Aesthetics December 2014 by Aesthetics & CCR

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VOLUME 2/ISSUE 1 - DECEMBER 2014

WELCOME TO THE FUTU

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Acne laser treatment CPD Article ChurchPharmacy-DecCover-Revised.indd 1

Dr Firas Al-Niaimi explores the use of laser and light treatments in acne management

18/11/2014 19:00:19

Technology in Aesthetics

Hand Rejuvenation

Power of Branding

A discussion of incorporating digital devices into your practice

Dr Carolyn Berry details treatment methods for ageing hands

Gary Conroy on why branding is crucial for business success

Syneron Candela Launches Breakthrough Technology. Again. Introducing PicoWay. PicoWay is a remarkably innovative dual wavelength picosecond laser from Syneron Candela, the most trusted brand in lasers. With both 532nm and 1064nm wavelengths, PicoWay can treat a very broad range of pigmented lesions and tattoo types and colors on any skin type. PicoWay has the highest peak power and the shortest pulse duration of any picosecond laser for superior efficacy, safety and comfort. Proprietary PicoWay technology creates the purest photo-mechanical interaction available to most effectively impact tattoo ink and pigmented lesions, without the negative thermal effects of other lasers. And, PicoWay has the reliability physicians want.

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ÂŠ2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB85961EN

Contents • December 2014 INSIDER 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month

CLINICAL PRACTICE Laser and Light Treatments in Acne Page 26

16 News Special A review of aesthetics in 2014 19 Aesthetics Conference and Exhibition Preview An insight into the ACE 2015 Business Track agenda

CLINICAL PRACTICE 21 Special Feature: Technology Practitioners address the use of technology within clinics 26 CPD Clinical Article Dr Firas Al-Niaimi explores the efficacy of laser and light treatments for acne managment 32 Advertorial: Church Pharmacy Introducing new online prescribing service DigitRx 34 25 Years in Aesthetics Amanda Cameron, Dr Tracy Mountford and Dr Patrick Bowler reflect on the past 25 years in the industry 37 Eyelash and Eyebrow Growth Michelle Washington reveals the science behind eyelash and eyebrow serums 40 Injectable Delivery Systems Leading practitioners discuss their preferred tools for administering injectables 44 Hand Rejuvenation Dr Carolyn Berry outlines treatment methods for ageing hands 48 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 50 Evolution of Business Pam Underdown highlights the importance of adapting to change 55 Power of Branding Gary Conroy on investing in brand building 59 Using LinkedIn Paul Jackson explains how to take full advantage of LinkedIn 62 In Profile: Dr JJ Masani We speak to leading aesthetic practitioner Dr JJ Masani 64 The Last Word: How Young is Too Young? Dr Raina Zarb Adami on the controversy surrounding age in aesthetics

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IN PRACTICE Evolution of Business Page 52

Contributors Dr. Firas Al-Niaimi is a consultant dermatologist and laser surgeon. He trained in Manchester and subsequently did a prestigious advanced surgical and laser fellowship at St. John’s Institute of Dermatology at St. Thomas’ Hospital, London. Michelle Washington is a skincare specialist and business development manager based in New Zealand. With a particular interest in mandarosis, she has conducted extensive research into hair loss treatments, alongside aesthetic practitioners. Dr Carolyn Berry grew up and trained as a general practitioner in Belfast. In 2008 she founded the Firvale Clinic in Southampton, with the aim of bringing a level of excellence to the medical aesthetics industry. Pam Underdown is the owner of Aesthetic Business Transformations. She works to help aesthetic business owners improve their marketing, increase their profits, reduce their costs and build a long-term sustainable business asset. Gary Conroy is co-founder of bespoke skincare supplier, 5 Squirrels. Previously, he was the sales and marketing director at Ambicare Health, as well as head of aesthetic dermatology for Sanofi-Aventis. He has more than 12 years industry experience. Paul Jackson is a senior marketing consultant at Reload Digital, specialising in social media and online marketing for the aesthetics industry. As a chartered marketer and Google certified partner, Paul regularly speaks at marketing events across the UK. Dr Raina Zarb Adami is a surgeon whose private practice, Aesthetic Virtue, is dedicated to facial aesthetic medicine. She is the medical director of The Academy of Aesthetic Excellence, which provides foundation and advanced training courses.

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Editor’s letter Well the Aesthetics Awards 2014 are nearly here! Saturday 6th December is the date and the Park Plaza Westminster Bridge Hotel is the place to be. The Aesthetics Awards is a unique occasion, bringing the whole industry together to recognise the Amanda Cameron Editor best in medical aesthetics and celebrate the achievements of the past year. Winners will be announced in 21 specially chosen categories and awards will be presented to those who strive to represent the highest standards in clinical excellence – from manufacturers and distributors, to clinics and individual practitioners. We are exceptionally proud of the importance that the industry places on winning one of these coveted awards and the tension is tangible amongst the finalists. Promoting education, safety and ethical practice are at the heart of everything we produce at Aesthetics, hence these awards are a fantastic opportunity for us to highlight success in our field and provide a positive and aspirational event for the industry. I look forward to seeing those of you that are attending, for what is sure to be a very special evening. As 2014 draws to a close, this issue of the journal looks back.

Our in-depth news report reviews the past year, speaking to practitioners and industry leaders regarding the major events and advances that took place in medical aesthetics during the last 12 months. Dr Patrick Bowler, Dr Tracy Mountford and I share our experiences and insights in a unique discussion of the changes to the industry over 25 years. Patrick and Tracy were two of the very first pioneers of the industry to move from general medicine to aesthetic medicine, and I am delighted to have watched them both become extremely successful over those 25 years. Our special feature this month focuses on the way that technology is used within the profession to enhance both the patient and practitioner experience. We also feature an informative article on the advances in filler delivery systems, and business consultant, Pam Underdown, explores the evolution of the sector from a commercial perspective. Additionally, this issue includes a comprehensive CPD article, explaining the use of lasers to treat acne by Dr Firas Al-Niaimi and a detailed discussion from Dr Raina Zarb Adami, who argues for a cautious and bespoke approach to treating younger patients. As usual, we are interested to hear your thoughts and comments on the issue - so get in touch on @aestheticsgroup to have your say.

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Tapan Patel is the founder and medical director of VIVA

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

and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

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

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

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

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

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

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New speakers announced for ACE 2015

#Dermatology PsoriasisAssociation / @PsoriasisUK #Psoriasis can occur on any area of the body including the scalp, hands, feet & genitals. Different types tend to occur on different areas #Teaching Beautoxology / @dee_hadley A great day teaching facial aesthetics... Great delegates #Allergan #Botulinum toxin Emma Davies / @daviesemma5 Botox at home? Good lighting for the injector? Good positioning? Convenient yes, but surely safer in a treatment room #whyriskit? #Facialaesthetics Dr Askari Townshend / @Dr_AskariT Heading to @UCLan to give a days teaching on facial volumisation for MSc facial aesthetics course. Art + science = safe beautification #Conference Dr Tapan Patel @drtapanp Can’t wait to catch up with the talented doctors and dear friends @imcascongress @goa

To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com

Aesthetics

Conference

Talk Aesthetics

#Education Dr Johanna Ward @DrJohannaWard Looking forward to getting my copy of @DrStefanieW book ‘Future Proof Your Skin’.. #anti-aging

Aesthetics Journal

More speakers for the Aesthetics Conference and Exhibition (ACE), to be held on 7 and 8 March 2015, have been announced for the live demonstration Expert Clinic programme. The agenda, set to take place in the Business Design Centre, Islington, will see a variety of industry leaders educating delegates on clinical practices. A range of topics will be addressed, from radiofrequency technology to chemical peels. Dr Sotirios Foutsizoglou, founder and director of SF Medica, will present an expert view on facial anatomy in aesthetics, which will incorporate a live facial mapping session. He said, “I will utilise my experience to offer advice on how to avoid serious complications when injecting the face and neck, based on my sound knowledge of the relevant facial anatomical structures.” Dr Yoram Harth, board certified dermatologist and originator of the use of blue light to treat acne, as well as an expert in radiofrequency technology, will present his demonstration on Saturday morning. “I am really excited about presenting at the Expert Clinic for ACE in March,” he said. “I’ll be talking about energy-based rejuvenation technologies, with a particular focus on radiofrequency.” Dr Harth’s emphasis will be on the role of radiofrequency in the modern aesthetic clinic, and how selecting the right platform can help to treat multiple rejuvenation indications, with excellent results and minimal patient down time. Other speakers announced for the Expert Clinic agenda will include consultant plastic surgeon and founder of Cosmetic Courses, Mr Adrian Richards, who will present a combination treatment of filler and toxin for optimal results. Lorna Bowes, director of Aesthetic Source, will provide an expert talk on chemical peels alongside a live treatment demonstration. ACE 2015 will feature a huge range of engaging and educational sessions, masterclasses, and business seminars across the weekend from renowned experts in the field of medical aesthetics. Visit www.aestheticsconference.com to keep up to date with the latest developments and book today.

Competency

BACN’s updated edition of competencies receives accreditation The Royal College of Nursing (RCN) has accredited the British Association of Cosmetic Nurses’ (BACN) updated edition of industry competencies. The Integrated Career and Competency Framework for Nurses in Aesthetic Medicine was initially published and accredited by the RCN in 2013. The updated 2014 edition has now also received accreditation, which includes the RCN’s own educational and specialist recommendations. The RCN highlight the importance of patient consultation and psychological care, as well as competency recommendations for the use of local and topical anaesthesia. The remainder of the competencies, created by the BACN, relate to the use of dermal fillers, lasers and IPL, and chemical peels. They also cover chemical denervation, skin health and rejuvenation, and the learning and development of aesthetic nurses. Aesthetic nurse practitioner and leader of the BACN’s competency 6

development group, Adrian Baker, explained it is believed that, The Integrated Career and Competency Framework for Nurses in Aesthetic Medicine is the only set of aesthetic nursing competencies available in the world. He said that publications released by the BACN would now be mapped against the standards addressed in the framework and be used by universities, and in training, alongside Health Education England’s (HEE) educational framework. “It is especially important as NMC validation is coming into effect in 2015 and could assist and guide in the mapping of their professional competence,” he added. Chair of the BACN, Sharon Bennett, said, “The competencies will allow nurses to clearly see the level of knowledge and education expected from them in order to practise aesthetics.” Electronic copies of the document will be available to BACN members by the end of this year.

Aesthetics | December 2014

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Standards

Lynton launches YouLaser MT

‘Aesthetic Surgery Services’ to be published as a European Standard

UK aesthetic equipment supplier, Lynton Lasers, has released a new product that it claims will revolutionise laser treatment and results. By combining non-ablative GaAs (1540nm) and ablative CO2 (10600nm) laser wavelengths, practitioners are told to expect quick and dramatic results from this new product. The YouLaser MT aims to maximise the advantages of each laser wavelength, providing stronger results and less ‘down-time’ than single wavelength lasers. Non-ablative resurfacing using GaAs targets minute sections of the skin’s surface, allowing the surrounding unaffected areas of skin to aid the natural healing process, while the small columns of thermal damage aim to enhance collagen renewal. According to Lynton Lasers, ablative CO2 skin resurfacing takes on a more dramatic effect, similar to non-ablative resurfacing but causing more trauma to the tissue. The CO2 laser still operates in fractional mode, so the untreated surrounding areas again promote rapid healing of the skin with less down time. Post-treatment, the skin appears tighter due to the process of collagen shrinkage and the long-term stimulation of fibroblasts that will usually produce new collagen for the next six months. Dr Tony Downs, consultant dermatologist at Exeter Medical, said, “Independent treatment databases and manual settings allow you to safely treat specific problems and lesions, or create bespoke treatment parameters depending on your own level of experience and expertise. This platform has been a welcome addition to our laser and aesthetic portfolio.” As this product contains mixed technology, the practitioner is able to provide specialised treatments depending on the patients needs as the Gold Standard lasers (CO2 at 10.6um and GaAs at 1540nm) can be used independently, simultaneously or sequentially.

The European Committee for Standardisation (CEN) and British Standards Institution (BSI) have announced that the ‘Aesthetic Surgery Services’ document will be published as a European Standard. After a successful voting period, the document was approved for publication in June 2014, however a couple of CEN member states (not the UK) subsequently raised some procedural issues. The CEN Technical Board discussed these issues at a meeting on October 28 and made the decision to publish ‘Aesthetic Surgery Services’, as originally planned. The contents of the document (EN 16372) addresses, amongst others, general requirements and recommendations for procedure rooms and operating theatres, hygiene standards, continuous professional development (CPD) and continuous medical education (CME). Mike Regan, chair of the BSI committee, explained that the Standard provides recommendations for procedures for clinical treatment, including the ethical framework and general principles, according to the clinical services provided by all aesthetic practitioners. It does not include dentistry, reconstructive surgery or non-surgical aesthetic procedures. A public consultation throughout Europe (including the UK) on the Non-surgical Aesthetic Standard is planned take place in January 2015. Associations

Society of Mesotherapy UK announces partnership with IMCAS The Society of Mesotherapy UK (SOMUK) has announced that it has become a scientific partner of IMCAS, Paris, set to take place in January 2015. The collaboration means that members of the society will be offered access to the Anti-Ageing Teaching Course at a discounted price. SOMUK confirmed that in 2015 they are also set to partner with other aesthetic conferences. President of the society, Philippe Hamida-Pisal, explains that the SOMUK aims to incentivise academic institutions in the United Kingdom to include mesotherapy as a key alternative treatment in their syllabus. He said, “We have achieved this by becoming a scientific partner of a number of important aesthetic congresses. Not only does this provide our members with an international reference and access to expert knowledge where the practice of mesotherapy is more prevalent, but also benefits our members by providing access, at the reduced fee, to the respective congresses where the SOMUK is scientific partner, improved networking as the Society grows from strength to strength, and access to expert advice through the society and network in the UK.”

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Industry

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Skincare

Large study finds minor cosmetic procedures to be ‘exceedingly safe’

Swiss company launches new skincare range in the UK

A study by an American university has found that minor cosmetic procedures lack risk of serious adverse events. The research, conducted by Northwestern University and published in the JAMA Dermatology Journal, is believed to form the first major study to analyse the number of adverse events among tens of thousands of cosmetic procedures performed across the US. It found that fillers, neurotoxins, laser, and energy device procedures were exceedingly safe. “The message for patients is that if you are thinking of getting one of these procedures, you are not indulging in something drastic or high risk,” said Professor Murad Alam, a member of the university’s dermatology department. “The take home is these procedures are very safe and can be mixed and matched to give the individual a significant cosmetic benefit, rather than getting one big cosmetic procedure that might be risky.” The research came from the results of 20,339 procedures conducted by 23 board-certified dermatologists at eight centres around the country, over three months, and staggered across seasons. Side effects such as bruising, redness, swelling and bumpiness, or skin darkening, were found to clear up on their own, and occurred in fewer than 1% of patients. While fillers were found to have a slightly higher (though still extremely low) adverse rate than other procedures included in the study, the authors claim this is to be expected, as fillers are slightly more invasive than other minor cosmetic treatments. This comes at the same time as research presented by the American Society of Plastic Surgeons (ASPS) at a conference in October showed that older men and women have no more complications than younger patients when undergoing cosmetic procedures. Through an extensive review of information from May 2008 to May 2013 from the CosmetAssure database, it was found that elderly patients had a complication rate of 1.94%, whilst younger patients’ rate averaged 1.84%. Researchers suggested that given the greater-than-average presence of health-related indicators among older patients, the similar complication rate is surprising, especially as the results showed a higher Body Mass Index (25.4% to 24.2%) and increased incidence of diabetes (5.7% to 1.6%) among the elderly patients. Dr Maksym Yezhelyev, from the department of Plastic Surgery at Vanderbilt University, Nashville, said, “I am convinced that we will continue to witness increasing demand for cosmetic procedures among the elderly. “Careful selection of surgical candidates by plastic surgeons should result in better aesthetic outcomes, more satisfied patients and thus would benefit the entire field of plastic surgery.” 8

Aesthetics Journal

Skin Concept AG, a Swiss skincare company, has released their new Swisscode collection of concentrates formulated from plant stem cells. The Swisscode Pure collection is made up of seven concentrates, which Skin Concept claim each address specific skin needs. The trio of Swisscode Bionic serums, designed for use alongside the Swisscode Pure concentrations, are also produced from the organic stem cells and aim to combat symptoms of ageing skin. The use of the cells was derived from the plants’ natural defence mechanism that protects them against environmental stress and limits harm. These formulations are also ISO certified, therefore free from alcohol, parabens, and preservatives, in order to reduce the chance of skin irritation. “These unique plant stem cells do not interact with human stem cells; claims to that effect are not only misleading but potentially dangerous,” says Wolfgang Mayer, chief operating officer of Medena AG, Skin Concept’s parent company. He said, “What they do is provide the highest levels of protection, including antioxidant protection, that cosmetic scientists have been able to achieve. The data supporting results in terms of improved moisture and collagen retention, the reduction of fine lines and wrinkles and overall restructuring of the skin are impressive.” Two or three drops of the concentrate are to be applied to the face and neck before moisturising. Each concentrate is specially formulated for a specific part of the face, or particular problem area, and can be combined with others to tackle multiple issues. Weight-loss

Study finds weight-loss surgery reduces risk of diabetes A recent study published in the Lancet Diabetes and Endocrinology Journal has found that weight-loss surgery can limit risks of developing diabetes later on. Over 4,000 British adults were assessed for effects of bariatric surgery on diabetes development in obese people over several years. Those who had undergone bariatric surgery were found to have an 80% reduction rate in the development of type 2 diabetes. 2,167 patients who had the surgery, and 2,167 who had not, were matched according to BMI, age, sex, index year, and HbA. Electronic health records were extracted across eight years, and analyses adjusted for matching variables, including cardiovascular risk. The study suggested that, “bariatric surgery could be a highly effective method for prevention of diabetes in patients with severe obesity.”

Aesthetics | December 2014

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Vital Statistics

Campaign

Allergan launches #THISISME campaign Allergan has begun a consumer campaign, dubbed ‘#THISISME’, aiming to empower women to embrace their age in the way that they want to. From extensive qualitative and quantitative research, it was found that the female population are now much more positive about getting older than in previous years. While 20% of women say they want to look 5 years younger, 41% just want to look fresher and more radiant. Another finding highlighted the social stigma attached to facial fillers, which makes women less willing to take the next step after considering treatment. 24% of women waited a year or more before committing to having treatment. “The anti-ageing category currently presents younger models as an aspirational, but unattainable, goal rather than reflecting the women’s desire simply to look their best for their age. We’ve learnt that women want to positively embrace their hard-won signs of getting older but they still want to choose the way they age,” said Allergan’s vice president and managing director, Caroline Van Hove. “Our bold campaign, #THISISME, features women of all ages and backgrounds encouraging other women to continue to embrace the positives about getting older, but empowering them to make their own treatment choices and not be ashamed, so they can age as they want to.” The campaign features six ordinary women, all who have been treated with Allergan’s Juvéderm filler. Allergan hope is that, by promoting #THISISME, and launching an enhanced clinic locator tool on their product website, patients will feel more confident to contact local practitioners and seek professional advice.

