Aesthetics December 2015

1 16 ng c 3 20 ki e E oo s D AC ly b end r t Ea un o sc di

VOLUME 3/ISSUE 1 - DECEMBER 2015

Results Without Compromise New For January 2016 Marini Luminate Eye Gel Marini Luminate Face Mask

The ABC of Moles CPD Mrs Barbara Jemec explains how to recognise a malignant melanoma

Vaginal Rejuvenation

Treating the Brow Area

Marketing to Men

Practitioners discuss patient concerns and options for successful treatment

Dr Victoria Dobbie details her techniques for treating eyebrow aesthetic concerns

Charlotte Moreso highlights the best ways to attract male patients to your clinic

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Contents • December 2015 06 News

The latest product and industry news

14 On the Scene

Out and about in the industry this month

16 News Special: Reflection on 2015

Practitioners discuss developments in the industry this year

19 Aesthetics Conference and Exhibition 2016

A look at the latest additions to the ACE 2016 Conference agenda

CLINICAL PRACTICE

Special Feature Evolution of Vaginal Rejuvenation Page 21

21 Special Feature: Vaginal Rejuvenation

Practitioners highlight patient concerns and treatments for the vagina

Clinical Contributors

26 CPD: The ABC of Moles

Consultant plastic surgeon Mrs Barbara Jemec explains how to recognise and treat a malignant melanoma

31 Treating the Brow Area

Dr Victoria Dobbie details her technique for addressing eyebrow concerns

35 Copper in Skincare

Dr Charlene DeHaven explores the use of copper in advanced skincare

38 Body Dysmorphic Disorder in Aesthetic Practice

Dr Dimitre Dimitrov and Dr Anthony Bewley discuss how to manage patients with BDD

42 Treating Birthmarks with Laser

Dr Salinda Johnson outlines the types of birthmark and how to treat them

44 Assessing the Lips for Successful Rejuvenation

Dr Souphiyeh Samizadeh gives insight and advice for lip-treatment trends

47 Managing Acne

Dr Terry Loong shares her aproach to treating acne and managing patients

51 Spotlight On: Radara

Aesthetics examines the new micro-channelling skincare system

53 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 54 Team Motivation

Victoria Vilas describes ways to motivate your team and boost trade

57 Finding the Funding Key to Business Growth

Peter Nolan explains clinic financing options

59 Introducing Laser and IPL Hair Removal to Clinics

Christine Clarke discusses why it can be beneficial to introduce hair removal treatments to your clinic

63 Patient Cancellations

Professor Bob Khanna shares his methods of managing late or cancelled clinic appointments

Mrs Barbara Jemec is a consultant plastic surgeon at the Royal Free Hospital with a special interest in skin cancer, as well as a member of its Multidisciplinary Team (MDT). The MDT works together to discuss both NHS and private patients with skin cancer.

Dr Victoria Dobbie has 13 years experience in aesthetics and has carried out more than 20,000 treatments. She is the director of the Face and Body clinic in Edinburgh, and previously ran her own dental clinic with the Royal Army Dental Corps.

Dr Charlene DeHaven is a certified physician in Internal and Emergency Medicine emphasising on age management and health maintenance. She is currently serving on the lecture faculty for the University of Washington Department of Family Medicine.

Dr Dimitre Dimitrov graduated medical school and specialised in dermatology and venereology in Bulgaria. He received full registration with the GMC in 2011 and is currently an honorary consultant at Whipps Cross Hospital and London Royal Hospital.

Dr Anthony Bewley is a consultant dermatologist at Whipps Cross University Hospital and the Royal London Hospital and lectures at the Universities of London and Hertfordshire. He is trained in all aspects of adult and child dermatology.

Dr Salinda Johnson is an aesthetic practitioner and has completed a specialist fellowship programme in cosmetic dermatology. She has lectured and trained in the specialty for many years, incorporating up-todate procedures and best practice as they develop.

Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in medical aesthetics. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. Dr Samizadeh also speaks at both national and international conferences.

Dr Terry Loong graduated from Guy’s and St. Thomas’ Hospital and completed her postgraduate qualifications with the Royal College of Surgeons.

Her earlier training was in general and plastic surgery before she began specialising as an anti-ageing doctor.

64 Marketing to Men

Charlotte Moreso provides advice on how to attract men to your clinic

67 In Profile: Nigel Mercer

Mr Nigel Mercer reflects on his career in plastic surgery and aesthetics

69 The Last Word

Dr Asim Shahmelak argues why we should put an end to the hard sell in aesthetic practice

NEXT MONTH • IN FOCUS: Weight-loss • CPD: Treating Scars in Asian Skin • Radiofrequency • Choosing Insurance

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Editor’s letter Welcome to the December issue of the Aesthetics journal; I can’t quite believe it’s the end of the year already – where has the time gone? As we prepare to send this issue to the printers, we are in the final weeks of preparation for the Aesthetics Awards and it really does Amanda Cameron not seem like 12 months ago that it last took Editor place! We are delighted that this year’s Awards finalists include newcomers as well as more established names, who each have a capacity for hard work and all presented the judges with a challenge when deciding the winners. The last 12 months in the aesthetics industry has been interesting as always, and it is no surprise that the market continues to grow significantly.

Turn to p.16 to read our review of the year, where we talk to practitioners about the advances, challenges and highlights of 2015.

We’d also love to hear your thoughts on the year and find out what you’re looking forward to in 2016, so get in touch with us using the contact details listed below.

One of the growing treatment sectors in 2015 has most certainly been vaginal rejuvenation. More and more practitioners are starting to offer procedures that can potentially enhance both the appearance and function of the vagina, which, according to reports,

is becoming increasingly popular with women in the UK. For our Special Feature, we speak to five practitioners, offering different types of treatments, about patient concerns, techniques and the results of vaginal rejuvenation – read their views on p.21. As we treat our patients’ aesthetic concerns, it is also important to remember the serious side of dermatology. As such, this month’s CPD article on the ABC of Moles (p.26), written by consultant plastic surgeon Mrs Barbara Jemec, shares advice on recognising suspicious lesions.

Please do read it carefully to ensure that your patients are given appropriate treatment when necessary.

On a lighter note, I am sure you are all seeing increased footfall in your clinics as the Christmas party season is upon us. And while it is usually women seeking aesthetic treatment, there is the chance that more men will be inclined to consider our services during the festive period. To help you pique their interest, public relations director Charlotte Moreso has written a fantastic article with lots of practical tips on Marketing to Men, featured on p.64.

Finally, on behalf of the Aesthetics team, I’d like to say that we’re all looking forward to seeing you at the Awards and wish you a wonderful Christmas!

Let us know how your year has gone by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

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

and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years.

Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Submental fat

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #OpenDay Simons Vitiligo Blog @SiVitilgoBlog @DrAnjaliMahto Great talk today on current #Vitiligo treatment and exciting research at @VitilgoSociety Open Day.

#Advice Dr Mark Hamilton @CosmeticDrMark Before injecting a simple wipe isn’t enough. If the pad still has traces of makeup on it its not clean. Then use antiseptic. Biofilm exists! #Skin Dr Emma Wedgeworth @DrEmWedgeworth Good talk to the team @BBCRadioLondon this morning about impact of skin conditions on young people.

A subject I’m passionate about. #Clinic Dr Stefanie Williams @DrStefanieW Most exciting Friday – just signed the lease to our new clinic premises! Should get some champagne out… #LiveShow Dr Raj Acquilla @RajAcquilla Rammed live show here in #Egypt today with my friend and mentor #KeonDeBoulle @Allergan #Botox #Juvederm

#Dermatology Wendy Lewis & CO LTD @WendyLewisCO At the @Syneron #ConfluenceOfPower event in Wash DC – top #dermatologists sharing their expertise @DrTanzi @DrTKeaney @ClarusDerm #Collaboration Dr Johanna Ward @DrJohannaWard Delighted to be working alongside Mr Taimur Shoaib to deliver first class cosmetic surgery @skinandbodyclin #Sevenoaks #CosmeticSurgery

Study suggests Kybella is effective in men A study has indicated a reduction in submental fat in men using deoxycholic acid. The research comes from two identical phase III trials of 1,022 patients with moderate to severe submental fat. Patients received either six treatments of deoxycholic acid (Kybella) or a placebo, over the course of a month.

Researchers then analysed the results of 156 men; 80 of whom received deoxycholic acid and 76 who received a placebo, 12 weeks after the final treatment. A composite 1-grade and 2-grade response, based on investigator and patient assessment, was then measured.

Men receiving deoxycholic acid had a composite 1-grade response of 64.4% compared with 8.6% in the placebo treatment group and 9.6% compared with 0% in the composite grade-2 response. The majority of patients using the Subject Self Rating Scale reported being happy with their appearance after treatment with deoxycholic acid (79.2%) compared with those in the placebo group (22.9%). “The post-hoc analysis of the Refine-1 and Refine-2 trials showed that men got very good results, just like women did,” said researcher Dr Vince Bertucci.

Acquisition

Lumenis acquires Pollogen Global laser manufacturer Lumenis has completed the acquisition of Israeli-based medical aesthetics company Pollogen.

Tzipi Ozer-Armon, CEO of Lumenis said, “We are excited to welcome the Pollogen team into the Lumenis family. This transaction complements our aesthetic product portfolio and positions Lumenis well in the dynamic beauty market.” She added, “The addition of Pollogen’s extensive portfolio is key to continuing to provide tailored and innovative beauty solutions to all of our existing and future aesthetic customers.”

Zion Azar, co-founder and chairman of Pollogen said, “This transaction is a positive outcome for our shareholders, employees and customers.

We are thrilled to join the Lumenis team and further develop our products and presence in this rapidly developing market.”

Laser

FDA expands indications for Syneron Candela C02RE device The Food and Drug Administration (FDA) has granted its approval for Syneron Candela’s C02 laser to be used for multiple indications. A total of 90 specific indications have now been approved for the system, including, scars, wrinkles, a wide array of dermatology indications and gynecology applications. Amit Meridor, chief executive officer of Syneron Candela, said, “This broad range of newly FDA cleared clinical indication of the CO2RE will enable Syneron Candela to address new physician markets with very high patient demand and creates a significant business opportunity for the company.”

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Botulinum toxin

Study indicates botulinum toxin may be effective to treat posterior cheek enlargement in HIV patients According to the results of a pilot study led by Dr Alastair Carruthers, botulinum toxin injections could be an effective, long-lasting treatment for HIV patients suffering from posterior cheek enlargement. Five HIV-positive men, all with posterior cheek enlargement, took part in the study and were treated with a total of 100 units per patient, divided into 50 units per side, injected into five points on each side directly within the area of enlargement. Improvement was measured through clinical, photographical and radiological evaluations.

According to the research team, 100% of test patients had good results, with a 21.4% mean decrease in masseter muscle volume and a 11.2% decrease in the volume of the parotid gland. Adverse effects, though short-lived with an approximate duration of one to four weeks post injection, included decrease in bite force, sunken cheeks and change in facial expression. The researchers claim that all patients continued to be satisfied with the results at six-month follow-ups, and although one patient did not follow-up at 12 months, the remaining four were reported to be either “satisfied” or “very satisfied”. The researchers concluded, “Botulinum toxin A was found to be effective for posterior cheek enlargement and could represent a novel treatment for this condition.” They continued, “This was easy to administer, generally well tolerated with no downtime and provided long-lasting results. However, it is a temporary treatment, and injections need to be repeated to maintain the desired result.”

Laser

Naturastudios launches the Forma Magma Diode Aesthetic equipment supplier Naturastudios has introduced a new platform offering a diode laser, Nd:YAG and IPL. The Forma Magma Diode aims to treat unwanted hair, pigmented lesions, vascular lesions, active acne and nail fungus, as well as offering skin lightening and photo rejuvenation treatments. A cooling system is also included which aims to make treatments more comfortable.

