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Hot and cold Heating versus freezing for body shaping and fat reduction

What lies beneath Anatomy and physiology of the skin CPD accredited article

The thick of it

The latest methods and procedures in FUE hair transplant technology

Don’t sweat it

Balancing act

HA Fillers

Dr Patrick Bowler on new technology for treating primary axillary hyperhidrosis via radio frequency

Wendy Lewis on how to strike a balance between art and science in clinic marketing

A surgeon’s view on the use of Hyaluronic Acid (HA) fillers in a facial aesthetics practice

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Contents • December 2013 INSIDER 06 NEWS The latest news on products, events and medical research 12 ON THE SCENE Out and about exploring aesthetics this month, from seminars to launches 14 NEWS SPECIAL REPORT What powers prevent non-medically trained individuals from injecting toxins?

CLINICAL PRACTICE Filler performance Page 33

CLINICAL PRACTICE 17 SPECIAL FOCUS: BODY CONTOURING Heating versus freezing for fat reduction

IN PRACTICE Marketing Page 52

22 CPD CLINICAL ARTICLE Lorna Bowes on the anatomy and physiology of the skin 27 CLINICAL PRACTICE Plastic surgeon Stephen McCulley on the use of HA Fillers

This month’s contributors

33 CLINICAL STUDY Looking at the results of a study into the physical properties of hyaluronic acid fillers and their relevance for clinical performance 36 TECHNIQUES Dr Alain Gondinet on combining PRP and organic silicon 38 SPOTLIGHT ON Dr Patrick Bowler discusses new technology for sweat reduction in primary axillary hyperhidrosis 40 HAIR LOSS Dr Patrick Treacy looks at the latest methods and procedures in FUE hair transplant technology

Lorna Bowes RGN NIP has trained many aesthetic professionals in fillers, toxins, medical needling, skincare and peels, and lectures regularly on aesthetic procedures. Stephen McCulley is a cosmetic plastic and reconstructive surgeon based at Nottingham’s renowned City Hospital. He is also a member of BAPRAS and BAAPS. Dr Alain Gondinet is an aesthetic medical doctor and nutritionist specialising in antioxidative mesotherapy. He is a medical consultant at Bio Bridge Foundation (Switzerland). Dr Patrick Bowler is a founding member and Fellow of the British College of Aesthetic Medicine. He has featured on GMTV, BBC Radio, Living TV and Channel 4’s Ten Years Younger.

44 ABSTRACTS The latest clinical studies

Dr Patrick Treacy is medical director of Ailesbury Clinics Ltd and Ailesbury Hair Clinics Ltd. He is an active member of many international societies and is a Fellow of The Royal Society of Medicine.

IN PRACTICE 46 AESTHETIC ARCHETYPES Richard Crawford-Small on branding and archetypes 48 BLOGGING John Castro on the benefits of blogging for your aesthetic business

Mike Regan is chair of the Aesthetic Surgery Services Committee (CH403) of the British Standards Institution and works full time as a Laser Protection Adviser in the aesthetics sector.


∞ Weight loss and body contouring focus ∞ Intradermal Botulinum Toxin-A injections for a total facelift ∞ Keogh Review latest ∞ Aesthetics Awards winners

50 IN PRACTICE Wendy Lewis on the art and science of clinic marketing 52 MARKETING Hayley Hutchings on marketing planning for success 54 IN PROFILE We speak to Debra Robson about running a successful body-shaping clinic 56 THE LAST WORD Mike Regan on the latest from the CEN European Standards for Aesthetic Surgery and Aesthetic Non-Surgical Medical Service

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Editors’ letters Welcome to the first issue of Aesthetics, a new journal marking the constant evolution of the medical aesthetics arena and of Cosmetic News. It seems pertinent that as we mark the end of 2013 and move into a new year, we are bidding farewell Vicky Eldridge to the past and welcoming in an exciting new phase Editor both for the Aesthetics brand and myself. While this will be my first issue of Aesthetics, it will also be my last. After five years editing Cosmetic News, I am moving on to pastures new and would like to take this opportunity to thank you, our loyal readers, and everyone who has supported both myself and the publication during this amazing time. My thanks also to the great team I have worked alongside and who will continue to make Aesthetics the must-read publication for medical aesthetic professionals. I would also like to wish the new editor, Leah Hardy, and the team at Synaptiq all the best for the future in taking the publication and its associated events, The Aesthetics Awards and The Aesthetics Conference and Exhibition (ACE), to even greater heights. It has been a fantastic few years and I have very much enjoyed my time as editor of Cosmetic News. My best wishes for the festive season and here’s to a happy and successful 2014.

Editorial advisory board

I’m delighted and proud to be joining as the new editor of Aesthetics. This is a fantastic time in the journal’s history, as it evolves from Cosmetic News with a new name, new design and clear positioning as the leading journal for medical Leah Hardy aesthetic professionals. Some of you may know Editor me already, as I’ve been writing about aesthetic procedures for magazines and newspapers and appearing on panels at conferences for almost twenty years. It has been a tricky time, with the Keogh Report highlighting issues that all good practitioners agree were a problem, but also a positive one, as we rebuild confidence in our industry and see unprecedented demand for non-surgical treatments. Aesthetics is here to support you in making your practice even more successful. With our expert contributors, we aim to bring you the very latest on products, devices, procedures, ethical and legal issues, business development alongside CPD approved educational content and clinical features. Behind everything we do is our common goal of creating happy, satisfied patients. From January, Aesthetics will include a letters page where you will be able to comment on anything in the journal, discuss topical issues and share your experience. So please start the dialogue by emailing me, I very much look forward to hearing from you.

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

Dr Mike Comins is a former President, current committee member and Fellow of the British College of Aesthetic Medicine (BCAM). He is on the faculty for the postgraduate certificate of Cosmetic Medicine, an honorary tutor in cosmetic medicine at Leicester University and is an accredited trainer for advanced Vaser liposuction.

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.

Sharon Bennett is currently Vice Chair of the British Association of Cosmetic Nurses (BACN) and also medical advisor for the BSI on their Beauty Services Sector standard committee. Sharon has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).

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Amanda Cameron is a sales and marketing professional, and was one of the first nurse injector trainers in the UK for dermal fillers. With over 20 years experience in the industry in both the UK and Europe, Amanda has extensive knowledge of medical aesthetics and business development.

Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, who fell in love with the results possible through minimally invasive methods. Now based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

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

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Insider News

Peter Sissons announced as chair of ACE Question Time Former BBC News and ITN Broadcaster Peter Sissons will be hosting an evening Question Time session at The Business Design Centre, London on Saturday March 8 as part of the Aesthetics Conference and Exhibition (ACE) 2014. Mr Sissons will be accompanied by a panel of medical aesthetic experts, who will discuss the latest topics influencing the industry today. Winner of The Apprentice, Dr Leah Totton has been confirmed as a panel member alongside Dr Mike Comins, former president, current committee member and Fellow of the British College of Aesthetic Medicine (BCAM), Dr Tracy Mountford, founder and medical director of The Cosmetic Skin Clinic and Sharon Bennett, vice chair of the British Association of Cosmetic Nurses (BACN). Prior to the debate there will be a drinks and canapé reception, which will provide delegates with the chance to network, share knowledge and communicate their ideas with colleagues. The event will start at 6pm and will last for two hours. The event has limited availability and front row seats are offered on a first come first served basis. Tickets are £39. To avoid disappointment, book your place online today at or call 01268 754 897.

Alma Lasers launches SPEED hand piece for Soprano Alma Lasers has launched a new hand piece for its Soprano laser that allows even faster hair removal. The SPEED hand piece enables practitioners to perform more treatment sessions in less time. A large spot size applicator of 20x10mm also allows larger areas to be treated more quickly. Dermatological clinical studies have proven the safety and efficacy of the Soprano laser, which is based on Alma’s Super Hair Removal (SHR) technology.

New garments from MACOM Medical target baby fat and cellulite Compression garment manufacturers MACOM Medical have just launched a new postnatal garment as well as cellulite busting hotpants. MACOM Postnatal binds the lower ribs and abdomen of women who have just given birth, helping them to get rid of post-baby fat, restore the abdomen’s natural shape and support weakened and separated stomach muscles. MACOM Smooth incorporates Emana® bioactive crystals, which harness the rays of infrared heat energy emitted by the surface of the body to smooth and tone the skin, improve elasticity and increase recovery time post exercise.


Merz Pharma acquires Swiss aesthetic medicine specialist Anteis Merz Pharma has further strengthened its position in the aesthetics market by purchasing the Swiss company Anteis. Anteis specialises in the development, manufacture and commercialisation of biomedical products in the area of aesthetics. The acquisition strengthens the Merz portfolio and reinforces its market position in the field of aesthetic medicine while merging the Anteis operations into one of the leading providers worldwide. The company has also recently acquired Neocutis, which specialises in the development of dermocosmetic pre- and post-treatments for aesthetic procedures. “The acquisition of Anteis by Merz is a unique opportunity to strengthen our presence in aesthetic medicine by bringing innovative solutions to doctors and patients,” said Philip Burchard, CEO Merz Pharma. “Anteis brings substantial additions to Merz in terms of products, talent, geographic presence and manufacturing capabilities. Our two portfolios complement each other perfectly.” Since 2005, Merz Pharmaceuticals has distributed the Belotero® range of fillers, developed by Anteis, which has become a strong global player in the area of injectable medical devices based on biopolymer transformation. The Anteis product lines include Esthélis, Fortélis, Mesolis and Modélis as well as the Jolidermis range and the Anteis Injection System. These products are now available in over 90 countries in five continents.

TUV Rheinland to pay compensation following faulty PIP implants German company TUV Rheinland is to pay compensation to hundreds of women after it awarded EU safety certificates to French breast implant manufacturer PIP. Six implant distributors and 1,700 women sued TUV Rheinland for €50million (£42 million). An initial payment of €3000 will be given to each victim to enable them to have surgery to remove the faulty implants. “Of course TUV has some responsibility and should be held to account. They’re the organisation that gives the CE certification for safety, and that was what my surgeon relied on when he gave the implants to me,” said British woman Jan Spivey, who had PIP implants fitted during reconstructive surgery after she had breast cancer. Founder of PIP, Jean Claude Mas, who ordered employees to hide the sub-standard silicone when inspectors visited the factory, and four of his executives are on trial for aggravated fraud in Marseilles. A ruling is expected for Mas on 10 December.

Aesthetics | December 2013

Insider News

Blood test could detect skin cancer spread Dundee University researchers are pioneering a simple blood test, which can be used to identify patients whose skin cancer has spread. It is believed that such tests will lead to faster diagnoses, and help avoid incidents of cancer misdiagnosis. According to their presentation during the National Cancer Research Institute Conference, the blood test measures levels of a gene called TFP12, found in the DNA in the blood. The landscape of the DNA then helps to identify if the cancer has spread. It is believed, that such findings could not just lead to faster diagnoses, but also new treatments. Particularly difficult to treat, certain skins cancers, such as melanomas, are also notoriously hard to detect. Dr Tim Crook, study author and consultant medical oncologist at the University of Dundee said, “By using a blood test, we have the basis of a simple and accurate way of discovering how advanced the disease is, as well as an early warning sign of whether it has started to spread. This work could lead to quicker diagnosis and potentially new treatments, giving patients and doctors an even better chance of beating the disease. There’s increasing evidence that the latest treatments are more effective in these early stages and, if we can identify patients whose cancer has only just started to spread, this would significantly improve the chances of beating the disease.”

Online booking now open for The Aesthetics Conference and Exhibition (ACE) Booking for The Aesthetics Conference and Exhibition (ACE) is now available on a new dedicated website - The website reveals details of the professional development lectures, workshops, masterclasses, business seminars and customer service workshops available at ACE, which takes place at The Business Design Centre in London on March 8-9, 2014. The meeting includes a two-day conference, where 20 expert speakers from the fields of cosmetic medicine, plastic surgery, dermatology, nursing, marketing and business will discuss relevant topics. The event is priced at £89 for a one-day pass, and £160 for a two-day pass. To find out more about ACE and to book your place, visit the website at or call 01268 754 897.

Vanquish produces positive results BTL Aesthetics has created a new noninvasive fat reduction treatment for the abdomen, flanks and thighs. Vanquish uses radio frequency technology cleared by the FDA for deep tissue heating. It is a no-contact device, whereby the patient lies on a table and a curved panel is placed across the body area to be treated. Patients undergo four 30-minute weekly sessions. There is no pain and patients can return to regular activity immediately after treatment.

News in Brief Love handles biggest beauty obsession A recent survey from British manufacturer BTL has found that love handles are the biggest beauty obsession. 38% of the consumers, beauticians and cosmetic surgeons polled cited this as the number one hang-up. Mills Medical Services provide doctors to salons and clinics Mills Medical Services is enabling salons and clinics to offer a range of aesthetic facial rejuvenation and cosmetic dentistry treatments nationwide by providing them with fully trained aesthetic doctors. Pollogen launches skin rejuvenation device Pollogen has launched a new medical-grade device for dermal volumising, wrinkle reduction, skin rejuvenation and lifting effects. Surgen is powered by Hybrid Energy Technology. It is also virtually painless, produces long-lasting results and is convenient with minimal downtime. Pulse Light invest in three new lasers Hair removal clinic Pulse Light has invested in three new lasers using the Soprano XL laser hair removal system. “The lasers allow each treatment to be carefully aligned to the client’s body and needs,” said Pulse Light senior nurse M. Maclean. “This precision delivers professional results, with no discomfort to the client.” Dr Britta Knoll authors mesotherapy book Mesotherapy specialist Dr Britta Knoll has written a book describing the dosages, active substances, and administration methods used for the treatment. The Illustrated Atlas of Esthetic Mesotherapy provides a step-by-step introduction to the practice of mesotherapy, accompanied by 165 colour illustrations. Aspect Dr available in UK Australian skincare line Aspect Dr is available in the UK. The range is the number one selling physician-exclusive skincare line in Australia, uses high concentrations of clinically active ingredients and is manufactured without harmful preservatives, parabens, dyes or perfumes. Meder Beauty Advanced Skincare Line Meder Beauty has added a premium cosmeceutical range of skincare products to its Meder Beauty Science line. The product formulations work synergistically with Meder Beauty Science professional treatments to enhance and maintain the results and achieve healthier, younger-looking skin.

Aesthetics | December 2013


Insider News

Winner of the Reader Survey announced

4T Medical introduce High Potency Cooling Fluid 4T medical has launched a new High Potency Cooling Fluid to reduce swelling after dermal filler injections. Strips or masks are soaked in the solution and placed on the treated area directly after treatment, reducing skin irritation, redness and swelling. The product is composed of natural ingredients only, including active Echinacia angustifolia extract, which has an antiseptic and antiinflammatory effect, and Andographis paniculata leaf extract, which has a cooling effect. Collagen strips and masks are available for full face, glabella, lip, nasolabial, neck and orbital frame.


Medical papers have found that the number of labial reduction procedures carried out on women has risen five-fold in the NHS over the past 10 years. Reports from the Royal College of Obstetricians and Gynaecologists (RCOG) and the British Society for Paediatric and Adolescent Gynaecology (BritSPAG) showed that over 2000 operations were performed in 2010. They also stated that little research currently exists about the clinical effectiveness, positive effects or the risks in female genital cosmetic surgery, and that women should be provided with accurate information about the variations of female genitalia. The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) has responded to these findings with Tim Goodacre, consultant plastic surgeon and Head of Professional Standards at BAPRAS saying that they “wholeheartedly support the research”. Mr Goodacre said, “Whilst there are some appropriate situations where this surgery is right for the patient, this increase is worrying as this surgery does not come without its risks. Some women have reported adverse effects, such as severe discomfort and ongoing problems with daily function, following the surgery. It should therefore only be performed when necessary and only ever by a properly qualified surgeon.”