When choosing a surgeon/practice, cost is a deciding factor for 71% of patients (American Academy of Facial Plastic and Reconstructive Surgery)

On average, people spend around £8,000 in a lifetime to remove unwanted body hair (Transform Cosmetic Surgery Group)

77% of psoriasis sufferers describe it as a ‘problem’ or ‘signiﬁcant problem’ impacting their quality of life (Psoriasis Association)

Injectable wrinkle-relaxers in America have a 93% satisfaction rate (American Society of Dermatologic Surgery)

Wrinkle treatment

New Smart Tip launched for iovera treatment Myoscience has launched a 1x55mm Round Smart Tip for iovera, a toxinfree wrinkle-reducing treatment now available in the UK. Myoscience claims the treatment can be expected to provide noticeable results within 20 minutes; effects can last up to three months. London-based plastic surgeon, Ms Angelica Kavouni, said, “The protocol changes have made a big difference, and now the treatment takes less time, provides instant results, and improved patient comfort.” Smart Tips, designed for use with the Focused Cold Therapy (FCT) delivery system, uses liquid nitrous oxide delivered through closed-end needles. Gaseous nitrous oxide is then expelled into the device, aiming to leave nothing behind in the body. Working in a temperature range allegedly incapable of causing permanent nerve injury, it uses the body’s natural reaction to the cold to smooth wrinkles, allowing practitioners to selectively treat specific nerves for precise results. Before iovera°

One in ﬁve men feel that they are expected to remove their chest hair to get a smooth, preened torso (Mintel)

The use of soft tissue fillers increased by 13% between 2012 and 2013 (American Society of Plastic Surgeons)

Low vitamin D status was evident in 23% of adults aged 19-64 living in the UK from 2008-2012 (Public Health England)

Immedeately Post Treatment

60% of patients considering aesthetic tweaks now get their information about plastic surgery online (American Academy of Facial Plastic and Reconstructive Surgery)

Aesthetics | December 2014

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Events diary 6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 29th January - 1st February 2015 International Master Course on Ageing Skin - IMCAS Annual Meeting 2015, Paris www.imcas.com/en/imcas2015/ congress 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com 26th - 28th March 2015 13th Anti-Aging Medicine World Congress, Monte Carlo www.euromedicom.com/amwc-2015/ index.html

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Industry

Aesthetic Source expands its team Specialist medical aesthetics distributor, Aesthetic Source, has announced the appointment of two new additions to their team in order to support their growing customer base. Caroline Gwilliam has been recruited as the new business development and sales manager for London and the South East, whilst Kathryn Avery will acquire the same role for the South West. Gwilliam said, “Aesthetic Source supports a true passion and drive to provide a premium service to its customers, and I am looking forward to working with the awardwinning NeoStrata cosmeceutical range and skin fitness products in the Aesthetic Source portfolio.” Both Gwilliam and Avery will be aiming to improve and develop new partnerships through excellent customer service that will include in-clinic training. Avery said, “I am delighted to join Aesthetic Source and work with evidence-based skin fitness products. It is an exciting time with a number of exciting brands coming on board.” In light of this expansion, Aesthetic Source director, Lorna Bowes, said, “Aesthetic Source is totally customercentric with the right systems and people in place to deliver a high quality bespoke service. It is an exciting time for Caroline and Kathryn to join us with many new products in the pipeline.”

Business

Actavis to acquire Allergan for $66 billion Global pharmaceutical company Actavis has confirmed that it will acquire Allergan for $66 billion, or $219 per share. The agreement sees Actavis purchase the Botox-maker for a combination of $129.22 in cash and 0.3683 Actavis shares, for each share of Allergan common stock. “This acquisition creates the fastest growing and most dynamic growth pharmaceutical company in global healthcare, making us one of the world’s top 10 pharmaceutical companies,” said Brent Saunders, CEO and president of Actavis. He added, “We will establish an unrivalled foundation for long-term growth, anchored by leading, world-class blockbuster franchises and a premier late-stage pipeline that will accelerate our commitment to build an exceptional, sustainable portfolio.” The transaction was unanimously approved by both boards of

directors and supported by both management teams. It is anticipated that the joining of the two companies will result in annual cost savings of $1.8 billion. “Today’s transaction provides Allergan stockholders with substantial and immediate value, as well as the opportunity to participate in the significant upside potential of the combined company,” said David Pyott, chairman and CEO of Allergan. “We are combining with a partner that is ideally suited to realise the full potential inherent in our franchise.” Allergan explain that whilst Saunders will head the combined company, the integration will be led by senior management teams of both companies – with the aim of providing a smooth transition. Two members of the Allergan Board of Directors will also be invited to join the Actavis Board of Directors following the transaction.

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Lasers

LoveLite launches fat reduction machine that combines laser treatment and cryo-therapy Lovelite has launched CrioLase, a fat-reducing treatment, which aims to revolutionise current weight loss treatments. The machine will combine laser treatment and cryo-therapy to provide a single-treatment solution, using a low-energy laser to melt fat and, followed by cryo-therapy, freeze the area. This combination is claimed to have remarkable results in contouring and toning fatty tissue. LoveLite clinical director, Debra Robson, said, “This is the most exciting advance in non-invasive fat reduction in the past 10 years. The combined effects of first melting, and then quickly freezing the treatment area, makes a vast difference in the effectiveness of the cyrotherapy. The effect has been dubbed the ‘Super Contour Effect’ because the results are really incredible.” LoveLite says that the non-invasive procedure involves a low-energy bio-stimulation, causing fat cells to shrink and lose their round shape, and releases intra-cellular fat to allow the flow of tri-glycerides into the interstitial space. The body then naturally processes the fat as a source of energy, and once cryotherapy has been used to freeze the fat cells (causing them to crystallize and die), they naturally waste away through the body’s metabolism. According to LoveLite, areas that can be treated by the new CrioLase include facial areas such as the chin, neck and cheeks, and other body parts such as the buttocks, calves, and inner knees. They also claim conditions such as gynecomastia can be treated with the technology. Digital

WhatClinic.com and The Pronto Network announce strategic platform integration WhatClinic.com and The Pronto Network have announced their platform integration that they claim will provide benefits to both clinics and patients. The strategic partnership will integrate TM2 and PPS practice management, online software programmes for patient and practice administration, with WhatClinic.com’s site functionality. For aesthetic clinics, the partnership will allow them to book patients more easily, saving time on scheduling and confirmation. WhatClinic.com claim that patients will feel the benefits by being able to search, compare, and book an appointment all on one site. Kyle Lunn, director of Blue Zince, the creator of the Pronto Network, said, “This integration allows us to add an extra layer of value to our product, and helps our clients reach more patients, which is a key advantage in today’s increasingly digital health environment.” Aesthetics | December 2014

Insider News

Wolfgang Mayer, chief operations officer of Swisscode What is Swisscode? Swisscode products apply expertise in raw materials and formulation techniques, to the development of high-value, new-generation brands. They comprise a selection of concentrated formulations to target specific skincare needs, utilising only the purest ingredients that are both revolutionary and results driven. Why does Swisscode have two ranges? Swisscode Pure is a collection of seven concentrates, which each address specific skin needs. Ingredients such as hyaluronic acid, genistein and kiribirth are featured in such high concentrations that they give their name to the product. Swisscode strips away all the extraneous, potentially irritating ingredients and focuses solely on the active elements in their purest recommended form. Swisscode Bionic capitalises on the protective capacity of plant stem cells to set standards for combating symptoms of ageing skin, enabling it to retain its youthful tone, texture and appearance. Combining the principles of bionics with advanced meristem (stem cell) biotechnology, the trio of high-intensity concentrations provide protection that allows skin cells to thrive and rejuvenate. Why is the technology ground-breaking? These unique plant stem cells do not interact with human stem cells; claims to that effect are not only misleading but are potentially dangerous. They provide the highest levels of protection, including antioxidant protection that cosmetic scientists have been able to achieve. How successful has your presence been internationally? Skin Concept is a multinational corporation with operations spread across Europe, Asia and the Middle East. From the beginning, we decided to take a pioneering approach to the market. From its conception, Skin Concept has been on a fasttrack to developing skincare products based on cutting-edge formulations. What does the future hold? Skin Concept UK’s partner, Pure Swiss Aesthetics has recently been appointed as the UK’s exclusive distributor. Pure Swiss Aesthetics specialise in the branding and distribution of high quality, innovative, niche brands, both in the organic and cosmeceutical sectors, with a focus on personalised customer service.

Insider News

News in Brief Christmas skincare gift set released by SkinCeuticals American skincare company, SkinCeuticals, has released a gift set containing two of their anti-ageing products. The A.G.E Interrupter is specifically formulated to improve mature skin, and the Retexturing Activator aims to improve surface exfoliation and hydration. SkinCeuticals claim the combination of the products will help skin to feel smooth and firm. Belnatur launches skincare range Professional skincare brand Belnatur has launched a skincare range in the UK, which claims to rehydrate dull-looking skin. Belnatur explain the products, as part of the ‘Oxygen Range’, work by increasing the skin cells’ oxygen consumption, which can be affected through stress, as well as pollution and other environmental factors. The technology is said to favour the oxygen’s transport and diffusion, helping the cells to maintain energy production and vital functions. MP raises regulation issues in Parliament Ilford South MP Mike Gapes has questioned health minister Jeremy Hunt on the regulation surrounding cosmetic laser treatments. His concern comes after a woman in his constituency claimed she suffered scarring after undergoing a laser hair removal procedure, without being given a patch test. Gapes, who is waiting for a response, asked Hunt, “What steps he plans to ensure more effective regulation of providers of cosmetic laser treatments, and whether it is his policy to introduce a register of such providers.” 4T Medical launch peeling gel A new peeling gel has been launched by 4T medical, who claim the product is just as effective as regular chemical peels. With multi-action enzymes, which peel and help to uncover a smooth, fresh complexion, the Silky Clear Peeling Gel aims to smooth and soften even the most sensitive skin. 4T medical believe the gel is an effective alternative to chemical peels, which they say can cause undue stress to skin. The company suggest the product should be used to prepare skin before dermal fillers, mesotherapy, and wrinklerelaxing treatments.

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Injectables

New Teosyal Pen wins AMEC award A new cordless device, specifically designed to inject hyaluronic acid into delicate areas, has received an award at the 2nd Anti-aging Medicine European Congress (AMEC), in Paris. The Teosyal Pen, from Juvaplus, won the 2nd Anti-aging & Beauty Trophy award at the AMEC for Best Aesthetic Device. Juvaplus have now collaborated with Teoxane Laboratories to market the product worldwide in the first quarter of 2015. Valérie Taupin, founder and chairwoman of Teoxane Laboratories, said, “Teoxane is constantly looking for the best solutions to improve patients’ comfort and to reduce recovery time, as well as the latest innovations to inject hyaluronic acid in a more precise way. That is why the Teosyal Pen totally met our expectations. Mr Bernard-Pierre Legrand, CEO of Juvaplus, and his team have invented a device (the Teosyal Pen) which significantly reduces injection pain and minimizes side-effects.” The product is the first motorised and cordless device specifically created to inject hyaluronic acid. The Swiss companies claim the Teosyal Pen will allow practitioners to focus on the more ‘artistic aspect’ of their work. The pen works on two programmes, which are used to control pressure, three speeds, and product quantity. Teoxane suggest that it will be particularly valuable when aiding delicate oral, peri-oral and peri-orbital areas where it is crucial to use high precision. “Two of the most important aspects in effective and safe dermal filler injections are accuracy and precision. Teosyal Pen has been designed to offer injectors accurate placement of precise amount of dermal fillers,” said Dr Kieren Bong, clinical lecturer and cosmetic doctor in dermatology. “The majority of my patients found the level of discomfort during injection much lower than the conventional syringe. This is not surprising as the gentle and more even flow of dermal fillers during injection mean there is less pressure exerted on the tissue, and this translates into a more comfortable experience for patients.” Research

Study shows photosensitive patients are vulnerable to low vitamin D levels all year A study has found that photosensitive patients are at a high risk of year-round low vitamin D status. The study, part-funded by the British Skin Foundation, focused on 53 patients with moderate to severe photosensitivity and compared them with healthy adults. It measured sunlight exposure, photo-protective behaviour, oral vitamin D intake and vitamin D levels in the blood. The research found that the main cause for year-round low vitamin D status is photosensitive patient behaviour. Professor Lesley Rhodes, from the Institute of Inflammation and Repair at the University of Manchester, said, “Photosensitive patients are disadvantaged in many ways, through their need to avoid sun exposure. This study is the first to examine vitamin D levels in photosensitive and healthy people side by side throughout the year.” She added, “A key finding is their high risk of year-round low vitamin D levels, contrasting with seasonal lows in healthy people, with potentially greater negative impact on health. National guidance on vitamin D supplements should specifically mention this at-risk group, in order to alert these patients and their doctors.” Aesthetics | December 2014

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Insider On the Scene

Sinclair IS Pharma Masterclass, London International pharmaceutical company, Sinclair IS Pharma, held a masterclass event at The Royal Society of Medicine on October 21. The day consisted of expert presentations and live demonstrations from speakers that included Dr Vincent Wong, Dr Askari Townshend and Mr Christopher Inglefield. Andrew Morris, country operations director, explained that the purpose of the event was to introduce Sinclair’s first-class training and inform practitioners of the company’s strategy to build a successful collagen stimulation portfolio. He told delegates, “We provide quality brands and are focused on training practitioners to use them appropriately. All of our products are supported with strong training and aftercare. We have knowledge, expertise and an ambition to be your partner. Our products provide solutions to the needs of patients. We want to help all aesthetic practitioners look after their regular patients and satisfy new ones.” With an excellent turnout and great feedback, aesthetic account manager, Claire Williams, said the masterclass was a success. “I have had many people wanting to sign up for training across all our product lines and all attendees will be followed up personally to make sure they get what they want from the meeting.” Aesthetic practitioner, Dr Daina Jones, said, “I already work with some of Sinclair’s products and the masterclasses give us practitioners all the tools to use the products safely and correctly. I especially enjoyed Dr Townshend’s lecture on infection control as there is never too much information, advice and precaution to be had as an aesthetic practitioner.” She added, “It was great to have an interactive evening as it is so useful to share the experience amongst fellow doctors.”

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National Aesthetic Nursing Conference, London The Journal of Aesthetic Nursing held their third National Aesthetic Nursing Conference at the Cavendish Conference Centre in London on November 3. The one-day event, ‘Clinical excellence in cosmetic medicine’, opened with the theme of introducing a new era for aesthetic nursing. The event aimed to send delegates away with both expert knowledge and practical ideas for implementing better practice in the future. The morning clinical sessions saw the Chair of the northwest branch of the British Association of Cosmetic Nurses (BACN), Karen Burgess, discuss the triple effect of radiesse, which was sponsored by Merz Aesthetics. Later, a video demonstration on rejuvenating the tear trough was presented by Helen Collier, aesthetic practitioner and director of Skintalks. In the afternoon Lorna Bowes, director of Aesthetic Source, and Eva Escofet, director and co-owner of Aneva Nutraceuticals Ltd, presented their talk titled ‘Skin Fitness – combining cosmeceuticals and nutraceuticals for optimal skin fitness’, sponsored by both Aesthetic Source and Aneva Nutraceuticals Ltd. Bowes said, “This is our third year exhibiting at the Journal of Aesthetic Nursing. It’s always nice to catch up with nurse colleagues, and we would like to thank everyone for their great interest in our study, which was presented as the European Academy of Dermatology and Venereology earlier in October this year.” Other topics covered throughout the conference included discussions on the appropriate clinical setting for performing non-invasive cosmetic treatments, and the best approach to acne management.

REVIV, London The global market leader in intravenous hydration, REVIV, held their UK launch in London on October 29. REVIV claim that through applying innovative western medicine to an eastern philosophy of balance, they can restore equilibrium through vitamin-infused IV therapies. President of REVIV Global, Sarah Lomas, explained that the IV treatments could be used to combat dehydration, fatigue and illness. She said, “For me, the message I want to send about IV hydration is that it should be used for preventative health – not as just a hangover cure as it is sometimes reported.” The company now has exclusive clinics in Cheshire and London, with an express clinic (as part of another clinic) situated in Newcastle. Dr Martin Kinsella, aesthetic practitioner and medical director of REVIV, said, “I’ve been giving intravenous vitamin infusion and anti-oxidant infusions for about three years. They have always been popular so I decided to take that forward with REVIV as I think the product has been well developed and well researched. REVIV has conducted clinical trials both in the US and the UK and has had very positive results.” Lomas explained that for practitioners to be able to administer REVIV, their clinics would need to go through a stringent approval process. “If an aesthetic clinic is interested in offering REVIV treatments, then a full review of their premises and an assessment from our medical team will be carried out.” REVIV are hoping to open another 50 exclusive clinics in the UK within in the next three months, as well as clinics in Canada, Continental Europe, South Africa and Australia. Aesthetics | December 2014

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News Special A Year in Review

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lip shapes.” He adds that the 8-point facelift has helped achieve this, as patients are focussing less on single areas and more on creating a balanced look and improving their skin overall. The development of skin and subcutaneous tightening is also something that Dr Rowland Payne has recognised. He believes that the technology to treat this is continuing to improve. Dr Johanna Ward, however, believes that the technological issue of IPL and laser regulation has been completely ignored in 2014. “These powerful machines remain unregulated and are therefore potentially able to cause harm. Cheap machinery continues to flood the aesthetics market with few safety standards and little empirical evidence of efficacy,” she says.

As 2014 draws to a close, Aesthetics speaks to practitioners working across the UK to reflect on the developments, achievements, and problems faced by our ever-changing industry

A Year in Review Aesthetics is the most exciting medical field to be involved in at the moment, according to Dr Christopher Rowland Payne. He says, “Innovation, research and development are mirrored by growing public interest.” Dr Raj Acquilla agrees, claiming that medical education in aesthetics is the best he has seen in a decade. “Our understanding of facial anatomy, and therefore injection strategy, has never been better,” he says. “This further optimises aesthetic outcomes and reduces adverse events.” One of the key developments that Dr Acquilla has noticed this year is the advancement in Hyaluronic Acid (HA) filler technology. This thought is echoed by Dr Britta Knoll, who says one of her favourite tools of 2014 is a filler delivery system, which she claims allows her to inject deep volumes of HA very comfortably. Dr Acquilla adds, “Low molecular weight products with high cohesivity allow for superior tissue integration and lifting capacity using low volume injection. This generates excellent results whilst minimising risks to the patients.” Dr Rowland Payne explains that this year, he has preferred administering filler with cannulas rather than needles. He says, “Flexible fine cannulas (e.g. 27 gauge) offer safety advantages over needles as they greatly reduce the risk of arterial embolization. They also offer improved possibilities for soft filling of the cheeks, as well as other sites.” Dr Rowland Payne also notes that thread lifting, although not a substitute for a facelift, is a major advancement in the non-surgical domain and is becoming increasingly accessible. Dr Sarah Tonks agrees, explaining, “They are a great alternative to dermal fillers if there is more tissue descent than you would correct with filler alone.” 2014 has been the year of the “natural look”, according to Mr Adrian Richards. He says, “Our clients are asking us to help them look naturally fresher and we have noticed a trend towards more natural 16

Whilst there have been many positive developments this year, regulation is still a substantial issue amongst practitioners, with some agreeing with Dr Ward that not enough has been done since the Keogh Review took place last year. Dr Rita Rakus explains that, for her, the rise in certain discount websites is a problem for the safe regulation of the industry. She believes that the lack of consultation with an appropriate practitioner is not acceptable. “A consultation will ensure that the customer is booking in for the correct treatment that will address their concerns – otherwise the desired results will not always be achieved.” Dr Rakus explains that aftercare is also an important part of any procedure. “Due to the treatments being booked through a third party, if there is a problem, it can be hard for the customer to communicate this with the correct person.” Dr Tonks believes that the Health Education England (HEE) proposed educational and training framework for their report: Non-surgical Cosmetic Interventions and Hair Restoration Surgery, has been a missed opportunity to implement tighter regulation. “Although we now have a training structure, in my opinion, we are going to be training the wrong people. The field has been opened up to anyone without a medical background to start performing procedures, which is pretty much where we are at the moment anyway.” Sharon Bennett, however, argues that the HEE framework is a step in the right direction. “It is hoped that some form of control will be put on those who are non-medically qualified when delivering non-surgical treatments,” she says. In addition, Dr Ward argues that misadvertising has continued in 2014 and there is lot of consumer confusion as to what treatments are safe and effective. “Practitioners have a duty of care for patients and need to be offering neutral, unbiased advice about treatments that help guide patients to make sensible and educated decisions about aesthetic treatments,” she says. “There is still a lot that individual practitioners can do to raise standards in the industry. Most importantly, we can all insist on buying products, treatments and machines that are of the highest quality to ensure patients are receiving the best possible aesthetic care.” Despite the negative aspects of the industry, Dr Sam Robson celebrated the fact that appraisal and revalidation will be extended to aesthetic nurses next year. She says, “Having been appraised every year since 2004 has really helped me focus my education and practice so that I remain safe, accountable and up-to-date.” She argues that introducing the regulation, set out by the Nursing and Midwifery Council (NMC) as mandatory practise, will ensure that

Aesthetics | December 2014

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the consequences for not engaging with its content cannot fail to improve standards. Dr Knoll explains how, for her, the highlight of 2014 was the Monte Carlo Anti-Aging Medicine World Congress (AMWC). “There was a huge number of international visitors with plenty of new products and techniques for minimally-invasive aesthetic procedures

“My wish for 2015 is that there is more practical training available in congresses; not only for selling activities but to offer practitioners good, scientific, clinical education. Economic success yes, of course, but safety comes first!”