A clinical study – Comparison of Long Pulsed Diode and Long Pulsed Lasers for Hair Removal: A Long Term Clinical and Histologic Study – carried out by the Washington Institute of Dermatologic Laser Surgery and Georgetown University Medical Center, found an 86% reduction in hair after just three sessions using the device. The device also claims to treat skin types 1-6 quickly and efficiently and can be used on patients during summer months, when they are likely to have an active tan. The key features of the device include; diode laser 808nm, 1064nm Nd:YAG laser, a choice of 10 IPL applicators and an electrical melaninometer.

Countdown to ACE 2016 Latest programme updates Dr Daron Seukeran is set to run an Expert Clinic session exploring the benefits of different laser treatments for problem-skin patients.

Dr Sotirios Foutsizoglou will be presenting on hair transplant techniques with an anatomy and physiology analysis at an Expert Clinic session on Saturday 16.

Insight Aesthetic nurse, BACN Chair and ACE Steering Committee member Sharon Bennett says: “The Aesthetics Conference and Exhibition is a great opportunity to learn about the latest products and treatments and share experiences with colleagues. ACE sessions are always full of practical content that professionals can bring to their clinics the next day. I’m honoured to be part of the ACE team and to be among next year’s Conference speakers at the session dedicated to perioral rejuvenation treatments. Practitioners attending the Conference will have the opportunity to perfect their skills and gain in-depth knowledge on consultation, treatment options, complication management and best practice for each anatomical area. The ACE 2016 Conference programme, as well as the other clinical and business content, is extremely well-designed to guarantee all delegates an outstanding learning experience.”

What delegates say “Now with nurses needing revalidation, it is important to get a certificate and CPD points. I think that the live demonstrations, the masterclass sessions, the exhibition and all of the programme content is good for the professional development and ACE is the best conference to attend.”

Aesthetic Nurse, Gloucestershire

www.aestheticsconference.com HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Industry

Alma Lasers introduces new handpiece for Alma Accent

A new ultrasound handpiece has been launched for use with the radiofrequency-based device Alma Accent. The body contouring handpiece aims to make treatments quicker, more comfortable and cost effective by targeting 60cm squared in a single session. The handpiece aims to work by utilising patented ultrasound selective resonance, which uses cold and hot ultrasonic waves that selectively resonate with and destroy fat cells, while leaving surrounding tissue unharmed. The company claims that selective sound waves disrupt fat cell membranes, which leads to the gradual breakdown and release of stored fat through the lymphatic system. Alma Accent is approved by the FDA for use on the face and body.

Skincare

Elizabeth Arden PRO releases two new products Skincare brand Elizabeth Arden PRO has released two products that aim to provide an instant boost of skin hydration and refreshment. The Hydrating Antioxidant Spray, which has been designed as an ‘on-the-go’ product, includes a range of key antioxidants such as; ferulic acid, resveratrol, white tea, ergothioneine and carnosine, and sodium hyaluronate. The company claims that the spray provides lightweight moisture and is beneficial for all skin types. The Intense Hydrating Cream aims to strengthen the skin’s natural defences by working to reduce the appearance of fine lines and wrinkles, and includes essential ingredients including; lactic acid (AHA), sodium hyaluronate, flaxseed extract, ceramides, caprylic/capric triglyceride, salicornia herbacea extract, sodium PCA and marimoist.

Allergan to acquire earFold Allergan is to acquire Northwood Medical Innovation, the developer of earFold. Implant technology earFold is a medical device for the correction of prominent ears in patients aged seven or older. Allergan hopes the technology will add to its medical aesthetics product portfolio and provide patients with an alternative to corrective surgery. The small implantable device is made from a short strip of nitinol metal alloy, which is designed to retain a pre-set shape. It is inserted under the skin and works by gripping onto the cartilage of the ear, enhancing or creating the shape of the anti-helical fold – thereby reducing the prominence of the ear. Mr Norbert Kang, consultant plastic surgeon and creator of the earFold, said, “In my clinical practice, there are a significant number of patients who are reluctant to undergo surgery and so put up with accepting the social hindrance of prominent ears. The beauty of the earFold treatment system is that it offers an evidenced-based alternative to standard otoplasty surgery that may meet the needs of a wider range of patients, by delivering immediate and predictable results, without the risks associated with general anaesthetic.”

Allergan hopes earFold will provide patients with a rapid and more predictable alternative to surgery. Paul Navarre, president and EVP of international brands at Allergan said, “Allergan is constantly searching to partner with or acquire companies with disruptive technologies that offer substantive value to our customers, often opening up new categories or setting new trends within our specialist segments. Many of Allergan’s plastic surgery customers currently perform otoplasty (pinnaplasty) procedures, emphasising our commitment to serving the unmet needs and practice of plastic surgery.”

Weight loss

Obesity to be referenced in advertising The Committee of Advertising Practice (CAP) has announced that for the first time, advertisers of responsible lifestyle weight loss programmes can make reference to obesity in their advertising. The change in advertising rules comes among wider public policy initiatives to try and tackle the issue, and now means advertising can be targeted at people who are classed as obese. “These new rules strike a sensible balance,” said Shahriar Coupal, director of the CAP. He continued, “Providing weight loss management programmes that meet necessary criteria allows advertisers the freedom to target their advertising at people who are obese while ensuring the right level of protections for consumers are in place.” The new rule will come into immediate effect and be reviewed by the CAP in 12 months’ time.

Industry

Lifestyle Aesthetics becomes Teoxane UK After more than ten years of partnership with distribution company Lifestyle Aesthetics in the UK, Teoxane Laboratories has announced the two companies are to merge together as one. Teoxane Laboratories hopes the new UK subsidiary will help to further the global expansion of the company’s hyaluronic acid filler products. Lifestyle Aesthetics founders Sandra Fishlock and Sue Wales, who will lead Teoxane UK, said, “After a strong ten year partnership with Teoxane International, we feel this latest business transition allows us to expand and improve both awareness and product innovation into the UK market. We are delighted to have joined forces and become Teoxane UK.”

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Conference

ACE Business Track sponsor announced Aesthetic distributor Church Pharmacy has announced its sponsorship for the Aesthetics Conference and Exhibition (ACE) 2016 Business Track sessions. This is the second year Church Pharmacy has chosen to support the ACE 2016 Business Track sessions, which provides expert guidance on building, sustaining and growing a practice in medical aesthetics. “Last year the response of the Business Track attendees was great, it was nice to know the delegates found it so useful and were able to take things away to improve their businesses from industry experts,” said Zain Bhojani, codirector of Church Pharmacy. He added, “ACE is one of my favourite shows and we have exhibited there more than any other show so far. Most of the delegates at ACE are customers and as Church Pharmacy is primarily an online business it’s a great opportunity to meet them face to face, which is why I am excited to sponsor and contribute to the success of the Business Track again in 2016.” Speaking in regards to 2015’s Business Track, Bhojani said there was a good response from those attending and people really benefited from the quality and diversity of the speakers. “I think everybody recognises the speakers, they are all faces within the industry and always have something new, innovative and useful to say. Church Pharmacy are delighted to be the proud sponsors of the ACE 2016 Business Track and look forward to discussing the success and new features of DigitRx which continues to lead the industry.” he said. The Business Track has a particular focus on supporting small businesses; providing sales, marketing and regulation advice and ideas on how to enhance their practice.

To find out more and to register for ACE 2016 visit www.aestheticsconference.com Melanoma

Vital Statistics In a survey of 2,006 respondents, 40% said they would undergo aesthetic treatment to satisfy their partners (Intraline Medical Aesthetics)

At least two 15-34 year olds are being diagnosed with malignant melanoma every day in the UK (British Skin Foundation)

More than 480,271 laser skin-resurfacing treatments were performed in 2014 globally (International Society of Aesthetic Plastic Surgery)

Research in 2014 suggested that there was a 109% rise in the number of people undergoing cosmetic treatment abroad over a two-year period (WhatClinic.com)

Skin cancer risk could increase with more than 11 arm moles New research published in the British Journal of Dermatology suggests people with more than 11 moles on their right arm are at a higher risk of developing skin cancer. Researchers claim that counting moles on the right arm is the best indicator to how many moles someone has altogether.

Having more than 100 moles on the body is thought to be a ‘strong indicator’ of a higher risk of melanoma.

The study examined data from 3,594 female Caucasian twins. Specially trained nurses from St Thomas’ Hospital in London performed a mole count on 17 areas of the twins’ bodies. Researchers found that the number of moles on the right arm was the most reliable predictor of total mole count than any other area. Further information on skin type, hair and eye colour, and freckles were also recorded.

“The findings could have a significant impact for primary care, allowing GPs to more accurately estimate the total number of moles in a patient extremely quickly via an easily accessible body part,” said Simon Ribero from the department of twin research and genetic epidemiology.

He added, “This would mean that more patients at risk of melanoma can be identified and monitored.” Malignant melanoma is now the fifth most common cancer in the UK, with more than 2,000 people dying from the disease each year.

1 in 3 facial surgeons

in the US claim that they saw an increase of patients requesting cosmetic surgery in 2014 due to the popularity of ‘selfies’ (American Academy of Facial Plastic and Reconstructive Surgery)

In a survey of 500 females, 38% said that they would consider cosmetic surgery procedures (OnePoll)

Approximately 85%

of people between the ages of 12 and 24 experience minor acne (British Journal of Dermatology)

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Events diary 3rd – 4th December 2015 B.A.D Research Techniques Course, London www.bad.org.uk/events

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

22nd January 2016 RSM Aesthetics 8, London www.rsm.ac.uk/aesthetics8

28th – 31st January 2016 IMCAS World Congress 2016, Paris www.imcas.com/en/attend/imcas-worldcongress-2016

4th – 8th March 2016 American Academy of Dermatology Annual Meeting, Washington D.C. www.aad.org/meetings/2016-annual-meeting

30th March – 2nd April 2016 AMWC World Congress 2016, Monte Carlo www.euromedicom.com

15th – 16th April 2016 Aesthetics Conference & Exhibition, London www.aestheticsconference.com

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Conference

New speakers announced for ACE 2016 New speakers for the Expert Clinic agenda at next year’s Aesthetics Conference and Exhibition (ACE) have been announced. A host of new presenters will join the established team of industry leaders at ACE 2016, providing informative discussions on the latest aesthetic topics and performing live treatments using the most up-todate techniques and products. April 15 will include talks from aesthetic practitioner Dr Victoria Dobbie, who will present on botulinum toxin off-label indications; plastic and cosmetic surgeon, Mr Adrian Richards, who will compare surgical and non-surgical options for the face; dental surgeon and aesthetic practitioner, Dr Souphiyeh Samizadeh, who will discuss different facial skeletal patterns and how to optimise facial aesthetics; aesthetic practitioner Miss Sherina Balaratnam, who will present the three-dimensional approach to injectables as well as a talk by nurse prescriber and director of AestheticSource, Lorna Bowes. The day will also have an international presence, with Serbian plastic surgeon Dr Vladislav Ribnikar to go through treatments using PDO threads. April 16 will include sessions led by aesthetic practitioner Dr Lee Walker, who will explain lip augmentation; dermatologist Dr Daron Seukeran, who will examine the range of laser treatments available for the skin; aesthetic practitioner, Dr Sangita Singh, who will explain ‘the red flag patient’; cosmetic surgeon, Dr Sotirios Foutsizoglou, who will share hair transplant techniques, anatomy and physiology, and dental surgeon Dr Kishan Raichura together with aesthetic doctors Dr Sarah Tonks and Dr David Jack, who will lead the session on different approaches to lower face treatments.