Lipotripsy launch contact thermography plates Spectrum Technology UK has introduced new contact thermography plates to the Lipotripsy Radial Wave device that accurately diagnose the grade of a patient’s cellulite to ensure effective treatment of the area. Lipotripsy clients will be provided with the opportunity to grade their cellulite both before and after a course of Lipotripsy treatments for complete transparency in the progress and improvement of their cellulite. Jim Westwood, MD Spectrum Technology UK, comments on this high-tech development, “Traditionally aestheticians would not only diagnose the severity of cellulite by visual assessment, but with a pinch test to diagnose its grade. The new contact thermography plates ensure a more accurate diagnosis is made to avoid any errors in grading and to ensure accurate treatment of the worst affected areas. Whilst these plates have been used widely in medicine since the 1970s, Spectrum Technology UK is thrilled to be able to claim a UK first for their use in the aesthetic market with Radial Wave therapy.”

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References: 1. Raspaldo H. J Cosmetic and Laser Therapy, 2008;10:134–142. 2. Fischer TC. Poster presented at EMAA, 1–3 October 2009, Paris. 3. Allergan Data on File (DoF), 2011. 4. Allergan Data on File (DoF) Marketing overview, 2011. Instructions and directions for use of JUvéDeRm® vOLUmA® with Lidocaine are available on request. Lidocaine does not affect the intrinsic performances of JuvéDERM® vOLuMA® and its safety profile, therefore, JuvéDERM® vOLuMA® data is representative of JuvéDERM® vOLuMA® with Lidocaine3

Date of Preparation: January 2013 UK/0008/2013a

Dr Sarah Tonks has been announced as the winner of an iPad mini after taking part in a recent reader survey. It was conducted to collect feedback that has helped to shape the Cosmetic News relaunch as Aesthetics. Dr Tonks will soon be offering treatments at Beyond MediSpa in Harvey Nichols, Knightsbridge. She plans to use the iPad in patient consent and medical record keeping, and said, “I participated because I think it’s important that practitioners help shape the direction in which the industry is heading.” The Aesthetics team would like to thank all the readers who took part in the survey. Readers’ views are always welcome and appreciated: please contact to get in touch.

Labial reduction procedures have risen five-fold

Industry News

Survey shows two thirds of dermatologists don’t refer to recommended psoriasis guidelines Two thirds of dermatologists do not refer to the recommended guidelines for managing psoriasis, a recent survey conducted by medeConnect shows. Additionally, 38% of dermatologists still refer to guidelines that are over four years old. The National Institute for Health and Care Excellence (NICE) provides clear recommendations on the management of psoriasis, to standardise clinical practice across the UK. Guidelines recommend that dermatologists should assess their patients’ psoriasis severity regularly using the PASI (Psoriasis Area and Severity Index) assessment and the impact of psoriasis on their life using the DLQI (Dermatology Life Quality Index). A 2012 survey of psoriasis patients showed that only one third of psoriasis patients have a PASI score, and 87% of patients were unaware of DLQI.

Plastic surgeon suggests new theory for male hair loss A plastic surgeon in Ankara, Turkey has suggested a new theory for male pattern baldness. Dr Emin Tuncay Ustuner, whose research is published in the journal Plastic and Reconstructive Surgery, has said that the baldness that men encounter is due to gravity, i.e. the weight of the scalp on hair follicles. This is in opposition to it being genetically inherited or due to hormones. He states that fat tissue keeps hair follicles well-hydrated, and as men age, fat disappears, causing their hair to fall out. He also says that declining levels of testosterone contribute to the decrease of scalp fat. He explains that the shape of the head can affect hair loss patterns, as different shapes will assert different scalp pressures. He states that ears resist the effects of gravity on the scalp, meaning hair loss around the sides of the head is reduced.

A third of Brits undergo cosmetic surgery abroad says study A new study has shown that almost a third of British people who undergo cosmetic surgery are now having operations abroad due to the cheaper cost. 19% of women having breast enlargements abroad have chosen to go to the Czech Republic whilst one in five lip fillers and nose jobs are also being carried out there. 28% of people having their teeth cosmetically enhanced abroad go to South-East Asia. 29% choose Switzerland for face-lifts, 28% for botox and 14% for liposuction. Research also suggests that over half are unhappy with the results, and 19% have follow-up treatment in Britain to correct problems, compared to just 6% of those who had a procedure in the UK. A third of those having a procedure abroad claim to have caught an infection compared to 9% who said this happened after a procedure in the UK.

News in Brief Sinclair IS Pharma announced as ACE 2014 Gold Sponsor The Aesthetics Conference and Exhibition (ACE) 2014 is proud to announce Sinclair IS Pharma as a Gold Sponsor for the event. The pharmaceutical company will offer a masterclass as part of the events programme. To find out more about ACE and to book your place, visit or call 01268 754 897. Maximus offers multi-layered approach to anti-ageing and body contouring Pollogen has launched Maximus, an aesthetic medical device which uses three proprietary technologies: TriLipo RF (for skin tightening, cellulite reduction and fat reduction), TriLipo DMA (to clear released body fat and to ‘lift’ the Superficial Muscular Aponeurotic System on the face) and TriFractional (advanced fractional skin resurfacing). A clinical study of 20 women aged 35-65 who received eight weekly facial treatments, showed significant wrinkle reduction, improvement in skin tonus and dramatic facial skin lift. New SkinCeuticals hydration treatment SkinCeuticals have created a hydration treatment that replenishes depleted moisture levels. The Hydrating B5 Gel Mask infuses dehydrated and stressed skin with hyaluronic acid and vitamin B5. It is a weekly treatment, enhanced with a complex containing constituents of the skin’s natural moisturising factor (NMF). Age-Defying Laser receives FDA clearance Tria Beauty has received FDA clearance for its Age-Defying Laser, which uses a proprietary version of non-ablative fractional laser technology. 76% of users said they had reduction in fine lines and wrinkles, and 95% said they had smoother skin and an improvement in overall appearance. Users reported visible results in two weeks, and optimal results in eight weeks. Dorchester Spa takes on Revitalash Eyelash conditioner RevitaLash Advanced is now available at Dorchester Spa. “We are proud to have the brand held within such prestigious environs,” said Tracey Beesley, marketing director of SkinBrands, who distribute RevitaLash in the UK. “We are delighted to support The Dorchester Spa and we are sure that this brand will be a perfect fit to complement the other services and products they offer.”

Aesthetics | December 2013


Insider News

Events diary 7th December 2013 The Aesthetics Awards 2013, London

Twin study shows real impact of smoking on skin ageing

8th - 9th March 2014 Aesthetics Conference and Exhibition ACE 2014, London

Research published in the journal Plastic and Reconstructive Surgery comparing identical twins has given more of an insight into the extent smoking contributes to skin ageing. 70 pairs of identical twins were photographed, either where one was a smoker and one a non-smoker, or where there was a smoking history difference of five years between them. Plastic surgeons analysed the photos without knowing which twin smoked. In the majority of cases, those who smoked had larger bags under their eyes, sagging eyelids, wrinkling of the upper and lower lips and sagging jowls. Photographic evidence also found that the ageing effect of smoking was most prominent in the lower two-thirds of the face. Dr Bahman Guyuron, lead author of the report said, “Even among sets of twins where both are smokers, a difference in five years or more of smoking duration can cause visibly identifiable changes in facial ageing.�

3rd - 5th April 2014 Anti-Ageing Medicine World Congress AMWC 2014, Monaco

Mesoestetic releases new skin care treatment energy C

30th January - 2nd February 2014 International Master Course on Ageing Skin - IMCAS Annual Meeting 2014, Paris

20th - 22nd June 2014 Facial Aesthetic Conference and Exhibition - FACE 2014, London 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London 3rd October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London

Epionce launch Intense Defense Serum Epionce has launched Intense Defense Serum. The advanced serum uses botanically-derived extracts of Vitamins A, B, C, D and E, which act as powerful anti-oxidants and anti-inflammatories to stimulate skin rejuvenation by helping your skin function properly. Results show improvement in visible signs of ageing, including fine lines and wrinkles: results can be seen after just one week.


Mesoestetic has developed a new anti-oxidant skincare treatment. energy C is formulated with a high concentration of vitamin C, which helps to prevent skin ageing. This also makes it ideal treatment for fragile skin that has been subject to excessive sun exposure, smoking, poor nutrition or stress. When applied topically, vitamin C remains on the skin for 48 hours, so has 30 times the therapeutic effect of oral supplementation. In vivo and in vitro studies have demonstrated energy C’s anti-oxidant, UVA and UVB photoprotective, skin brightening and collagen-boosting properties. A home maintenance line includes an intensive cream, eye contour and energy c complex. The professional treatment line includes a serum, crystal fibre mask and an intensive cream.

Hyalual launches Daily Delux Swiss cosmetic and skincare product company Hyalual have produced the Hyalual Daily Delux spray. The product has many benefits, which includes preserving the moisture of the skin, increasing the free water content of the stratum corneum and helping to reduce water evaporation from the skin surface. It also provides deep cleansing of the skin, enriches the skin with minerals, enriches cells with oxygen, removes toxins and promotes rapid skin renovation. The company is recognised for its innovations in anti-ageing products for the face and body.

iS Clinical produce new skin brightening treatment iS Clinical have produced a skin brightening treatment that is clinically proven to reduce hyperpigmentation and to lighten skin. White Lightening Complex contains a blend of proprietary lightening ingredients and pharmaceutical grade botanicals, including Norwegian kelp extract, which instruct melanocytes to produce less pigment, resulting in an improvement of hyperpigmentation in the skin. A study showed a 75% reduction in the intensity of pigmented areas, 37% reduction in melanin production after 72 hours and 84% reported overall skin lightening effects.

Aesthetics | December 2013

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Insider On the scene

Syneron Candela VelaShape III launch, The Institute of Physics, London

The Institute of Physics in London was the setting for the exclusive International launch of Syneron Candela’s latest innovation – the VelaShape III. Syneron’s founder and company chairman Shimon Eckhouse introduced the new technology and talked about the latest advancements in the body shaping market as well as talking about changing perceptions of RF body contouring, presenting new studies and findings. Dr Grant Hamlet then gave a talk about noninvasive body contouring from the patient perspective before leading beauty and anti-ageing expert Wendy Lewis talked about hot new trends and desires from the USA. Powered by elōs technology, VelaShape III combines IR (infrared), bi-polar RF (radio frequency) and vacuum to precisely heat the tissue up to 3mm and 15mm depth respectively. The combination of IR and vacuum coupled RF technologies causes deep heating of the fat cells, their surrounding connective fibrous septae and the underlying dermal collagen fibers. Efficient heating of the adipocytes is achieved by higher output of the RF. The optimal design of the electrodes and the concurrent application of vacuum allows for deeper and faster heat penetration. In turn, this promotes an increase in circulation, lymphatic drainage, cellular metabolism and collagen depositing. Furthermore, it stimulates fibroblast activity and remodels the extracellular matrix. This results in a localised reduction in skin laxity, volume and an overall improvement in skin structure and texture.

Temple Medical clinic launch, Aberdeen The award-winning Aberdeen based clinic Temple Medical has quadrupled its business with a five-figure investment in a prestigious city centre clinic. Led by Dr Sam Robson, the new clinic in West Craibstone Street is four times the size of the previous Cults clinic, to accommodate continued growth in the business and client base. Dr Robson launched the medical-led business in 2007 and it now has a fully qualified medical team of 15, with plans to expand to 20 by 2014. She said, “Opening a substantially larger clinic in the city centre provides us with a more convenient location, allows us to expand on our treatments and facilities, and will enable us to achieve our goal of becoming Scotland’s leading medical-led clinic.”

Toskani Mesotherapy Seminar, London Toskani UK welcomed Dr Britta Knoll to London to lead its Mesotherapy Seminar last month. Since training with mesotherapy pioneer Dr Michael Pistor in the ‘80s, Dr Knoll has performed over 20,000 mesotherapy procedures. The event included an overview of the philosophies and methodologies underpinning mesotherapy, complemented by product descriptions, protocols and live demonstrations. Toskani also took time to launch the Pistor range of mesoguns, now available in the UK and Ireland through Vida Health and Beauty.

Absolute Aesthetics Open Evening, Guildford Absolute Aesthetics hosted an open evening to coincide with the launch of its new cosmetic surgery arm, which sees four new plastic surgeons join the clinic: consultant surgeon Mr Vasu Karri, Mr Amir Nakhdejevani, Mr Peter Arnstein and Mr John Pereira. They have a host of expertise in breast, head and neck plastic surgery, hair restoration surgery and reconstructive surgery. They have also appeared on many high-profile TV shows including Sky’s Extreme Makeover and Channel 4’s Embarrassing Bodies. Absolute Aesthetics medical director Vicki Smith said, “The addition of cosmetic surgery to the clinic is an exciting development for us at Absolute Aesthetics. Since we opened four years ago, we have been at the forefront of the aesthetic industry. This expansion will enable us to meet the needs of our clients who are after more than the non-invasive treatments we currently offer.”

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1. Body Language No. 59 September/October 2013 2. Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs Dermatol. 2012 Sep; 11(9):1032-5 3. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.

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Insider News special report

In the wake of a high profile court case, what laws can prevent unqualified people from giving botulinum toxin injections? We investigate a surprisingly complex area.

