone, “I know a lot of people who are incredibly experienced in facial aesthetics and still won’t go near a nose because it’s just not within their confidence or skill set – it’s wise to be cautious.” Chan concludes, “It’s an advanced procedure – be sure you’ve got good protocols and guidelines in place for adverse event management and support within your own clinic and don’t do it too soon! It’s a very high risk procedure and you have to be an expert in facial anatomy and injectables before you even consider taking on the treatment.”

The nose is an extremely risky area and a high level of anatomical knowledge is needed according to what type of correction the patient needs and some are more advanced than others. Point of injection is very important and the injection has to be done precisely and gently. I trace between the skin and the bone, as well as the skin and the cartilaginous plane, and massage it. In 15 minutes the procedure is done and results last between 12-18 months. The amount of filler required varies, but I never use more than a syringe so the absolute maximum is 1ml.” Treatment considerations The complications and side effects for NSR are the same as any other HA dermal filler procedure, however practitioners note that the nose is an extremely risky area and a high level of anatomical knowledge is needed. Chan says, “There is a rich vascular blood supply so our biggest concern is vascular compromise and anatomical structure damage; it’s very important to observe the patient after the treatment.” Mr Ravichandran adds, “The midline on the face is where you have

REFERENCES 1. Ase Kristine Rognmo Mikalsen, Ivar Folstad,corresponding author Nigel Gilles Yoccoz, and Bruno Laeng, ‘The spectacular human nose: an amplifier of individual quality?’, PeerJ, 2014. <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC3994647/ 2. BAAPS, ‘The Bust Boom Busts, 2017. <https://baaps.org.uk/media/press_releases/29/the_bust_ boom_busts> 3. Louis S.Belinfante, ‘History of Rhinoplasty’, Oral and Maxillofacial Surgery Clinics of North America, 2012. <http://www.sciencedirect.com/science/article/pii/S1042369911001737> 4. Deo, S, ‘The History of Indian Rhinoplasty, Aesthetics, 2016. <https://aestheticsjournal.com/feature/ the-history-of-indian-rhinoplasty> 5. Y.Gao, J.Niddam, W.Noel, J.P.Meningaud, ‘Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon’s perspective’, Asian Journal of Surgery, 2016. <http://www.sciencedirect.com/science/article/pii/S1015958416301798> 6. Stephen S. Park, Fundamental Principles in Aesthetic Rhinoplasty, Clin Exp Otorhinolaryngol, 2011 Jun; 4(2): 55–66. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109328/> 7. JeongHoon Suhk, JinSoo Park, & Anh H. Nguyen, ‘Nasal Analysis and Anatomy: Anthropometric Proportional Assessment in Asians—Aesthetic Balance from Forehead to Chin, Part I’, Semin Plast Surg, 2015 Nov; 29(4): 219–225. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4656173/> 8. Jacob I. Beer, David A. Sieber, Jack F. Scheuer, & Timothy M. Greco, ‘Three-dimensional Facial Anatomy: Structure and Function as It Relates to Injectable Neuromodulators and Soft Tissue Fillers’, Plast Reconstr Surg Glob Open, 2016. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5172484/> 9. Beleznay K, Carruthers J, Humphrey S, Jones D, ‘Avoiding and Treating Blindness From Fillers: A Review of the World Literature’, Dermatologic Surgery, 41 (2015), pp.1097-1117. 10. Gronow, C, ‘News Special: The AIIVL Consensus Group’, Aesthetics, 2017, <https://aestheticsjournal. com/feature/news-special-the-aiivl-consensus-group>

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Aesthetic Procedures During Pregnancy Mr Nihull Jakharia-Shah, Miss Priyanka Chadha and Miss Lara Watson review literature for the delivery of aesthetic procedures during pregnancy

Treatment during pregnancy, whether medical or aesthetic, is a contentious topic and practice differs greatly between professionals. The debate on the safety of these procedures centres on the transient, but significant, physiological changes that occur during pregnancy and the sharing of blood and nutrients (or toxins) between mother and foetus. Due to the risks and ethical considerations involved, drugs are rarely tested on pregnant women. Thus, data on safety profiles is limited in this patient group and due to differences in physiology, it would be inappropriate to translate data from trials in non-pregnant women to dictate practice during pregnancy. The general consensus is to defer non-essential procedures until after pregnancy.1 However, the aesthetic changes that can occur during pregnancy, such as melasma, hirsutism and striae,2 can be dramatic and cause significant upset to the mother. This can cause devastating effects on her mental health and in extreme cases, disrupt her relationship with her child as well as her ability to care for the child.3 In such situations, the advantages and disadvantages of the procedure must be evaluated to reach a decision that creates the best possible outcome for mother and child. In this article, we will review literature on the safety of common aesthetic procedures during pregnancy.

text narratives to provide more comprehensive information for patients and practitioners. The new labels include subheadings of pregnancy, lactation and male and female reproductive potential, but still refrain from providing definitive guidance on use as this should be considered on a per-case basis.7 However, since most of the literature mentioned in this article occurred before this date, we will discuss products in terms of the old system. A breakdown of the classification system is shown in Figure 1. Bleeding is another significant risk in pregnancy as pregnant women are especially susceptible to anaemia, which is linked to adverse outcomes in the event of haemorrhage.8 However, pregnancy itself is a hypercoagulative state so the risk of developing a significant bleed is reduced.9 Wound healing during pregnancy does not pose Category

Recommendation

A

Well-controlled studies have failed to demonstrate a risk to the foetus at any stage in pregnancy.

B

Animal studies have failed to demonstrate a risk to the foetus but there are no wellcontrolled studies in pregnant women.

C

Animal studies have shown an adverse effect on the foetus and there are no wellcontrolled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

D

There is positive evidence of human foetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

X

Studies in animals or humans have demonstrated foetal abnormalities, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

General procedural risks during pregnancy A significant risk from any procedure that causes breaks in the skin is infection. This is especially important in pregnancy as infections can lead to maternal and foetal complications such as; sepsis, chorioamnionitis, intrauterine growth restriction, malformations and prematurity.4 Increased precaution is therefore needed to prevent infection, including taking special care with hand washing, gloving and appropriate skin preparation. Iodine and hexachlorophene are both contraindicated in pregnancy due to thyroid and central nervous system toxicity, respectively.5 Therefore, alcohol or chlorhexidine gluconate solutions should be used to achieve sterility of the procedure site.3 Alongside the increased risk of infection, there is also a difficulty in treating infections during pregnancy as all common antibiotics are classified as either Category B or C by the old FDA guidelines.6 Amongst many other reasons, we reference the US system in this article because a significant majority of the published literature refer to the FDA categories in their work, even from some UK institutions. The category based system was replaced by the FDA in 2015 to a new labelling system, which uses block

Figure 1: A breakdown of the â&#x20AC;&#x2DC;oldâ&#x20AC;&#x2122; FDA classification system for antibiotics4

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a significant health threat, but creates many challenges against the delivery of aesthetic procedures. Due to changes in hormones and tension factors, pregnancy is linked with the development of hypertrophic and keloid scarring.10 There is also an increased incidence of hyperpigmentation during pregnancy.11 Considering these factors, the decision to undertake aesthetic procedures could be counterintuitive as it can lead to worse aesthetic outcomes in the long term due to the altered scar healing process.

Aesthetic procedures in pregnancy Chemical peels A variety of chemical peels exist in the market and they are used for multiple purposes, including the treatment of melasma. However, some studies that support their use in the treatment of melasma have excluded pregnant women from the trials.12,13,14 2% lactic acid is known to be used to treat gestational acne without any reported negative pregnancy outcomes15,16 and it has a low level of dermal penetration, meaning there are likely to be negligible systemic effects.17 Lactic acid is also used in conjunction with salicylic acid and resorcinol in a combination known as a Jessner peel.18 This is a medium-depth peel, meaning deeper dermal penetration, which makes its use more contentious, especially due to the inclusion of salicylic acid. Salicylic

A study in 1997, with nearly 300 pregnant women, showed no relative increase in the number of adverse foetal events in women who had lidocaine administered during the first trimester of their pregnancy acid is classified as a Category C drug for pregnancy, according to the aforementioned FDA guidelines, thus the FDA says its use in pregnancy is acceptable if the potential benefits justify the risks, of which it does not specify.19 It produces up to 25% dermal penetration, however this would likely still produce an insignificant systemic concentration.20 Studies on the effect of cutaneous salicylic acid in pregnancy are limited, both on its own and as part of a Jessner peel. However, many large studies have been conducted that evaluate the safety of low-dose oral acetylsalicylic acid (Aspirin) in pregnancy.21,22 This is commonly used as a prophylactic agent in women who have a high risk of developing hypertension and pre-eclampsia.23 The studies, including a systematic review that looked at data from more than 12,000 women, concluded that there was no increase in the baseline rate of adverse events such as pre-term birth, major malformations or low birth weights.19 Since the absorption from topical application would produce even lower systemic concentrations, it would be unlikely that these peels would cause adverse outcomes if used during pregnancy,19-22 however, it is still recommended that

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it is used with caution and coverage should be limited, and without occlusion, if used during pregnancy.24 Another popular chemical peel agent is glycolic acid, an ingredient that is widely used for acne treatment. A study on rats showed the development of adverse reproductive effects, however doses were significantly higher than those used in cosmetic products.25 No trials in pregnant women have been conducted. Glycolic acid could therefore be regarded as a Category C product, meaning practitioners should carefully consider use in pregnancy. In reality, the minimal dermal invasion means the product should be safe to use in pregnancy.13,26 Injectable anaesthetic agents Lidocaine is a commonly used injectable local anaesthetic agent and it is used in the delivery of botulinum toxin and dermal fillers. Lidocaine is classified as a Category B drug in pregnancy; once in the blood stream it can cross the placenta and enter the foetal circulation.27 A study in 1997, with nearly 300 pregnant women, showed no relative increase in the number of adverse foetal events in women who had lidocaine administered during the first trimester of their pregnancy.28 A more recent study conducted in 2015, which analysed adverse pregnancy events in 210 women receiving lidocaine for dental procedures, showed a slight increase in adverse outcomes, including miscarriage, congenital malformation and medical/surgical complications, compared to a control population (4.8% versus 3.3%).29 A study on rats failed to show an increase in adverse events following the use of lidocaine in pregnancy.30 The major risks from injecting lidocaine come from high-dose exposure or accidental arterial injection, both of which could theoretically lead to foetal cardiac or central nervous system toxicity.5 However, the maximum safe injectable dose of lidocaine is 4.5mg/kg, or 300mg, which is well below the typical amount used for aesthetic procedures.31 High-dose or accidental arterial exposure can result in lidocaine toxicity in the mother, causing symptoms such as light-headedness, tachycardia, headaches and agitation.32,33 Once symptoms are present in the mother, it can be assumed that the dose is significant to cause some level of foetal toxicity. It is reported that the concurrent use of a vasoconstrictor, such as adrenaline, alongside lidocaine can reduce toxicity by restricting systemic spread.32,34 Although this increases the safety of local anaesthetic, it also increases risk profile as systemic absorption of adrenaline, such as through accidental intra-arterial injection, could lead to uterine artery spasm, resulting in foetal compromise.32 However, these effects are minimised by the relatively small doses of adrenaline used in aesthetic injections, which are as low as 1 in 200,000.35 Other injectable local anaesthetics, such as bupivacaine and mepivacaine, are classified as Category C drugs for pregnancy and should therefore be avoided as there are safer alternatives, namely lidocaine.36 The use of mepivacaine has been reported to cause complications such as foetal bradycardia, preterm labour and a doubling of congenital abnormalities.37 Topical anaesthetic agents Lidocaine is also a popular topical anaesthetic agent, but is usually combined with prilocaine when used in this form as it provides superior analgesia.38 The mixture is classified as Category B in pregnancy but increased risks are present due to the inclusion of prilocaine, which has been shown to produce methemoglobinaemia in the foetus when used during pregnancy.39,40

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Benzocaine and tetracaine are other topical anaesthetic agents, but both are Category C drugs due to more dermal penetration and a stronger association with foetal methemoglobinaemia.41 A lidocaine/prilocaine mixture is therefore the preferred choice of topical local anaesthetic if required. An important note about topical anaesthetic agents is that their effectiveness increases with occlusion, however, penetration into the systemic circulation also increases with occlusion.42 Therefore, if used during pregnancy, occlusion should be avoided to minimise the risks of adverse events. Botulinum toxin Botulinum toxin is one of the most common aesthetic agents administered, however it also has various medical uses such as in achalasia and hyperhidrosis, to name a few. Botulinum toxin is officially a Category C drug in pregnancy and pregnancy is a contraindication for its use, according to manufacturer recommendations.43 Very few trials of aesthetic administration of botulinum toxin in pregnancy have been conducted. The consensus from literature is that it causes a negligible increase in adverse foetal events.35,44,45 However, multiple trials have been conducted which analyse the effects of using botulinum toxin for medical indications during pregnancy, including achalasia, migraine prophylaxis and cervical dystonia.46,47 Despite the use of higher concentrations for medical purposes, many safety studies suggest that there is no significant increase in risk compared to the general population when using botulinum toxin during pregnancy.15,48 If administered correctly, intramuscularly or intradermally, botulinum toxin is unlikely to enter the systemic circulation.49 The large size of the molecule also makes it unlikely that it would be able to cross the placental barrier.49,50 The doses of botulinum toxin used for aesthetic procedures is also much lower than the estimated hazardous concentration (100 units versus 600 units).51 The arguments for the safety of botulinum toxin in pregnancy are convincing, however, it is still believed that there is insufficient data to confirm absolute safety. Dermal fillers There are numerous filler agents available on the market, the most common are collagen, hyaluronic acid, hydroxylapatite and poly-L-lactic acid. To our knowledge, there are no published trials on the safety of any filler agents during pregnancy.In general, the

Very few trials of aesthetic administration of botulinum toxin in pregnancy have been conducted. The consensus from literature is that it causes a negligible increase in adverse foetal events

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most commonly reported complications from dermal fillers include hypersensitivity reactions and injection site infections.51 Theoretically, fillers are likely to be safe for use in pregnancy due to the limited range of effects seen in non-pregnant women and the fact that the large polymers are unlikely to be able to diffuse through tissue/ vessels and enter the systemic circulation.52 However, the lack of safety evidence and the manufacturer recommendations that they should be used with caution in pregnancy53 mean their use should be delayed until after pregnancy if possible. Other factors to consider when administering fillers in pregnant women include the altered scar healing processes in pregnancy, susceptibility to hyperpigmentation and the concurrent use of lidocaine for the procedure.11 Lasers There are a variety of lasers that can be used for aesthetic procedures, but, to our knowledge, none have been tested for their safety profiles for aesthetic procedures during pregnancy. There are, however, numerous studies evaluating their safety for medical treatments during pregnancy, such as for kidney stones, pyogenic granulomas or genital condylomata. Carbon dioxide lasers,54 neodymium-doped yttrium aluminium (Nd:YAG),55 holmium yttrium aluminium56 and pulsed dye lasers57 have all undergone studies that suggest they are safe for use during pregnancy. The lack of data specifically relating to aesthetic procedures means that it is generally advised to avoid using them until after pregnancy. There is a high risk of hyperpigmentation following the use of lasers,58 which would be accentuated during pregnancy, thus the long-term aesthetic outcome of laser treatment should be considered before administering it. Minor procedures Common minor procedures, including removal of benign lesions using cryotherapy, snipping, punch or shave removal and electrocautery all have a verified safety record in pregnant women.59 Other than a risk of bleeding or incomplete removal of the lesion, these procedures have relatively small risk profiles. Some may require the concurrent use of a local anaesthetic agent, for which we have previously discussed the safety considerations, however, most can be performed without this.

