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VOLUME 5/ISSUE 9 - AUGUST 2018

Using HA Fillers CPD: Part Two

Dr Souphiyeh Samizadeh explores the different technologies of dermal fillers

Special Feature: Mid-facial Thread Lifting Practitioners explain their best tips for a successful mid-face lift

Jawline Sculpting Using Filler

Dr David Ong presents his technique for shaping the jawline

The Unhappy Patient

Dr Qian Xu details how new practitioners can avoid unhappy patients

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Contents • August 2018 06 News The latest product and industry news 16 On the Scene Out and about in the specialty 17 Conference Report Aesthetics details the Galderma Aesthetics Academy Annual Conference 18 News Special: JCCP to Update HEE Framework A report on the proposed change to the HEE framework for injectables

Special Feature Mid-facial Thread Lifting Page 22

CLINICAL PRACTICE 22 Special Feature: Mid-facial Thread Lifting Practitioners discuss their suture preferences for a mid-face lift 29 CPD: Using HA Fillers in Practice Dr Souphiyeh Samizadeh explores the different technologies of dermal fillers 33 Case Study: Facial Thread Lift Dr Victoria Manning and Dr Charlotte Woodward discuss the treatment of

a patient using a new thread protocol

36 Hand Rejuvenation Using Laser Skin laser specialist Dr David Goldberg introduces procedures for ageing

skin on the hands

41 Case Study: Knee Sculpting Mrs Aggie Zatonska demonstrates knee sculpting using fat-dissolving injections 44 Advertorial: Using Cellfina Practitioners share their experiences of treating patients’ cellulite 47 Nose Reshaping with Threads Dr Simon Berrisford details the use of PDO threads in nose reshaping 51 Jawline Sculpting with Filler Dr David Ong presents his preferred technique for shaping the jawline

using fillers

IN PRACTICE 56 Finance Options to Expand your Clinic Sales manager Sally-Anne Whybrow examines how finance options can keep aesthetic clinics on track for expansion

58 The Unhappy Patient Dr Qian Xu explains how new practitioners can avoid unhappy patients 63 Digital Marketing for Devices Digital marketing consultant Adam Hampson presents ways for clinics to

market new machines

67 In Profile: Dr Raul Cetto

Dr Raul Cetto reflects on his pathway into aesthetics, peer feedback and love for training

68 The Last Word: Uniforms in Aesthetics

Dr MJ Rowland-Warmann discusses why aesthetic practitioners need to take uniform policies seriously

NEXT MONTH • IN FOCUS: Combination Treatments • Treating Nasolabial Folds • Implementing a Maternity Policy in Clinic

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Clinical Contributors Dr Souphiyeh Samizadeh is the founder of the Great British Academy of Aesthetic Medicine and the clinical director of Revivify London. She is an honorary clinical teacher at King’s College London and Queen Mary University of London.

Dr Victoria Manning is a global threads trainer and key opinion leader. Working alongside Dr Charlotte Woodward, they run the River Aesthetics Training Academy, delivering clinical training to other clinicians, particularly in thread lifting techniques.

Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is 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 David Goldberg is recognised nationally and internationally for his work with skin lasers, cosmetic dermatology and facial rejuvenation techniques. Since 1985, he has treated patients and taught doctors throughout the world in the use of these technologies.

55 Abstracts A round-up and summary of useful clinical papers

In Practice Finance Options to Expand your Clinic Page 56

Mrs Aggie Zatonska has more than ten years’ experience in facial aesthetics. She is a specialist ENT surgeon, holds a post-graduate degree in Aesthetic and Anti-Ageing Medicine and is the founder of Atelier Clinic.

Dr Simon Berrisford has 25 years’ experience in the medical profession and is a member of the British College of Aesthetic Medicine. He is the medical director of Select Aesthetics in Cheshire and the co-founder of The Harley Street Skin Clinic.

Dr David Ong is the medical director and masterclass trainer at the Facial Aesthetics Centre for Excellence Academy in Brisbane. He graduated from the University of Western Australia in 2009 and proceeded to specialise in cosmetic injectables.

Book your tickets now for the Aesthetics Awards 2018 www.aestheticsawards.com

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

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As I write this, the journal team members are sitting in the office with fans blasting trying to keep cool – I wonder if we will still have a heatwave when you read this issue! This is the month when most clinics and companies close for Amanda Cameron the summer to enjoy their holidays... yet when they Editor are all slowing down, our team is gearing up for the Aesthetics Awards at Christmas!

There’s just one month until finalists are revealed so voting and judging can begin; a stringent process is followed to ensure that multiple voting is closely monitored and judges are carefully selected to avoid conflicts of interest for the categories they are assigned. This means the Aesthetics Awards can be held in the highest regard, and all finalists can be proud to be associated with such a prestigious ceremony! If you haven’t already secured your tickets, visit our website to do so today.

Threads are a relatively new treatment in the non-surgical medical arena but how much do you know about them for treating the mid-face? There

Knocked out logo

are different types with different techniques required for placement, which we have aimed to cover in our overview on p.22. We also have an article on treating the nose with threads and a case study of successful treatment with PLLA threads on p.33.

Did you benefit from part one of our CPD on hyaluronic acid fillers last month? Well part two is here so go to p.29 to follow up your learning.

Remember you can answer the multiple-choice questions and add your CPD points to your training record by visiting aestheticsjournal.com/ training/my-record. What do you wear when you’re injecting and what do you think is the most appropriate attire? Take a look at the Last Word on p.68 for Dr MJ Rowland-Warmann’s views – it’s a great read and raises some very important and topical issues. She not only discusses uniform in clinic but at conferences as well when, arguably, it is even more important to be professional and hygienic!

If you’re interested in sharing your views in an upcoming Last Word or just sharing your knowledge in general, please do get in touch via editorial@aestheticsjournal.com

Editorial advisory board

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

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

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

Bennett has been developing her practice in aesthetics for 25 years.

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

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

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

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

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

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

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

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Events diary 21st September 2018 International Association for Prevention of Complications in Aesthetic Medicine Symposium, London www.iapcam.co.uk

22nd September 2018 British College of Aesthetic Medicine Annual Conference 2018, London www.bcam.ac.uk

4th – 5th October 2018 British Association of Aesthetic Plastic Surgeons Annual International Conference, London www.baaps.org.uk

8th – 9th November 2018 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

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

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Partnership

Church Pharmacy confirmed as Radara distributor Innoture, the manufacturer of microchanneling skincare treatment line Radara, has confirmed that Church Pharmacy is now distributing the products.

Ken Jones, CEO of Innoture explained that the partnership will be fundamental for the brand’s future. He said, “In two years, we’ve seen Radara go from a technological concept to an award-winning skincare brand, which has held its own in a highly competitive market and garnered support from top aesthetic practitioners and national clinics.”

Jones added, “This partnership means we can provide an expanded distribution for Radara across the UK and Ireland, to meet the increased demand we are seeing from clinics looking for a proven, innovative addition to their practice.”

Zain Bhojani, director of Church Pharmacy, also commented, “We are excited to be working with Innoture on this partnership. We pride ourselves on providing the highest quality products within our portfolio, alongside industry-leading customer service, so the addition of the Radara microchannelling skincare range to our offering is a great fit.” Radara products can be purchased through Innoture or Church Pharmacy.

Awards

Learning

Cosmetic Courses establishes new training Aesthetic training provider Cosmetic Courses has launched a new CPD-accredited injectable skincare course, Rederm. It comes after a partnership with product developer Institute Hyalual, featuring its injectable product Xela Rederm.

According to the company, the course will give delegates an understanding of the Xela Rederm treatment, which aims to increase collagen production and reduce pigmentation on the body. It will also teach delegates about the importance of the molecular weight of hyaluronic acid for skin health and allow them to gain a deeper understanding of the ageing skin. Attendees will have hands-on experience during the training and access to follow-on support from trainers. Claire Williams, UK sales and marketing director for Institute Hyalual said, “This course gives delegates a great tool to improve skin health, structure, texture, tone and hydration. It is great for those who are just starting out on their aesthetics journey as it allows them to practice their needle and product skills with less risk, as Rederm is injected very superficially into the mid-dermis.”

Upon successful completion of Rederm, delegates can add the treatment to their clinic portfolio. The course is led by Dr Fiona Durban and will be held at the Cosmetic Courses National Training Centre in Buckinghamshire. Delegates must be registered with their appropriate regulatory body or have overseas equivalents.

ACE wins silver at Conference Awards 2018 The annual Aesthetics Conference and Exhibition (ACE) has been recognised as one of the best free to attend conferences in the UK at the Conference Awards 2018. The event, which took place on June 29, is the largest gathering of conference professionals in the UK and recognises events that show development, continuous evolution and high achievements.

Judges described ACE as a, “Slick, impressive event with strong attendance, year-on-year improvements and excellent use of social media.” The company behind ACE is Aesthetic Media Ltd, which also publishes the monthly Aesthetics journal.

Aesthetics Media Ltd brand director, Suzy Allinson, said, “This was the first time we have entered ACE into this awards ceremony and we are thrilled to come out with such a great result. This recognition shows that ACE strives to further the education of aesthetic practitioners and is continuing to develop year on year.”

ACE 2019 will take place on March 1-2 next year.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Complications

IAPCAM announces first training course The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) is holding its first training course on September 20 at the Anatomy and Surgical Training Centre at King’s College London. According to IAPCAM, the training course will provide practical, hands-on training to show the latest evidence-based methods and advice from aesthetic professionals on how to manage complications.

The event will also cover training on injection techniques using cannulas and needles, the handling of hyaluronidase, discussions on protocols, practical scenarios of potential complications and interactive sessions with a range of complication cases.

Aesthetic practitioner and founder of IAPCAM, Dr Beatriz Molina, said that this course is designed to address the lack of uniformity on training and guidelines in complications. She also suggested that hands-on training of in-depth anatomy in real tissue specimens provides both cognitive and muscle memory that delegates retain for a much longer time-period.

The IAPCAM faculty includes Dr Molina, facial aesthetic surgeon Mr Jeff Downing, consultant dermatologist Dr Sandeep Cliff, and consultant trauma and orthopaedic surgeon, Mr Ansar Mahmood.

The course is limited to 16 delegates who will be divided into smaller working groups throughout the day. It will take place the day before the IAPCAM conference, which is on September 21.

Dr Molina said, “As we are carrying out medical procedures, complications could happen to any of us, so it is important to learn how to manage these. We must share our knowledge to avoid complications and ensure that we refresh our anatomy.”

Fat reduction

Alma Lasers introduces treatment protocol Manufacturer of aesthetic laser solutions and equipment, Alma Lasers, has launched a new treatment protocol which amalgamates two applicators, aiming to promote longer-lasting skin tightening and fat reduction in areas that are more challenging to reach. The new protocol is designed for the contouring of small treatment areas such as the underarms, submental region and loose skin. It consists of a radiofrequency handpiece, named the TuneFace, and a miniature ultrasound applicator, called the MiniSpeed.

The MiniSpeed was created to target smaller areas and provide a treatment for cellulite, skin laxity and body contouring while the TuneFace applicator aims to tighten the skin.

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Balance Dr Sabrina Shah-Desai @perfecteyesltd Life is about balance – happy I got a chance to admire the architectural and gastronomic beauty of Valencia after my Galderma masterclass!

#Learning Academy 102 @Academy 102 It’s always great to share our knowledge. The cosmetic industry never stops learning and developing, so neither should we! #WednesdayWisdom #Advertising BAAPS @BAAPSMedia BAAPS has proposed a ban on #CosmeticSurgery advertising, but also minimum requirements – including prohibiting ads targeting under 18s – to keep Britons safe. #Laser sk:n @sknclinics Congratulations to Dr Sean Lanigan, co-founder of sk:n Medical Standards Committee, for being awarded ‘Vasant Oswal Oration 2018’ for outstanding contributions to laser medicine by the British Medical Laser Association. #BAD2018 British Journal of Dermatology @BrJDermatol Dr Pauline Nelson is telling us all about the progress of dermatology qualitative research at the British Association of Dermatology Annual Meeting #BAD2018 #BJD #Dermatology #Equality Harrison Carter @HarryDECarter Delighted to be here @TheBMA to create a turning point on race equality in medicine. “Racism forces us into an individual identity: Indian doctor, African doctor, but I’m just a doctor.” #NHSFuture

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Bioidentical hormones

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

REGIONAL LEADERS’ MEETING The BACN has a number of regional groups that provide support, education, and networking on a local level. Every group is led by a BACN Regional Leader who demonstrates commitment to other nurses in the area through peer-to-peer review, promoting and chairing meetings and events in their area, and engaging with BACN members in a local capacity.

In August, each BACN Regional Leader will meet in London to discuss and evaluate the last round of regional meetings, while planning the final details for the autumn round in September and October. They will also consider issues that they face within their particular region, and coordinate actions for the future with other leaders, along with BACN HQ staff.

AUTUMN CONFERENCE UPDATES Booking is now in full swing for our Autumn Aesthetic Conference in Birmingham on November 8 and 9. Workshops and masterclasses are open for booking for the first day, along with our evening dinner reception held at Edgbaston Stadium on the eighth. For more information regarding agendas and booking, go to the events page of the BACN website.

Clinics partner for bioidentical hormone training Surrey-based clinic The Marion Gluck Clinic has announced its first UK partnership with The Mews Practice in Guildford to provide further training for practitioners on bioidentical hormone replacement therapy (BHRT). The Mews Practice will give patients the opportunity to be treated with BHRT under the supervision of Dr Marion Gluck, who specialises in the treatment. Bioidentical hormones are used to treat hormonal conditions such as menopause and premenstrual syndrome, alongside aesthetic indications, including hair loss and acne. According to Dr Marion Gluck, founder of The Marion Gluck Clinic, there is a growing demand for this type of treatment in the UK and an increased need for practitioners to be trained in how to safely prescribe bioidentical hormones. Dr Seema Kapoor, founder of The Mews Practice said, “I really look forward to the prospect of helping patients optimise their wellbeing with good governances and support from the UK’s leading authority.

Bioidentical hormones complement our strong ethos in delivering regenerative solutions to patients’ needs.”

Hair removal

Venus Concept introduces new hair removal device Manufacturer of non-invasive aesthetic devices Venus Concept has launched a new hair removal system, the Venus Velocity. The device uses diode laser technology and a real-time cooling system, which offers fast treatment of up to 10Hz and two modes of operation, slide and pulse. The company states that the slide mode allows the practitioner to deliver a high repetition rate of short pulses, whereas the pulse mode delivers higher energy to tissue at a lower repetition rate, which results in fewer treatment sessions. Venus Concept CEO Domenic Serafino said, “We are thrilled to be able to reinvigorate the aesthetics specialty with a hair removal device that can actually generate a positive return, while also delivering a fast and comfortable treatment for patients.”

BACN SHADOWING Throughout the last few months a number of BACN shadowing sessions have taken place between BACN members and BACN Shadowing Providers. The service offers practitioners new to the aesthetic specialty the opportunity to work alongside and observe experienced aesthetic nurses in clinical practice, as well as learn about the treatment techniques and products used. Although not carrying out any treatments themselves, the opportunity to ask questions in relation to theoretical and clinical practice at the end of the day has been considered extremely valuable to members who have completed the service.

To find out more information about the shadowing and being matched with a BACN Shadowing Provider email BACN Operations Manager, Sarah Greenan at sgreenan@bacn.org.uk.

This column is written and supported by the BACN

Needles

SoftFil EasyGuide introduces new sizes Microcannula and needle manufacturer Soft Medical Aesthetics has launched two new sizes for its SoftFil EasyGuide pilot needle, a 22 gauge 50mm and 23 gauge 70mm. The products combine the pre-hole puncture and the cannula together.

According to Soft Medical Aesthetics, the SoftFil EasyGuide’s V-shape aids in guiding the cannula into the created insertion point through its open axis and results in smooth contact with patients’ skin. The pilot needle is a half diameter needle that is used as a sharp gutter to slide and guide the cannula into the pre-hole. The SoftFil EasyGuide aims to offer a gripping area for easy and precise use, while ensuring the practitioner has ideal visibility of the injection point to minimise traumatism, haematoma and oedemas. The products are distributed in the UK by Healthxchange Pharmacy.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Formula

NeoStrata reformulates serum Skincare company NeoStrata has reformulated its Enlighten Illuminating Serum to increase the product’s effectiveness in treating pigmentation.

The serum now contains B-resorcinol that aims to reduce melanin production; niacinamide B3 to protect against the inflammatory effects of UV; liquorice extract for the reduction of free radicals; and vitamin C to brighten the skin. The product also aims to treat existing pigment spots and lighten existing melanin.

Marisa Dufort, director of product development and ingredient innovation for NeoStrata, said, “In addition to formulating new products, we also look at our existing formulations to see if we can improve them by adding new ingredients into the existing formulation. For the serum, we were able to add additional benefit ingredients that provide more intense brightening effects.” NeoStrata is distributed in the UK exclusively through AestheticSource.

Radiofrequency

Endymed begins marketing campaign Skincare distributor AesthetiCare is introducing a UK-wide consumer marketing campaign named ‘Picture Perfect Skin’ which promotes the Endymed radiofrequency treatments.

The campaign is part of the new Endymed clinic partnership programme, which intends to increase brand awareness and encourage patients into clinics. The Picture Perfect Skin campaign aims to show existing and new patients that Endymed provides both pain-free treatments for skin tightening and high intensity treatments for more advanced ageing and sun-damaged skin. It will include investment in digital advertising to drive patients to a webpage where they can find information about Endymed, search for their nearest clinic and view treatment videos. AesthetiCare’s managing director, Roger Bloxham said, “Endymed is a fantastic treatment; we are committed to ensuring it is highly sought after and is a big success in our Endymed clinics. The new patient marketing campaign and our Endymed partnership programme highlights our investment and support to them.”

Vital Statistics In a study of almost 6,000 marketers, only 8% said they would use Snapchat and 72% said they have no plans to use it for their business in the next 12 months – making it the least popular social media platform to market on (Statista, 2018)

In 2017, 34.9% of people aged 16 and over in the UK reported their happiness as very high (Office for National Statistics, 2017)

As of April 2017 there were 540 registered consultants of dermatology in the UK (Statista, 2017)

401,000 items were prescribed for the treatment of obesity in primary care in 2017 (NHS, 2018)

In a US study, it was reported that 740,287 people had a microdermabrasion treatment last year, this was a 4% decrease to the previous year (ASAPS, 2017)

Skincare

New vegan skincare brand launched by Vida Aesthetics Vida For You vegan skincare range has launched in the UK. The range consists of eight products, including a combination of creams and serums specifically design for targeting concerns such as signs of ageing and loss of skin elasticity, while also aiming to brighten the skin.

Eddy Emilio, director of UK distributor Vida Aesthetics and founder of Vida For You said, “I wanted to produce a luxury vegan range that was also friendly to the environment. Being able to use what is considered ‘surplus produce’ and turning it into super-charged raw ingredients has made this range incredibly eco-friendly and, at the same time, has resulted in creams and serums that I believe deliver what they promise.”

77% of Twitter users appreciate a brand more when their tweet is responded to and expect a response within four hours (Disruptive Advertising, 2018)

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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60

How important is the patient consultation?

Patient satisfaction is key. We understand that almost half of aesthetic patients have changed practice since their first treatment because they haven’t been satisfied with their previous experience.

I have noticed that patients are seeking better communication from their practitioner, more realistic expectations, more long-term treatment plans, and more natural results – we are now seeing more and more people keeping their treatment a secret.

Galderma and I have developed a consultation process, the Harmony Programme, which is designed to involve the patient much more in the process of choosing their treatment plans.

What makes for a great treatment result for you?

A great treatment result is when we have reached the goals that we set out to achieve in the initial treatment plan. This means we will have delivered patient satisfaction. I also like to make sure that my patients don’t look like they’ve had aesthetic work done as they leave the clinic. I like my work to be invisible. My goal is for the patient to look like they are refreshed and rested, they simply look like how they used to look a couple of years back. It’s no longer about looking ten years younger, people want to look great for their age.

RES18-06-0374 DOP June 2018 This column is written and supported by

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Distribution

BeCa Lasers to distribute Forma-TK Distributor BeCa Lasers, which launched in May this year, has become the sole distributor for Forma-TK systems in the UK. Forma-TK systems include the Magma platform, Magma Spark, Forma System and the Forma-Light system. According to the company, BeCa Lasers offer marketing, training, technical and practical support to ensure that practitioners can safely and successfully integrate the system into their clinic. Claudio Caldeira, director of BeCa Lasers said, “Forma-TK has established itself as a trusted reputable company with industry veterans on the board. We are pleased to be able to work with them and supply the technology into the market where there is an ever-growing demand.

The systems offer innovative technology that allows aesthetic practitioners to offer multiple technology treatments to their clients in just one platform.”

Dr Ravi Jain, founder and medical director of Riverbanks Wellness Clinic in Harpenden How important is product selection when administering facial fillers?

When you examine someone’s face, it’s important to identify their skin quality, bone structure, tissue density and the proportions and shape of their face.

It is also important to consider their desires and treatment goals. If you are consulting on a younger patient who would like structural enhancement, they will need a product which has a relatively high G prime, such as Restylane Lyft. If your patient requires restoration rather than enhancement, and has thinner tissue, a bit more sun damage, muscular atrophy and bone absorption, I would use a product with OBT technology that is softer and integrates better into the tissue, for example Restylane Volyme or Restylane Refyne.

Aesthetics Journal

Skin treatment

Starter kits added to PRX-T33 range Two starter kits have been added to the PRX-T33 range, one for the face and one for the body. The kits enable clinics to order the correct amount of products and the necessary equipment, as well as the best-suited creams for patients to use at-home following a PRX-T33 treatment. Included in both kits is one PRX-T33 skin bio-revitalisation treatment, ten cannulas and one spatula. The face kit contains three Smoothing Face Fluids which aim to regenerate the skin, while the body kit has three Elasticizing Anti-drying Body Creams which intends to promote skin elasticity. The PRX-T33 uses hydrogen peroxide and trichloroacetic acid to stimulate the dermis non-invasively and treat the face, stretchmarks and scarring. PRX-T33 is distributed in the UK by Medical Aesthetic Group.

Technique

FTG updates Meso Skin Needling treatment Aesthetic manufacturer and product supplier Finishing Touches Group (FTG) has introduced new techniques and training for its Meso Skin Needling treatment.

The Meso Skin Needling procedure is now conducted using two varying techniques – the Meso Me, which uses an 18-point plastic needle cartridge, and Meso +, which uses a six-point metal 0.5mm needle cartridge. According to FTG, Meso Me is a gentle skin needling concept which is suitable for all skin types. The company added that it has minimal downtime and patients can see an instant improvement in skin texture as FTG claims it will smooth the appearance of fine lines and wrinkles. Meso + is tailored to be a more intense skin needling technique. FTG has also introduced new entry level training which covers both the Meso Me and Meso + techniques. The course consists of a two-day workshop with theory and practical training.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Body shaping

4T Medical to distribute new suncare range Aesthetic product supplier 4T Medical is now the official UK and Ireland distributor for Swiss suncare range, Ophrys.

The range features three products, which include the Ophrys Facial Protect SPF46, designed for those with sensitive or troubled skin conditions such as acne or rosacea; Face SPF30, containing hyaluronic acid and vitamin E, which has been developed for normal to dry skin types; and the Active SPF50, which is designed to offer reliable coverage during active periods and, according to the company, is suitable for all skin types and ages.