News Special A Year in Review

available,” she says. “My wish for 2015 is that there is more practical training available in congresses; not only for selling activities but to offer practitioners good, scientific, clinical education. Economic success yes, of course, but safety comes first!” Sharon Bennett agrees, saying, “The fantastic conferences and expos throughout the year are a constant source of education and networking, and our specialism is at last being recognised,” She adds, “The requirement and hunger for research and evidence – in all we do – has triggered the imagination of many and we are now starting to see a trickle of well researched, evidence-based papers, and consensus on areas such as complications, becoming available.” In regards to 2015, Bennett suggests that the biggest area of change will be a stronger focus on health and wellbeing. “Today’s men and women want to feel healthy as well as looking good. Our work won’t just be with fillers, toxins and lasers, I believe there will increased demand for supportive anti-ageing medicine, bio-rejuvenation and hormone management.” It is clear that, despite its challenges, this year has been an educational, exciting, and enthralling year for everyone involved in medical aesthetics. As we look toward the new year, we hope that it will bring further success and happiness to both practitioners and patients. To conclude, Dr Ward expresses her hope that aesthetic practitioners continue to work tirelessly to deliver standards of clinical excellence for all patients. She says, “I hope that we can all come together and work towards a more ethical, regulated and clinically sound industry in 2015.”

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Building success at the Aesthetics Conference and Exhibition With the commercial demands of the aesthetics industry growing constantly, the ACE 2015 Business Track will help you to stay one step ahead of the competition. Alongside the interactive main conference programme, live demonstration Expert Clinics and product and treatment Masterclasses, the Aesthetics Conference and Exhibition 2015 will also feature a comprehensive Business Track agenda where expert speakers will share invaluable guidance on building, sustaining and growing a practice in medical aesthetics. During the two days of sessions, industry leaders will educate and advise attendees on a vast range of topics including how to make their business more efficient and cost-effective, successfully marketing to customers and practising within the current regulatory market framework. Zain Bhojani, co-director of Church Pharmacy, who are sponsoring the Business Track and will also be providing two sessions within the agenda providing support to practitioners in using their new e-prescribing system DigitRx, says, “All healthcare practitioners need to have a business hat on to some extent or another.” He continues, “We started as a very small company, and we know the kind of challenges that people face when they’re trying to scale a business, especially when they don’t have people resources and it’s literally just one or two people running the show – so we’re very excited to be sponsoring and we can’t wait for ACE.” Sessions taking place during the Business Track include a discussion from Dr Sarah Tonks, who will share her experience in making the transition from full-time dentist to established aesthetic provider. Dr Tonks will advise on the range of treatments that a practising dentist can easily and appropriately incorporate into their existing business, along with potential pitfalls and how to overcome these successfully. VAT advisor, Veronica Donnelly, will be utilising her extensive 26 years of experience to inform visitors on the complicated issue of how to manage VAT in aesthetic practice, whilst Gilly Dickons will share insights and tips on how to create an excellent first impression with potential and

existing customers. As founder of specialised aesthetic call-handling and enquiry company Aesthetic Response, Dicksons is ideally placed to advise on the significance of this positive experience in adding value to your clinical offering. This year, UK industry and media attention has been focused on the need for increased regulation within the aesthetics industry, an issue which has yet to be resolved at a government level. Brett Collins recently formed Save Face, a body that has been set up in light of the Keogh Review to help consumers find well-accredited practitioners for non-invasive procedures. “The aesthetic market is moving forward, which is why it is now so important that we come together as a collective industry, with our prime focus on patient safety,” says Collins. “Whilst endlessly interesting and rewarding, the industry can prove challenging to navigate whilst maintaining a healthy and safe balance between the ethics and standards we hold as healthcare professionals, and the competitive forces of a thriving and fast paced market place.” As part of the Sunday agenda, Collins will present an independent perspective on why it is so important for practitioners and clinics to become part of a professional association, and the necessity for statutory regulations, given the growing aesthetics industry. The Business Track will also feature a host of sessions centred around marketing, sales and branding; business essentials in the competitive aesthetics market. During her two sessions, US based author and business consultant Wendy Lewis will be focusing on the use of social media and multimedia content within business marketing strategy, drawing on her two decades of experience in medical aesthetics. Essential guidance on brand building will be provided by Gary Conroy, director of 5 Squirrels Ltd; a company offering customised skincare to the UK aesthetics industry. Conroy will explore how businesses can develop their branding to establish and promote their identity to Aesthetics | December 2014

ACE 2015 Business Track

potential customers and cement their position in the market. A sales workshop with the managing director of Advance and company director of Fitzwilliam Transformation Clinic, Anna Louise Kenny, will advise practitioners and front of house staff on how to maximise selling opportunities within a clinical environment. Additionally, Dan Travis, director of The Marketing Clinic, will lead a Sunday afternoon session revolving around the concept of critical business numbers. “These numbers are the lifeblood of your business,” he says. “Most business owners do not know their business numbers and suffer directly as a result.” Travis adds, “This session is far from being a lesson in accountancy. Once you begin to grasp your business numbers, you will be far better placed to grow your business.” Providing an excellent platform for attendees to increase their understanding of how to build and boost a successful aesthetic clinic, the Business Track is the perfect opportunity to learn valuable business skills whilst networking with other professionals. The content is ideal for both practitioners and individuals in management, front of house and administration roles, working within an aesthetic practice. The Business Track is just one of the agendas on offer at the Aesthetics Conference and Exhibition, taking place on March 7 and 8 in Central London. Free exhibition registration will also include sponsored Masterclasses and Expert Clinic live demonstration sessions, along with Business Track workshops. This year, ACE features a brand new main conference agenda format, the first of its kind for the medical aesthetics profession. Delegates will be able to choose to attend individual three hour learning experiences on body and fat, injectables expert sessions parts I and II, or skin health. Alternatively they can choose to attend the full two day programme for the complete learning package in medical aesthetics. Each of the four main conference agenda sessions are priced at £95 including VAT, with a cumulative discount for the more sessions booked. Book now for an additional 10% limited early booking discount. Visit www.aestheticsconference.com for the full agenda and to register.

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Special Feature Technology

for an appointment that might only take a few minutes. Instead, they can send a photograph of themselves to Dr Patel via text, WhatsApp, or email – whichever method they prefer – and in a matter of seconds he can view the photo, assess the patient’s condition, and respond with the appropriate course of action. It also saves Dr Patel time: “With a few strokes of the keyboard I can communicate with 10 or 12 patients a day, who otherwise would have to come in for reviews. They will always have the choice to come and see me if they’re uncomfortable sending a selfie. But pretty much 100% of the time, they would rather share a photo.”

Technology in aesthetics Allie Anderson speaks to practitioners about their experience of adapting technology to their clinics In the 21st century, technology pervades every aspect of our existence. We conduct our business and social lives on handheld devices, communicating digitally and accessing information about others and ourselves in a virtual space, all at the tap of a keyboard or the swipe of a screen. The aesthetics industry has arguably been behind the curve when it comes to adopting and embracing new technologies to streamline treatment processes and push the boundaries of results. Slowly but surely, however, the use of pioneering software, programmes and apps is becoming less the reserve of the trailblazers, and moving more into the domain of everyday clinical practice. Picture perfect The last few years have seen the influence of the selfie become unescapable. In 2013, ‘selfie’ was named Oxford Dictionaries’ ‘Word of the year1 and more recently, with the help of social media, the ‘no makeup selfie’ movement racked up £8 million in donations to Cancer Research in just six days.2 For cosmetic dermatologist Dr Tapan Patel, there is a place for the trend in aesthetic practice too. Historically, when patients came to him for laser resurfacing, the risk of post-treatment reactions and infection meant he had to follow up with the patient in person in the days and weeks immediately following the procedure. Now, he asks patients to send a ‘selfie’ from the comfort of their own home, so he can assess their progress remotely without them needing to come to clinic. “With a photograph, I can see easily if there is an area of redness or an area that’s taking longer to heal,” he explains. “I can then ask them to send a more detailed photo of that area, ask them how it’s feeling, and follow up with them as necessary. They’ll typically send one photo of themselves a day, I assess it and if everything looks OK, I simply tell them to come back in one month.” The benefits to the patient are clear; it’s saving them the time and expense of making a journey – often a long one – to the clinic

Interactive relationships The advancement of technology has itself bred an expectation that we ought to be able to interact with the people we come into contact with in creative ways. As a result, gone are the days when the doctor-patient relationship was restricted to telephone calls, clinic appointments and letters sent through the post – sending the practitioner a photograph via WhatsApp is one example of that. “More interconnections between doctors and patients will be necessary; they want to be followed up and taken care of personally, even some months after they visit our clinic,” says Dubai-based aesthetic practitioner, Margaret Lorimer. “Doctors need the latest technology for the benefit of patients and clinics. Patients are all using smartphones to plan appointments, store photos, sharing on social networks – they all interact. So it’s logical that they can interact with their favourite clinic.” To that end, Lorimer uses Sygmalift, a tablet and smartphone app that enables clinicians to store data and images and automatically conduct patient follow ups, as well as managing a number of admin functions. Patients can also use the interface, so they can view before and after photos shared by their clinician, access clinic news and updates, and contact their practitioner by email. The app streamlines the consultation process, too. “You can have a patient file handy with pre and post-treatment photos done immediately. There is no need to download the photos from your camera and put them on your PC to compare and resize them, etc. The Sygmalift app does it all automatically.” The app has the advantage of saving precious time for patients who lead busy lives and need to minimise the time spent in clinic, offering remote ‘pre-clinic’ and aftercare advice to speed things along when they come in for the procedure. According to Lorimer, this form of communication between patients and practitioners is essential. “We propose a tailor-made service to patients and this interconnection can lead us to follow patients’ skin evolution and give preventative advice for long-lasting results. I see the future of clinics is to offer interactive medical advice to patients, in order to offer a better service.” Optimising patient involvement There is a degree of scepticism about the aesthetics industry in the UK, according to aesthetic practitioner Dr Raj Acquilla. He believes it is propagated by patients not feeling in control of any aspect of their treatment journey. Using technology to enable patients to interact with doctors and clinics, and learn more about procedures and outcomes, is crucial to breaking down barriers. “You’re giving [patients] a level of involvement, so they can take ownership of a significant part of that process,” says Dr Acquilla. Used in a clinical setting, the Allergan Facial Anatomy app helps to do just that. The app uses a computer-generated, three-dimensional image of a face with multiple layers that can be removed one by

Aesthetics | December 2014

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Sygmalift (Image courtesy of Medixsysteme)

one to reveal the anatomical structures beneath the surface. Its primary patient-facing use is to demonstrate, for example, the exact positioning for botulinum toxin injections, as Dr Acquilla explains: “You mark little dots on the 3D image – and you can use different colours for different products – and then you can peel away the skin to show the fat, then peel away that to see the muscle, take away the muscle to show the nerves and blood vessels, and then the facial skeleton.” The marks remain in position on each layer, allowing you to see and show the patient the impact of the treatment far below the surface of the skin. “You can recheck your injection sites and see what dangers and pitfalls lurk in the background,” says Dr Acquilla, “but also, you’re showing the patient that there’s a rationale for where you’re placing the needle to generate the most positive effect and to avoid any adverse event. Patients love anatomy – they love to know how everything works – so it gives them a sense of control.” Dr Acquilla also uses the Allergan app as an educational resource in a training environment. “I recently used it at a conference with around 2,000 delegates. I could stream it wirelessly to a huge screen so I could show what was going on with the anatomy. It’s fantastic for that, and as a reference tool,” he comments. “Even the most advanced clinician can never know too much anatomy, so you can have it open during clinic to refer back to.” Enhancing objectivity within consultancy One of the most important factors in optimising the results of a treatment or procedure is to ensure that both parties are on the same page when it comes to what the patient wants and expects, and what the practitioner can deliver. Patients, however, can be shy and embarrassed when discussing their perceived flaws and problem areas. “In consultations, when people do things the oldfashioned way of looking in the mirror, they tend to put their best side forward. They make little tweaks to their face, to perhaps make their lips fuller or puff their cheeks out a little,” says aesthetic nurse, Nikki Zanna. “I use the iConsult app to capture real-time images of the client, which we can look at and identify concerns together. It makes it much more holistic, as you’re looking at the face as a whole, rather than them honing in on one line or one part of 22

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their face that bothers them.” Patients get a more objective and accurate appraisal of their needs, while practitioners are better able to present various treatment options, bringing obvious benefits to their business. “Selling doesn’t even become an issue,” Zanna adds, with increased patient spend and consistent cross-selling both integral aspects of the solution. As an early adopter of this technology and having used it since its launch around 18 months ago, Zanna has seen the app go through stages of development and evolve into a patient management system that simplifies all aspects of the treatment process, including record keeping, data capture, consent, medical notes and visual representations of treatments. It also enables product selection and mapping, recording of batch numbers and expiry dates, and various admin tasks such as diary management and financial reporting. One of the most compelling functions of iConsult is that, in providing a structured process for consulting, it also effectively puts in place safeguards – there are compulsory fields that the clinician must complete before they can move forward, which means, as Zanna says, “you can’t miss anything”, thereby protecting the patient and the practice. Security concerns? With the advancement of various technologies come inevitable questions about privacy and the security of personal data. With solutions like iConsult, the user has an account with robust registration procedures and a personal login, which is used to access the tablet interface. “Nothing is held on your iPad – it’s all kept on a secure server,” says Zanna. “Even if your iPad was lost or stolen, nobody can access those patient notes because you have to log in to see everything.” But what about digital assets that are in the public domain? When a patient shares a photograph with Dr Patel, he instantly deletes it once he has viewed it and decided on an appropriate course of action. As Dr Patel points out, there is no more an issue with privacy as there is with anyone placing a photo in the public domain by sharing it on a social network. “We don’t use the photos afterwards, and we treat patients’ selfies with the same confidentiality we treat any patient photo,” he comments. However, issues arise when assets – such as photos, videos and personal data – are broadcast and made publicly available without a person’s clear consent, or even their knowledge. This is the basis of concerns about Google Glass,3 a ‘wearable technology’ that allows users to take videos and images, commit

Aesthetics | December 2014

iConsult (Images courtesy of Richard Crawford-Small)

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them to their personal files and share them with others, through a head-mounted frame: think a tiny camera hidden in the frames of a pair of glasses, with built-in access to the Internet. Google Glass is still in its infancy and it is currently only available in the US (a UK user would have to buy them in the States and import them), but one London practitioner is using the technology in everyday practice to push the boundaries of what’s possible. “It allows me to harness the power of the Internet or Wi-Fi, and have anything streamed to that Glass [device], so I can see that information while I’m doing other things,” explains facial cosmetic surgeon, Dr Julian De Silva. “In surgery, I can access a patient’s folder [via the Glass device] and see all the information about that patient, access photographs of their face in different positions, view X-rays and compare all Google Glass (Image courtesy of Dr Julian De Silva) of that in real time with what I’m looking at during the surgery. That is all incredibly useful.” Particularly fascinating is the capacity to use a photograph or computer-generated image and superimpose it onto the patient’s own face. Glass also enables Dr De Silva to take photos and videos during the procedure to share with the patient afterwards, for example, to demonstrate problems encountered or how the surgery went. All files and images are automatically saved to the user’s Google Drive account, so they can be accessed later via a computer or other device. Moreover, the user can connect to the Internet or Wi-Fi and stream photos or videos captured from the surgeon’s perspective, giving viewers a unique view of exactly what the surgeon is looking at. The Google Glass technology has very clear and useful applications in this setting; privacy is not a concern because patient consent would be required for taking photographs during surgery in any case. “If you find something during the surgery and you need to document that, there is no privacy issue because it’s a medical record,” Dr De Silva adds. “It’s only a consideration if you’re going to share that information.” As such, aesthetics is

DigitRx (Image courtesy of Church Pharmacy)

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Google Glass enables Dr De Silva to take photos and videos during the procedure to share with the patient afterwards to demonstrate problems encountered or how the surgery went arguably the ideal arena for Google Glass, as its users – doctors and practitioners – are already bound by legal and moral obligations over patient privacy and consent. A prescription for the future Records generated on automated systems can be secured by the use of personal logins, which identify that users have appropriate authorisation to access that data. Developers at Church Pharmacy have built on this concept to establish DigitRx, a free online prescription system that enables practitioners to create original scripts online securely, without needing to post them. Dr David Bowden, an aesthetic practitioner who has been using DigitRx since its launch in October, explains how it has streamlined the process of prescribing, saving time and resources. “The old process of having to fax or email the prescription meant we were effectively sending a picture – usually a poor quality one – of the prescription to the pharmacy for them to process,” he says. “That created problems in itself, because the dispenser might not be able to read it properly, or they might have questions about the quantities, so you’d end up speaking on the phone several times to clear things up. You would also then have to send the original version, with your signature, through the post as well.” DigitRx users are subject to a robust and thorough registration and are provided with a four-digit pin, which is unique to that prescriber in the same way a signature is. As such, an original script is generated online with the prescriber’s unique pin, negating the need for the paper version to satisfy regulatory requirements. The online prescriptions go automatically to the pharmacy, where they are processed by a qualified dispenser. The system has safeguards in place to flag up erroneous data, such as particularly high quantities of certain products or contraindications with other medications a patient is taking. Dr Bowden says, “It can pick up human error, like a typo for example, but there is also a function that allows you to give an explanation if the product you’ve prescribed is marginally over the usual dispensing limit. It gives you the control, but at the same time there’s zero margin for error.” Traditionalists and sceptics may still need to be convinced about whether technology in these forms has a place in aesthetic practice. But there is no doubt that it is beginning to permeate the industry in many and varied ways: the question therefore may be when, rather than if, the masses should join the ranks of the pioneers and fully embrace the shift. REFERENCES 1. ‘Selfie’ named by Oxford Dictionaries as word of 2013 (London: bbc.co.uk, 2013) <http://www.bbc. co.uk/news/uk-24992393> [accessed 12/11/2014] 2. No-makeup selfies raise £8m for Cancer Research UK in six days (London: theguardian.com, 2014) <http://www.theguardian.com/society/2014/mar/25/no-makeup-selfies-cancer- charity> [accessed 12/11/2014] 3. Arthur, C, Google Glass: is it a threat to our privacy? (London, theguardian.com, 2013) <http://www. theguardian.com/technology/2013/mar/06/google-glass-threat-to-our-privacy> [accessed 12/11/2014]

Aesthetics | December 2014

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

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision,

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BEL141/1014/LD Date of preparation: October 2014

blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Inﬂuenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualiﬁcations and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1181/BOC/OCT/2014/LD Date of preparation: October 2014

CPD Lasers and Acne

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photochemical effect on the superficially-located P. acnes. Both visible and ultraviolet light sources have been reported to result in a reduced number of lesion counts.4 Endogenous porphyrins within P. acnes are thought to absorb light at specific wavelengths which then produce phototoxic effects in the form of singlet oxygen production resulting in bacterial destruction.5 Current hypothesis regarding infrared lasers is that they are thought to momentarily damage sebaceous glands via thermal effects, detailed in Table 1.6 This article explains the effectiveness of laser and light therapy in the treatment of acne. The article does not cover the treatment of acne scarring with laser and light devices.