To book your place at ACE 2016 and to find out more about the speakers visit www.aestheticsconference.com Surgery

Aquisition

Med-fx bought

by The Dental Directory The Dental Directory has acquired Med-fx as part of its growth strategy.

Facial aesthetics and skin rejuvenation provider Med-fx has a long history of working with The Dental Directory, which claims to be the largest purchaser of dental products in the UK. The addition of Med-fx to the company opens up a new segment of the medical sector, as well as expanding its product offering. Chief operating officer at The Dental Directory, Mark Stephenson, said, “Med-fx is a great brand and a natural fit for The Dental Directory. We are delighted to be expanding our facial aesthetics expertise for our existing dental clients as well as providing Medfx customers with a superior choice of medical supplies partner.”

The deal formalises the relationship between the two companies and it is hoped the partnership will deliver enhanced value and service for customers of both organisations.

RCS calls on surgeons to prepare for changes in standards The Royal College of Surgeons (RCS) is requesting that hospitals and cosmetic and aesthetic surgeons prepare for changes that will improve standards of care in the industry. From spring 2016, surgeons will be able to apply for certification that will show they are qualified and competent to perform specific procedures.

It is hoped this will allow surgeons working in the private sector to demonstrate that they have reached a high standard of training and experience to perform cosmetic surgical procedures. Mr Stephen Cannon, chair of the Cosmetic Surgery Interspecialty Committee (CSIC), which was set up to oversee the changes said, “We are calling on all surgeons who perform cosmetic surgery to prepare for these very important changes. This new system of certification will raise standards of care for patients and enhance the reputation of the profession as a whole.”

Currently, cosmetic surgery is not defined as a specialty, but from spring next year, surgeons will be able to demonstrate their skills and expertise upon certification.

“It will make cosmetic surgery safer for patients, who for the first time, will be able to identify a highly qualified, experienced surgeon to perform a procedure through a register of surgeons,” said Mr Cannon. He continued, “It will also make it simpler for hospitals to check the qualifications, experience and training of the doctors who work there. All eligible surgeons should apply for certification.”

Surgeons will be able to obtain certification in one or more groups of closely related procedures, as long as they are on the General Medical Council’s specialist register, in a specialty that demonstrates training and experience in the chosen area of practice, and they can demonstrate they meet certification requirements.

These changes come in response to the PIP breast implant scandal, which led to the Keogh report in April 2013.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Laser

Syneron Candela releases PicoWay Resolve Aesthetic medical device company Syneron Candela has launched a new dual wavelength fractional modality for the PicoWay picosecond laser.

The Resolve fractional picosecond modality features both 532nm and 1064nm wavelengths. The device employs a holographic fractionator, which aims to deliver precise, consistent energy to the entire treatment area. The two different wavelengths aim to allow treatment of shallow lesions with the 532nm wavelength and deeper lesions with 1064nm.

“PicoWay continues to exceed expectations and delight customers,” said Amit Meridor, chief executive officer of Syneron Candela. “We are thrilled to introduce to the market the next step in the PicoWay story, Resolve, the fractional modality that uniquely includes two wavelengths. Our PicoWay customers know that we have a robust road map for PicoWay which includes expanded applications and new capabilities enabled by outstanding technology. It is energising to witness the excitement that this product is experiencing in the marketplace as we introduce appealing new ways to utilise the technology to treat patients.”

Clinic

Mr Dalvi Humzah opens clinic in Oxfordshire The AMP (Aesthetic Medical Practitioners) Clinic has opened in Greatworth, near Banbury in Oxfordshire. The new clinic, launched by consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah and cosmetic and dermatology nurse practitioner Anna Baker, aims to be a multidisciplinary clinic, incorporating treating patients, and teaching and training practitioners. It offers a variety of treatments including non-surgical injectables, skin peels, dermatology and laser hair removal. Baker said, “We are delighted to have opened a new site due to recent expansion and have had a fantastic response so far. We look forward to developing the service in the future.”

Award

Skin to Love Clinic receives award Aesthetic manufacturer Teoxane UK awarded The Skin to Love Clinic in St Albans the ‘Teosyal Outstanding Clinic’ award. The award, presented quarterly, is judged upon performance in areas such as customer service, patient safety, treatment results and commitment to training and product knowledge, as well as recognising the standard of Teosyal-certified practitioners and clinics throughout the UK. Kerri Lewis, clinic manager, said “We are so thrilled to have won the Teosyal Outstanding Clinic award. At the clinic we strive for excellence in our customer service, patient safety and treatment results so it’s fantastic that Teoxane UK has recognised us in this way.”

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Gary Conroy, co-founder of 5 Squirrels Why did you decide to start 5 Squirrels?

Having developed strong partnerships with medical aesthetic practitioners, the issue of mainstream skincare brand manufacturers selling skincare products directly to patients was causing real issues with patient trust and retention. Essentially, many practitioners were being used to endorse and recommend mainstream brands, only to find the manufacturers selling the products at discounts directly to patients. Being faced with an angry patient who has bought a brand from a practitioner at a reasonable price and then finds it at a bargain price on Amazon does not evoke trust!

How does 5 Squirrels solve this problem?

We are the silent partner of concerned practitioners, supporting them in the development of their own skincare brands.

They are then able to recommend their own brand products; re-establishing trust and loyalty with patients. Our research revealed that there is a relatively small number of molecules used in skincare with robust clinical evidence; the majority of mainstream brands essentially all have the same generic ingredients, L-ascorbic acid, retinol, alpha hydroxy acids, humectants, emollients, metallic oxides, etc. Practitioners who work with us can offer the same clinicallyproven ingredients to their patients at an affordable price.

What success have you had?

Some brands have appeared on national television and been recommended by celebrities in the national press. Others are now sold in high-end retail outlets. This has really disrupted the current skincare trends and successful clinics are able to recruit new patients for treatments following exposure to their brands.

Is the process complicated?

Launching a new brand can be very expensive and time consuming, without the guarantee of success. We remove most of the risk by allowing our partners to order low quantities of products.

We have streamlined the process and have a network of suppliers who are able to handle all of the brand artwork, regulatory requirements, production, supply and batch traceability, without individual practitioners having to start from scratch every time.

This column is written and supported by

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Launch

Skyncare releases Biocare-one UK-based aesthetic technology provider Skyncare has launched a new multifunctional device to deliver a range of aesthetic treatments.

Biocare-one is an all-in-one system that encompasses laser, IPL and radiofrequency technologies. The system supports eight interchangeable handpieces and aims to offer a combined capability of more than 20 different aesthetic treatments, including stretch-mark reduction, hair removal and skin rejuvenation.

Skyncare director Rob Knowles said, “It gives you the flexibility to provide a range of aesthetic treatments suited to your clientele, and all from just one device.” He continued, “Platform devices are the future of aesthetic technology. With such versatility in its application, the ability to expand a growing business, or streamline an established one, the Biocare-one embodies the progressive direction of the industry.”

Research

Nearly a third of visibly scarred men feel compelled to change their behaviour A survey conducted by OnePoll has suggested that 31% of men with visible scars feel pressured to adhere to the ‘tough guy’ image associated with facial scarring.

The survey indicated that 10% of visibly scarred men have felt negatively judged as a result of their scars and 15% feel the need to joke or explain about their scars on first meeting people, to ‘get it out of the way’.

The founders of Science of Skin, clinician scientist Dr Ardeshir Bayat and cosmetic surgeon and British Association of Aesthetic Plastic Surgeons (BAAPS) member Mr Douglas McGeorge, commissioned the study after formulating their Solution for Scars cream. The cream, which aims to treat scars that are still symptomatic, contains a form of green tea extract that Dr Bayat and Mr McGeorge claim has been proven to be particularly effective in actively shrinking scars.

Light therapy

Skinbrands launches Lightfusion Aesthetic product supplier Skinbrands has released a new non-invasive light therapy device.

The company explains that Lightfusion aims to rejuvenate the skin by delivering 10 minutes of optimised red and near-infrared (NIR) light simultaneously.

The product uses wavelengths of light that energises cellular functions within the body and aims to help the absorption of skincare. It is claimed that phototherapy creates a cascade of biochemical reactions, which continue after the treatment is finished, and aim to stimulate collagen, improve skin laxity and reduce pigmentation. Skinbrands claim that Lightfusion has a simple user interface and includes an inbuilt timer and three treatment heads that overlap the cheeks, forehead, hairline, chin and periorbital region, or alternatively the chest area. The heads are designed to help reduce light scattering – which in turn improves treatment efficiency by maximising the light dose. Lightfusion is available now.

Aesthetics aestheticsjournal.com

News in Brief AestheticSource launches Xxtralash Medical aesthetics distributor AestheticSource has launched eyelash growth serum, Xxtralash. The product, which is formulated using hydrolysed soy protein, myristoyl pentapeptide-17 and lysophosphatidic acid, amongst other ingredients, aims to improve length and volume of eyelashes. The product, designed to be used daily, is brushed onto the base of the eyelashes at night. AestheticSource claims the serum can stimulate new growth, repair weak and thinning lashes, nourish the eyelash and prevent lash loss.

Active Gold Collagen re-released with new ingredient Minerva Research Labs has reformulated its Active Gold Collagen drink and remarketed the supplement to both men and women.

The liquid collagen drink, which aims to promote younger and healthier looking skin, has a new flavour of apple and mango and now contains chondroitin, which, according to Minerva, aims to give extra support to skin health, joints and muscles.

Fotona launches new app and touchscreen interfaces Fotona Lasers has re-designed its range to incorporate new technology. The new touch-screen interface aims to make the lasers easier to use for practitioners. The company has also created an iPad app, which allows Fotona users from around the world to communicate with each other and review the latest clinical studies and procedures.

In addition, the laser company has incorporated a customer relationship management (CRM) system with an integrated camera. Fotona Lasers also aims to enhance the safety and accuracy of treatments by introducing the MatrixView Thermal Detection System in the laser hand piece.

HA-Derma appoints new sales and marketing manager Aesthetic distributor HA-Derma has appointed a new sales and marketing manager. Iveta Vinklerova, who graduated with a master’s degree in Economics from the University of London, has more than five years of experience in the medical sales field, previously working with Boston Medical Group. Vinklerova said, “I am delighted to join the team.”

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Conference

IMCAS Annual World Congress 2016, Paris Thousands of aesthetic practitioners, plastic surgeons and dermatologists from across the world are set to attend the 18th International Master Course on Aging Science (IMCAS) Annual World Congress on January 28-31 at the Palais des Congrès, Paris.

As well as hosting 200 exhibiting companies, the Continued Medical Education (CME)-accredited programme will provide practitioners with more than 150 learning hours. The sessions will be available throughout eight rooms over four days and will allow practitioners to build and develop their knowledge of aesthetic procedures, alongside practice management skills, market analysis and industry insights.

IMCAS will host an array of speakers from across the world, including, Dr Arthur Swift, Dr Marina Landau, Dr Raj Acquilla, Dr Uliana Gout, Mr Dalvi Humzah, Mr Christopher Inglefield and Dr Tapan Patel. Topics covered in the conference will include, amongst others: skin ageing: basic and applied research, genital treatments using laser, clinical dermatology, business strategy: branding and planning, and managing your reputation. There will also be cadaver workshops on threads and injectables, as well as live demonstrations of best practice methods.