Julien Tordjmann, 4T Medical managing director, commented, “We are delighted to extend our offering with such a quality Swiss product from Ophrys. Our customers tell us there is a demand for suncare for specialist patient needs like sensitive skin complaints. Using an Ophrys sunscreen will lower the risk of sun damage and minimise the visible signs of ageing, whilst working hard to protect sensitive or troubled skin.”

DEKA launches new body shaping device Italian laser manufacturer DEKA has launched a new device called the ONDA, which is designed to treat fat adiposities, cellulite, skin laxity and is suitable for any skin type. The device includes a handpiece delivery system that controls the microwave emission to the subdermal layers. This is done using a patented technology, known as Coolwaves, which the company states are ‘special microwaves that target fat cells to reduce localised deposits’.

Dr Paolo Bonan, dermatologist and European Society for Lasers and EnergyBased Devices key education officer, said, “DEKA’s unceasing search for new sources and applications has led to the invention of a completely non-invasive system, which specifically destroys the lipocyte membrane, just as the laser did.” He continued, “This technology makes it possible to treat cellulite even in the most advanced stages and skin laxity.”

Industry

John Bannon appoints superintendent pharmacist

4D breast augmentation

Crisalix introduces breast augmentation software Medical technology company Crisalix has introduced its 4D Augmented Reality software for aesthetic and reconstructive breast procedures.

The software allows patients to see themselves with their desired outcomes in real time. It works by the practitioner scanning the patient to generate their breasts in 3D, before creating a live, full body visual of patients’ proportions and how they will look with either implants, breast reconstruction or reduction. According to the company, the new technology combines several years of advanced medical and scientific research with 3D and 4D imaging technology. Crisalix describes the 4D Augmented Reality as a fully immersive experience before any surgery takes place.

The Cadogan Clinic in London is the first clinic to utilise the software in the UK to aid patients with their surgical planning.

Mr Olivier Branford, consultant aesthetic, plastic and reconstructive surgeon is leading the implementation of the software at the Cadogan Clinic. He said, “The 4D imaging is a very big step forward for breast augmentation and reconstruction. This technology allows surgeons to fully understand the expectations of the patients whilst equipping patients with knowledge and confidence in their choice.”

Medical device and aesthetic supplier John Bannon Ltd has appointed Andrew Pickin as its new superintendent pharmacist. In his new role, Pickin will oversee the compliance of all legal and professional requirements in relation to the pharmaceutical aspects of the business. He will also manage the training of employees and ensure all facilities and equipment enable the provision of services to professional standards. Pickin has more than 20 years’ experience in running NHS pharmacies. “I am really looking forward to working in this fascinating industry and have already met some practitioners to discuss what they value in their preferred pharmacy. I am thrilled to be working with John Bannon and, using the experience that I have already gained in the industry, I will be looking to expand the portfolio of products we offer,” Pickin explained.

Face mask

AlumierMD launches new treatment Skincare developer AlumierMD has introduced the Aqua Infusion Mask, a light-weight, oil-free treatment which aims to increase the skin’s ability to retain moisture. According to AlumierMD, the serum-like mask is suitable for all skin types and features a low molecular weight hyaluronic acid, working to infuse the skin with increased hydration. It aims to strengthen the skin barrier function, provide a glowing complexion and increase the skin’s ability to fight daily pollutants such as UV exposure.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Skincare

The Skin Cream Parlour launches at 5 Squirrels Private label cosmeceutical supplier, 5 Squirrels has launched a new initiative called The Skin Cream Parlour in its Brighton-based head office. The aim is for skincare professionals to develop their own formulations or adapt existing formulations to improve their brand. 5 Squirrels’ clients will be able to visit The Skin Cream Parlour so that they can make decisions on the packaging, fragrances, bottling and ingredients of their own skincare line, allowing business owners to take home a concept before product development, testing and certification takes place. Gary Conroy, co-founder of 5 Squirrels Ltd, said, “Whilst protecting their service proposition and rewarding customer loyalty, The Skin Cream Parlour is an exciting new concept which allows us to visualise and create what clients are thinking and make their skincare dreams come true!”

LED

Celluma launches in the UK Light emitting diode (LED) device manufacturer Celluma has now launched in the UK after being available in the US since 2013. The company has a portfolio of five LED devices that use proprietary phototherapeutic technologies to treat skin, muscle and joint conditions including acne and facial wrinkles. The flagship device, Celluma PRO has been cleared by the Food and Drug Administration (FDA) to treat acne, wrinkles and a variety of musculoskeletal and pain conditions. It is also CE marked as a Class IIa medical device for dermal wound healing. According to the company, Celluma devices emit particles of light energy, called photons, which provide compromised cells with the energy to regain and restore vitality naturally, helping to increases the production of the chemical, adenosine triphosphate. This results in an increase in microcirculation, tissue repair, and a decrease in inflammation and pain, Celluma states. Denise Ryan, vice president of Celluma, explained, “The versatile and multi-functional Celluma can be used as a powerful stand-alone or adjunctive modality following a variety of services, including: surgery, laser, microdermabrasion, microneedling, peels and injections.”

Vaginal mesh

Government announces pause on use of vaginal mesh The use of vaginally-inserted surgical mesh has been put on hold after the government accepted a recommendation by the Independent Medicines and Medical Devices Safety Review. Vaginal mesh is used to address stress urinary incontinence, and involves the placement of synthetic mesh under the urethra to provide support. The government has announced that this method will be put on hold to reduce the risk of injury from the procedure and until a new set of conditions are met. However, it may be used where there is no suitable alternative and only after a thorough consultation has occurred with ‘rigorous oversight and governance’. The proposal was made by the Independent Medicines and Medical Devices Safety Review after an evaluation, chaired

by Baroness Julia Cumberlege in February, examined feedback from patients who had received the treatment. Work is now underway by NHS England to cease procedures that do not meet the guidelines.

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News in Brief Endermologie facials launched French skincare brand LPG has launched three new endermologie facials using its CELLU M6 Alliance technology as part of its ‘no makeup’ programme. According to LPG, the programme aims to provide a luminous complexion for all skin tones and ages. It includes three treatments: the detox facial to drain toxins to reoxygenate the skin; the instant glow facial to reactivate fibroblasts; and the face, eyes and lips zone facial to stimulate the skin, plump the lips and lift the eyelids.

Initial Medical creates e-learning platform for waste management Waste management service Initial Medical has launched an e-learning platform called myLearning. The company explain that the service is designed to educate staff through in-depth online courses about clinical waste disposal, without having to leave the practice. Initial Medical has indicated that the courses are split into small modules and use videos and infographics to aid learning.

New director appointed at Snowbird Finance George Miller will be the new director of the treatment division at specialist credit broker, Snowbird Finance. Miller has more than 20 years’ experience within retail and consumer finance. He will be responsible for driving growth of the treatment finance programme across the aesthetics and cosmetic markets.

Managing director, Simon Freeman, said, “Based on George’s wide-ranging experience, we’re confident he will deliver the finance products that both the profession and their patients are looking for in these changing times.”

DSL Consulting Ltd to hold hair restoration event Business advisory company DSL Consulting is organising a networking event dedicated to the business behind hair restoration in November at the National Exhibition Centre (NEC) in Birmingham. According to the company, the event aims to help practitioners run a successful business covering areas such as social media and marketing. Speakers will include digital marketing consultant Adam Hampson, trichologist Eva Proudman and aesthetic insurance and claims manager from Hamilton Fraser Cosmetic Insurance, Naomi Di-Scala.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

Aesthetics Carboxytherapy

Rosmetics distributes Carbomed CO2 Aesthetic distributor Rosmetics has become the exclusive UK distributor for the Carbomed CO2 device.

The Carbomed CO2 aims to increase blood circulation and thus stimulate collagen fibres and tissue regeneration. The device uses carboxytherapy, a treatment technology where CO2 gas is administered subcutaneously or intradermally through microlocalised injections. The device is used for body contouring and to address aesthetic indications such as dark circles, stretch marks, psoriasis and skin laxity. Zak Shotton, operations manager for Rosmetics, explained, “Practitioners are always looking for ways to improve the results they currently obtain. A combination therapy using carboxytherapy gives improved results, especially in difficult to treat areas.

The machine itself is easy to use and virtually painless as it heats the CO2 before injecting, therefore giving a complete treatment for aesthetic patients.”

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Treatment of the Year 2016 Global skincare brand Medik8 has launched the Balance Moisturiser. The formula contains a blend of prebiotics and probiotics as well as niacinamide, beta-Glucan and cinnamon extract, which all aim to rebalance the skin’s microbiome, promoting a healthy, radiant complexion and decrease shine, whilst boosting hydration. The product comes as a duo with the Glycolic Acid Activator, that is said to ‘boost the performance’ of the moisturiser. It is advised by Medik8 to use the Glycolic Acid Activator two or three times a week and once the face is dry, apply the Balance Moisturiser.

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On the Scene

Out and about in the specialty

WACS Summer Conference 2018 On June 30, the Welsh Cosmetic and Aesthetic Society (WACS) held its first conference in Cardiff. The event offered networking opportunities and CPDcertified education to around 150 aesthetic practitioners. The day consisted of eight hours of presentations and live demonstrations covering topics including transgender patients, skin peels and the current climate of aesthetics. Amongst the speakers were Dr Patrick Treacy, Dr Lee Walker, Professor Steve Davies, Dr Tim Pearce, Dr Martyn King, independent nurse prescriber Sharon King and product and education specialist, Victoria Hiscock. It was also supported by companies including, Galderma, Merz Aesthetics, Schuco Aesthetics, Teoxane UK, AlumierMD, Cutera Medical Ltd, Energist Medical Group, Hamilton Fraser Cosmetic Insurance, The Consulting Room Group, You Can Clinic, online course Diploma MSc, supported by the University of South Wales, and Allergan, all of whom exhibited and showcased their latest products and equipment. Dr Treacy said of the conference, “It was a pleasure to join the inaugural WACS Conference 2018.

Being a keynote speaker with a 60-minute presentation, I used the allocated time to demonstrate anatomical dissections from Professor Sebastian Cotofana and various pearls of wisdom of injection techniques from Dr Arthur Swift. The speakers were all very professional and delivered the topics nicely. The venue was very nice, the food was great and everything ran on time!”

Achieving Aesthetic Excellence, London Aesthetic practitioners were invited to join Dr Suzan Obagi, Dr David Eccleston and business consultant Marcus Haycock in what was the second Achieving Aesthetic Excellence event on Saturday June 30. The event, held at the Royal College of Physicians in London, aimed to educate delegates on skin health, customer service and dermal filler complications. It was also Dr Obagi’s first trip to the UK. Dr Obagi held lectures throughout the day, outlining skin anatomy, clinical studies and patient results. Haycock then presented on how to deliver ‘five-star customer service’ before Dr Eccleston discussed prevention, recognition and management of dermal filler complications.

Dr Obagi said of the day, “It’s all about education. I am educating practitioners about skincare, breaking it down into basic building blocks and then advising how to address conditions, given the numerous topical agents that are out there. I’m not here to market but instead am arming practitioners with the knowledge to help them get the best results for their patients.” She added, “I love sharing knowledge, I learn so much by doing these events too! I like showing people what you can do when you fix skin.” The event then concluded with a focus group session and drinks reception. Steve Joyce, marketing and technology director of Healthxchange said, “We would like to thank all of our guests, speakers and exhibitors for making Achieving Aesthetic Excellence 2018 such a huge success. To hear from leading experts such as Dr Suzan Obagi on the latest skincare innovations from Obagi, and Dr David Eccleston on managing complications with injectables was inspiring; many of our clients are looking forward to another event next year.”

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Teoxane 15-year anniversary

Image courtesy of Paparazzi VIP Photography.

Global aesthetic manufacturer Teoxane Laboratories celebrated its 15 years in operation at The Trafalgar St. James rooftop bar in London on the evening of July 20. Around 150 of Teoxane’s clients, suppliers and industry partners attended the cocktail themed evening. They were greeted with drinks and canapés, whilst enjoying a magnificent view of London’s Trafalgar Square. Founder and CEO of Teoxane Laboratories, Mme Valérie Taupin, said, “Tonight was a very special event.

The UK was one of our first partners, so it’s important to celebrate here. It was lovely to mingle with our UK customers and suppliers and I would like to thank everyone for their loyalty and continued support. Our 15-year anniversary is only the beginning of our journey and we are looking forward to new developments and progress in innovation and excellence.” Teoxane UK country expert, Dr Raul Cetto, added, “This is a remarkable achievement for the company I feel honoured to work for, but especially for Mme Taupin, who has been a true visionary.”

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Aesthetics

GAA-AC, London

Aesthetics reports on the Galderma Aesthetics Academy Annual Conference On Friday June 29, aesthetic practitioners were invited to attend the Galderma Aesthetics Academy Annual Conference (GAA-AC) at the Royal College of General Practitioners in London. The event, which was titled ‘Au Natural’, encouraged guests to take a fresh look at their patients to recognise and fully understand the differences in anatomy and desired results across various generations. The GAA-AC is part of Galderma’s educational platform that aims to provide training programmes to ensure a commitment to developing a responsible aesthetic community and offer innovative aesthetic education on evidence-based medicine.

Presentations, live demonstrations and lectures gave key insights into how to achieve the best results using the Restylane portfolio, and delegates had an opportunity to network with peers. After kick-starting the day with a welcome and introduction from the conference chair, Professor Syed Haq, the first lecture began, titled, ‘Understanding Natural Beauty: The Anatomy of Beauty and the Beast’, which was presented by consultant oral and maxillofacial surgeons, Mr Mark Devlin and Mr Jeff Downie. The lecture discussed how the ageing process begins and the psychology of what influences aesthetic treatment. The seven speakers at the event also included aesthetic practitioner Dr Ravi Jain, who explained how both business and treatment approaches must change to accommodate the younger generation, while nurse prescriber and chair of the British Association of Cosmetic Nurses Sharon Bennett provided a live demonstration of her injecting technique focusing on the projection of cheeks, lips and chin using the Restylane NASHA gel technologies. Galderma international key opinion leader Professor Bob Khanna, aesthetic practitioner Dr Kuldeep Minocha, and consultant dermatologist Dr Sandeep Cliff were also speakers at the conference. The event concluded with a panel discussion with all the speakers who answered questions from the audience.

Following the event, Bennett said, “These smaller conferences are really important as they bring together a group of people who are shown a different dimension of skill sets, then given the opportunity to ask questions. People love sharing their ideas and often have very different opinions on a patient’s treatment plan.”

Toby Cooper, head of medical solutions at Galderma UK Ltd, added, “The theme of the conference is Au Naturel, so what you have with the Restylane portfolio is the ability to really fine-tune the results for the patient. Patients want a natural experience and to look refreshed and feel self-confident.”

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around who should be injecting for aesthetic procedures have also been highlighted since the launch of the JCCP, according to Professor Sines, who shares this concern.

The original 2016 HEE education and training framework places certain injectable procedures at Level 6 under supervision. Professor Sines states, “Many healthcare professionals have agreed that Aesthetics reports on the JCCP’s latest should only be administered by HCPs announcement proposing a change to the HEE injectables and have voiced their concerns. It is therefore training framework for injectable procedures as a result of this feedback and in the interests of public safety that the JCCP and CPSA wish to In March this year, the Joint Council for Cosmetic Practitioners review this earlier decision and consider whether to restrict access (JCCP) was officially launched at the House of Lords alongside the to Level 7 injectable procedures to registered HCPs only for those Cosmetic Practice Standards Authority (CPSA). The stated aim was modalities.” According to the JCCP and CPSA, Level 7 training must to provide a ‘new and comprehensive evidence-based set of practice be undertaken at a post-graduate level and must be carried out by and education standards’, to ‘protect the public’ and eventually gain attendance at relevant training courses that have been approved for statutory regulation from the Government.1 Both organisations are the specific modality.7 encouraging practitioners and training providers to join the voluntary If what Professor Sines is proposing is accepted by the JCCP Board of registers by asking them to demonstrate that they can meet the Trustees, it will mean that practitioners joining the register for injectable standards set originally by, and contained within, the Health Education procedures at Level 7 will have to provide evidence that they are England (HEE) framework. registered HCPs. It is important to note, however, that this does not In April 2013, Sir Bruce Keogh published an analysis of the regulation mean that non-HCPs cannot register at Level 7 (or Levels 4-6) for other of cosmetic interventions, commonly known as the Keogh review. modalities, which do not involve injectable procedures. If a non-HCP Following this, HEE guidance was commissioned by the Department has had the relevant training through approved or accredited Level of Health to produce an education and training framework for the 7 courses, in lasers for example, then they will still be able to register medical aesthetics specialty. In 2016, Part Two of these guidelines with the JCCP for this modality. were published establishing the qualification requirements for At the time of going to print, an updated framework is due to be delivery of non-surgical cosmetic interventions.2 The Keogh review published on the JCCP website confirming the decicisons made. indicated that there was a lack of regulation and protection for both the practitioner and the patient, especially in regards to dermal fillers, What about those who don’t join the register? which the report stated was ‘a crisis waiting to happen’.2 When asked what difference this will make for those who aren’t on The 2016 HEE guidelines, which are voluntarily followed by the voluntary register, beauticians who inject for example, Professor practitioners and training providers, indicate what ‘level’ a practitioner Sines explains that the end goal was to publicise the register in order should be at to safely and effectively perform a particular aesthetic for patients to check their practitioner before having a treatment. He treatment. It uses a minimum training grading system from Level says, “We will be undertaking a publicity campaign to make members 4 to Level 7, with various education routes to each of these of the public aware of the need to seek treatment only from those grades.3 Within each grade there are different treatment modalities, practitioners who are able to evidence that they have the required which require different levels of qualifications, knowledge and practice competencies; these were deigned for both healthcare professionals (HCPs) and non-HCPs. The guidelines also suggest that training courses should be regulated by qualification regulator Ofqual,4 or by education providers who have their own degree of awarding powers. They recommend that a minimum of 50% of the curriculum must be devoted to practical skills, particularly for botulinum toxin and dermal filler training.3 However, Aesthetics has learnt that, at the time of publication, changes to the HEE framework are being proposed by the JCCP Council to the members of the JCCP Board of Trustees. The main proposal, which is being endorsed by Professor David Sines, chair of the JCCP, is to review the decision whether non-HCPs should be eligible to register for Level 7 injectable and dermal filler procedures. At the moment, technically, a non-HCP could register at Level 7 in injectable treatments, providing they have had undergone the required training prescribed by HEE and the JCCP.

JCCP to Update HEE Framework

The main proposal is to review the decision whether non-HCPs should be eligible to register for Level 7 injectable procedures

Why has the change been proposed?

Not only mentioned in the Keogh review, but more recently in the form of social media and national news coverage,5,6 is the discussion around ‘who should be allowed to inject?’. Questions

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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level of training and practice proficiently to deliver safest possible care to patients and consumers.”

He adds, “Plans are currently being made to not only continue our work with the UK government, but to also create a steering group to lead the work on a publicity campaign. We will also seek to encourage as many practitioners as possible to adopt our standards and to join the JCCP Register in the interest of public protection.”

Aware that there may be non-HCPs who continue to inject despite these changes being made, Professor Sines believes that the best way to overcome this is to push a drive for the practitioner register to be publicised, which he confirms will begin in the autumn.

Additional updates In addition to this new plan to update the HEE guidelines, the JCCP is also aiming to amend their registration process. Currently, practitioners can join the register on a full or provisional licence, based on their qualifications, training and experience. The JCCP is now planning to allow all practitioners to join on a full licence, however it will still require them to demonstrate that they meet all of the CPSA and JCCP pre-requisite standards for proficient practice. In accordance with the JCCP’s previously agreed ‘grandparenting’ procedure (where previous qualifications and experience will be considered when being assessed) all registrants will, after a two-year period, provide evidence that they remain ‘fit for practice’ and meet all of the JCCP and CPSA standards of proficiency. The cost of registration, currently £450, will not change as a result of this new development.8 The JCCP has also formally approved a new set of education and training competencies, called the JCCP Education and Training Competence Framework. These newly approved standards will replace the HEE standards, incorporate the CPSA standards and the outcomes of three providers who have already trialled the updated guidelines. Training providers will be required to show that: • Trainees meet all of the knowledge practice requirements specified in the JCCP Education and Training Competence Framework and are able to demonstrate practice proficiency in accordance with the CPSA practice standards • Trainers and those assessing trainees also need to meet practice requirements and obtain proficiency in the level of the specific modality being taught and assessed by them • Delegates have access to a suitable learning environment (i.e. online resources, clinical learning space, library support) • There is access to audited and ‘fit for purpose’ practice learning placements/environments, whether this is in clinic or on the training site

How can the JCCP update the HEE framework?

In June 2018, HEE formally transferred the ownership of its education and training standards framework to the JCCP, something which Professor Sines says has all been part of an agreed ‘transition plan’. He explains, “The HEE standards were published in the same month that the JCCP and the CPSA were created. At that time, we agreed that the CPSA and the JCCP would radically review and revise the practice and educational standards contained within the HEE guidelines for each level and each modality following consultation with the sector.”

Aesthetics

“Many healthcare professionals have agreed that injectables should only be administered by HCPs and have voiced their concerns“ Professor David Sines

Site audits will be carried out by the JCCP to ensure that these standards are being met prior to any determination of being awarded the training provider ‘Approved’ educator status.

Professor Sines explains, “If you think about it, if in three years’ time there are 3,000 people on our register who are newly recruited from their JCCP-approved training courses, that will start to make a big difference and have an impact on the specialty. The future really starts with the training providers and I believe that getting their support is the best way to protect the public.”

Moving forward The JCCP now has full ownership of the HEE guidelines, has made updates to the training register and is proposing a significant change to the injectables modality of the practitioner register.

According to Professor Sines, revising the eligibility to register under Level 7 for injectable procedures means that there will be a much higher bar for minimum training requirements for dermal filler and botulinum toxin procedures. This will also aim to protect the public even further, Professor Sines says, reiterating that this is at the core of the JCCP’s values.

He says, “I think the JCCP has been regarded previously as a closed system and I am very keen to reach out to open this Council to a wider group of constituents, so that they have a voice and can help us to influence change in the interests of patient safety and public protection.”

REFERENCES 1. JCCP, JCCP Press Release January 2018 < https://www.jccp.org.uk/NewsEvent/jccp-press-releasejanuary-2018> 2. Gov.UK, Review of the Regulation of Cosmetic Interventions, (2013) <https://www.gov.uk/government/ publications/review-of-the-regulation-of-cosmetic-interventions > 3. Health Education England, PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, The Department of Health, (2015) pp.15- 22.

4. Gov.uk, Ofqual <https://www.gov.uk/government/organisations/fqual> 5. BBC, Botox Bust: How some doctors are breaking the rules <https://www.bbc.co.uk/bbcthree/ article/184e6102-5cc9-4148-9528-a349804e3e1b> 6. Aesthetics journal, Joint council debate takes place on radio 4 <https://aestheticsjournal.com/news/ joint-council-debate-takes-place-on-radio-4> 7. Cosmetic Practice Standards Authority, Dermal Filler Standards < http://www.cosmeticstandards.org. uk/uploads/1/0/6/2/106271141/20180303_cpsa_dermal_filler_standards_final.pdf > 8. JCCP, Membership Type <https://www.jccp.org.uk/JoinNow>

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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done but want to have a good result very quickly.” In comparison to other aesthetic treatments such as dermal fillers, Mr Humzah adds that by using sutures, the practitioner can achieve a lift in the facial structures, which can’t be achieved with a volumising product, as well as some rejuvenation.

Aesthetic nurse prescriber Yvonne Senior adds, “I absolutely love the versatility of threads, their safety profile and the patient’s response to them – patients get that instant wow factor.” She also mentions that she uses threads, in particular those with cogs, because patients see an immediate lift, as well as results that develop over time.