Laser and light treatments in acne: in search of the evidence Abstract Acne vulgaris is a common condition which remains challenging to treat in some cases. Laser and light-based therapies offer an alternative to medical therapies with the advantage of high compliance and relatively low side-effects. Light-based therapies in acne exert their effects through photochemical, photothermal, or a combination of both mechanisms. This article explains the mode of action for each light-based modality and examines the current evidence in this field. Introduction Acne vulgaris is one of the most prevalent skin disorders, which often occurs in a large number of individuals during their adolescent years. It has the potential to cause significant scarring and psychological impact.1 There are a large number of treatment options available to patients at present, however, these are not without side-effects. In many cases the disease can be resistant to therapy, hence the desire for additional, alternative treatment options. Non-compliance, the lack of desire for systemic therapy, coupled with the desire for the use of modern technology has led to an increase in the demand for alternative non-medical therapies in acne. Of late, interest in lasers and other light-based treatments has increased. One of the main advantages of the use of lasers in acne is the high degree of compliance and the negligible rate of potential systemic adverse events.2 The mechanisms of light-based therapies in acne could be divided into: photochemical effects (with or without the use of exogenous photosensitizer), photothermal effects, or the combination of both. An alternative approach is to divide the effects of lightbased therapies on specific targets in the skin; namely the Propionibacterium acnes (P. acnes), the follicular infundibulum, or the sebaceous glands. It is worth mentioning here that therapies directed at either of these targets will have a degree of antiinflammatory effects, leading to an overall improvement in the treatment of acne. UV phototherapy is not often used in the treatment of acne due to the carcinogenic potential. Its mechanism of action is likely to be related to the production of superoxide anions, as well as membrane damage and single strand breaks in DNA.3 Desquamative effects are also likely to play a role as well as a mild 26

Blue and red light: Low-level light in the form of continuous, non-coherent blue and/ or red light-emitting diodes (LEDs) were known to be used in acne treatment because of their photochemical effects. With pulsed systems, low fluences can exhibit similar photochemical effects depending on the tissue oxygen availability and may require an extrinsic photosensitizer or multiple passes in comparison to the continuous-output LEDs. Although blue light has poor skin penetration (less than 100 micron), with a wavelength of 407-420 nm it exhibits the strongest porphyrin photo-excitation co-efficient and thus is the most effective wavelength to photoactivate the endogenous porphyrins contained in P. acnes.7 The coproporphyrins, the main porphyrin produced by the P. acnes acts here as a chromophore. An in vitro study demonstrated that blue light activation of porphyrin led to structural membrane damage in P. acnes, suggesting cell death.8 Culture growths were indeed decreased 24 hours after one illumination with intense blue light at 407-420 nm. Growth was reduced 4-5 orders of magnitude further with second and third illuminations of light.8 One of the main limitations of blue light is its poor penetration and a degree of loss, secondary to scattering or melanin absorption. Its main target is therefore likely to be in the follicular infundibulum. Red light however penetrates the skin at a deeper level, reaching up to the sebaceous gland. It is thought to have antiinflammatory properties by influencing the release of cytokines from macrophages, as well as photothermal effects directly aimed at the sebaceous glands.9 There have been a number of studies involving both blue and/or red light in the treatment of acne. Most were open-labelled with few split-face comparative studies. The sample sizes were relatively small (20-50 patients) and all studies noted an improvement in acne lesions. One study looked at red light alone and found that, when used in a split-faced randomised controlled trial; there was a significant improvement in both inflammatory and non-inflammatory lesions.10 In summary, blue and red light may act synergistically in the treatment of acne through bactericidial effects (blue light) and antiinflammatory effects (red light). Pulse dye laser (PDL): The 585/595 nm PDL targets oxyhaemaglobin and results in selective photothermolysis of the dilated vessels that form a part of the inflammatory process in inflammatory acne.5 Additional mechanisms possibly include a photochemical effect on the porphyrins produced by the P. acnes. Porphyrins are activated via the delivery of yellow light, which results in phototoxic effects.5,7 Fourteen studies using PDL to treat acneiform lesions have been reported throughout the literature available. There were significant methodological differences between the studies; six

Aesthetics | December 2014

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used PDL therapy alone and five used PDL therapy combined with topical agents (5-aminolevulinic acid, methylaminolevulinic acid, clindamycin, or benzyl peroxide). In the studies that used PDL in combination with topical agents, four cases reported an improvement in inflammatory lesions ranging from 30-80%. In cases of PDL used alone, three cases reported a significant reduction (53-86%) in inflammatory lesions. PDL did not significantly reduce the number of non-inflammatory lesions in any of the cases. Three studies reported PDL to have no significant change in the number of lesions when used alone or in combination with topical agents. One study by Seaton et al suggested that PDL had no effect on P. acnes colonization or sebum production (measured using the application of absorptive tape).11 They did however note upregulation of transforming growth factor B (TGF-beta). Given that this is a potent inhibitor of inflammation, the finding suggests that this laser may act through anti-inflammatory effects. It has also shown to inhibit CD4+ T-lymphocyte mediated inflammation. TGF-beta may also induce keratinocyte growth arrest, which could possibly interfere with comedone formation. Sami et al compared PDL/Intense pulsed light (IPL) and LEDs in the treatment of 45 patients with moderate to severe acne. They found that a clearance of 90% of inflammatory lesions was achieved quicker with the use of PDL over IPL, which was more effective than LED.12 The exact mechanism of how PDL works appears to be multifactorial. The photothermal effect on the sebaceous glands is achieved partly by heating the dermal microvasculature, secondary to the oxyhaemoglobin absorption. It is hypothesized that the generated heat leads to the induction of heat shock proteins, such as HSP70, which in turn could play a role in TGF-beta production. In summary, although the exact parameters are not yet established, and the studies have shown conflicting and inconsistent results, PDL is likely to work due to both photochemical and photothermal effects. The debate on the true efficacy and role of PDL in acne treatment is ongoing.

CPD Lasers and Acne

Infrared lasers 1450 nm and 1540 nm lasers: Infrared lasers penetrate deep into the dermis targeting water as their main chromophore. Water is the dominant chromosphere in the sebaceous gland, thus infrared lasers are thought to arrest the production of sebum and eliminate acne. Both the 1450 nm and 1540 nm lasers have been used in this manner.15 Seventeen studies reported the use of these lasers, 12 were open-label and five were randomised. The 1540 nm laser: The 1540 nm Erbium glass laser is a mid-infrared laser and has effectively been used to treat acne lesions in four studies. A 78% reduction in acne lesions was observed in 25 patients after four treatments at four weeks interval.16 Kassir et al noted a similar reduction (82%) at three months in 20 patients who received treatments twice a week for four weeks.17 Angel et al demonstrated the longest clearance effects of the 1540 nm laser (two-year follow up).18 The mean percentage reduction of 18 patients treated with four treatments at four-week intervals was 71%, 79% and 73 % at six, nine and 24-month follow-up respectively. Inflammatory acne was shown to improve by 68% in 15 patients with moderate to severe acne treated four times at two-week intervals; however there was no reported change in sebum production.19 Virtually no side-effects were reported with the use of this laser. It is likely that this laser exhibits its effects through non-selective heating of the sebaceous glands. The 1450 nm laser: This laser was first used in a study of 19 patients with inflammatory acne in which traditional therapies had failed. A fluence of 14 J/cm2 was used in three treatments at four to six week intervals and a 37% and 83% reduction in lesion count was observed after the first and third treatment respectively. Side effects included transient erythema and oedema.20 A randomised split-face trial was carried out to compare two treatment fluences by Jih et al. Twenty patients received three treatments at three to four week intervals, after one treatment the percentage reduction in mean acne lesion count was 43% (14 J/cm 2) and 34% (16 J/cm2), patients were followed up for 12 months and the reduction in lesion count was 76% (14 J/cm 2) and 70% (16 J/cm).21 Acne scarring and sebum production also improved. The 1450 nm diode laser heats the upper mid dermis to a depth of 500 micrometres and can result in thermal coagulation of the sebaceous lobule and the follicular infundibulum.5 It is thought to improve acne lesions via heating the sebaceous gland and reducing its activity. Perez-Maldonado et al displayed an 18% reduction in sebum production (measured by sebutape scores) in eight patients treated with the 1450 nm diode laser for three treatments over a period of six weeks.22 Contrasting results were

Potassium titanyl phosphate (KTP): This 532 nm laser emits green light pulsed laser therapy, which penetrates deeper than blue light. It activates porphyrins, which target P. acnes, as well as causing non-specific thermal injury to the sebaceous gland. It therefore exhibits a photochemical as well as mild photothermal effect. It has been shown to have short-term results on acne lesions with few side effects. Four open-label studies have assessed the effectiveness of the KTP laser in the treatment of acne. In a split-face, prospective controlled trial of 26 patients with moderate acne, Baugh et al reported that KTP laser was a safe and effective method of treating acne Table 1: Target chromophore of laser/light in the treatment of acne lesions.13 Results lasted up to four weeks after treatment, with a 21% reduction on lesion count at four weeks versus a 35% reduction at one Target Laser/light device week. Bowes et al carried out a prospective, split-face study of 11 patients and noted a 36% UV, blue light, red light, reduction of mild to moderate acne lesions in P. acnes blue/red light combination comparison to 2% in the control side. Yilmaz et al also supported the use of this laser in Infrared lasers (1064 nm the treatment of mild to moderate acne in 38 Sebaceous glands Nd:YAG, 1320 nm, 1450 patients. Their findings showed that there was nm, 1540 nm), and PDT no difference between once or twice weekly applications.14 Despite these studies, the results Combination of P. acnes KTP, PDL, IPL, and PDT are generally short-term and this laser is not and sebaceous glands often used in the management of acne. Aesthetics | December 2014

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seen in fourteen healthy subjects (without active acne), with this laser showing no significant reduction on sebum production.23 A split-face bilateral paired study treated 11 patients with the 1450 nm diode laser at a fluence of 11 J/cm2. One half was treated with a single pass consisting of stacked double pulses and was compared to a double pass treatment of single pulses. The stacking of pulses was more effective in reduction of acne lesion count compared to the multi-pass technique.24 Lower fluences elicit less pain whilst still effectively treating inflammatory lesions. Single pulse multiple pass methods may have a reduced chance of cryogen-induced transient hyperpigmentation in comparison to the standard high fluence techniques. Yeung et al supported that multiple pass/lower fluence can still retain efficacy but reduce post-inflammatory hyperpigmentation.25 Bernstein et al performed a randomised split-face trial of six patients with papular acne, comparing single pass high-energy treatment (13-14 J/cm2) and double pass low-energy treatments (8-11 J/cm2) for four treatments at monthly intervals. Single pass high energy had greater reduction in lesion count reduction (78% vs 67%), however pain score was greater in the single pass group (5.6 vs 1.3).26 The 1450 nm diode laser in combination with the 585 nm laser has been shown to be effective in the treatment of inflammatory acne, acne scarring and post inflammatory erythema in 15 patients. The addition of microdermabrasion to the 1450 nm diode laser showed no significant benefit for treatment effectiveness or pain in a randomized split-face trial of 20 patients.27 Despite the results of the aforementioned studies, this laser is associated with a relatively high degree of pain and discomfort and is no longer considered a laser of choice in the treatment of acne by many laser dermatologists worldwide. Photodynamic therapy (PDT) PDT involves the use of a photosensitizer, which is taken up by the pilosebaceous unit and undergoes metabolism through the haemsynthesis pathway and results in the production of protoporphyrin IX.28 The activation of this pathway leads to the production of free radicals and singlet oxygen, which are cytotoxic. Accumulation of this in the epithelium and pilosebaceous unit lead to elimination of the P. acnes and modulation of the sebaceous gland and infundibulum. P. acnes cultures grown in the presence of ALA led to a 5-fold decrease in culture viability after 3 illuminations of high intensity blue light. For PDT to be effective, light, oxygen and a photosensitizer are required: 5-aminolevulinic acid or methylaminolevilunate (MAL), Indocyanine green (ICG) and Indole3-acetic acid are used as photosensitizers. A light source can be a light emitting diode, fluorescent lamps, lasers, sunlight, xenon flash lamps, arc lamps and filtered incandescent lamps. P. acnes photo-inactivation can be altered depending on the concentration of porphyrins which is governed by the type of acne lesion, effective fluence, wavelength of the photons emitted and the temperature.29 Twenty studies using PDT in acne were published, (11 randomised trials and nine open-label). Intense Pulsed light (IPL) source was used in four studies (one randomised split-face, open-label; one randomized open-label study, and one split-face pilot study). Aminoluevelunic acid (ALA) was used in four cases and MAL in one case. Yeung et al noted a 65% reduction in inflammatory lesions after 12 weeks following PDT in comparison to 23% reduction when using IPL alone.30 Similar findings were found by Rojanmatin et al at 12-week follow-up in a split-face trial.31 The PDT side had 87% reduction in lesions in comparison to 66% reduction with IPL alone. 28

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P. acnes photo-inactivation can be altered depending on the concentration of porphyrins which is governed by the type of acne lesion, effective fluence, wavelength of the photons emitted and the temperature Another split-face trial using ALA with IPL was conducted by Santos et al, which assessed 13 patients. Ten out of 13 patients using the combination treatment showed marked improvement in comparison to the IPL alone group. Different modalities were compared by Taub et al, which compared IPL, IPL and bipolar radiofrequency (RF) and blue light for activating ALA-induced protoporphyrin IX. ALA-PDT activation with IPL provided the greatest and longest lasting effects in comparison to RF-IPL and blue light.32 Five studies used longpulse PDL, (one randomised controlled split-face single blinded trial, one cross-sectional comparative controlled prospective study, one split-face open-label study, and one prospective randomized study). MAL was used in conjunction with long-pulse PDL in two studies Haersdale et al33 saw a significant reduction in lesion count in the PDT-treated areas. A reduction in both inflammatory and noninflammatory lesions was noted; however erythema and oedema were reported as significant side effects. An interesting study by Hongcharu et al34 with ALA followed by irradiation with red light showed histological evidence of sebaceous gland hypotrophy with glandular destruction. Furthermore, ALAPDT decreased P. acnes fluorescence, a marker for bacterial colonization, as well as sebum secretion post therapy. Despite such encouraging findings, some studies using ALA followed by red light have failed to show any significant reduction in sebum production or P. acnes colonization.34 Of 18 patients studied by Taub et al, 11 were noted to have a 50% improvement and five to have a 75% improvement.32 Side-effects included erythema and peeling. Goldman et al followed-up 22 patients for two weeks and noted an improvement in lesion count with no reported side effects. There was a greater response in the ALA-blue light group compared to the blue light group alone.35 The same author used short contact ALA of one hour with either an IPL source or blue light with relative clearance of the inflammatory lesions. Gold et al also used short contact ALA of 30-60 minutes in combination with blue light in moderate-to-severe inflammatory acne and noted a response rate of 60%. Blue light was also used in combination with ALA in two studies. Itoh et al used halogen light with a filtered band of 600-700 nm in combination with ALA in 13 patients. All patients showed an improvement in their inflammatory component.36 MAL is a lipophilic derivative of ALA and may therefore have better penetration. Its use as a photosensitizer in acne therapy was used in two European studies. The first by Wiegell and Wulf37, the second study by Horfelt et al.38 Both studies showed a modest improvement in acne lesions with occlusion time of three hours.