A brand new e-learning platform, IMCAS academy, will also launch at

On the Scene

the upcoming congress. The online platform will allow practitioners to catch-up on lectures after the meeting or view missed sessions from the comfort of their own home. At the end of the conference, delegates can obtain a Certificate of Attendance as well as CME credits, by filling out an evaluation form. Additionally, there will be lots of opportunities for networking with like-minded peers. Attendees can meet with companies from around the world in the large exhibition hall and develop new collaborations or partnerships during the Networking Cocktail session. On the Saturday evening IMCAS will host the Gala Dinner where attendees can socialise, relax and dance with fellow delegates. Dr Benjamin Ascher, plastic surgeon and IMCAS scientific director said, “IMCAS Annual World Congress 2016 promises to be the most exciting and innovative medical aesthetic event of the year. We’re looking forward to welcoming more participants, speakers and exhibitors than ever before and to providing a fantastic platform for the exchange of knowledge of experts from around the world.”

Practitioners can register online now for a full or partial access badge.

Early Bird rates are available until Wednesday December 16.

On the Scene

Meet The Face Surgeons, London Female-only led clinic The Face Surgeons (TFS) launched its new practice on Wimpole Street in London on October 28.

The five specialist surgeons, Miss Sarah Osborne, Miss Caroline Mills, Miss Katherine George, Miss Helen Witherow and Miss Sarah Little, welcomed friends, colleagues, patients and practitioners to the event.

TFS is a multidisciplinary team, with surgeons having expertise in different areas of the face. Miss Osborne performs eyelid surgery; Miss Mills, Miss George and Miss Witherow provide maxillofacial surgery and Miss Little, ear, nose and throat surgery.

Whether patients are seeking anti-ageing treatments, facial feminisation, ear, nose and throat procedures, maxillofacial or ophthalmic surgery, the surgeons aim to tailor treatment plans to each individual. Miss Mills explained she recognised a gap in the market in 2014 for a clinic that patients could go to seeking facial surgery that had a specialised surgeon for each part of the face. ‘For anybody contemplating facial surgery, this is often a daunting prospect,” said Miss Mills. “Some people are told they have to have surgery; others choose to have surgery for aesthetic reasons. Either way, who you choose as your surgeon is of paramount importance.” Miss Little added, “The mission of our clinic is to provide anyone who requests surgery the best possible advice from a true UK specialist in their field of care. We are a multi-skilled team and the first female-led clinic in the country which is very special.”

Mrs Sabrina Shah-Desai Eye Boost Launch, London Consultant ophthalmologist and aesthetic oculoplastic surgeon Mrs Sabrina Shah-Desai presented her new ‘Eye-Boost’ procedure in a private room at Chutney Mary restaurant in London on November 4. Friends, practitioners and members of the press were treated to breakfast at the Indian restaurant before Mrs Shah-Desai presented her new procedure, which aims to diminish eye bags and dark circles. She spoke about the anatomy of the eye, before explaining how she came to create her new eye treatment. The Eye-Boost treats the tear trough – the area between the eyelid and the cheek – by placing a hyaluronic acidbased dermal filler into the thin skin of the lower eyelid and medial tear trough; not deeply in the inner corner under the eyes, which Mrs Shah-Desai believes is the more common procedure.

“As we get older, the eye area can age in a number of ways,” said Mrs Shah-Desai.

“One of the biggest problems is the tear trough area – the hollow between the eye and the upper cheek, which can deepen, creating a tired look. It can also make dark circles and eye bags appear more prominent.” Mrs Shah-Desai explained that the filler aims to strengthen the skin’s inner matrix and add volume to pronounced tear troughs, plumping hollows and rejuvenating the area. She also claims to be the first practitioner in the country to use this technique and commented that she has been thrilled by the results seen from her patients so far.

“I am hoping to educate patients and the industry as the tear trough is a complex area and should only be treated by practitioners who are highly experienced.” said Mrs Shah-Desai. “I was really pleased at the interest generated by the Eye Boost treatment launch on November 4.”

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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A Reflection on 2015 Aesthetics looks back at the industry over the past year and asks practitioners what they think have been the biggest and most significant changes to occur in 2015 Patients This year has brought about a significant change in patients’ attitude toward aesthetic procedures, according to aesthetic nurse prescriber Adrian Baker. He believes patients are becoming more wary and careful than ever before. “What I have seen from my patients this year is a lot more caution and a lot more questions being asked – which I think is a good thing. Usually I would have to try and encourage my patients to ask questions or simply hand them the information I think they should know; now they are asking themselves. It’s nice to see patients coming in more informed and probing me as practitioner.

Patients ask, ‘Who are you?’ ‘What do you do?’ ‘Is that safe?’ ‘How long has that been used?’ – It’s great.”

Aesthetic practitioner Dr Beatriz Molina has also seen a change in her patients’ this year, as she says they now want to be able to get everything they want from one clinic or practitioner. “We are noticing a huge difference in our clinic; patients are coming in and wanting us to provide them with everything they require. Not only do they want the treatment, but they want the aftercare products, the moisturisers, and the supplements.” Dr Molina has tried to cater for this demand by offering a bespoke skincare range, which she believes has been another big development in 2015. “In the patient consultations, we would work hard to recommend the branded products that we sold in the clinic, but then the patients would go away and find it cheaper online, and it’s not necessarily the same quality.” Dr Molina decided to adopt the recent move of launching her our own branded skincare range, “Its been really popular and people have been coming back and buying it because they can’t get it anywhere else and it’s a really good price. I’ve seen other clinics starting to do this too and I think we are going to see a lot more of this in 2016.”

Treatments There has also been an increase in patients wanting minimally invasive treatments this year. Aesthetic practitioner Dr Preema Vig says her patients are now requesting a more natural-looking outcome to their treatments. “This year has been all about the ‘tweakment’ –

Aesthetics Journal

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little treatments that tweak rather than tuck. My patients’ want subtle treatments, to look rested, uplifted and refreshed – not like they’ve just had a procedure done.” Plastic and cosmetic surgeon Mr Adrian Richards agrees the natural-look is back, “It has become almost fashionable to look natural – less is now more.”

Looking at developments in treatments and techniques, Dr Molina believes that the advance in thread lift treatments has been a big achievement in the industry. “I know they have been around for a long time but there has been a big boom in threads this year – they’re huge. There is more competition now with more brands of threads available, which does means it’s a little bit costly, so I would like to see the prices revised.”

Although the mainstay of most aesthetic clinics still tends to be dermal fillers and botulinum toxin, Dr Vig believes that aesthetic body treatments have proved very popular this year, especially fat freezing treatments. “There has been a number of cryolipolysis devices launched in 2015 and I’ve definitely seen an influx of patients wanting these procedures.” Mr Richards has also noticed the patient demand for fat freezing treatments, “These treatments weren’t big last year but this year they certainly are. Lots of colleagues have told me how popular these treatments are and commented on the amount of enquiries they have had.”

Challenges Reflecting on the issues faced by the aesthetics industry in 2015, Dr Vig suggests that the ‘selfie culture’ on social media is causing patients to over-analyse their appearance and leads them to seeking out treatments they don’t necessarily need. “I’ve seen an increase in requests from younger patients for aesthetic treatments,” Dr Vig explains. “Whereas normally I might not see a patient until their late 30s, 40s or older, I have now seen women in their 20s wanting procedures. I think there is a fixation on looking perfect and it’s causing people to hone in on tiny imperfections just because of a certain angle on a photograph or ‘selfie’, when in real life, it isn’t obvious.” Many practitioners also worry that the industry still is not being taken seriously. Dr Molina says “I want recognition for aesthetic medicine, for it to be seen as a real, serious specialty. It’s very sad because, for practitioners who are passionate about aesthetics like me, we have felt that our industry is being vandalised by the bad practitioners – and unfortunately it has still been an issue in 2015.”

Regulation has remained a concern for most practitioners this year.

“It is the same old argument that has been carrying on since the Keogh Report,” says Baker. “I think sometimes we are considered by some professionals and members of the public as a bit of a cowboy industry. I do think some patients are almost playing Russian roulette when they choose a practitioner because there is currently no way for them to know who they are or how competent they are to do the procedure. Although it has been a slow process, I am confident regulation is going to happen.”

Competency In September this year, Health Education England (HEE) released the final publication of its 2015 guidelines, giving its recommendations regarding the safe practice of non-surgical aesthetic treatments.1 This was in response to the 2013 Keogh Report, which called for greater regulation of the industry and labeled the lack of regulation with dermal fillers a ‘crisis waiting to happen’.2 Some practitioners have viewed these guidelines as a big step in the move towards tighter regulation of the aesthetic industry in 2015.

“Practitioners have been striving for regulation in the aesthetic and

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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cosmetic sector for years – and often when policy has tried to be implemented, it has failed,” says Dr Tristan Mehta, managing director at the Harley Academy. “Off the back of the Keogh report, HEE created the first real framework for how qualifications in non-invasive cosmetic medicine can be achieved. This comes at a time when the General Medical Council (GMC) is opening up the possibility of credentialing; which will allow for doctors to gain formal acknowledgement for their competencies in this field.”

‘Credentialing’ would provide official recognition of practitioners’ capabilities in a particular area.3 Dr Molina also believes the possibility of credentialing and the HEE guidelines are an important move in the right direction this year. “We’re all working really hard to bring in better training and exams so that the profession is taken more seriously. Hopefully it will stop people being able to do a day course and start injecting straight away. The guidelines are another step forward towards this.” Similarly, the Nursing and Midwifery Council (NMC) has announced that from April 2016, they will be revalidating nurses and midwives to ensure they practice safely and effectively.

This is something Baker is particularly excited about, “As a nurse, this has been something very exciting to happen this year. The revalidation that’s coming will allow nurses to feel empowered and it will encourage better learning and better practice. It’s going to give us confidence and ensure we are competent.”

What does the future hold?

Looking ahead to 2016, Dr Mehta believes this year’s HEE guidelines, along with the hard work industry bodies are putting in,

Aesthetics

will ensure positive changes for next year. He says, “Expect to see a wave of higher-education options for aesthetic training in 2016. As practitioners we should aspire to best-practice guidelines. We can ultimately pave the way to improved patient safety.”

Dr Molina hopes next year will bring more cohesion between the different specialties. “I would love to see more unity between aesthetic practitioners, surgeons, nurses, dentists and more. I believe together we can move forward and make the standards in this industry much better – working as a team and helping each other to minimise the risks, as well as push out the rogue practitioners.

I know the different bodies, such as the BACN (British Association of Cosmetic Nurses), BAAPS (British Association of Aesthetic Plastic Surgeons) and BAPRAS (British Association of Plastic and Reconstructive Aesthetic Surgeons) are working hard independently to make this industry safer and better, but it would be good to see us all join forces next year.”

Mr Richards concludes, “The aesthetics industry has got a lot bigger this year and treatments are better than ever before, but what we need is regulation. It’s still a bit of a jungle out there, however I am hopeful we will see improvement next year.”

REFERENCES 1. Harley Academy, Health Education England 2015 Guidelines, Are you ready? (2015) <http://www. harleyacademy.com/hee-guidelines/> 2. Department of Health, Review of the Regulation of Cosmetic Interventions, (2013) p.5 <https:// www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_ Regulation_of_Cosmetic_Interventions.pdf> 3. General Medical Council, Introducing regulated credentials, (2015) <http://www.gmc-uk.org/ Introducing_Regulated_Credentials_Consultation_W_form_FINAL_distributed.pdf_61589419.pdf>

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Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

MAGROUP V-Soft Lift

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ACE 2016: The Conference Agenda With a 10% early booking discount running until December 31, we look at the comprehensive Conference agenda and detail what’s in store for delegates at the Aesthetics Conference and Exhibition 2016 Featuring expert speakers and high-quality educational content, the Aesthetics Conference and Exhibition (ACE) 2016 is not to be missed. Hundreds of aesthetic practitioners have already registered for the two-day event and delegates are still able to benefit from a special early booking discount for the first-class Conference.