Who should you treat?

Mid-facial Thread Lifting Aesthetics interviews practitioners about their suture preferences for midfacial lifting and they explain their best tips for successful and safe treatment Sutures are commonly used by aesthetic medical professionals due to their lifting capacity and rejuvenation effects. Colloquially known to patients and marketed as ‘threads’, different types of sutures can be placed into the skin, depending on the indication, the treatment area, the protocol, and the desired result.

Historically, both non-absorbable and absorbable sutures were, and still are, used in surgery to close and support wounds and tissues within the body.1,2 The use of a barbed suture to lift ptotic facial tissues was first described in the late 1990s, but the popularity of sutures really took off in the aesthetic world after Contour Threads received the first FDA clearance in 2004.3,4,5 The use of sutures for facial rejuvenation has been met by some level of scrutiny in the past, mainly because of safety considerations and low patient satisfaction. Contour Threads, for example, lost FDA clearance in 2007 due to high post-operative complications such as infection and patient complaints.3,4,6 However, practitioners interviewed for this article believe that developments in technologies and protocols, as well as further knowledge in appropriate patient selection, has enabled the results to improve. They believe that the procedures now have higher safety profiles and even better patient satisfaction.

Although threads can be used across the face and body, according to the practitioners interviewed, a treatment of the mid-face to provide a lift is most commonly performed in UK aesthetic clinics, so this will be the focus of this article.

Why use sutures?

Consultant plastic and aesthetic surgeon Mr Dalvi Humzah explains that he believes sutures are useful for patients that present with facial sagging and laxity, but are not willing to have a major operation like a facelift. He states, “The downtime is less than a surgical approach as it’s less invasive. It’s good for people who don’t want a lot of work

To see if his patients require a ‘lift’ or a more volumising treatment, aesthetic practitioner Dr Ian Strawford will observe the patient both lying down and standing up to see how their fatty facial tissues move.

“Most of my patients are presenting with increasing nasolabial folds due to laxity of the mid-face, jowl formation and a loss of jawline contour – putting volume in doesn’t always address this,” he explains, continuing, “It may be that the patient’s fatty tissue has been displaced downwards so when they stand up, gravity has an effect and everything comes down. If we can demonstrate this, then I know it’s not about putting volume in for them. Instead, it’s about repositioning, lifting those tissues and maintaining that position so the tissues stay in that lifted position when they stand up and gravity has an effect.”

Mr Humzah adds that determining patient expectations is essential for patient selection, “I will almost under-lift their skin with my finger to near where I expect the lift to be. If they are happy with that, then you can go ahead. If they want a really tight face, then threads may not be the best solution; they could be the way forward, but they would need to compare the cost of that compared to something a bit more permanent.” He advises that practitioners show photographs of other cases, showcasing the immediate results as well as the improvement achieved with time. Aesthetic practitioner Dr Morkel Jacques Otto adds that when selecting patients, practitioners must consider the thickness of the patient’s facial structure. “If you have a patient who has very thin skin and no subcutaneous fat, you will insert the sutures almost directly onto muscle – this isn’t usually a good candidate. You need enough tissue and enough subcutaneous fat to get a good aesthetic result. You can still get some lift, but thin-skinned patients tend to pucker a lot, so it doesn’t look very nice,” he explains.

“You need to have really good consultation and assessment skills for these patients,” Senior points out, explaining that because thread lifts can be more expensive and more invasive than other non-surgical aesthetic treatments, practitioners must select their patients carefully and strongly communicate pricing in their consultation. “Patients often come in thinking that they are going to spend a few hundred pounds and get the results of a facelift, so you should communicate that this isn’t the case,” she adds.

Considerations before you lift Asymmetry is another consideration that must be pointed out in the patient’s consultation, the practitioners interviewed explain. “No one is symmetrical,” Dr Otto states, adding, “So you need to firstly point out any asymmetry. After the treatment, what you find is people pay more attention to their face and think that you may have caused asymmetry with your threads.”

This is one of the reasons why Dr Otto will always take images before, during and after the procedure. “Pictures are the most important thing. I take before pictures, treat one side of the face and then take

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Key terminology SUTURE MATERIALS Polypropylene suture: non-absorbable, permanent.

Polycaprolactone (PCL): absorbable, tends to dissolve in around 12-15 months.7 Poly-L-lactic acid (PLLA): absorbable, tends to dissolve after 12 months.7 Polydioxanone (PDO): absorbable, tends to dissolve after six months.7

POSSIBLE SUTURE FEATURES Barbed suture: uni- or bi-directional barbs/cogs that are featured along the thread act to grasp, lift and suspend a relaxed facial area. Barbed sutures are used to lift tissues.8 Non-barbed suture: a smooth suture which can either be plain or feature a screw or spiral. Non-barbed sutures are commonly used to stimulate collagenases for skin quality and support.8 Cones suture: acts like ‘baskets’ with a large surface area, allowing the subcutaneous tissue to be anchored inside the cone. They are positioned along the length of the suture and separated by a knot.6

a picture again – I call these the ‘half-time pictures’. I then take the patient to the mirror to point out the lift. If you don’t do this, patients may not see a big change because they have already forgotten what they used to look like,” Dr Otto says, adding that if there is no ‘half-time lift’ then the practitioner has not got the technique right.

Very importantly, Dr Otto points out, that in his experience, the treatment must cause some degree of swelling. He explains, “If there is no swelling, which is part of the wound healing response, then there are not going to be any cells infiltrating the area and there is not going to be new collagen formation.”9 He therefore recommends that the patient is not on any non-steroidal antiinflammatories for pain or discomfort and instead recommends paracetamol or ice.

Immediately before the treatment, Senior will always prepare an aseptic field by cleansing and disinfecting the skin. She will also anaesthetise and map out the treatment area using a pen. This includes entry points, end points and the lines in-between these where the threads will follow, as well as any danger zones to avoid. She states, “The patient has to be completely upright for pre-treatment assessment and marking. Once we have marked these considerations out we check that the vectors are what we want in order to achieve the desired outcome. I never treat without pre-treatment marking and that’s a key factor for looking for any asymmetry – allow yourself enough time to not rush this.”

In aiming for a safe and successful mid-face lift, like other procedures, practitioners must consider infection prevention methods. “The first and most important thing to note is that you must work clean to prevent infection,” stresses Dr Otto, explaining that the hair in particular must be considered for the mid-face lift. He frequently sees other practitioners touch patients’ hair while they are inserting sutures, “This is contamination,” he exclaims, adding, “I put down a hair cap and tape the boarders so that no hair can push through underneath. Then I put a second hair cap on top of this.”

Dr Otto adds that as with other aesthetic procedures, anatomy knowledge is important and you should ensure to not damage the

Aesthetics

facial nerve. “If you insert sutures above the cheek bones you are near one of the temporal branches of the facial nerves and you run the risk of cutting it. You also have a risk of puncturing veins or arteries and you can cause haematoma, so you have to be very careful when inserting the sutures,” he states.

Prior to the treatment, practitioners must also consider how they plan to tighten the threads, Mr Humzah states, saying that some have the tendency to overtighten, which can cause an unideal aesthetic result. “Never overtighten the suture – the problem is that they can all come apart if they are too tight. Less is more; you just want a correction. The scarring tissue tends to creep up the suture and pull everything tighter, so, if you overtighten it you get a worse result than if you don’t overtighten it,” he proclaims.

Choice of sutures for the mid-face Currently, there are four common types of sutures available to the aesthetic practitioner in the UK. These include those made of polypropylene,10 polycaprolactone (PCL), polydioxanone (PDO) and poly-L-lactic acid (PLLA).7 The below types are the sutures of choice for the practitioners interviewed, but note that other types and technologies are available.

Polydioxanone Dr Otto and Mr Humzah both use PDO regularly in their practice.

Although there are several types of PDO sutures,11 Dr Otto recommends those that have barbs for tightening the mid-face. He explains, “To create a tissue lift, you need hooks to anchor them so the thread will need to have cogs or barbs. The sutures I am currently using have been barbed six-dimensionally and these really hook and grip the tissue to maximise the lifting effect.”

Mr Humzah also chooses to use barbed PDO sutures, and will use these over PLLA when the skin is not extremely saggy and when more stimulation is needed to improve skin quality.

“I tend to insert more sutures when using PDO compared to PLLA, as I find the lifting capacity isn’t as strong.12 I find the PDOs are very good at stimulating the skin because you use quite a few threads and you can create a network of tissue support,” he explains.

Dr Otto says that he can achieve a considerable lift with PDO threads.

To accomplish this, he will insert a maximum of 10 barbed each side

“If you have a patient who has very thin skin and no subcutaneous fat, you will insert the sutures almost directly onto muscle – this isn’t usually a good candidate” Dr Morkel Jacques Otto

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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tension on each individual suture and cone.

Therefore, I find that they maintain their position for longer,” he explains.

When inserting PLLA sutures, Dr Strawford’s top tip is to ensure you have a correct tightening technique. He explains, “You need to make sure that the lifting part of the suture is well within the tissues that you are trying to lift. You should not pull them from above, and instead you should just try to reposition those tissues and then anchor them in a better position by holding the skin with your hands and moving it up along the thread. In the past we thought we needed to pull them from above to Figure 1: Patient before and after treatment using V Soft Lift PDO threads, Arte and Mono get a lift, but that’s not the case.” Once inserted, sutures. Results demonstrate improvement in the mid-face and neck. Images courtesy of the sutures will stimulate collagen production and Dr Hassan Soueid. the results will develop over the next 12 months, of the face using four entry points with a 19 gauge cannula. His PDO which is around the time that the sutures will dissolve. However, suture of choice is the IntraVita range, a company of which he is the researchers have noted that the benefits can last anywhere from medical director and trainer.

18-36 months.6,7,12 He explains that for a lift, practitioners should learn a specific It should be noted that in the UK, aesthetic nurses are not insertion sequence. Dr Otto explains his technique, “For a lift, permitted to use Silhouette Soft PLLA threads. my first thread will go just below the corner of the mouth into the marionette line. That will automatically give you a cheek lift without Aftercare having to put threads into the cheek. Then you can put another Mr Humzah says that after the procedure, it’s common for two through the pre-jowl sulcus and through the jowl. Those are practitioners to place tape or plasters over the entry points. the three most important sutures.” He will then insert more sutures Although he sometimes still does this, he now more commonly depending on the individual patient’s lifting needs. Mr Humzah uses a spray-on plaster that he has developed called Derma-Seal. uses V Soft Lift PDO sutures, and his best advice to practitioners is “This acts as an impervious barrier. Occasionally, for someone who to ensure they are not inserting the sutures too superficially. “They wants just a bit more reassurance, I use pink micropore on the skin are designed to go into the hypodermis subcutaneous plane, for support. But, when it’s removed you need to make sure that it’s rather than intradermally. People can put them in too superficially removed in the right direction – you need to pull the tape upwards as it’s very easy to start in the right plane and quickly move into and not downwards so you don’t pull the skin down and off the the wrong one. By staying in the hypodermis subcutaneous plane, thread,” he explains. it prevents visibility of the thread and folds in the skin (puckering), Dr Otto advises against immediate exercise to prevent bruising and which is what you want to avoid,” he says. swelling and to gently re-introduce it after three days. He adds, “Very Once the sutures are inserted, the practitioners note that they will importantly, patients shouldn’t make a dental appointment for two trigger fibroblasts to produce more collagen and will dissolve in weeks following the treatment because the mouth opening can be around six months.7 restricted and it can be uncomfortable for them.”

Similarly, Mr Humzah says that he recommends patients eat softer Poly-L-lactic acid food until the face settles.

Mr Humzah explains that in his opinion, PLLA threads are a good option if the patient wants a longer-lasting and more dramatic lift of the mid-face.

“If somebody has tissue that is sagging quite a lot and they need a really good lift, I would go for the Silhouette Soft PLLA threads.

I get a slightly better lift with PLLA sutures than PDO, although as technology develops this might change.”

Dr Strawford adds that this lifting capacity is the reason he chooses Silhouette Soft PLLA sutures for treating a lax mid-face – he is also a key opinion leader and trainer. “These sutures are unique as they have bidirectional cone technology that makes the suture have long-lasting results, if inserted correctly. With these PLLA threads you get a very strong anchorage and a very strong suspension. I find that with other sutures, because they do not have bidirectional cones, the anchorage isn’t as strong,” he explains.

Dr Strawford continues to explain that a needle is used for the mid-face lift and ten sutures are now recommended by the Yvonne Senior, aesthetic nurse prescriber manufacturers, which will also help improve the appearance of the neck.13 “The use of five sutures on each side allows us to spread the load of the forces against the sutures, creating less individual

“Patients often come in thinking that they are going to spend a few hundred pounds and get the results of a facelift, so you should communicate that this isn’t the case”

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Figure 2: Patient before and after treatment of the mid-face using Silhouette Soft. Images courtesy of Dr Ian Strawford, Skin Excellence Clinics.

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Figure 3: Patient before and after treatment of the mid-face using Silhouette Soft. Images courtesy of Dr Ian Strawford, Skin Excellence Clinics.

Lift your skills to lift your patients

“Never overtighten the suture – the problem is that they can all come apart if they are too tight. Less is more; you just want a correction” Mr Dalvi Humzah

Lift in combination Practitioners interviewed all note that because sutures do not have the same volumising effect as dermal fillers, they can be used as a combination and each have their own preference of doing so. “I often use this combination when the patient has both sagging and volume loss. Using the filler and suture combination is quite useful; some of the fillers, such as polycaprolactone and calcium hydroxylapatite, have a good skin stimulating effect. I tend to use the filler first, wait about two months and then put the thread in after,” says Mr Humzah, adding, “The other combination I’ve used is a skin stimulator called PRX-T33, which has been quite useful for patients who need to address skin quality. I find that it stimulates the skin a bit more and gets the threads to have a bit more grip.” Dr Otto adds that toxin can be used to treat patients with prominent platysmal bands about two weeks before a thread treatment to get a better lift. He states that this muscle sometimes pulls the face downwards, instead of the desired upwards direction, so the toxin helps with this. “If the nasolabial folds are quite deep I will also use fillers. I will inject the toxin first, then the threads. About a month later I will treat using fillers; usually calcium hydroxyapatite. I inject deep, just above the bone and insert the filler underneath the threads,” he explains.

Senior states that although the above considerations are essential when treating patients with threads, before practitioners think about incorporating them into clinic they should think not only about the type of threads they will use, but the support they will get from the suppliers. She says, “Quality training and support is key for any practitioner when they are introducing a new modality. Even after performing threads for more than six years I still need updates, technique changes or improvements, and if I had a complication I know that I will get support. This is something that you can’t put a price on.”

Dr Strawford agrees that good-quality training, which is continuously updated, is essential for successful results. He states, “Using sutures is a technique-dependent procedure and that technique involves everything from selecting the right patient to how they are inserted. If you are not getting the results you want, you may need to either look at another type of suture or do some refresher training.”

REFERENCES 1. J&J, Stitch in Time: 18 Fascinating Facts About the History of Sutures, 2016. <https://www.jnj.com/ our-heritage/history-of-sutures-ethicon> 2. C Dennis, S Sethu, S Nayak, LM Morsi, G Manivasagam, Suture materials — Current and emerging trends, Journal of Biomedical Research materials, 2016. <https://onlinelibrary.wiley.com/doi/ full/10.1002/jbm.a.35683> 3. PlasticSurgeons.com, FDA Approval Status for a Threadlift, <https://www.plasticsurgeons.com/article/ face/threadlift/fda-approval-status-for-a-threadlift> 4. Tonks, S ‘Understanding Thread Lifting’, Aesthetics, October 2015. <https://aestheticsjournal.com/ feature/understanding-thread-lifting> 5. Google Trends, ‘Threadlift’ <https://trends.google.com/trends/explore?date=all&geo=US&q=threadlift> 6. MP Ogilvie, et al., Rejuvenating the Face: An Analysis of 100 Absorbable Suture Suspension Patients, Aesthetic Surgery Journal, 2017, 1–10. <https://sinclair-college.com/wp-content/uploads/2018/01/JuliusFew-study.pdf> 7. Vincent Wong, Rafiq N, Kalyan R, Hseriksen A & Funner R, Hanging by a Thread: Choosing the Right Thread for the Right Patient, Journal of Dermatology & Cosmetology, 2017. <https://pdfs. semanticscholar.org/35fd/0a72ee2b9dfee72a1a458a22b5784d2c6ed7.pdf> 8. Rakesh Kalra, Use of barbed threads in facial rejuvenation, Indian J Plast Surg. 2008 Oct; 41(Suppl): S93–S100. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825122/> 9. Ana Cristina de Oliveira Gonzalez, et al., Wound healing - A literature review, An Bras Dermatol, 2016 Sep-Oct; 91(5): 614–620. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5087220/> 10. NG Isse & PB Fodor, Elevating the Midface with Barbed Polypropylene Sutures, Aesthetic Surgery Journal, Volume 25, Issue 3, 1 May 2005, Pages 301–303.

11. Panprapa Yongtrakul, et al. Thread Lift: Classification, Technique, and How to Approach to the Patient, World Academy of Science, Engineering and Technology International Journal of Medical and Health Sciences Vol:10, No:12, 2016.

12. SP Lorence, et al., Expert Consensus on Achieving Optimal Outcomes With Absorbable Suspension Suture Technology for Tissue Repositioning and Facial recontouring, Journal of Drugs in Dermatology, 2018.

13. Aesthetics journal, Sinclair Pharma launches Silhouette XLift after pilot study, May 2018.<https:// aestheticsjournal.com/news/sinclair-pharma-launches-silhouette-xlift-after-pilot-study?authed>

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Aesthetics

Using HA Fillers in Practice In the second of a two-part article, Dr Souphiyeh Samizadeh explores the different technologies of dermal fillers and their characteristics to aid product selection Choice of a hyaluronic acid (HA) dermal filler cannot be defined by a single parameter. It must be chosen according to a combination of parameters such as tissue layers and anatomical zones, in addition to other patient-related factors.1,2 The patient response to HA implantation varies in each individual and notably, the degradation of the product is also not the same in everyone.1 Factors such as the tissue layers involved and the depth of product implantation affect the post-implantation hydration of the product and also the induced inflammatory response.1 In the previous article published in the July issue of the Aesthetics journal,3 the basic characteristics of HA dermal fillers were described.

An understanding of these characteristics will aid a practitioner’s choice of correct product for the correct indication, taking patient factors into consideration.

Dermal fillers in the UK The HA dermal fillers featured in Figure 1 describe some of the most popular products in the UK and the technologies that are used to produce them. More information about the technology, filler characteristics and uses are discussed in more detail below.

Restylane range The Restylane range contains Non-Animal Stabilized Hyaluronic Acid (NASHA) technology and the Emervel range (renamed and included within Restylane range) uses Optimal Balance Technology (OBT). The NASHA technology produces a firm gel that results in an enhanced lifting capacity. In comparison, OBT results in a softer gel that distributes more evenly. The particle size within the change varies; for

The cohesive polydensified fillers have been reported to demonstrate homogeneous integration post implantation

example, the HA Restylane Skinboosters contain smaller gel particles and Restylane has larger gel particles. The range produced by the OBT have the same concentration of HA, with varied particle gel size, and cross-linkage.4,5 These products are manufactured by Galderma.

Juvéderm range Hylacross technology results in a smooth and homogenous gel with high cross-linkage.6 Vycross technology uses low and high molecular weight of HA, with varying HA concentration, and greater crosslinking.7,8 The HA concentration varies in each of these products. It is 20mg/ml, 17.5mg/ml and 15mg/ml in Voluma, Volift and Volbella respectively. In the Vycross range, Voluma has the highest G’, and is most cohesive (relative to other products, not easily spreadable) with the highest lift capacity (volumising effect). Volbella has the lowest G’ and cohesivity and hence useful for more superficial and subtle application.8 These products are manufactured by Allergan.

Technology

Products

NASHA10

Restylane, Restylane Skinboosters, Restylane Lyft (previously Perlane)

XpresHAn (Optimal Balance Technology)10,11

Restylane Refyne (previously Emervel Classic), Restylane Volyme (previously Emervel Volume), Restylane Fynesse (previously Emervel Touch), Restylane Defyne (previously Emervel Deep), Restylane Kysse (previously Emervel Lips)

Hylacross12

Juvéderm Ultra 2, Juvéderm Ultra 3, Juvéderm Ultra 4, Juvéderm Ultra Smile

Vycross13

Juvéderm Volite, Juvéderm Volift, Juvéderm Volbella, Juvéderm Voluma

Cohesive polydensified matrix (CPM) technology16

Belotero Hydro, Belotero Soft, Belotero Balance, Belotero Intense, Belotero Volume

Patented technology (no studies that discuss technology were found)

Teosyal First Lines, Teosyal Touch Up, Teosyal Global Action, Teosyal Deep Lines, Teosyal Ultra Deep, Teosyal Ultimate, Teosyal Kiss PureSense Redensity [I], PureSense Redensity [II], Teosyal Meso Teosyal RHA 1, Teosyal RHA 2, Teosyal RHA 3, Teosyal RHA 4

The E-BRID Technology20

Perfectha Derm, Perfectha Deep Perfectha Subskin, Perfectha Complement Perfectha FineLines

Hydrolift Action

Aliaxin GP- Global Performance, Aliaxin FLLips, Aliaxin SR-Shape and Restore, Aliaxin EV-Essential Volume

Figure 1: The technology of popular HA dermal fillers available in the UK

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Belotero range The Cohesive Polydensified Matrix technology produces a gel that contains cross-linking of variable densities in a cohesive structure and high molecular weight HA strands.9 This range of products contain highly cross-linked HA, cohesive with improved tissue integration post implantation.10 These products are manufactured by Merz Aesthetics.

Teosyal range The Teosyal products contain 15-25mg/ml of HA with various viscosity, cohesivity and G’ and includes long chain HA.11 The Teosyal RHA range of products are reported to be beneficial in the mobile areas of the face. Teosyal PureSense Deep Lines and Ultra Deep have high G’ and high cohesivity.12 This range of products are manufactured by Teoxane Laboratories.

Perfectha These are biphasic HA fillers. The E-BRID Technology contains differing gel particle sizes with a cross-linking process that is unique.

Covalent bonds are formed within and between HA particles.13 There are very limited scientific papers published in English on this product.

A Google Scholar seach using the search term ‘Perfectha’ results in 49 papers, including three citations, 19 non-English papers, and five non-relevant results.

These products are manufactured by (French company Laboratory ObvieLine), Sinclair Pharma plc.

Aliaxin range The Aliaxin range all have the same total concentration of HA (25 mg/ mL). This range relies on the hydro-action (hydrolift) of the product, which is solely dependent on the water uptake capacity of the HA gel post implantation. The products are reported to have a high hydration capacity and high insoluble HA concentration.14 The degree of cross-linking varies in these products. Aliaxin EV-Essential Volume has the highest cross-linkage within this range, and the lowest water absorption and the reverse is true for Aliaxin SR.14 This range of products have a high insoluble HA which results in improved filling and volumizing capacity.14 These products are manufactured by IBSA Farmaceutici Italia.

Projection can be achieved using a high G’ and low cohesivity product. A product with low G’, viscosity and high cohesivity produces tissue expansion

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Product characteristics and aesthetic indications Much of the below was discussed in detail in my previous article, but when choosing your products these basic points must be considered.

Numerous studies have focused on safety and tolerability of various HA dermal fillers available in the author’s country. Most studies focus on one specific product and a specific indication. To avoid bias, a comprehensive review of all the studies for a specific product and a specific indication is to be carried out, followed by examining differences between different products. However, this is beyond the scope of this article and only some of the studies are quoted.