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Key points • Laser and light-based therapies offer an alternative to the currently available medical therapies in the treatment of acne vulgaris • The mode of action in light-based therapies is achieved largely through photochemical, photothermal, or the combination of both mechanisms • The current literature provides conflicting and inconsistent results with most of the evidence in favour of blue/red light and photodynamic therapy • Intense pulsed light and pulsed dye laser are useful adjuncts in the treatment of – predominantly – inflammatory acne with associated acne erythema • Photopneumatic therapy is an exciting novel therapy in acne with evidence in it’s use in mild-to-moderate acne cases

Intense pulsed light (IPL) An IPL device delivers an intense source of light, the wavelength of which can be modified via the use of filters. The generated pulsed light is polychromatic and non-coherent and the emitted light can be tailored to the treatment by alteration of the filtered light, pulse duration, and fluence. IPL technology works in singleand burst-pulse modes. In the single-pulse mode, the fluence will be delivered in single shot, whereas in burst-pulse mode fluence is divided into series of pulses with a delay between each one. The theory of treating acne lesions with IPL is based on the photochemical and photothermal (higher settings) effects on the bacterial-derived porphyrins, as well as the inflammatory cells that mediate an inflammatory cascade, heating of the sebaceous glands, and small vessels associated with the process.39 The photochemical effects are likely to occur due to the blue and red range of light emitted by the IPL, whereas the infrared range of light has more of a photothermal effect on the sebaceous glands and dermal vasculature. IPL was used in nine studies with mixed results. Elman et al used 430-1100 nm source in patients with moderate acne and saw a 74% and 79% reduction in inflammatory and non-inflammatory lesions, respectively, following twice weekly therapy for four weeks.15 Lee et al carried out a split-face control trial in patients with mild to moderate acne and noted a significant reduction in both inflammatory and non-inflammatory lesions in comparison to no treatment.40 A further split-face trial with the use of Benzoyl peroxide with or without IPL did not show a significant difference in comparison to using IPL alone. Dierickx et al demonstrated a clearance rate of 72% at six months post therapy.41 IPL was combined with RF and results showed that the mean lesion count was reduced by 47%; it was suggested that this reduction was due to reduction in sebaceous gland size and decreased perifollicular inflammation. Their findings were based on post treatment skin biopsies. 42 In comparison with other modalities, IPL has been found to be less effective than PDL but more effective than blue or red light. Photopneumatic therapy Photopneumatic therapy (PPX) combines pneumatic energy and broadband light (400-1200 nm) encompassing the blue wavelength 410 nm, which is the wavelength that is greatest for porphryin absorption. The suction acts to lift the contents of the dermis bringing them closer to the skin surface, thus making energy transfer more effective. The epidermis, and therefore melanin in 30

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the epidermis, is spread out and the photo pneumatic treatment reduces adverse effects on the epidermis such as pigmentary changes.43 In addition, the suction applied due to negative pressure may help to rid comedones of their contents. The action of PPX therefore involves a combination of thermal and vacuum-related mechanical effects. A number of studies have used this technology in the treatment of acne. Fifty-six patients with mild to severe acne were treated with PPX and were reported by Shamban et al to have a 50% clearance of lesions after one session and 90% after four sessions.43 Omi et al observed ultrastructural changes to the pilo-sebaceous unit after PPX treatments.44 Histologically, the authors were able to observe extrusion of comedone contents from the infundibulum and thermal injury to the bacteria and pilosebaceous apparatus, supporting the theory that PPX decreased sebaceous gland activity. No adverse effects were reported. Gold and Biron demonstrated efficacy with PPX in seven patients treated with a total of four treatments at three-week intervals.45 A larger study by Wanitphakdeedecha et al involving 20 patients who were treated at two-week intervals demonstrated modest improvement in acne lesion counts.46 In a prospective, multicentre, clinical trial involving 41 patients with mild-to-moderate acne, Narurkar et al reported a 69% reduction in the inflammatory component, in contrast to 41% reduction in the non-inflammatory component of the disease.47 There were no adverse effects caused by the treatment, with mild discomfort and transient erythema being the most reported side-effects. In my experience, this treatment is effective in the mild to moderate cases of acne and in combination with topical therapy. Discussion The treatment of acne vulgaris often requires combination therapy and a tailored treatment regimen, specific to each case. Despite advances in our understanding of the disease and the wide array of topical and systemic therapies available, in many cases the disease can still be resistant to medical therapy and hence lightbased treatments may offer an alternative or act as adjuncts. Lightbased technologies can largely be based on their photothermal effect, predominantly on the sebaceous glands and their associated dermal vessels, or on their photochemical effects by targeting the coproporphyrins produced by P. acnes, leading to cell death. The photochemical effects can be produced with or without the application of a photosensitizer such as ALA, although most of the current evidence points toward the PDT-mediated effects of therapy on acne. This is particularly the case when a sustainable duration of the results is taken into consideration. Unfortunately the side effects with PDT appear to be the main limiting factor for their use in the treatment of acne in the majority of the cases. • Blue and red light therapy in the form of LEDs has shown efficacy with the former exhibiting a photochemical effect and the latter a predominantly immunomodulator and anti-inflammatory effect, in addition to some photothermal effects. These effects appear to be superior again when combined with a photosensitizer (i.e PDT effect as opposed to LED alone). • IPL has shown to be effective with its broadband range having a combination of photochemical and photothermal effects, although again the studies have shown that IPL combined with a photosensitizer is superior to IPL therapy alone. Furthermore, when compared against PDL, the latter showed a superior effect.

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Despite the large number of studies published utilising light-based technologies in acne, the results are mixed and firm conclusions are difficult to draw • Studies using the PDL in acne showed conflicting results too, and although evidence of TGF-beta upregulation has been shown, this does not appear to be sufficient in controlling the disease in many cases. Both PDL and IPL have a place in acne treatment today, particularly in the cases where it is associated with acne-induced facial erythema. This is similarly the case with the KTP laser. Infrared lasers are less widely used for acne treatment nowadays, due to the associated pain and discomfort. • PPX is a relatively new technology in the treatment of acne and appears to be effective in mild-to-moderate cases combining both photochemical effects with mechanical extrusion of comedonal contents in addition to a mild photothermal effect. • Despite the large number of studies published utilising light-based technologies in acne, the results are mixed and firm conclusions are difficult to draw. Many studies were open-labelled or lacked optimal methodological qualities and involved a relatively small number of patients. Lack of objective assessment of outcome further contributes to the somewhat tempered enthusiasm of the use this technology in acne. Larger, randomized, controlled trials with clear objective outcome measures and consistent agreed settings (which vary hugely among the published studies) would be needed. Conclusion Laser and light based therapies may act as alternative treatments for patients that have not responded or are not suitable for medical therapy. The effects of light-based therapies rely on photochemical, photothermal, or the combination of both. For light-based therapies to be effective, ideally targeting both the P. acnes, as well as the sebaceous glands, appears to be the best approach. To date, most of the studies were underpowered or showed inconsistent results with relatively small number of patients involved. Optimal parameters are yet to be established. In my opinion, light-based therapies often offer very effective treatment when combined with medical therapies in selected patients. Dr. Firas Al-Niaimi is a consultant dermatologist and laser surgeon. He trained in Manchester and subsequently did a prestigious advanced surgical and laser fellowship at the world-renowned St. John’s Institute of dermatology at St. Thomas’ Hospital in London. He has authored more than 80 publications including chapters of books and is on the advisory board for a number of respected journals.

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REFERENCES 1. Webster GF. Acne vulgaris. BMJ. 2002;325(7362):475-9. 2. Jih MH, Kimyai-Asadi A. Laser treatment of acne vulgaris. Semin Plast Surg 2007;21(3):167-74. 3. McGinley KJ, Webster GF, Leyden JJ. Facial follicular porphyrin fluorescence. Correlation with age and density of Propionibacterium acnes. Br J Dermatol. 1980;102:437-41. 4. Papageorgiou P KA, Chu A. Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. Br J Dermatol. 2000;142:973-8 5. Rai R NK. Laser and light based treatments of acne. Indian J Dermatol Venereol Leprol. 2013;79(3):300-9. 6. Lloyd J R MM. Selective photothermolysis of the sebaceous glands for acne treatment. Lasers Surg Med. 2001;31:115-20. 7. Elman M SM, et al. The effective treatment of acne vulgaris by a high-intensity, narrow band 405- 420 nm light source. J Cosmet Laser Ther. 2003;5(2):111-7. 8. Ashkenazi, H., et al., Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light. FEMS Immunol Med Microbiol, 2003. 35(1): p. 17-24. 9. Leyden JJ MK, et al Propionibacterium levels in patients with and without acne vulgaris. J Invest Dermatol 1975. 1975;65(4):382-4 10. Na JI SD. Red light phototherapy alone is effective for acne vulgaris: randomized, single-blinded clinical trial. Dermatol Surg. 2007;33(10):1228-33 11. Seaton ED MP, et al Investigation of the mechanism of action of nonablative pulsed-dye laser therapy in photorejuvenation and inflammatory acne vulgaris. Br J Dermatol. 2006;155(4):748-55. 12. Sami NA AAea. Phototherapy in the treatment of acne vulgaris. J Drugs Dermatol. 2008;7(7):627-32. 13. Baugh WP KW. Nonablative phototherapy for acne vulgaris using the KTP 532 nm laser. Dermatol Surg. 2005;31(10):1290-6. 14. Yilmaz O SN. Evaluation of 532-nm KTP laser treatment efficacy on acne vulgaris with once and twice weekly applications. J Cosmet Laser Ther. 2011;13(6):303-7. 15. Elman M LG. The role of pulsed light and heat energy (LHE) in acne clearance. J Cosmet Laser Ther 2004;6(2):91-5. 16. Boineau D AS, et al Treatment of active acne with an erbium glass (1.54 micron) laser. Lasers Surg Med 2004;16(1):55. 17. Kassir M ND, et al. Er: Glass (1.54 mm) laser for the treatment of facial acne vulgaris. Lasers Surg Med 2004;34:s65. 18. Angel S BD, et al . Treatment of active acne with an Er:Glass (1.54 microm) laser: a 2-year follow- up study. J Cosmet Laser Ther. 2006;8(4):171-6. 19. Bogle MA DJ, et al. Evaluation of the 1,540-nm Erbium:Glass Laser in the Treatment of Inflammatory Facial Acne. Dermatol Surg. 2007;33(7):810-7. 20. Friedman PM JM, et al. . Treatment of inflammatory facial acne vulgaris with the 1450-nm diode laser: a pilot study. Dermatol Surg. 2004;30(2):147-51. 21. Jih MH FPea. The 1450-nm diode laser for facial inflammatory acne vulgaris: dose-response and 12-month follow-up study. J Am Acad Dermatol. 2006;55(1):80-7. 22. Perez-Maldonado A RT, Krejci-Papa N. The 1,450-nm diode laser reduces sebum production in facial skin: a possible mode of action of its effectiveness for the treatment of acne vulgaris. Lasers Surg Med. 2007;39(2):189-92. 23. Laubach HJ AS, et al. . Effects of a 1,450 nm diode laser on facial sebum excretion. Dermatol Surg. 2009;35(8):1181-7. 24. Uebelhoer NS BMea. Comparison of stacked pulses versus double-pass treatments of facial acne with a 1,450-nm laser. Dermatol Surg. 2007;33(5):552-9. 25. Yeung CK SS, et al. Treatment of inflammatory facial acne with 1,450-nm diode laser in type IV to V Asian skin using an optimal combination of laser parameters. J Drugs Dermatol. 2009;8(3):239-41. 26. Bernstein EF. A pilot investigation comparing low-energy, double pass 1,450 nm laser treatment of acne to conventional single-pass, high-energy treatment. Lasers Surg Med. 2007;39(2):193-8. 27. Wang SQ, Counters JT, Flor ME, Zelickson BD. Treatment of inflammatory facial acne with the 1,450 nm diode laser alone versus microdermabrasion plus the 1,450 nm laser: a randomized, split-face trial. Dermatol Surg. 2006;32(2):249-55. 28. Pollock B TD, et al . Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br J Dermatol. 2004;151(3):616-22. 29. Riddle CC, Terrell SN, Menser MB, Aires DJ, Schweiger ES. A review of photodynamic therapy (PDT) for the treatment of acne vulgaris. J Drugs Dermatol. 2009;8:1010-9. 30. Yeung CK SS, et al comparative study of intense pulsed light alone and its combination with photodynamic therapy for the treatment of facial acne in Asian skin.Lasers Surg Med. 2007;39(1):1-6. 31. Rojanamatin J CPT. Treatment of inflammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study. Dermatol Surg. 2006;32(8):991-6. 32. Taub AF. A comparison of intense pulsed light, combination radiofrequency and intense pulsed light, and blue light in photodynamic therapy for acne vulgaris. J Drugs Dermatol. 2007;6:1010-6. 33. Haedersdal M, Togsverd-Bo K, Wiegell SR, Wulf HC. Long-pulsed dye laser versus long-pulsed dye laser-assisted photodynamic therapy for acne vulgaris: A randomized controlled trial. J Am Acad Dermatol 2008;58:387-94. 34. Hongcharu W, Taylor CR, Chang Y, et al. Topical ALA-photodynamic therapy for the treatment of acne vulgaris. JID 2000;115(2):183-92. 35. Goldman MP BS. A single-center study of aminolevulinic acid and 417 NM photodynamic therapy in the treatment of moderate to severe acne vulgaris. J Drugs Dermatol. 2003;2:393-6. 36. Itoh Y NY, et al Photodynamic therapy of acne vulgaris with topical delta-aminolevulinic acid and incoherent light in Japanese patients. Br J Dermatol. 2001;144:575-9. 37. Wiegell SR, Wulf HC. Photodynamic therapy of acne vulgaris using methyl aminolaevulinate: a blinded, randomized, controlled study. Br J Dermatol. 2006; 154 (5):969-76. 38. Horfelt C, Funk J, Frohm-Nilsson M, Wiegleb Edstrom D, Wennberg AM. Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study. Br J Dermatol. 2006; 155(3):608-13. 39. Babilas P, Schreml S, Szeimies RM, Landthaler M. Intense pulsed light (IPL): a review. Lasers Surg Med. 2010;42(2):93-104. 40. Lee EJ LH, et al An open-label, split-face trial evaluating efficacy and safty of photopneumatic therapy for the treatment of acne. Ann Dermatol. 2012;24(3):280. 41. Dierickx CC. Treatment of acne vulgaris with a variable-filtration IPL system. Lasers Surg Med 34(S16):66 (2004). 42. Prieto VG ZPJ. Evaluation of pulsed light and radiofrequency combined for the treatment of acne vulgaris with histologic analysis of facial skin biopsies. J Cosmet Laser Ther. 2005;7(2):63-8. 43. Shamban AT EM, et al Photopneumatic technology for the treatment of acne vulgaris. J Drugs Dermatol. 2008;7(2):139-45. 44. Omi T MG, et al .Ultrastructural evidence for thermal injury to pilosebaceous units during the treatment of acne using photopneumatic (PPX) therapy. J Cosmet Laser Ther. 2008;10(1):7-11. 45. Gold M, Biron J. Efficacy of a novel combination of pneumatic energy and broadband light for the treatment of acne. J Drugs Dermatol. 2008;7:639:42. 46. Waniphakdeedecha R, Tanzi E, Alster T. Photopneumatic therapy for the treatment of acne. J Drugs Dermatol. 2009;8:239–41. 47. Narurkar VA, Gold M, Shamban AT. Photopneumatic technology used in combination with profusion therapy for the treatment of acne. J Clin Aesth Derm. 2013;6(91):36-40.

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25 years in aesthetics Aesthetics editor, Amanda Cameron, reflects on 25 years of medical aesthetics with industry pioneers Dr Tracy Mountford and Dr Patrick Bowler I first started working in the aesthetic medical market in 1989 when, apart from surgery, chemical peels and some lasers, there was only one injectable for wrinkle correction – bovine collagen. Whilst I worked for Collagen Corporation as a sales and training manager, I met innovators who were moving into the world of non-surgical rejuvenation. At the time it was deemed as a significant move away from other medical specialities. I soon became used to dealing with questions from those who found injecting a substance into the face – for what appeared to be reasons of vanity – a very strange subject. Reflecting on the number of products and services available to improve the appearance of the face and body, the number of practitioners offering those services, as well as the number of companies involved in the manufacturing and distribution of aesthetic products, it is clear that the industry has come a long way in the past 25 years. In those early days, two of my first customers were Dr Tracy Mountford and Dr Patrick Bowler, who I am delighted to say remain my friends today. They saw the potential of the market and worked hard to gain the knowledge and skills required to practise aesthetics. I need not tell you about the success they have achieved, as I am sure that most of you will know them well! Patrick is the founder of Courthouse Clinics (now a chain of 11 clinics nationwide), whilst Tracy is the founder of The Cosmetic Skin Clinic and is about to open her second in London later this year. Patrick also founded the British College of Aesthetic Medicine (BCAM), formerly the British Association of Cosmetic Doctors (BACD), which was the first non-surgical professional group for doctors working in this field. I am delighted that they have both managed to take some time out of their busy schedules to catch up and reflect on the changes we have seen within the industry in the last 25 years. Both Dr Bowler and Dr Mountford agree that patients’ perceptions of aesthetics have evolved significantly since 1989. “Initially it was challenging trying to communicate to people what these treatments involved,” explains Dr Bowler. “When Botox was 34

launched it was like trying to persuade patients that we wanted to inject a poison into them. Now though, patients come in and say ‘I want Botox’, rather than, ‘Is it going to cause me any harm?’” Dr Mountford agrees, saying, “They are more aware of what is available and have become ‘mini experts’ – sometimes rightly, sometimes wrongly.” Both argue that the internet and celebrity culture has had an influence on patients’ increased knowledge. “The internet is a double-edged sword, as patients can be well informed but can also interpret information inappropriately,” explains Dr Bowler. He advises that offering a thorough consultation before procedures will better inform patients and ensures that they have realistic expectations of results. “Managing expectations is a priority in our clinics, as I’m sure it is with most practitioners,” he says. “It’s a continuous reinforcement through our consultations to make sure we don’t end up with disappointed patients.” Patient demographics have also noticeably evolved since the aesthetics industry began. “When we first started we barely ever saw a man from one year to the next,” explains Dr Bowler. “Within the last five years there has been a big increase in the numbers of men we see.” In addition to this, it seems patients are getting younger. Dr Bowler says, “There has been a noticeable shift towards younger patients and, these days, it seems patients are more concerned about maintenance of looks rather than reversing the signs of ageing.” Courthouse Clinic statistics reveal that laser hair removal is particularly popular with younger women. He suggests that the rise in social media over the last five years has had a significant impact on their demographics. Dr Bowler does admit that, although he hasn’t seen any official statistics, he has noticed a rise in patients suffering from body dysmorphic disorder (BDD). “There seems to be more young women in that group rather than our usual patient demographic of 40-50 year olds,” he says. He does note, however, that we are a lot better equipped to recognise and deal with the problem than we were 25 years ago. “Whatever treatment we offer will make no difference to their perception of themselves. We are able, however, to refer them to a psychologist to help treat their issues.” With so many new technologies available, Dr Mountford believes it is little wonder that practitioners are achieving continually improving results. She says, “Treatments are more refined with a more comfortable experience for the patient; we can now sculpt, contour or rejuvenate parts of the body we couldn’t have dreamed of nonsurgically 25 years ago.” Being aware of which products are worth purchasing is also essential to running a successful practice. “This just comes down to

Aesthetics | December 2014

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Clinical Focus 25 Years in Aesthetics

“There has been a noticeable shift towards younger patients and, these days, it seems patients are more concerned about maintenance of looks rather than reversing the signs of ageing” experience,” says Dr Mountford. “You should watch how a product or technology develops in the market place before jumping on the bandwagon. Generally speaking, using only FDA approved products is crucial to this.” She adds, “I always say, ‘new does not always mean better.’” With the advent of new treatments and technologies, along with high quality consultations and injectable products, the financial side of business has also improved, says Dr Mountford. “Some patients may save £10 a week to finance their treatment, whilst others have unlimited budgets. The average spend has gone up significantly.” Some would argue that working in aesthetics in 2014 comes with new challenges that weren’t necessarily around in 1989. As the market grows, there has obviously been an increase in other practitioners opening clinics. However, Dr Mountford advises, “By remaining focused on the practice and patients’ needs and not looking sideways at potential competitors, you can fend off any competition.” Discussing regulation within aesthetics, both agree, as many others do, that the industry is not monitored as well as it should be. “The Keogh Report and its findings should be very useful to help clarify what is appropriate best practise,” says Dr Mountford. “I would, however, have expected more legislation to be in place by now.” Dr Bowler says, “I am uncomfortable with beauty therapists being able to give injection treatments, which may well happen if the current educational framework from HEE gets implemented. In the European Union, the idea of beauty therapists giving Botox injections is laughable.” On a more positive note, however, Dr Mountford adds, “All we can do is forge forward with our own self-regulation, and help to educate the public further.” Educating the public is important to both practitioners, and Dr Mountford often takes up PR and television opportunities. “They are useful as they can help educate the public in some way,” she explains. “I always view them with a healthy degree of caution and only tend to give interviews to journalists who I respect, to ensure that I give the

T H E A R T O F FA C I A L R E J U V E N AT I O N

public the right message.” Continued aesthetic training is also vital to the pair, with both explaining that they regularly attend lectures and conferences to keep up-to-date with all of the scientific developments. “We are lucky now as we have training updates on site for all the team,” says Dr Mountford. Reflecting on their quarter of a century working in aesthetics, I wonder if my colleagues have any regrets. Dr Mountford says, quite simply, no she doesn’t, but Dr Bowler notes that, looking back, he would have got more involved in the politics of aesthetics. “My only real regret is that I wasn’t strong enough when I was in the BACD.” He explains that he would have pushed the General Medical Council (GMC) harder to implement tighter regulation and stress its importance to create a safer industry. “At the time though, there wasn’t enough interest,” he says. “Now there is a much bigger interest. I look at how well the nurses and the beauticians have organised themselves and think the doctors have been a little bit slow on the uptake.” Entering the world of medical aesthetics is challenging for any practitioner, whether it was 25 years ago when the industry was unknown to patients and bovine collagen was the only product on the market, or today, when patient awareness and product development is at the highest level we have seen it. Either way, advice for newcomers remains the same. “Start small and hone your craft,” says Dr Mountford. “If you are good, patients will come. Keep your level of training high, regularly attend conferences and share with colleagues ideas and concepts regarding best practise.” For Dr Bowler, having excellent business acumen is also essential. “The impression that some newcomers have is that it is an easy revenue generator. A small clinic run from home premises can be profitable but, if you start to grow your business by expanding and moving to new premises, your overheads and staffing levels will increase, which can be a game changer.” He explains that the jump from working in an aesthetic clinic to opening your own clinic is also a big hurdle. “Quite a few businesses fail because they underestimate the running costs and the importance of marketing. My advice is, whilst clinical education and training is very important, it needs to be accompanied by strong business skills, which are vitally important if you want to be successful.” Dr Mountford concludes, “It’s a tough, highly competitive industry, but the rewards are there if you are truly passionate about your craft and truly love enriching people’s lives.”