Summary As a result of the physiological changes that can occur during pregnancy, some women seek specialist help to undergo procedures to counteract these. Minor procedures, including excision, cryotherapy and shave removal are all safe to perform during pregnancy. Chemical peels are generally considered safe, however, excessive systemic infiltration has been shown to cause adverse events in both animal and human studies.26 When considering more invasive procedures, a secondary factor to consider is the use of anaesthetic agents, the most common of which is lidocaine. This has been shown to be the safest of the injectable and topical anaesthetic agents to use during pregnancy,31 but, again, it can produce adverse events in extreme circumstances. Injectable procedures, such as botulinum toxin and dermal fillers, have limited studies evaluating their use for aesthetic purposes during pregnancy. Aesthetic procedures are non-urgent and there is limited data on safety profiles alongside studies which have indicated small risks; adverse reactions mean the benefits of having these procedures may not justify the risks involved. An important point to consider is the altered wound healing process during pregnancy, which can

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cause worse aesthetic outcomes for the patient.11 The best advice would be to centre consultations on patient counselling, reassuring them of the transient nature of many changes during pregnancy and of the short window of pregnancy during which they would be best to avoid treatments, encouraging patients to delay procedures until after pregnancy. Mr Nihull Jakharia-Shah is a final year medical student at King’s College London. He has completed a BSc degree in Regenerative Medicine and Innovation Technology, passing with First Class Honours. During this he studied biomaterials, including aesthetic skin grafting products, and has developed a passion for research and clinical practice of the skin. Miss Priyanka Chadha is co-director of Acquisition Aesthetics training academy and currently works as a plastic surgery registrar in London. Her academic CV comprises national and international prizes and presentations, as well as higher degrees in surgical education and training. Miss Lara Watson is co-director of Acquisition Aesthetics and is pursuing a career in maxillofacial surgery. Currently in the final year of the Dentistry Entry Programme for Medical Graduates (DPMG) at King’s College, London, Miss Watson has been awarded an academic distinction for the course to date. REFERENCES: 1. Lily Talakoub & Naissan Wesley, ‘Cosmetic procedures in pregnancy’, Dermatology News, 2015. <http:// www.mdedge.com/edermatologynews/article/98661/aesthetic-dermatology/cosmetic-procedurespregnancy> 2. Yalda Afshar & Tania F. Esakoff, ‘The skin and pregnancy: Physiological changes and dermatoses’, Contemporary OB/GYN, 2014. <http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/ content/tags/aesthetic-lasers/skin-and-pregnancy-physiological-changes-and-dermat?page=full> 3. Sansone, RA, Sansone LA, ‘Cosmetic Surgery and Psychological Issues.’, Psychiatry (Edgmont), 4.12 (2007): 65–68. 4. Smith DS, ‘Bacterial infections and pregnancy’, Medscape, 2016. <http://emedicine.medscape.com/ article/235054-overview?pa=0FsmfVNSQ9EKVwk2SqEQSVRumcJ737oELzCSkUDGRmug5VJgj5jK7r Kgn1QJpMyhpROahLXkdIe1UVsrq2Waf1%2FDMAtBBAsM6eN9kpLn%2Fas%3D> 5. Richards KA, Stasko T, ‘Dermatologic surgery and the pregnant patient’, Dermatologic Surgery, (2002) 28: 248–256. <http://onlinelibrary.wiley.com/doi/10.1046/j.1524-4725.2002.01177.x/full> 6. Lee, KC, Korgavkar, K, Dufresne, RG & Higgins, HW, ‘Safety of Cosmetic Dermatologic Procedures During Pregnancy’, Dermatologic Surgery, (2013) 39:1573–1586. <http://onlinelibrary.wiley.com/wol1/ doi/10.1111/dsu.12322/full> 7. Drugs.com, FDA Pregnancy Categories, 2016, <https://www.drugs.com/pregnancy-categories.html> 8. Lykke JA et al., ‘First-trimester vaginal bleeding and complications later in pregnancy’, Obstet Gynecol, 2010 May;115(5):935-44. 9. Greer IA, ‘Hypercoagulable states and pregnancy’, Curr Hematol Rep, 2002 Sep;1(1):56-62. 10. Gauglitz, Gerd G et al., ‘Hypertrophic Scarring and Keloids: Pathomechanisms and Current and Emerging Treatment Strategies’, Molecular Medicine, 17.1-2 (2011): 113–125. <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3022978/> 11. Goldberg, D. and Maloney, M, ‘Dermatologic surgery and cosmetic procedures during pregnancy and the post-partum period’, Dermatologic Therapy, 26: 321–330. (2013). <http://onlinelibrary.wiley.com/wol1/ doi/10.1111/dth.12072/full> 12. Sharquie, K. E., Al-Tikreety, M. M. & Al-Mashhadani, S. A. Lactic Acid as a New Therapeutic Peeling Agent in Melasma, Dermatologic Surgery, 31: 149–154. (2005). <http://onlinelibrary.wiley.com/wol1/doi/10.1 111/j.1524-4725.2005.31035/full> 13. Andersen FA, ‘Final report on the safety assessment of glycolic acid, ammonium, calcium, potassium, and sodium glycolates, methyl, ethyl, propyl, and butyl glycolates, and lactic acid, ammonium, calcium, potassium, sodium, and TEA-lactates, methyl, ethyl, isopropyl, and butyl lactates, and lauryl, myristyl, and cetyl lactates’, Int J Toxicol, (1998) 17:1–241. <http://journals.sagepub.com/doi/ abs/10.1177/109158189801700101> 14. Sharquie, K. E., Al-Tikreety, M. M. and Al-Mashhadani, S. A, ‘Lactic Acid as a New Therapeutic Peeling Agent in Melasma’, Dermatologic Surgery, (2005) 31: 149–154 15. Trivedi MK, Kroumpouzos G, Murase JE, ‘A review of the safety of cosmetic procedures during pregnancy and lactation’, International Journal of Women’s Dermatology, 3:1. 6-10. (2017). <http://www. sciencedirect.com/science/article/pii/S2352647517300059> 16. Rothman KF, Pochi PE. Use of oral and topical agents for acne in pregnancy. J Am Acad Dermatol. (1988) 19(3):431-42 17. Okuda M, et al, ‘Negligible penetration of incidental amounts of alpha-hydroxy acid from rinse-off personal care products in human skin using an in vitro static diffusion cell model’, Toxicol In Vitro. 2011;25(8):2041-7. 18. The Dermatology Review, Jessner Peel, <http://www.thedermreview.com/jessner-peel/> 19. James AH, Brancazio LR, Price T, ‘Aspirin and reproductive outcomes’, Obstet Gynecol Surv, 2008;63(1):49–57. 20. Cosmetic ingredient expert review panel, ‘Safety assessment of Salicylic Acid, Butyloctyl Salicylate, Calcium Salicylate, C12-15 Alkyl Salicylate, Capryloyl Salicylic Acid, Hexyldodecyl Salicylate, Isocetyl Salicylate, Isodecyl Salicylate, Magnesium Salicylate, MEA-Salicylate, Ethylhexyl Salicylate, Potassium Salicylate, Methyl Salicylate, Myristyl Salicylate, Sodium Salicylate, TEA-Salicylate, and Tridecyl Salicylate’, Int J Toxicol, 2003;22 3:1-108.

Aesthetics 21. Schiff E et al, ‘The use of aspirin to prevent pregnancy-induced hypertension and lower the ratio of thromboxane A2 to prostacyclin in relatively high risk pregnancies’, N Engl J Med, 1989 Aug 10;321(6):351-6. 22. Coomarasamy A, ‘Aspirin for prevention of preeclampsia in women with historical risk factors: a systematic review,’ Obstet Gynecol, 2003 Jun;101(6):1319-32. 23. Allen KM, Green A, Wallace SVF, ‘Use of low-dose aspirin in pregnancy – how will the nice ‘hypertension in pregnancy’ guideline alter current practice?’, Archives of Disease in Childhood - Fetal and Neonatal Edition, 96:112-113. (2011). <http://fn.bmj.com/content/96/Suppl_1/Fa112.4> 24. P. Bozzo, A. Chua-Gocheco, A. Einarson, ‘Safety of skin care products during pregnancy’, Can Fam Physician, 57 (2011) 665–667. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3114665/#b26-0570665> 25. Munley SM, Kennedy GL and Hurtt ME, ‘Developmental toxicity study of glycolic acid in rats’, Drug Chem Toxicol, 22:569–82, (1999). <https://www.ncbi.nlm.nih.gov/pubmed/10536749> 26. Bozzo, Pina, Angela Chua-Gocheco, and Adrienne Einarson, ‘Safety of Skin Care Products during Pregnancy’, Canadian Family Physician 57.6 (2011): 665–667. 27. Kuhnert BR, Knapp DR, Kuhnert PM, Prochaska AL, ‘Maternal, fetal, and neonatal metabolism of lidocaine, Clin Pharmacol Ther, (1979) 2.6:213-220. 28. Heinonen Op , Sloane D , Shapiro S, ‘Birth defects and drugs in pregnancy’, Littleton, 357–365. (1977). <https://www.abebooks.com/9780884160342/Birth-Defects-Drugs-Pregnancy-Maternal-0884160343/ plp> 29. Hagai, O. Diav-Citrin, S. Shechtman, A. Ornoy, ‘Pregnancy outcome after in utero exposure to local anesthetics as part of dental treatment: A prospective comparative cohort study’, J Am Dent Assoc, 146. 572–580. (2015). <http://www.sciencedirect.com/science/article/pii/S000281771500433X> 30. Fujinaga M, ‘Assessment of teratogenic effects of lidocaine in rat embryos cultured in vitro. Anesthesiology’, 89: 1553–1558. (1998). <https://www.ncbi.nlm.nih.gov/pubmed/9856732> 31. Sweeney SM, Maloney ME, ‘Pregnancy and dermatologic surgery’, Dermatol Clin, 24:205–14. (2006). <https://www.ncbi.nlm.nih.gov/pubmed/16677967> 32. E.P. Fayans, H.R. Stuart, D. Carsten, Q. Ly, H. Kim, ‘Local anesthetic use in the pregnant and postpartum patient’, Dent Clin North Am, 2010, 54. 697–713. <http://www.sciencedirect.com/science/article/pii/ S0011853210000686> 33. Anaesthesia UK, ‘Pharmacology of Regional Anaesthesia’, 2009, <http://www.frca.co.uk/article. aspx?articleid=100816> 34. Sinnott CJ, et al, ‘On the mechanism by which epinephrine potentiates lidocaine’s peripheral nerve block. Anesthesiology, (2003);98(1):181-8. 35. P.A. Moore, ‘Selecting drugs for the pregnant dental patient’, J Am Dent Assoc, (1998)129, 1281–1286. <http://www.sciencedirect.com/science/article/pii/S0002817714662693> 36. Drugs.com, ‘Mepivacaine’, 2017. <https://www.drugs.com/pro/mepivacaine.html> 37. Donaldson, D, & JG Meechan, ‘A Comparison of the Effects of EMLA Cream and Topical 5% Lidocaine on Discomfort during Gingival Probing’, Anesthesia Progress 42.1 (1995): 7–10. 38. Chen BK, Eichenfield LF, ‘Pediatric anesthesia in dermatologic surgery: when hand-holding is not enough’, Dermatol Surg, 27:1010–1018 (2001) <http://onlinelibrary.wiley.com/doi/10.1046/j.15244725.2001.01854.x/full> 39. J. Guay, M’ethemoglobinemia related to local anesthetics: A summary of 242 episodes’, Anesth Analg, (2009), 108. 837–845. <https://www.ncbi.nlm.nih.gov/pubmed/19224791> 40. Taddio A, et al, ‘Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision’, N Engl J Med, (1997) 24;336(17):1197-201. 41. Svensson, P, & JK Petersen, ‘Anesthetic Effect of EMLA Occluded with Orahesive Oral Bandages on Oral Mucosa: A Placebo-Controlled Study’, Anesthesia Progress, 39.3 (1992): 79–82. 42. Allergan, ‘Botox guidelines’, 2016, <https://www.allergan.com/assets/pdf/botox_pi.pdf> 43. Hooft N., Schmidt ES., Bremner RM, ‘Achalasia in pregnancy: Botulinum toxin A injection of lower esophageal sphincter’, Case Rep Surg, 2015. 44. Morgan, J C et al, ‘Botulinum Toxin A during Pregnancy: A Survey of Treating Physicians’, Journal of Neurology, Neurosurgery, and Psychiatry 77.1 (2006): 117–119. 45. EO Montiero, ‘Botulinum toxin and pregnancy’, Skinmed, 2006;5(6):308. 46. Robinson AY., Grogan PM, ‘OnabotulinumtoxinA successfully used as migraine prophylaxis during pregnancy: A case report’, Mil Med, 2014;179. 47. WJ Newman, ‘Botulinum toxin type A therapy during pregnancy’, Mov Disord, 2004;19(11):1384-5. 48. M. Tan, E. Kim, G. Koren, P. Bozzo, ‘Botulinum toxin type A in pregnancy’, Can Fam Physician, 59. (2013) 1183–1184. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828093/> 49. Morgan JC, Iyer SS, Moser ET, Singer C, Sethi KD, ‘Botulinum toxin A during pregnancy: a survey of treating physicians’, J Neurol Neurosurg Psychiatry, 77(2006), 117–119. <https://www.ncbi.nlm.nih.gov/ pubmed/16361610> 50. M. Lolis, SW Dunbar, DJ Goldberg, TJ Hansen, DF MacFarlane, ‘Patient safety in procedural dermatology: Part II. Safety related to cosmetic procedures’, J Am Acad Dermatol, 73(2015) 15–24. <http://www.sciencedirect.com/science/article/pii/S0190962214023172> 51. Allergan, JUVÉDERM VOLLURE guidelines, 2017. <https://www.allergan.com/news/news/thomsonreuters/juv-derm-vollure-xc-approved-by-u-s-fda-for-correc> 52. Jd Bos, ‘The 500 Dalton rule for the skin penetration of chemical compounds and drugs’, Exp Dermatol, 2000;9(3):165-9. 53. C. Gay, J.J. Terzibachian, C. Gabelle, S. Reviron, R. Ramanah, C. Mougin, ‘Carbon dioxide laser vaporization of genital condyloma in pregnancy’, Gynecol Obstet Fertil, 31. 214–219. (2003). <http://www. sciencedirect.com/science/article/pii/S1297958903000407> 54. S. Buzalov, E. Khristakieva, ‘The treatment of neglected cases of condylomata acuminata in pregnant women with the Nd: Yag laser’, Akush Ginekol (Sofiia), 34. 38–39. (1995). <https://www.ncbi.nlm.nih.gov/ pubmed/8651421> 55. S. Adanur, T. Ziypak, F. Bedir, T. Yapanoglu, H.R. Aydin, M. Yilmaz, et al., ‘Ureteroscopy and holmium laser lithotripsy: Is this procedure safe in pregnant women with ureteral stones at different locations?’, Arch Ital Urol Androl, 86. 86–89. (2014). <https://www.ncbi.nlm.nih.gov/pubmed/25017585> 56. S.J. Carlan, S.J. Schorr, M.F. Ebenger, P.A. Danna, G.B. Anibarro, ‘Laser lithotripsy in pregnancy. A case report’, J Reprod Med, 40. 74–76. (1995). <http://europepmc.org/abstract/med/7722982> 57. Arora, Pooja et al., ‘Lasers for Treatment of Melasma and Post-Inflammatory Hyperpigmentation’, Journal of Cutaneous and Aesthetic Surgery 5.2(2012): 93–103 58. Ellen Meyer, ‘When the Patient is Pregnant’, The Dermatologist, 18;5. (2010). <http://www.thedermatologist.com/content/when-patient-pregnant> 59. HC Mofenson, TR Caraccio, HM Greensher, ‘Lidocaine Toxicity from Topical Mucosal Application’, Clinical Pediatrics, (2016) 22;3.190-192.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Beautifying the Young Face Dr Rupert Critchley presents his technique for improving the face of young female patients according to the three triangles of beautification As aesthetic practitioners, safety should be our number one priority. In the best interests of our patients, we evolve and develop new skills and approaches to consultation and treatment. Regardless of experience and training, one of the toughest challenges of consultation is merging patient ‘wants’ with patient ‘needs’ or marrying the opinions of our patients with our own. Greek derivations of the third century BC phrase says, ‘beauty is in the eye of the beholder’,1 however, in more recent times, it seems that beauty is now ‘in the eye of Instagram’. With the rise in social media and photo editing software such as Photoshop and Instagram filters, we are seeing an increase in younger patients hoping to replicate the looks they can achieve through photo editing. My method, the 3D face-refresh, hopes to marry ‘patient want’ with ‘patient need’. For example, a patient may want nasolabial fillers, but from an aesthetic perspective, they may benefit more from improving mid-face volume or subtle cheek enhancement rather than a direct injection into the fold. It is important to note that young patients do not necessarily ‘need’ treatments, but this approach, which uses dermal fillers, can be a safe and methodical treatment for the younger age category (21-30) who want to tweak, touch up and correct minor imperfections that are commonly addressed using Photoshop and filters. I have found that young patients are often looking to correct prominent nasolabial grooves, tear trough hollowness, flat cheeks and chin contour and proportion imbalance. This procedure involves small injections of a volumising dermal filler using the three beautification triangles to create lift, volumisation and enhancement of the upper, mid and lower face.