Stopping the ‘botox’ Cowboys The case of Jamie Winter, the beauty therapist who bought botulinum toxin on the Internet for £70 then injected it into clients in their homes, has just ended with her being convicted of fraud. Her offence in the eyes of the law? Telling her customers that she had completed a training course, which she’d actually ducked out of for being too expensive. Now, many in the industry are asking why Winter was prosecuted for fraud: not for injecting someone else with a prescription only medicine. Initially she was charged with assault, because one of her clients suffered swollen eyes after the injections, but because they consented to the treatment, those charges were dropped. Had Winter admitted that she was untrained, and her clients were willing to go ahead with the injections, she would not have been guilty of fraud either. So how does the law apply to rogue operators? Despite the Keogh report, it is still legal for anyone – qualified or not – to inject botulinum toxin. In that respect, Winter was in the clear. Also, it is not illegal to buy a licensed medicine over the Internet, or to administer it in people’s homes. The only way Winter broke the law was in acting alone. The Medicines and Healthcare Regulations Agency (MHRA) say that botulinum toxin injections should be done ‘under supervision or under the directions’ of a medical practitioner. Botox® is a prescription only medicine (POM), and The Human Medicines Regulations 2012 makes it illegal to sell, administer or possess a POM with intent to supply. The offences carry a maximum penalty of two years

imprisonment or an unlimited fine. Sally Taber, director of the Independent Healthcare Advisory Services says, “Botox® has to be prescribed by a doctor, dentist or nurse prescriber. If they feel that an unqualified injector is competent to do it, currently they can authorise this. But it is certainly not good practice.” Janet Kettels, director of corporate affairs and public relations at Allergan agrees, “These treatments are medical procedures and should only be given in the right clinical environment by a qualified healthcare professional trained in clinical assessment and patient care,” but this is not a legal obligation. However, Jeanette Aspinall, department head of medical negligence and litigation at Fletchers Solicitors, says, “The European Committee for Standardisation published a draft guideline on who can provide cosmetic procedures and where these should be carried out, which could be introduced by autumn next year. Anyone who flouts it could face prosecution, fines and possibly imprisonment.” Given the side effects reported, it seems unlikely that the product Winter bought for £70 over the internet was a genuine botulinum toxin injectable, and almost certainly not Botox®. However, if clients believed it to be the real thing - the law should still hold, as the Medicines Act states: “No person shall, to the prejudice of the purchaser, sell any medicinal product which is not of the nature or quality demanded by the purchaser.” And if Winter was passing off one product as another she might have been sued for damages from her own clients. If she claimed to be providing Botox®, she might be subject

to an infringement claim from Allergan. So why was she charged with fraud? The MHRA has special powers to investigate, arrest and prosecute for medical crimes, however, a MHRA spokesperson explains, “In legal terms, fraud is a more serious offence than medical offences and this explains why the police brought the prosecution. If we discover evidence of more serious crimes, such as fraud, then we will refer our investigation to the police.” Also, Botox® is a very complex area. For example, an unqualified person who bought a drug claiming to be Botox® via the Internet could claim they were being paid to supply their services, not the drug. They would still need to be acting under the supervision of a doctor, dentist or nurse prescriber. It comes down to the specific details of each case and regulatory action can lie between professional bodies, the Care Quality Commission (who are responsible for the regulation of private clinics) and the MHRA which can make punitive action complex, and outcomes less certain. Is Jamie Winter a lone bad apple, or are there others in the barrel? “There is no data on this, but it is likely to be far more common than we would like to believe,” says Emma Davies, chair of The British Association of Cosmetic Nurses. While regulation is necessary, no amount will stop those determined to operate outside the law. However, exemplary prosecutions with appropriate sentencing by the MHRA for medical crimes that are reported in newspapers may do more to dissuade cosmetic cowboys and educate patients to their danger, than any amount of regulation.

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ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss.

Cryolipolysis Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months.

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key

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Clinical Practice Body contouring

Going hot and cold We examine the benefits of heating and freezing technologies in fat reduction and body shaping One of the biggest growth areas in aesthetic medicine in recent years has been the global body shaping market. Predicted to reach $2billion by 2017, the market growth is being largely driven by minimally invasive non-surgical devices, which offer more cost effective, lower downtime treatments. All of this makes body contouring potentially one of the most lucrative areas of cosmetic medicine and one that aesthetic clinics cannot afford to ignore. Advances and developments in technologies have significantly enhanced the treatment outcomes of non-surgical devices. While procedures such as VASER and laser lipolysis have carved their own niche, bridging the gap between non-invasive treatments and surgery, it is the more minimally invasive sector of the market that is seeing the most growth: there has been a significant boom in the number of devices available on the market in recent years. Two technologies that approach body contouring from opposite ends of the spectrum are radio frequency and cryolipolysis, one using heat energy and the other using cold. Cryolipolysis has undoubtedly been one of the most talked about treatments of 2013 using freezing rather than heating technology to destroy fat cells. But does the advent of this new generation of body shaping treatments mean RF has had its day or do the two offer their own distinct advantages and disadvantages?

and UltraShape and the boom in cryolipo devices, which are often more effective in targeting fat, the radio frequency body market has not rested on its laurels. We have seen new and improved versions of existing technologies coming to market, such as the VelaShape III from Syneron Candela and Accent Ultra (ABC Lasers), as well as new technologies incorporating RF such as Venus Freeze (Ellipse), Vanquish and Exilis (BTL Aesthetics), i-Lipoxcell (Chromogenex), 3D-Lipo (3D-Lipo Ltd) and Viora Reaction (AZTEC Services). RF energy works for body contouring because it is able to penetrate deep into the dermis and sub-dermal layers of the skin, without damaging the epidermis. It also increases blood circulation, allowing the fatty deposits to be drained through the lymphatic system, which is why it also works to reduce the appearance of cellulite. The first RF body contouring devices that came to market were predominantly RF only and offered limited results in fat reduction, which were highly dependent on patient selection, what system you were using and operator technique. As such, many practitioners only found it useful for body contouring when combined with other treatments. Dr Ravi Jain from the Riverbanks Clinic in Harpenden comments, “RF provided temporary changes in appearance of skin laxity and cellulite but the volume changes were absolutely minimal at best. I found it often worked in combination with other technologies such as VASER Liposuction as a post-operative care method to help massage the treated areas and encourage skin tightening as well as help minimise fibrosis. One of the biggest problems with RF is that it is extremely operator dependent and even then results were modest and temporary. We discovered a high proportion of unhappy patients.”


Dr Kim Singh has been using Accent as a stand-alone treatment since 2005 as well as to enhance his treatment outcomes from VASER. He says, “Since 2007 when we started doing VASER we have been adding Accent into our post-treatment care protocol. It smoothes out the end result and it helps with skin tightening if there is any lax skin. After VASER you can often get a few small ripples and Accent can really finish that off nicely.”

Offering the additional advantage of skin tightening and cellulite reduction, radio frequency has become one of the most commonly utilised technologies in aesthetic body contouring devices. Facing tough competition from ultrasound assisted treatments such as VASER

The industry has recently seen an influx of next generation RF devices, which incorporate new technologies to allow for more optimal and consistent results in fat reduction as well as cellulite and skin tightening. BTL Aesthetics has launched two RF devices onto the market, which are showing positive results. The first was the Exilis, a device that claims to be ‘redefining’ radio frequency (RF) technology. The treatment harnesses its energy through its Energy Flow Control (EFC) system. The Aesthetics | December 2013


Clinical Practice Body contouring

installed EFC module controls the energy flow and automatically eliminates energy peaks. This process is known as Square (‘Flat Top’) Spectrum Energy Profiling and is a unique feature of Exilis therapy. EFC automatically monitors the energy distribution on the body through multiple sensors. “Exilis is unique in delivering monopolar RF with a grounding pad, so we know it is penetrating to the appropriate, therapeutic skin level - from the epidermis down to the subcutaneous layer - and the results have been outstanding,” says Robert Weiss, MD, associate professor of dermatology, Johns Hopkins School of Medicine. “The built-in temperature sensor permits delivery of enough energy to improve skin without pain. In fact, our patients liken the heat sensation to a warm massage. Using Exilis is like driving a Ferrari with the best brakes. It is high performance yet very safe, and you always feel you are in total control of its power.” The latest system the company has brought to the market is the Vanquish. The noncontact device uses selective RF energy that heats the adipose tissue to the point of apoptosis. The Vanquish is able to selectively heat the fat cells to a temperature of 44-45°C while the surrounding tissue remains unaffected at 40-41°C. The system was trialled at San Diego Cosmetic Surgery Practice Moradi MD for three months, to reduce fat in the abdomen and flanks of selected patients. One patient who has seen improvements says, “After only three treatments, my abdomen is firmer and tighter. Where my clothes were tight before, they now feel loose. Vanquish is truly a remarkable treatment for anyone who wants to tighten and firm unwanted midsection fat on their body.” As the body shaping market has advanced we are also seeing the launch of more combination devices, which combine RF with other modalities in one device. VelaShape (Syneron Candela) for example combines RF with infrared as well as tissue mobilisation and suction. This has been proven to enhance results for fat reduction as well as cellulite reduction. The latest VelaShape III device, launched this month, takes this further by incorporating increased RF power. The higher energy density gives improved heating in the tissue. This means that the end point temperature is achieved much faster, and the treatment time and number of sessions required to achieve an optimal result are reduced. Another combination device launched onto the market this year was the i-Lipoxcell (Chromogenex). It incorporates four technologies for intelligent body fat analysis and measurement, laser diode fat reduction, IR Vacuum massage and radio frequency skin tightening. The system incorporates both visible red and infrared laser for bio-stimulation of metabolic pathways resulting in the release of fatty acids and glycerol, shrinking fat cells. Results are seen immediately. Another company that quickly realised the benefits of combining RF with other technologies was Alma Lasers who launched the Accent Ultra™ as an update to the original Accent system. It uses combined hot and cold selective resonance ultrasound with high frequency RF. Split into two modules, the Ultra™ module provides ultrasound energy for treating cellulite and reducing fat whilst the UniForm™ module provides radio frequency energy and lymphatic drainage for body reshaping and skin tightening.


THE BIG FREEZE: CRYOLIPOLYSIS Cryolipolysis is undoubtedly one of the biggest recent trends in body contouring. Ideal for removing pockets of body fat, particularly in the stomach area, flanks, thighs and back, it is proving popular with patients and practitioners alike because of its low downtime, minimal discomfort and impressive results in destroying fat. Devices utilising cryolipolysis include CoolSculpting, CoolTech, Lipoglaze and 3D-Lipo. Like RF, cryolipo is not a weight loss treatment and is not indicated for obese patients. Results can be expected to be visible within four to six weeks in most cases. Although multiple treatments may be required there is also no need for post-procedure massage or exercise to enhance results. However, it does not have the additional benefits of skin tightening, which you get with RF. Cryolipolysis effectively cools the subcutaneous fat cells in order to induce apoptosis and lipolysis, without damaging any of the surrounding tissues or the skin. These lipids are then transported by the lymphatic drainage system to be processed and eliminated through the body in the same way that fat from your food is eliminated. This process is very gradual, meaning that there is no danger of your lymphatic system being overloaded. Dermatologist Dr Penelope Tympanidis says, “Interestingly, the exposure to cooling is set so that it causes cell death of subcutaneous fat tissue without apparent damage to the overlying skin. The fat cells in the treated area are gradually eliminated through the body’s normal metabolic processes. With a single treatment subjects have a 20% reduction after two months and 25% reduction at six months in the fat layer as assessed by ultrasound. The lipolytic effect


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Aesthetics | December 2013



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“I’vebeen beenso soimpressed impressedby bythe theresults resultsofof ofmy myown ownclinical clinical “I’ve “I’ve been so impressed by the results my own clinical trialsthat thatI would wouldrecommend recommendthis thisbusiness businessopportunity opportunitytoto to trials trials that II would recommend this business opportunity anyforward forwardthinking thinkingclinic” clinic”- -Dr - Dr DrMartyn MartynKing King any any forward thinking clinic” Martyn King (Finalist Aesthetic Practitioner of The Year 2013/14) (Finalist (Finalist Aesthetic Aesthetic Practitioner Practitioner ofof The The Year Year 2013/14) 2013/14)

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Clinical Practice Body contouring

of treatment takes place within about two to four months. It appears primarily applicable for limited, discrete fat bulges. As long as the patient maintains his or her weight with diet and exercise, long-term results should remain stable.” Rajiv Dash, managing director of Aesthetics of London, has noticed some positive results. He says, “Cryogenic lipolysis is much more suitable for pockets of fat. There are primarily two reasons for this: the first is cost. It is a more expensive treatment for the area covered and if a client needed to repeat treatments or cover multiple areas the cost can quickly mount up. The biggest advantage of this treatment is that posttreatment the fat cells undergo apoptosis and die off, so it is a more permanent solution. Cryogenic lipolysis is very effective on clients who are otherwise within their desired weight range but have small pockets of fat to lose, the added advantage being that any fat loss would be permanent.” The first cryolipolysis device on the market was CoolSculpting® by Zeltiq, which set the gold standard for the use of this technology in body shaping. Over 400,000 CoolSculpting® by Zeltiq treatments have been performed worldwide. The CoolSculpting® device is positioned on the area of the body to be targeted and using a suction action, draws the fat bulge into the CoolSculpting® treatment applicator where two cooling plates are situated. The list of areas of the body that the system can now treat is more comprehensive with the launch of CoolCurve+, a specially designed and developed applicator for flanks, and for really slim people who have stubborn, exercise-resistant areas of fat. The anatomically shaped curvature of CoolCurve+ allows for an effective fit to the body and ultimately improved tissue draw,

making it easier to treat more areas and a multitude of body shapes. Final results can be seen in 60-90 days when the frozen fat cells are gone for good. Another treatment that has been making headlines is the Lipoglaze from LoveLite Ice. The Lipoglaze machine works by first gently heating and then rapidly cooling the target area. This causes the fat cells to crystallise and permanently destroys up to a third of fatty deposits per session. The body then naturally eliminates this waste tissue over the next few weeks. Debra Robson from LoveLite says, “Our preliminary clinical studies, due for full publication by the beginning of 2014, have proven that the treatment works, is safe and results have shown from 11% up to a huge 59% reduction in subcutaneous fat. The difference in results seems to be based on the thickness in the layer of subcutaneous fat..” Dr Ravi Jain uses the CoolTech system. He says, “I evaluated three systems before choosing CoolTech. At first I wasn’t sure if this would work, with claims of results in just one session. I started to see a few lipo patients come to me because they’d had a freezing treatment which had left a large indentation in their stomachs. To me this meant that the technology actually did kill off fat cells in one session, and so the only improvement needed was to learn how to feather it better. Also, some of the business models for other technologies did not suit my practice profile with very high installation and running costs. I wanted a technology that would have low ongoing costs but be highly effective with pleasing results. So I invested in CoolTech and we waited anxiously for the results to come through. At one month, after a single session, we saw changes better than an eight-week course of RF or USS. At three months some







of the results were akin to liposuction. I was staggered and my patients were thrilled. Dr Tympanidis believes further studies are needed but is encouraged by the outcomes of cryolipolysis for fat reduction. She says, “Although the mechanism of action for cryolipolysis is not yet completely understood, the efficacy and safety of this non-invasive procedure for fat layer reduction has been demonstrated in the studies available to date. Further studies will assist in identifying the mechanism and elucidate the full potential of this technology to perform safe, non-invasive fat reduction for areas of local fat accumulation.” If you still can’t decide whether hot or cold treatments provide the best results then one system that offers both is the 3D-Lipo. The system has applications for both cavitation and cryolipolysis to physically destroy the fat cells. Added to this, with the combination of radio frequency and 3D-Dermology (vacuum skin rolling for targeted cellulite reduction), you are able to combine an effective skin tightening application for both face and body, and also target cellulite. Dr Martyn King, medical director of Cosmedic Skin Clinic in Tamworth believes it is 3D-Lipo’s multi-faceted approach that offers a key advantage. He says, “It appealed to us that 3D-Lipo offered a combination of technologies. We tried it out and the cavitation and RF seemed to be a lot better than some other devices we had seen and tried on the market. At the same time cryolipolysis was something we were interested in. There are stand-alone machines for this but they work out a lot more expensive and the consumables are a lot more so having it all in one machine was the best option for us.”