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Eyelash and Eyebrow Growth Michelle Washington reveals the science behind eyelash and eyebrow serums Throughout history, eyelashes and eyebrows have been at the forefront of our concept of beauty. In modern times, the beautification of the eye area is as popular as ever. Trends in the shape and style of eyelashes and eyebrows have changed significantly over the decades, from the Marlene Dietrich skyscraper arches to the Cara Delevingne power brows. Despite this, long lashes and strong eyebrows have remained an intrinsic factor to many patients’ perceived idea of femininity and attractiveness, as well as playing an important role in improving their overall confidence. Practitioners continue to hear patients bemoan the fact that their brows and lashes no longer give them the ‘wow’ factor. Age, hormones, illness, stress and genetics all influence the growth and density of lashes and brows, while some patients suffer from madarosis, the clinical loss of eyelashes and eyebrows,1 which can have a range of causes that include the menopause and systemic disorders such as hypothyroidism, lupus and alopecia areata.1 Options for artificially improving the appearance of lashes and brows include: tinting, micro pigmentation, fake eyelashes, fibres, mascara and eyelash extensions.

In extreme cases eyelash transplantation surgery is undertaken, which involves follicles being taken from the back of the scalp and implanted into the lid margin. Artificial enhancements are not everyone’s first choice of treatment, for a variety of reasons. In the case of surgery, the hair resulting from implanted follicles needs maintenance and is cost prohibitive to a lot of people, with significant risks involved.2 Similarly, the use of eyelash extensions has fallen because users have reported undesirable side effects after lengthy use.3 Since the development of glaucoma eye drops in 2001, patients and practitioners have reported, anecdotally, that a side effect of glaucoma treatment is an increased thickness, darkening and lengthening of the lashes. It was found that the key ingredient promoting the side effect of thicker, longer lashes was the Prostaglandin analogue (PG) Bimatoprost. There are different types of PGs used clinically, but those with the index F2 have captured the attention of lash serum manufacturers.4 Given consumers’ desire for long, natural lashes, Over The Counter (OTC) preparations were developed. In 2003, The Dermatology Online Journal published a paper, ‘Prostaglandin analogs (PGs) for hair growth: Great Expectations’5 Aesthetics | December 2014

Treatment Focus Eyelashes and Eyebrows

anticipating the growth of OTC products in the cosmetic industry. In my experience, I have noticed a significant increase in OTC eyelash conditioning serums since 2005. Since then, cost barriers have reduced and, from my experience, it seems that many women now regard them as mandatory items within their daily grooming products. In 2012, the estimated revenue of the whole US cosmetic market was $54.89 billion5 and, with the advent of internet-based cosmetic companies, this is anticipated to increase even more.6 PG’s are hormonelike lipid compounds, which work locally as messengers between cells stimulating eyelash growth on the lid line. Testing of PGs for eyelash growth has been undertaken in both animals7 and humans8 showing the efficacy for hyportrichosis. Some countries, such as Sweden and Australia regard all PGs as medicines, thus they are banned from OTC preparations.9 Incidentally, research undertaken in Sweden in 2013 found that some manufacturers were not declaring the inclusion of a PG as an ingredient.9 Nowadays, consumers have a huge choice of OTC products to choose from with a price range that varies just as widely. Commercially available serums fall into two basic categories: those with PGs and those without. The only Food and Drug Administration (FDA) approved PG for eyelash growth is Bimatoprost, attained in

Since the development of glaucoma eye drops in 2001, patients and practitioners have reported, anecdotally, that a side effect of glaucoma treatment is an increased thickness, darkening and lengthening of the lashes 37

Treatment Focus Eyelashes and Eyebrows

LiLash Set 1 before

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LiLash Set 2 before

LiBrow Set 1 before

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LiLash Set 2 after

Images courtesy of Dr S Wasserman

2008 following clinical trials.10 The common practice nowadays is for manufacturers to use non-prescription PGs, in conjunction with additional ingredients (e.g. peptides, vitamins, conditioning agents and minerals) as part of OTC formulations, to assist in the conditioning of the newly formed hair. Many of these OTC growth serums are not subject to FDA premarket approval and the strict regulations of pharmacological assessment and, as a result, it could be considered that their efficacy remains to be clinically substantiated. The OTC products are not marketed as growth serums and avoid government regulatory agencies. Instead they are marketed as conditioning serums and thus, treated as cosmetics. It’s important to understand that the eyelash and eyebrow follicle cycle differs from scalp hairs; the anagen phase is significantly shorter, with a longer telogen phase. The PG works to extend the growth cycle of the lash follicle and is believed to increase the percentage of active follicles. Daily application of growth/conditioning serums is typically recommended throughout the active growth phase, followed by a maintenance dosage to preserve the results. Typically, the application of a maintenance dosage would be every other day. Some products require new sterile applicators daily. In my experience, this is to preserve the integrity of the solution. The majority of OTC serums, however, are applied in the same method as liquid eyeliner. There

are also a number of potential risks associated with the use of PGs, which include, but are not limited to, ocular irritation, hyperemia, iris colour change, macular edema, ocular inflammation, hyperpigmentation of the iris and lash line, erythema, contact dermatitis, dry eye, fungal infections, and interference with glaucoma therapy.11 In addition, PGs for ophthalmic use are currently classified as Pregnancy Class C. This classification means that there have been no human studies of the drug, but that animal studies have revealed some potential abnormalities.11 When consulting patients in the use of these products, following manufacturers’ instructions is of the upmost importance. Common safety guidelines include: application to clean dry skin, do not overdose, do not use on broken or irritated tissue, and avoid cross contamination with makeup and facial products. It is also important to increase awareness amongst consumers of counterfeit products, with unknown manufacturing standards and potential issues. In summary, eyelash and eyebrow conditioning serums containing PGs are more likely to give patients visible results compared to those serums containing purely vitamins and conditioners. For safety reasons I believe that these products should be purchased from reputable clinics where you should provide a consultation and address potential side effects. Patients can then have their expectations managed accordingly

For safety reasons I believe that these products should be purchased from reputable clinics where you should provide a consultation and address potential side effects. 38

Aesthetics | December 2014

and enjoy the experience of thicker, longer lashes and brows. Overall, we find that improved eyelashes and eyebrows can be a highly enjoyable and safe experience for most patients. Michelle Washington trained as a skincare specialist in New Zealand, before opening a clinic in Auckland. Her interest in hair loss solutions began after treating patients suffering from mandarosis. After conducting extensive research and working alongside aesthetic practitioners, Michelle is now a business development manager for hair growth products, based in New Zealand and the Middle East. REFERENCES 1. A Kumar, and K Karthikeyan, ‘Madarosis: A marker of many Maladies’, International Journal of Trichology, 4 (2012) http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3358936/[accessed 2 October 2014] (p.3-18). 2. M Dalton, Eyelash Transplant Surgery Poses Serious Risks (US: Eyeworld, 2007) http://www.eyeworld.org/article.php?sid=3786 [accessed 2 October 2014] 3. O Avitzur, Eyelash extensions can pose health risks (US: Consumer Reports, 2013) http://www.consumerreports.org/ cro/2013/05/eyelash-extensions-can-pose-health-risks/index. htm. [accessed 7 September 2014] 4. K Kamal, A Mubarak, A review of prostaglandin analogs in the management of patients with pulmonary arterial hypertension (Science Direct, 2014) http://wwwsciencedirect.com/science/ article/pii/S0954611109002479 [accessed 2 October 2014] 5. R Wolf, H Matz, M Zalish, A Pollack, E Orion, ‘Prostaglandin analogs for hair growth: Great expectations’, Dermatology Online Journal, 9 (2003) http://escholarship. org/uc/item/4hz1f3rr [accessed 4 September 2014] 6. Statistics and facts on the cosmetic industry (US: The Statistics Portal, 2013) http://www.statista.com/topics/1008/cosmetics- industry/ [accessed 5 September 2014] 7. AT Giannico, L Lima, H Russ, F Montiani-Ferreira, Eyelash growinduced by topical prostaglandin analogues, bimatoprost, tafluprost, travoprost, and latanoprost in rabbits (US: National Library of Medicine National Institutes of Health, 2013) http:// www.ncbi.nlm.nih.gov/pubmed/23981234 [accessed 5 September 2014] 8. K Beer, Latisse (Bimatoprost .03% Opthalmic Solution) for the treatment of hypotrichosis of the eyebrows: Latisse versus placebo (US: Clinical Trials, 2012) http://clinicaltrials.gov/show/ NCT01387906 [accessed 5 September 2014] 9. Pharmaceutical ingredients in one out of three eyelash serums (Sweden: Lakemedelsverket Medical Products Agency, 2013) http://www.lakemedelsverket.se/english/ All- news/NYHETER-2013/Pharmaceutical-ingredients-in-one- out-of-three-eyelash-serums/ [accessed 5 September 2014] 10. Drugs development approval process (US: FDA, 2012) www. fda.gov/downloads/drugs/developmentapprovalprocess/ developementresources/usm415322.pdf [accessed 1 October] 11. EducatedEsty, ‘Déja Vu all over again for prostaglandin based eyelash growth serum’, www.educatedesthetician.com (2011) http://educatedesthetician.com/2011/04/deja-vu-all-over-again- for-prostaglandin-based-eyelash-growth-serum/ [accessed 5 September 2014]

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Injectable delivery systems Ruth Donnelly speaks to aesthetic practitioners about their preferred injectable delivery tools

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2011. Consisting of a control unit with a foot pedal and four colour-coded syringe handpieces, which attach to the control unit via a lead, the system uses carbon dioxide to apply a more consistent pressure than can be achieved by hand alone, and claims to offer improved injection control with reduced hand fatigue for the practitioner. Dr Martyn King, co-founder of the Cosmedic Skin Clinic, has been using the Artiste system in his practice and says, “People get better results with this system and less pain, because it injects slowly, which sends out fewer pain receptors, and you can inject very small, consistent amounts so there’s less risk of causing lumps.” Dr King also offers injectable training courses and has found the system to be of great help in demonstrating the ideal injection flow. “If you get people to inject onto a piece of card to try and create one line of the same thickness all the way down, even with quite experienced injectors the line will get thicker and thinner, which is to do with how hard they press and how quickly they move their hand,” he explains, “whereas with the Artiste, you get a nice, consistent flow.” Mr Humzah agrees to a point, and says, “The Artiste is a good system and occasionally I still use it, but it’s cumbersome loading it up. The new systems are more portable, which is better for the cosmetic world.”

Injectables have come a long way since collagen injections were first used in the 1970s, and it’s not just the products themselves that have changed; injection techniques and the devices we use to administer treatments are evolving all the time. Syringes have been adapted to become more comfortable for the practitioner to use and now produce a smoother flow and, more recently, automated systems that assist in the injection process itself have become available. “The fillers are all different now, with different properties, so the pressure you use when injecting has to be adjusted accordingly,” says consultant plastic surgeon, Mr Dalvi Humzah. “I think that’s what has led to the development of these mechanically-aided delivery systems. They started off as rather cumbersome machines, but they did seem to work and were particularly good for delivering in large volumes, which I do a lot of in my reconstructive work.”

The U225 Mesogun Artiste In the short time that these systems have been available in the UK, even these have seen great change. The Artiste Controlled Injection System, from Nordson Micromedics, was launched in the UK and parts of the US in May 40

Aesthetics | December 2014

The Frenchmade U225 Mesogun is one example of these more portable devices. It has been available in the UK for longer than Artiste, and is really only suitable for mesotherapy, rather

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than filler injection. Using pneumatic pressure generated by an air compressor, the U225 has two basic modes: continuous injection or intermittent injection. In intermittent mode, the user can vary the frequency, from one injection every three seconds to 300 per minute. Independent nurse prescriber, Ros Bown, founder and CEO of the Rosmetics clinic chain, favours the U225 gun for mesotherapy, claiming that it is, “easy to set up and operate, allowing me to use many different products, including non-cross-linked hyaluronic acid, mesotherapy products, multivitamins, platelet rich plasma (PRP) and even botulinum toxin for hyperhidrosis.” Dr Jamshed Masani, founder of the Mayfair Practice, has been using the mesogun since 2007 and says he bought it because, “it was well designed, it was pain free owing to the design of the device (no vibration) and the special 32G needle it uses.”

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Dr Linda Eve, founder of EvenLines in Dorset, has been impressed. “The new SmartClick syringes offer increased precision and control of injections,” she says. “A micro-droplet, 10µL in size, is produced with every subtle click of the syringe, and this helps the injector spread the product across a wider area and allows you to concentrate on your injection technique, rather than worrying about the amount of product you are injecting. The 1ml syringe delivers approximately 100 doses of micro-droplets, and yet the syringe can very easily be switched back to normal injection mode with needles or cannulas – thus giving the injector a choice of techniques.”

The TSK 3dose syringe

Aquagold fine touch Another mesotherapy delivery system, Aquagold fine touch, is a single-use microneedle applicator that delivers product to the dermis through 20, 0.6mm long, 0.13mm wide, microneedles. Dr Steven Fagien, an ophthalmologist and aesthetic practitioner based in Florida, has found the device to be useful in tackling the issues associated with mesotherapy. “Previously, many practitioners who administered this sort of treatment used standard needles to deliver multiple injections to the skin. This can be painful and time consuming, whereas a delivery device that can deliver many injections at once can accomplish mesotherapy treatment in a very efficient and acceptable manner.” Unlike the U225, Aquagold is not a pneumatically-powered device, but rather a disposable applicator. It contains a reservoir that can be filled with the substance of your choice – Fagien favours vitamins, or microquantities of botulinum toxin or hyaluronic acid – and is then applied gently to the surface of the skin, “much like a rubber stamp on paper,” he explains.

Restylane Skinboosters SmartClick Not so much a filler as a skin hydration therapy, Restylane Skinboosters treatments – Restylane Vital and Vital Light – are microinjections of hyaluronic acid, delivered at a precise point in the dermis with the aim of reducing the appearance of lines and improving skin texture. The SmartClick system, which recently won the prestigious Red Dot design award, is an ergonomically designed syringe with an audible dosage indicator, which when activated generates a clicking sound. The sound is automatically generated during the injection as a metallic plate is pressed over grooves on the surface of the plastic piston. 42

TSK Laboratories launched its 3dose syringe, specifically designed for botulinum toxin injections, at the Aesthetic and Anti-Aging Medicine World Congress (AMWC) 2014 meeting in Monaco. Similarly to the Restylane SmartClick system, the 3dose syringe has an adjustable clicker system, which provides a precise dose injection of 0.025ml, 0.04ml or 0.05ml. Each syringe comes packed with two 33G 13mm needles, which are 22% thinner than a standard 30G needle and aim to reduce discomfort for patients. Dr King, who has used the syringes, says, “The TSK syringes are very nice, I like them. You can tell when you are using a quality needle, compared to a cheaper one.”

Teosyal Pen Not yet available in the UK, Teoxane laboratories have recently bought the rights to the Teosyal Pen from JuvaPlus, a motorised, cordless device. It has an adjustable flow speed and the choice of small, medium or large drops, which the manufacturers claim optimises product use, increases precision and ease of application, and produces a more natural result than manual injection alone. Dr Sabine Zenker, a dermatologist in Munich, Germany, has used the Teosyal Pen in her clinic. “I am always curious about developing and discovering new approaches, new ideas, new ways and the best methods to develop my skills and improve my work,” says Dr Zenker. “It is important for me to always serve my patients at my very best. This means reducing side effects such as pain and swelling and increasing precision and quality. In using filler delivery systems [such as the Teosyal Pen], I have experienced a clear improvement in the overall aesthetic outcome.”

Aesthetics | December 2014

“If you’re going to go down the route of these mechanical devices there is going to have to be some kind of standardisation”

mct injector

Delivery systems versus manual injection If filler delivery systems continue to improve at the current rate, are we likely to enter a world where cosmetic injections are administered by machine, while practitioners sit back and watch? According to those we spoke to, probably not. Whilst they all agree that delivery systems have a place in aesthetic practice, there are reservations. Independent nurse prescriber, Andrew Rankin, owner of Regenix Medical Aesthetics Clinic in Malvern, has his concerns. “Any system that provides a level of control which can minimise bruising and pain, thus enhancing the patient experience, has evident value. However, no system can remove the need for correct product placement, particularly in terms of depth, and it is important not to lose sight of this as a priority when learning about dermal fillers,” Rankin warns. “Further, when the clinician is new to dermal fillers, I believe it is necessary for them to develop a feel for the filler that they are using. To my mind, therefore, a dermal filler delivery system is something of use to the more experienced practitioner, rather than something which may be relied on by the novice.” Mr Humzah’s worry is that filler manufacturers will use these devices to hold their customers to ransom. “If you’re going to go down the route of these mechanical devices there is going to have to be some kind of standardisation, otherwise all the filler companies will bring out new delivery systems specific to their particular syringe,” he asserts. “As a sector we should be saying, we’re not going to tolerate this. It’s great having these things, but it is a delivery system and not a right of a particular product or brand.”

What does the future hold? In terms of the ideal, Dr King would like to see a device that is semiautomated, “so you could choose to either inject yourself, or get the machine to do it for you,” which, in his opinion, would resolve some of the issues mooted by Rankin. Mr Humzah has his own blueprint for the perfect injection system. He says, “In the future what I’d really like to see is one or two ergonomically designed devices into which a filler could fit in like a dental cartridge, where you have a fixed syringe and you just drop the cartridge in, then you would be able to choose the needle or cannula, screw it onto the body of the syringe, then use the machine to gradually inject it at the right pressure.” He continues, “And all that would come in a small, handheld, battery-powered unit, without leads trailing. It would be very cost effective for the filler companies, because they could just produce cartridges, without the cost of producing syringes.” It seems that there is still room for improvement in the world of assisted injection, but with new devices being released at a rapid rate (and if aesthetic practitioners do take a stand in favour of standardisation), it might not be long before Mr Humzah’s dream becomes a reality.