Three triangles of beautification The basis of a holistic approach to facial aesthetics has been around for a while now, as more practitioners move away from just fixing nasolabial folds and marrionette lines to addressing actual Before

After

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ageing factors like mid-face volume loss. The face, independent of age, is divided into the upper, mid and lower face. Using small quantities of a volumising hyaluronic acid-based dermal filler, improvements can be made in these regions. The three triangles of beautification provide the practitioner with a template of safe points to address facial aesthetic concerns using both syringe and cannula techniques. Different areas of the face require different approaches, for example, unsafe zones such as the lower face and tear troughs should be addressed with cannula.3 You should ensure you have adequate experience and training to undertake advanced dermal filler procedures such as those described below. 1. Cheek beautification triangle This consists of the three points shown on Figure 2 (C1-C3). Small periosteal bolus injections should be inserted, ensuring that you aspirate your syringe before injection.2 It is important to note that the amount of product is dependent on the individual. This will provide a subtle cheek lift and volume enhancement as well as improve lateral cheek and zygoma definition. It also softens the lateral epicanthal folds and lateral tear trough. When injecting, I personally use cannula due to the sensitively of the area and surrounding nerves/arteries such as the infraorbital nerve and angular vessels. I also find that the use of cannula can reduce the risk of bruising. 2. Jawline lift and contour triangle Three points on Figure 2 (J1-J3) are accessed with a 25G cannula using an anterograde linear approach. This will aim to provide a tightening effect and muscle modulation across the superior and middle insertion points of outer masseteric muscle in the subcutaneous plane. A needle can be used instead, but cannula is my preference as I find that it allows the product to spread evenly within the tissues, which can create more effective augmentation over a larger surface area. This triangle should tighten the jawline, improve the appearance of the jowls and treat nasolabial and marionette lines, providing the patient lower face rejuvenation. The marionette lines can also be addressed by combining the lower face triangle described below, but in my experience younger patients benefit from having the jawline lift and contour triangle first. 3. Lower face and chin-shaping triangle Three points are injected as shown in Figure 2 (L1-L3) using bolus injections – I prefer to use a syringe. The practitioner should perform a deep nasolabial periosteal injection into the piriform fossa. Use a bolus injection into the inferior-medial modiolus to provide a lifting/ inversion effect on the lip corner, reducing the appearance of subtle, early marionette lines. If the patient requires chin enhancement, use a deep bolus injection into the sagittal plane. Injectors should be aware of the danger zones, which are branches of the facial artery and mental vessels.3

Treatment approach

Figure 1: Patient before and immediately after treatment using the 3D face-refresh approach with 1.5ml of dermal filler

Firstly, a thorough consultation should be carried out to discuss prior medical issues and history. Contraindications are essentially the same as those used for any dermal filler treatment and should include relevant psychology such as body dysmorphic disorder. I have found that unrealistic expectations are especially common in this age group. It is a good idea to divide the treatments into a number of sessions and to undergo a ‘less is more’ approach. It is recommended to take before and after photos and gain appropriate consent during each

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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L1

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Tringle type

Imperfections addressed

Cheek beautification triangle (Figure 2: C1-C3)

• Cheek volume/zygoma definition • Lateral tear-troughs/dark circles • Periorbital lines

Jawline lift and contour triangle (Figure 2: J1-J3)

• Jawline contour • Jowls • Marionette lines

Lower face and chin shaping triangle (Figure 2: L1-L3)

• Nasolabial folds • Chin shape • Marionette lines

C1

C2

C3

J1

J2

Figure 3: Imperfections addressed with the three beautification triangles J3

Complications and side effects L2

L3

Figure 2: Injection points for each triangle of beautification. C1-C3 are indicated for the cheek, J1-J3 are indicated for the jawline and L1-L3 are indicated for shaping of the lower face and chin.

session. Emphasis should be placed on natural-looking results and enhancement for a more refreshed appearance, as this treatment method does not result in drastic or unnatural looking changes in contour or shape. To avoid overcorrection, you can make smaller volume injections at a time. Ensure patients know of the appropriate aftercare and are mindful of downtime. Some of my aftercare advice is to avoid touching or rubbing the area, keeping the area clean and dry,

Regardless of set and safe points of injection, every person is different and you should be aware that our patients’ physiology varies not to do any excessive exercise or use saunas or steam rooms for 48 hours and not to have facials for two weeks. I also advise them to go back to their usual skincare regime the next day. Even though there are relatively few points of injection, there is always risk of bruising and dermal filler-related complications, which should be outlined to the patient before the treatment.3,4 After the consent process is complete, skin preparation should be conducted. Use an anti-bacterial based wipe and topical local anaesthetic to ready the patient for the procedure with emphasis on aseptic technique. Please also note that regardless of set and safe points of injection, every person is different and you should be aware that our patients’ physiology varies so some points of injection and beautification triangles may not be applicable. To spot these, you need good knowledge of the anatomy and an aesthetic eye, which comes with experience. Product quantity is variable, however, most often, between 1-2ml of a volumising hyaluronic acid is required for the whole procedure.

Complications should be divided into immediate, early and late. Immediate complications, as with any dermal filler injection, include bleeding, bruising, pain and discomfort, all of which should be minimised with safe technique and application of topical anaesthetic. The practitioner should be mindful of the appropriate anatomy to reduce the risk of rarer complications such as vessel occlusion and avascular necrosis. After injections are carried out, early issues can involve further bruising, pain and discomfort. Late complications can include asymmetry, prominent filler lumpiness and discolouration if the superficial volumising filler has been left too close to the skin’s surface (Tyndall effect).4

Conclusion For your young patients who present in clinic, the 3D face-refresh approach can be a good option for natural improvements for contouring. If the practitioner is aware of facial anatomy and uses small quantities of volumising dermal filler in safe injection zones, downtime and complication risk is minimal. The practitioner should provide a detailed summary of the treatment plan and ensure thorough consultation to make sure patient expectations are addressed prior to the treatment. The practitioner should use a less is more approach and consider doing the treatments over multiple sessions, with a follow-up after two weeks and be aware of the contraindications and possible side effects. Dr Rupert Critchley is the director of Viva Skin Clinics and its sister training faculty, the Viva Academy. After qualifying as a medical doctor in 2009, he has completed an array of courses in advanced non-surgical aesthetics and is also a fully qualified GP. REFERENCES 1. Bloomsbury International, ‘Beauty is in the eye of the beholder’, <https://www.bloomsburyinternational.com/en/student-ezone/idiom-of-the-week/list-of-itioms/100-beauty-is-in-the-eye-of-thebeholder.html> 2. Yasir Sepah, Lubna Samad, et al. Aspiration in injections: should we continue or abandon the practice?, 2017, <https://f1000research.com/articles/3-157/v1> 3. Braz A, Humphrey S, Weinkle S, et al. ‘Lower Face: Clinical Anatomy and Regional Approaches with Injectable Filler’, Plast Reconstr Surg, 2015. 4. DeLorenzi C, ‘Complications of injectable fillers, part 2: vascular complications’, Aesthet Surg J, 2014; 34:584. 5. Jaishree Sharad, ‘Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes’, J Cutan Aesthet Surg, 2012, 5(4) pp.229–238.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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autoimmune diseases such as psoriasis and active alopecia areata. He notes, “Before the procedure, the patient should be consulted by a specialist doctor to address any autoimmune diseases on the scalp, check blood pressure and take a HIV blood test, as patients at an advanced stage of the virus would be unsuitable for treatment.”3 After a consultation, the first step before the procedure is a patch test. Dr Bogan explains, “This is where we do Aesthetics explores the use of a new a small implantation session of 100-200 fibres to observe artificial hair treatment for balding patients the patient for one to two months in order to check for any possible rejection or allergy to artificial hair that may Hair loss can be a devastating occurrence for both men and women. occur. If there is no reaction or a controllable reaction after one According to a study of 1,536 men in 2005, 62% said hair loss would to two months, then we can proceed with a full session.” The affect their self-esteem, with the biggest concern being that they most likely reaction is inflammation, which can be treated with an would lose whatever attractiveness they had.1 For women, a study on ointment steroid. the psychological impact of alopecia suggested that around 40% of alopecia sufferers have had marital problems, and around 63% claimed Procedure to have career-related problems, linked to the hair loss condition.2 With One day before the procedure, smoking and alcohol are to be this is mind, treatments for hair loss have a firm place in the aesthetics avoided, and the patient should start taking a systemic broadspecialty. Surgical treatments, such as follicular unit extraction (FUE) spectrum antibiotic.4 Biofibre hairs are implanted one by one and follicular unit transplantation (FUT), are generally accepted as the in a 45° radius, leaving a space of 2mm between each implant, most common ways to treat hair loss. However, there are less invasive following the natural pattern of the hair. The implantation is treatments now available; one being a newly-launched procedure that performed by an automatic implant machine, which fires the uses a polyamide artificial hair implant, Biofibre. Biofibre through the epidermis, dermis, subcutaneous layer and into the galea capitis. “This is where fibrosis occurs,” explains Dr What is Biofibre? Bogdan. “After the formation of fibrosis around the knot, located at Biofibre can be used in hair restoration procedures when FUE or FUT the end on the fibre implanted into the scalp, the fibres will become may not be suitable, such as when there is a lack of donor hair, the strongly fixed and will be able to handle 350-450 grams of traction. patient has an atrophic or cicatricial scalp, or burn sequelae.4 Dr Al Fibrosis can take between one to two months.”4 Bzour Bogdan Morad, the UK trainer for the automatic Biofibre Hair At the end of the procedure, the implanted area is cleansed and Implant System, which aids the implantation of Biofibre, says, “It is also disinfected with an antiseptic solution, avoiding any traction on recommended for patients pursuing fast results with minimally-invasive the fibres that might produce unwanted hair loss. An ice pack is intervention and fast healing post procedure. In addition, it can be applied for five to ten minutes and if necessary, an analgesic may used as a combined technique with other hair treatments, with the aim be administered. The number of treatments needed will depend of achieving a higher level of hair density.” on the size of the implanted area and how many fibres the patient A large or small quantity of Biofibre hair can be fixed and the device requires. Dr Bogdan says, “The protocol recommends that for the can implant between 800 and 1,200 hairs per hour. Dr Bogdan first session, 1,500-2,000 fibres should be implanted and for the explains that, “Biofibre hairs are fibres with identical aesthetic aspect following sessions up to 3,000 fibres each time, spaced between and thickness of normal hair, made out of polyamide and inorganic two and two and a half months.” pigments. The pigment is melted with the polyamide to ensure Follow-up sessions can be performed after three to four weeks. medical safety and to avoid migration to the tissue.” There are 13 According to a study by Ramos et al., the elapsing time between different shades available, which can be blended to create a unique sessions is said to allow for a gradual change of image and better and tailor-made colour match for the patient. Different lengths and psychological acceptance both by the patient and by other people.4 various styles can be obtained, including straight, wavy, curly, or afro, to satisfy patient requests. Post procedure Some patients can develop localised infection in the implanted Patient selection and preparation area due to lack of personal hygiene or aftercare negligence, but Most patients are suitable for the procedure, according to Dr it can also be controlled with antibiotic ointment. Dr Bogdan says, Bogdan, with the exception of patients that suffer from scalp “There is a haircare line specially made for Biofibre patients to use post procedure to maintain the results and guarantee Before After longevity of the fibres. It consists of a sanitising spray, pH neutral cleansing foam and anti-sebum lotion.” After the hair implant, the patient receives systemic antibiotic therapy for a week, sometimes together with antihistamines. The first shampoo can be performed after three to four days with gentle motions and it is advised that hair should not be cut for two weeks to avoid risk of infection. The patient can lead a normal active lifestyle, with results seen to last five to seven Figure 1: Patient before and after treatment with Biofibre years on average.4

Spotlight On: Biofibre

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


aestheticsjournal.com During

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After

Figure 2: Patient during and after treatment with Biofibre.