This premium programme will comprise eight sessions presented by a team of more than 20 world-leading speakers, sharing their extensive knowledge and expertise on treating aesthetic patient concerns. Focused on key facial and body anatomical areas, each session will include anatomical explanation and discussion, a range of treatment options with live demonstrations, presentation of case study results, and vital complication management guidance.

The sessions, which will run for either 1 or 1.5 hours each, will cover aesthetic treatments for the forehead, temple and brow, perioral, chin and submental area, periorbital region, mid-face, lower face, neck, décolletage and breast, buttock and thighs, and vaginal rejuvenation. Each will provide an in-depth and thorough learning experience, enabling delegates to enhance their skillset, develop greater aesthetic results and improve patient satisfaction. Delegates can also share their opinions and participate in peer discussions with interactive voting pads, which will be utilised throughout the Conference agenda. All sessions will feature the latest audio-visual congress technology to allow maximum effect and optimise learning.

Mr Dalvi Humzah, Dr Tapan Patel and Dr Raj Acquilla will once again provide attendees with exclusive insights into their anatomy and injectables expertise during multiple sessions.

Aesthetics

Other popular ACE speakers returning for 2016 include Dr Simon Ravichandran and Dr Maria Gonzalez who will share their advice on treating the mid-face for volumisation and pigmentation, respectively. Dr Firas Al-Niaimi and Mr Taimur Shoaib will join the panel for the lower body session; Dr Kate Goldie will perform a periorbital live demonstration in Friday’s ‘Enhancing the Eye’ and Mr Adrian Richards and Dr Aamer Khan will draw on their experience to guide delegates in the neck and breast session. In the upperface module, specialist dermatologist Dr Stefanie Williams and aesthetic nurse prescriber Anna Baker will form key members of the esteemed panel, while Dr Sherif Wakil and Dr Kannan Athreya will look at treatment options for vaginal rejuvenation in their Saturday session. For the lower face, aesthetic nurse prescriber Sharon Bennett will perform a live demonstration of perioral rejuvenation, while consultant dermatologist Dr Sandeep Cliff will detail how to treat this area with active ingredients.

Joining the faculty will be new additions to the ACE team, including cosmetic practitioner Dr Uliana Gout, who will present on medical skincare and chemical peels; clinical lecturer and practitioner Dr Kieren Bong, who will give a presentation on the ‘Two-Point Eye Lift’, and GP and aesthetic practitioner Dr Shirin Lakhani, who will present the latest O-shot case studies. Also new to the agenda will be aesthetic nurse prescriber Frances Turner Traill who will highlight common pitfalls of treating the mid-face, Mr Sultan Hassan who will outline key anatomy and treatments for the buttock and thigh, and board certified ophthalmologist Dr Maryam Zamani who will discuss complications associated with treating the periorbital area with fillers.

To attend the Conference, delegates can choose to book either a one-day pass for the Friday or Saturday, or a two-day pass to experience the entire Conference agenda. The Conference Pass will also give visitors access to all the practical free content on the educational programme that includes; Masterclasses, where delegates can learn how to achieve the best results with the leading products from aesthetic suppliers; the Expert Clinic agenda, which will offer invaluable advice through live demonstrations of the most up-to-date techniques from the UK’s most successful practitioners; Business Track sessions providing essential advice on how to develop a thriving aesthetic practice, and a new addition to this year’s agenda, Treatments on Trial, where delegates can directly compare products with similar indications and join debates with company representatives on their use and success in aesthetic practice. A networking event, sponsored by 3D-lipo, will take place on Friday 15 from 5.30-7pm, offering delegates the opportunity to build new business contacts and liaise with peers and industry suppliers. For every ACE session attended, delegates will be awarded CPD points, with a total of 50 points available over the full education programme.

Aesthetic professionals can book Conference attendance on the new ACE website, where they are also able to view the full agenda timetable and search speaker biographies and exhibitor profiles.

Once logged in, delegates can create their own programme for ACE by saving the sessions that they particularly don’t want to miss to a personalised agenda in order to plan out their visit before arrival.

Early booking discount ends December 31. To book your place at ACE 2016 and find out more visit www.aestheticsconference.com HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

Consumer insight shows that patients fear an unnatural looking result.1 Achieving the natural look they desire involves careful treatment planning.2

JUVÉDERM® VOLIFT® Retouch (2 x 0.55ml) is a convenient configuration of JUVÉDERM® VOLIFT® with Lidocaine, to help you achieve the desired result for each patient.3

The smaller size can be used as part of a personalised treatment plan or for follow-up, helping you maximise patient satisfaction – while minimising product wastage.

2x 0.55ml

For flexibility to refine your patient outcomes ask about JUVÉDERM® VOLIFT® Retouch 1. Allergan Data on File. Medical Combined DOF 003 – Key insights. Aug, 2014. 2. Michaud T et al. J Cosmetic Dermatol. 2014;0:1–13. 3. JUVÉDERM® VOLIFT® Retouch DFU. 72733JR10, Rev 2015-01-16.

UK/0530/2015 Date of Preparation: November 2015

V O L I F T R E T O U C H

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Vaginal ageing The vagina ages in much the same way as the skin covering the rest of the body. It loosens and sags, taking on a droopy and wrinkled appearance. Women often notice differences after pregnancy and childbirth,1 but are particularly susceptible to vaginal changes following menopause. These include vaginal atrophy, whereby the vagina’s lining becomes thinner, drier and less elastic, due to declining levels of the hormone oestrogen.2 As well as being less attractive and appealing, an atrophic vagina is often the source of great discomfort, owing to the lack of lubrication, causing general itching and dyspareunia (pain during sex).3 What’s more, symptoms are likely to continue or worsen if left untreated.3

Treatment Options Dermal fillers At her Real You Clinics in Richmond and Godalming, Dr Taylor-Barnes offers a number of vaginal rejuvenation treatments. These include:

Vaginal Rejuvenation Allie Anderson talks to practitioners about the demand, concerns and treatment approaches used to enhance the function and appearance of the vagina Vaginal rejuvenation is a rapidly expanding treatment area offering solutions to complaints that, just a few years ago, those seeking such treatment would have been reluctant to even talk about. Now, however, treatments that aim to improve the form and/or function of the vagina are gaining recognition in the industry and among the public.

Why do women seek treatment?

Once restricted to invasive surgery and perhaps considered the most extreme form of vanity, the perception of the ‘designer vagina’ is now being challenged. According to the practitioners interviewed for this article, women of all ages are undergoing a range of minimally and non-invasive procedures to not only boost the appearance of their vaginas, but also – crucially – to overcome conditions that could seriously impinge on their quality of life.

“As a GP with more than 20 years of clinical experience, I have had a significant amount of exposure to intimate women’s health problems,” says aesthetic practitioner Dr Kathryn Taylor-Barnes. “I have realised that there is a need among women to have better solutions to problems of the genital skin, which they have previously just put up with because there hasn’t been treatments readily available that give a superior result.” And while many patients seek treatment primarily for medical reasons, the resulting cosmetic enhancement can have a positive effect, too. “There can be a great improvement in a woman’s confidence following treatment of her genital skin problem,” Dr Taylor-Barnes adds, explaining, “An aesthetic uplift can lead to a psychological uplift. This is what motivates me to offer these specific options in my clinics.”

• Non-ablative ‘soft surgery’ lifting, for episiotomy scar treatment and skin resurfacing, treatment of Bartholin’s cysts, ingrown hairs and follicular hypertrophy.

• Hyfrecator electrocautery for removal of labial and vulval warts and skin tags.

• Botulinum toxin to treat vaginismus and vulvodynia, caused by vaginal muscle tension or scarring.

• Dermal fillers for labial enhancement.

One of the most popular treatments is the use of dermal fillers containing hyaluronic acid (HA) gel. The benefits of HA as a panacea for anti-ageing have been well documented, and indeed HA-based fillers have been commonly and successfully used to rejuvenate facial skin for many years. The science behind HA is fairly simple: it is a naturally occurring substance found in cell and tissue fluids, and is a key component of well-moisturised skin.4 The skin’s high water content helps to keep it plump and pliable – properties associated with youthful skin – and therefore, HA fillers are a very effective tool for lip and cheek augmentation and correcting lines, wrinkles and folds.5 Dr Taylor-Barnes explains that since 2014, however, aesthetic practitioners in the UK have been offering a revolutionary procedure – injecting HA gel in the vagina – to treat vaginal atrophy. The filler contains HA gel that has an interpenetrated cross-linked structure to increase its longevity. The formula used

by Dr Taylor-Barnes also contains mannitol, a naturally occurring antioxidant that significantly slows down the breakdown of the filler by free radicals.6 First, local anaesthetic is applied superficially, followed by delivery of the filler through a 25-gauge cannula (to minimise the risk of haematoma) into the labia majora. “I massage the area post treatment to improve the filler-tissue integration and aesthetic contour,” explains Dr Taylor-Barnes, adding, “Most importantly, I conduct thorough disinfection with chlorhexidine pre and post treatment and prescribe oral acyclovir if there is a history of genital herpes.”

The effect of the filler – known as ‘labial puff’ treatment – is to volumise the labia majora, thereby concealing the labia minora in order to give a more proportioned appearance. It aims to restore tone and elasticity, strengthen the intra-vaginal muscles, and improve sensitivity, while also reducing mucosal dryness.7 This can have a significant impact on the patient’s day-to-day life, making simple things like sitting, exercising and wearing tighter trousers

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THE BUSINESS DESIGN CENTRE / LONDON / 15-16 APR 2016

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more comfortable. “The psychological benefits of a woman feeling happier in herself, and with her partner when naked or in an intimate situation, is priceless and can have a positive knock-on effect in other areas of her life,” Dr Taylor-Barnes says.

HA fillers for vaginal rejuvenation are not without their disadvantages, though. One of the main problems Dr TaylorBarnes reports is that the initial post-treatment swelling gives the patient the experience of much plumper labia majora than will be achieved in the long term, leading to disappointment when the swelling dissipates and the labia deflate. Aligning patients’ expectations with their budget and the treatment’s limitations can also be challenging. Infection, haematoma and labial asymmetry caused by lumping and drifting of the product are among the complications she has encountered. More worrying risks have been highlighted in the media, including pain, nerve paralysis, bleeding and loss of sensation during sex, due to the abundance of nerves and blood vessels around the clitoris, labia and urethral opening.8 However, research studies have concluded that high-molecular weight HA can be effective in improving postmenopausal vaginal atrophy with no adverse events,9 and that HA gel could be safely used more widely in women presenting with vaginal dryness of any cause.10 Laser resurfacing Just as dermal fillers have been adapted for use in genital rejuvenation, so have lasers. Lasers are commonplace in medical aesthetics, used to effectively treat the likes of unwanted hair, vascular lesions, scars and acne, pigmented lesions, tattoo removal, skin rejuvenation of the face and décolletage, and varicose veins.11 A more recent development is the fractional laser, in which the laser beam is optically split into thousands of tiny dots, each targeting a minuscule area at a time and leaving the surrounding tissue undamaged.12 Whereas HA fillers specifically target the outside of the vagina (as they are injected into the labia majora), the fractional laser is directed at the vagina’s inside wall.

Plastic surgeon Mr Christopher Inglefield explains that the practitioner inserts a probe into the vagina, through which the laser beam is directed. At the end of the probe is a small mirror angled at 45 degrees, which allows the beam to be reflected to hit the required spot of the interior wall of the vagina with precision.