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Techniques Hand Rejuventation

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Hand rejuvenation Dr Carolyn Berry considers rejuvenation techniques for the ageing hand Hands are exposed, both to the elements and to public scrutiny, and their appearance often reflects how well they have been cared for, as well as the general lifestyle of their owner. Nowadays, it seems that we are entering an era of hand rejuvenation and, in my experience, patient demand for treatment is increasing. This could be because we are dealing with a more informed population, as patients are now able to research potential treatments online and read about their results in the media. Facial rejuvenation is considered by aesthetic practitioners to be very successful, however this is difficult to evaluate.1 Patients realise that they no longer have to endure hands that look older than their face. As aesthetic practitioners, for a holistic approach, it is important to take the ageing hand into consideration and assess how best to achieve patients’ desired results. The skin on hands, like skin elsewhere on the body, undergoes both intrinsic and extrinsic ageing. Extrinsic ageing is caused by environmental factors such as sun exposure, chemicals and smoking. This will affect the epidermis and dermal layers leading to uneven pigmentation, solar lentigines, actinic keratosis, punctate hypopigmentation and solar purpura. Intrinsic ageing is affected by genetics and nutrition, also by disease processes such as diabetes, peripheral arterial occlusive disease, autoimmune disorders and medication, including chemotherapy. The capillary microcirculation of the dorsal hand differs between healthy individuals and those of the same age with diabetes or PAOD,2 hence why taking a full medical history is of paramount importance. Intrinsic changes alter the deeper soft tissue planes, decreasing skin elasticity, loss of the subcutaneous tissue (dermal and fat atrophy) and dermal vascularity. The skin becomes paper-like and thin, whilst veins become more prominent. Distal pip joints swell and tendons become more apparent. Hand ageing can be graded in a five point system. Carruthers et al published a validated grading scale for assessment of the ageing hands,3 whilst others use the Busso hand volume severity scale.4

It is important to take the ageing hand into consideration and assess how best to achieve patients’ desired results 44

If we address the patient’s concerns, we will get the best patient satisfaction rates. According to one study, 5 it seems that patients are most concerned by prominent veins and view these as the most ageing feature of hands. Therefore, I would suggest that reducing the appearance of veins should form part of the treatment plan. Treating the veins directly, or altering the soft tissue volume around them, can alter their appearance and make them less prominent. Treating the veins of the hand with sclerotherapy (the injection of an irritant liquid which causes vein walls to inflame and stick together) requires a higher concentration of sclerosing agents than is used for leg veins and often results in a tender phlebitis cord. Another option to consider is phlebectomy (the surgical removal of veins). Studies have investigated an endovenous laser technique (introduction of a laser probe into the vein) to abolish unwanted hand veins.6 All patients were satisfied with the outcome but there were adverse events including the swelling of hands for two weeks and one case of skin burn. Rejuvenation of hands should be considered as a successful reversing of the three-dimensional process of ageing.7 Hand ageing is a three dimensional process that involves osseous and subcutaneous structures as well as the skin. Often only one modality of treatment is considered and this will seriously limit the outcome. Hand anatomy is of paramount importance when considering treatment. Bidic et al studied 10 fresh cadaveric hands.8 Specimens were evaluated microscopically after histologic staining. They also used Doppler ultrasound on eight living hands to explore lamination of the dorsal hand fat. They showed three distinct fatty laminae separated by thin fascia. The large dorsal veins and dorsal sensory nerves resided within the intermediate lamina. The extensor tendons were found in the deep lamina. Eight to 10 perforating vessels travel within fascial septae traversing the laminae. In my opinion, consideration of this may improve results of treatment. In my experience, patients have previously been concerned with extrinsic ageing, complaining of pigment changes and age spots in particular and have often requested laser treatments to remove pigment spots. A common theme is that they know that they don’t like the look of their hands but they don’t know how to correct it. As practitioners, we have responded by treating hands with chemical peels, microdermabrasion, tretinoin, IPL and 5- fluorouracil. Intense pulsed light (IPL) has also been used very successfully to treat extrinsic ageing, showing excellent results in treating solar lentigines and improving skin quality.9 In Goldman et al’s study, patients were treated with four IPL sessions at three to four week intervals. There was a very high patient satisfaction with no significant side effects. Various lasers have been used to improve skin quality, including

Aesthetics | December 2014

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Techniques Hand Rejuventation

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CO2 fractional laser and 1320-nm Nd:Yag. Sadick et al showed an improvement with Nd:Yag,10 but they were only able to show mild to moderate improvement and one could argue that this is insufficient to make it a treatment of choice. Plasma skin regeneration has shown promising results on the face and many patients favour this type of less invasive treatment. Alster et al evaluated face, chest and hands treated with PMR and discovered clinical improvements of 57%, 48% and 41% respectively. There was significant reduction in wrinkle severity and hyperpigmentation, with increased skin smoothness.11 Volume restoration dramatically improves the appearance of the ageing hand by minimising the appearance of veins. A method favoured by surgeons is autologous fat injections, where fat is harvested and then injected into the hands. The fat is generally taken from the abdomen or thighs. This is an invasive procedure but can be combined with liposuction at the patient’s request. If fat is centrifuged, this is associated with better results.12 Giunta et al studied fat grafting with 3D surface laser scanning, which permits evaluation of the permanent volume over time and were able to show 69% of initial fat volume was present at six months, and this seems to be the amount integrated as a graft.13 Another method of treatment involves using hyaluronic acid (HA). The ageing process results in depletion of endogenous HA, which has an important role in the dermal extracellular matrix for hydration, biomechanical integrity and oxidative stress protection.14,15 Crosslinked HA is not degraded as quickly as native HA and has been shown to enhance the production of collagen.16 Native HAs will increase the thickness of dermis but don’t last as long. Biphasic HA needs to be injected sub-dermally to prevent the Tyndall effect, a preferential scattering of blue light, giving a bluish appearance. One has to treat the very aged hand, with thin and papery skin, with great care, as it is less forgiving of a poor technique. Adverse events can include papule development, which are hard, circumscribed, elevated skin lesions. Hyaluronic acid fillers have been favourably compared to collagen.17 Calcium hydroxyapatite (CaHa) has become popular for the treatment of hands in recent years, with considerable success. The volume of CaHa injected, as well as the amount of lidocaine used for the mixture, varies according to the practitioner’s preference.18 It can also be injected with lidocaine as a bolus technique. In one study, at 12 months post-procedure, 60% of subjects rated their results as “satisfactory” or “better”.19 The opacity of CaHa blends well with the skin and conceals veins and tendons. Long-lasting results may be attributed to the neocollagenesis, which in laboratory studies

Before

Aesthetics Journal

Aesthetics

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continued up to 72 weeks.18 Another option for treatment is poly-l-lactic acid (PLA), which can be successfully used to rejuvenate hands. It requires careful patient selection as they will need multiple injections and several treatments. Results cannot be appreciated immediately but can last up to 24 months.21 In a study of three clinical practices using PLA, no papules or nodules were reported.19 Patients were very satisfied with the results and experienced only minor adverse events such as bruising, swelling and pain. One author,22 recommends it for patients requesting longer lasting results. The results by Redaelli et al were evaluated by a definitive graduated score (1 to 10) and ranged from 4 to 9 (av 6.55).23 There was one case of unnoticeable nodulations. Nodules can be minimised by using 7mls of diluent per PLA bottle and massaging daily for one month post-treatment. Polycaprolactone (PCL) is a relatively new treatment emerging at the moment. This consists of microspheres suspended in an aqueous carboxymethylcellulose gel carrier. Due to the gel carrier, there is an immediate volume replacement and improved appearance. The gel carrier is gradually resorbed by macrophages over a period of several weeks. The smooth PCL microspheres stimulate neocollagenesis to replace the carrier. The PCL microspheres become coated with a monolayer of macrophages and a scaffold of new collagen. The PCL microspheres are bioresorbed into non-toxic degradation products and excreted into CO2 and H2O. Satisfaction among patients has been high in studies, 24 and rated as 82% at 24 weeks, with 88% of patients saying they would be likely to return for repeat treatments. Some patients may opt for surgical intervention. This is particularly beneficial if a patient has a lot of excess skin on the dorsum of their hands. One option is a minimal-scar hand lift.25 This technique limits scar size and visibility by locating the incision in a unique position on the ulnar side of the dorsum of the hand. This involves skin flap advancement and rotation and can be performed under local anaesthesia and sedation. Satisfaction amongst patients was high in the study cited. It would appear that the treatment selected would depend very much on the individual patient’s requirements. It is very advantageous and cost effective for the patient to select a treatment that will provide them with both volume restoration and neocollagenesis. Maintenance has to be part of the regime; very few patients will think of applying SPF to their hands. Patients who are treated for pigmentation need to be counselled that if they do not protect hands in the sun, their pigmentation will return. Some feel staying out of the sun and using high SPF is too high a price to pay and will opt for volume restoration

After

Aesthetics | December 2014

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Aesthetics Journal

and live with their pigment spots. So what does the future hold? We need studies to compare modes of volume restoration, for efficacy, and for length of action. The message to use high factor sun cream on the face is gradually getting through to patients, but they have, as yet, to care in the same way for the rest of their body. I find it amazing that patients would rather have solar lentigines than give up a tan, particularly when the bottled tans are so good. Neocollagenesis seems to be of key importance but I am extremely interested to follow the mixing of growth factors with platelet rich plasma and we need to see more research conducted in this area. Dr Carolyn Berry is the medical director and founder of Firvale Clinic in Southampton. She completed her medical training at Queens University, Belfast, before working as a general practitioner. With a keen interest in aesthetics she founded her clinic in 2008 and now splits her time between both specialties.

Aesthetics

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Techniques Hand Rejuventation

REFERENCES 1. Kosowski et al, ‘A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation’, Plastic Reconstructive Surgery Journal, 123 (2009), 1819-27. 2. Kraemar R, Kabbani M, Sorg H, Herold C, Branski L, Vogt PM, Knobloch K, ‘Diabetes and peripheral arterial occlusive disease impair the cutaneous tissue oxygenation in dorsal hand microcirculation of elderly adults:implications for hand rejuvenation’, Dermatol Surg, 38 (2012), 1136-42. 3. Carruthers A, Carruthers J, Hardas B, ‘A validated hand grading scale’, Dermatol Surg, 34(suppl 2), (2008), s179-s183. 4. Busso M, Moers-Carpi M, Storck R, ‘Multicenter, randomized trial assessing the effectiveness and safety of calcium hydroxyapatite for hand rejuvenation’, Dermatol Surg, 36 (2010), 790-797. 5. Bainss RD, Thorpe H, Southern S,, ‘Hand aging: patients opinions’, Plast Reconst Surg, 117(7), (Jun 2006), 2212-8. 6. Shamma AR, Guy RJ, ‘Laser ablation of unwanted hand veins’, Plast Reconstr Surg, 120(7), (2007 Dec), 2017-8. 7. Jakubietz RG, Kloss DF, Guenert JG, Jakubietz MG, ‘The ageing hand. A study to evaluate the chronological ageing process of the hand’, J Plastic Reconstr Aesthet Surg, 61(6), (2008 Jun), 681-6. 8. Bidic SM, Hatef DA, Rohrich RJ, ‘Dorsal hand anatomy relevant to volumetric rejuvenation’, Plast Reconstr Surg, 126(1), (2010 Jul), 163-8. 9. Goldman A,Prati C, Rossato F, ‘Hand rejuvenation using intense pulsed light’, J Cutan Med Surg, 12(3), (2008 May-Jun), 107-13. 10. Sadick N, Schecter AK, ‘Utilization of the 1320-nm:Yag laser for the reduction of photoaging of the hands’, Dermatol Surg, 30(8), (2004 Aug), 1140-4. 11. Alster TS, Kanda S, ‘Plasma skin resurfacing for regeneration of neck, chest and hands:investigation of a novel device’, Dermatol Surg, 33(11), (2007 Nov), 1315-21. 12. Butterwick KJ, ‘Rejuvenation of the aging hand’, Dermatol Clin, 23, (2005), 515-27. 13. Giunta RE, Eder M, Machens HG, Muller DF, Kovacs L, ‘Structural fat grafting for rejuvenation of the dorsum of the hand’, Handchir Mikrochir Plast Chir, 42(2), (2010 Apr), 143-7. 14. Presti D, Scott JE, ‘Hyaluronan-mediated protective effect against cell damage caused by enzymatically produced hydroxyl(OH) radicals is dependent on hyaluronan molecular mass’, Cell Biochem Funct. 12, (1994), 281-8. 15. Toole BP, ‘Hyaluronan: from extracellular glue to pericellular cue’, Nature Reviews Cancer, 4(2004), 528-39. 16. Wang F, Garza LA, Kang S, Varani J,Orringer JS, Fisher GJ, ‘In vivo stimulation of de novo collagen production caused by cross linked hyaluronic dermal filler injections in photodamaged human skin’, Arch Dermatol, 143, (2007), 155-63. 17. Man J, Rao J, Goldman M, ‘A double blind, comparative study of nonanimal-stabilised hyaluronic acid versus human collagen for tissue augmentation of the dorsal hands’, Dermatol Surg, 34(8), (2008 Aug), 1026-31. 18. Edelson KL, ‘Hand recontouring with calcium hydroxyapatite(Radiesse)’, J Cosmet Dermatol, 8(1), (2009 Mar), 44-51. 19. Sadick NS, ‘A 52 week study of safety and efficacy of calcium hydroxyapatite for rejuvenation of the aging hand’, J Drugs Dermat, 10(1), (2011 Jan), 47-51. 20. Alam M, Gladstone H, Kramer EM, Murphy JP, Nouri K, Neuhaus, ‘ASDS guidelines of care: injectable fillers’, Dermatol Surg, 34(suppl 1), (2008), s115-48. 21. Sadick NS, Anderson D, Werschler WP, ‘Addressing volume loss in hand rejuvenation: a report of clinical experience’, J Cosmet Laser Ther, 10(4), (2008 Dec), 237-41. 22. Rendon MI, Cardona LM, Pinzon-Plazas M, ‘Treatment of the aged hand with injectable poly-l-lactic acid’, J Cosmet Laser Ther, 12(6), (2010 Dec), 284-7. 23. Redaelli A, ‘Cosmetic use of polylactic acid for hand rejuvenation: report on 27 patients’, J Cosmet Laser Ther, 12(6), (2010 Dec), 284-7. 24. Figuerido VM, ‘A five patient prospective pilot study of a polycaprolactone based dermal filler for hand rejuvenation’, J Cosmet Dermatol, 12(1), (2013 Mar), 73-7. 25. Handle M, Bonfatti-Ribeiro LM, Barcaro-Machado BH, ‘Minimal scar handlift: a new surgical approach”, Aesthet Surg J, 31(8), (2011 Nov), 953-62.

Abstracts Clinical Papers

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Aesthetics Journal

Aesthetics

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A summary of the latest clinical studies Title: Aesthetic analysis of the ideal eyebrow shape and position Authors: Yalçınkaya E, et al Published: European Archives of Oto-Rhini-Laryngology,

October 2014 Keywords: eyebrow, eyelids, lifts Abstract: Eyebrows and eyelids, vary among different races, ages and genders. It is considered to be of primary importance in facial expression and beauty. For the modern acceptable concept of the ideal brow, the medial brow should begin on the same vertical plane as the lateral extent of the ala and the inner canthus and end laterally at an oblique line drawn from the most lateral point of the ala through the lateral canthus. The medial and lateral ends of the brow lie approximately at the same horizontal level. The apex lies on a vertical line directly above the lateral limbus. Individual perceptions and expectations also differ from person to person. The brow should over lie the orbital rim in males and be several millimetres above the rim in female. Male tend to have a heavier, thicker brow with a little arch present. There are some pitfalls in brow aesthetics. Overelevation creates an unnatural, surprised look which is the most common surgical mistake in brow lifting. Medial placement of the brow peak would create an undesired ‘surprised’ appearance. Moreover, a low medial brow with a high lateral peak induces an angry look. Overresection of the medial brow depressors may lead to widening and elevation of the medial brow, which creates an insensitive look and can also lead to glabellar contour defects. It is impossible to define an ideal eyebrow that is suitable for every face. However, one must consider previously described criteria and other periorbital structures when performing a brow surgery. Title: Cosmetics for acne: indications and recommendations

for an evidence-based approach

Authors: Dall’Oglio F, et al Published: G Ital Dermatol Venereol, October 2014 Keywords: acne, cosmetics, agents Abstract: The aim of this review was to evaluate, by a

thorough revision of the literature, the true efficacy of currently available topic and systemic cosmetic acne agents. The efficacy of currently available cosmetic acne agents has been retrospectively evaluated via thorough revision of the literature on matched electronic databases (PubMed). All retrieved studies, either Randomized Clinical Trials or Clinical Trials, controlled or uncontrolled were considered. Scientific evidence suggests that most cosmetic products for acne, if correctly used, may enhance the clinical outcome. Cleansers should be prescribed to all acne patients; those containing benzoyl peroxide or azelaic/salicylic acid/triclosan show the best efficacy profile. Sebum controlling agents containing nicotinamide or zinc acetate may minimize excessive sebum production. Cosmetics with antimicrobial and anti-inflammatory substances such as, respectively, ethyl lactate or phytosphingosine and nicotinamide or resveratrol, may speed acne recovery. Topical corneolytics, including retinaldehyde/glycolic acid or lactic 48

acid, induce a comedolytic effect and may also facilitate skin absorption of topical drugs. Finally, the use of specific moisturizers, photoprotective agents, shaving, and camouflage products should be strongly recommended in all acne patients. Cosmetics, if correctly prescribed, may improve the therapeutic outcome, whereas wrong procedures and/or inadequate cosmetics may worsen acne. The goal of a cosmetological algorithm should be to allow clinicians to make informed decisions about the role of various cosmetics and to indentify the appropriate indications and precautions, choosing the most effective product, taking into consideration the ongoing pharmacological therapy and acne type/severity as well. Title: ACELIFT: a minimally invasive alternative to a facelift Authors: Sarnoff DS, Gotkin RH Published: Journal of Drugs in Dermatology, September 2014 Keywords: ACELIFT, non-surgical, facelift Abstract: Cervicofacial aging is often characterized by a

combination of skin and subcutaneous tissue laxity, midfacial deflation, an accumulation of excess submental fat, an obtuse cervicomental angle, jowls, and rhytides of the face and neck. Traditional treatment, and the “gold standard” against which other treatments are compared, is a facelift. Objective: Demonstrate that a combination technique called ACELIFT - an acronym for the Augmentation of Collagen and Elastin using Lasers, Injectable neurotoxins, Fillers, and Topicals - in selected patients, is a viable, safe, and effective alternative to a facelift. Ten healthy women, ages 50-62 (mean age = 58), with cervical and facial stigmata of aging were enrolled in a prospective study conducted in the authors’ private practice. Patients underwent a two-step procedure; the first step was laser lipolysis of the submental and anterior cervical areas with a pulsed 1440 nm Nd:YAG laser with a side-firing fiber (PrecisionTx, Cynosure, Westford, MA). Three months later, the patients were treated in a single session that combined injectable neurotoxin, fillers, and fractional (Fx) CO2 laser resurfacing delivered in a novel “hammock” distribution. After two weeks, following complete re-epithelialization, the patients were started on a topical regimen that included daily use of sunscreen and antioxidants and nightly use of retinoids and peptides. This regimen was continued for a period of six months when all patients returned for final evaluation. Nine months following the initiation of treatment, all patients were evaluated by the following: Global Aesthetic Improvement Scale, cervicomental angle scale, physician, and subject evaluation. Clinical improvement was evident, and often marked, for all subjects. Both physician and subject satisfaction scores were high, indicating overall satisfaction with the procedure and the outcomes. Sideeffects were mild and transient; there were no incidents of adverse scarring, thermal injuries, permanent nerve injury, or dyschromia, hematomas, seromas, or infection. Subjects were likely to recommend the procedure to a friend. In properly selected patients, the ACELIFT proved to be a safe and effective, minimally invasive alternative to a facelift.