Studies A study on the efficacy and safety of Biofibre followed 133 patients for three years’ post procedure. The study involved 98 males and 38 females with alopecia or baldness, who were deemed to have good health, a healthy scalp, and were diligent with scalp cleaning. A clinical evaluation was carried out at one month, four months, and every four months thereafter. The fibre loss was no more than 10% per year in 91.4% of cases, 15% in 7.8% of cases and 20% in 0.8% of cases. When asked about the results, patient satisfaction was 96.2%. As for post-implantation tolerability and complications, 90.3% of patients recorded no pathology after surgery, 5.9% presented mild infection pathologies and 3.8% presented inflammation pathologies. The resolution of the septic and chemical pathologies occurred in 97.9% of the cases within an average of 15 days using a systemic antibiotic and/or steroid local therapy. In 2.1% of the cases, it was necessary to remove the fibres, which took place without leaving any lasting scar.4 There are currently few treatments for scalp scars that provide

Aesthetics

sufficient results, but the implantation of artificial fibres could be a viable alternative. An analysis of the utility of Biofibre hairs to treat scalp scars looked at 54 scars from 44 patients. There were no complications in 49 of the scars (90.7%), mild adverse outcomes in four scars (7.4%), and moderate adverse outcomes in one scar (1.9%). Occasional minor skin reactions, sebum plugs, and hyperseborrhea were successfully controlled and were well accepted by patients. The rate of which the fibres were lost was 20% on average per annum.5 Summary Biofibre is the result of more than 20 years of investigation and is approved as an implantable hair prosthetic medical device by CE 0373 certification. Supported by clinical data, the Biofibre hair implant treatment indicates positive cosmetic results, which in turn, according to researchers, could lead to psychological benefits.6 Training is available for qualified doctors only. REFERENCES 1. Alfonso M, Richter-Appelt H, Tosti A et al. The psychosocial impact of hair loss among men: a multinational European study, Current Medical Research and Opinion, (2005) <https://www.ncbi.nlm. nih.gov/pubmed/16307704> 2. Hunt N, McHale S. Understanding alopecia. London: Sheldon, 2004. 3. O Ramos, G Tchernev, A.A. Chokoeva et al. Biofibre Hair Implant – Impact on the Quality of Life, Journal of Biological Regulators and Homeostatic Agents, Vol. 30 no.2 (2016) 4. N Serdev, A.M D’ Erme, J Hercogova, Z Zarrab et al. Polyamide Hair Implant (BIOFIBRE): Evaluation of Efficacy and Safety in a Group of 133 Patients, Journal of Biological Regulators and Homeostatic Agents (2015) 5. Mariangela Santiago, Roberto Perez-rangel, Angelo D’ugo et al. Artificial Hair Fiber Restoration in the Treatment of Scalp Scars, Dermatologic Surgery, (2007) 6. Implant or Transplant? Biofibre (2017) <http://www.biofibre.com/en/hair-implants/implant-or-transplant/?>

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Treating the Brow

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fascia, which is continuous with the superficial musculoaponeurotic system (SMAS) layer of the face and the platysmal layer of the neck.9

Dr Victoria Manning and Dr Charlotte Woodward present their techniques for performing a non-surgical brow lift using threads for medial elevation When a person is young, their brow should lie just above the upper edge of the orbit. The outer portion of the young brow is higher than the inner portion as it slopes gently upwards, before dropping slightly at its tail. Factors such as ageing, decreasing skin elasticity, the effects of gravity and repetitive periorbital muscle contractions will inevitability result in sagging brows, especially laterally, producing a flat, droopy appearance over time. As well as this, the loss of temporal support to the lateral brow, alongside volume loss in the upper eyelid, can create the illusion of brow ptosis. A brow-lift will help reposition the forehead and eyebrows to achieve a natural, subtle youthful appearance, and can correct brow asymmetry. If a patient is against surgery, a combined non-surgical approach can often deliver great results.1,2 There are multiple options for lifting the brow, such as dermal fillers, botulinum toxin and now threads, and they can all be used in combination. In this article, we will discuss treating the brow with a combination of botulinum toxin and threads for medial corrections and we will explore anatomy, patient selection, techniques, complications and how to best manage them.

Sensory nerve supply The insertion of threads has the potential to cause nerve damage if the anatomy is not correctly understood. The nerve supply to the brow and anterior scalp is the ophthalmic division of the trigeminal nerve. The ophthalmic division divides into the lacrimal nerve and the frontal nerve, which further divides into the supraorbital and supratrochlear nerves. The supratrochlear innervates the conjunctiva, upper eyelids, and inferomedial part of the forehead, whereas the supraorbital nerve innervates the upper lid, forehead, and anterior scalp. For marking out purposes, the supratrochlear nerve lies 1.5-1.7cm from the midline, and the supraorbital nerve lies 1cm lateral to the supratrochlear nerve (Figure 3).4 The temporal part of the facial nerve supplies the muscles of the forehead and the orbicularis oculi muscle.4 Skin Connective tissue Aponeurosis

Loose areolar tissue

Periosteum

Aesthetic considerations of the brow Subtle elevation of the medial, central, and/or lateral portions of the brow can be achieved with a variety of advanced brow-lifting techniques. It is critical when balancing the face to know whether the brow should be elevated, as well as which parts of the brow should be lifted and why. As a guide, Figure 1 illustrates the ideal positioning of the brow. Practitioners can use this to help determine how the brow needs to be altered and decide if an elevation is needed.

Anatomy Before conducting any aesthetic procedure, the practitioner should be well informed of the anatomy in the treatment area to avoid potential complications. The scalp consists of five layers: the skin, subcutaneous tissue, galea aponeurosis, loose areolar tissue, and periosteum (Figure 2). The galea is tendinous connective tissue that connects the frontalis muscle with the occipitalis muscle. The frontalis muscle originates from the galea and inserts into the forehead skin. Superiorly, the galea becomes tightly attached to the periosteum. Laterally, the galea continues as the temporoparietal

1 A

2 B

3

1. The medial origin of the eyebrow should be in the same vertical line as the alar. 2. The peak of the arch should be at a line above the lateral limbus of the cornea (2-3mm away from the outer edge of the iris). 3. The lateral part of the eyebrow should end at an oblique line connecting with the alar and the lateral canthus. The height of the medial and lateral brow should lie at the same level.

Figure 1: The positioning of the ideal brow12,13

Bone

Figure 2: The five layers of the scalp9

Blood supply The internal and external carotid arteries supply the forehead. The internal carotid artery, via the ophthalmic artery, divides to form the frontal, supraorbital, and supratrochlear arteries. The external carotid artery system supplies the largest area of the scalp via the superficial temporal artery.4 Muscles There are four muscles in the eyebrow: frontalis, procerus, corrugator supercilii and orbicularis oculi. The frontalis is a divaricated, subcutaneous muscle that inserts into the skin of the eyebrow. The frontalis muscle has no bony insertions, and its sole action is brow elevation. Horizontal forehead lines are due to continual frontalis activity. Infero-nasally, the frontalis muscle extends to form the procerus muscle.4 The procerus inserts onto the medial belly of the frontalis muscle and the dermis between the eyebrows. The action of the procerus muscle produces inferior brow movement and creates the horizontal glabellar lines.4

Non-surgical brow lift procedure The minimally invasive non-surgical brow thread lift is performed under local anaesthetic and is designed to rejuvenate the

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Figure 3: The supratrochlear nerve and artery lie 1.51.7cm from the midline, and the supraorbital nerve and artery lie 1cm lateral to the supratrochlear nerve. The vessels and nerves lie in the medial aspect of the brow so caution is required whenever treating this area so as not to damage these structures and cause excessive bruising.4

forehead. It takes around 60 minutes, involves minimal discomfort and the recovery time is generally five to seven days. However, due to the potential bleeding risk, we always advise patients not to plan anything special for a few days post treatment. The results can last up to 18 months.14 Patient selection As with all aesthetic procedures, it is paramount to assess patient suitability. Taking the patient’s medical, cosmetic and aesthetic history is mandatory. Identify the following contraindications: inflamed skin/tissue, history of keloid scarring, autoimmune diseases (such as scleroderma, sarcoidosis, amyloidosis due to unpredictable results), anticoagulant medication, haemophilia, pregnancy, IVF, malignancy, history of bacterial endocarditis (existing systemic infection), body dysmorphia and unrealistic expectations.17 Appropriately manage patient expectations and do not try and advocate a thread lift as an alternative to a surgical procedure – the results are moderate, and a patient may end up unhappy with results. Avoid patients with thin skin as there is more chance of sutures showing and bruising. Finally, inform the patient of downtime, risks, side effects and possible complications, which are outlined below. Alternatives for treatment should also be discussed, which might include surgical options if there is excessive skin laxity, or dermal filler to give a subtle result. Patients whose main concern is mild to moderate flattening, where an arched brow has become flattened with age, or asymmetry, are the best candidates. Thread lifting, although non-surgical, does result in more downtime than other non-surgical procedures; for example, I advise a few days downtime compared to a dermal filler treatment. This is because the thinner tissue of the scalp and high vascularity inevitably results in more bruising and possible thread visibility.3 Assessment Assess the skin quality, pre-existing asymmetry of the brows, tissue laxity and muscle activity. With the patient seated upright, and with patient participation so they can view the process in a mirror, decide on desired shape of brow. It is important to note that although this article focuses on the medial lift, you may also require a lateral lift, or both. The number of threads used to lift the brow varies from one to two per side, depending on what lift is required.

Medial lift procedure There are multiple protocols for brow lifting for different types of threads, which act as a scaffold for the ptotic skin and mechanically lift it while stimulating collagen. We use polydioxanone (PDO) barbed blunt cog for medial elevation, as we find it safer due to the ‘danger areas’ medially of the supra-orbital and supratrochlear arteries.

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Appropriately manage patient expectations and do not try and advocate a thread lift as an alternative to a surgical procedure – the results are moderate, and a patient may end up unhappy with results We find that using threads in conjunction with botulinum toxin gives the best results. Pre-treat the orbicularis with botulinum toxin two weeks prior to the thread lift procedure as hyperactivity of the lateral orbicularis oculi muscle can pull down on the lateral aspect of the brow.16 The orbicularis oculi muscle pulls down on the tail of the brow and opposes the lifting action of the frontalis muscle.5,6 Before

After

Figure 4: Patient before and after treatment. Image demonstrates correction of asymmetry using a unilateral ‘inverse V technique’ with PDO threads.

To prepare for thread insertion, practitioners should clean the patient with chlorohexidine or other skin sterilising agent, mark the desired lift and infiltrate entry and exit points in the brow and along the suture track with local anaesthetic mixed with adrenaline. This helps separate the tissues to allow for easier suture insertion. Allow time for maximal vasoconstriction and await blanching, this may take up to 10 minutes. Create a sterile field and drape the patient. Remember to consider the danger zones of the supraorbital and supratrochlear vessels. Firstly, puncture the skin at the apex of the inverse V technique using 18G needle with a blunt cannula using 60mm 3D barbed threads. The inverse V technique involves a single entry hole at the apex, which widens at the anchor points in the brow, which is the wider part of the V. Then, insert the suture, advancing towards the brow. The suture is placed in the subdermal plane, avoiding deep placement through the aponeurosis. Exit in the hairline for good anchorage. Once the suture has been inserted, slight compression is made to the tissue overlying the suture to reshape the brow. The non-inserted ends of the suture are cut off. Once in place, anchor the suture and tighten it to get the desired lift. Avoid overtightening – always check with the patient to agree on the correct amount of lift. Ensure the thread springs back beneath the dermis to limit thread migration and finish by applying antibiotic ointment to the entry points.

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If placed too superficially, the threads may need removing as they can cause hyperstimulation of the dermis and eyebrows

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Nerve damage,7 sensory impairment,8 chronic pain8 and hypersensitivity:8 To prevent these, when cutting the thread, pull the thread away from the skin so it will spring back beneath the dermis. Palpable visible threads: These usually settle after several days but may need intervention using hydrodissection to lift the overlying skin off the thread. If placed too superficially, the threads may need removing as they can cause hyperstimulation of the dermis and eyebrows.

Conclusion Treating the brow in the correctly selected patient can enable excellent satisfaction and results that can last 18 months, or even longer. Practitioners should note that this is an advanced procedure and adequate training must be taken before going ahead with treatment. Dr Victoria Manning is an aesthetic practitioner and GP, with more than 20 years’ clinical experience. She is the co-founder of River Aesthetics in New Forest and London, which specialises in thread lifting. She is a national threads trainer and is also an aesthetics industry media contributor, writer and speaker.

Aftercare Advise patients not to rub or massage the forehead for two weeks post treatment. In our experience, mild discomfort after the procedure is normal and it may last for up to two weeks, so reassure the patient of this. If the patient feels pain, advise them to take paracetamol 500mg, one to two tablets every six hours as required. It is also important to advise against anti-inflammatory medication such as ibuprofen, as inflammation is necessary to initiate the new collagen stimulation18 and increases bruising. Tell them to avoid impact exercise for two-weeks post procedure to allow the threads to embed within the tissue. It is also strongly recommended that patients avoid radiofrequency or any heat-producing treatments of the threadtreated areas for 12 weeks, as we have found that it can affect how the threads settle. The patient should be reviewed two weeks later with photography at three months’ post treatment.

Avoidance of risks and complications Asymmetry: Always involve the patient at the tightening stage to ensure desired effect. Bleeding/haematoma: This is rare, but if it occurs, tape up the brow as support, as the threads cannot anchor within fluid and will need additional support until haematoma resolves.7 Puckering: If overtightened, the skin will bunch up over the thread and cause visible puckering. Sometimes slight unevenness can be caused by oedema and the local anaesthetic along the tract, causing the tissues to swell. Infection: In our experience, infection post-thread procedures is extremely rare. All threads should be placed using an aseptic technique to reduce the risk of infection and in our practice antibiotic ointment is applied to entry points post treatment. Granuloma: These arise from threads being placed too superficially in the dermis.7,15 Thread breakage: Typically, this occurs during tightening of the PDO cogs. Thread migration or loss: It is paramount to ensure that when the thread is cut, the end will spring back into the skin – migration of a thread through the skin is an infection and granuloma risk. If the end of a thread is left in a superficial plane, then there is increased likelihood of granuloma formation.10

Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is the co-founder of River Aesthetics in New Forest and London, which specialises in thread lifting and feminine rejuvenation. She was one of the first in the UK to offer non-surgical breast lifting using PDO threads and is a national trainer. REFERENCES: 1. ASAPAS, Cosmetic Procedures Increase in 2012 <https://www.surgery.org/media/statistics> 2. Shimizu, Y. & Terase, K, ‘Thread Lift with Absorbable Monofilament Threads’, J Japan Soc Aesthetic Plast Surg, 35(2013) <http://www.mesothread.com/filebox/[JSAPS]Dr. Yuki Shimizu_LFL.pdf> 3. Zimbler MS, Kokoska MS, Thomas JR, ‘Anatomy and pathophysiology of facial aging,’ Facial Plast Surg Clin North Am, 9(2001), pp. 179–1. 4. Weinberger MS, Becker DG, Toriumi DM, ‘Sensory nerves of forehead’, published by Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds, Otolaryngology Head and Neck Surgery, 3rd ed. (1998). 5. Ahn MS, Catten M, Maas CS, ‘Temporal brow lifting using botulinum toxin’, Plast Reconstr Surg, 2000 105(3):1129-35, 6. Huang W, Rogachefsky AS, Foster JA, ‘Brow lift with botulinum toxin’, Dermatol Surg, 2000 Jan:26(1):55-60. 7. Kalra, R, ‘Use of barbed threads in facial rejuvenation’, Indian J. Plast. Surg, 41, S93–S100 (2008). 8. Della Torre, F., Della Torre, E. & Di Berardino, F, ‘Side effects from polydioxanone’, Eur. Ann. Allergy Clin. Immunol, 37, 47–8 (2005). 9. Weinberger MS, Becker DG, Toriumi DM. Rhytidectomy. In: Cummings C, Fredrickson J, Harker L, Krause C, Richardson M, Schuller D, eds, ‘Otolaryngology Head and Neck Surgery’, 3rd ed. St. Louis: Mosby; 1998:649. 10. Paul MD. Complications of barbed sutures. Aesthet Plast Surg. 2008;32:149 11. Manavpreet Kaur, Rakesh K Garg, Sanjeev Singla, ‘Analysis of facial soft tissue changes with aging and their effects on facial morphology: A forensic perspective’, Egyptian Journal of Forensic Sciences, V5, 2015, pp.46-56 <http://www.sciencedirect.com/science/article/pii/ S2090536X14000501> 12. Esin Yalcınkaya, Cemal Cingi, Hakan Soken et al., ‘Aesthetic analysis of the ideal eyebrow shape and position,’ Eur Arch Otorhinolaryngol, 2014, <https://www.researchgate.net/publication/267742996_ Aesthetic_analysis_of_the_ideal_eyebrow_shape_and_position> 13. Romm S, ‘Art, love, and facial beauty’, Clin Plast Surg, 1987, 14(4):579–583 14. Suh DH, Jang HW, Lee SJ & Lee WS, ‘Outcomes of polydioxanone knotless thread lifting for facial rejuvenation’, Dermatological Surgery, 6(2015). 15. Sardesai MG, Zakhary K, Ellis DA, ‘Thread lifts: The good, the bad and the ugly’, Arch Facial Plast Surg, 2008;10:284–5. 16. Huang W, Rogachefsky AS, Foster JA, ‘Brow lift with botulinum toxin’, Dermatol Surg, 2000 Jan:26(1):55-60. 17. Yuki Shimizu, Kanae Terase, ‘Thread lift with absorbable monofilament threads’, Journal of Japan Society of Aesthetic Plastic Surgery (JSAPS), 2013 Vol.35 No. 2. 18. Pountos I, Georgouli T, Blokhuis TJ, Pape HC, Giannoudis PV, ‘Pharmacological agents and impairment of fracture healing: what is the evidence?’, Injury, 2008; 39(4):384-94.