Aesthetics | December 2013



NewDimension Dimension Non-Surgical Technology AANew in in Non-Surgical Technology

AArevolution aesthetic skincare market... revolutionininthe thenon-surgical non-surgical aesthetic skincare market... is set to create a revolution in the is set to create a revolution in the non-surgical Aesthetic skincare market. Following the of of non-surgical Aesthetic skincare market. Following success the success the award winning 3D-lipo which combines technologies for the the award winning 3D-lipo which combines technologies for the effective treatment of of fat,fat, cellulite andand skin-tightening we are effective treatment cellulite skin-tightening we set are set to launch a phenomenal new multi-functional device for the face. to launch a phenomenal new multi-functional device for the face. Here are just some of the reasons why 3D-skintech will become the Here are just some of the reasons why 3D-skintech will become the brand of choice in 2013 brand of choice in 2013 • Complete treatment portfolio for anti-ageing, •pigmentation Complete treatment and acne portfolio for anti-ageing, pigmentation and acne • 4 technologies ensure a prescriptive & total approach •to4your technologies ensure a prescriptive & total approach clients needs to your clients needs • Used in conjunction with medical peel and •cosmeceutical Used in conjunction skin carewith line medical peel and cosmeceutical skin care line • Unsurpassed results ensures maximum •client Unsurpassed results ensures maximum loyalty clientprofitable loyalty with a multitude of • Highly •services Highly to profitable offer with a multitude of • Provides servicesyou to with offera competitive in youryou area •edge Provides with a competitive • Affordable as package edge in your area price is under £10,000 a product • Affordable aswith package price is starter pack worth £1,000 under £10,000 with a product • Affordable finance packages starter pack worth £1,000 available • Affordable finance packages




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Rotational Diamond Peel Microdermabrasion Rotational Diamond Peel Microdermabrasion

Utilising Utilising the latestthe technology available you can work in conjunction latest technology available you can work in conjunction with topical skincare to ensure that hydration and comfort are not with topical skincare to ensure that hydration and comfort are not compromised whilst delivering excellent peeling results. compromised whilst delivering excellent peeling results.

Radio Frequency Radio Frequency Tri-polar Radio Frequency is the most advanced technology Tri-polar Radio Frequency is the most advanced technology

available for skin-tightening ensuring excellent results without the available for skin-tightening ensuring excellent results without the discomfort associated with mono or bi – polar devices. discomfort associated with mono or bi – polar devices.

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LEDLED ensures both rapid treatment time and excellent Full canopy Fullachieved. canopy LED ensures both rapid treatment and excellent results are Available wavelengths Red (640nm time - 700nm), Blue (425nm - 470nm), YellowAvailable (590nm) and Green (520 - 564nm) results are achieved. wavelengths Red (640nm - 700nm), ensuresBlue effective treatment for anti-ageing, pigmentation, acne and- 564nm) (425nm - 470nm), Yellow (590nm) and Green (520 detoxification. ensures effective treatment for anti-ageing, pigmentation, acne and detoxification.

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A compact range of medical grade peels and cosmeceutical 3D-skintech peels and clinical skincare skincare productsA complete Skintech’s unique offering you compact the range of medical grade peelsand andenables cosmeceutical skincar to both use as a “stand-alone” or combine equipment products complete theservice Skintech’s unique with offering and enables you protocols. to both use as a “stand-alone” service or combine with equipment protocols.

‘To compliment our core injectable business the 3D-skintech has added an array of new result driven facial services to our clinic’s menu as well as the combination services for ‘Tocurative compliment ourWe core injectablethat business the 3D-skintech has added an array of n our more patients. recognized this device offered the stand alone quality driven infacial services to our clinic’s menu that as well as the combination of eachresult technology a unique machine that will ensure we both deliver the resultsservices but equally can make money from the due its that affordability. As offered a clinician many our more curative patients. We start recognized this device thetoo stand alone qu times inofthe past we have invested huge sums ofthat money in a single has the res each technology in a unique machine will ensure that concept we boththat deliver proven but difficult to profit my opinion system represents the in our too m equally can from. makeInmoney fromthis thetype startof due its affordability. Asfuture a clinician industry.’ Dr Martyn GPhave and Clinical director Skin Clinic times in the King past –we invested huge Cosmedic sums of money in a single concept that proven difficult to profit from. In my opinion this type of system represents the future in industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic

Clinical Practice CPD/Anatomy and physiology

one point

Under the skin

Lorna Bowes on anatomy and physiology of the skin

ABSTRACT Aesthetic practice has evolved and blended with medical and surgical practices as well as with non-medical areas such as beauty. Knowledge of the structure and function of the skin is imperative whether dealing with symptomatic relief of photodamage, or considering managing or advising on simple dermatological issues. If we are to treat dermatological skin complaints then further academic study is needed, however we are constantly facing patients with aesthetic dermatological concerns who ask for advice and opinions. This article is designed as a revision aid to review the anatomy and physiology of the skin as it relates to healthy skin, to intrinsic and extrinsic ageing processes, and to the ingredients that are available to us and our patients.

KEY WORDS: Epidermis, dermis, hypodermis, keratinocyte, photodamage

INTRODUCTION Skin is a major part of the integumentary system, along with hair, nails, subcutaneous tissues and various associated glands. The skin comprises three layers: epidermis, dermis and subcutaneous tissues (hypodermis). These layers work both together and separately as the interface between the body and the outside world with its physical and environmental factors. The skin is the largest organ in the body, and is responsible for an average 15% of total average adult human weight, and although many characteristics are identical throughout the skin there are variations in terms of colour, texture and thickness. There is also, for example, variation in the number of hair follicles and sebaceous glands per square centimetre. The skin has a surface area of between 1.5-2.0 square meters: over most of the body it measures 2-3mm in thickness, with the thinnest skin being in the periorbital area and thicker skin associated with the soles of the feet. The average square centimetre of skin holds 100 sweat glands, 15 sebaceous

THE EPIDERMIS The outermost portion of the skin is known as the epidermis, and as such is a key component of skin from an aesthetic perspective – few patients would wish for a non-flexible, rough, dehydrated epidermis. Any changes to the surface of the skin are immediately apparent, so surface texture must be addressed in an anti-ageing protocol. It is therefore important to understand the epidermis and the epidermal changes brought about by the ageing process. The epidermis is a multi-layered structure consisting mostly 22

glands, three blood vessels, nearly 1,000 melanocytes, 10 hairs and more than 150 nerve endings. The skin of the face and other areas of visible skin, are inextricably linked with the appearance and perceptions of youth and beauty. This article looks at the structure of the skin and at the components of the skin that are most closely implicated in the appearance of photo damaged and aged skin. Continuing research is teaching us how the components of the skin respond to extrinsic and intrinsic ageing. The quest for topical solutions to the physiological changes brought about by the ageing process and the aesthetic appearance those changes produce will increase our need for understanding how the skin responds to the ingredients and therapies we are presented with.

of keratinocytes organised in stratified layers. Cells migrate upwards from the bottom layer to the outermost layer, the stratum corneum, in a process leading to cell death, or apoptosis, that takes 26 to 42 days depending on various factors such as the age of the person1. The end point of the cells is desquamation, the shedding of individual or groups of cells from the surface of the skin. It is important to note that melanin is not a functional component of the epidermal barrier, despite its undisputed role in prevention or reduction of the damage caused by ultra violet (UV) radiation. The role of melanin is not within the scope of this article.

Aesthetics | December 2013

Clinical Practice

CPD/Anatomy and physiology

Basal layer (stratum basale): The basal layer comprises stem cells (10%), amplifying cells (50%) and postmitotic cells (40%), and forms the base membrane of the epidermis. As with other layers the cells are joined by desmosomes – structures that create adhesion between the cells. Epidermal Growth Factor (EGF) binds to the Epidemal Growth Factor Receptors (EGFR) in the stratum basale, activating tyrosinase kinase activity and this stimulates proliferation of the cells2. Other growth factors such as transforming growth factors and keratinocyte growth factors affect processes such as hyaluronic acid formation, and control of the inflammatory response in wound healing. Spinous layer (stratum spinosum): The first signs of keratinisation can be found in the cells of the stratum spinosum. Known as lamellar granules, they contain fatty acids, ceramides and cholesterol as well as various enzymes. The lamellar granules formed here travel to the skin surface and are an essential part of the barrier function of the skin. Granular layer (stratum granulosum): Profilaggrin crosslinks the keratin filaments and this infers structure and stability to the cell structure. These cells are known as keratohyalin granules, and they contain proteins that promote hydration and crosslinking of keratin. Clear layer (stratum lucidum): A thin clear layer of flattened keratinocytes. Horny layer (stratum corneum): Comprises mature keratinocytes that have run the full course of keratinisation, these anucleated cells are known as corneocytes. The structure of the stratum corneum is frequently compared to that of a brick wall with bricks and mortar being the main components. The bricks are the keratinocytes and the mortar is the intracellular lipid and other components of the lamellar granules such as

THE DERMIS The dermis is the middle layer of the skin, and as it is the thickest portion of the skin, is of critical importance to the aesthetic appearance of the skin. The depth of the dermis decreases steadily throughout the ageing process, and many of the integral structures deteriorate, leading to many of the external signs of ageing. The structure of the dermis is more complex than the stratified epidermis, although it has two main components: the papilliary dermis, which consists of connective tissue, capillaries, collagen and elastin and the reticular dermis, which consists of dense connective tissue, bundles of collagen

proteins. The filaggrin that started in the granular layer is broken down in the stratum corneum, and amino acids are produced. These amino acids form the Natural Moisturising Factor (NMF), and the NMF plays a major role in skin hydration as a powerful humectant, and in balancing trans epidermal water loss (TEWL). Therefore, it is of great importance that only increases in patients suffering from dry skin conditions. NMF levels are known to decrease with age. Lipids play a role in maintaining the NMF inside the cells and thereby limit water loss, as well as the lipids produced the lamellar granules. Hormones control the excretion of further lipids from the sebaceous glands. The stratum corneum is comprised of 15% water, while the total epidermis has a water content of 70%. The acidic pH of the skin is part of the natural defence systems preventing damaging attack by bacterial, viral and fungal activity. Antimicrobial peptides also exhibit broad spectrum activity adding to the skin’s defence against these attacks. The keratinocytes have standard cell structure with a semipermeable cell membrane and a nucleus containing the DNA. The keratins in the keratinocytes change as the keratinocyte migrates from the stratum basale outwards to the stratum corneum. Furthermore, the stratum corneum is a highly effective barrier preventing penetration of topically applied drugs and other substances. Ingredient developers and pharmacologists continue to develop novel ways to increase permeation and to find novel routes for penetration of drugs and topical ingredients. The stratum corneum is also where environmental aggressors such as metals and of course UV affect their initial damage. The complex cascade of reactions and production of free radicals adversely affect the natural processes in the skin, accelerating the physical signs of photodamage.

fibres and large blood vessels. Within the dermis are important structures such as the sebaceous glands, hair follicles and blood vessels. Between the epidermis and the dermis is the Dermal Epidermal Junction (DEJ), and what is known as the rete pattern or the rete pegs, finger-like protrusions of the epidermal tissues that act more or less like a Velcro fastening to join the epidermis to the dermis. The predominant cells of the dermis are the fibroblasts, and they are responsible for the formation of matrix proteins such as collagen and elastin, as well as enzymes such as collagenase and stromelysin. Aesthetics | December 2013


Clinical Practice

CPD/Anatomy and physiology

Collagen: Collagen, an abundant protein, is the main component of connective tissue and is found in fibrous tissues, for example the skin, but it is also found in tendons, ligaments, cartilage, bones, corneas, blood vessels, and intervertebral discs. It has been associated with the aesthetics industry for many decades, and was the first of the injectable fillers dating back to the 1980s, as well as being written about time and again in the search for topical ingredients, injectable substances or resurfacing treatments that increase the production of or longevity of collagen. Collagen is a complex of proteins, in a triple helix pattern. There are 18 known collagen sub-types, of which 11 are found in the dermis. Type I collagen is the predominant dermal collagen, being nearly 80% of total dermal collagen. It is responsible for the tensile strength of the dermis, and has been shown to decrease with age and interestingly to increase as a result of dermabrasion3. Type III collagen, sometimes known as foetal collagen due to its abundant presence in embryos, comprises between

collagen structure

10 and 15% of dermal collagen, and resides close to or surrounding blood vessels within the dermis as well as just below the DEJ. Other collagen types that are relevant in photo-ageing are types IV, V, VII and XVII. Craven proposed that Collagen Type VII is reduced in photoaged skin, and that it is responsible for the weakened anchoring fibrils at the DEJ, and this weakness is in turn in part responsible for the production of wrinkles4. During the ageing process, the relative proportions of collagen also change, as collagen Type I reduces compared to Type III. Elastin: Like collagen, elastin is present in many structures in the body, not just in the skin. Elastin only makes up around 3% of the dry weight of skin, whereas collagen makes up 70% of the dry mass of skin. Elastin is also present in abundance in the lungs and in blood vessels. Elastin fibres vary from collagen fibres in 24

that they are present at varying levels of maturity within the dermis. For example young elastin fibres are found stretching vertically from the DEJ to the top of the reticular dermis and are known as oxytalan, whereas mature elastic fibres, known as elaunin, lie horizontally in the deeper reticular dermis. The most mature of the elastin fibres are found in the deep reticular dermis, but are unnamed. Elastin is known to bind with collagen and hyaluronic acid, creating a three dimensional structure, but elastin fibres are produced in early years, and no new fibres are produced in adulthood. Degradation of elastic fibres is associated with UV exposure, and ellastosis is one of the key features of photoaged skin. The fact that new elastin fibres are not produced is a challenge in aesthetic dermatology, with much research going in to stimulation of elastin production. Glycosaminoglycans (GAGs): GAGs are well known in the aesthetics industry, after twenty years of working with hyaluronic acid (HA) based fillers from Hylaform, through to Restylane, Juvederm, Teosyal, Belotero and the many other injectable forms of HA available to us. It is easy to forget that GAGs are simple repeating chains of disaccharide units that occur naturally in the dermis, and it is common knowledge that HA absorbs 1000 times its own weight in water. HA is in fact the most abundant GAG, and other GAGs include heparin and chondroitin sulphate. The main relevance of HA in ageing skin is its ability to attract water and thereby to create volume in the dermis. However HA also performs other functions such as cell adhesion, keratinocyte differentiation and formation of lamellar bodies. Matrix Metalloproteinases (MMPs): MMPs are responsible for the breakdown of the different types of collagen described above as well as other key dermal and extracellular components. It is a logical step for ingredient manufacturers to look for MMP inhibitors, and there are many on the market such as the retinoids and bionic hydroxyacids.

THE HYPODERMIS The subcutaneous layer, or hypodermis, is mainly an area dedicated to fat storage. It represents 9 to 20% of normal weight in an average population group. The dilemma in aesthetic dermatology is the Aesthetics | December 2013

balance between the desire for a healthy ‘slim’ body shape, and the need for sufficient adipose tissue for a pleasing, youthful facial appearance. SUMMARY We have reviewed the structures and major components of the skin in relation to both healthy skin and photodamaged, prematurely aged skin. There is a plethora of cosmetic ingredients available to us, as well as a number of pharmaceutical options. It is important to understand how these ingredients may impact on our patients’ skin and to do this we need a sound understanding of the structure of the skin, and of the many components that make up the epidermis, dermis and hypodermis. FURTHER READING (1) Oikarinen A. The ageing of skin: chronoageing versus photoageing. Photodermatol Photomed. 1990;17;3. (2) Vrhovski B, Weiss AS. Biochemistry of tropoelastin. Eur J Biochem, 1998;258:1. (3) Nelson B, Majmudar C et al. Clinical improvement following microdermabrasion of photo aged skin correlates with synthesis of collagen I. Arch Derm 1994;1130:1136. (4) Craven NM, Watson RE et al. Clinical features of photodamaged human skin are associated with a reduction in collagen VII. Br J Derm. 1997;137:344. With thanks to the invaluable information in Cosmetic Dermatology: Principles and Practice, Second Edition, Dr Leslie Baumann, MD; 2009 McGraw Hill; and Cosmetic Dermatology; Products and Procedures, Dr Zoe Draelos, 2010 Wiley Blackwell. Lorna Bowes RGN NIP. As well as many years of delivering aesthetic procedures, Lorna has trained many doctors, nurses and dentists to administer basic and advanced fillers, toxins, medical needling, skin care and peels, and lectures regularly on aesthetic procedures and aesthetic business management. Lorna is a founding member of The British Association of Cosmetic Nurses (BACN), and Consulting Editor for The Journal of Aesthetic Nursing and so has a unique understanding of the aesthetic industry.