G prime G’ determines the ‘tissue supporting capacity’ of a product.2 A high prime (G’) product has better resistance during dynamic movement.

For example, during animation, a high G’ provides a better support and lift, volumising effect and improved longevity in dynamic areas.

Low G’ dermal fillers are best suited for areas that are static, superficial or require some volumisation.1,2,7 For example, the low G’ and viscosity of Belotero Balance/Basic (Merz Aesthetics) makes the product a soft and easily spread gel that enables efficient and successful injection of very superficially using the ‘blanching technique’.21 High elasticity means less product is required to produce the same results in comparison to a product with less elasticity.22 Viscosity Viscosity values can determine how the gel behaves during extrusion and after the product is implanted and when subjected to shear forces. In addition, it is a factor that influences the pattern of HA tissue integration.14 A highly viscous product would spread and integrate less easily within the tissues injected and is therefore more suitable for less superficial treatment.14 Similarly, less viscous gels are less palpable post implantation and result in a natural looking outcome.14 In 2013, Sundaram and Cassuto studied the biophysical characteristics of the below HA dermal fillers and their relevance to aesthetic applications. They reported on the viscosity and elasticity of the following technologies/products:2 • NASHA – Restylane and Perlane: highest • Hylacross – Juvéderm Ultra: intermediate • CPM – Belotero Balance: lowest Cohesivity A highly cohesive product tends to remain at the site of implantation and does not migrate. HA products with lower cohesivity can dissociate easier than those with a higher cohesivity.7 Viscosity and cohesivity are two characteristics that predict tissue distribution of the HA gels post implantation.23 Cohesivity contributes towards tissue expansion.23 In 2015 Sundaram et al studied the cohesivity of six US FDA approved HA dermal fillers. They reported that the cohesivity of some of the commonly available products are as follows in sequence:23 • CPM – Belotero Balance: highest • Hylacross – Juvéderm Ultra: medium to high • Vycross – Juvéderm Voluma: low to medium • NASHA – Restylane and Perlane: lowest Tissue integration Cohesivity and viscosity of a product determine its tissue integration potential.7 The cohesive polydensified fillers have been reported to demonstrate homogeneous integration post implantation.24 In 2014, Tran and colleagues studied the bio-integration of three HA

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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dermal fillers in human skin. Their histological study revealed that the cohesive polydensified filler used in their study was distributed evenly within the dermis and showed most bio-integration. The cohesive monodensified filler showed a less even and homogeneous distribution; and the non-cohesive (biphasic) filler showed the least homogeneous distribution. These findings were constant at eight and 114 days post implantation.24 Water absorption A highly hydrophilic product that has not been fully hydrated during the manufacturing process will absorb water after it is injected.

Hence, much care is needed with these products when treating sensitive areas such as a tear trough deformity, where undercorrection will be needed.1 Uncross-linked, high molecular weight HA products have the highest water absorption and swelling.24 In 2011 Sundaram reported that the concentration of insoluble HA is approximately the same for Juvéderm Ultra Plus, Perlane and Restylane and reported the gel swelling varied among all these three fillers. Gel swelling indicates a HA product’s ability to absorb water after being implanted. Sundaram reported that amongst the above fillers, Perlane and Restylane have the lowest (50%) capacity and Juvéderm Ultra Plus has the highest (300%).These products produce more swelling on the second or third day after implantation.21 The Aliaxin range has a high water absorption capacity post implantation. La Gatta and Schiraldi reported that 1ml of HA in the Aliaxin EV filler can absorb water up to 111ml. This means 25mg/ml of HA in one syringe could absorb water and expand to an end volume of 2.8ml. Aliaxin SR has a high swelling degree post implantation.14 Injection depth according to product characteristics Within each range of dermal fillers, specific characteristics are used to create fillers for various tissue layers and purposes.27 Injection depth, in addition to the aims and objectives of the treatment, will influence the choice of products. Projection can be achieved using a high G’ and low cohesivity product.23 A product with low G’, viscosity and high cohesivity produces tissue expansion.23 The optimal HA dermal filler characteristics for superficial injections are: low G’ and low viscosity.2 For deep tissue/structural support, the optimal HA dermal filler characteristics are: high G’ and high viscosity as they are firm, have less spread and hence can provide deep tissue support.2

Conclusion Understanding the rheology and characteristics of various HA products can help aesthetic practitioners in selecting the best possible product and injection technique for specific indications and injection region. Furthermore, it can simplify and enables treatment planning and the achievement of clinical aims and objectives.

Dr Souphiyeh Samizadeh is a visiting associate professor, the founder of the Great British Academy of Aesthetic Medicine and the clinical director of Revivify London clinic. The focus of her clinical work, academia and research is aesthetic medicine. She frequently presents at national and international conferences and trains aesthetic practitioners worldwide.

Aesthetics REFERENCES 1. Kablik, J., et al., Comparative physical properties of hyaluronic acid dermal fillers. Dermatologic Surgery, 2009. 35(s1): p. 302-312.

2. Sundaram, H. and D. Cassuto, Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications. Plastic and reconstructive surgery, 2013. 132(4S-2): p. 5S-21S. 3. Samizadeh, S, Characteristics of HA Dermal Fillers, Aesthetics journal, June 2018. <https:// aestheticsjournal.com/cpd/module/characteristics-of-ha-dermal-fillers> 4. Restylane, OUR PRODUCT PORTFOLIO, 2018.<https://restylane.co.uk/overview/technology> 5. Galderma Laboratories, L.P. Restylane Defyne?, 2018. <https://www.restylaneusa.com/restylane-defyne> 6. Allemann, I.B. and L. Baumann, Hyaluronic acid gel (Juvéderm™) preparations in the treatment of facial wrinkles and folds. Clinical interventions in aging, 2008. 3(4): p. 629.

7. Molliard, S.G., et al., Key rheological properties of hyaluronic acid fillers: from tissue integration to product degradation. 2018.

8. Goodman, G.J., A. Swift, and B.K. Remington, Current concepts in the use of Voluma, Volift, and Volbella.

Plastic and reconstructive surgery, 2015. 136(5): p. 139S-148S. 9. Micheels, P., et al., Ultrasound and Histologic Examination after Subcutaneous Injection of Two Volumizing Hyaluronic Acid Fillers: A Preliminary Study. Plastic and Reconstructive Surgery Global Open, 2017. 5(2): p. e1222.

10. Lorenc, Z.P., et al., Review of Key Belotero Balance Safety and Efficacy Trials. Plastic and Reconstructive Surgery, 2013. 132(4S-2): p. 33S-40S. 11. Carey, W.D. and G. Sito, A new filler to treat the perioral area, PRIME journal, 2016.

12. Bourdon, F., E. Charton, and S. Meunier, Lift capabilities evaluation of hyaluronic acid fillers. 2017.

13. Park, K., H. Kim, and B. Kim, Comparative study of hyaluronic acid fillers by in vitro and in vivo testing.

Journal of the European Academy of Dermatology and Venereology, 2014. 28(5): p. 565-568.

14. La Gatta, A., et al., Biophysical and biological characterization of a new line of hyaluronan-based dermal fillers: a scientific rationale to specific clinical indications. Materials Science and Engineering: C, 2016.

68: p. 565-572.

15. Product details JUVÉDERM® ULTRA 2, 3 & 4. © ALLERGAN 2018, <https://www.allergan.co.uk/products/ list/juvederm%C2%AE-ultra-2,-3-4.> 16. Juvederm® VYCROSS, 2018. <https://www.consultingroom.com/Treatment/Juvederm-VYCROSSVOLIFT-VOLBELLA-VOLITE> 17. PHARMACEUTICALS, M. BELOTERO® – HOLDING BACK THE YEARS, 2018 <https://www. merzaesthetics.com/products/belotero/> 18. Teosyal® Products. 2018. <http://teoxane.com/en/teosyal-range> 19. Sinclair Pharma, Perfectha: How would you define beauty? 2018. <https://www.sinclairpharma.com/ perfectha> 20. Prasetyo, A.D., et al., Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Clinical, cosmetic and investigational dermatology, 2016. 9: p. 257.

21. Sundaram, H., Going with the flow: an overview of soft tissue filler rheology and its potential clinical applications (2 of 3). Practical Dermatology, 2011: p. 23-28.

22. Bingöl, A. and A. Dogan, Physical Properties of Hyaluronic Acid Fillers and their Relevance for Clinical Performance. <http://www.vamerpharma.com/HCP/Varioderm%20comparative%20study%20vs%20 other%20HA%20Fillers.pdf> 23. Sundaram, H., et al., Cohesivity of hyaluronic acid fillers: development and clinical implications of a novel assay, pilot validation with a five-point grading scale, and evaluation of six US Food and Drug Administration–approved fillers. Plastic and reconstructive surgery, 2015. 136(4): p. 678-686.

24. Tran, C., et al., In vivo bio-integration of three hyaluronic acid fillers in human skin: a histological study.

Dermatology, 2014. 228(1): p. 47-54.

25. Lee, D et al., Influence of Molecular Weight on Swelling and Elastic Modulus of Hyaluronic Acid Dermal Fillers. Polymer (Korea), 2015. 39(6): p. 976-980.

26. Ardeleanu, V., et al., The Use of Hyaluronic Acid Combined with Teosyal Redensity II for the Treatment of Dark Circles Under the Eyes. MATERIALE PLASTICE, 2017. 54(1): p. 37.

27. Berguiga, M. and O. Galatoire, Tear trough rejuvenation: A safety evaluation of the treatment by a semicross-linked hyaluronic acid filler. Orbit, 2017. 36(1): p. 22-26.

28. Verpaele, A. and A. Strand, Restylane SubQ, a non-animal stabilized hyaluronic acid gel for soft tissue augmentation of the mid-and lower face. Aesthetic surgery journal, 2006. 26(1_Supplement): p. S10-S17.

Reflection questions 1. How would you choose a HA dermal filler for a specific indication?

2. Why is understanding G’, viscosity and cohesivity of a product important?

3. Can a product that has high water absorption be used for areas like the tear trough deformity?

Answers: 1. By taking its rheology and characteristics into consideration, in addition to host factors, treatment indications, and local factors.

2. The G’, viscosity and cohesivity of a product will determine how the filler will react and for what indication it is best to be used for.

3. Yes, but this needs to be taken into consideration and the area should be under-corrected during the treatment session.

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Working with you to deliver natural-looking results

A lifting and regenerating suture treatment for the mid-face, jowls and neck.

A bioresorbable collagen stimulator for facial correction and volumisation.

A tailor-made range of HA dermal fillers for wrinkle correction, facial contouring and volume restoration.

An innovative product portfolio to give a lift to your patients and your business For more information on the Sinclair aesthetic products and training support visit: www.sinclair.com Sinclair Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. Date of preparation: May 2018

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elevation has improved the outcomes by repositioning ptotic soft tissues into a more anatomical vertical direction.6 In our practice, thread lifting for correcting ptotic tissue has led to a high uptake in our patients due to its lower risk of complications, minimum length of downtime and effectiveness, than compared to surgery. In this case study, we will be exploring a newly-launched thread lift procedure for face and neck rejuvenation, focusing on patient selection, methodology and achieved results.

Case Study: Facial Thread Lift

Treating a 49-year-old patient Our patient was a 49-year-old, menopausal, slim, female, with a previous history of long standing, debilitating migraines requiring regular interventions with botulinum toxin, triptans and beta blockers. As a result of these factors, she said that she suffers from constant fatigue and feels older than her years. In addition, she presented with marked signs of photoageing due to previous extensive sun exposure.

The consultation Her request was for a subtle facial rejuvenation to make her look less tired. In particular, she wanted to address Dr Victoria Manning and Dr Charlotte her nasolabial folds, marionette lines – which she felt made her appear sad, and her early jowls. She desired ‘a Woodward discuss the treatment of a natural and fresher appearance’. In the initial consultation, 49-year-old patient using a new thread we discussed the risks, benefits and treatment protocol that uses 10 sutures alternatives. We explained that there are a few options for repositioning facial volume and that it can be achieved Full face and neck rejuvenation is becoming an increasingly with several types of interventions, including injections with a variety requested treatment in our clinic. We find that most patients of hyaluronic acid gels or fat.7,8 However, we discussed that although request natural results and want to steer very clear of the overdone good results can be achieved with fillers, in our experience their use look. The growing demand to improve ageing with less invasive may result in increased facial volume with unnatural contours, and techniques has led to the success of a new generation of so-called an overfilled appearance, which is not what she wanted. Ablative or ‘puppet’ facelifts, referring to the lift that threads produce. In our non-ablative resurfacing techniques allow for the improvement of the experience, the utilisation of suspension sutures typically results in skin surface, but do not adequately lift the underlying ptotic tissues; an minimal trauma and meets patients’ expectations.1-3 Regardless of important step in achieving a younger appearance. the technique used, any lifting or repositioning procedure should We discussed the use of threads to address her concerns, which she consider the fact that the deeper tissues must be repositioned found appealing because she required a little bit of volumising as or filled before the skin is tightened.4 For all of these techniques, well as a ‘lift’, rather than just volumising. We therefore decided that soft tissue suspension with absorbable sutures is key.5 Recent repositioning using sutures was the preferred option. We chose polyunderstanding and appreciation of the vectors and biomechanics L-lactic acid (PLLA) sutures over polydioxonone (PDO) threads as in our of the sutures that should be applied to achieve optimum tissue practice PDO threads tend to be used for the more hypertrophic ptotic tissues. We chose to use Silhouette Soft sutures with the new XLift procedure as Exit points in scalp fascia – minimum we have found that these threads and of 5cm from entry protocol have high patient satisfaction.

First marking entry point – 1.5cm lateral, 2cm inferior In the initial consultation, we discussed from lateral canthus the risks, benefits and alternatives to the Silhouette Soft XLift procedure Mid point of nasolabial fold, 1cm intercal from first entry point 2cm anterior from last cone (explained in more detail below).

We discussed the procedure fully with Lower part of nasolabial the patient and ascertained that there fold, 2cm ahead from On mandibular border along last cone were no contraindications to treatment, the central line of jowl namely autoimmune diseases, hepatitis Superficial jowl, 2cm ahead from last cone B and C, HIV infection, pregnancy and breastfeeding, anticoagulation therapy, body dysmorphic disorder, existing Figure 1: The placement of threads for the Silhouette Soft XLift. The procedure involves four sutures plus one straight suture in the submandibular plane. infection, history of keloid formation and

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Benefits of PLLA threads All threads involve the repositioning of the soft tissues, with subsequent triggering of an inflammatory response and production of fibrosis around them.14 The benefit of the PLLA sutures is that studies have shown that the collagen produced after the initial inflammatory Type III collagen is predominantly Type I collagen.14 Type I collagen is a more youthful collagen and improves skin elasticity and hydration. Silhouette Soft suspension suture is re-absorbable, biocompatible and biodegradable. It is broken down by ester bond hydrolysis, while its degradable components are resorbed through the metabolic pathways with the production of lactic acid. On average the cones remain in the tissue for six to nine months.14

patients with unrealistic expectations.9 The patient was also educated about potential adverse events.

There have been no major complications reported in most studies on the use of sutures;10,11 however, minor and transient complications occur and are mostly practitioner related rather than product. The common side effects remain to be facial asymmetry, erythema, oedema, bruising, entry-point dimpling, puckering, haematoma and discomfort for up to 14 days.10 Thread migration, extrusion, and scar formation at their sites of entry and exit are the late complications described but are rare and again tend to be due to incorrect suture depth placement.

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A two-week cooling-off period was then given, respecting the latest guidance from the General Medical Council.12 The procedure Photographs were taken before and after the treatment. This was to not only show the patient what has been achieved following the procedure, but also to point out any asymmetry that may have been present initially, as this can be heightened following a thread lift treatment. We then began the Silhouette Soft XLift, which uses PLLA monofilament sutures and bi-directional cones that are made of polylactic-co-glycolic acid.

The bi-directional cones mean that the fixation method has been modified. Previously, practitioners would use an â&#x20AC;&#x2DC;Lâ&#x20AC;&#x2122; like formation in the jaw, but better results have been achieved using straight lines so the biomechanics work at optimum efficiency. Also, in our experience, exit points in the scalp fascia rather than in the face give much better anchorage. Although several techniques for thread insertion have been used over the years, from my knowledge and experience, most of them involve the interposition of the soft tissues to the cones, with consequent triggering of inflammatory response and production of fibrosis around them.

With this new technique, we find that you get improved anchorage in the temporal fascia so the sutures resist suspension traction, retighten the tissue effectively and therefore provide an immediate strong anchorage in the subcutaneous tissue.

As per the protocol, we used five sutures for each side of the face (Figure 1), rather than three as per the previous protocol. In our experience, this results in a more even distribution of the weight

Before

Before

Before

Before

After

After

After

After

Figure 4: The 49-year-old patient before and four weeks after treatment using the Silhouette Soft XLift.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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defined jawline, reduced nasolabial folds and presented with malar projection (Figure 4). Improvement will continue to occur after two to three months, when induction of new collagen begins.14 This patient’s results are expected to last up to around 18 months, depending on lifestyle and the heaviness of their tissues.

Figure 2: The markings that were made on the 49-year-old patient

Conclusion This procedure was well-tolerated and had an excellent safety record after correct implantation. Patient expectations were met and a natural rejuvenated appearance achieved. Optimal results will be apparent at the three-month review following the secondary neocollagenesis action of the sutures.15 In this patient’s case, we feel that she remains slightly volume deficient and will likely require volume replacement into her midface after her three-month review. In our experience, to fully address the signs of ageing, a combination approach is key to reposition the tissues and volumise. For practitioners considering this procedure on their patients, know that it should not be presented as an alternative to a surgical facelift and should only be seen as a temporary procedure that may be maintained until patient ageing requires further interventions. Patients will be disappointed if they expect the thread facelift to show the same outcome as the traditional facelift surgery.16 Disclosure: Dr Victoria Manning is a global trainer and key opinion leader for Silhouette Soft.

Figure 3: The 49-year-old patient mid-treatment showing suture insertion

of tissue between more cones and a greater lift of the skin tissue than if you only use three. From treating more than 50 patients over the past year, we noticed that other advantages of treating patients with increased numbers of sutures is that there are fewer complications and results show an immediate lift, without any puckering or dimpling.

Additionally, we have found that recovery time using five sutures is much shorter than with other patients who have been treated with fewer sutures, as the increased number of sutures has been able to spread the forces around each individual cone more effectively, putting tissues under less tension. As there is less tension on individual sutures, this patient, along with others we have treated, reported less pain and less discomfort during the procedure.

The technique for suture insertion is relatively straightforward.

Tiny bidirectional cones on the sutures were placed into the subcutaneous layer of the skin under local anaesthetic at the entry and exit points. Xylocaine with adrenalin is our anaesthetic of choice, purely for the vasoconstrictive effect.13 Each suture required three injections at the cones; these not only bring about the tension to compress and elevate the sagging facial tissues, but they also prevent the risk of breakage, migration and extrusion.

Results The effect of the treatment is two phased. An immediate lift in the face and neck and a regenerative action in the ensuing weeks, which brings about a second gradual and natural lift. This is because after insertion, the cones bring about neocollagenesis that continues over time, helping to increase the volume and restore the shape to the face gradually – typically over a period of six weeks to three months.15 The results were instantly visible after the treatment of this patient.

Four weeks following the treatment she appeared to have a more

Dr Victoria Manning is a global threads trainer and key opinion leader, who also trains in dermal fillers for feminine rejuvenation. Working alongside Dr Charlotte Woodward, they run the River Aesthetics Training Academy, delivering clinical training to other clinicians, particularly in thread lifting techniques. Dr Manning is a regular media contributor for the aesthetics specialty, writer and conference speaker.

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, Sandbanks and Belgravia. She was one of the first in the UK to offer non-surgical breast lifting using PDO threads and is a national trainer for Ellanse.

REFERENCES 1. Villa MT, White LE, Alam M, Yoo SS, Walton RL. Barbed sutures: a review of the literature. Plast Reconstr Surg. 2008;1213:102e-108e.

2. DeLorenzi CL. Barbed sutures: rationale and technique. Aesthet Surg J. 2006;262:223-229.

3. Horne DF, Kaminer MS. Reduction of face and neck laxity with anchored, barbed polypropylene sutures (Contour Threads). Skin Therapy Lett. 2006;111:5-7.

4. SW Watson , CA Morales-Ryan , DP SinnPoster 14: internal midfacelift: the foundation for facial rejuvenation. J Oral Maxillofac Surg , 61 (2003). p.88 5. MD PaulBarbed sutures for aesthetic facial plastic surgery: Indications and techniques Clin Plastic Surg , 35 (2008). pp.451–461 6. MT Villa, LE White , M. Alam , SS Yoo , RL WaltonBarbed sutures: a review of the literature Plast Reconstr Surg , 121 (2008). pp. 10 –108 7. M.D. Paul Barbed sutures for aesthetic facial plastic surgery: Indications and techniques 8. Clin Plastic Surg, 35 (2008). pp.451-461 9. M.A. Sulamanidze, G. Salti, M. Mascetti, G.M. SulamanidzeWire scalpel for surgical correction of soft tissue contour defects by subcutaneous dissection Dermatol Surg, 26 (2000), pp. 146-151 10. Suh DH, Jang HW, Lee SJ & Lee WS, ‘Outcomes of polydioxanone knotless thread lifting for facial rejuvenation’, Dermatological Surgery, 6(2015).

11. M.D. PaulComplications of barbed sutures Aesthet Plast Surg, 32 (2008), p. 149 E.R. Helling, A. Okpaku, P.T.H. Wang, R.A. Levine Complications of facial suspension sutures. Aesthet Surg J, 27 (2007), pp. 155-161 12. GMC, ‘Guidance for all doctors who deliver cosmetic interventions’, (2016), <http://www.gmc-uk.org/ guidance/news_ consultation/27171.asp> 13. NICE, local anaesthesia, 2018. <http://bnf.nice.org.uk> 14. Consiglio F, Pizzamiglio R, et al., Suture With Resorbable Cones: Histology and Physico-Mechanical Features. Aesthet Surg J. 2016 Mar;36(3):NP122-7.

15. Tavares JP,OliveiraCA,TorresRP,BahmadJr. Facial thread ifting with suture suspension.Braz J Otorhinolaryngoly 2017;83:712 16. Sarigul Guduk S, Karaca N. J, Safety and complications of absorbable threads made of polyL-lactic acid and poly lactide/glycolide: Experience with 148 consecutive patients. Cosmet Dermatol. 2018 Apr 17. J. Flynn, Suture suspension lifts: a review, Oral Maxillofac Surg Clin North Am. 2005 Feb;17(1):65-76

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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ability to elevate elastin levels and to substantially increase proteoglycan formation. Therefore, fillers can â&#x20AC;&#x2DC;fillâ&#x20AC;&#x2122; thinned skin, but also make overall skin look and feel healthier.3 In addition to fillers, a variety of topical products can also increase skin collagen formation. These include products with vitamin A analogues (retinols), growth factors, antioxidants and a variety of other agents that either leads to or provides a support structure for the formation of new collagen.4

Hand Rejuvenation Using Laser Skin laser specialist Dr David Goldberg introduces treatments for ageing skin on the hands and presents a case study of successful rejuvenation using laser The process of all skin ageing relates to both intrinsic and extrinsic factors. Intrinsic ageing is due to genetic background, while extrinsic ageing is caused by a whole host of factors, the most important of which is ultraviolet exposure.1 Thus, the best way to lessen extrinsic skin ageing is to use sunscreens from early childhood. Unfortunately, approximately 90% of our ultraviolet damage is completed by age 20 and is not reversible.2 This DNA-induced damage manifests itself years later in a variety of forms. These include thinned skin, wrinkles and abnormal pigmentation. The skin on the hands is one of the most exposed areas of the body, and often patients do not think to apply sunscreen in this area so damage can be obvious. This prompts many patients to seek treatment to reduce the signs of ageing on the hands.