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The Epidermal Barrier Dr Daniel Chang explains the function of the epidermal barrier and provides an overview of how it is affected by aesthetic treatment In this paper, I will review existing aesthetic treatments in relation to their effect on the epidermal barrier. Three main aesthetic treatment types will be considered: topical, energy-based and needle-based.

The epidermal barrier The epidermis is the outer layer of our skin. It consists of keratinocytes, melanocytes, Langerhan cells and corneocytes. Langerhan cells are present in all layers of the epidermis except the stratum corneum. The stratum corneum, which is the outermost layer of the epidermis, primarily forms the epidermal barrier. It is made up of anucleated keratinocytes, known as corneocytes, and inter-corneocyte lipids. These lipids are synthesised by keratinocytes and are under strict regulation from subcellular processes, hence facilitating barrier requirements. The ratio of ceramides, cholesterol and fatty acids – of which an ideal ratio is yet to be fully established – in an equimolecular distribution, contributes to optimal barrier function.1,2 However, the epidermal barrier changes as a result of age, environmental and physiological factors. For example, low humidity reduces desquamation of corneocytes and improves barrier competence, while increased stress raises cortisol levels and disrupts the barrier.1,2 The key barrier function, on a macroscopic level, consists of the following actions: • Mechanical – acts as an antimicrobial barrier, helping to block off external agents • Permeable – prevents water loss and preserves hydration through the natural moisturising factor (NMF) – chiefly derived from the breakdown products of filaggrin,

urea and glycerol • Protective – against UV rays through the action of melanocytes and keratinocytes At a subcellular level, functions of the epidermal barrier include: • Maintaining water content – limiting transepidermal water loss (TEWL) • Sustaining lipid synthesis – a key component of the barrier • Maintaining shedding of stratum corneum cells – hence regulating barrier homeostasis The barrier maintains itself and achieves barrier homeostasis, which is attained by regulating corneocyte growth and desquamation, lipid production and cellular processes.9 So, what are the effects of the three main aesthetic treatment types on the epidermal barrier?

Topical treatments 1. Cosmeceuticals According to the Oxford Dictionary, the term cosmeceutical can be defined as ‘a cosmetic that has or is claimed to have medicinal properties’.3 The word itself is not officially recognised by the FDA4 or the Medicines and Healthcare product Regulatory Agency (MHRA).5 Cosmeceuticals serve two main functions with respect to the epidermal barrier. Firstly, to enhance delivery through the epidermal barrier to reach deeper layers to repair and maintain, and secondly, to protect the epidermal barrier and skin from external pollutants.

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Types of cosmeceuticals include the following: Moisturisers: A moisturiser aims to augment the function of epidermal lipids, hence enhancing barrier properties. For example, moisturisers containing ceramide help to repair and maintain the epidermal barrier. Glycerol and urea are humectants which work by absorbing and retaining moisture, hence reducing water loss.6 Sunscreen: These can be divided into physical and chemical agents. The delivery of sunscreen has evolved, and currently, many manufacturers now use microionised nanoparticles, hence enhancing penetration.27 Sunscreens limit the free radical damage from UV rays and serve to protect the epidermal barrier and underlying skin. Topical green tea extract or epigallocatechin gallate (EGCG), has a vital role in protecting cells from free radical damage. Green tea extract, useful as an ingredient in sunscreen, can increase the SPF of the sunscreen.7 Antioxidants: Antioxidants play a significant role in anti-inflammation and antiageing.10,28 Vitamin C is a powerful antioxidant, but is water soluble, hence has difficulty penetrating the stratum corneum, so needs to be delivered via other means. Vitamin E is a lipid antioxidant and it protects the lipid environment by removing lipid-free radicals. This reduces the damage to the epidermal barrier and underlying skin. A formula of notable benefit is vitamin C, E and ferulic acid. Ferulic acid helps stabilise the vitamin derivatives, hence improving absorption.29 The use of nanoparticles has also improved the delivery of antioxidants.39,34 Delivery enhancers It is important to highlight key vehicles in the delivery of cosmeceuticals in order to identify the optimum delivery tool. There are studies currently looking at measures to enhance delivery whilst keeping the epidermal barrier intact.28,41,42 Delivery enhancers can be divided into solvents, delivery vectors and delivery devices.26,35,36 • Solvents such as alcohol and propylene glycol increase the solubility within the stratum corneum, hence enhancing delivery. • Delivery vectors include liposomes, niosomes and nanoparticles, which enhance delivery through the epidermal barrier. Collectively known as submicron delivery systems, they enhance drug penetration through the epidermal barrier

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PRP Platelet rich plasma (PRP) is gaining more evidence in its effectiveness in skin healing. A Korean study has indicated that topically-applied PRP can help fibroblast proliferation and collagen production to boost skin elasticity and healing post-fractional laser. Results noted increased subject satisfaction and skin elasticity, as well as a decrease on the erythema index. PRP increased the length of the dermoepidermal junction, the amount of collagen, and the number of fibroblasts.18 Presently, there is no standardised way to deliver PRP into the skin. More research through robust clinical trials needs to be conducted to validate its efficacy in the arena of antiageing and regenerative medicine.

via their special chemical and physical properties and small molecular size. â&#x20AC;˘ Delivery devices such as ultrasound, patches, microneedles and iontophoresis promote the penetration of the cosmeceutical through the epidermal barrier. Chemical peels Chemical peels consist of superficial, medium and deep peels, in association to their depth of penetration. Peels work by inducing epidermolysis, through reducing corneocyte adhesion, reducing desmosomes, increasing desquamation and coagulation of epidermal proteins. All of these factors help to improve the overall penetration of the ingredients through the epidermal barrier.30 In addition, at a histological level, peels, for example alpha hydroxy acid (AHA) peels, can increase dermal thickness by 25% through speeding up keratinocyte renewal.13 Some examples of AHA peels include glycolic, lactic, oxalic and malic. Beta hydroxy acid (BHA) peels, such as salicylic acid and tropic acid, have an additional comedolytic effect due to their lipophilic quality, enhancing their action on sebaceous glands, hence controlling acne.12,13

2. Energy-based devices Lasers Laser treatment is based on the principle of selective photothermolysis. This is when the target skin chromophore absorbs photons, leading to its destruction by thermal energy. Lasers breach the epidermal barrier and reach the correct depth of penetration through varying the following factors:31 Wavelength: longer wavelengths have deeper penetration Spot size: smaller spot size increases depth of penetration Energy: larger (higher) energy has deeper penetration Lasers can be classified under two broad categories, namely ablative and non-ablative. Ablative lasers Ablative treatment is in the form of CO2 and Erbium-YAG lasers. It involves the use of electromagnetic energy to induce damage to the entire epidermis and a portion of the upper dermis â&#x20AC;&#x201C; the chromophore here is water. Their function lies in skin resurfacing. CO2 works at a 10600 nm wavelength, which targets water both intra- and extracellularly. Erbium-YAG works on a 2940 nm wavelength, targeting water both intra- and extracellularly, but because it is more selective for water, its

Long pulsed 1064 nm Nd:YAG lasers, through increasing pulse duration, protect the epidermis, while targeting chromophores, water and oxyhaemoglobin in the dermis

energy is mainly confined to the epidermis and superficial papillary dermis, hence there is less depth of penetration compared to CO2, so side effects are reduced, but peak efficacy is less rapid than the CO2 machine. A subset of ablative lasers is fractional ablative lasers, namely the fractional CO2 and fractional Erbium lasers. They work through inducing microthermal zones, with healthy skin cells inbetween, therefore promoting faster healing and recovery. The potential for improvement in skin resurfacing is dependent on the depth and extent of tissue damage.14,15,16,17 Non-ablative lasers Non-ablative resurfacing treatments target structures in the underlying dermis, while protecting the overlying epidermis. This is achieved through varying the wavelength, energy, pulse duration and spot size. Some examples include Q-switched Nd:YAG laser, intense pulsed light (IPL) and light-emitting diode (LED). Q-switched Nd:YAG and IPL can be used to treat pigmentation, pores and acne and, to a small degree, skin texture. Q-switched Nd:YAG 1064 nm lasers, through a process of selective photothermolysis, target the chromophore and melanin in the epidermis, hence reducing damage to the overlying epidermis.12 Long pulsed 1064 nm Nd:YAG lasers, through increasing pulse duration, protect the epidermis, while targeting chromophores, water and oxyhaemoglobin in the dermis. They work to stimulate collagen and reduce vascularity in deeper vessels.12 IPL via a broad-spectrum wavelength of 515 nm to 1200 nm is based on the principle of selective photothermolysis, selectively targeting melanin and haemoglobin in the superficial skin layer.11-14 3. Needle-based treatments Botulinum toxin, dermal fillers and microneedling make use of a needle to breach the epidermal barrier. Knowing that the epidermis has varying depths throughout the face, for example 0.05mm over the eyelids and 0.3-1mm for the rest of the face,25 when performing needlebased treatments, the right needle depth is vital to ensure treatment efficacy. When injecting botulinum toxin, depth of injection is important in order to target the right area. This is due to the fact that injections need to be intramuscular for the forehead and glabellar region and intradermal for the crowâ&#x20AC;&#x2122;s feet to achieve optimum results.24

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It is postulated that microneedling and the deposition of hyaluronic acid can stimulate fibroblasts to increase collagen stimulation, hence improving skin thickness and texture When using a device for microneedling, the average injection depth is 1mm, but individual variations exist. However, due to presence of needle bevel, actual injection depth is less than 1mm.23 Of note are skinboosters, a form of combination therapy, which are hyaluronic acid fillers delivered through a microneedling technique to achieve skin hydration and healing. The use of microneedles supports the intradermal injection and deposition of the treatment in the dermis. The physical nature of the needle helps breach the epidermal barrier. It is postulated that microneedling and the deposition of hyaluronic acid can stimulate fibroblasts to increase collagen stimulation, hence improving skin thickness and texture.22

Combination therapy The current trend for skin rejuvenation is moving towards the use of combination therapies, which could potentially enhance the delivery process through the epidermis and improve results. Here are some demonstrable combination therapies: Microdermabrasion with AHA chemical peel: This is used to increase treatment efficacy. AHA peels reduce corneocyte adhesion, hence improving the abrasion.19 Laser and IPL: Laser, by virtue of its longer wavelength, targets deeper layers of the skin, and coupled with IPL, which works on a more superficial layer, enables a more efficient skin rejuvenation.20 Fractional laser before Q Switched ND Yag laser: It is postulated that fractional lasers, through inducing microthermal zones, form channels for the broken-down products of melanin to be eliminated through.21 Laser-assisted delivery of cosmeceuticals: Fractional laser, through its action on ablating tissue, can bypass the epidermal barrier and enhance delivery of cosmeceuticals.32 Ultrasound energy: Ultrasound through formation of temporary cavitation, can improve delivery of cosmeceuticals.33

Conclusion The effectiveness of aesthetic treatment on the epidermal barrier lies in the penetration through the stratum corneum. Further research is needed to identify the most effective types of combination treatments, the sequence, timing, and number of sessions required for optimal results. Longer follow-up time and larger sample size clinical studies would help to answer these questions.