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Clinical Practice HA Fillers

A surgeon’s view Stephen McCulley MBChB, FCS(SA)Plast, FRCS(Plast) on the use of Hyaluronic Acid (HA) fillers in his facial aesthetics practice Stephen McCulley is a cosmetic plastic and reconstructive surgeon based at Nottingham’s renowned City Hospital. He is on the specialist register for Plastic Surgery and is a member of BAPRAS and BAAPS.

I have been combining the use of HA fillers and surgery in my practice for the last 12 years. As treatments they complement each other but cannot replace each other. Therefore, it is important that a surgeon understands the value of fillers, just as it is for the cosmetic practitioner to know the limitations of fillers.

FILLERS AS A VOLUMISING TECHNIQUE There has been a shift recently in the use of fillers to a concept of volumising tissues, as opposed to simply filling lines. This is hardly a surprising evolution as the connection between facial youthfulness and volume has long been recognised. The child’s full cheeks and short lower eyelid length give the mid-face its youthful appearance. As we age there is a huge change in both fat and bone volumes in the face. This ‘volumising approach’ has been part of the face-lift culture for many years. However, the days of filling facial wrinkles are far from over! Just as the modern concepts in breast augmentation have moved away from being about volume to dimensions, make no mistake, for many patients it remains about volume. Similarly in facial fillers as we move towards ‘volumising’ it remains about wrinkles for many. There is obviously a place for both to complement each other. In youth we observe the movement or mimetic wrinkles such as around the eyes and forehead that turn into the permanent dermal creases of age.

Then with time we see the emergence of what I call ‘decent’ or ‘gravity wrinkles’ as the combination of volume loss and skin elasticity changes create skin folds such as the marionette naso-labial changes amongst many others.

WHEN SURGERY IS REQUIRED There is no clear distinction between the role of fillers or surgery. However, the jowls, jawline and neck laxity remain the main roles of face-lift surgery. The square jawline created by the descent of the jowl can only be improved significantly and long term with surgery. Yet of all cosmetic surgery to the face, the eyes are one of the most successful and are important to discuss. Many patients I see come in requesting a face-lift to ‘improve their appearance’. I always ask them, as we all should with any treatment, what are the aims of the treatment for them. If they tell me they wish to look fresher or more youthful, I suspect in over 50% of patients, surgery to their eyes is probably the single biggest change they can make. This is very important to recognise as a patient can have all the fillers and toxin treatments possible, however, if it is the eyes that make them look tired or older then eyelid surgery should be at least discussed to augment their non-surgical treatments. Patients and alas some professionals, are not always that good at assessing what the real issues may be. Look at the face as a whole. If you are treating wrinkles alone you may not open your eyes to the whole face. Similarly, there is no point doing a face-lift when the real issue for the patient is actually just peri-oral lines.

FACE-LIFT TECHNIQUES There are many face-lift techniques. The short scar techniques are becoming more popular and have real advantages of both shorter scars and quicker recovery. They are good at managing the jowls and to a degree the mid-face and neck. However, a full face-lift is still better at managing large amounts of loose skin and neck laxity. Most techniques will show good changes to the jowls at five years and beyond, although changes to the neck do not always maintain as well. Many of these surgical techniques can improve mid-face fullness and now with the addition of fat injections this has become even better. However, reliable mid-face fullness can be elusive with surgery. There Aesthetics | December 2013


Clinical Practice HA Fillers

are some areas of the face that surgery will not impact upon. If one draws a line down from the inside of each pupil, very little to the midline of these lines will be changed by surgery. Therefore, the peri-oral, the inner mid-face and the glabellar remain the remit of cosmetic treatments in my practice.

MAKING AN ASSESSMENT A further useful tool to help assess the potential role of surgery for a patient is to take a photograph of them lying down and compare it to a photograph of them sitting up. This is a reasonable prediction of what a face-lift, and to a degree eye surgery, will achieve once it has settled. This can be done a few weeks following non-surgical treatments. If there are good changes noted then facial surgery will have a good additional role to non-surgical treatments administered. If there is little change noted with this photograph test then the continued use of non-surgical treatments remains reasonable. I think there is also a misconception that there

“There has been a shift recently in the use of fillers to a concept of volumising tissues, as opposed to simply filling lines. This is hardly a surprising evolution as the connection between facial youthfulness and volume have long been recognised.� effect and safely, albeit it is quite expensive to patients. Skin re-surfacing must also be considered as part of the regime for a patient particularly around the peri-oral area. Resurfacing in combination with fillers later can give excellent results. So when to use fillers and when to use surgery? Obviously it is not black and white. However, when a relatively modest volume of filler can create changes to the areas that bother a patient in that corridor of the face between the pupils then this remains a good treatment option as surgery is not going to impact these areas. In my practice this will be the glabellar lines with toxin and a combination of toxin and filler if deep; the peri-oral area, with or without resurfacing; the lips; small volume changes to the nasolabial folds and marionette lines. The deep filling of the cheeks is the only exception to these conservative rules in terms of absolute filler volume.

should be a choice between surgery or cosmetic treatments. I tell all my face-lift patients they will probably still benefit from fillers or toxin injections. The major difference is they may require less and the impact of the treatments can be even more dramatic in terms of eradicating troublesome areas. When fillers are needed in larger volumes, particularly in the naso-labial or lower face to create change then one must at least question using fillers alone. Indeed the use of large volume sub-dermal filler is questionable full stop as it creates skin changes over time. The exception to this volume rule has come in terms of deep cheek fillers creating cheek fullness. This concept has enabled larger volumes of HA to be used to good 28

However, when the main problems for the patient are the eyes, the jowls, the neck, marked lateral brow ptosis or large volumes of filler are required around or particularly below the mouth then the question of surgery should be raised. Not to eliminate the need for non-surgical treatments, but to return them to their ideal role of providing fine or finishing touches to the face and adding proportional volume changes without damaging the skin. Don’t forget the photograph test to assess the impact of surgery. Of course, look at the face as a whole and always question what the patient wants to achieve. Finally, always question yourself, as a surgeon or cosmetic practitioner, to ensure you are delivering the optimal and tailored treatments the patient needs. Aesthetics | December 2013

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Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to or on +44 (0) 333 200 4143. 1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. Date of preparation: August 2013 1102/BOC/AUG/2013/LD




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Clinical Practice Filler performance

Filler performance We summarise the results of a study comparing the physical properties and clinical performance of Varioderm® with other HA fillers



Hyaluronic acid (HA) is an essential polysaccharide that is ubiquitous in the human body and has been in clinical use for over thirty years. Properties of HA make it an attractive substance for dermal fillers for managing volume loss in the ageing face, such as its ability to bind large amounts of water, its natural presence in the skin and its low potential for adverse reactions. Three-dimensional facial re-contouring through softtissue augmentation with fillers can provide patients with a fuller, youthful appearance that softens the appearance of ageing. There are currently a number of dermal fillers available on the market based on injectable HA hydrogel. They differ in the specifics of their physical properties, and these differences have an effect on their final clinical performance. The physical properties of HA dermal fillers are determined by their HA concentration, cross-linking degree, gel hardness (elasticity), and injectability. A better knowledge of some of the physical properties of HA fillers can therefore be very useful for physicians in choosing the appropriate HA dermal filler for facial recontouring and/or a specific indication. In this study, the physical properties of seven selected HA dermal fillers were evaluated using the rheological testing method and compared.

Three-dimensional facial re-contouring through softtissue augmentation with fillers can provide patients with a fuller, youthful appearance that softens the appearance of ageing.

In the past, scientists and physicians have discussed the effects that certain properties of dermal fillers might have on the actual filling effect of a product. It has long been thought that the key parameters for the clinical application of dermal fillers were the HA concentration and the size of the gel particles in the product1. The clinical evaluation of Restylane® and Perlane (two products of identical chemical composition with a mean particle size of 300 μm and 650 μm respectively) showed however that the particle size does not affect the time of retention in the body2, 3. For cross-linked HA, its concentration is the decisive factor for high efficacy (with regard to filling effect and retention time). This however does not apply to non-cross-linked HA, as such substances are decomposed in the body within only a few days4. Table 1 shows the concentrations of the selected HA dermal fillers and their measured physical properties. The gel hardness (elastic modulus G’) plays a major role for the efficacy of a HA filler. This parameter is determined by the HA concentration, the molecular weight of the HA and the share of non-cross-linked HA in the end product. The elastic modulus can be used to determine the suitability of a HA filler for a specific application. HA fillers with greater elastic modulus have a better filling effect and a longer retention time in soft tissue. The measured elastic modulus values (Table 1) indicate that Juvéderm Ultra 2 is the lowest of the selected HA fillers (G’=75.5 Pa), followed by Teosyal Global Action (G’=140 Pa), Restylane® Perlane (G’=695 Pa), Varioderm® Plus (G’=940 Pa) and Varioderm® Subdermal (G’=2190 Pa). The elastic modulus of Varioderm® Subdermal is thus three times greater than that of Restylane® Perlane, while the elasticity modulus of Varioderm® Plus is seven times greater than that of Teosyal® Global Action, and even 12 times greater than that of Juvéderm® Ultra 2 (Figure 1). Given the high elasticity of the Varioderm® fillers, these products can achieve better volumising effect and a longer lasting augmentation in the soft tissue5,6. In addition, the high elasticity of these fillers means that less product is required to achieve the same effect as with less elastic dermal fillers.

Aesthetics | December 2013


Clinical Practice Filler performance

Varioderm® dermal fillers are produced by means of monophasic particle technology (MPT). The tests show that the Varioderm® fillers offer better injectability than the other dermal fillers, as the HA gel in the Varioderm® products are particulated (Figure 2). The measured extrusion forces (Figure 2) show that Teosyal® Ultra Deep requires by far the greatest extrusion force (Fmax = 57.06 N), followed by Juvéderm® Ultra 2 (Fmax= 32.74 N) and Restylane® Perlane (Fmax= 19.35 N). In contrast, Varioderm® Subdermal (Fmax= 17.02 N) and Varioderm® Plus (Fmax = 10.00 N) require a significantly smaller extrusion force. The maximum extrusion force of Teosyal® Ultra Deep is about three times greater than that of Varioderm® Subdermal and even six times greater than that of Varioderm® Plus. In addition, curve progression of Teosyal® Ultra Deep shows that the product does not possess a homogeneous mixture (Figure 2).

Table 1

Figure 1

CONCLUSIONS HA dermal fillers currently available on the market have their limitations related to clinical performance, persistence and ease of injection. Therefore, a better knowledge of the chemical and physical properties of HA dermal fillers may help physicians in choosing the appropriate HA dermal filler for facial enhancements [4].

Figure 2

The results of this rheological study indicate that seven selected HA dermal fillers possess a range of physical properties. Varioderm® products have significantly better elastic properties and are easier to inject than the other evaluated fillers (Teosyal®, Juvéderm® and Restylane®). This is mainly due to the innovative monophasic particle technology (MPT) used in the production process for the Varioderm® fillers. The optimised physical properties of the Varioderm® fillers therefore allow for better clinical results. Understanding of physical properties of dermal fillers and their potential impact on clinical performance may better equip the physicians to select appropriate HA filler products based on patient needs and desired outcomes5.



Monheit GD, Coleman KM, Hyaluronic acid fillers, Dermatol. Ther., 2006, 19: 141-150. 2. Narins RS, Brandt F, Leyden J, et al., A randomised, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds, Dermatol. Surg., 2003, 29: 588-595. 3. Carruther A, Carey W, De Lorenzi C, et al., Randomised, double-blind comparison of the efficacy of two hyaluronic acid derivatives, Restylane Perlane and Hylaform, in the treatment of nasolabial folds, Dermatol. Surg., 2005, 31: 1591-1598. 34

Tezel A, Fredrickson GH, The science of hyaluronic acid dermal fillers, J. Cosmet. Laser. Ther., 2008, 10: 35-42. 5. Weidmann MJ, New hyaluronic acid filler for Subdermal and long-lasting volume restoration of the face, European Dermatology, 2009, 1: 65-68. 6. Alsoufi A, New and innovative developments in hyaluronic acid fillers for lip enhancement and contouring, European Dermatology, 2010, 5: 50-53. 7. Stocks D, Sundaram H, Michaels J, Durrani MJ, Wortzman MS, Nelson DB, Rheological evaluation of the physical properties of hyaluronic acid dermal fillers, J. Drugs Dermatol., 2011, 10(9): 974-980.

Aesthetics | December 2013

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Clinical Practice PRP & organic silicon

Dr Alain Gondinet on how a combination of PRP and organic silicon can rejuvenate the skin

The Keystone in Regenerative Medicine

HOW DO DOCTORS USE PRP? “Nappage” cell mesotherapy with PRP for rejuvenation Through the technique of mesotherapy, PRP is injected in the papillaris dermis, either by nappage or point-by-point. As this is a highlyvascularised area, there is a slow release of platelets and growth factors towards the dermis, where they stimulate fibroblast proliferation and new extracellular matrix formation. This will rejuvenate elasticity and the texture of damaged skin. PRP also benefits the tone and secretions of the epidermal layer of the skin. This treatment can be performed in all areas where tissue regeneration is necessary, such as the face, neck, back of the hands and arms, hair and décolleté.

The use of thrombin/PRP gel for remodeling, and treating wrinkles and dark circles Like any practitioner working in the field of aesthetic medicine, skin ageing is the main focus of my practice and its management is therefore extremely important. One of the safest and most efficient solutions to targeting skin ageing, in my experience, is the use of living cells obtained from the patient’s own platelet rich plasma (PRP), combined with organic silicon.

WHAT IS PLATELET RICH PLASMA (PRP)? PRP is produced through centrifugation of the patient’s blood, obtaining an autologous concentration of human platelets in a small volume of plasma (4-5ml). This is measured as less than twofold to the native blood level. PRP contains specific selected white cells (monocytes and lymphocytes), plasmatic proteins (fibrin and globulins), vitamins, electrolytes and anti-oxidative enzymes. PRP also contains a concentration (two to three-fold) of growth factors, which are secreted when platelets are activated and initiate wound healing. All constituents of PRP are from autologous origin, meaning that there is no risk of a local immunological reaction or of transmission of diseases.

HOW DOES IT WORK? PRP is an in-vivo bio-scaffold, which functions by a ‘structure and signal’ process, consisting of: 1.