The probe can be rotated at right angles, thereby enabling the practitioner to target the whole area through 360 degrees. “This gives a much more reliable, reproducible treatment,” comments Mr Inglefield, who uses a fractional CO2 laser. “It aims to improve the tone of the vaginal wall, thereby improving sexual function and pleasure for both the patient and her partner,” he comments. “By treating the anterior wall of the vagina, it also has very significant effects in treating stress urinary incontinence.13” How does it work? The laser uses light that transfers into heat energy, which penetrates to a depth that stimulates and promotes the regeneration of collagen and elastin fibres in the vaginal tissue.14 This newly synthesised collagen and elastin causes the vaginal skin to thicken – in the same way as the facial skin plumps when collagen production is boosted. The outcome is rejuvenated and toned vaginal skin, which increases sensitivity and has the added benefit of reducing symptoms of vaginal atrophy, such as dryness, burning and itching, dyspareunia and dysuria.15 Laser treatment has also been demonstrated to have a therapeutic effect on stress urinary incontinence, and is associated with a high level of safety and short recovery period.13

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Research studies have concluded that high-molecular weight HA can be effective in improving postmenopausal vaginal atrophy with no adverse events

As dermatologist Dr Harryono Judodihardjo explains, successful treatment can have a major impact on a patient’s life. “It can be particularly helpful for women who have dyspareunia, which can be due to a lack of lubrication in the vaginal wall,” he says.

“After treatment, because the cells are renewed, they are able to produce more mucous, and lubricate during sex, therefore reducing friction and pain.16” According to aesthetic practitioner Dr Kannan Athreya, the psychological effect in older women is even more profound. “Some ladies in their 60s will come to see me and after the first treatment, they tell me they are getting a physiological discharge again, when the last time they experienced that was in their 40s or even their 30s,” he says. “It can be a very emotional thing for them, because it reminds them of an earlier time, and things are beginning to work once more.”

Practitioners report that vaginal laser treatment is relatively painless and problem-free. Dr Judodihardjo recommends that, following treatment with the CO2 laser, patients should refrain from sex for five to seven days, and with the erbium YAG laser, for three days. Side effects are limited to mild bleeding or spotting, and the procedure lasts around 20-25 minutes. “The main disadvantage is that because it’s a non-invasive treatment, it offers gradual improvement,” Mr Inglefield comments. “Most patients need two or three treatments to achieve good results, which can take several months to come about and can last approximately two years.”

According to Mr Inglefield, it is suitable for most women, with the exception of those suffering severe vagina laxity or severe urinary incontinence; in such cases he suggests that surgery would be more appropriate.

Platelet-rich plasma (PRP) A string of celebrity endorsements has plunged the ‘vampire facelift’ firmly into the spotlight in the last few years. But now, this treatment – which involves withdrawing the patient’s own blood, processing it to create platelet-rich plasma (PRP), and then re-injecting it to smooth wrinkles and regenerate collagen – has applications in other, more intimate areas. As well as the ‘vampire breast lift’, some women are beginning to opt for vaginal rejuvenation using PRP. Blood is taken from the patient (usually their arm), and is spun

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Although some side effects have been reported, all the treatments discussed have anecdotally yielded impressive results through a centrifuge machine to separate out plasma containing a high concentration of platelets – at least four to eight times normal levels.17 This PRP is rich in growth factors, naturally occurring substances that stimulate cell growth and proliferation, and thereby promote tissue regeneration.18 Aesthetic practitioner Dr Sherif Wakil pioneered the use of one vaginal PRP system in the UK just last year, but therapeutic properties of PRP have been used for many years in orthopaedics, dentistry, maxillofacial surgery and wound healing.19 “The point of this treatment is that when you inject platelets into one place, it regenerates the area that is injected, whether it is bone, muscle or skin,” explains Dr Wakil. “In the vagina, the skin becomes thicker and firmer, giving it a glow and making it look much more youthful. You also increase vascularisation into the area, which in turn means sensitivity is dramatically increased.”

In addition, the newly plumped skin of the vaginal wall provides a supporting structure for the urethra, making PRP an effective treatment for urinary incontinence.20 A third indication is a condition called lichen sclerosus, a chronic disorder affecting the skin around the genitals, causing very itchy and sore white spots.21 “Patients with this disease are often brushed off by their GPs because there is no treatment for it, other than topical steroid cream that also makes the skin thinner, causes other side effects and cannot improve sexual function,22” Dr Wakil adds. PRP injections, however, have been shown in a small number of early studies to result in regeneration of normal skin.23 While other types of PRP system take around 10 to 20ml of blood and centrifuge it to produce 8ml of platelet-rich plasma, the machine Dr Wakil uses takes 60ml and breaks it down to 8ml of PRP, resulting in a far higher concentration which yields superior results, he claims. “The procedure is safe and effective, it takes about 40 minutes and patients can go back to work straight afterwards, and can even have sex the same day,” he adds.

The ease and lack of down time associated with PRP injections may explain why they are rapidly becoming so popular. Recent figures predict the global market will reach US $0.35 billion by 2020.19 Dr Athreya postulates that the increasing numbers of women seeking these types of treatments for post-menopausal vaginal symptoms reflects the decline in take-up of hormone replacement therapy (HRT). This was typically prescribed for many women going through menopause until 2002, when the US Women’s Health Initiative study suggested that women using HRT were at a higher risk of breast cancer.24 A UK study the following year corroborated these findings.24 “There is still a lot of concern and anxiety over HRT (since the reports) and many women have stopped taking HRT at the time of menopause,” Dr Athreya comments. “This leads to vaginal atrophy, and in the end, these ladies develop the problems associated with it, such as irritation, dryness and painful intercourse. It’s great that we can now address this for ladies who don’t want to try HRT.”

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Conclusion It’s clear that numerous benefits can be derived from all the treatments on offer, both aesthetically and clinically. Although some side effects have been reported, all the treatments discussed have anecdotally yielded impressive results. At the very least, the growth in this area of medical aesthetics is generating more open discussion among women about common intimate problems that, left untreated, can drastically impinge on their quality of life. And that can only be a good thing.

Dr Sherif Wakil and Dr Kannan Athreya will share their techniques for vaginal rejuvenation at the Saturday afternoon Conference programme session of the Aesthetics Conference and Exhibition 2016, taking place on April 15 and 16. To find out more visit www.aestheticsconference.com/programme REFERENCES 1. NHS Choices, Vagina changes after childbirth (UK: NHS, 2013) <http://www.nhs.uk/Livewell/vagina-health/Pages/vagina-after-childbirth.aspx> 2. The North American Menopause Society, Changes in the vagina and vulva, (US: North American Menopause Society, 2015) <http://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva.> 3. NHS Choices, Menopause – symptoms, (UK, NHS, 2014) <http://www.nhs.uk/Conditions/Menopause/Pages/Symptoms.aspx.> 4. Papakonstantinou E et al., ‘Hyaluronic acid: A key molecule in skin aging’, Dermatoendocrinol, 4 (2012) pp.253-258.

5. Lupo MP, ‘Hyaluronic acid fillers in facial rejuvenation’, Semin Cutan Med Surg, 25 (2006), pp.122-6 and Sundaram H et al., ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications’, Plast Reconstr Surg, 132 (2013)Clinical introduction to the hyaluronic acid dermal filler using cohesive polydensified matrix technology):5S-21S, cited in: Robert S Bader MD, ‘Dermal Fillers: Hyaluronic acid’, Medscape, 2015 <http://emedicine.medscape.com/ article/1125066-overview#a3.> 6. Ramos-e Silva M, ‘STYLAGE: a range of hyaluronic acid dermal fillers containing mannitol. Physical properties and review of the literature’, Clin Cosmet Investig Dermatol, 6 (2013) pp.257-261. <http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3810198/> 7. Consulting Room, Desirial – product summary (UK: Consulting Room, 2015) <http://www.consultingroom.com/treatments/desirial-vaginal-rejuvenation> 8. Ruth Styles, Would you plump up your vagina with fillers? Top cosmetic doctor warns of risky new trend... after being inundated with clients looking for ‘genital enhancements’, (UK: Daily Mail, 2015) <http://www.dailymail.co.uk/femail/article-3114937/Top-cosmetic-doctor-warns-risky-new-trend-genital-filler-jabs.html> 9. Grimaldi EF, Restaino S, Inglese S, Foltran L, Sorz A, Di Lorenzo G, Guaschino S., ‘Role of high molecular weight hyaluronic acid in postmenopausal vaginal discomfort’, Minerva Ginecol. 64 (2012) pp.321-9. <http://www.ncbi.nlm.nih.gov/pubmed/22728576> 10. Stute, P., ‘Is vaginal hyaluronic acid as effective as vaginal estriol for vaginal dryness relief?’, Arch Gynecol Obstet, 288 (2013) pp.1199-201.

11. Patil, UA and Dhami, LD., ‘Overview of lasers’, Indian Journal of Plastic Surgery, 41 (2008) S101-S113.

12. Ngan, V., ‘Fractional laser treatment’, DermNet New Zealand Trust, 2015. <http://www.dermnetnz. org/procedures/fractional.html.> 13. Ivan, F et al, ‘Minimally invasive laser procedure for early stages of stress urinary incontinence’, Journal of the Laser and Health Academy, 1 (2012) <http://www.laserandhealthacademy.com/ media/objave/academy/priponke/67_74_laha_journal_2012_1.pdf> 14. Salvatore S, Leone Roberti Maggiore U, Athanasiou S, Origoni M, Candiani M, Calligaro A, Zerbinati N. ‘Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue: an ex vivo study’, Menopause, 22 (2015) pp.845-9.

15. Salvatore S, Nappi RE, Zerbinati N, Calligaro A, Ferrero S, Origoni M, Candiani M, Leone Roberti Maggiore U., ‘A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study’, Climacteric, 17 (2014) pp.363-9. <http://www.ncbi.nlm.nih.gov/pubmed/24605832> 16. Perino A, et al, ‘Vulvo-vaginal atrophy: A new treatment modality using themo-ablative fractional CO2 laser’, Elsevier, 2015 <http://www.happyhooha.com.au/files/5514/3037/8480/V2LR_Perino_et_ al_Maturitas_2015.eng_IN_PRESS.pdf> 17. MedGadget, Platelet Rich Plasma Market Set to Reach US$0.35 billion by 2020 (US: MedGadget, 2015) <http://www.medgadget.com/2015/11/platelet-rich-plasma-market-set-to-reach-us0-35-billionby-2020.html> 18. El-Sharkawy H, Kantarci A, Deady J, Hasturk H, Liu H, Alshahat M, Van Dyke TE., ‘Platelet-rich plasma: growth factors and pro- and anti-inflammatory properties’, J Periodontol, 78 (2007) pp.661-9. <http://www.ncbi.nlm.nih.gov/pubmed/17397313> 19. Ashish Jain, Ravneet Kaur Bedi, and Kshitija Mittal., ‘Platelet-rich plasma therapy: A novel application in regenerative medicine’, Asian J Transfus Sci, 9 (2015) pp.113–114. <http://www.ncbi.nlm.nih. gov/pmc/articles/PMC4562126/> 20. ‘Urinary incontinence: Novel nonsurgical method to treat vesicovaginal fistula’, Nature Reviews Urology 10, 125 (2013) <http://www.nature.com/nrurol/journal/v10/n3/full/nrurol.2013.5.html> 21. NHS Choices, Lichen sclerosus – introduction (UK: NHS, 2014) <http://www.nhs.uk/conditions/ lichen-sclerosus/Pages/Introduction.aspx.> 22. NHS Choice, Topical cortocosteriods – side effects (UK, nhs, 2015) <http://www.nhs.uk/Conditions/ Corticosteroid-preparations-(topical)/Pages/Side-effects.aspx> 23. Casabona F, Priano V, Vallerino V, Cogliandro A, Lavagnino G., ‘New Surgical Approach to Lichen Sclerosus of the Vulva: The Role of Adipose-Derived Mesenchymal Cells and Platelet-Rich Plasma in Tissue Regeneration’, Plastic & Reconstructive Surgery, 126(4) (2010). <http://www.dermnetnz.org/ immune/lichen-sclerosus.html.> 24. NHS Choices, Health scare ‘clouded views on HRT’, (UK: NHS, 2012) <http://www.nhs.uk/ news/2012/05may/Pages/hrt-risk-examined-after-health-scare.aspx>