Aesthetics Dr Daniel Chang specialises in aesthetic medicine and is a key opinion leader and trainer for injectables and threadlifting. Dr Chang founded Asia Aesthetic Academy in 2015 and has developed a number of signature treatments, including the DC 3D-Dreamlift and the DC 3D-Noselift. He maintains a Korean medical aesthetics informative website. REFERENCES 1. S Pillai, M Cornell, C Oresajo, Epidermal Barrier Cosmetic Dermatology Zoe Diana Draelos (2009): 3-13, 62-71, 269-308, 377-417 2. R Weller, J Hunter, J Savin, M Dahl Clinical Dermatology (4th edition 2008) 1 and 2:4-34 3. Oxford Dictionaries, cosmeceutical, English, (2016) <http://www.oxforddictionaries.com/definition/ english/cosmeceutical> 4. FDA, ‘Cosmeceutical’, U.S Food and Drug Administration, (2014) <http://www.fda.gov/Cosmetics/ Labeling/Claims/ucm127064.htm> 5. Cosmetic Business, Tell-tale signs, Home, (2008) <http://www.cosmeticsbusiness.com/technical/ article_page/Tell-tale_signs/48716> 6. M cornell, S Pillai, C Oresajo, Delivery of Cosmetic skin actives. Cosmetic Dermatology Zoe Diana Draelos (2009): 8: 62-70 7. Y Appa, Facial Moisturisers Cosmetic Dermatology Zoe Diana Draelos (2009): 16:123-130 8. Morganti, Pierfrancesco, Morganti P, Sud M. Clinics in dermatology: Cosmeceuticals. Elsevier; 2008;26:317. 9. Epstein H. Clinics in dermatology: Cosmeceutical vehicles. Elsevier; 2009;27:453. 10. Zhou Y, Banga AK. Enhanced delivery of cosmeceuticals by microdermabrasion. Journal of Cosmetic Dermatology. 2011;10:179-184. 11. Device-assisted Transepidermal Delivery of Cosmeceuticals: A New Way to Enhance Aesthetic Procedures? Neil S. Sadick Aesth Plast Surg (2013) 37:973–974 12. B Fuller, Antioxidants and anti inflammatories Cosmetic Dermatology Zoe Diana Draelos (2009): 35: 281-291 13. Z Tannous, M Avram, S Tsao, M Avram Colour Atlas of Cosmetic Dermatology (2nd ed 2011) 5: 29-38 14. Grunewald S, Bodendorf MO, Simon JC, Paasch U. Journal der Deutschen Dermatologischen Gesellschaft: Update dermatologic laser therapy. Blackwell Publishing; 02/01/2011;9:146. 15. Trelles MA, Lecle`re FM, Martı´nez-Carpio PA (2013) Fractional carbon dioxide laser and acousticpressure ultrasound for transepidermal delivery of cosmeceuticals: a novel method of facial rejuvenation. Aesthetic Plast Surg. doi:10.1007/s00266-013-0176-3 16. Bloom BS, Brauer JA, Geronemus RG (2013) Ablative fractional resurfacing in topical drug delivery: an update and outlook. Dermatol Surg 39(6):839–848. doi:10.1111/dsu.12111 17. K Jongseo Effects of Injection Depth and Volume of Stabilized Hyaluronic Acid in Human Dermis on Skin Texture, Hydration, and Thickness. Arch Aesthetic Plast Surg 2014;20(2):97-103 18. Kim DH, Je YJ, Kim CD, Lee YH, Seo YJ, Lee JH, Lee Y, Can Platelet-rich Plasma Be Used for Skin Rejuvenation? Evaluation of Effects of Platelet-rich Plasma on Human Dermal Fibroblast. Ann Dermatol. 2011 Nov;23(4):424-431. <http://dx.doi.org/10.5021ad.2011.23.4.424> 19. Rendon, Marta I., et al. “Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing.” Journal of Clinical & Aesthetic Dermatology 3.7 (2010). 20. Alexiades-Armenakas, Macrene R., Jeffrey S. Dover, and Kenneth A. Arndt. “The spectrum of laser skin resurfacing: nonablative, fractional, and ablative laser resurfacing.” Journal of the American Academy of Dermatology 58.5 (2008): 719-737. 21. Clementoni, Matteo Tretti, et al. “Non sequential fractional ultrapulsed CO2 resurfacing of photoaged facial skin: Preliminary clinical report.” Journal of Cosmetic and Laser Therapy 9.4 (2007): 218-225. 22. Landau, Marina, and Steven Fagien. “Science of hyaluronic acid beyond filling: Fibroblasts and their response to the extracellular matrix.” Plastic and reconstructive surgery 136.5S (2015): 188S-195S. 23. Kim, Jongseo. “Effects of injection depth and volume of stabilized hyaluronic acid in human dermis on skin texture, hydration, and thickness.” Archives of Aesthetic Plastic Surgery 20.2 (2014): 97-103. 24. Sundaram, Hema, et al. “Global Aesthetics Consensus: Botulinum Toxin Type A—Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications.” Plastic and reconstructive surgery 137.3 (2016): 518. 25. Mercurio, D. G., et al. “Morphological, structural and biophysical properties of French and Brazilian photoaged skin.” British Journal of Dermatology 174.3 (2016): 553-561. 26. Sadick, Neil S. “Device-assisted transepidermal delivery of cosmeceuticals: a new way to enhance aesthetic procedures?.” Aesthetic plastic surgery 37.5 (2013): 973. 27. Abdel-Mottaleb, Mona MA, and Alf Lamprecht. “Polymeric Nano (and Micro) Particles as Carriers for Enhanced Skin Penetration.” Percutaneous Penetration Enhancers Chemical Methods in Penetration Enhancement. Springer Berlin Heidelberg, 2016. 187-199. 28. Farris, Patricia K., and Yevgeniy Krol. “Under Persistent Assault: Understanding the Factors that Deteriorate Human Skin and Clinical Efficacy of Topical Antioxidants in Treating Aging Skin.” Cosmetics 2.4 (2015): 355-367. 29. Campos, Valeria, Fernanda Ferrara, and Denise Steiner. “Long-term evaluation of postoperative vitamin C, E and ferulic acid serum use in Brazilian population for the treatment of photoaging.” Journal of the American Academy of Dermatology 72.5 (2015): AB18. 30. Khunger, Niti. Step by Step: Chemical Peels. JP Medical Ltd, 2014. 31. Trelles, Mario A. “Lasers and Intense Light Systems as Adjunctive Techniques in Functional and Aesthetic Surgery.” International Textbook of Aesthetic Surgery. Springer Berlin Heidelberg, 2016. 1133-1153. 32. Sklar, Lindsay R., et al. “Laser assisted drug delivery: a review of an evolving technology.” Lasers in surgery and medicine 46.4 (2014): 249-262. 33. Lepselter, Joseph, et al. “Ultrasound-Assisted Drug Delivery in Fractional Cutaneous Applications.” (2016). 34. Kovacic, Peter, and Ratnasamy Somanathan. “Biomechanisms of nanoparticles (toxicants, antioxidants and therapeutics): electron transfer and reactive oxygen species.” Journal of nanoscience and nanotechnology 10.12 (2010): 7919-7930. 35. Naik, Aarti, Yogeshvar N. Kalia, and Richard H. Guy. “Transdermal drug delivery: overcoming the skin’s barrier function.” Pharmaceutical science & technology today 3.9 (2000): 318-326. 36. Guy, Richard H. “Current status and future prospects of transdermal drug delivery.” Pharmaceutical research 13.12 (1996): 1765-1769.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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A summary of the latest clinical studies Title: Can UK undergraduate dental programmes provide training

in non-surgical facial aesthetics? Authors: Walker TWM, Gately F, Stagnell S, et al Published: British Dental Journal, June 2017 Keywords: Training, dentist, non-surgical facial aesthetics Abstract: Recently, more and more dentists have found themselves engaging in the delivery of non-surgical facial aesthetics (NSFA) as part of their regular practice routine. NSFA is a growing field in aesthetic medicine that is practiced by a range of clinicians including doctors, dentists and registered prescriber nurses and is an industry estimated to be worth over £3 billion in the UK alone. In the past few years, several public scandals in aesthetic medicine have prompted reactions by several bodies including the Government and Royal Colleges. With Health Education England (HEE) having recently released standards in education, it is clear that a shift in attitude towards training is imminent. With a large volume of dentists making up this NSFA workforce it is reasonable to consider the stance of undergraduate training and the relevance of the existing knowledge within dentistry in the context of the HEE standards. All dental schools in the UK were contacted to establish the range of subjects taught within the curriculum, with particular reference to those relevant to NSFA. The two largest aesthetic pharmacies were contacted regarding numbers of registered dentists they serve. Twelve out of 16 dental schools responded. Two-thirds of responding dental schools do not cover NSFA in their curricula. However, many dental schools cover related subjects including: facial anatomy/material science/neuromuscular junction physiology (100%), anatomy of the aging face (66%), pharmacology of botulinum toxin (25%) and ethical-legal implications of aesthetic dentistry/NSFA (50%/42% respectively). Dentists are well placed to deliver NSFA given their background in relevant subjects and surgical training. With the emergence and growth of such a large multi-disciplinary field it is crucial that dentistry is not left behind. Just as most dental schools have embraced the evolution of cosmetic dentistry and implantology, it would be prudent to consider that training standards around NSFA are reflected in both undergraduate curricula and appropriate post-graduate clinical training for dentistry.

Title: Anatomy and Aesthetics of the Labia Minora: The Ideal Vulva? Authors: Clerico C, Lari A, Mojallal A, Boucher F Published: Aesthetic Plastic Surgery, June 2017 Key words: Vaginal rejuvenation, labiaplasty, vulva Abstract: Female genital cosmetic surgery is becoming more and more

widespread both in the field of plastic and gynecological surgery. The increased demand for vulvar surgery is spurred by the belief that the vulva is abnormal in appearance. What is normal in terms of labial anatomy? Labia minora enlargement or hypertrophy remains a clinical diagnosis which is poorly defined as it could be considered a variation of the normal anatomy. Enlarged labia minora can cause functional, aesthetic and psychosocial problems. In reality, given the wide variety of vulvar morphology among people, it is a very subjective issue to define the “normal” vulva. The spread of nudity in the general media plays a major role in creating an artificial image and standards with regard to the ideal form. Physicians should be aware that the patient’s self-perception of the normal or ideal vulva is highly influenced by the arguably distorted image related to our sociopsychological environment, as presented to us by the general media and internet. As physicians, we have to educate our patients on the variation of vulvar anatomy and the potential risks of these surgeries.

Title: Body to Scalp: Evolving Trends in Body Hair Transplantation Authors: Saxena K, Savant SS Published: Indian Dermatology Online Journal, June 2017 Keywords: Hair transplantation, alopecia, follicular unit extraction Abstract: Follicular unit extraction (FUE) is becoming an increasingly

popular method for hair restoration. As FUE leaves behind no linear scars, it is more suitable to harvest from various body areas including beard, chest, and extremities in hirsute individuals. Body hair characteristics such as thickness, length, and hair cycle may not completely match to that of the scalp hair. The techniques of harvesting body hairs are more time consuming, requiring higher degree of skill than regular scalp FUE. Body hair transplantation can be successfully used either alone or in combination with scalp hair in advanced grades of baldness, for improving the cosmetic appearance of hairlines and in scarring alopecia when there is paucity of donor scalp hair. Harvesting of body hairs opens up a new viable donor source for hair restoration surgeons, especially in cases of advanced Norwood grades five and above of androgenetic alopecia.

Title: Safety and Efficacy of Peeling During Different Periods of the Menstrual Cycle on Acne Authors: Bulbul Baskan E, Tilki Günay I, Saricaoglu H Published: Journal of Cosmetic and Laser Therapy, June 2017 Keywords: Peeling, estrogen, glycolic acid Abstract: The aim of this study was to investigate the efficacy of 50%

glycolic acid peeling performed at different phases of menstruation on acne. 30 female patients were included in study and all patients’ menstrual cycles were regular. All groups were homogenous in terms of initial acne severity scores. Acne severity scores decreased in all groups after 3 months of therapy statistically significant differences were achieved only in the second group. The results of our study suggest that chemical peeling administered during ovulation provides the most significant benefit for acne lesions. Ovulation is the period when estrogen reaches its highest level. Estrogen decreases sebum production through different mechanisms. The beneficial effects of estrogen on acne and healing in combination with those of chemical peeling may cause synergistic therapeutic effects with pronounced results.

Title: Injectable and topical neurotoxins in dermatology: Indications,

adverse events, and controversies Authors: Giordano CN, Matarasso SL, Ozog DM Published: Journal of the American Academy of Dermatology, June 17 Keywords: Neurotoxins, dermatology Abstract: The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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diversify and support your business? Examples could include working with a manufacturer as a KOL spokesperson, or creating a brand partnership with a complimentary product to boost your clinic sales. Evaluate when and how to announce these, and maintain visibility. • Are you looking to establish more of a leadership position, or tackle any key competitors? Are there any competitor milestones you need to defend against, such as a new clinic launch, business anniversary or award? Are there opportunities for you to lead the way in the industry (and be seen to do so by consumers) – such as piloting or launching a new brand, product, technique or service?

Marketing Planning to Maximise Success PR and communications consultant Julia Kendrick shares her top 5 tips to keep your clinic ahead of the curve with a robust marketing approach Whether you employ a PR and marketing supplier or are juggling everything by yourself, keeping on top of clinic marketing can be a daunting prospect that can often be overwhelming. Best intentions of regular planning sessions and reviews can easily fall by the wayside under the burden of clinical work or broader business management. In this hyper-competitive industry, your clinic cannot afford to fall behind with efforts on marketing, promotion and positioning. Customers can be all too fickle if they don’t receive regular nurturing from clinic communications – drifting away to the lure of competitors with a more robust marketing strategy that entices them in through successful campaigns. In this article, I will outline key strategies to help you keep your clinic marketing plan up and running with minimal stress.

1. Consider and review your business objectives Marketing done in isolation will never truly deliver the results you want for your business. To maximise your valuable time, energy and money, activities must be tied to the broader business strategy and objectives. At the start of your marketing planning process and on a quarterly basis throughout the year, make sure you are sitting down and considering your overarching business objectives, such as: • Are you looking to grow, or maintain your current income? If so, by how much, and by when? Set realistic targets and deadlines. • Are you working towards new developments in your clinic, such as more treatments, more staff or additional premises? Consider when these will be phased into your business and plan backwards for any launch campaigns. • Are you looking to enter any strategic partnerships to

Map these business objectives out at a ‘macro’ level – sketching out when you aim to achieve them across the year. You can then layer in your planned marketing and promotional activities in line with the business objectives and key timings, ensuring you never feel ‘caught out’ with nothing scheduled in your plan. Don’t forget to consider your budget allocations – map out the main peaks and troughs to align with your targets and marketing activities. I recommend always ensuring you have some ongoing maintenance marketing budget so you do not stop activities for an extended length of time throughout the year.

2. Start big and drill down Now that you have the ‘big picture’ of what’s needed within the business across the year, you can focus on a monthly basis of what your marketing needs to be doing. Use a big visual aid, like a calendar wall planner with different coloured post-its or pens to map out the information you’ve collated on business objectives and the big ‘trends’ for your clinic over the year – including any specific campaigns or topics you plan to run in order to meet your objectives. These could include a new treatment launch, an industry congress activity or a special promotion to welcome a new staff member. Brainstorm with your suppliers or clinic team what could be happening each month in terms of:

I recommend always ensuring you have some ongoing maintenance marketing budget so you do not stop activities for an extended length of time throughout the year

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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• Environmental milestones or trends – New Year, Christmas, Valentine’s Day, spring skin, bridal season, summer skin, back to school, winter skin, weight loss • Treatment/product focus – what core products or treatments do you want to profile each month that align with the environmental milestones and your business or sales objectives? Don’t forget any new launches or your signature treatment, or any special offers for treatments you want to re-invigorate • Clinic Milestones – your clinic birthday, awards season, new premise’s launch, new staff, staff birthdays, events, charitable activities, congresses

3. Organising your content

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If you don’t have an external social media management provider, you should also map out a monthly framework for posts on each of your channels to include approximately two to three posts per day

Just imagine – how good would it feel never having to worry about what you’re going to write in your clinic blog or newsletter each month? Or what social media campaigns you need to be running? This is the ‘nitty gritty’ stage – map out in detail what the monthly marketing content looks like across your key channels: events, website, social media, blogs and newsletters. Whilst this can feel time-consuming at the start, in the long run I guarantee it will save you so much time, energy and stress. In addition, detailed planning at this stage will increase the chances of you eventually being able to delegate this work within your team or to an external supplier, if you haven’t done so already. For each month, brainstorm and plan the content topics for at least: • 1x patient newsletter – try to keep a consistent structure so it is easier to plan the content in advance and be sure to include links to your website in your newsletter. If you can send it at around the same time each month, this can help with client expectations and time management • 2-3x clinic blogs – try to come up with the titles and angles of these straightaway to keep you focused. For optimum SEO, you should aim for 500 words minimum and post to your website • 1x email campaign or social media advertising campaign – what do you want to promote that month and drive action for? Examples could include a new treatment, or for lapsed patients to come in for a free skin review, or maybe to promote an event If you don’t have an external social media management provider, you should also map out a monthly framework for posts on each of your channels to include approximately two to three posts per day with: • A generic ‘library’ of information, tips, advice, inspirational images • Promotional posts – tied to specific events or promotions that month • Treatment information and before/afters • Personal touches; for example flowers from a patient or good patient feedback

or clinic manager, consider delegating some of the responsibilities to them as part of their role – perhaps to compile the newsletter, or write one blog per month based on your plan. Having clear actions and deadlines will help ensure that the marketing becomes an integral part of everyone’s function in the clinic – not an add-on or a burden which keeps getting forgotten.

5. Keep track of success Marketing is an investment and needs to demonstrate value. Ultimately, if your blogs aren’t driving traffic, or customers aren’t opening your newsletter, or nobody is clicking on your social media posts – you need to know. Undertake regular reviews of the analytics (monthly if possible) – on your website, through your customer relationship management (CRM) system and via your social channels to identify engagement, interaction and ultimately what is being delivered in terms of revenue. If something is not working effectively, it’s best to find out early on and adjust your strategy accordingly until you get it right!

Conclusion With everything on your plate, it can be difficult to find the time for marketing – but with a bit of advanced preparation you can cut the time and effort in half. Remember, new patients won’t come through the door if they don’t know about you, and existing patients can drift away if you don’t nurture the relationship. So, if you truly want to grow your business and bring in more revenue, you have got to make marketing an integral part of your business. Julia Kendrick is an award-winning communications and PR consultant specialising in medical aesthetics. With more than 12 years’ experience, Kendrick aims to deliver a unique strategic approach to help aesthetic brands, clinics and practitioners build and grow their reputation, stand out from the crowd and secure tangible business growth. A regular industry media contributor, congress presenter and trainer, Kendrick has just launched the E.L.I.T.E. Reputation Programme.