The formation of a tri-dimensional (3D) polymerised fibrin network from fibrinogen, activated by the autologous thrombin enzyme. 2. The release of growth factors by thrombocytes and leucocytes in their biologically determined ratios. There are over 80 known growth factors (GFs). In the field of aesthetics, the most important GFs are EGF, VEGF, PDGF, TBGF, IGF, KGF and FGF. 3. The chemo-attraction of macrophages and fibroblasts (mesenchymal stem cells). 4. Mitosis (M. Stem cell proliferation), differentiation and new extracellular matrix deposition. 36

Aesthetics | December 2013

PRP is combined with autologous thrombin produced in a dry tube without anticoagulant, and is injected into deep dermis, forming a gel texture. This provides a locally dense formation of the bio-scaffold, which will improve volume defects. PRP does not act as other cross-linked fillers, because the aim is to regenerate new tissue, which is the same as that surrounding the point of injection, rather than simply fill the wrinkle with biomaterial. It is autologous, so there is little bruising and no fibrosis encapsulation. It is a long-term process, but provides a natural and smooth result. Three injections at onemonth intervals are necessary to obtain visible improvements. Following this, one injection every six to 12 months helps to maintain results.

COMBINATION THERAPY USING PRP AND ORGANIC SILICON The organic silicon salicylate monomethyltrisilanol, has the best bioavailability for the body, and is the most well-known form of organic silicon used in therapy. In the aesthetics market, Conjonctyl from Sedifa is the organic silicon available for mesotherapy injections. Connective tissue is rich in silicon when the human embryo develops. The silicon is then depleted naturally as growth and ageing occurs. Organic silicon is a bridging element for the molecules that constitute the extra-cellular matrix of connective tissue, and is soft in the skin and dense in the joints. Injections of organic silicon into the dermis improve its structure and texture, and can be injected before PRP in the same session. The injections can be given in three sessions with an interval of two weeks, and follow the same protocol as for PRP injections. Organic silicon can

Clinical Practice PRP & organic silicon

also be mixed with non-cross-linked hyaluronic acid and Vitamin C. By forming links within and between individual polysaccharide chains, and by linking these chains to proteins (GAGs, glycoproteins, fibrin), organic silicon improves structure and texture by developing the architecture of the fibrous element and contributing to its structural integrity. It is mandatory when undertaking these treatments, that medical doctors use sterile and authorised medical devices in a safe, secure way. This includes PRP kits that are CE mark medical device Class II b and FDA approved, and organic silicon that is CE mark medical device class III. PRP, organic silicon and hyaluronic acid can be used in the same session to improve the quality of the skin in terms of hydration, cell biostimulation and regeneration. As long as doctors maintain safe, secure, efficient methods of injection, the combination of PRP with Organic Silicon will help improve skin quality in patients needing tissue repair or those wanting to manage the skin ageing process, and can be defined as a keystone of skin rejuvenation.

WHAT IS CONJONCTYL? Conjonctyl is currently the only authorised form of injectable silicon organic in the world. All other forms are for topical, external use only. It is a small outline specification of silicon organic (Si â&#x20AC;&#x201C; C) medical device class III, trademarked from Sedifa Laboratoire Monaco. It is a sterile solution of 0.5% sodium monomethyltrisilanol orthohydrobenzoate (i.e a Salicylate of silanol). The product is stable in aqueous solution. Increased demand to regain visible youth has encouraged scientists to look more closely at the extra cellular matrix and to look for products that will produce natural results. Adding Conjonctyl to treatment will produce significant visible results in terms of reconstruction of tissues, facial correction and younger skin. The whole procedure takes only a few more minutes than classical methods, but the glow of the face is noticeable instantly. Conjonctyl is now available in UK and Ireland through Synergy Beauty Med UK Ltd SBM.

Dr Alain Gondinet is an aesthetic medical doctor and nutritionist specialising in antioxidative mesotherapy. He is a medical consultant at Bio Bridge Foundation (Switzerland).

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Clinical Practice Hyperhidrosis

No sweat Dr Patrick Bowler discusses new technology for sweat reduction in primary axillary hyperhidrosis Excessive sweating, or, to give it its medical name, hyperhidrosis, is a condition that affects millions of people throughout the UK. Until now, treatment has consisted of medical-strength aluminum chloride antiperspirant, or Botox® to the sweat glands. Surgery has been a painful, complicated option too. But the use of non-invasive bimodal RF technology (Alma SweatX) is safe and effective for long-term (up to six months) sweat reduction in patients with primary axillary hyperhidrosis and offers a pain-free and non-invasive solution that could change patients’ lives. We’ve got over two million sweat glands in the body: tiny, minute glands that number up to 370 per centimetre squared if you look at the palm of your hand. Even when we’re not aware of it, we’re sweating constantly, as this is the body’s way of regulating temperature and cooling us down. Eccrine glands are a few millimetres under the skin. Apocrine glands are deeper under the skin’s surface, and sweat from these glands contain proteins and fatty acids that give a discoloured appearance. This occurs in the groin and underarm areas. A body at rest simply reabsorbs sweat produced, but after exertion or exercise, excess sweat makes it to the surface of the skin to evaporate. When sweat comes into contact with bacteria on the skin, a smell can occur. We can produce up to three litres of sweat an hour, but the average is closer to half a litre a day. However, up to 2% of us don’t produce any underarm odour at all, proving that everyone experiences sweat differently. Hyperhidrosis is a medical condition whereby the signals sent to the sweat glands are exaggerated and so excessive sweat is produced irrespective of activity levels. Surgical procedures include cutting through the chest wall to cut the nerve fibres supplying the eccrine glands, or going under the skin of the armpit and liposuctioning out the glands. With both, there’s a risk of damage to skin structures. Alma SweatX is non-invasive and pain-free. It works by using radio frequency. Electric and magnetic energy targets water molecules in and around the sweat glands, which respond by rotating rapidly, generating friction and in turn heat. This temporarily deactivates the glands. In hyperhidrosis the glands contain excess water compared to other structures and are therefore heated preferentially in the skin. The treatment occurs in two parts, with the first probe targeting the deeper, apocrine glands, and the second part working on the more superficial eccrine glands. Patients experience a mild warming sensation and little else. Clinical trials support anecdotal evidence. In a trial conducted by Prof. Igor Pinson, MD, PhD et al, all patients demonstrated sweat reduction at one, three and six months after their last treatment, as indicated by the iodine-starch test and hyperhidrosis disease severity scale (HDSS) questionnaire. One month after the last treatment all patients shifted from HDSS three or four to HDSS one or two. At a six-month follow-up, 11 patients (55%) reported HDSS=2 and 38

Aesthetics | December 2013

nine patients (45%) reported HDSS=1. In the control group, 80% of patients (eight patients) showed HDSS=2 and two patients HDSS=1 (no change from baseline). It’s proven to be safe and effective for long-term (up to six months) sweat reduction in patients with primary axillary hyperhidrosis. Results may even last longer but more trials will need to be done before we know if it offers a more permanent solution to the problem. Patients notice results in a few days, with no odour and little dampness. For clinics, Alma SweatX offers a targeted treatment for hyperhidrosis and osmidrosis with no disposables and a user-friendly interface. Treatments are short, and easy to delegate, ensuring an incredible high return on investment. Dr Patrick Bowler is a founding member and Fellow of the British College of Aesthetic Medicine, and a member of the American Society for Laser Medicine and Surgery. He is also the founder of Courthouse Clinics.

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Clinical Practice Hair loss

Dr Patrick Treacy, MD of Ailesbury Clinics, looks at the latest methods and procedures in FUE hair transplant technology

The hair and now

Until recently, having a hair transplant was not something you could do in secret. A Follicular Unit Extraction (FUE) procedure requires the patient to shave their head prior to treatment and the strip surgery leaves a large permanent scar. A newly shaved head or a scar on the scalp leaves it difficult to keep the procedure secret. We have seen some celebrities trying to keep their treatment, quite literally, under their hat until their shaved hair grows back, but the constant wearing of a cap or hat causes questions to be asked too. Developments in treatment methods, and in particular specialist skill sets now make it possible to perform an FUE procedure without shaving the head before treatment. Follicular Transfer is a modern hair restoration technique where hairs are transplanted in groups of one to four hairs - exactly as they grow in nature. It is a major advance over the older hair transplantation procedures that used larger grafts and often produced a pluggy, unnatural look. FT technique is actually a two-step procedure where the aesthetic results mimic the way hair grows in nature and will be undetectable as a hair transplant. During the first step, also called FUE (Follicullar Unit Extraction), direct extraction of selected individual follicular units from the patient’s donor area is performed, allowing the surgeon to control the potential problem of visibly lower donor area density after the procedure. The second part of the procedure is the Follicular Implantation where the surgeon implants the grafts with a predetermined density, pattern and angle in a realistic hair pattern. Many clinics now offer adjunct hair restoration techniques that combine adjuncts such as stem cell technology, motorised micropunch extraction, anabolic nutrition or red light phototherapy to shorten the time required for complete hair growth and increase follicular graft survival. Each represent a small advance on methods of hair implant technology currently available by concentrating on a shortened recovery time, increased graft survival and reduced risk of complications.

STEM CELL TECHNOLOGY Many clinics have been testing the use of platelet–rich plasma (PRP) in hair transplant surgery since 2009 when Carlos Uebel from Brazil and Joseph Greco from Florida reported improved healing and graft survival with use of this method. Platelets, key players in the body’s wound healing mechanism are activated to release various hair growth factors that stimulate the healing process. These factors stimulate new blood vessels to form (angiogenesis) and collagen to be produced. Cells are stimulated to divide and go into action surrounding the wound. PRP reduces infection and offers a minimally invasive surgical procedure that benefits from a shortened recovery time, increased graft survival and reduced risk of complications. 40

MOTORISED MICROPUNCH EXTRACTION Many hair implant surgeons prefer small punches (really sort of a special needle of 0.72 mm diameter) with a motorised drill to remove individual follicular units, eliminating the need for excision of skin from the back of the head. Punch gauges and preferences can widely vary. Typical ranges are 0.75mm to 1.0mm. Small punches are great for minimising scarring but are not really suitable for larger two, three and four-hair grafts. Using a 0.75mm punch to extract a triple-hair graft could result in partial or full transection of the graft. Many clinics feel that something like a 0.9mm gauge is more suited to a reproducible outcome. Respectively, using a larger gauge can preserve yield levels but also create scars larger than desired and damage surrounding follicles. Words of wisdom dictates that one size does not fit all.

ANABOLIC AWARE NUTRITION Hair is made from nutrients in the body, and nutritional deficiencies can cause hair damage and hair loss. For example, biotin deficiencies have been linked to hair loss and skin disorders, and sufficient levels of the B vitamins are necessary for hair health and growth. Many Western diets are lacking in nutrients and a poor diet may contribute to early onset of hair loss symptoms in people genetically prone to hair loss. Ailesbury Clinic uses Help Hair™ Shake which contains nutrients and herbs specifically selected for their positive effects on hair, including Niacin (vitamin B-3), Folate, Vitamin B-12, Biotin, Zinc, Manganese, Fo-ti Root (Ho Shou Wu or Polygonum multiflorum) - a popular Chinese herb traditionally used to darken pre-mature grey hair, Kudzo Root - Pumpkin Seed to help regulate testosterone levels and PABA, Chlorophyll to remove sebum, which carries DHT. As part of an overall hair loss program, Ailesbury Clinics put patients on a low anabolic profile by telling them to consider eliminating or reducing certain supplements in their diet. This includes using the SHAPIRO Chart and monitoring the use of anabolic steroids, creatine, Growth Hormone, Androstenedione, HCG diet or Whey Protein Isolate often found in body building additives.

Aesthetics | December 2013

Clinical Practice Hair loss


RED LIGHT PHOTOTHERAPY The technique uses wavelengths with red light therapy in the range of 630 to 670 nanometers (nm) immediately post FUE procedure. Visible red light is capable of being absorbed by the molecules of the hair follicle and can stimulate the growth or re-growth of the hair following a natural biological reaction. Red light is absorbed because of an intracellular enzyme called cytochrome c, which is responsible for stimulating the hair follicle by sending it certain signals. Those signals promote gene activity and lower apoptosis (cell death regulated by the genes) as well as other reactions. This has been known since 1967 when it was accidentally discovered by a Hungarian scientist who noticed that exposed, shaved mice experience faster hair re-growth.


• More than 50% of men over the age of 50 will have experienced some form of hair loss. • The average number of hairs on a male human head is approximately 100,000 - 150,000. • Men with fair hair actually normally have more hair on their heads than men with darker hair. • Hair loss can affect men of all ages, from their late teens upwards. • The average FUE hair transplant procedure takes approximately eight hours to complete (depending on the number of hairs to be transplanted). • The average number of hairs transplanted in a FUE hair transplant procedure is around 5,000 hairs. • The U-FUE (Unshaven Follicular Unit Extraction) hair transplant procedure allows men, now, to undergo a hair transplant without having their head shaved - so it is, in effect, undetectable. Dr Patrick Treacy is Medical Director of Ailesbury Clinics Ltd and Ailesbury Hair Clinics Ltd. He is an active member of many international medical societies and is a Fellow of The Royal Society of Medicine.


GB16982_SIG-ART 15/11/2013 10:24 Page 1




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Forming an Eliance The new Pistor Eliance injection gun provides painless, precise penetration for practitioners and patients alike. When it comes to mesotherapy, no name is more synonymous with clinical efficacy and expertise than Pistor. The original Pistor injector gun was co-invented by the founding father of mesotherapy, Dr Michel Pistor, and the products are now designed and manufactured in France by MI Medical Innovation, a world leader in the field itself. Distributed in the UK and Ireland by Vida Health and Beauty, MI Medical Innovation’s range of mesoguns are designed to make mesotherapy treatments more accessible, comfortable and effective for patients and practitioners alike and are seen as the gold standard among leading meso practitioners across the Globe. The company’s new generation mesotherapy gun, Pistor Eliance, is one such innovation. The ergonomic design of the gun means that the handset is lighter and allows practitioners to deliver treatment with enhanced comfort, and therefore with more efficiency and with less fatigue. Fatigue is one of the number one concerns among physicians performing a significant volume of mesotherapy. Doing several treatments in one day can be quite demanding on the hand and wrist, a problem that is alleviated by the use of mesogun. Not only does it take away the need for holding a syringe but it improves consistency. Practitioners can choose from six pre-programmed precise injection modes, allowing specificity for

administering different injections. The ergonomic control panel is also clear, meaning that tactile control management is possible, allowing for fast and easy specific programming and eradicating product-use confusion. Unlike older injection guns, there are no cables, meaning it is easy for practitioners to work around their clients. It is also suitable for injecting solutions with a high viscosity index, such as hyaluronic acid, which has a viscosity index of 5500 Pa/s. The gun’s electronics enable easy and precise adjustments of penetration depth, injection volume and injection time, and the needle is attached directly to the syringe rather than a catheter tube, meaning that there is no product wastage. When working with small quantities of product, the gun also ensures the exact same dosage is delivered every time. The Pistor Eliance is also fully ambidextrous, so can be used with the left hand as well as the right. In case of an emergency, it automatically switches to standby mode in the event of an error in use, showing that it is a safe product. It is versatile and can be used worldwide, as the new generation battery recharges on both 220 V/50 Hz and 110 V/60 Hz power supplies. For the patient’s benefit, the gun is gentle, quiet and virtually painless, even in sensitive areas such as the scalp or face, providing the luxury of client wellbeing that is not achieved by compressor operated guns. All of this combined makes mesotherapy an exciting and dynamic treatment option to add to your practice.