Approaches to ageing skin on hands There are a wide variety of approaches to rejuvenate the hand, all of which depend on the problem. This ranges from dermal filler injections to skincare, chemical peels, lasers and more.

Thinning skin Aged, sun-damaged, thinning skin will need replenishment.3 Generally, dermal fillers are used to accomplish this, while also making the overall skin look and feel healthier. The categories of fillers that promote collagen, elastin and proteoglycans include those made of hyaluronic acid, poly-L-lactic acid, calcium hydroxyapatite and PMMA beads. Although all categories can fill and lead to formation of collagen, the last three groups are generally best at this.3 A recent study suggested that calcium hydroxyapatite has an

Wrinkles Wrinkles can also be treated with the above approaches, but often more is needed to achieve best results. Like the face, there are a variety of lasers and radiofrequency devices that can be used to treat wrinkles on the hands.

When performed safely and correctly, laser treatment can improve wrinkles with low downtime and with a low risk of scarring, as well as without post-treatment induced pigmentary changes. Such devices are categorised as non-ablative and ablative devices. In general, non-ablative devices require more treatment sessions and have minimal to no downtime, while ablative fractional devices require fewer treatment sessions, but do have more associated downtime than their non-ablative fractional counterparts.5

Abnormal pigmentation There is a wide variety of sun-induced pigmentary changes ranging from melasma to diffuse hyperpigmentation.

The most common form is called solar lentigines, also known as age spots or liver spots, although, they have nothing to do with age or liver-related issues. Solar lentigines are the direct result of excess sun exposure and can be seen on any sun-exposed area; however, patients most commonly present for treatment for lentigines on either the face or the tops of hands.6 A wide variety of methods have been used to lighten these brown spots. These include bleaching agents, peeling agents, non-specific destructive approaches and energy-based devices.

Peeling agents Peeling agents can improve lentigines, however mild agents do not usually produce significant results. Strong acid peeling agents can be highly effective, but carry similar risks to the aforementioned full field ablative lasers.7-9 Destructive modalities Lentigines can easily be removed by non-specific destructive modalities such as hyfrecator and cryotherapy. Both can be used to destroy the involved skin and lentigines. However, because of their destructive nature they are associated with a significant risk of scarring and pigmentary changes.10 Energy-based devices Broad-based light sources, known as intense pulsed light sources (IPL), are much more selective than the above approaches. As their emitted light is well absorbed by lentigines containing melanin, IPL can be effective in lightening lentigines. However, a series of multiple treatments is usually required and generally the results are

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

TRUST IN EXTENSIVE RESEARCH. More peer-reviewed publications and clinical studies than any other toxin.1 Allergan is committed to furthering research in facial aesthetics.

BOTOX® is indicated for the temporary improvement in the appearance of the following facial lines, when the severity of these lines has an important psychological impact in adult patients: moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines), moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile, moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously.

Prescribing Information can be found overleaf.

UK/0187/2018b Date of preparation: July 2018

Produced and funded by

TM

BOTOX® (botulinum toxin type A) Glabellar and Crow’s Feet Lines Abbreviated Prescribing Information Presentation: Botulinum toxin type A (from clostridium botulinum), 50 or 100 or 200 Allergan Units/vial. Indications: Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar lines); moderate to severe lateral canthal lines (crow’s feet lines) seen at maximum smile; moderate to severe crow’s feet lines seen at maximum smile and glabellar lines seen at maximum frown when treated simultaneously in adults, when the severity of these lines has an important psychological impact for the patient. Dosage and Administration: See Summary of Product Characteristics for full information. Do not inject into blood vessels.

Botulinum toxin units are not interchangeable from one product to another. Not recommended for patients <18 years. The recommended injection volume per muscle site is 0.1 ml (4 Units). Glabellar Lines: Five injection sites: 2 in each corrugator muscle and 1 in the procerus muscle: total dose 20 Units. Crow’s Feet Lines: Six injection sites: 3 in each lateral orbicularis oculi muscle: total dose 24 Units. In the event of treatment failure or diminished effect following repeat injections alternative treatment methods should be employed. Contraindications: Known hypersensitivity to any constituent. Infection at proposed injection site(s). Warnings/Precautions: Use not recommended in women who are pregnant, breast-feeding and/or women of childbearing potential not using contraception. The recommended dosages and frequencies of administration of BOTOX should not be exceeded due to the potential for overdose, exaggerated muscle weakness, distant spread of toxin and the formation of neutralising antibodies. Initial dosing in treatment naïve patients should begin with the lowest recommended dose for the specific indication. Prescribers and patients should be aware that side effects can occur despite previous injections being well tolerated.

Caution should be exercised on the occasion of each administration.

There are reports of side effects related to spread of toxin distant from injection site, sometimes resulting in death. BOTOX should only be used with extreme caution and under close supervision in patients with subclinical or clinical evidence of defective neuromuscular transmission and in patients with underlying neurological disorders. Caution in patients with underlying neurological disorder and history of dysphagia and aspiration. Patients should seek medical help if swallowing, speech or respiratory disorders arise. Previously sedentary patients should resume activities gradually. Relevant anatomy and changes due to prior surgical procedures must be understood prior to administration and injection into vulnerable anatomic structures must be avoided.

Pneumothorax associated with injection procedure has been reported.

Caution is warranted when injecting in proximity to the lung, particularly the apices or other vulnerable structures. Serious adverse events including fatal outcomes have been reported in patients who had received off-label injections directly into salivary glands, the oro-lingualpharyngeal region, oesophagus and stomach. If serious and/or immediate hypersensitivity reactions occur (in rare cases), injection of toxin should be discontinued and appropriate medical therapy, such as epinephrine, immediately instituted. Procedure related injury could occur. Caution in the presence of inflammation at injection site(s), ptosis or when excessive weakness/atrophy is present in target muscle.

Reports of adverse events involving the cardiovascular system, including arrhythmia and myocardial infarction, some with fatal outcomes. New onset or recurrent seizure occurred rarely in predisposed patients, however relationship to botulinum toxin has not been established.

Clinical fluctuations may occur during repeated use. Too frequent or excessive dosing can lead to antibody formation and treatment resistance. It is mandatory that BOTOX is used for one single patient treatment only during a single session. May cause asthenia, muscle weakness, somnolence, dizziness and visual disturbance which could affect driving and operation of machinery. Interactions: Theoretically, the effect may be potentiated by aminoglycoside antibiotics or other drugs that interfere with neuromuscular transmission. Adverse Effects: See Summary of Product Characteristics for full information on side effects. Based on controlled clinical trial data, the proportion of patients treated for glabellar lines that would be expected to experience an adverse reaction after treatment is 23% (placebo 19%). In pivotal

controlled clinical trials for crow’s feet lines, such events were reported in 8% (24 Units for crow’s feet lines alone) and 6% (44 Units: 24 Units for crow’s feet lines administered simultaneously with 20 Units for glabellar lines) of patients compared to 5% for placebo. Adverse reactions may be related to treatment, injection technique or both. In general, adverse reactions occur within the first few days following injection and are transient, but rarely persist for several months or longer. Local muscle weakness represents the expected pharmacological action. Localised pain, tenderness and/or bruising may be associated with the injection. Fever and flu syndrome have been reported.

Frequency By Indication: Defined as follows: Common (≥1/100 to <1/10), Uncommon (≥1/1,000 to <1/100). Glabellar Lines (20 Units): Infections and infestations. Uncommon: Infection. Psychiatric disorders.

Uncommon: Anxiety. Nervous system disorders. Common: Headache.

Uncommon: Paraesthesia, dizziness. Eye disorders. Common: Eyelid ptosis. Uncommon: Blepharitis, eye pain, visual disturbance.

Gastrointestinal disorders. Uncommon: Nausea, oral dryness. Skin and subcutaneous tissue disorders. Common: Erythema. Uncommon: Skin tightness, oedema (face, eyelid, periorbital), photosensitivity reaction, pruritus, dry skin. Musculoskeletal and connective tissue disorders.

Common: Localised muscle weakness. Uncommon: Muscle twitching.

General disorders and administration site conditions. Common: Face pain. Uncommon: Flu syndrome, asthenia, fever. Crow’s Feet Lines (24 Units): Eye disorders. Common: Eyelid oedema. General disorders and administration site conditions. Common: Injection site haemorrhage*, injection site haematoma*. Uncommon: Injection site pain*, injection site paraesthesia (*procedure-related adverse reactions). Crow’s Feet Lines and Glabellar Lines (44 Units): General disorders and administration site conditions. Common: Injection site haematoma*. Uncommon: Injection site haemorrhage, injection site pain* (*procedure-related adverse reactions). The following adverse events have been reported since the drug has been marketed for glabellar lines, crow’s feet lines and other indications: Cardiac disorders: Arrhythmia, myocardial infarction. Ear and labyrinth disorders: Hypoacusis, tinnitus, vertigo.

Eye disorders: Angle-closure glaucoma (for treatment of blepharospasm), strabismus, blurred vision, visual disturbance, lagopthalmos.

Gastrointestinal disorders: Abdominal pain, diarrhoea, constipation, dry mouth, dysphagia, nausea, vomiting. General disorders and administration site conditions: Denervation atrophy, malaise, pyrexia.

Immune system disorders: Anaphylaxis, angioedema, serum sickness, urticaria. Metabolism and nutrition disorders: Anorexia. Muscoskeletal and connective tissue disorders: Muscle atrophy, myalgia. Nervous system disorders: Bronchial plexopathy, dysphonia, dysarthria, facial paresis, hypoaesthesia, muscle weakness, myasthenia gravis, peripheral neuropathy, paraesthesia, radiculopathy, seizures, syncope, facial palsy. Respiratory, thoracic and mediastinal disorders: Aspiration pneumonia (some with fatal outcome), dyspnea, respiratory depression, respiratory failure. Skin and subcutaneous tissue disorders: Alopecia, dermatitis psoriasiform, erythema multiforme, hyperhidrosis, madarosis, pruritus, rash. NHS Price: 50 Units: £77.50, 100 Units: £138.20, 200 Units £276.40. Marketing Authorization Number: 50 Units: 426/0118, 100 Units: 426/0074, 200 Units 426/0119. Marketing Authorization Holder: Allergan Ltd, Marlow International, The Parkway, Marlow, Bucks, SL7 1YL, UK. Legal Category: POM. Date of preparation: June 2015.

Further information is available from: Allergan Limited, Marlow International, The Parkway, Marlow, Bucks SL7 1YL

Adverse events should be reported.

Reporting forms and information can be found at https://yellowcard.mhra.gov.uk Adverse events should also be reported to Allergan Ltd. UK_Medinfo@allergan.com or 01628 494026.

UK/0187/2018b Date of preparation: July 2018 1. Allergan. Data on file. INT/0721/2017. September 2017.

Produced and funded by

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Case study A 65-year-old female patient came to me with extensive pigmentation (solar lentigines) across her hands and was seeking a solution. She had previously treated her solar lentigines for almost an entire year using prescribed hydroquinone bleaching creams, without success. She wanted improvement with a single treatment, minimal discomfort and quick healing.

We reviewed the possibility of approaches including other bleaching creams, destructive modalities, light sources and lasers. We decided that laser treatment would be the best option for this patient because it could achieve her aforementioned goals. I chose to use the Lumenis PiQo4 laser. This laser can produce four different colours of light (532 nm – green; 650 nm – red; 585 nm – yellow; and 1064 nm – infrared). It produces both nanosecond and picosecond pulses and is a high-powered device, with varying spot sizes that range from 2-15mm.13 For treatment of solar lentigines, very low energies are required, leading to minimal wounding, minimal discomfort and fast healing.

I explained to her that healing on the hands may take one week longer than on the face. I also said that she will continue to get newer spots in the area after the treatment because of her extensive sun exposure throughout her life, even if she were to apply a high SPF regularly thereafter.

I also said that she will possibly require two treatments using this laser, which in retrospect she did not need. I also discussed the benefits of PiQo4 compared to other technologies as, in my experience, it results in less discomfort, quicker healing and better results than other modalities. The PiQo4 laser provided a fast and effective treatment solution. A low energy was used so there was almost no discomfort with treatment and healing occurred within one week. The results were seen one month later when the patient came back into clinic for a review. As the results were better than expected, we decided that the patient did not require a second treatment. She had total clearance of her lentigines. I recommended that she continue to use sunscreens with SPF 30 or higher on the area to help maintain the results and to prevent further skin damage. However, I also made sure that she understood the periodic need for more treatments for new spots as they arise.

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not as good as pigment-specific lasers.11 Q-switched or nanosecond lasers can be used for the specific goal of lessening pigment. Such lasers are generically known as ruby, alexandrite and Nd:YAG lasers. Although such devices produce much better results than all the prior non-light based methods, their use is associated with significant discomfort and longer healing time than the newer picosecond lasers.

Because nanosecond pulses produce both photothermal and photoacoustic wounds, there is usually more of a wound, and associated downtime, than that induced by the newer purely photoacoustic picosecond lasers.12 Bleaching agents It is important for practitioners to note that as bleaching creams include both hydroquinone and non-hydroquinone variations they are helpful for the treatment of melasma, but they are notoriously unsuccessful in the lightening of solar lentigines.12

Conclusion There are many approaches to rejuvenating the hands, depending on whether the patient has thinned skin, wrinkles or abnormal pigmentation. I have found that laser represents an ideal treatment for solar lentigines, in addition to its use on other forms of pigmentation as well as scars.

Disclosure: Dr Goldberg has received a research grant from Lumenis.

Dr David Goldberg is recognised nationally and internationally for his work with skin lasers, cosmetic dermatology and facial rejuvenation techniques.

Since 1985, he has treated patients and taught doctors throughout the world in the use of these technologies.

REFERENCES 1. Ganceviciene R, Liakou AI, Theodoridis A, Makrantonaki E, Zouboulis CC. Skin anti-aging strategies. Dermato-endocrinology. 2012; 4(3):308-319. doi:10.4161/derm.22804.

2. DeHoratius DM, Dover JS. Nonablative tissue remodeling and photorejuvenation. Clinics in dermatology. 2007;25(5):474-479.

3. Gonzalez N and Goldberg DJ. Evaluating the Effects of Injected Calcium Hydroxylapatite on Changes in Human Skin Elastin and Proteoglycan Formation. Dermatol Surg. On file.

4. Anunciato TP and da Rocha Filho PA. nCarotenoids and polyphenols in nutricosmetics, nutraceuticals, and cosmeceuticals. J Cos Dermatol. 11: 51-54, 2012 5. Tarjarian A and Goldberg, DJ. Fractional Ablative Laser Resurfacing: A Review. J Cosmetic & Laser Ther. 13, 262-264, 2011 6. Healthline, Lentigo (Liver Spots), 2018. <https://www.healthline.com/health/lentigo> 7. Sezer E, Erbil H, Kurumlu Z, et al. A comparative study of focal medium-depth chemical peel versus cryosurgery for the treatment of solar lentigo, Eur J Dermatol. 2007 Jan-Feb;17(1):26-9. Epub 2007 Feb 27.

8. Marta I. Rendon, et al., Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing, J Clin Aesthet Dermatol. 2010 Jul; 3(7): 32–43.

9. Mohamad Goldust, Farideh Golforoushan, et al., ‘A Comparative Study in the Treatment of Solar Lentigines With Trichloroacetic Acid 40% Versus Cryotherapy’, Cosmetic Dermatology, 2011.

10. Farhaad Riyaz, David Matthew Ozog, ‘Hand rejuvenation’, Seminars in Cutaneous Medicine and Surgery, 2015, 34(3):147-152.

11. Ciocon DH, Boker A and Goldberg DJ. Intense Pulsed Light: What Works, What’s New, What’s Next? Facial Plast Surg. 25: 290-300, 2009 12. Butani A. Dudelzak J and Goldberg DJ. Recent Advances in Laser Dermatology. J Cosmetic & Laser Ther. 11: 2-10, 2009 13. P iQo4 By Lumenis <https://lumenis.co.uk/Portals/0/pico%20brochure%20PB-2008139%20 Rev%20A.pdf>

Figure 1: A 65-year-old female patient presenting with extensive pigmentation (solar lentigines) across her hands before treatment and one month after treatment using the Lumenis PiQo4 laser.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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The subcutaneous layer of fat is usually palpable and has a distinctive feel; if the folded skin can be rolled between fingers easily it usually means that there is very little fat underneath the dermis. For such patients, lipolysis will not be an appropriate option.

Treatment options Patients with little to no subcutaneous fat should be offered alternative treatments, including radiofrequency (RF), high intensity focused ultrasound (HIFU) and, depending on skin laxity, they may also consider surgery. There are a range of energy-based devices that are used for body sculpting. Cryolipolysis is another popular approach to body sculpting, but in my experience and, due to specifics of the technique, it is very difficult to draw the tissue around the knee into the applicator. Surgical liposuction is another alternative.

However, it is an invasive treatment and many patients (especially with those with small, stubborn fat pads) feel that surgery would be a step too far in addressing their concerns. Surgical treatments are usually more expensive, more time consuming, and might require Mrs Aggie Zatonska provides a case study considerable amount of downtime for the patients. that demonstrates successful knee sculpting In the case presented below, I use a sodium using fat-dissolving injections deoxycholate to dissolve the fat around the knee.

Adipocytolysis is the word to describe the chemical Adipose tissue deposition around the knee is a concern for many destruction of adipose tissue following the use of sodium patients as it can make one’s legs look distorted and unbalanced. deoxycholate and when fat cells are destroyed, triglycerides and This can cause patients to feel self-conscious about the appearance fatty acids are liberated.2 Over the next three months, the fatty of their legs, which may affect what they wear and what activities acids are naturally removed by the body. Studies have indicated they choose to avoid; swimming for example. This article describes a that deoxycholate is a very effective tool for minimally-invasive fat successful treatment of adipose tissue deposited around knees using reduction.3,4,5 a sodium deoxycholate solution.

Case Study: Knee Sculpting

Do results last?

Patient selection Assessment of the treated area is essential for distinguishing whether the volume of unwanted soft tissue is a result of accumulation of fat or an issue with skin laxity. The latter would dictate further treatment options (mentioned below).

A pinch test is a very simple and useful tool in this diagnosis; the pinched fold of the skin should be between 1.5-3cm thick and it should be difficult to roll the pinched skin between one’s fingers.1

Case study Consultation A 23-year-old female patient presented in my clinic with concerns about the shape of her knees. She complained about large fat pockets on the inner side and above her knees, explaining that she felt that it made her legs look unbalanced and unattractive.

So much so that she wouldn’t wear skirts or shorts and explained to me that the look of her knees caused her a great deal of discomfort. We discussed her concern in detail during the consultation and aside from her knees, the patient was otherwise

As the fat cells are destroyed after injection with deoxycholate, patients who can maintain weight are expected to see longlasting results.7 Once dissolved, fat cells are unlikely to redevelop; however, it should be noted that the remaining fat tissue can significantly increase in size when patients put on additional weight.8 For this reason, patients should be advised that maintaining a healthy diet is essential for ensuring long-lasting results of the treatment.

happy with her body. Her body mass index (BMI) was within normal limits and she led a fit and healthy lifestyle. In this case, the pinch test showed that the skin fold was approximately 2-2.5cm thick and the fatty tissue was palpable during an attempted roll of the pinched skin. Treatment with sodium deoxycholate solution was therefore proposed to the patient. The product I use is called Aqualyx, which is CE marked in Europe and is indicated for the treatment of stubborn fat pads.6 It’s necessary to note that deoxycholate solution will not improve issues with skin laxity, so this was discussed with the patient to set realistic expectations.

After performing the pinch test, the patient’s skin was marked while she was standing up, as this allows for appropriate assessment of the treatment area, easier identification of excessive fat and allows for more a more precise injection (Figure 1). After marking the treated area, I find it is worth discussing the approach and procedure again with the patient, just to ensure they know exactly what to expect. All of my patients are offered a cooling-off period after initial consultation and I always discuss possible side effects and expected downtime with them. When patients decide to progress with the treatment a consent form

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Before

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After

Figure 1: Image taken before treatment

Figure 2: Image taken six weeks after treatment

should be completed and photographic documentation obtained.

Treatment An aseptic technique was used and four vials of sodium deoxycholate (two per each limb) were injected into the treated areas, directly into the subcutaneous fat. Each vial was mixed with 0.2ml of 2% lidocaine. In my practice, I use 25 gauge cannulas in the chin and on larger body areas but prefer to use a 30 gauge needle in smaller areas, as in my experience it is more precise.

With this being said, a 30 gauge needle was used for this particular treatment. It is very important to inject into adipose tissue within its boundaries and the cannula or

needle introduced into fatty tissue cannot be visible or palpable, otherwise it will dissolve the thin layer of subcutaneous fat causing superficial indentations or it simply just won’t work. If you can see the tip of the cannula or needle, you are too superficial.4 It is not recommended to use more than 40ml of sodium deoxycholate (five vials) in total during one visit, and never more than four vials per one treated area; this is the maximum dose that can be used whilst maintaining favourable benefit recommended by the manufacturer.4 After injecting, which was within borders of adipose tissue, not too superficial, and ensuring even distribution of the product (to potentially reduce the risk of

Possible complications and side effects Managing patients’ expectations is very important. If the patient has several areas of concern that relate to a weight issue, practitioners should suggest addressing the problem with a tailored weight loss programme, followed by cryolipolysis. However, it is important to note that this is not always necessary, like in this case for example.

Remaining areas requiring improvement (small stubborn fat pads) whether on the abdomen, chin, flanks or knees (which are some of the most common areas) can be then treated with sodium deoxycholate. After treatment with sodium deoxycholate, some discomfort and redness should be expected and it is common for immediate swelling post procedure to increase within the next 48 hours following the injection. It is important to make your patients aware of this prior to the procedure. Erythema, haematomas and rigidness in the treatment area are to be expected in the first few days and it is also normal for the treated area to feel numb or itchy for at least few days after injection, however both symptoms can be present for up to a few weeks after the treatment.6 Rare episodes of transitory pain were also described in literature and serious complications are relatively uncommon, however they must be taken into consideration.9 Tissue necrosis was also reported in literature when using solution of phosphatidylcholine and deoxycholate.6

necrosis) a gentle massage of the treated area was performed as this is generally recommended to help evenly distribute the product. Post treatment, patients should be advised to avoid exposure to heat and sun for a minimum of two weeks and a balanced nutrition protocol is recommended by the manufacturer to achieve best results. A few days after treatment, regular exercise is also recommended.6 Additional injections may be performed no earlier than three months after the initial treatment and although there may be a visible improvement after the first treatment, most of the time a course of two or three visits, spaced at least three months apart, is required. In this case, the patient underwent only one treatment session and was satisfied with the final result.

This patient reported that most noticeable swelling occurred within 24 hours and lasted for 96 hours’ post treatment.

Initially, she felt some discomfort but said that it subsided over the first 48 hours.

Haematomas disappeared within a week. The patient started to notice visible improvement approximately six weeks after treatment (Figure 2).

treatments can also be considered, especially in the era of prevalent energy-based treatments. The treatment results can be expected to be very long lasting and the safety profile appears to be favourable.