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The ABC of Moles

Consultant plastic surgeon Mrs Barbara Jemec shares advice on recognising a malignant melanoma Skin cancer is increasing, and the incidence of Malignant Melanoma (MM) has been rising by 3-7% every year since 1989.1 MM accounts for only 2% of all skin cancers worldwide, however it causes the majority of skin cancer related deaths.2 The occurrence is highest in New Zealand and Australia, while, in Europe, the incidence for men is highest in Switzerland and for women in Denmark.2 Caucasian people now have a 2.4% (1 in 40) chance of developing MM in their lifetime, while Hispanics have a 0.5% (1 in 200) chance and Africans a 0.1% (1 in 1,000) chance of developing the disease.3 According to the American Cancer Society, an estimated 9,940 people in the US will die of melanoma in 2015.3 Most MMs arise in previously normal skin, though having more than 100 moles increases the chances of having a MM fourfold, as do atypical or very large moles.4 Any changes in asymmetry, border, colour, diameter and evolution of a pigmented lesion, including the ‘Ugly Duckling’ sign – which refers to a mole that doesn’t look like the others – should also be treated as suspicious. The main treatment remains removal through surgery, though recent advances in immunotherapy has improved survival in advanced disease.5 While it is not the duty of aesthetic practitioners to treat an MM, they can play a role in identifying any suspicious lesions early and alerting patients of when to seek specialist help. Working closely with patients to treat age-related and aesthetic concerns means practitioners have direct and regular access to patients’ skin, allowing them the opportunity to monitor any changes in the appearance of moles and provide valuable advice on appropriate sun care to reduce the chance of developing a malignant melanoma. This article aims to offer comprehensive advice on what changes to be aware of, and how to best manage them.

Occurrence of MM MM arises de novo in about 75% of cases and in 25% from preexisting moles.4 Having numerous moles (100+) or Dysplastic Naevus Syndrome increases your lifetime risk of developing MM 4-10 times.4 Atypical Naevus Syndrome is associated with a melanoma called Familial atypical multiple mole melanoma (FAMMM) which is a syndrome (autosomal dominant) genodermatosis, characterised by multiple melanocytic nevi, usually more than 50 moles, and a family history of melanoma.6 Figure 1

Figure 2

Unevenly pigmented melanoma with irregular border

Red melanoma

86% of MMs can be attributed to UV radiation7 and the risk of a MM doubles if a person has experienced more than five sunburns in their lifetime.8 The regular use of SPF 15 reduces the risk of MM by 50%,9,10 and using a higher SPF will likely give even more protection, but people who use a tanning bed before the age of 35 increase their risk by 75%.11 A single indoor tanning session increases a person’s chance of developing MM by 20%, and every subsequent tanning session in the same year by 2%.12 Learning the ABC Of course, a normal mole does not become a MM overnight; it will undergo a gradual change that can usually be identified using what we call the ‘ABCDE of moles’. The ABCDE details five changes that could occur within a mole, providing practitioners and patients alike with information on what factors to be aware of.

A is for Asymmetry: Any mole that is not symmetrical if halved is suspicious, so an oblong mole is acceptable, but a mole which has a bizarre shape should be looked at by an expert. I have excised a perfectly round MM, but this is a rarity and other features (such as growth, change in colour etc.) in a round mole should make you suspicious.

B is for Border: A benign mole usually has a smooth border, whilst the border of a MM might be indistinct, irregular, notched and uneven (Figure 1). A specific and very visible difference is when moles become Halo Naevi, which is discussed in more detail later in the article.

C is for Colour: A normal mole is evenly pigmented, while a MM is usually not (Figure 1), however an evenly pigmented mole, which suddenly starts growing, or ulcerating, or is asymmetrical should be treated as suspicious. MMs usually become darker, and can sometimes appear black unevenly within the previous pigmented area of the mole. 4% of MMs are, however, red (Figure 2), and are now recognised as a separate entity.13 The red colour is most likely present because the pigment is missing.

D is for Diameter: Small moles are rarely dangerous, but larger moles carry a 4-10 times greater risk of becoming a MM,14 which is why doctors sometimes recommend large moles are excised, even if they do not exhibit any of the warning signs that they have turned bad. A mole is classified as large when it has a diameter larger than 6mm.

E is for Evolution: As we become older, we develop more moles.

Figure 3

‘Ugly Duckling’ sign

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BAD advice The British Association of Dermatologists (BAD) guideline from 201018 outlines the required minimal histological dataset for a MM. The guidance offers a broad overview of what dermatologists should be aware of when examining skin, hence, I advocate aesthetic practitioners familiarise themselves with the guidance and follow it in their own practice. Noteworthy points include: Presence or absence of ulceration: Ulceration has prognostic value as it changes the overall thickness of the tumour.

Thickness: Found to be the single most predictive marker of outcome.

Mitotic count: The number of mitoses has prognostic value, it also tips very thin tumours under 1 mm into the Sentinel Lymph Node Biopsy group (see SLNB section).

Histological subtypes: Desmoplastic melanoma in particular behaves differently, and the subtypes: superficial spreading, nodular, Lentigo Maligna and acral lentiginous melanomas all have good clinicopathological correlation.

Margins of excision: To determine whether the excision is complete.

Pathological staging: For prognosis and further treatment.

Growth phase: MM has horizontal and vertical growth phases.

Regression: Has not been shown to affect long-term outcome.

Tumour-infiltrating lymphocytes: It is still unclear whether this has prognostic value.

Lymphatic or vascular invasion: Vascular or lymphatic infiltration has prognostic value.

and disappears, while the paler skin surrounding it gradually re-pigments.17 These moles are usually benign, at worst atypical, but the process can be triggered by a MM somewhere else, so a careful skin examination is required.17 The formation of a halo surrounding a naevi occurs when white blood cells (CD8+ T lymphocytes) destroy the melanocytes. This is presumably because the body recognises them as abnormal, something that a MM might have sensitised the immune system to. A Halo Naevi is mostly found in children and young adults.17 Excision The width of the primary excision is determined by the thickness of the tumour: in situ tumours are excised with a 5mm margin, 1mm tumours with 1cm, between 1 and 2 with 1-2cm, between 2 and 4mm by 2-3cm and more than 4mm by 3cm.18 Bearing this in mind, the primary excision biopsy, to determine the thickness and the exact histology, is done with a 2mm margin, though it must be complete and must take into account a later re-excision, so orientation is paramount.18 Defects resulting from excision of MM can be quite extensive, but can be reconstructed with flaps to make the aesthetic result more acceptable, without compromising detection of local recurrence. The MM is not suitable for excision with Mohs’ surgery as Mohs’ is used for for lesions that are not well circumscribed and an MM is a well-circumscribed lesion.19

Sentinel lymph node biopsies The next step is to determine whether to offer the Perineural infiltration: Correlates with increased local recurrence and is patient a Sentinel Lymph Node Biopsy (SLNB), which most commonly associated with desmoplastic melanoma. is also mostly determined by the thickness of the Microsatellites: These are defined as islands of tumour outside the main tumour. Any MM that is thicker than 1mm is offered a tumour and are predictive of regional lymph node metastases.

SLNB, and, in the presence of mitoses, even thinner MMs are too.20 The mitotic count is taken as a measure Precursor naevus: The presence of a contiguous melanocytic naevus. of activity in the tumour. There is some controversy Clark level of dermal invasion: This is less reliable for prognosis than regarding SLNBs, as some practitioners feel a fine thickness. needle aspiration is enough.20 There are also concerns that a biopsy could result in a false negative and that it could be an unnecessary operation, as the disease Whilst most moles appear before the age of 20, sun exposure wouldn’t necessarily progress.20 The decision to offer patients increases the incidence of moles later in life,15 however any mole this option is taken by the Multi-Disciplinary Team (MDT). The MDT or previously normal skin that changes colour, grows or bleeds consists of all parties involved in the care of MM patients and spontaneously is better looked at by an expert and potentially includes members from the oncology, dermatology, plastic surgery, removed. For people with many moles, doctors look for the ‘Ugly pathology and radiology departments.

Duckling’ sign (Figure 3) – a mole that is the odd one out.16 For people with many moles, most are usually of similar size and The SLNB is the hypothetical first lymph node or group of nodes colouration, those that look different are an easy indicator of what draining a cancer, and identifying and examining this lymph node could be malignant. Examination of the lesion by dermatoscope, is an effective staging tool. If the SLNB is negative, the patient which is a hand-held skin microscope with a bright light source that is followed up on a regular basis: three months for the first two magnifies the skin 10 times, can give more certainty to determine years, then every six months for another three years. If the SLNB whether a lesion is benign or malignant. The dermatoscope is positive, then the patient undergoes imaging in the form of a contains polarised filters, which remove the glare of the bright light CT scan for staging, and if this scan does not show widespread and allow the user to examine the mole in much more detail and metastatic disease, the patient is offered a clearance of the to a deeper layer in the skin. A Halo Naevus deserves a special affected lymph node basin. The lymph node basins cleared include mention. It is a mole which presents with a lighter (un-pigmented) the groin, the popliteal fossa, axilla and neck. Further staging area of skin around it, which gradually changes colour in the middle depends on the number of further involved lymph nodes.21,22

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Local recurrences can be treated with surgery or electrochemotherapy (ECT). ECT refers to the combination of electroporation and administration of anticancer drugs for local treatment of solid neoplasms. Electroporation uses short and intense electric pulses to induce a transient permeabilisation of the cell membrane by creation of pores, which allows chemotherapeutic agents to freely diffuse into the cytosol.

The chemotherapeutic agent, for instance bleomycin, is given systemically.23 Regional recurrences are treated surgically, but when a MM is disseminated the treatment becomes oncological.

Recently, the development of immunotherapy for disseminated MM has brought new hope for patients.24 Immunotherapy Immunotherapy drugs used in MM treatment work by targeting molecules that serve as checks and balances in the regulation of immune responses. By blocking inhibitory molecules, these treatments are designed to unleash or enhance pre-existing anticancer immune responses.25 Almost 50% of MMs harbour mutations in the human gene (BRAF), which makes a protein (B-raf) that helps transmit chemical signals from outside the cell to the cell’s nucleus.26 B-raf is part of a signaling pathway, which controls several important cell functions such as proliferation, differentiation, migration, and apoptosis. BRAF is an oncogene, which when mutated, has the potential to cause normal cells to become cancerous.

Vemurafenib was approved in 2011 and is a BRAF inhibitor, which can induce the growth of cutaneous squamous-cell carcinomas – a unique side effect. Unfortunately, most responses to Vemurafenib are partial and disease progression is typically seen at a median of five to seven months.27 Ipilumumab is a mono-clonal antibody, which targets cytotoxic T-lymphocyte associated antigen 4 (CTLA-4), a protein found on the surface of T-cells which act as a brake for the cell’s cytotoxic activity. Ipilumumab removes this block and consists of four injections over three months.28 Pembrolizumab is also a monoclonal antibody, which binds to the programmed cell death 1 receptor (PD-1), in order for the T-cells to discover and kill the MM cells.29 All immunotherapy has the potential side effect of attacking the patients’ own normal tissues, and the process, therefore, has to be monitored closely.