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Clinical Practice Abstracts

A summary of the latest clinical studies TITLE: The Role of Hyaluronidase in the Treatment of Complications From Hyaluronic Acid Dermal Fillers AUTHORS: Cavallini M, Gazzola R, Metalla M, Vaienti L PUBLISHED: Aesthet Surg J. 2013 Nov 6 KEYWORDS: Cosmetic medicine, dermal, facial skin necrosis, fillers, hyaluronic acid, hyaluronidase, noninvasive plastic surgery ABSTRACT: Hyaluronidases, a family of enzymes that are able to degrade hyaluronic acid (HA), are employed in medicine to increase drug diffusion and reverse the effects of HA filler injections. Hyaluronidases are able to dissolve subcutaneous nodules or to correct excessive quantities of injected filler. Knowledge of the use, methods of application, and adverse effects of hyaluronidases is essential for the aesthetic practitioner. The authors performed an extensive review of the available literature from 1928 and compared the different enzymes available, recording each author’s indications regarding usage and side effects. TITLE: Stylage®: A Range of Hyaluronic Acid Dermal fillers Containing Mannitol. Physical Properties and Review of the Literature AUTHORS: Ramos-E-Silva M, Fonteles LA, Lagalhard CS, Fucci-da-Costa AP PUBLISHED: Clin Cosmet Investig Dermatol. 2013 Oct 23 KEYWORDS: Fillers, hyaluronic acid, mannitol, Stylage® ABSTRACT: Minimally invasive dermatological procedures, such as those using hyaluronic acid injectable fillers, have revolutionised anti-ageing treatments of the face. By promoting replacement of lost volume and attenuating grooves and wrinkles, they ensure a more youthful appearance and recovery of facial aesthetics. The authors review some of the main physicochemical characteristics of these dermal fillers, highlighting the product line Stylage®, the manufacture of which includes mannitol. TITLE: The Use of Infrared Radiation in the Treatment of Skin Laxity AUTHORS: Gentile P, Felici M, De Angelis B, Puccio L, Puglisi A, Felici A, Cervelli V, Delogu P PUBLISHED: J Cosmet Laser Ther, 2013 Nov 11 KEYWORDS: Infrared radiation, laser therapy, skin laxity, scars ABSTRACT: This study examined the use of infrared lights in treating facial and body skin laxity. Between 2007 and 2011, in the Department of Plastic and Reconstructive Surgery at the Hospital S Camillo - Forlanini, 303 patients were enrolled in the study and underwent laser therapy, operating at wavelengths from 1100 to 1800nm. Areas treated include face, neck, eyebrows, abdomen, legs and buttocks. Results showed no systemic complications. The satisfaction degree of patients was 70% ‘very satisfactory’ for facial, neck and eyebrow lifting and 40% ‘very satisfactory’ for all other areas. Conclusions indicated that the use of infrared radiation represents a valid alternative to surgical lifting, but cannot replace it. The infrared light technique used has turned out to be useful in contrasting skin laxity of the face and other parts of the body. The absence of scars and surgical risk makes this technique useable for a large number of patients. 44

TITLE: Acne in Patients with Skin of Color: Practical Management. AUTHORS: Yin NC, McMichael AJ PUBLISHED: Am J Clin Dermatol. 2013 Nov 5 KEYWORDS: Acne vulgaris, topical retinoids, azelaic acid, dapsone, antimicrobials, hydroquinone, post-inflammatory hyperpigmentation, isotretinoin, laser therapy ABSTRACT: Acne vulgaris is a prevalent and nondiscriminatory condition affecting individuals of all races and ethnicities. Dermatologic care must evolve accordingly to address the distinct concerns of people with skin of color. Patients of colored skin with acne can be particularly challenging, given their potential for complications including post-inflammatory hyperpigmentation and keloid development. A variety of treatments have proved to be effective in preventing or treating these complications. Topical retinoids are considered first-line therapy for acne in patients of color; topical alternatives include azelaic acid, dapsone, and antimicrobials. Hydroquinone may be used in combating post-inflammatory hyperpigmentation. For severe acne, oral agents, including antibiotics or isotretinoin, may be used. Most recently, various lasers and phototherapies have been suggested for their safety and efficacy. Recognising the clinical and histologic differences, as well as the variations in treatment regimens for darker skin types, will allow for better care and patient satisfaction. TITLE: Consensus Recommendations on the Aesthetic Usage of Botulinum Toxin Type A in Asians. AUTHORS: Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. PUBLISHED: Dermatol Surg. 2013 Oct 11 KEYWORDS: Botulinum toxin type A, BTA in Asians, forehead lines, glabellar lines, infraorbital wrinkles ABSTRACT: The use of botulinum toxin has rapidly expanded into various aesthetic applications. This study provides consensus recommendations on common aesthetic problems, which are treated by neurotoxins in Asians. A panel of experienced Korean dermatologists developed a clinical consensus on common aesthetic problems involving the face, neck, and calves in Asians. The recommended final concentration of BTA was 50U/mL after reconstitution with physiologic saline. For horizontal forehead lines, the members recommended nine injections in two rows into the frontalis with 1U/point. For glabellar lines, the members recommended three injection points (a total of 8U). For crow’s feet, the members recommended three injections per side (7 U/side) at the lateral part of the orbicularis oculi. For infraorbital wrinkles, one to two points per side in the superficial subcutaneous space approximately 1cm below the lash line were recommended (1-2U/side). For nasal flare, one injection point in the middle of each ala nasi was recommended (a total of 2U). For depressed nasal tip, a single injection deep within the columella was recommended, with a dose of 3U. This guideline provides a framework for physicians who wish to perform safe and efficacious injections of BTA in Asians.

Aesthetics | December 2013

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In Practice Brand archetypes

Richard Crawford-Small on branding and archetypes

I then remembered the solution to the problem; know what your brand archetype is and communicate that to the world. A couple of questions and a Twitter chat later, I was introduced to the book The Hero and the Outlaw; Building Extraordinary Brands Through the Power of Archetypes by Margaret Mark and Carol S. Pearson. So armed with this, I set forth on my mission to create an extraordinary brand.

What’s your story? Richard Crawford-Small Primarily the Creator Archetype, because he loves making things, (but a little bit of an outlaw too). Creator of iConsult & Practice Transformations. Twitter @iconsultsoft. “Tell me about yourself?” This is one of the most difficult questions in the world to answer. It could be a question asked between two people who go on to marry; it could be the first question asked of a new employee who goes on to become the CEO. Ask the next person you see that question and don’t be surprised if they struggle to formulate a response. So why is this question so difficult to answer? Because, arguably, it is the most poignant question you can ever really ask an individual. For a company, it is the most important question to be able to answer as it reveals your core beliefs and philosophies and ultimately enables you to articulate your identity, or ‘brand’. When I was creating the brand for iConsult, I’d found it extremely difficult to extract the core elements from my usually accommodating mind without coming across as a complete narcissist or missing out some key elements, I took a break from the white board and let my mind wander, as my normal thought processes wouldn’t solve the problem; “What is iConsult? What makes it special? What is it’s story?” A massive glass of Cockspur Rum later and my mind drifted to university and a lecture on screenwriting (my film-making career was very short). We discussed the key elements of character creation and the “What is my motivation?” question that actors need to be able to answer in order to understand the one thing their character is trying to achieve. That was a bingo moment. 46

So, what is an archetype? Imprints, hardwired into our psyches, influence the characters we love in art, literature, the great religions of the world and contemporary cinema. Plato called these imprints ‘elemental forms’ and saw them as the idea structures that formed a template for material reality. C.G. Jung called them ‘archetypes’. These archetypes are commonplace, and once you know what they are, you will gain a deeper level of understanding in not only how some brands communicate to you, but also how you can improve the effectiveness of your own marketing messages. Each of the 12 archetypes has a unique philosophy and identity. They are a key tool in helping us not only to understand ourselves, but also to understand our customers and help us to avoid a very common scenario; the ill-considered rebrand. A rebrand is not a new logo; that is a refresh. It could be that you have spent a significant amount of money on marketing to your customers with a strong safety message (Caregiver), when in fact they would respond to the latest treatments and techniques (Creator). Do you rebrand to a Creator? Maybe, if appropriate, but it is definitely cheaper to look for people who would respond to a Caregiver brand. Over the next few articles, I want to bring these archetypes to life. We need to look at some examples of how they relate to real life people, brands and products and how you can apply this powerful tool to maximise the impact of your marketing. So, let’s get started.

THE 12 ARCHETYPES The Innocent

Helping you to retain or renew your faith

The Explorer

Helping you to maintain your independence

The Sage

Helping you to understand your world

The Hero

Helping you to act with courage

The Outlaw

Helping you to break the rules

The Magician

Helping you to transform

The Regular Guy

Helping you to thrive, just as you are

The Lover

Helping you to find and give love

The Jester

Helping you to have a good time

The CareGiver

Helping you to care for others

The Creator

Helping you to create something new

The Ruler

Helping you to exert control

Aesthetics | December 2013

In Practice Brand archetypes

THE INNOCENT Brands: Disney, Dove, Tellytubbies Characters: Forrest Gump, Princess Leia Adverts: John Lewis & Coca Cola Christmas Advertising

The new John Lewis advert, an example of the Innocent archetype

Our first archetype, The Innocent, is a great archetype for use in a medical aesthetics environment because it embodies many relevant core elements. It’s clean and signifies the search for paradise, renewal and promise, neutral colours and also anything to do with the natural environment. Whether you’re a fan of the new John Lewis advert or not, it has been a big hit. According to Marketing Week, 79% of Facebook posts referencing the ad have been positive, and John Lewis marketing director, Craig Inglis, echoes the use of archetypes when he says, “Our ads aren’t about products, they’re about telling a story.” The link to paradise is interesting as many older people seem to look to a nostalgic past for their ideals of a better time. So being able to ‘restore’ part of that and enable them to enjoy their later life with the freedom associated with youthful looks, could be important. As the book says, “When the Innocent archetype is active in an individual, a person is attracted to certainty, to positive and hopeful ideas, to simple, nostalgic images and to the promise of rescue and redemption.” The Innocent is also strongly associated with Christmas. Coca-Cola are often referred to as an innocent genius brand for getting fizzy sweet sugary brown water that makes you fat and rots your teeth, connected with Christmas. In 1931, artist Haddon Sunblom created a series of magazine ads for Coca-Cola based on the 1822 poem The Night Before Christmas by Clement Clark Moore. Because these images were in print for nearly 30 years and had such a wide audience, the generic depiction of Santa Claus is now as per Sunblom!

THE EXPLORER Brands: Land Rover, Starbucks, North Face Characters: The Crew of the USS Enterprise, The Scott Expedition, Richard Branson. Adverts: Anything to do with freedom and adventure,

THE SAGE Brands: Mayo Clinic, Harvard, BBC News Characters: Confucius, Yoda, Oprah Winfrey, Bill Gates. Adverts: The expert, the leading voice.

off road, the outdoors, the Internet The Explorer archetype is used very heavily in the marketing and positioning of products or services that help you on your Land Rover represents the Explorer archetype quest to ‘find a better world’, express a narrative or the sense of a journey. The obvious examples of this are Land Rover, Levi’s, Wrangler and basically any product that needs to appeal to rugged outdoorsy types that desire escape. Science Fiction also tends to draw heavily from this archetype. Star Trek’s split infinitive “To boldly go where no one has gone before” is a classic example of an explorer archetype strap line and has endured for over 40 years. Explorer brands can also be web based; an early example being “Amazon - taking you from A to Z” However, the best example of an Explorer brand for me is Starbucks. I love brands that have their identity pulled right through from bottom to top. The name “Starbucks”, is a reference to the first Mate of the Peaquod in Moby Dick, (not, as I was disappointed to find out, Dirk Benedict’s character in Battlestar Galactica), and the logo is very much a goddess of the sea. The brand experience continues inside the shop, and regardless of your feelings on the company’s tax dealings, Starbucks has recreated the expectation of customer experience in a coffee shop. Think back to the old days of no choice, no WiFi, no seats. Now think Starbucks; blazing the trail, challenging the status quo, and turning a semi skimmed medium black coffee into a Skinny Grande Americano.

The final Archetype we will look at for now is The Sage, another great archetype to use for medical aesthetics. The obvious positioning for someone in this industry is to embody that of the expert, who shares their knowledge with their customers, maximising retention by creating compelling experiences. Most people respond well to brands that lead and make them feel comfortable that they’re in good hands, and it’s evident that lots of software companies adopt this archetype to convey a feeling of security to their users. Oprah Winfrey is probably one of the most powerful Oprah Winfrey, represents the Sages in America as she Sage archetype, being wellrespected, highly-acclaimed & sells records, books, viewed as an expert in her field and even has Tom Cruise jumping on her sofa because people believe what she says without question. Interestingly Richard Branson is rapidly moving from an Explorer archetype to the Sage as he enters his semi-retirement. This brief introduction to the Archetype concept and explanation of the first three should have allowed you to consider the branding of familiar products and begin to analyse your own marketing. Look at yourself, your business and your patients and see if you recognise any of the traits we have identified. Ask yourself: are you focusing on the correct group?

Aesthetics | December 2013


In Practice Blogging

1. BECOME THE TRUST AGENT The real task for any aesthetic business is to gain the trust of potential new clients. Most people feel they do this well in a face-to-face consultation but how about gaining their trust before this meeting to allow you more time during the consultation to discuss treatment options and the next steps? Blogging can help with this because when someone visits your website they can see it’s up-to-date with relevant and new information about your industry, treatments, clients experiences etc. This shows you are putting in that little bit extra to give potential clients as much value as you can. As human beings we love more, so give more to your website visitors and start blogging.

Around the blog


John Castro asks whether you should be blogging and what the benefits are to your aesthetic business 85 million unique visitors per month - that is the number of people who visit the most popular website blog on the Internet today: The Huffington Post. Now of course that is an extreme example, but what it proves is that the world today wants regular information, they want it in ‘real time’ and they want to interact with that information too. You may not see much comparison with a news blogging website like The Huffington Post but there is a lot to be learned from this site as they are using the practice of blogging in the right way. In the information hungry world we live in today, the internet gives us so much information: information that is used in many cases to make buying decisions. As such, a blog gives you the opportunity to supply relevant and up-to-date information to the internet-surfing public that will, in turn, encourage them to buy from you. In this article I am going to present the opportunities for you as an aesthetic professional in setting up and running your own blog. Even though I have used the word ‘running’, there is no need to panic and think, “Oh no, more time I have to spend on something”. A blog doesn’t require the attention or efforts you may think. With the industry we are in, blogging gives website visitors more opportunity to engage with you, interact with you and ultimately build trust in you. This should be the intention of your blog; to gain trust. Below I have listed three main reasons to start blogging and how each will help your aesthetic business bring in new potential clients. John Castro is the founder and director of Website For Cosmetics, a specialist in Web Marketing to Cosmetic and Aesthetic Healthcare Professionals. 48

Engagement is so under valued. Just look at the word ‘engagement’ for a second. We use this word in ways that mean commitment. I encourage you to look at a blog the same way. What a blog does is engage your audience, which essentially has them commit to you for a specific period of time. They have taken time to read your information and that is commitment. You gain their interest by providing them with content no one else probably is. Do this regularly and you start to see how your blog posts actually play a big part in generating new leads into your aesthetic business from your website.

3. INTERACT AND YOU WILL ATTRACT Probably one of the most difficult parts in any blogger’s agenda is to get the users to interact, but if you get this right you are on to a real winner. Interaction with the user encourages enquiries. Why? Because you are essentially asking them to take a specific action related to your blog post, which means you have all their attention and they are actually listening to you. The best way to get interaction is to mix it up in your blogs by adding videos, Facebook ‘like’ buttons, share buttons for all social media and comment boxes for them to leave their thoughts on your blog. All of these things get the reader/user interacting and if you keep your blog posts interesting and informative as well as up-to-date, website visitors will encourage their community (more potential clients) to read it by sharing it. Get this right and I promise you people will return again and again to your website and start sending more and more potential clients your way.