Mrs Aggie Zatonska is a practitioner with more than ten years’ experience in facial aesthetics. She is a specialist ENT surgeon, holds a post-graduate degree in Aesthetic and Anti-Ageing Medicine accredited by the L’Union Internationale de Medecine Esthetique. She is the founder and director of Atelier Clinic in Egham and works with Medicetics, an award-winning clinic in Central London.

REFERENCES 1. Wong V; Injectable treatment of localised adiposity, Aesthetics Journal, 01 November 2014 (https:// aestheticsjournal.com/feature/injectable-treatment-of-localised-adiposity) 2. Motolese, P., ‘Phospholipids do not have lipolytic activity. A critical review,’ Journal of Cosmetic and Laser Therapy, (2008) pp. 114-118 3. Kamalpour S, Leblanc K. Injection Adipolysis: Mechanisms, Agents, and Future Directions. The Journal of Clinical and Aesthetic Dermatology. 2016;9(12):44-50 4. Rauso R, Salti G; A CE-Marked Drug Used for Localized Adiposity Reduction: A 4-Year Experience, Aesthetic Surgery Journal, Volume 35(7), 1 September 2015, 850–857 5. Pinto H, Melamed G, Fioravanti L. Intralipotherapy Patient Satisfaction Evaluation Study (IPSES). Eur J Aesth Med Dermatol 2012;2(1):29-34 6. Aqualyx product information website. http://www.aqualyx.com 7. Mullan G,; Body Contouring Using Cryolypolysis; Aesthetics Journal, 16 January 2018 (https:// aestheticsjournal.com/feature/body-contouring-using-cryolipolysis) 8. Cooke K.; Treating the Submental Area. Aesthetics Journal; 4 Jan 2018 (https://aestheticsjournal.com/ feature/special-feature-treating-the-submental-area) 9. Amore R, Pinto H, Gritzalas K, et al. Intralipotherapy, the State of the Art. Plastic and Reconstructive Surgery Global Open. 2016;4(10):e1085

Conclusion I believe deoxycholate is a very effective tool for minimally-invasive fat reduction. Proper selection of eligible patients and efficient management of their expectations are critical for achieving optimal results. Although not performed in this case study, combination

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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®

Dr Rosh Ravindran details the occurrence of cellulite dimples and how Cellfina® offers successful treatment What are cellulite dimples?

Cellulite is characterised by dimpling and uneven skin texture on the buttocks and thighs, which affects an estimated 1.4 billion women worldwide.1,2,3* 84% of women who are at least somewhat concerned about their cellulite dimples are motivated to do something about it.4

marked8 and US FDA-cleared9 minimallyinvasive procedure clinically proven to treat the primary structural cause of cellulite dimples.5,6 Cellfina® is a simple, effective treatment which offers long-lasting, reproducible results in a single 45-60 minute treatment.5,6

What are the benefits of Cellfina®?

How does Cellfina work? ®

Cellfina® is a minimally-invasive treatment which offers precise results in one single inclinic procedure.5,6 Unlike other procedures, it treats the structural cause of cellulite dimples, the fibrous septae – connective bands found under the skin which are woven throughout fat in the thighs and buttocks.6,7 These tight bands pull down the skin creating the common puckering effect seen on the surface of the skin.7

What makes Cellfina® unique?

Many of my patients with cellulite dimples have turned to remedies such as creams, lotions, lasers, massages and wraps. But the reality is that these remedies have been shown to have limited success at treating both the underlying cause of cellulite dimples, or providing long-lasting outcomes.1,5 What makes Cellfina® unique is that it hits cellulite at its core. It is the only EU CE-

Before

After

Cellulite has been a heart-sink for surgical and aesthetic doctors, as no current treatments tackle the primary cause of cellulite dimples in a precise and targeted way. When liposuction was introduced there was initial excitement, but this immediately

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proved false as removing fat did not affect the bands that causes cellulite. What ultimately drew me to Cellfina® were the clinically-proven results. Patients have noted a smoother appearance on their buttocks and thighs in as little as 14 days.6 Cellfina® has an established safety profile, with rapid recovery time after treatment.5

Is the treatment painful and how do you manage this with patients?

As Cellfina® is minimally invasive, patients are able to go about their day as normal following the procedure, but may want to take it easy for up to 24 hours.5 There is a chance that patients will experience some bruising, but this reduces over time.5 A study found that just three days after treatment, patients rated their pain as minimal (2.7 on a scale of 0 to 10; 0 = no pain, 10 = extreme pain) and the majority felt pain only with touch or pressure to the area treated.10 This minimal pain improved quickly with time.10

“I am delighted to be able to offer Cellfina® by Merz to my patients at KLNIK. Unlike other technology, Cellfina® provides a long-term, minimally-invasive solution to cellulite dimples” Dr Rosh Ravindran, KLNIK

Patient Feedback Natasha, treated at KLNIK “As a mother I felt self-conscious taking my son swimming and avoided wearing outfits on certain occasions. I have worked in the beauty industry for over 15 years and have tried every lotion and potion available; nothing worked and my problem remained persistent. Since having Cellfina® my confidence has been restored. Now I don’t have to worry about prepping before going on holiday and I won’t feel shy on the beach. Cellfina® has eased my worries. I was drawn to Cellfina® as I found it was the only clinicallyproven cellulite6 dimple treatment available.”

Images courtesy of Dr Rosh Ravindran *1.7 billion is the total amount of post-pubertal females aged 25-64 worldwide. 85% of women (1.4 billion) are estimated to suffer from cellulite, based on a cellulite review study.

44

Aesthetics | August 2018

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Dr Maria Gonzalez shares her experiences of treating patients’ cellulite dimples with this FDAcleared procedure

should last indefinitely. However, the current Cellfina® data available demonstrates that results are maintained at three years, and the data does not exist for longer-term follow up of those treated.6 Officially, patients can be told that their results will be maintained at three years, however, this is the longest duration of results in comparison to any other cellulite dimple treatment in the market.6

Patient Feedback How does Cellfina® work to treat cellulite dimples?

Cellfina® uses a technique known as subcision where a blade or needle is used to break down fibrous bands, which run through the subcutaneous fat and are tethered to deeper tissue layers.6,7 These bands cause the fat to bulge resulting in dimpling of the skin which appears as cellulite.7

Who is the ideal Cellfina® candidate?

The ideal Cellfina® patient has good skin quality with minimal laxity.

This means the treatment is often not suitable for those over the age of 55. As excessive weight may also result in more severe cellulite dimples, the treatment is best suited to those with a stable weight.

Can you explain the science behind cellulite dimples?

The way fat is laid down in our skin is linked to our hormones and of course to our genetics. Oestrogen, which is at higher levels in women, affects the structure of fat and connective tissue.1 While women produce fibrous bands which are wider apart and more perpendicular to the skin, the fibrous bands in men develop with a more of a mesh-like pattern.

This means less fat cells are contained in the spaces of the mesh in men compared to the large compartments in women. This results in more bulging of fat and, therefore, cellulite dimples in women.1 For this reason, around 85% of post-pubertal women have cellulite dimples.3

At what point should a patient consider having the Cellfina® treatment?

Cellfina® is effective even for one or two deep dimples, so for those patients who have tried other options and failed to get any improvement in their cellulite, then Cellfina® would be the next appropriate step, once the criteria regarding age and skin laxity are met.11

How long do the results of Cellfina® last and what are the benefits of this?

Based on the work of dermatologist Dr Doris Hexsel and her extensive years of experience treating cellulite dimples with subcision, the fibrous bands do not regrow once subcised. So theoretically the results

Emma, treated at Specialist Skin Clinic “The cellulite dimples on my buttock area had become much more visible during my 40s, and the orange peel effect was starting to appear on the top of my legs and thighs. I researched the treatment and the findings, and supporting images demonstrated Cellfina® made an impressive difference to cellulite dimples. I decided to give it a go. I removed the dressings the next day and my husband could not believe the difference. The cellulite dimples had completely gone. It is amazing. I did encounter bruising, which lasted two weeks, and some tenderness, but nothing to complain about. It is now four weeks since I had the treatment and the skin continues to improve. I am absolutely thrilled with the results.”

Before

After

Images courtesy of Dr Maria Gonzalez

REFERENCES 1. Wanner H, Avram H. An evidence-based assessment of treatments for cellulite. Drugs Dermatol.

2008; 7:341-5.

2. Worldometers, Population by gender, age, fertility rate, immigration <http://www.worldometers.info/ world-population/world-population-gender-age.php>.

3. Avram MM. Cellulite: a review of its physiology and treatment. J Cosmet Laser Ther. 2004; 6:181-185.

4. CEL-DOF1-001_01 Cellfina – Global cellulite market research, October 2016.

5. Kaminer et al., Multicenter pivotal study of vacuum-assisted precise tissue release for treatment of cellulite – Dermatol Surg | 2015;41:336-347.

6. Kaminer, M.S., et al., A Multicenter Pivotal Study to Evaluate Tissue Stabilized-Guided Subcision Using the Cellfina Device for the Treatment of Cellulite With 3-Year Follow-up. Dermatol Surg, 2017(0): p. 1–9.

7. Green J, Cohen J, Kaufman J, Metelitsa A, Kaminer M, Therapeutic approaches to cellulite, Semin Cutan Med and Surg. 2015;34:140-143.

8. Cellfina CE Mark Approval, July 2016 9. US Food & Drug Administartion, Cellfina, <https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/ pmn.cfm?ID=K161885> 10. Kaminer et al., Multicenter pivotal study of the safety and effectiveness of a tissue stabilisedguided subcision procedure for the treatment of cellulite: 3 year update – American Academy of Dermatology (74), 2016 11. Cellfina Instructions For Use, 2017

What do other practitioners say?

Dr Benji Dhillon, PHI Clinic

“With Cellfina® I am now able to offer a treatment for cellulite that is precise, consistent and addresses the underlying structural causes of it with high rates of patient satisfaction.”

Find out more about Cellfina®at CCR on the Merz Aesthetics stand (J10) - 4th and 5th of October 2018.

Dr Dinesh Maini, Zenith Cosmetic Clinic

“The Cellfina® machine is a huge advance. I have been shocked by its effectiveness and it has exceeded my expectations.”

Dr Apul Parikh, PHI Clinic

“My patients are delighted with their Cellfina® treatments. We can finally offer a robust, proven solution for cellulite dimples.”

Hear plastic surgeon Mr Nick Rhodes talk about his experience with Cellfina®, including treatment details: BAAPS - 4th October 2018 at 2.55pm. CCR Expo - 4th October 2018 at 4.15pm, and 5th October 2018 at 2.30pm.

Cellfina® - BAAPS platinum sponsor / CCR Expo non-surgical theatre headline sponsor.

For more information about Cellfina® call 0208 236 3516 or email customerservices@merz.com M-CEL-UKI-0249 Date of preparation: July 2018 Aesthetics | August 2018

45

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Nose Reshaping with Threads Dr Simon Berrisford details case studies on the use of PDO threads and HA filler in non-surgical nose reshaping The popularity of nose reshaping in the UK is apparent; the British Association of Aesthetic Plastic Surgeons (BAAPS) annual report into trends in 2017 indicated an increase of 2% in surgical rhinoplasty.1 However the trend towards ‘soft surgery’ or minimallyinvasive treatments continues, and in my own clinic I see patients requesting non-surgical nose reshaping almost every day.

For minimally-invasive non-surgical purposes the nose can be divided into two parts, the visible external and the hidden internal.

It is the visible external part that we are concerned with in aesthetic medical practice. This is the protruding part whose shape is determined mainly by the ethmoid bone and the cartilaginous nasal septum.2 It is important to recognise the nose as a ‘mobile organ’ whose musculature is involved in function such as dilation of the nostrils by the dilator naris muscles and in communicative facial expression by the procerus, the alar nasalis and the levator labii superioris alaeque nasi and others. The point of this is to understand that changes to the shape of the nose must be considered not only in the resting neutral expression but also in normal expression.

The types of presentations to aesthetic clinics include those who would like parts of the nose increased in size, those who need parts decreased in size, and those who require only positional change. It is important to clarify these requirements early on as patients often do not understand that adding HA filler materials or polydioxanone (PDO) threads to the nose will make the overall size larger, not smaller. Generally, those who require reductions in size of a segment of the nose should be referred to a plastic surgeon specialising in rhinoplasty. The precise width, angle and tip shape of the nose can become something of an obsession for some patients who may focus upon this and present with a history of multiple previous procedures, each followed by dissatisfaction, with a complaint that one can barely discern but the patient insists is dreadful. In my clinic, each new patient is given an iPad on arrival in order to fill in their personal details and their medical history, view the relevant consent form for their proposed procedure and then complete the Body Dysmorphic Disorder Questionnaire (BDDQ).

This test has been validated and can be quickly administered to select those most at risk of having the condition.3,4 Our in-house psychologist is then available for assessment and referral if the patient agrees.

History of nose reshaping using fillers and threads Nasal reshaping dates back to New York at the turn of the 19th century when liquid paraffin was used to correct the common ‘saddle nose deformity’, but proved to be harmful.5,6 More modern materials appeared in the 1960s, such as silicone and bovine collagen, and were more successful. It was in Asia and in particular South Korea, where the appetite for making the nose look more Western has

Aesthetics

driven the development of techniques to achieve minimally-invasive rhinoplasty7 – sometimes dubbed by certain clinics, especially in the US, the ‘lunchtime nose job’ or ‘liquid rhinoplasty’.

The next step was the Hiko nose thread-lift developed in Seoul 15 years ago.8 Hiko means ‘high nose’. The procedure, which uses polydioxanone (PDO) threads, can achieve a higher and straighter nasal bridge, a sharper definition of nasal profile and a more defined nose tip. This procedure has advantages over dermal filler procedures as the PDO threads cannot migrate out of position and widen the nose unnecessarily.8 Also, the main risks of dermal filler injections into the nose include occlusion or compression of blood vessels leading to visual change or loss9 and skin necrosis. These risks are minimised by the thread lift procedure as, by their nature, the threads cannot be injected into vessels and do not move out of their original position.

Selecting the appropriate treatment For patients attending their initial assessment, it is important to differentiate between those who have contraindications amenable to dermal fillers and/or PDO thread insertion, and those who will require open surgery. As an example, a patient attending my clinic recently was a Philippino female who considered herself to have two problems with her nose. Firstly, she had a deep glabella and radix which affected her profile significantly, and secondly, she had a very broad lower third which she wanted to be narrowed into the Western shape. In this case, it was possible to correct the first issue with dermal fillers injected into the glabellar region to make it project further and straighten the profile of the dorsum of the nose. However, it was not possible to narrow the lower third with threads, or any other non-surgical procedure so the patient was advised accordingly. The options for patients considering nasal remodelling include surgery, hyaluronic acid fillers, calcium hydroxyapatite fillers, PDO threads, PDO cogs, which are barbed threads, and hybrid procedures utilising more than one of these options. It is important to understand what your limitations are and discuss this openly with the patient.

Case study one The first patient described is a 40-year-old female whose nose was deviated to her left after being hit in a disturbance at a party several years ago, probably breaking her nose and most certainly shattering her confidence. As she did not seek medical assistance at the time, the nose remained permanently deviated but she was unable to face open surgery, which was the most suitable procedure for her.

Before

During

After

Six weeks post treatment

Figure 1: 40 year-old patient was treated with PDO cogs to straighten the nose

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Instead, it was agreed that we might attempt to shift the soft tissues of the nose to the right to improve her visage when viewed from the front, without attempting to alter the underlying structure. The patient preferred the idea of threads, and I decided on using PDO cogs as they can ‘pull’, whilst filler can only ‘push’. I would select cogs when trying to correct a deviation rather than a defect. Lidocaine was injected into the glabella region and three barbed absorbable PDO cogs were inserted and guided downwards toward the tip of the nose. Two were placed laterally, so as to allow the soft tissue to be pulled to the side, and the third centrally to allow the tip to be raised and reduce the hump on the dorsum of the nose. The cogs selected were 100mm 19g PDO as this is the widest gauge, giving best grip for a good pull. The type used in this case was the Honey Derma 3D cogs. These were chosen because, in my experience, they anchor strongly to the tissues after being placed in the supra-periosteal and then supra-chondral planes. With the patient able to watch, which can be helpful as they can indicate when they are happy with the correction, tension was applied to the anchored cogs and the nose pulled back towards the centre. A significant improvement was achieved, despite the obvious post-operative swelling. The light reflex on the after picture can be seen to be linear in comparison to the pre-op picture which is decidedly curved. After the swelling had subsided at the six-week check the result was even more effective.

Case study two

The second patient was a 32-yearold female who had undergone open surgery previously and remained dissatisfied with the appearance of her nose. She still felt that the profile showed a central hump with a depression above and below. The patient After also felt that the tip dipped down too far and she would like it raised. Both issues were minor but she was disappointed that they still existed after her surgery three years ago. On examination, the soft tissues of the nose were quite mobile over the Figure 2: 32-year old patient was underlying bony and cartilaginous treated with PDO threads using the Hiko method structures. By sliding the tissues a few millimetres cranially, it was possible to disguise both the bony hump and to raise the tip.

The patient did not want to have dermal filler injected as this may bulk out the nose, which she wanted to remain slim. PDO threads were discussed as an alternative. This patient was treated with the Hiko method, with lidocaine to the nasal tip and two different sized threads. The dorsum was treated with 29g 38mm mono threads of the Honey Derma type, and the columella treated with 30g 25mm mono threads. The result was the minimum needed for the patient to be happy with the outcome whilst not increasing the size of the nose noticeably. I believe this would not have been achievable with dermal filler.

Before

Considerations Nose reshaping should be considered an advanced procedure in view of the risks associated with it. The anatomy of the nasal organ is complex and variable, and the vessels travel onto vital and delicate structures, such as the eye. Also, the skin of the middle

Aesthetics

This patient was treated with the Hiko method, with lidocaine to the nasal tip and two different sized threads third of the nose is the thinnest and most strongly adherent to the sub structures with the least ability to stretch to accommodate dermal filler, PDO threads and surgical instruments. Products put into this area can cause pressure increase and subsequent compression of vessels, as well as the more obvious danger of intra-arterial injection of product. This can lead to blindness and skin necrosis, which are unlikely to be recoverable. The best treatment to attempt should this happen is injection of significant amounts of hyaluronidase into the area and ideally into the affected blood vessel.10 Summary The minimally-invasive nose reshaping procedure is becoming rapidly more popular, but should not be considered a natural extension of one’s repertoire just because one already uses a certain treatment. The complications can be disastrous and a thorough understanding of nasal anatomy is needed. I believe PDO threads appear to offer an effective alternative without the risk of intra-vascular injection for treating the nose.

Dr Simon Berrisford has 25 years’ experience in the medical profession and is a member of the British College of Aesthetic Medicine. He has worked in general practice, been a consultant medical editor at Pulse Magazine and written and lectured on a broad range of medical topics.

He is the medical director of Select Aesthetics in Cheshire.

REFERENCES 1. BAAPS, Cosmetic surgery stats: dad bods and filter jobs, (2018), <https://baaps.org.uk/media/ press_ releases/1535/cosmetic_surgery_stats_dad_bods_and_filter_jobs> 2. Richard W Brand, Donald E Isselhard, Anatomy of Orofacial Structures E-Book: A Comprehensive Approach, P. 312 3. Laryngoscope. 2016 Aug;126(8):1739-45. Epub 2016 May 25. Body Dysmorphic Disorder in aesthetic rhinoplasty: Validating a new screening tool. Lekakis G1, Picavet VA, Gabriëls L, Grietens J, Hellings PW 4. Sabine Wilhelm, Jennifer L. Greenberg, Elizabeth Rosenfield et al. The Body Dysmorphic Disorder Symptom Scale: Development and preliminary validation of a self-report scale of symptom specific dysfunction, Body Image. (2016) Jun; 17: 82–87. Published online 2016 Mar 11.

5. A.JMartineauF , The Lancet, A Case of Saddle-nose Treated by subcutaneous injection of Paraffin, Volume 160, Issue 4119, 9 August 1902, Page 351 6. Kontis TC, Rivkin A, The history of injectable facial fillers, Facial Plast Surg. 2009 May;25(2):67-72.

7. Léonard Bergeron and Philip Kuo-Ting Chen, Asian Rhinoplasty Techniques, Department of Plastic and Reconstructive Surgery, Craniofacial Center, Chang Gung Memorial Hospital, Taipei, Taiwan 8. Chiam Chiak Teng, The Perils of Non-surgical Rhinoplasty: A Safer Approach Needed? A Comparison between PDO nose threads and fillers, (2017) <https://www.ifaas.co/single-post/2017/01/18/The-Perilsof-Non-surgical-Rhinoplasty-A-Safer-Approach-Needed--Review-of-Applying-PDO-Nose-ThreadLifting-Compares-to-Fillers> 9. Carruthers, Jean et al. Avoiding and Treating Blindness From Fillers: A Review of the World Literature, Dermatologic Surgery: October (2015) - Volume 41 - Issue 10 - p 1097–1117 doi 10. Joo Hyun Kim Duk Kyun Ahn Hii Sun Jeong and In Suck Suh, Treatment Algorithm of Complications after Filler Injection: Based on Wound Healing Process, J Korean Med Sci. (2014) Nov; 29(Suppl 3): S176–S182. Published online 2014 Nov 21.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Key treatment subunit areas Below are the three key areas practitioners should be looking to address, together with my treatment approach.

Jawline Sculpting with Filler Dr David Ong presents his preferred treatment technique for sculpting and shaping the jawline using hyaluronic acid dermal fillers Aesthetic patients often present with a loss of continuity that comes with a straight, youthful jawline, commonly associated with agerelated jowling. Facial ageing is a result of fat atrophy and volume loss from both bone resorption and tissue descent.1 Facial jowling can be worsened by the attenuation of the mandibular septum leading to the descent of the superior and inferior jowl fat compartments.2

Considerations for sculpting the lower face The accurate placement of an appropriately selected hyaluronic acid (HA) dermal filler at the mandibular angle, in the chin and the peri-jowl region can recreate an aesthetically youthful and structured jawline. When considering lower third treatments, I would recommend revolumising the upper and middle thirds of the face first, providing superior volumetric support to the jawline.2 The key areas to consider are the temples, cheeks and preauricular regions.

It is important to recreate the angular contours as the face transitions inferiorly from the jawline to the neck. In contrast to the mid-face, where soft transitions make for the aesthetical ideal,3 the jawline should demonstrate relatively sharp and angular transitions to the neck, as a sharp jawline frames the lower third of the face.

To create this look, I use a high G prime filler, in a superficial (subdermal) layer, to accentuate desired angulations and shadowing.

Furthermore, a HA filler with good soft tissue integration is required to provide lift and superior support. A combination of Restylane Volyme, Restylane Lyft and Restylane Defyne are my products of choice here. There are alternative volumising HA fillers that may be suitable for jawline treatment such as Princess Volume, Belotero Volume and JuvĂŠderm Voluma. Jawline sculpting can be divided into three main treatment subunits: the angle of the mandible, the chin and the peri-jowl region.

1. Angle of the mandible The angle of the mandible is often an overlooked and undertreated area. It is on the lateral aspect of the face and is therefore less often noticed in self-portrait photography and patient self reflection.

The mandibular angle can be defined as an angle formed by the junction at the gonion (the midpoint) of the posterior border of the ramus and the inferior border of the body of the mandible.4 Radiological studies have demonstrated that females have an average gonial angle of 125 degrees however this is highly variable even between aesthetically attractive individuals.5,6 The angle of mandible is a superolateral structure relative to the jowl, and by creating shape and angulation with dermal fillers, volumetric support to the jowls is also provided. When sculpting the jawline, the aim should be to define and enhance a patientâ&#x20AC;&#x2122;s natural mandibular angle.