Uploading two to three posts per day will ensure that you start to build more of a following and are seen as an active contributor. If it’s too overwhelming to try to do this for a 12-month cycle, break it up into quarters and ensure that you plan your next quarter at least a few weeks in advance.

4. Delegation Now you should have a comprehensive overview of what your clinic marketing looks like over the course of the year. If you have a team

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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train them to become familiar with your original clinic’s operation, standards and overall company culture. They can work and train in your existing or primary site to ensure they are familiar with the clinic’s day-to-day running process and priorities that need to be focused on before your new clinic opens.

7 Tips for Expanding Your Business Multiple clinic owner Lucy Xu shares her key considerations for opening additional practices When the time is right, you may consider expanding your aesthetic business and opening multiple clinics. Like opening your first clinic, expanding requires a great deal of thought and strategic planning, as well as many other aspects of expansion, which may not have been considered the first-time round. Expansion may be an option because you have patients in different locations and want to provide them with your services, or maybe the demand is so high at your current clinic that you can’t keep up and need another site. One challenge that many business owners face when embarking on this venture, including myself, is maintaining the same high quality services of care and overall consistency between the clinics. In my opinion, the key areas for success are quality of service, customer satisfaction, reputation, image and ethics. Keeping these factors in mind is vital because your customers will recommend your business to their families and friends; staying loyal to you after you made them feel special and after they have seen good treatment results. The following points need to be considered when you are opening multiple sites to ensure you maintain and retain happy patients.

company and gains the trust of patients, as well as allowing them to identify your clinic brand easily. If you have inconsistent branding, it can make it difficult for your patients to recognise your unique products and services. Maintaining brand recognition is something you can manage yourself, but the more clinics you have, the more time this takes, so to save you time and to ensure that it is done correctly, you can choose to appoint an experienced branding consultant to help achieve consistency. They can analyse all areas from online and offline marketing, content writing, promotion, logos, clinic interiors and PR aspects to achieve consistency and continuity. If your first site is not compatible with the image of a multiple-site chain, for example, if your brand is specific to one location and you have positioned yourself as a local service, this may make it difficult to expand, so it may be worth completely rebranding your business to cater for your current sites and future growth.

1. Branding Your new premises should carry the same branding as your first, including its image, colour scheme, interior design, furniture, signage, marketing material and brochures. In my experience, brand consistency demonstrates the professionalism of the

Operations manager You should next consider appointing an operations manager, who has a different role from an individual clinic manager in that their responsibility is to monitor the overall business, ensuring smooth running of the sites; overseeing each clinic’s productivity and line managing the clinic managers. They will also ensure all sites are running under the same treatment, health and safety, and training protocols and are achieving targets to maximise profits. Sales and marketing manager It is also a good idea to employ a sales and marketing manager who will work on marketing campaigns, increase new revenue, generate new leads, report on performance results through various marketing channels, organise company’s promotional events and undertake PR activities.

2. Management structure

All managers and their departments should cooperate and communicate well to ensure the smooth running of the operations with improved results within each clinic and across the business. Arranging a weekly meeting is very important. The clinic managers should be providing feedback from each site, which helps the operations manager to identify gaps and improve the success of the business, and will allow the marketing manager to modify the marketing efforts to maximise sales. If you don’t have one already, you should look to develop your own company operations manual, setting out your company’s culture, customer care, goals, standards and ethics, so all your staff understand what is expected of them and maintain a high standard of consistency throughout all sites.

As you expand, your management structure should expand and evolve too.

3. Clinic staff and training

Clinic manager For multi-clinic operations, you should make sure each site has an individual clinic manager who will oversee the operations of that particular site. Prior to opening a new site, you can appoint your clinic manager for the new forthcoming site and

The new clinic staff you employ should have the qualities that replicate those who are working in your original business. Your new recruits should be trained to the same standard as your existing staff. Training by the equipment manufacturers, product suppliers, as well as general in-house training is a good idea to ensure they know

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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how to offer good quality treatments and have excellent product knowledge. Training is a long-term commitment; your staff must continuously receive updated protocol training on existing treatments, as well as for new technology and devices you add. It is during the training process that the recruit should learn your company culture, targets, and how to cooperate with other team members. Prior to treating patients, it is essential for newcomers to shadow their colleagues or senior practitioners who have been performing treatments in the clinic for a while, so they can become familiar with your treatment processes to maintain a consistent customer journey. It is also helpful to make sure that your staff are all trained in the same way so that they can work in different clinics sites if necessary.

4. Targets and incentives When you have multiple sites, it is good practice to create healthy competition between the clinics. You can do this by setting monthly revenue targets, such as retail and service targets, and rewarding those who reach the target. A well-thoughtout and varied incentive programme can optimise your staff and performance. Ensure you have clear, transparent salary tiers and goals for your staffs to work towards. Targets should be allocated fairly, taking several things into account; for example, size and location of premises, and the number of employees.

5. Technology In the aesthetics specialty, new technology emerges very fast. Where possible, make sure all your clinics are equipped with the latest technology and related training to offer the best service to your patients. A good management software and IT system is essential for good internal communication, information flow, and a more effective operation with better efficiency. Management software also gives accurate reports, allowing you to clearly see new business leads, revenue driven by marketing activities and expenditure. You should aim to keep your technology the same between clinics if possible, so that all patients know what to expect at each clinic.

6. Processes It is important to replicate the processes that you know work well in your first clinic to your others. It doesn’t matter which site a patient goes to, they should receive the same welcome, and same level of service and

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In my experience, brand consistency demonstrates the professionalism of the company and gains the trust of patients, as well as allowing them to identify your clinic brand easily

experience, just like we would expect the same standard of coffee from every coffee shop in a chain. For example, all practitioners in your clinic should follow the same consultation process. It is very useful to have a consultation guide printed as a small, concise booklet so that everyone can use it for each new patient’s consultation. Of course, this may vary because every patient is different and each practitioner may have their own style of consulting, however basic principles, such as exploring various treatment options and taking a thorough patient history, should be a standard part of every consultation. One of our most valuable clinic processes is taking before and after treatment photographs of every patient. As we know, this is very important in aesthetics because they provide evidence of your treatment success and document any side effects/complications that may occur. To the best of your abilities, you should use the same photography equipment in your clinics, as well as the same type of lighting, backdrops, angles and the same consent procedures for marketing. Ensure your staff are not skipping this vital step as it is a very convincing and powerful tool to increase consultation conversion and to monitor a patient’s results.

7. Appointment booking Patients should also expect the same process for booking appointments for each clinic. When you have several clinics, consistency of high customer service from clinic to clinic can be a challenge. If one clinic is busy and the call is transferred or directed to another clinic, the service on the phone must be to that same high standard,

otherwise new enquiries may not be dealt with in the most appropriate way. For a successful and smooth customer experience over the phone, a central call centre, manned by professionally trained staff (with in-depth knowledge of treatments as well as telephone sales skills), can be extremely effective to increase conversion. You can choose to employ a company to do this, or you can do this in-house. If you do this inhouse, your call centre could benefit from a booking and management software system, so all new enquires can be effectively booked into each clinic’s daily systems according to the location of patients.

Conclusion I have found that the above seven considerations have been extremely important in my journey as a multiple-clinic owner. The core of running an aesthetic business is to deliver exceptional customer service and treatment results; laying a solid foundation to work from before you consider expansion. When opening additional sites, ensure you really consider the above points to maintain a consistent customer journey. All the best to my industry colleagues who wish to expand their business in the near future! Lucy Xu is an aesthetic treatment and cosmeceutical skincare specialist, as well as the founder and CEO of Premier Laser & Skin Clinics and Derma Revive Skincare. Xu founded her first clinic in 2008 and has since grown the company to eight sites with further expansion planned this year.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Training in Waste Management and Infection Control Clinic waste technical manager Luke Rutterford discusses the importance of waste management and infection control training In all areas within the aesthetic clinic, and indeed throughout the healthcare profession, staff training is essential to ensure the whole team knows and understands their responsibilities. This involves everything from the clinical treatment delivered to patients, to record keeping, complaint handling and infection control procedures. Staff require ongoing training in each area to ensure they have the knowledge and skills to maintain the highest standards of care. Infection control, in particular, remains an important aspect of staff training. As pathogens develop, new research is published and new products are being created to deliver protection, so it is crucial that those with a means to manage the risk in the clinic are kept up-to-date. An essential part of infection control – in addition to frequent surface disinfection and effective hand hygiene – is waste management. Both surgical and non-surgical cosmetic procedures produce a wide range of waste items that must be discarded in a safe way. Further to this, efficient waste segregation is key to protecting the environment and ensuring the disposal of different waste streams in the most appropriate way.

Why training is important It goes without saying that staff need the know-how to maintain a safe environment for patients, hence the need for training on the topic. It is also a regulatory requirement for all healthcare providers that they undergo appropriate training in the areas of infection control and the management of clinical waste. The Health and Social Care Act 2008; Code of Practice on the prevention and control of infections and related guidance states that ‘all relevant staff, whose normal

duties are directly to indirectly concerned with providing care, receive suitable and sufficient information on, and training and supervision in, the measures required to prevent risks of infection’.1 It goes on to highlight the importance of safe handling and disposal of waste, stating a need for all providers to: • Assess risk • Develop appropriate policies • Put arrangements in place to manage risks • Monitor, audit and review the way in which arrangements work • Be aware of statutory requirements, legislative change and managing compliance To do so, precautions in regards to handling must include training and information for the professional team. The Health and Social Care Act 20081 mandates induction training for new members of staff and ongoing education for existing staff, which is widely recommended to be an annual refresher. An up-to-date record of all staff training must also be kept. Other legislation governing waste management includes: The Environmental Protection Act 1990 (including Duty of Care Regulations),2 The Controlled Waste (England and Wales) Regulations 2012,3 The Hazardous Waste Directive 20114 and The Carriage of Dangerous Goods Regulations.5 These all cover slightly different areas of the waste management and disposal process, but The Environment Protection Act 1990 is probably the most important, stating that all producers of waste have a duty of care to ensure the correct management of waste is performed. All members of staff therefore need to be aware of these regulations and the

requirements they set for infection control processes and waste management.

What should training include? So, what should training cover? The content of training will vary slightly between education providers and clinics, and will often be tailored according to the professional workflows and procedures performed within the clinic. In general, key topics for waste management should include information and demonstrations on waste segregation, best practice guidelines for colour coding waste streams and details on the use of the correct waste containers and bags. Segregation and the colour code All waste produced should be separated according to the risk it poses to patients, professionals, public health and the environment. The Department of Health’s guidelines6 for best practice waste segregation outline a colour coding system by which to separate different waste streams. Consisting of ‘clinical and infectious waste’, ‘medicinal waste’, ‘dental waste’, ‘clinical and highly infectious waste’, ‘anatomical waste’, ‘cytotoxic and cytostatic waste’, ‘offensive waste’ and ‘mixed municipal waste’, the guidelines allocate specific colours to make segregation easier and quicker. Waste must be further separated according to its state; liquids and solids must be placed in different waste containers, waste sharps in rigid sharps containers and only soft clinical waste in orange or yellow bags. Training should be provided to all members of staff who might come into contact with clinical waste and be responsible for disposing, handling or moving it. They need to know what waste items are allocated to

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Staff training isn’t something to worry about later – it is essential that all members of the team know exactly what is required of them which colour and what type of container each waste stream requires. They should also be aware of the requirements for the storage of waste when bags or containers are full, the collection details and information that must be provided along with the waste when it is picked up by the waste contractor. They may also be interested to learn more about how different waste streams are repurposed or disposed of. Finally, training should be given on how to deal with any accidents with or spillages of waste, to ensure the safety of staff and patients alike.

as they are performing a task. This tends to be a sign of an auditory learner, as they repeat information of each step of a process out loud to remind themselves of what comes next. When learning something new, they are likely to prefer listening to audio books or discussing a subject with a colleague to really understand it. To integrate this style of learning into staff training, it’s worth ensuring that short summaries are provided at the end of each section, and creating an environment where staff can ask and be asked questions is also beneficial to the audio learner.

How should training be done? With a considerable scope of topics and routines to be mastered by all professionals in the aesthetic clinic, it’s necessary to consider the best ways staff members can learn all of this. It is widely acknowledged that different people absorb and retain information in different ways, with the key methods being visual, audio and kinaesthetic, although many people will prefer a combination of two or more of these learning styles.7 Visual This style of learning involves seeing things in situ and using colour and illustrations to explain important processes. There are two sub-channels – linguistic and spatial.8,9 Visual-linguistic learners tend to prefer studying written language, making notes for retention of information and often remembering details by reading through a list of instructions, for example. Visual-spatial learners usually do better with diagrams, charts, photos, or even demonstrations and videos, where they can watch a process to learn what it involves. Meeting the visual learner’s needs, providing written materials with diagrams and imagery during training, and displaying flow charts around the practice afterwards can be helpful. Audio Many of us have the experience of working with someone that likes to talk to themselves

Kinaesthetic This group of learners can also be separated into two further categories – kinaesthetic (movement) and tactile (touch). These people will normally concentrate better in the presence of external stimulation or movement, as well as getting involved in demonstrations and learning a process from the experience of taking part. They might also benefit from training delivered off-site, or by participating in quizzes and physical exercises to retain the most information. Applying this to the learning environment for aesthetic practitioners might involve the use of music, active engagement of the audience and role play activities that get learners up and moving. A perfect blend It may be useful to ask staff what their preferred methods of learning are, so you can tailor training to their needs. With several preferred learning methods likely among your team, and many often preferring a combination of styles, a blended approach will usually be the most effective and will therefore encourage the best return on investment. If considering external training, finding a flexible provider that will deliver the course content at a time and in a way that suits all your staff is a must. There might even be cost-efficient packages available that include annual refresher training for staff. In addition, some waste contractors

offer added value by providing customers with access to online learning portals that cover a huge range of topics, including waste management and infection control, which the team can access whenever and from wherever they wish and, critically, as often as is required.