Aesthetics | December 2014

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Commercial Development Evolution of Business

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The evolution of business in aesthetics Pam Underdown highlights the importance of adapting to change in order for your clinic to thrive in the ever-changing aesthetics industry For the aesthetic businesses that were established before the global recession, memories of the marketplace being ‘easier’ in those days frequently spring to mind. A decade ago you really didn’t have to try too hard to fill up your appointment book with high-spend patients. You opened your doors and the patients really did come flooding in. Credit was readily available, consumers were spending, and increased curiosity about the celebrity lifestyle and reality TV made it possible for everyone to believe that they could have a new life with cosmetic enhancement. Having been involved in the medical aesthetics business for nearly a decade, I have seen first-hand how the industry has evolved. When I opened my first aesthetic business in 2005, things were very different. Today it’s certainly not easy; business owners are frequently contending with increased public scrutiny and changing consumer behaviours. Competition is everywhere, with deals and discounts flooding the high street. Changes in legislation have affected the livelihood of many practitioners and a growing number of business owners feel like their business is running them, instead of the other way around. The pace of change also seems to be ever quickening. 50

Despite this, there continues to be a growing number of health professionals quitting their day job and setting up their dream anti-ageing business. And who can blame them? For many, the appeal of the aesthetics industry can be glamorous and far more exciting than shift work, sickness and death. Health professionals can combine their keen judgment, with their clinical skills and creative eye. All they need to do is learn facial aesthetics, practice on some friends then go and get a logo and a website – right? Well no, it is not that easy. This is a highly competitive and demanding industry and just having great clinical skills does not guarantee success. So is the “dream” a good enough reason to risk everything and start again as you hope to claim your slice of the aesthetics pie? What about those established businesses, the ones who did survive the global recession? Whilst we should never underestimate the power of being first, that power only helps you if you have continued to evolve, innovate and change. Regrettably a number of businesses did not evolve; they played it safe, remaining comfortable and complacent. However, they are now starting to learn the hard way that playing it safe is a dying strategy. The world is changing, business is changing and change really is Aesthetics | December 2014

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essential if you want to progress in medical aesthetics. So, how can businesses thrive when faced with these challenges? Certainly not by doing nothing, or ‘playing’ at change. The world has turned upside down, you can’t hide and you can’t keep repeating the things you’ve been doing, hoping that it will be sufficient to cope in the future. Whilst most people are determined to avoid change, it’s key to remember that change and evolution are the very essence of life. So for those business owners who wish to not only survive, but also thrive, there is no option to ignore change. However, change on its own is insufficient; continuous improvement, innovation and ongoing education are essential. Successfully running and operating a small business in today’s dynamic world is not easy. Aesthetic business owners really do have to do it all. Delivering treatments, dealing with day-today operations, staffing issues, finances, marketing, and keeping up to date with the latest techniques and technologies can be hectic and overwhelming. As time goes on, the growing realisation of what it takes to make a business run can shatter many dreams and bring reality crashing down. As the global economy continues to improve, the business of aesthetics continues to be flourishing, with no end in sight. Cosmetic intervention is fast becoming a cultural norm, however, the expectations and demands of patients are on the rise and the perception of aesthetic medicine among the general population has changed. Today, we see more and more young patients in consultation rooms wanting to hold back the ageing process, just like their favourite celebrities and just like their parents. So what can you do to stay one step ahead? For a start, it’s time to throw away any old rules or beliefs that won’t help you in today’s evolving marketplace. What worked six years ago, or even six months ago, won’t necessarily work today. Resourcefulness and innovation combined with continuous evaluation and improvement will enable you to stay one step ahead.

Consistently educate yourself In the words of the late Nelson Mandela, “Education is the most powerful weapon that you can use to change the world”. Our growth, evolution and happiness depend upon the continued development of our knowledge and skills. Keeping up to date with both clinical and business skills is essential. For better or worse, both sets of knowledge and skills are measured in our bottom line results.

Botulinum toxin and its applications a day course Thursday 29 January 2015 Royal Society of Medicine, London RSM member rates from £539 Non member rates from £599 Dermal fillers course Friday 30 January 2015 Royal Society of Medicine, London RSM member rates from £599 Non member rates from £699 Botulinum toxin and dermal fillers course intermediate Thursday 22 to Friday 23 January 2015 Manchester Conference Centre RSM member rates from £539 - £999 Non member rates from £599 - £1,199 For more information about these courses and to register online, visit www.rsm.ac.uk/courses Early bird rates expire Monday 5 January 2015

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I M C A S 1 7 th A N N U A L W O R L D C O N G R E S S

The leading subjects on aesthetic surgery and cosmetic dermatology « This is the most enjoyable and the best teaching conference I can remember. The cadaver workshop is spectacular. I can not remember a meeting with more positive and enthusiastic feedback from the audience. So many people told me how much they have learned and have enjoyed this meeting. This is a wonderful learning experience. » Dr Joel Pessa, Plastic Surgeon from the United States

« I truly think it is the meeting at which I learn the most and become inspired about how I treat my patients. Each year I take home innovative new techniques to improve my skills. I have always found IMCAS to provide the most exciting professional learning experiences. It is an honor to be a part of this conference. » Dr Susan Weinkle, Dermatologist from the United States

« Congratulations for this excellent academic conference. You did a fabulous job. You have built and organized a meeting which is truly impressive. I continue to be impressed by your meeting, in organization, scope, and quality. » Dr Jonathan Sykes, Facial Plastic Surgeon from the United States

« I congratulate you all for the commitment in the organization of the congress and care of the details. I must say your meeting is an example of professionalism and seriousness for the sake of science in the aesthetic field. » Dr Alessandra Nogueira, Dermatologist from Brazil

« By not attending IMCAS on an annual basis, every aesthetic physician/surgeon would be starving him/herself of the most valuable updates available. The most illuminating tool and up-to-date conference on aesthetics that one can attend. It can never be taken away. An absolute MUST! » Dr Hugo Kitchen, Cosmetic Surgeon from the United Kingdom

IMCAS Annual World Congress JAN 29 to FEB 2015 NOVEMBER 14 to1,16, 2014

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Commercial Development Evolution of Business

Disrupt or be disrupted Leaders disrupt because they continually innovate. If you are not innovating, if you don’t keep asking yourself, “How do I differentiate myself?” there is very little chance you will ever succeed. If you don’t disrupt the market, you will eventually be surpassed by someone who will. Apple disrupted Microsoft. Apple made a larger screen on their iPhone, now Samsung are disrupting them. Netflix disrupted Blockbuster. Amazon disrupted traditional bookshops.

Gut-based decisions Every leader makes decisions fast. In my opinion, there are three ways to think: mind, heart and gut. The more you think about doing something, the more reasons you are going to find not to do it. This is commonly known as analysis by paralysis, which can often be the killer of budding entrepreneurs. The second way is to think with the heart. In my experience, many people have been burned doing this because their emotions get in the way and they start to ask the ‘what if’ scenarios: ‘what if it doesn’t work?’ ‘What if I fail?’ or even, ‘What if I succeed, how will I cope?’ However, in my experience, when you make a decision with your gut, you are usually right. So the key is to make a quick decision and then re-evaluate it. If it’s right – great, if not – learn from it and move on.

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challenges. In reality it is usually a lack of clear communications, expectations and detailed marketing knowledge – all of which are the responsibility of the business owner. The key is to master the marketing and understand it before you outsource or delegate it – even when you know you won’t be carrying out the day-today actions yourself – you must take the time to really understand exactly what the marketer is doing with your money. Every skill is learnable, so take the necessary time to truly understand marketing, learn how to articulate what you want and then outsource or delegate the day-today ‘doing’ of it to someone who clearly understands your vision, your needs and your expectations. Trust me, it will be worth it in the long run. If you are not getting the results you expect, think: are you still marketing the same way you did a decade ago? If so, it is time to launch yourself into modern-day transparent and authentic social media marketing. Without a doubt, social media provides everyone with a phenomenal capacity for interacting and engaging with existing patients, whilst at the same time, reaching out to prospective patients. With social medial we are all living in the public eye, so don’t forget: if you don’t manage your online brand and reputation, someone else will take it away from you.

Be unique Master marketing If you really want to stay ahead of the pack, marketing is a critical piece of the puzzle. I have spoken to a number of clinic owners who have outsourced their marketing or social media production to someone else, paid them a lot of money but had little results in return. So, why is this? There are possibly many reasons: Perhaps the marketing person has not been given clear guidelines, expectations, branding information, ideal patient profile, unique selling proposition or other useful information. They therefore may end up secondguessing the requirements and not really understanding the individual business needs or the aesthetic marketplace. Perhaps they didn’t grasp the business vision, so they couldn’t get the messaging right. Or maybe the clinic owner found it difficult to explain what they were looking for and assumed the marketing person would create something wonderful that would solve all of their marketing 52

How many times have you visited somebody else’s website or seen another practice’s marketing and thought to yourself – that looks just like my marketing? The infamous stock models are everywhere. So, do you want the same images that everybody else uses to represent your brand? If not, then use real patients to brand your business. Use their pictures, their results and their stories. There is nothing more powerful than the word of the patient.

Keep your patients at the forefront of your mind In too many cases, marketing efforts fail because businesses identify themselves as the “beneficiary” of the end goal. I can’t stress enough how important it is to keep your patient in mind. What is it that the patient wants? Will they benefit from your promotion? Does it appeal to them? Always make sure to identify these things and speak their language. Constantly put yourself in your patients’ shoes and keep asking, “WIIFT – what’s in it for them?” Aesthetics | December 2014

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Use visual content A great way for your prospective patients to feel connected to you before they even meet you is by using video. According to an article in Forbes Magazine,1 people are more likely to watch a video than they are to read an article. Use videos for testimonials, to breakdown complicated surgical procedures, and to introduce you and your team when you are marketing your business. It is not only a great way of building trust, but as YouTube is the number two search engine in the world – it can also help to drive new patients to your website.

Stay current Responding to changing demands will grow your business and keep it current. Helping your patients to reach their goals requires you to be up to date with the latest products, the latest devices, and the latest technologies.

Protect your patients and your business Client information is no longer stuck in the computer locked in your office, but accessible on your smartphone or tablet, enabling you to take a call about your patients’ concerns no matter where you are. While technology provides ease and convenience however, it also adds to your exposure and can become a double-edged sword. Your online payment account or tablet could be hacked and all of your patients’ medical history information obtained. As your business evolves, your insurance coverage must keep up with it and continued compliance with the Data Protection Act and the Information Commissioner’s Office (ICO) is essential. The good news is that the clinic owners who take all of this on board will ensure that their business not only survives, but thrives. They’ll be the ones who attract the best staff and have their appointment book consistently packed with top patients. Pam Underdown is a business growth specialist and the owner of Aesthetic Business Transformations. She works exclusively to help medical aesthetic business owners improve their marketing, increase their profits, reduce their costs and build a long-term sustainable business asset. Pam has over 25 years of business development, sales and marketing experience, including nine years in the aesthetics marketplace. REFERENCE 1. Sean Rosensteel, Why Online Video Is Vital For Your 2013 Content Marketing Objectives (US: Forbes, 2013) http://www. forbes.com/sites/seanrosensteel/2013/01/28/why-online-video- is-vital-for-your-2013-content-marketing-objectives/ [6/11/14]

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Aesthetics Journal

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Business Process Brand Building

It is clear that the top three listings may have excellent search engine optimisation (SEO) to appear on the first page, however, looking at their proposition objectively, it is not often clear why new patients would choose one clinic listing over the other.

The Secret Power of Brands Gary Conroy talks about why it is important to invest in your brand equity in the ever-commoditising aesthetic market The current UK medical aesthetics market place is awash with treatment options for patients. Pop-up clinics, discounters, GP surgeries, dental practices, chiropodists, dermatologists, beauty salons, national chains, department stores, ‘Botox parties’, hen packages, and home treatments are just some of the options available. With the huge influx of healthcare practitioners, as well as less qualified individuals, developing their skills and starting new businesses in medical aesthetics, we may now be at a pivotal point in the market place when supply begins to outstrip demand. The global increase in sales of professional aesthetic products in 2012 from 2011 was 7.5% – with average patient retention rates estimated at 10-30% and an estimated doubling of healthcare professionals delivering services.1,2 A simple Google search will list a wide range of similar sounding clinics offering similar services at various prices with little explanation of price rationale or service differentiation. It is no wonder that many patients find themselves in a ‘Goldilocks’ scenario in their search for an optimal aesthetic outcome. Let’s take the example of the Google search term ‘Wrinkle treatment clinic London’:

Figure 1: Google search for ‘Wrinkle treatment clinic London’ - Google and the Google logo are registered trademarks of Google Inc., used with permission

What is a Brand? We have come a long way from the original meaning of brand, initially, the word ‘brand’ meant, “an identifying mark burned on livestock or (especially in former times) criminals or slaves with a branding iron.” 3 This then developed over time to form more tangible assets suitable for different media, such as logo’s and trademarks designed to identify the source of manufacture. Nowadays however, the word ‘brand’ has grown to mean a lot of different things to a lot of different people. It comes as no surprise that many businesses are poorly differentiated and their external service proposition (ESP) leaves patients confused. It is therefore crucial that time and money is not wasted in developing a weak brand or one which does not properly communicate your business strategy, leaving your proposition lost amongst competitors on search engines. Brands are highly valuable intangible assets and should be taken as seriously, and have the same investment consideration, as even the most expensive piece of capital equipment. Investment education site Investopedia discuss the worth of ‘intangible assets’ by explaining, “While intangible assets don’t have the obvious physical value of a factory or equipment, they can prove very valuable for a firm and can be critical to its long-term success or failure. For example, a company such as Coca-Cola wouldn’t be nearly as successful were it not for the high value obtained through its brand-name recognition. Although brand recognition is not a physical asset you can see or touch, its positive effects on bottom-line profits can prove extremely valuable to firms such as Coca-Cola, whose brand strength drives global sales year after year.”4 I will now break down the process of brand development into five clear parts, relevant to a service-based market such as medical aesthetics.

Brands are highly valuable intangible assets and should be taken as seriously as even the most expensive piece of capital equipment 1. The Brand Promise Fundamentally your brand is your ESP: your promise to your patients. It is what you are telling patients they will receive when they purchase a product or service under your brand umbrella. It is very important that the promise or proposition is delivered consistently at each point of customer contact, time after time.5 This also includes the feelings that patients get when they use your products and services. In medical aesthetics it is important to consider what differentiates your promise to your patients from what your local competition is promising. What emotions or feelings do your existing loyal patients have and how do you consistently communicate these to new patients Customer experience specialists Smith+Co argue that, “A strong brand promise is one that connects your purpose, your positioning, your strategy, your people and your customer experience. It enables you to deliver your brand in a way that connects emotionally with your customers and differentiates your brand.”6

Aesthetics | December 2014

Business Process Brand Building

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It is even more important in a medical environment that your brand promise is realistic and that you never over-promise to set unrealistic expectations

Aesthetics Journal

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Brand Development Checklist Define internally what your brand objectives are. Where would you like to be? What is your staff’s view of the current service proposition? What are your current and lapsed patients view of (conduct primary qualitative research): • Your external service proposition? • Your brand persona? • Expectation v. Promise? What gaps exist between your customer’s and staff’s perceptions and your own? Develop tactics to address these.

2. The Brand Perceptions A brand is what is produced when a product or service promise meets the consumer’s expectations. Exploring the thoughts, feelings and emotions that your existing or lapsed patients have about your brand equates to your brand perception, regardless of what you were hoping your brand perception was. Due to the patients’ emotional involvement in the product you are offering them, as well as their overall perception of your services, your aesthetic brand is built by your patients’ response. We live in a world where feedback is gathered easily through quantitative surveys, usually based on a five-point scale of satisfaction with the intent of using these results for further marketing. In order to truly understand your brand perception, primary research is required to openly gather qualitative feedback about how your brand is currently perceived. This will allow you to determine if your promise is being met or not and help to support development and improve brand perception. Ari Jacoby, CEO of advertising agency Solve Media, says, “The most accurate composite of a brand’s true identity seems to come from a consumer’s first gut reaction to it. Complex brand memories are created over time, and the first word(s) or image(s) that spring to mind are really the sum total of a consumers experiences with a brand, in its marketing and use.” 7 3. The Brand Expectations It is even more important in a medical environment that your brand promise is realistic and that you never over-promise to set unrealistic expectations. Not only is this unethical, but patients who part with their hard-earned cash will feel disappointed and turn away from your brand. This may not be because the results or service were necessarily bad, but because they will feel the brand does not live up to its promise. They may instead turn to competitors because your brand has lost value for them. 4. The Brand Persona Primary research with existing and lapsed patients will truly allow you to explore your brand persona. Your brand persona means its personality; for example in terms of its mannerisms, behaviour, integrity, age, and style. How it makes people feel will be the deciding factor on whether people will transact or continue to interact with the brand. Whilst you may have set out with a particular idea in mind of the brand persona you wanted to create, patients are the only ones who can tell you what you have actually created. 56

5. The Brand Elements Brands are represented by the above intangible elements as well as tangible elements, such as: Brand Logo: Recognition, consistency, individual, reflects brand promise Messaging: Promise, differentiation, meets consumer needs Packaging: Advertising, social media, information leaflets, website consistency Consultation: Relevant, thorough, discreet, consultative Staff Interaction: Knowledge, personality, empathy, gratitude, consideration Premises: Comfort, cleanliness, location, accessibility, parking Pricing: Fair, value, competitive, sustainable, affordable All of these elements must be consistent, complementary, and supportive of your brand promise. They will help shape brand perception, meet brand expectations and define your brand persona. “Ultimately, brand is about caring about your business at every level and in every detail, from the big things like mission and vision, to your people, your customers, and every interaction anyone is ever going to have with you, no matter how small.” 8 Gary Conroy is co-founder and director of 5 Squirrels Ltd, which delivers products and services to UK medical aesthetics industry. Previously, Gary was the sales and marketing director at Ambicare Health, and formerly the head of Aesthetic Dermatology for Sanofi-Aventis. With more than 12 years experience of aesthetics, he has an in-depth understanding of the financial and clinical aspects of the industry. REFERENCES 1. [Reference on file via The Consulting Room] 2. [Reference on file via The Consulting Room] 3. Oxford University Press, Brand (Oxford: Oxford Dictionaries, 2014) http://www.oxforddictionaries. com/definition/english/brand [Accessed 12 November 2014] 4. Investopedia, Intangible Asset (California: Investopedia, 2014) http://www.investopedia.com/terms/i/ intangibleasset.asp [Accessed 12 November 2014] 5. Brad VanAuken, What is a brand? (California: Brand Strategy Insider, 2011) http://www. brandingstrategyinsider.com/2011/03/what-is-a-brand.html#.VFt0pfmsX4s [Accessed 12 November 2014] 6. Smith+Co, Workshops Brand promise definition (London: Smith+Co, 2013) http://www. smithcoconsultancy.com/workshops/brand-promise-definition [Accessed 12 November 2014] 7. Ari Jacoby, A Common Sense Approach To Measuring Brand Perception (New York: Forbes, 2012) http://www.forbes.com/sites/ciocentral/2012/05/14/a-common-sense-approach-to-measuring-brand- perception/ [Accessed 12 November 2014] 8. Dan Pallotta, A logo is not a brand (Massachusetts: Harvard Business Review, 2011) https://hbr. org/2011/06/a-logo-is-not-a-brand/ [Accessed 12 November 2014]

Aesthetics | December 2014

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