Technique 1. Identify any volume loss of the pre-auricular space 2. Palpate and mark the angle of the mandible 3. Create an entry point that is superomedial (often 0.5cm) to the angle of the mandible using a 23 gauge needle 4. Mark out the intended inferior border of the ramus and posterior mandibular body (Figure 1) 5. Treat using a 25 gauge 5cm cannula and aspirate prior to injecting to check for intravascular entry 6. Perform slow retrograde threads of dermal filler, tightly approximated (0.1ml per thread) to a total of 0.5ml-1ml per side 7. Gentle palpation between the edge of two fingers helps to shape the product for ideal angular contour Potential difficulties The facial nerve and parotid gland are at risk during shaping of the posterior mandibular ramus as they are both deep structures, located deep to the superficial musculo-aponeurotic system (SMAS). They can be avoided by injecting in the subdermal plane. When injecting the inferior border of the ramus, be mindful of the facial artery as it courses along the anterior border of the masseter. It is palpable at this point and should be identified and protected prior to injection.

Summary Goal: To define and enhance the angle of mandible Depth: Superficial/subdermal Volume: 0.5-1ml per side Technique: Cannula technique Products of choice: Restylane Defyne, Restylane Volyme or Restylane Lyft

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Upper third

Middle third

Lower third

Figure 2: The division of the face into vertical fifths and horizontal thirds8

2. Chin contouring For ideal facial proportions, the face is generally divided into equal vertical thirds (upper, middle, lower) and horizontal fifths (Figure 2). The ideally proportioned chin width is said to occupy the central horizontal fifth of the face.7 A one third to two thirds ratio should exist for the distance between the nasal and superior upper lip border to the inferior lower lip border to the pogonion.7 When contouring the chin, start with a focused assessment of chin length, anterior projection and the depth of the pre-jowl sulcus region. Rickettsâ&#x20AC;&#x2122; Esthetic Plane connects the tip of the nose to the pogonion of the chin and states that the upper lip is an average distance of 4mm to this line and the lower lip is an average distance of 2mm.9 I use Rickettsâ&#x20AC;&#x2122; Esthetic Plane9 as an assessment guide to the overall relationship between the tip of the nose, the lips and pogonion of the chin for lower third facial harmony. The rule of facial thirds can be applied to determine if the chin requires elongation.7 However, as a general principle, ageing causes mandibular resorption and is associated with hyperactivity of the mentalis.2 These factors all contribute to a shortened chin and a less projected lower facial third.

Technique 1. Assess the contour deformity in the pre-jowl sulcus, the mental crease, and the mentalis muscle 2. Palpate and mark the pogonion of the chin 3. Improve the projection and length of the chin with deep dermal fillers via sharp needle using a high G prime product in the deep periosteal plane 4. For cannula treatment, choose an entry point that allows access to the pre-jowl sulcus 5. Aspirate to check for intravascular cannulation 6. Slow retrograde threads, in a spread fanning technique (0.1ml per thread) to a total of 0.5-1ml per side 7. Gentle palpation helps to smooth the treated area Potential difficulties The inferior alveolar artery and nerve exiting from the mental foramen are the main dangers in this area. The mental foramen is commonly located between the first and second premolar teeth and should be protected from direct injections.10 Summary Goal: To shape and contour the chin Depth: Subdermal and periosteal Volume: 1-2ml total Technique: Cannula for subdermal and needle for periosteal Products of Choice: Restylane Volyme or Restylane Lyft

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3. Peri-jowl region By treating the angle of mandible first, followed by the chin, the soft tissues surrounding the jowl area (superolaterally and inferomedially) will be slightly tensioned. Hence, less product is required when focusing our attention to the jowls directly. In my experience, three perpendicular dermal filler threads can adequately shape the inferior edge of the mandibular ramus.

Technique 1. Identify the borders of the jowls and be mindful not to volumise the area (Figure 3) 2. Palpate and mark the pogonion of the chin and the angle of mandible 3. Mark out lines that connect the angle of mandible to the pogonion of the chin, representing the inferior edge of ramus 4. Aspirate to check for intravascular cannulation 5. Slow retrograde threads tightly approximated of dermal filler product of 0.1ml per thread to a total of 0.5ml per side 6. Gentle palpation between the edge of two fingers helps to shape the product for ideal angular contour Potential difficulties Be careful not to place any volume within the jowls as, in my experience, this will act to worsen the pre-jowl sulcus.

The mental artery, nerve and the facial artery must also be considered during treatment of this subunit and have been previously discussed.

Summary Goal: To straighten and sharpen the jawline by camouflaging the jowl Depth: Subdermal Volume: 1ml total Technique: Cannula for subdermal Products of Choice: Restylane Volyme or Restylane Lyft

The jawline should demonstrate relatively sharp and angular transitions to the neck, as a sharp jawline frames the lower third of the face

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Figure 1: The cannula entry points and the filler thread placement. The arrows indicate the direction of the cannula.

Before

After

Aesthetics

Figure 3: The pre-marking of the jowls. It is important not to volumise the jowls, represented by the area between the lines. The white dots represent the cannula entry points.

Before

After

Figure 4: Before jawline sculpting and after treatment. Results show improved angulation, contours and definition. Angle of mandible: 1ml Restylane Lyft per side (2ml total) chin contouring: 0.5ml Restylane Lyft per side (1ml total).

Figure 5: Before jawline sculpting and after treatment. Results demonstrate a lessening of the jowls and a sharper, more youthful jawline. Angle of mandible: 1ml Restylane Defyne per side (2ml total) Chin contouring: 0.5ml Restylane Lyft per side (1ml total) peri-jowl treatment: 0.5ml Restylane Lyft per side (1ml total).

Considerations and complications

Dr David Ong is the medical director and masterclass trainer at the Facial Aesthetics Centre for Excellence (FACE) Academy in Brisbane, Australia. He graduated from the University of Western Australia in 2009 and proceeded to specialise in cosmetic injectables in California in the US before returning to Australia.

Jawline sculpting is a demanding treatment area. The heaviness and descent of the upper two thirds influence the lower third,2 often requiring the cheeks, temples and pre-auricular regions to be pre-treated. It is a large treatment area, requiring a sufficient volume of dermal filler for complete treatment. This is reflected in higher financial cost to patients, who will in turn be looking for a higher aesthetic outcome. It should only be attempted after adequate training.

The risk of intravascular injection can be minimised by remaining in the superficial (subdermal) plane or the deep (periosteal) planes. Furthermore, I believe aspiration prior to injection can also minimise intravascular risk. A benefit of performing treatment with HA dermal fillers is the ability to reverse treatment with the use of hyaluronidase. Practitioners should be well versed in the use and application of hyaluronidase when treating dermal filler.

Conclusion A straight, youthful jawline is a treatment area commonly requested by aesthetic patients. At the same time, it is a demanding area that should be approached by experienced injectors with suitable training. The jawline sculpting technique describes a treatment progression from the angle of the mandible to chin contouring and to the peri-jowl region. With a focus on anatomical dangers, this technique can provide a safe treatment guide to achieving a good aesthetic outcome for patients.

REFERENCES 1. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992; 89: 441-451.

2. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg. 2008; 121(4): 1414-1420.

3. Coleman SR Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthetic Plast Surg 2006; 26: S4-S9.

4. Mandibular Angle. (n.d.). In Merriam-Webster’s Online Medical Dictionary retrieved from <https://www. merriam-webster.com/medical/mandibular%20angle> 5. Pirgousis P, Brown D, Fernandes R. Digital measurements of 120 mandibular angles to determine the ideal fibula wedge osteotomy to re-create the mandibular angle for microvascular reconstruction. J Oral Maxillofac Surg. 2013; 71 (12): 2169-75.

6. Taleb NSA, Beshlawy ME. Mandibular Ramus and Gonial Angle Measurements as Predictors of Sex and Age in an Egyptian Population Sample: A Digital Panoramic Study. J Forensic Res. 2015; 6: 308.

7. Zhang, David et al. Typical Facial Beauty Analysis in “Computer Models for Facial Beauty Analysis.”

Springer International Publishing. 2016.

8. Milutinovic J, Zelic K and Nedeljkovic N. Evaluation of Facial Beauty Using Anthropometric Proportions. The Scientific World Journal. 2014; 2: 1-8.

9. Ricketts RM. Esthetics, environment, and the law of lip relation. Am J Orthod: 1968; 54:272-289.

10. Currie CC et al. Determination of the mental foramen position in dental radiographs in 18–30 year olds. Dentomaxillofac Radiol. 2016; 45(1): 20150195.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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A summary of the latest clinical studies Title: A Review of the Use of Ultrasound for Skin Tightening, Body Contouring, and Cellulite Reduction in Dermatology Authors: Juhász M, Korta D, Mesinkovska, N Published: Dermatologic Surgery, July 2018 Keywords: Ultrasound, body contouring, cellulite, skin tightening Abstracts: Ultrasound (US) technology uses acoustic waves to heat tissue, resulting in thermal damage and coagulative necrosis leading to the renewal of skin elasticity, body contouring, and destruction of cellulite. This review will discuss the use of US for skin tightening, body contouring/sculpting, and cellulite reduction. A literature search identified studies using US for skin tightening, body contouring/sculpting, and cellulite reduction. Two hundred thirtyone studies were identified using US technology. Twenty studies each were identified addressing body contouring/sculpting and skin tightening, and two studies for cellulite reduction. Ultrasound is efficacious for skin rejuvenation, body contouring, and reduction of cellulite of the face, décolletage, abdomen, and thighs. Ultrasound lipolysis results in a 2-4.6cm decrease in abdominal circumference.

Ultrasound is safe and can be used in all skin types with minimal concern for post-inflammatory hyperpigmentation. Ultrasound seems to be an efficacious, effective, and safe modality for correction of skin laxity, lipolysis, and decrease the appearance of cellulite.

Adverse effects are minimal including procedural pain, postprocedure erythema, and swelling. Clinicians and patients are both satisfied with results after treatment. In this review, the authors will provide an update on the use of US in the dermatologic field.

Title: Review and Clinical Experience Exploring Evidence, Clinical Efficacy, and Safety Regarding Nonsurgical Treatment of Feminine Rejuvenation Authors: Gold M, Andriessen A, Bader A, Alinsod R, French E, Guerette N, Kolodchenko Y, Krychman M, Murrmann S, Samuels J Published: Journal of Cosmetic Dermatology, June 2018 Keywords: CO2 lasers, feminine rejuvenation, radiofrequency devices Abstracts: The use of energy-based devices for the treatment of vaginal laxity, orgasmic dysfunction, and stress incontinence, such as minimally ablative fractional laser and radiofrequency, is gaining momentum. This review aims to answer clinical questions on the application of energy-based devices for feminine genital rejuvenation. The target group includes physicians involved in esthetic medicine and feminine genital rejuvenation. A literature review was conducted on technologies in use for feminine rejuvenation to explore their safety, efficacy, tolerability, patient satisfaction, and clinical usability. A panel of physicians with clinical experience conducting these types of treatment reviewed and discussed the results of the literature search and gave clinical evidence-based recommendations. Energy-based devices may induce wound healing, stimulating new collagen, and elastin fibre formation. Radiofrequency treatment may also increase small nerve fibre density in the papillary dermis, improving nerve sensitivity, sexual function, including arousal and orgasmic dysfunction. Both minimally ablative fractional laser and radiofrequency has been shown to be effective when treating mild to moderate primary or

secondary vulvovaginal laxity and associated secondary conditions.

These treatments are reported to be safe, effective, and well tolerated with a rapid return to activities of daily living. As this is an evolving medical field, clinical evidence often lacks robustness. Studies and clinical experience suggest that feminine genital rejuvenation using energy-based devices seems an attractive option for patients with mild-to-moderate medical conditions. The treatment can be safely and effectively delivered by trained staff as part of the comprehensive care, that is, currently available to women.

Title: A High Crosslinking Grade of Hyaluronic Acid Found in a Dermal Filler Causing Adverse Effects Authors: Keizers P, Vanhee C, Van Den Elzen E, De Jong W, Venhuis B, Hodemaekers H, Schwillens P, Lensen D Published: Journal of Pharmaceutical and Biomedical Analysis, July 2018 Keywords: Crosslinking, fillers, hyaluronic acid Abstract: Facial treatments with dermal fillers for medical or esthetic purposes occasionally give rise to adverse effects, ranging from temporary effects such as reddening of the skin, to long term effects such as hardening of tissue. There appears to be a relationship between the lifetime of the filler product and the risk for adverse effects. The lifetime of hyaluronic acid-based fillers is dependent on the presence and amount of crosslinking agents such as 1,4-butanediol diglycidyl ether (BDDE). It would therefore make sense to establish methodology to analyze the crosslinking grade of HA-based filler products on a routine basis. To this end, an analytical method was developed and validated to identify HA-BDDE-based fillers and to quantify their modification and crosslinking grade. The method was subsequently applied to products from the legal supply chain and the illegal market. It was found that the product Hyacorp H 1000, previously taken from the market, indeed contains a high modification grade and crosslinking grade, as was the assumed reason for the increased risk for adverse effects of this product.

However, it was also shown that the Hyacorp products are highly unreliable in relation to their product composition in general. In this study, authentic products could not be distinguished from the illegal market products based on their modification and crosslinking grade.

Title: Nonsurgical Treatment of Earlobe Aging in Mowlawi Stages I and II Earlobe Ptosis with Hyaluronic Acid Fillers Authors: Di Gregorio C, D’Arpa S Published: Journal of Cosmetic Dermatology, July 2018 Keywords: Aging, earlobe, hyaluronic acid Abstract: Earlobe deflation caused by fat atrophy is normally treated with lipofilling, mostly in the context of facelift surgery. In this report, we aim at reporting on Hyaluronic Acid injections to treat earlobe deflation. 16 Mowlawi Grade I and II patients were treated with HA injections, followed by molding to shape the lobule. Effective correction, lasting 14 months on average, is achieved. Five patients needed a touch-up procedure after 4-6 months to improve the result.

Earlobe augmentation with HA is an ideal option for correction of earlobe atrophy in cases of Mowlawi Grades I and II ptosis. Longlasting (about 14 months) correction is achieved with no downtime.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Finance Options to Expand your Clinic Sales manager Sally-Anne Whybrow examines how finance options can help to keep aesthetic clinics on track for expansion It’s a well-known fact that the aesthetic market is growing.1 As the specialty is becoming so saturated, with new clinics opening every day, businesses need to be able to up-scale their treatment offering to remain competitive and meet patient demand. Keeping pace with technological advancements – especially in the new world of developing products and technologies – requires considerable capital expenditure, which clinics may struggle to achieve.

This is where finance options come into play.

Clinics have a number of options that can help to spread the cost of purchasing new equipment and technologies. The range of financing techniques available is described later in this article, but they would typically be available for new equipment and technology including lasers, imaging systems and other aesthetic devices.

Not only that but making use of finance options also allows clinics to deploy precious funds into other areas, for example to improve service quality, like staff development and marketing.

Working with financers In order to get funds to add your new treatment into clinic, you will have to go through a third party finance company, some of which are specialist and some are not.

A financer’s main role is to help your business acquire the technology you need, in a way that’s affordable and sustainable, and fits in with the revenues that the equipment is likely to generate. Sometimes the finance is ‘integrated’ – offered as part of the equipment sales package. At other times, it is ‘referred’ –

where the technology vendor recommends a particular financier.

I would personally recommend that if you are looking for a more tailored financing package, then it may be more beneficial for you to go with a specialist healthcare financer as they usually have an in-depth understanding of aesthetic technology production and the demand for the latest devices. For example, if a clinic wants to purchase a laser device, then the financer might be able to amend the financing period from three years to five years to suit the organisation’s cash flow.

Whichever finance provider you chose to go with, they are likely to have the following options available to you.

Pay to use This option is specifically designed to enable the acquisition of a system, piece of equipment or technology. Usually there will be some form of either a finance lease,2 where the financer purchases and owns the asset then leases it to you, an operating lease,3 where the products and equipment is owned by the financer but is accounted for as a rental expense with no asset or liability appearing on your balance sheet, or a hire purchase arrangement,4 which is where your business can acquire an asset by paying an initial instalment. An example of this would be by paying 30% of the total price upfront and repaying the remaining balance as an agreed monthly installment cost. You will then have full ownership of the equipment.

Some financiers will be happy to flex the finance period and terms and conditions to align with the likely benefits the clinic will

Master agreement To enable rapid purchasing decisions for more devices, a financier will often have a master agreement with a clinic, streamlining the process of agreeing future leases. A master agreement is a framework between the financier and clinic that pre-approves a certain volume of finance in advance, which the clinic can then draw upon as equipment becomes required, without the need to make an individual application for finance each time. In short, this helps the clinic’s financial planning and saves time.

Aesthetics aestheticsjournal.com

gain from the technology. In other words, one clinic’s predicted usage rate for a given piece of equipment – say a fractional laser skin resurfacing unit – may be twice that of another clinic. A smart financier will recognise this and agree a financing period that aligns payments with the rate of earnings that is particular to the individual clinic. Often payto-use financing will cover associated costs of ownership, such as maintenance, into a ‘bundled’ monthly payment.

Of course, a clinic can always buy technology outright if the cash is available. Many, however, prefer to invest their working capital in, say, marketing and advertising, or other activities that will generate new business, rather than tying those funds up in depreciating technology assets.

Results based Financing agreements are increasingly being set up where payments are predicated on the expected benefits of the business, or ‘outcomes’, that the technology makes possible. Savings or gains from access to the technology are used to fund monthly payments, making the technology cost-neutral for the manufacturer. For example, where energy-efficient equipment delivers cost savings from lower energy consumption, a financing plan may align payments to the rate of energy savings made each month.

Both the financier and the clinic must be sure that there are clearly definable outcomes on which to base such payments, so this option is only available in those circumstances.

Working capital solutions Cash flow and working capital challenges do not only arise at the point of acquiring new (often digitalised) technology. New technology may increase throughout capacity and productivity, while improving price competitiveness to the extent that a clinic’s appointments experience a sudden and/ or significant upswing. A good example is non-surgical laser technology that can be used for the aesthetic treatment of many vascular lesions, unwanted hair, tattoo removal and pigmented lesions, enabling clinics to attract more potential patients. The latest laser technology halves treatment sessions, reduces downtime, treats all skin colours and achieves far better clearance than previous technology. This is good news, but brings its own challenges – such as suddenly having to bring in more clinicians or to rapidly extend facilities, which will obviously have an impact on working capital.

Financing services, usually based on some

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Upgrading Since technology and innovation is evolving so rapidly, upgrade periods are shortening. Equipment and technology financers can offer options to upgrade during the arranged financing period, offering protection against technological obsolescence. Typically, this situation occurs in areas such as medical imaging, where precision levels can advance substantially between versions. Upgrades might involve replacing with a newer model, or retrofitting enhancements onto the main technology platform.

This option is clearly advantageous where upgrades are likely in the short to medium term. It is not, however, a technique for technology that is unlikely to change substantially over a typical financing term of five or six years.

form of invoice finance, are available to help manage the cash flow challenges that success through technological advancements

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brings. Invoice finance basically means that the financier buys the clinic’s outgoing bills, so that the clinic gets the money earlier. Invoice finance, for example, can enable clinics to leverage unpaid invoices to unlock funding.

With invoice finance, when a clinic invoices its customer, usually around 85% of the approved invoice total is directly advanced by the finance provider, with the remaining percentage paid once their customer settles the balance.5 Invoice finance provides the clinic with essential working capital so it can invest in expanding its business without having to wait for bills to be paid. Of course, for this to beneficial to the clinic, management must have a very clear view of how and where that faster cash flow can be deployed.

Conclusion I believe that access to state-of-the-art technology is an important part of the development of a clinic’s brand and its marketing. Yet, there is no denying that sudden peaks of investment can be difficult to handle. The answer is not only access to finance, but access to the right kind of finance. Clinic owners that are considering

deferring investment in new technology due to high costs could benefit from specialist finance options to enhance resources without using precious capital.

Disclosure: Sally-Anne Whybrow is the sales manager for Siemens Financial Services in the UK, which offers finance options for clinics.

Sally-Anne Whybrow has over 15 years’ experience in the healthcare sector. Whybrow joined the SFS healthcare team in 2016 after she spent eight years in a global vendor finance company working as new business development manager for the healthcare business unit.

REFERENCES 1. PR Newswire, Europe cosmetic surgery and procedure market forecast <https://www.prnewswire.com/newsreleases/europe-cosmetic-surgery-and-procedure-marketforecast-2017-2026-300554623.html> 2. Siemens, Finance lease <https://www.siemens.com/uk/en/ home/products/financing/equipment-and-technology-finance/ financial-products/finance-lease.html> 3. Siemens, Operating lease <https://www.siemens.com/uk/en/ home/products/financing/equipment-and-technology-finance/ financial-products/operating-lease.html> 4. Siemens, Hire purchase <https://www.siemens.com/uk/en/ home/products/financing/equipment-and-technology-finance/ financial-products/hire-purchase.html> 5. Telegraph, Invoice Financing <https://www.telegraph.co.uk/ connect/small-business/finance-and-funding/invoice-financing/>

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Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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The Unhappy Patient Dr Qian Xu explains how new practitioners can avoid an unhappy patient and provides tips on how which to deal with one should the situation arise Have you ever had that heart-sinking moment when you receive communications from a patient you had treated a couple of weeks ago saying, “I’m not happy with the result, you need to sort it out otherwise I want my money back”? Although this is a scenario that none of us want, I can guarantee that it is something that all of us will come across at least once in our aesthetic careers.

Despite all of your good intentions and doing the best treatment that you can, sometimes the patient is still unhappy with the result. This can be very upsetting and can really damage your confidence. As if that’s not bad enough, if your patient is really unhappy, they could give you a negative review on your social media sites, speak badly of you to other people within the specialty, or even decide to take legal action. Needless to say, this would be devastating for you and your business.

Being able to deal with the unhappy patient effectively is a vital skill you need to learn, and often this is not something that is covered in your foundation training. In this article, I will talk about three common scenarios in relation to the unhappy patient and explain my management approaches.

I would always encourage you to select patients that you can build a long-term relationship with

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When you should say no I believe that the most effective way to reduce the number of unhappy patients you treat is to learn to say ‘no’ to the wrong patients. This will be really difficult to do when you are first starting out because getting patients through the door is not easy, and you will want to do whatever it takes to keep them. It’s a bit like looking for a partner when you are single, if you just go for the first person who comes along and try to make it work, there is a good chance that one or both of you will be unhappy and the relationship won’t last. I would always encourage you to select patients that you can build a long-term relationship with, for example, patients who share your values and understand what you tell them.

It does mean it’s a slower way to grow your business, however it also means that your business will be built on solid foundations and will last for the long term.

As a general rule of thumb, I would avoid treating those who: • Have unrealistic expectations and lack insight into how they can’t be achieved • Do not understand what you are trying to explain to them • Have already been over treated • Are difficult to get on with • Go from practitioner to practitioner and do not stay loyal to any one person • Do not have a realistic budget for your treatments I also believe that body dysmorphic disorder (BDD)1 is an area that needs to be treated with extreme caution because this is something that you are likely to see quite a lot in your aesthetic practice. BDD is a mental health condition characterised by obsessive worries about perceived flaws of one’s body, which other people cannot see. Individuals often develop compulsive routines to deal with these worries, such as regular mirror checking or picking their skin. The severity of BDD symptoms can vary from day to day and among individuals – even in the same person. According to an article published by Bjornsson et al in 2010, BDD is relatively common, with a prevalence of about 2% in the general population and can be as high as 53% in the cosmetic surgery (including surgical and non-surgical) setting.2 In my experience, this is a group of people you should definitely not treat because evidence has shown that cosmetic procedures do not make them feel any better about themselves even though the

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I believe that the most effective way to reduce the number of unhappy patients you treat is to learn to say ‘no’ to the wrong patients

procedure was a success in the eyes of the practitioner.3 Furthermore, you could make their BDD worse.4 What they need is psychiatric input, not aesthetic procedures.