Conclusion Staff training isn’t something to worry about later – it is essential that all members of the team know exactly what is required of them in terms of waste management and infection control from the moment they start work in an aesthetic clinic. Induction training, appropriate supervision and regular refreshers are key to ensuring all members of staff stay up-to-date in the field, ensuring your waste management is as effective and as efficient as possible and that your staff, patients and the environment are protected from harm. Disclosure: Luke Rutterford is the clinic waste technical manager at Initial Medical, which provides waste and infection control services Luke Rutterford is technical manager for the Initial Medical and Specialist Hygiene divisions of Rentokil Initial in the UK, with responsibility for training, service development, innovation, quality and compliance. Rutterford also worked within the documentary industry for the National Geographic show ‘Pests from Hell’ and holds a BSc (Hons) in Forensic Science from Anglia Ruskin University, Cambridge. REFERENCES 1. Department of Health. The Health and Social Care Act 2008. Code of Practice on the prevention and control of infections and related guidance. Guidance Paper. Pub July 2015. <https://www. gov.uk/government/uploads/system/uploads/attachment_data/ file/449049/Code_of_practice_280715_acc.pdf> 2. Legislation.gov.uk, The Environmental Protection Act 1990. <http://www.legislation.gov.uk/ukpga/1990/43/contents> 3. Legislation.gov.uk. The Controlled Waste (England and Wales) Regulations 2012, <http://www.legislation.gov.uk/uksi/2012/811/ schedules/made> 4. Gov.uk. The Hazardous Waste (England and Wales) Regulations 2011, <https://www.gov.uk/government/publications/2010to-2015-government-policy-waste-and-recycling/2010-to2015-government-policy-waste-and-recycling#appendix-6hazardous-waste> 5. Health and Safety Executive. The Carriage of Dangerous Goods Regulations. <http://www.hse.gov.uk/cdg/> 6. Department of Health. Environment and sustainability. Health Technical Memorandum 07-01: Safe management of healthcare waste. <https://www.gov.uk/government/uploads/ system/>uploads/attachment_data/file/167976/HTM_0701_Final.pdf> 7. Visual, auditory and kinesthetic learning styles (VAK). <http:// www.nwlink.com/~donclark/hrd/styles/vakt.html> 8. Edutopia. Multiple intelligences: What does the research say? (2013) <https://www.edutopia.org/multiple-intelligencesresearch> 9. learning-styles-online.com. The visual (spatial) learning style, <https://www.learning-styles-online.com/style/visual-spatial/>

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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“The only way to make progress in this field is by sharing knowledge” Dr Daniel Sister reflects on his career in medical aesthetics and explains how he developed an interest for trying new antiageing treatments Dr Daniel Sister tried retiring from his career as an antiageing and hormone specialist once, but he soon discovered that he was not as good at retirement as he was at working. “I was in my 50s and travelling quite a lot and one day I thought, ‘That’s it! I’m retiring!’ But then I got bored of doing nothing because my friends were still working. So, I began working again, but this time I focused more on aesthetics – that was about 20 years ago,” he explains. Born in Paris, Dr Sister received his medical doctorate from the Paris Medical School in 1973. “I studied in A&E and general medicine, and specialised in hormone treatments because I always found this field fascinating. My work in the aesthetic specialty began because I was typically helping people who were a bit older and starting to complain about the way they looked, which sparked my interest in the world of aesthetics,” he says.  Dr Sister opened his first clinic on Harley Street around 15 years ago. He says that he finds the specialty ‘totally fascinating’ because he believes that it is a segment of medicine that has seen rapid progression, “When I started I wanted to concentrate on new treatments, but they had to be innovative, safe and efficient. I was among the first in the UK to use products such as Radiesse and the VI Peel and offer treatments such as carboxytherapy. So, in 10 years of practising aesthetics, I have introduced 10 new treatments to the UK.”  It was his fascination with new treatments that encouraged Dr Sister to consider using platelet rich plasma (PRP) for rejuvenation 10 years ago; a treatment that he is very well-known for today due to his developments and adaptations to his treatment protocol. He says, “One day I stumbled across PRP and I thought it was interesting in principle because no one can be allergic to their own blood, so it ticked the ‘safe’ box. No one was really doing it, so it ticked the ‘innovative’ box. Then came the efficient part. I learnt that it was discovered in 1953 and received a Nobel Prize, so it wasn’t new, but they don’t give out a Nobel Prize for nothing!” When Dr Sister started using PRP and saw good results, he was frustrated that only the platelet rich plasma was used and not the platelet poor plasma (PPP). He says, “There were some studies showing that PPP stimulates the fibroblasts so I moved from PRP to using all the plasma. I also started to inject differently; at the time it was injected through mesotherapy, but ageing is not just to do with the skin, so I started injecting more deeply to rejuvenate the muscles and bones in the face too. PRP (and PPP) has ticked the ‘innovative, safe and efficient’ boxes for me and now I have performed more than 1,500 treatments.” Dr Sister says the title ‘Dracula Therapy’, the name and protocol of which is trademarked, came about by accident and was never the intended name. He says, “One day a journalist heard my colleague and I joking about how the PRP procedure made you look like Dracula

had bitten you, and they wrote the first article in the press, calling it Dracula Therapy. The article happened to have come out at the same time as a Twilight movie – so we got 900,000 hits on Google in two weeks! The name was not something that was planned and it was not something we wanted, but it just happened so we had to roll with it and it worked!” His extensive experience in all kinds of aesthetic treatments has led Dr Sister to have a large role in training. He says, “It is so important to share your knowledge and the only way to make progress in this field is by sharing. Training is very interesting, I love it, not because I want to boost my ego and say ‘I am a trainer’ but because we have a lot of treatments now and nobody is perfect in anything. If you master one technique better than others, I think it’s our duty to pass it on.” Throughout his career, Dr Sister has had the pleasure of watching the aesthetic specialty grow and develop, however, in addition to the lack of regulation in the specialty, he does have another pet hate. “I really dislike it when practitioners don’t stay within their limits. For example, I don’t use laser much because I am not confident in using it correctly. You have to know your limits and what I don’t like is when people think they are better than their limit,” he says. Upon reflection, Dr Sister says that he never knew his career would turn out this way. He says, “For me, it’s just the way it has happened, so what people need to know is that things happen in life, circumstances change and you either grab opportunities or you don’t.” What treatment do you enjoy giving the most? I like combining PRP with a lower-face thread lift as I think it gets really nice results. What’s your best advice? For many fields of medicine, you don’t really need to be hands on, but in aesthetic medicine you do, so go to different training sessions and find someone to shadow and learn this. What’s your favourite part of your day? Between 6:30 and 7:30 in the morning when I get to walk my dog. Why? Because it’s quiet and I can think about new projects I’m working on and how I can accomplish these. Do you have any regrets? With insight there are always things you would have done differently, but it doesn’t mean that if you did them differently it would have worked out either! So, do I regret anything? No, I don’t.

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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Patient perspective on aesthetics Previous NHS patients who had been waiting months for referrals and appointments only to be told to do their Kegel exercises and take some extra vitamins, couldn’t believe the support they had when turning to the aesthetics sector. An array of treatments await them; CO2 lasers and radiofrequency devices are providing amazing results for female patients I have spoken to. But most of all, they are delighted that they can walk away from a consultation at an aesthetic clinic with a mobile number for a fully-trained practitioner, should they have any worries or questions after the appointment.

The Last Word Aesthetic journalist Gina Clarke provides patients’ perspective of vaginal rejuvenation treatments in the specialty, and how these procedures are positively affecting lives The practicalities of nursing, medical care and journalism may differ, but there is one thing they have in common – we all get to hear people’s stories. As a journalist, I have been moved by some of the women I have spoken to on behalf of The Women’s Health Clinic, a new group of clinics that offers what the mainstream media considers a pretty newsworthy treatment: vaginal rejuvenation. But it wasn’t the need for a ‘designer vagina’ that the ladies I spoke to requested, despite the public persona of the treatment. Instead, each one had their own story about stalled sex lives, embarrassment with partners and friends, and a need to regain their old self, be it prebaby or pre-menopause. One lady, an ex-nurse, revealed to me that after 12 months of no intimacy with her partner, and after a spiral into anxiety and depression, she finally plucked up the courage to see her GP who simply said, “Well, you did agree to ‘in sickness and in health’.” He was stumped as to why changes after the menopause could leave her so dry from vaginal atrophy that a sex life was simply inconceivable. Although many GPs will not have the same viewpoint and lack of understanding as this particular one, it is a stark reminder of the misunderstanding around the issue. As a journalist, I have spoken to more than 40 women who have not wanted, but needed treatment. Whether psychologically, to ‘get over’ their own body hang-ups and once again feel fulfilled in a relationship, or physically, to stop an endless cycle of UTIs. In this article, I will relay the positive effects the aesthetics specialty has had on these patients. Functional issues So much of the essence of a woman is being able to feel like one. It is very difficult for patients to tell their GP that their desire is failing, that they are embarrassed by their own bodily functions, or even that childbirth has taken its toll and they no longer look or feel the same ‘down there’. Incontinence is a huge problem for women in the UK with more than nine million women reporting some form of bladder weakness problem, according to the Bladder and Bowel Foundation.1 A study from Balance Activ of 1,000 women found that a third of them would avoid speaking to their doctor when it came to women’s healthcare, but 92% would go straight to looking it up online.2

The impact of the aesthetics specialty Without the option of aesthetic treatment, patients could end up having needless operations that initiatives such as the ‘Sling the Mesh’ campaign have highlighted.3 Started by fellow journalist Kath Sanson, placement of the surgical mesh after childbirth, prolapse and other symptoms such as incontinence, has been used incorrectly and without sufficient trials in the UK for years now. The mesh is a loosely woven sheet, usually made from synthetic polypropylene, intended to provide support for weakened tissue. It is thought around 10,000 women in the UK have had the implant in the last 10 years, but programmes such as the BBC Victoria Derbyshire show have uncovered numerous complications.4 The mesh can shrink, twist, degrade and cut/erode into nearby tissues and organs causing chronic pain.1 The FDA released figures that indicated that trocar hooks, used to implant the mesh, caused injuries for up to 39% of women having a prolapse mesh and 29% of women having a mesh inserted for incontinence.5 Many mesh patients I have spoken to have since sought out vaginal rejuvenation to help relieve pain, end dryness and encourage the production of new cells so they can once again insert tampons and have sexual intercourse. These patients have spoken of their relief when finding these aesthetic treatments. Summary From my experience speaking to female patients, they are not getting the service they need on the NHS, but the aesthetics specialty appears to have provided an ideal place for them to seek help. Awareness is key when it comes to the female body, knowing what is and isn’t normal is a huge part of the service I have seen at The Women’s Clinic, and when patients talk to me, it is their number one selling point; a dedicated practitioner who will listen, reassure and advise – something that is not available on an overstretched NHS, but could become a huge part of the ever-growing aesthetics specialty. Gina Clarke is a journalist specialising in women’s health for national newspapers and magazines. She started her career in broadcast journalism for the BBC and BFBS before making the move to online. Clarke has a BA (Hons) and MA in Journalism. She went freelance in 2016 after launching Gina Clarke Media. REFERENCES 1. HEE, New qualifications unveiled to improve the safety of non-surgical cosmetic procedures, 2016, <https://hee.nhs.uk/news-events/news/new-qualifications-unveiled-improve-safety-non-surgical-cosmetic-procedures> 2. HEE, Part One: Qualification requirements for delivery of cosmetic procedures: Non-surgical interventions and hair restoration surgery, 2015. <https://www.hee.nhs.uk/sites/default/files/ documents/HEE%20Cosmetic%20publication%20part%20one%20update%20v1%20final%20 version.pdf> 3. Hopper AN, Jamison MH, Lewis WG ,’Learning curves in surgical practice’, Postgraduate Medical Journal. 2007;83(986):777-779. 4. Qualifications & Credit Framework, ‘The Qualifications and Credit Framework (QCF) and higher education: Working together to benefit learners’, 2010, <http://www.ukipg.org.uk/meetings/ further_and_higher_education_working_party/QCF_HE_brochure_web.pdf> 5. General Medical Council ‘Guidance for doctors who offer cosmetic interventions’ 2016, <http://www.gmc-uk.org/static/documents/content/Guidance_for_doctors_ who_offer_cosmetic_interventions_080416.pdf>

Reproduced from Aesthetics | Volume 4/Issue 9 - August 2017


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blowmedia Creative and Digital Design agency Contact name: Tracey Prior tracey@blowmedia.co.uk 01628 509630 www.blowmedia.co.uk

Breit Aesthetics Jazz Dhariwal info@breitaesthetics.com www.dermafill.eu 020 7193 2128

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

Hyalual UK 1 Harley Street Tel. 02036511227 e-mail : info@hyalual.com web: www.hyalual.co.uk

DermaLUX Contact: Louise Taylor +44 0845 689 1789 louise@dermaluxled.com www.dermaluxled.com Service: Manufacturer of LED Phototherapy Systems

b

Beamwave Technologies 0208 191 7117 hello@beamwave.co.uk www.beamwave.co.uk

Natura Studios 0333 358 3904 info@naturastudios.co.uk www.naturastudios.co.uk

Syneron Candela UK Contact: Head Office 0845 5210698 info@syneron-candela.co.uk www.syneron-candela.co.uk Services: Syneron Candela are global brand leaders in the development of innovative devices, used by medical and aesthetic professionals.

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

t

TEOXANE UK 01793 784459 info@teoxane.co.uk www.teoxane.co.uk

MedivaPharma 01908 617328 info@medivapharma.co.uk www.medivapharma.co.uk Service: Facial Aesthetic Supplies

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

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

v WELLNESS TRADING LTD – Mesoestetic UK Contact: Adam Birtwistle +44 01625 529 540 contact@mesoestetic.co.uk www.mesoestetic.co.uk Services: Cosmeceutical Skincare Treatment Solutions, Cosmelan, Antiagaing, Depigmentation, Anti Acne, Dermamelan

Aesthetics | August 2017

Vida Aesthetics Contact: Eddy Emilio +44 (0)1306 646256 vida-aesthetics.com info@vida-aesthetics.com Exclusive distributor of Tannic {CF] Serum, Uniq-White and Plenhyage


GOOD SKIN

GLOWS

C onfidence shines

ONE TREATMENT AND UP TO 6 MONTHS OF FEELING GREAT1,2,*,†,‡

With Juvéderm® VOLITE you can improve your patients’ skin quality attributes — increasing smoothness,§ hydration and elasticity — for up to 6 months with just one treatment.2,†,‡,||

Utilising patented VYCROSS® technology,3 Juvéderm® VOLITE is injected intradermally and can be used for areas such as the face, neck, décolletage and hands.4 When your patients glow on the outside, they feel great inside.2,5

References: 1. Allergan Data on File INT/0655/2016. Juvéderm® VOLITE Clinical Study (V12-001), 6 months top line, patient satisfaction results. Sep, 2016. 2. Allergan Data on File INT/0653/2016. Juvéderm® VOLITE Clinical Study (V12-001), 6 months top line, summary. Sep, 2016. 3. Lebreton P, 2004. Réticulation de polysaccharides de faible et forte masse moléculaire; préparation d’hydrogels monophasiques injectables; polysaccharides et hydrogels obtenus. Publication number: WO 2004/092222 A2. 4. Juvéderm® VOLITE DFU. 73140JR10, Revision 2016-02-19. 5. Allergan Data on File INT/0448/2016(1). Allergan Skin Quality Market Research Insights. Jul, 2016. 6. Allergan Data on File INT/0773/2016. Juvéderm® VOLITE Names. Oct, 2016. 7. Goodman GJ et al. Plast Reconstr Surg. 2015;136:139S–48S. Footnotes: * Based on FACE-Q satisfaction with skin mean score improvements at Month 1= 64.6%, Month 4= 60.3%, and Month 6 = 57.7% (p<0.001). Baseline satisfaction was 43.5%.1 † After a single treatment, which included initial (n=131) and top-up administered at Day 30 (n= 31).2 ‡ Study conducted using Juvéderm® VOLITE B without lidocaine.6 Added lidocaine enhances patient comfort during injections and has no substantive effect on the rheological properties of HA products.7 § Smoothness is defined as the absence of fine lines. ‖ Cheek skin hydration (secondary endpoint) improved significantly from baseline at Months 1, 4 and 6. Skin smoothness (primary endpoint) improved in patients at Month 1 (96.2%), Month 4 (76.3%) and Month 6 (34.9%). Five of the 10 cheek skin elasticity parameters (secondary endpoint) improved significantly from baseline at Month 1 and 4 but not Month 6.2 Please refer to the Juvéderm® VOLITE Directions For Use for further information.4

December 2016 UK/0869/2016

Aesthetics August 2017  
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