CONCLUSION Blogging can play a major part in your website’s ability to generate new client enquiries. If done correctly, you can really benefit from this marketing action. Current internet users want new information every day and the more you can supply them with what they want, the more they will consider coming to you or telling people about you. The point is be informative and creative when writing blogs: two to four per month is enough. Do not think you need to bombard the blog daily. Something to leave you with:


Aesthetics | December 2013



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Azzalure® Abbreviated Prescribing Information 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 frown, 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. 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. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. 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: 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 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: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects 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). Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP) IRE 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 2011.

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In Practice Marketing

Wendy Lewis on the art and science of clinic marketing: striking the right balance

human behavior. Marketing is about telling your story, building relationships and giving customers direct value. This is where the artistry comes in. Marketers must inspire and connect with a target audience on a deeply personal level. Regrettably, scientists are not inclined to do that very well. It’s just not in their DNA. Having a robust online presence and online marketing are vital for growing a successful clinic today. But some clinics may be overlooking the benefits of tried and true marketing methods by focusing solely on their web strategy. So before you sign up for complex and costly marketing strategies, keep in mind some simple tactics that may be more cost effective and have always worked. These methods may include, but are not limited to, eblasts, open house seminars, loyalty programs, and giving five-star service.

Balancing act


Many marketing experts are all about doing the math. They throw out countless methods of analytics to test and measure clicks, calls and ka-ching. They are rather obsessed with outsmarting Google. They promote the ROI (return on investment) on every strategic decision. These marketers have a formula that they ascribe to for promoting a clinic. Some are just passionate about it; but others are dogmatic that theirs is the only way and nothing else matters. In my view, these sort of tactics sometimes work for a period of time, but that is not engraved in stone. Why? Because they are failing to calculate perhaps the most obviously inconclusive element – the human factor. Yes, that is right – we are dealing with h-u-m-a-n-s, i.e., patients! No one can truly predict human behaviour 100% of the time. There are too many twists and turns to account for. We can make assumptions, an educated guess, or even base conclusions on past behaviour. However, this method is just not as foolproof as SEO experts will lead you to believe.

Social media is a vital tool yet many clinics still have not figured out how this form of marketing will benefit their business. Those who are still on the fence about diving into the social space are missing out on an important channel in which to highlight their services and products in a unique and creative way. A strong social media strategy should be an integral part of a proactive clinic marketing programme in today’s competitive market. Social media offers up the perfect combination of art and science. It affords marketers more flexibility to think outside the box. Facebook, Twitter, and some of the newer key platforms including Instagram and Pinterest, are a marketer’s dream come true. Small businesses like solo practitioner clinics in particular must make the most of every opportunity to promote their brand. However, there are some obvious forms of marketing that may be overlooked in the day-to-day operations of a busy clinic. For example, having a powerful email signature on every email sent from the clinic, treating every patient professionally, offering good value for money on popular repetitive treatments, and servicing patients efficiently and in a timely manner. All of these pivotal touch points can have a dramatic effect on your bottom line, yet they are much harder to measure than tracking how many people clicked on your landing page or how many seconds they spent on the photo gallery. Social media is all about people. It is a form of human communication. It cannot just be measured by clicks and likes. Techs may be brilliant at links, algorithms, writing code and programming. PRs and writers are good at words, visuals, and communicating with people. Being creative or artistic dictates a way of thinking and of viewing the world. Creative people have been said to use the right side of their brains more than the left. They tend to be more open-minded thinkers and are often more emotional. So if you are a right brained sort of person, you will probably succeed best in a career that allows you the freedom to go a little crazy. Left brained people, on the other hand, are usually good at science, math and music. They are more analytical, adept at tasks that require attention to detail and numbers, and tend to be more logically minded. Sound familiar? It should. It is widely accepted that doctors and especially surgeons are often left brained kind of people.



Marketing an aesthetics clinic properly surely requires skill and expertise, but it also requires a basic understanding of

What do you want to be - an artist or a scientist? Until you make up your mind, you won’t be as effective as you could be in your

Among marketers of aesthetic clinics there appears to be a growing divide. The lingering question is whether clinic marketing is about art or science. I would argue that it is really about both, and that striking a healthy balance is the key to success.



Aesthetics | December 2013

There is a place in clinic marketing for the scientist and the artist. They can co-exist beautifully. However, you can only wear one hat at a time. Figure out what you are good at and like to do, and delegate or outsource the aspects of marketing a clinic that do not come naturally to you. endeavours. You will probably get frustrated, spin your wheels in the wrong direction, and go through your budget faster than you should. There is a place in clinic marketing for the scientist and the artist. They can co-exist beautifully. However, you can only wear one hat at a time. Figure out what you are good at and like to do, and delegate or outsource the aspects of marketing a clinic that do not come naturally to you. Every clinic can benefit from a healthy combination of these opposing buckets of expertise. Understanding what you want to be known for will shape your entire business from the content you create to the people you have on board. It will dictate the culture of the clinic that you are presenting to the community. Decide who you want to have as customers to create a dialogue that speaks to them. Donâ&#x20AC;&#x2122;t try to appeal to every single patient out there, and get more focused. If you choose too narrow a niche, you may be limiting your marketing too much. If your target demographic is too broad, for example, women over 40, it may be too expensive to reach that group efficiently because it is too big. Identifying a secondary and even tertiary target audience should also be considered in your clinicâ&#x20AC;&#x2122;s marketing plan. Decide what the solutions are that your clinic offers to your target audience. Listen to what your patients are already saying about your clinic online and pay attention to them. At the end of the day, technologies come and go. Hot platforms get cold and new ones arise to take their place. But one thing remains constant; people love a good story. Rather than focusing only on the how, focus on the why, and let the scientists do their thing.

Wendy Lewis Wendy Lewis is the president of Wendy Lewis & Co Ltd, and Founder/Editor in Chief of

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In Practice Marketing planning

Hayley Hutchings, aesthetic sales and marketing manager at Lynton Lasers Ltd on marketing planning for success

Stick to these three simple sections for an easy to follow plan: 1. Top Level Goals 2. Bite Size Goals 3. Action Plan

TOP LEVEL GOALS What do you really want from your business next year? It’s hard to know where to go without knowing where you currently are so completing a mini business audit can help lay the foundations for a great marketing plan. In your audit you’re asking the question “How are we doing at the moment?” Analysing various aspects such as financial performance, conversion rates, target market, competitors, marketing spend and product/ treatment portfolio can all help to identify areas for improvement which then relay into next year’s goals.

Best laid plans

Top level goals will typically be related to the financial aspects of the business e.g. increase annual turnover to £240,000 or increase profitability to 20%. However, you may also have non-financial goals that you wish to achieve, such as becoming the market leader in your local area or repositioning your brand and key messages. Don’t try to do too much at once: having fewer goals and achieving them is far better than having seven half-completed goals. Each goal needs to be achievable and have a timeframe attached to it.

BITE SIZE GOALS 2013 is rapidly coming to a close and if you’re anything like me you’re astounded at the speed it seems to have flown by at: it seems such a short time ago I was working with the Lynton marketing team to set the goals and objectives for 2013, and here we are again. We like to plan ahead at Lynton and aim to have an annual marketing plan complete by October for the following year. You’ll find the most successful cosmetic clinics are also those that plan ahead to achieve goals and proactively drive the business forward. If you’re not currently creating an annual marketing plan now is a great time to start. A marketing plan helps to prevent overspending throughout the year and allows you to create strategic marketing campaigns in line with your business objectives, reducing the risk of sporadic or irrelevant marketing communications. I understand the immediate reaction that comes into play upon hearing this suggestion – “I just haven’t got the time!” Don’t worry, this does not need to be a lengthy laborious project. The first step is to book a few hours out of your diary: if you are thinking “I’ll wait until I have a quiet spot and fit it in then,” it will never get done. You have to plan the time to do the planning – squeeze in a three hour slot and make sure you have a quiet space to work in when the time comes. For me it’s all about actions, actions, actions. You can spend a great deal of time trying to create the perfect text book marketing plan but let’s face it what we really want is something quick, simple and effective. Your marketing plan should be a guide that you can refer to throughout the year, easy to follow and designed to keep your business on track. 52

Aesthetics | December 2013

Taking each top level goal at a time, you now break this down into several smaller goals that will help you achieve the end result you desire. For example if you have a top level goal to increase profitability you might set the following bite size goals: Set aside time to analyse highest margin and lowest margin products and treatments from 2013 – to be completed by end Jan 2014 Allocate marketing spend to planned activities throughout 2014 to promote highest margin treatments and products – to be completed by end Jan 2014 Identify any cost saving opportunities to employ in 2014 by end Jan. Hayley Hutchings has worked as a business consultant with a range of practices from NHS to single room sites. Hayley is the marketing manager at Lynton Lasers Ltd where she is responsible for the introduction of new IPL & Laser technologies into the Lynton portfolio.

In Practice Marketing planning





You now take your bite size goals and create a month by month action plan to achieve them. This is really the guts of your annual plan: itâ&#x20AC;&#x2122;s a well-planned annual to-do list designed to keep your marketing activities in line with current top level goals, keep your budget on track, and ensure you get the results you want in the time identified. It will look something like this: Subject




Profitability analysis - identify highest and lowest margin treatments/products

6th Jan


Plan one promotion per month for 2014 that focuses on highest margin retail products and treatments

Mid Jan


Implement any cost saving opportunities

Mid Jan

Website analysis

Work with website provider to perform Keyword and SEO analysis - set goals for 2014

End Jan


Contact local press about opportunities for editorial in 2014, plan in time throughout the year to provide content

Mid Feb


Create Facebook and Twitter accounts, target to FB/Tweet every few days

End Feb


Run training session for all employees based on the next promotion

End Feb


Ensure outside of business is communicating the right brand image to increase walk-ins

Mid March


Create and run an eshot campaign to promote specific treatment

Mid March


Spring open day planning for April open event

End March

Ideally your marketing plan should work three months in advance so in January you are completing activities for implementation in April, February is preparation for May communications, and so on. Creating your marketing plans is a process that will evolve and develop over the years but is key to successful marketing communications and achieving your key objectives. Start simple just giving it a few hours a month and see what a difference it can make to you.

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In Practice In profile body contouring and fat reduction has been proven to be one of the most effective methods.” Debra recognised that getting maximum press coverage for the treatment would not only boost their distribution of Lipoglaze but make their own clinic, the LoveLite clinic in Harley Street, a flagship centre for the procedure. A woman who knows how to create a buzz about the treatments she offers, Debra’s signature FAME HD micro-pigmentation system and the much-copied Power Brow treatment have both had huge amounts of column inches dedicated to them.

The shape of things Antonia Mariconda speaks to Debra Robson about running a successful aesthetics business As a pioneer of non-invasive aesthetic treatments, Debra Robson has always been a savvy marketeer. Her semi-permanent make-up procedures have set an industry benchmark, with others following where she has led. It is no surprise then that Debra is now making her mark on the industry in a different way by tapping into the booming market of body shaping. Noticing a trend towards non-invasive, body shaping procedures with minimal downtime, Debra, and business partner Donnamarie McBride, sourced and brought to the UK a fat freezing body system that has since taken the market by storm - Lipoglaze. She says, “Body contouring is a really fast growing sector of medical aesthetics. Statistics show that there has been a huge downturn in more invasive procedures. Cryotherapy as a method of

It was with this same approach that the LoveLite team made Lipoglaze a household name overnight. Social media sites were awash with pictures of the young and beautiful stars of hit shows such as Made in Chelsea and The Only Way is Essex as well as top beauty editors and journalists having the treatment and this celebrity endorsement has certainly worked. Debra says, “Social media is a massive means of marketing these days and it has definitely worked for us in respect of both journalists and celebrities coming in and having treatments and getting the word out there. Before and after pictures have been published and they are real true results from people who have taken selfies and posted them themselves on Twitter and Facebook. Because of that the word has spread very quickly.” However while celebrity endorsement may get patients through the doors, Debra realised that to get more physicians on board, serious scientific data was needed so they set up their own clinical trials, the data from which is due to be published in early 2014. Initial findings have shown reductions in subcutaneous fat of between 11% and 59%, depending on the thickness of the fat. While fat freezing may be the project of the moment, Debra still harbours further ambitions. She hopes to create a governing body for beauticians and non-invasive clinics, granting them a better standing within the aesthetics industry. She explains, “We need to set clear standards of quality of care to our customers so that when a client visits a member clinic they know they are going to be treated well and will undergo an effective procedure that will deliver great results.” Antonia Mariconda The Cosmedic Coach is a beauty writer, author, and anti-ageing coach. Antonia has written four published books in beauty, surgery and health and is a popular blogger and Twitter beauty influencer. She is currently a beauty presenter for Sky Fitness and Beauty TV. Follow Antonia @CosmedicCoach on Twitter.

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In Practice Standards update

Mike Regan, chair of the BSI Committee CH/403 Aesthetic Surgery Services, gives us an update on the European Standards

Setting the standard For the past three and a half years a new pan European services standard (EN 16372) for the aesthetics sector has been in development. This work has been coordinated at the European level by CEN, the European Committee for Standardisation. Member States, including the UK, have been placing extensive input into this work.

Aesthetic surgery is defined in EN 16372 to include all highly invasive treatments such as face-lifts and liposuction Within CEN, a specific group, CEN/TC 403 (Technical Committee 403) is leading the project. It had originally been understood that both aesthetic surgery and also aesthetic non-surgical medical services were within the scope of CEN/TC 403. Indeed up until very recently considerable progress on writing the sections for all these types of procedures was being made by working on them in parallel. Aesthetic surgery is defined in EN 16372 to include all highly invasive treatments such as face-lifts and liposuction, whilst the aesthetic nonsurgical medical services sections of the standard were to deal with treatments such as injectables and also non-invasive laser and IPL procedures, such as hair reduction.

agreement was reached to proceed on the basis of splitting the document into two separate standards: one for surgery, and the other for non-surgical procedures. However this type of scoping issue needed to be ratified at the top level, and was accordingly further discussed and in due course agreed at the meeting of the CEN/BT in mid-October 2013. [CEN/BT is the Technical Policy Board of CEN]. It is anticipated that the overall content of the two separate standards will be similar to the draft of EN 16372 that was put out for public consultation for several months at the start of 2013. A team of experts from within CEN/TC 403 is being set up to ensure the split is done accurately and efficiently. The current target dates are to publish the surgery standard in May/June 2014, with the non-surgical standard expected to be published a few months later in October/November 2014. Mike Regan has been actively involved in the National and International Standardisation sector since 2001. This experience ideally positions him to advise and manage the BSI CH403 Committee from a process point of view: how standards are developed, managed, voted on and implemented.

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A few months ago however two CEN Member States raised a detailed procedural point, that strictly speaking the original scope of CEN/TC 403 (which was formed in early 2010) only included surgical procedures. This came as something of a surprise to quite a few other Members States, including the UK, because we thought there had been a general understanding that the non-surgical procedures were also in scope. At the meeting of CEN/TC 403 held in Vienna in late August 2013 the matter was discussed again, and broad

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