Therefore, it is really important to screen for BDD, and there is an easy-to-use online screening questionnaire you can use from The BDD Foundation.4 If BDD is indicated, then it is your duty not to treat them.

By saying no to the wrong patients, you will not only save yourself a lot of unnecessary hassle, but will be acting in the best interest of those with BDD or BDD traits.

This will mean that you will have more time for the right patients who will value your time and expertise.

When you are happy but they are not So, what if you have been selective, but you still get a patient who is not happy with what you have done, even though it was some of your best work? This can and will happen from time to time.

What you need to do first is to talk to your patient, listen to what they have to say and understand what it is they are upset with.

You need to understand exactly why they are not happy. Maybe they weren’t 100% sure about the treatment in the first place; maybe a friend made a negative comment about them after the treatment or maybe the results weren’t as dramatic as they had hoped they would be. It’s also important to find out what they are expecting you to do about it. Never assume that they want a top up or their money back. Most of the time, they just need to be listened to and know that you are prepared to make things better for them.

Once you have understood why the patient is unhappy, then you can discuss the solutions. Often, this means educating the patient better about what is realistic, and if there is nothing drastically wrong, you can

talk about what you can do differently in the next treatment. It is possible that they may not want another treatment with you, and they may ask for a refund. If they feel very strongly about it, it may be better to just give them the refund and let them go. However, in my experience most patients will appreciate the fact that you took time to understand the problem and that you are taking steps to resolve the issues.

There is no one-size-fits-all solution, so be guided by what they are expecting, as to what solution you offer. Personally, even if I have done nothing wrong, I would still offer some gesture of good will, such as a free skincare product or the next treatment at a reduced cost. If the situation is handled well, the patient will have more respect for you, and could become one of your most loyal patients. Even if they are still unhappy about the result and will not come back to you again, they will hopefully be less likely to post terrible reviews about you online. You see, just because a patient is unhappy about their treatment result, it doesn’t necessarily mean they are unhappy with you.

When you have got it wrong Sometimes, you just have to own up to the fact that your treatment didn’t work quite so well. Becoming a great injector, for example, will not happen overnight, and to expect all of your treatments to turn out perfectly is just unrealistic. However, you shouldn’t let the fear of getting something wrong stop you, because the only way to get better is by doing and learning from mistakes.

Having said that, it is vital that you have had appropriate training on how to inject safely to avoid complications and know how to deal with them if they arise.

I believe that if the patient is unhappy because your technique wasn’t good enough, then it is your responsibility to correct

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it at your own cost. It means that you might be running your business at a loss initially, but view the situation as money spent on education and think of this as an investment.

By bettering yourself, you will significantly increase your earning potential for the future.

In my opinion, learning from real life situations is the best way to learn and the pain of having to spend your own money to correct mistakes will hopefully mean that you will not make the same mistake twice.

Taking responsibility for your own actions and being willing to sort out any issues that arise is what will make you stand out above the crowd. Most patients are reasonable and they understand the risks, and if you show that you care and see them through a problem, they will come back to you again.

Conclusion The topic of ‘the unhappy patient’ is complex, and I have only scratched the surface in this article. A lot of complaints can be avoided by selecting your patients carefully and managing their expectations.

When you do get an unhappy patient, rather than taking things personally and getting upset, offer a solution, reflect on it and try to find ways to avoid it next time. It’s also good to network with other practitioners, so that you can share your experiences and support each other. I would advise joining aesthetic communities; there are many on Facebook such as the one I run, the Aesthetics Practitioners Community closed group, or organisations such as BCAM and BACN. I’d also recommend attending as many events as you can to help you connect with other practitioners.

Dr Qian Xu is the founder and medical director of Skin Aesthetics. She is passionate about teaching and sharing knowledge. Dr Xu has been a lead trainer and mentor at Harley Academy, and she is now setting up her own aesthetics business training academy.

REFERENCES 1. Lifespan,org, BDD <https://www.lifespan.org/sites/default/files/ lifespan-files/documents/centers/body-dysmorphic/bddq-updated-feb2017.pdf> 2. Bjornsson AS, Didie ER, Phillips KA. Body Dysmorphic Disorder.

Dialogues Clin Neurosci. 2010 Jun; 12(2): 221–232 3. Castle DJ, Phillips KA, and Dufresne RG. Body dysmorphic disorder and cosmetic dermatology: more than skin deep. J Cosmet Dermatol. 2004 Apr; 3(2): 99–103.

4. BDD Foundation. Do I have BDD? <https://bddfoundation.org/ helping-you/questionnaires/>

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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Digital Marketing for Devices Digital marketing consultant Adam Hampson explains effective ways to market your clinic’s new machine to optimise enquiries online With the rise in the popularity of nonsurgical cosmetic procedures and industry growth,1 there comes a rise in new machines and technologies. Taking on some of the latest in aesthetic technology is extremely exciting for an aesthetic clinic and the decision to purchase or upgrade is often reactive; it performs well, or better than others, so you invest in it.

But, if you’re not marketing your new technologies at the right time or in the right way then you risk missing out on precious

patient interest, engagement, enquiries and appointments. So, let’s explore effective strategies for marketing your new machine or device in the digital and online setting for optimum engagement. This article will focus on digital marketing efforts in the pre-launch period, although you should continue to market the technology after that.

Plan before you launch Having the latest and greatest machine at your clinic/business keeps you ahead of the

The key to planning and successfully implementing a pre-launch strategy is to create an expectant atmosphere around this machine that is new, exciting and, most importantly, relevant to your target patients

curve, a forerunner in your local aesthetics community, and a trusted source for new treatments. However, unless you have marketed your new device prior to its launch and introduced it into your clinic through a pre-launch campaign, your patients won’t even know about it and certainly won’t be excited about it. Even if you are in your trial period with this machine and using it on a willing patient before taking bookings for it, it’s still useful to market it as ‘coming soon’ to your clinic so that there is some form of expectation when you do decide to launch it. Planning ahead by at least a month is important when introducing a new machine and failing to do so could detract a lot of wind from beneath your new machine’s wings.

This is because you need this time for your website’s search engine optimisation (SEO) and keywords to take effect and rank in a search engine.

One of the most common mistakes is to launch a new machine without implementing a carefully thought-out digital marketing strategy behind it.2 Without marketing your machine properly online, you’re not introducing it to the combined worlds of new and existing website traffic early enough to garner fresh interest.

Most brands and companies will already have a pre-prepared marketing toolkit for those who invest in their machines to use.

Depending on the company, these might include things like case studies and statistics, as well as licensed before and after images, other promotional imagery and branded graphics. These are useful when marketing during your machine’s pre-launch because you may not have this organic content yourself, but you can still provide valuable patient insight into the machine’s capabilities and possible treatment outcome.

When you implement a strategy before the treatment is launched, you effectively stir the pot and entice enquiries, or at least engagement with this new machine. You can then hit the ground running, so to speak, with potential enquiries and introductions when the machine is launched.

Content marketing strategies for your new machine Digital platforms such as social media, your website and blog are ideal places for marketing your new machine. By combining these, you have the potential to reach new traffic and convert those already trusted in your services to a new treatment course.

The key to planning and successfully implementing a pre-launch strategy is to

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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To build trust in your brand and the new machine during pre-launch marketing, include photos of you and your team during and after their training to showcase professional development

create an expectant atmosphere around this machine that is new, exciting and, most importantly, relevant to your target patients.

Create a web presence When you introduce a new device, you should firstly ensure it is showcased on your website around four weeks before you launch. This could take the form of a banner on your home page that is complete with a product photo and language invoking that this machine is the machine for the selected treatment, and an exciting ‘coming soon’ cliff-hanger (Figure 1). Personalise this approach with a solution to a problem this machine treats or pose a rhetorical question related to this problem area, such as ‘do you have stubborn cellulite?’

This will lead your website traffic’s thought processes into how this new machine could benefit them, and potentially lead to further investigation and enquiries.

This teaser banner can include a URL link that takes the individual to a full treatment page dedicated to your new machine on your website and/or blog posts regarding it. This is where, through engaging copywriting and carefully chosen images, you can cultivate more of an understanding of this new treatment or machine. Break this down into key information; present a short and engaging title that encapsulates the machine’s unique selling point. Short imperatives such as ‘restore lost volume’ or ‘reintroduce a natural glow’ are suggestive of treatment outcomes before your traffic is even aware of the procedure. Follow this with the areas or conditions this machine targets, and frequently-asked

questions. This prepares your potential patient with all the information they need to decide whether they are interested in the treatment or not, and signing off your blog posts with a call to action to contact you provides a real-time potential for enquiries.

and are usually already acquainted with your treatments, so engaging them with a new machine is paramount.

Curate a careful content campaign by utilising the marketing materials that may have been provided to you from the company or create your own. Use stock images, your brand colours, text, and your logo to provide an infographic, for example.

New machines mean new training, and this is ideal for social media interaction. In order to build trust in your brand and the new machine during pre-launch marketing, include photos of you and your team during and after their training in order to showcase professional development and the perceived skills necessary in order to use this machine.

Letting your following see the faces behind this new machine to learn who will be carrying out the treatment is likely to boost their trust in your brand.5 Photos with the industry leader, trainer, or even machine branding in the background coupled with smiling faces and certificates work well on social media, and your patient base will reward you for it.

Conclusion Organic reach and SEO Remember that for your new device to be successful on your website you need your website to be well-positioned on search engines. This provides you with a ‘base’ of traffic to communicate your new machine to. The aforementioned web content should contain search engine-friendly attributes like keywords and satisfactory page lengths to positively contribute to your SEO.3 For keywords, you need to place yourself in your traffic’s (or potential patient’s) shoes; they might not know the technical name or brand for a treatment but know they would like the effects and results of it. For example, if the treatment provides the results of a ‘nonsurgical facelift’, use this phrase as a keyword, rather than its full treatment name that your potential patients wouldn’t recognise or even know yet. By using these accommodating phrases in your copywriting and other targeting techniques, consumers searching for treatments that deliver their desired results are more likely to find your website and engage with your content.4

When adding a new machine or treatment to your digital marketing strategy, it’s important to act pre-emptively and proactively rather than reactionary. Build the suspense, interest, and prestige of the machine before you launch with an event, open day, or treatment taster offer and you increase your chances of attracting enquiries and conversions.

Adam Hampson is the director of Cosmetic Digital, a web design and digital marketing agency based in Nottingham that works with clients in the cosmetic, aesthetic, and healthcare sectors.

REFERENCES 1. Business Wire, ‘Global Medical Aesthetics Market to Grow at a CAGR of 12.2% by 2023: Shift in the Preference from Surgical to Non-Surgical Procedures’, <https://www.businesswire.com/ news/home/20170802005575/en/Global-Medical-AestheticsMarket-Grow-CAGR-12.2> 2. Entrepreneur, ‘4 Strategies for a Strong Early Marketing Plan’, <https://www.entrepreneur.com/article/299818> 3. Search Engine Land, 8 major Google ranking signals’, <https://searchengineland.com/8-major-google-rankingsignals-2017-278450> 4. Cyberclick, ’10 marketing strategies for your product launch’, <https://www.cyberclick.es/numericalblogen/10-marketingstrategies-for-your-product-launch> 5. OnePageCRM, ‘5 ways to win your customers trust with content’, <https://www.onepagecrm.com/blog/win-customerswith-content>

Social media content Social media is exceptionally useful at reaching and converting your audience who already have experience and trust placed in your clinic. Your followers, especially those in your local area, likely know of your services

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

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“It’s very important to have someone observe and critique me each year” Dr Raul Cetto reflects on his pathway into aesthetics from his surgical beginnings, the importance of peer feedback and his love for training Born in San Diego, California, Dr Raul Cetto experienced a cosmopolitan upbringing, growing up in several different countries before beginning his medical degree at the University of Guadalajara in Mexico and later transferring to the University of Arizona. Now settled in the UK, he is a visiting researcher at Imperial College London, owner of Clinic 1.6 in London, the medical director and a trainer for Harley Academy and acts as a key opinion leader for Teoxane UK. Dr Cetto first discovered his passion for facial aesthetics while working as an intern at the Banner University Medical Center in Arizona and later specialising in ear, nose and throat surgery. He reflects, “I always liked medicine and assisting people even before I was a doctor. I used to volunteer as a paramedic and I thrived on the fast-paced environment. In 2005 I completed one year of social service in rural Mexico and as a medical volunteer in a Somalian refugee camp. After I qualified from the University of Arizona, I came to the UK where I started my foundation training at the East Anglia Deanery, then core surgical training at the London Deanery in 2009, which was themed in ENT. After this, I proceeded to higher surgical training in ENT at the London Deanery where I was an academic registrar.”

It wasn’t until Dr Cetto assisted in organising a rhinoplasty course at St Mary’s Hospital in 2010 that he began to expand his knowledge of the evolving world of non-surgical aesthetics. He recalls, “At the annual course, which focused on the aesthetic side of rhinology, one of the speakers was aesthetic practitioner Dr Tapan Patel. At the time, not many of my colleagues from the surgical side of medicine knew much about non-surgical aesthetics. I remember listening to Dr Patel discuss everything that aesthetics can be applied to and it really sparked an interest within me.”

Initially, Dr Cetto found the aesthetics specialty a little overwhelming due the high amount of information and products that were available. However, he soon learnt that applying his surgical perspective to aesthetics enabled him to successfully navigate the space. He explains, “Like many of us, you don’t know where to start because there is so much out there and so many claims from manufacturers. The way that I learnt to approach aesthetics is the same as anything in medicine, which is with an evidence-based and scientific-based approach.”

Opening his own clinic in 2016, Dr Cetto holds continued education and constructive criticism as two of the most important factors in his further development. He explains, “I try to go to as many congresses as I can and do at least three courses annually where I refresh my anatomy, my injecting skills and my general knowledge.” He adds, “I think it’s very important and valuable to have someone observe and critique me doing my job each year. It’s very easy, even if you work in a busy clinic, to get caught up in your own ways.”

Passing on information and educating others is also of high importance to Dr Cetto, which is why in 2016 he began his role in

teaching through Harley Academy. “Training is something that has always been part of my career, in medicine there is the ‘see one, do one and teach one’ mentality and the apprenticeship style of training is very common,” he says, adding, “Therefore, beginning a role as a trainer was something that felt very natural. When I was approached

by Dr Tristan Mehta before he started Harley Academy I was very happy to have the opportunity to further the education of others in my own field.”

His cultured upbringing has resulted in Dr Cetto being able to speak various languages and he has recently performed lectures and live demonstrations in Spanish, Italian and Portuguese. He explains, “I have taken advantage of the fact that I’ve lived in so many countries, so that means that I speak a few languages and have had the opportunity to put them into practice. If there is one thing I’ve learned, it’s that you may be able to speak a different language but having to do your job in a different language is very different!”

Although not all of his experience throughout his career has been directly relevant to aesthetics, Dr Cetto cites them as indispensable to his progression as a practitioner and believes that those looking to enter the specialty should keep this in mind. “The experience of managing theatre lists in the NHS and dealing with complications, even if they are completely different from what you are doing in the aesthetics field, is very, very valuable. I think that everyone should have that experience before they embark on a career in aesthetics,” he concludes.

What treatment do you enjoy giving the most?

I love treating noses using dermal fillers. I find any treatment with dermal filler is very gratifying as you can change someone’s appearance so quickly and the look on their face when they see the end result is just incredible.

What is the best piece of career advice that you’ve been given?

Don’t try to run before you can walk. Everyone’s career progression is a little bit different. A piece of advice that I took from someone who I really admire, aesthetic medicine doctor Mr Geoffrey Mullan, is, “Treat an aesthetic patient as any other patient you would see in medicine. Be kind, do what is in their best interest and follow them up.”

What advice do you give to those beginning a career in aesthetics?

Always to approach aesthetics like any other branch of medicine and train yourself in a structured way. Continue to set milestones for yourself to achieve and build from there.

Yes, I am a trainer but this is a very rapidly evolving field and I am constantly learning.

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

@aestheticsgroup

The Last Word Dr MJ Rowland-Warmann discusses why she believes aesthetic practitioners need to take uniform policies more seriously and outlines where she thinks the industry is going wrong Uniforms are introduced to us all from a very young age and it is likely that many of us will wear some sort of uniform for the rest of our professional adult lives.

As early as the nineteenth century, doctors wore recognisable white lab coats to treat their patients, this was to connote authority and attempt to distinguish themselves from mystics and ‘quacks’.1 Professions from policemen to paratroopers have a history of livery to inspire, protect and assist, so wear uniforms that reflect this. But what is the dress code for an aesthetic practitioner, who I believe also has a duty to inspire, protect and assist?

Few will be able to argue that uniforms do not have a valid purpose; the right attire can actively promote patient safety and hygiene, as well as showing patients you take your professional presentation seriously. They’re also an opportunity to identify with your team and improve morale. Unless you’re a particularly fashion-conscious practitioner, isn’t there also something liberating about not having to choose an outfit each morning?

Dressing appropriately is not just for your benefit, but it shows how our fledgling profession is viewed by others such as patients and aesthetic colleagues. Clinicians should ask themselves, how do you want to present yourself? How do you want to present your corporate entity? But most importantly, how do you want to present the aesthetic industry to the public? So, why am I so frequently surprised by some of the most experienced practitioners in what they perceive as appropriate?

Aesthetics Journal

Aesthetics aestheticsjournal.com

Current guidelines There are no guidelines set out by any medical regulatory bodies on what is classified as suitable attire for aesthetic practitioners working in private clinics.

The British Medical Association (BMA) advises that it is good practice to ‘dress in a manner which is likely to inspire public confidence’, ‘wear clear identifiers (i.e. a name badge)’ and ‘keep finger nails short and clean’, whereas it is seen as poor practise by the BMA to ‘wear hand or wrist jewellery/wristwatch’ and ‘wear false nails for direct patient care’.2 In dental practice, uniforms are mandated – the practitioners are not permitted to wear these uniforms outside the practice and the same goes for the NHS;3 this is a significant issue that a lot of practitioners fall foul of. This is for the simple reason that outside germs should be kept away from procedures, and biohazards should stay within the practice to protect the wider public. A report released by the National Institute for Health and Care Excellence indicated that in 2010 in England, infectious diseases accounted for 7% of all deaths and around 300,000 patients a year acquire a healthcare-associated infection as a result of care within the NHS.4 This just confirms how important hygiene is.

Personal protective equipment (PPE) guidelines state that personal appearance must be tidy, long hair should be tied back, earrings to be studs and a conspicuous absence of any rings or watches.

These are just the top line minimum standards, but are supported by a study held by Cambridge Core which shows that bacterial load and bacteria transmitted were significantly higher on ringed fingers compared with control hands.5,6 I shouldn’t need to elaborate on why uniforms should be gold standard in performing any type of medical procedure for cross-infection purposes. You know not to wear your hair down when performing a thread lift and are likely to be aware of the types of bacteria living on the skin and hair. Your patients don’t deserve to develop an infection after treatment from the bacteria stuck under your watch strap. Yet time and time again I see practitioners treating their patients, pausing to flick their hair out of their eyes with a gloved hand and rings bulging through nitrile.

Symbolic meaning Not only is dressing appropriately for clinical treatments vital in ensuring health and safety standards are high, but it has been indicated through a 2012 study held by the Journal of Experimental Social Psychology that wearing a uniform can increase work performance and instil trust for the patient. ‘Enclothed cognition’ is the product of research surrounding the symbolic meaning of specific clothes, coupled with the physical experience of wearing them. It found that lab coats on physicians not only make patients pay more attention, but actually increase the wearer’s sustained attention and ability. Those who donned lab coats performed better in critical tests versus the group who wore their own clothes.6 Whether it’s lab coats or other scrubs, there is a genuine and real argument that what you wear matters. It has been shown to increase the receptive performance of the patient and the clinical performance of the caregiver, even improving attention to detail. This has not only been demonstrated in medicine, but across the board in professions and disciplines; think barristers’ gowns, chefs’ hats and I’m sure you’d agree that putting on your gym gear makes you more likely to become active.

So, if wearing the right clothes makes you a better clinician and improves patient outcomes then why do so many just get it so wrong?

Reproduced from Aesthetics | Volume 5/Issue 9 - August 2018

Aesthetics

Presenting at conferences When I watch others demonstrate medical procedures, I often find myself asking whether a medical procedure is taking place or if it’s a night out on the town. Aesthetics is a glamorous industry, there’s no disputing that. Like the very patients we treat, practitioners are often conscious about the way they look too. Some will think that wearing a designer suit shows others they are a good practitioner because it’s opulent and aspirational. But, we need to be thinking harder about this. What sort of patients do you really want to attract and how do you want your specialty to be perceived by others? Not only that, but it is important to think about the messaging we are sending to our junior peers. Are we a serious profession, or a multitude of blundering fools fixated on fashion?

I have found that this is particularly apparent at industry conferences, so it’s not only within the practice that our attitude to attire should change for the benefit of patients. Conferences are a place to be educated, share knowledge and to network with friends and colleagues, not to show off who has the most success by the tag on your suit, and we still need to maintain clinical standards, especially when performing live demonstrations.

Conclusion As aesthetic practitioners we need to stop hiding behind the lack of regulations and perform a little more self-discipline with the hope of shaping opinion across the industry. Alongside the obligatory mask and gloves, I believe that scrubs or, at the very least, lab coats should be considered mandatory.

Appropriate medical clothing to perform aesthetic procedures should not be optional. It enhances patient safety and reinforces the professionalism with which we, as medical professionals, should present ourselves. I believe that clothing choices must be appropriate and overtly professional. They should correlate with the serious and technically demanding job that aesthetic practitioners are part of, which I believe contributes to the specialty’s standards and reputation. Changing the mentality of an entire industry requires the kind of effort that we can only achieve with a global, concerted and paradigm shift in attitude. I think we should all start to think about changing the fabric of aesthetics – for the sake of our patients.

Dr MJ Rowland-Warmann is the founder and lead clinician at Smileworks dental and facial aesthetics practice in Liverpool. In 2016, she completed her MSc in Aesthetic Medicine (with distinction) from Queen Mary University of London. She has a special interest in the management of complications; writing extensively on the subject.

REFERENCES 1.

BBC, Death of the doctor;s white coat <http://news.bbc.co.uk/1/hi/health/6998877.stm> 2.

British Medical Association, Dress codes at work, 2018 <https://www.bma.org.uk/advice/ employment/contracts/consultant-contracts/dress-codes> 3. http://www.nhsborders.scot.nhs.uk/media/154759/dress_code_uniform_policy.pdf 4.

National Institute for Health and Care Excellence, Infection control <https://www.nice.org.uk/ guidance/qs61/documents/infection-control-briefing-paper2> 5.

Isopharm, PPE, staff uniform & appearance, https://www.isopharm.co.uk/dental/ppe-staffuniform-appearance 6.

Cambridge Core, Infection Control & Hospital Epidemiology <https://www.ncbi.nlm.nih.gov/ pubmed/19344265> 7.

Science Direct, Enclothed cognition, 2012 <https://www.sciencedirect.com/science/article/ pii/S0022103112000200>

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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

Keep it natural.

Keep it real.