Conclusion At present the overall five year survival for localised MM is 98%, with lymphatic spread 63% and distant spread 16%.3 Melanoma accounts for less than 2% of skin cancer cases, but the vast majority of skin cancer deaths.3 All practitioners dealing with skin can help early detection by being vigilant and using the ABCDE of moles and the ‘Ugly Duckling’ sign to recognise any abnormalities. Early detection is paramount to long-term survival and the changes can be subtle.

Although surgical removal remains the mainstay of treatment, and the outlook for patient with very thin melanomas remains very good, immunotherapy has brought some hope for patients with disseminated disease.

Aesthetics Journal

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Acknowledgement: I would like to thank Tina Rasmussen and Kristine Saad for the photographs.

Mrs Barbara Jemec is a consultant plastic surgeon at the Royal Free Hospital with a special interest in skin cancer, as well as a member of its Multidisciplinary Team (MDT). The MDT works together to discuss both NHS and private patients with skin cancer, and recommend the best treatment available.

FURTHER READING Skin Cancer Facts (New York: Skin Cancer Foundation, 2015) <http://www.skincancer.org/skin-cancer-information/skin-cancer-facts#melanoma> Skin cancer risk factors (UK: Cancer Research UK, 2015) <http://www.cancerresearchuk.org/healthprofessional/cancer-statistics/statistics-by-cancer-type/skin-cancer/risk-factors#heading-Two> REFERENCES 1. Parkin DM, Bray F, Ferlay J, Pisani P, ‘Estimating the world cancer burden: Globocan 2000’, Int J Cancer, 94 (2001) pp.153-156.

2. Ferlay J, Soerjomataram I, Ervik M, et al, ‘GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11’, International Agency for Research on Cancer (2013) <http:// globocan.iarc.fr> 3. American Cancer Society, Cancer Facts & Figures 2015 (American Cancer Society, 2015) <http:// www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf> 4. Olsen CM, Carroll HJ, Whiteman DC, ‘Estimating the attributable fraction for cancer: A meta-analysis of nevi and melanoma’, Cancer Prev Res 3 (2010) pp.233-45.

5. C Fellner, ‘Ipilimumab Prolongs Survival In Advanced Melanoma Serious Side Effects and a Hefty Price Tag May Limit Its Use’, Yervoy, 37 (2012) pp.503-511.

6. Atypical Mole (Dysplastic Nevus) (US, Medscape, 2015) <http://emedicine.medscape.com/ article/1056283-overview> 7. Parkin DM, Mesher D, P Sasieni, ‘Cancers attributable to solar (ultraviolet) radiation exposure in the UK in 2010’, Br J Cancer, 105 (2011), S66-S69.

8. Pfahlberg A, Kolmel KF, Gefeller O, ‘Timing of excessive ultraviolet radiation and melanoma: epidemiology does not support the existence of a critical period of high susceptibility to solar ultraviolet radiation-induced melanoma’, Brit J Dermatol, 144 (2001) p.471.

9. Green A, Williams G, Neale R, et al., ‘Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinoma of the skin: a randomized controlled trial’, Lancet, 354 (1999) pp.723-729.

10. Green A, Williams G, Logan V, Strutton G., ‘Reduced melanoma after regular sunscreen use: randomized trial follow-up’, J Clin Oncol, 29(2011) pp.257-263.

11. Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM., ‘Indoor tanning and risk of melanoma: a case-control study in a highly-exposed population’, Cancer Epidem Biomar Prev 19(2010), pp.1557-1568.

12. Boniol M, Autier P, Boyle P, Gandini S, ‘Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis’, BMJ, 345 (2012).

13. McClain SE, ‘Amelanotic melanomas presenting as red skin lesions: a diagnostic challenge with potentially lethal consequence’, Int J Dermatol,51 (201), pp.420-6.

14. Richard Bränström et al, ‘Melanoma Risk Factors, Perceived threat and Intentional Tanning: An Online Survey’, Eur J Cancer Prev, 19 (2010) pp.216-226.

15. Heinz, V, ‘Progress in Skin Cancer Research’, Horizons in Cancer Research, (2007), p.43.

16. Grob JJ, Bonerandi JJ., ‘The ‘ugly duckling’ sign: identification of the common characteristics of nevi in an individual as a basis for melanoma screening’, Arch Dermatol, 134 (1998) pp.103-104.

17. Patrizi A, Neri I, Sabattini E, Rizzoli L, Misciali C., ‘Unusual inflammatory and hyperkeratotic halo naevus in children’, Br J Dermatol, 152 (2005) pp.357-60.

18. Marsen et al, ‘Revised UK guidelines for the management of cutaneous melanoma’, British Journal of Dermatology, 2010.

19. Bogle M et al, ‘The role of soft tissue reconstruction after melanoma resection in the head and neck’, Head & Neck, 23 (2001), pp.8-15.

20. Phan GQ1, Messina JL, Sondak VK, Zager JS, ‘Sentinel lymph node biopsy for melanoma: indications and rationale’16(2009) pp.234-9.

21. Pieter J Tanis, corresponding author Omgo E Nieweg, Renato A Valdés Olmos, Emiel J Th Rutgers, and Bin BR Kroon, ‘History of sentinel node and validation of the technique’, Breast Cancer Res, 3 (2001), pp.109-112.

22. ‘Revised U.K. guidelines for the management of cutaneous melanoma’, British Journal of Dermatology, 163 (2010 ), pp.238-256.

23. Testori A, Rossi CR, Tosti G., ‘Utility of electrochemotherapy in melanoma treatment,’ 2 (2012), pp.15561.

24. Jedd D. Wolchok, Melanoma, (New York; 2015) <http://www.cancerresearch.org/cancerimmunotherapy/impacting-all-cancers/melanoma> 25. Yale J, ‘Biol Med. Focus: Immunology and Immunotherapeutics Ipilimumab and Cancer Immunotherapy: A New Hope for Advanced Stage Melanoma’, Curr Opin Oncol, 84 (2011), pp.381389.

26. Paolo A Ascierto, John M Kirkwood, Jean-Jacques Grob, et al. ‘The role of BRAF V600 mutation in melanoma’, J Transl Med, 10 (2012), p.85.

27. Jang S1, Atkins MB, ‘Which drug, and when, for patients with BRAF-mutant melanoma?’, Lancet Oncol, 14 (2013) pp.1470-2045.

28. C Fellner, ‘Ipilimumab (Yervoy) Prolongs Survival In Advanced Melanoma Serious Side Effects and a Hefty Price Tag May Limit Its Use’, 37 (2012) pp.503-511.

29. Robert C, Schachter J, Long GV, Arance A, et al, ‘Pembrolizumab versus Ipilimumab in Advanced Melanoma’, N Engl J Med, 372 (2015) pp.2521-32.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Aesthetics Journal

Treating the Brow Area

Case study

Dr Victoria Dobbie presents her techniques for treating aesthetic concerns around the eyebrows Every day I have patients asking me to treat the lines that are etched across their forehead and/or between their eyebrows. It is one of the most common requests for aesthetic treatment at my clinic. In my early days of practice I would have only considered botulinum toxin type A for the upper third of the face – primarily because it was the glabella that received the first cosmetic indication for the use of botulinum toxin type A in 2002.1 The basic course on the use of toxin was therefore focused on the lines between the brow, with little consideration to the end position and shape of the female brow. You may have seen patients with poor aesthetic results from toxin treatments, where their brows are too high laterally and too low medially, or too low and flat, giving the patient a heavy, tired appearance. Either way, they are not enhancing the patient’s overall appearance – even if the line that was bothering them was successfully treated. I believe that the eyebrow is the most dominant feature on the forehead and should be a key consideration at the diagnosis and planning stage, in order to improve the aesthetic outcome of forehead and glabella treatments. Practitioners who consider the brow first get optimal results that patients love and want to have repeated.

Treatment approach

1

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2

3 4

Figure 1: The ideal brow shape

1. Head of brow is in line with the width of the nose.

2. The brow should rise at an angle of 10-20 degrees.

3. Peak of the brow is at the same length as the intercanthal distance. At its highest it should peak at a PHI ratio of 1:1.618 with the patient’s hair line.

4. Tail of the brow is at 1:1.618 in relation to the peak and sits above the head of the brow, along the line that passes through the outer corner of the eye and tip of the nose.

The ideal brow is based on the principal that PHI or the ratio of 1:1.618 when applied to an individual’s face will make the face more beautiful. By aiming for the brow to be closer to the ideal position for the patient, they will have an aesthetically pleasing result.2

When consulting a patient, examine the brow at rest for any obvious asymmetry and balance. Even younger patients can present with a significant asymmetry, which will need to be factored into your treatment and discussed with the patient before treatment. Watch how Figure 2: Patient A – frontal the brow shape alters on movement, on elevation of the frontalis, and when contracting the corrugators, procerus and orbicularis oculi. Consider; does the full length of the brow sit on the orbital rim or is there a natural ptosis? If there is a ptosis then you need to ask yourself: 1. Is the use of toxin going to exacerbate a ptosis?

2. Can you correct the ptosis by repositioning the brow with dermal filler?

3. Or, is it more effective to treat the presenting line with dermal filler?

4. If there is excess skin, where is it and how will a toxin treatment effect the skin laxity? Often in older patients, forehead lines are an indication of excessive and loose skin.

Patient A (Figure 2) has an obvious asymmetry; with the exception of the head of the brow, her upper left brow is higher. In addition, the patient has temporal hollowing, asymmetric forehead hollowing over her right brow, thin skin, loss of elasticity and poor skin quality.

Examine Patient A in Figure 3 – does the patient’s forehead have a 12-15 degree curve? A curve of this description provides ideal bony support to the skin of the forehead and the position of the brow.2 Are there asymmetries in the bony support of the forehead?

Figure 3: Patient A – profile I find this is best analysed by laying the patient backwards and viewing their forehead from a superior position. If this is what is causing the lines, then addressing these asymmetries may give the patient the most effective aesthetic outcome. Projection of the brow is another consideration as soft tissue fullness and projection alters as we age. Temporal hollowing also causes lateral brow laxity, excess muscle contraction and lateral lines over the brow.3 Patient A (Figure 2) has flattening of the curve to her forehead and loss of brow projection. Assessment of skin quality is also fundamental to treatment and product choice: • What is the skin thickness?

• What is the skin elasticity?

• What is the severity of wrinkle and how many are there?

• How many millimeters of excessive skin do you find?

Treatment plans I take all of these factors into account when devising an appropriate treatment plan for my patient. It allows me to explain the limitations of a single modality and frame their expectations, inform the patient of any asymmetry before treatment, explain why and how these may be addressed as they age, and why botulinum toxin alone is unlikely or no longer able to give them an optimum result. Treatment plans should give the patient every treatment option with agreed goals, benefits, risks, financial costs and time involved in appointments. This is our duty of care as medical professionals.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Botulinum toxin type A Botulinum toxin is often the first choice for younger patients with good bony support, tight skin and good symmetry. In these patients the result is more predictable and they often see a good result within two weeks. Consider the position of the brows to enhance the overall beauty of the patient when planning a toxin treatment.

It’s believed that 80% of middle-aged women have a brow asymmetry4 and they often have looser skin and show bony ageing.

Dosing of the toxin needs to be adjusted to correct this asymmetry and a brow lift of 1-3mm can be achieved.5 Dermal fillers Consider using dermal fillers as they enable you to directly lift and address any static lines. You can then combine with toxin to treat dynamic lines with a more predictable outcome. When the brow is asymmetric, low on the orbital rim or there is significant lateral brow droop – you need to decide: • Am I replacing structure to support the position of the brows?

• Or, treating the lines on the forehead directly?

To treat the forehead lines directly, consider the thickness and elasticity of the skin. Following this, select a product that is soft and elastic when placed in the superficially layers of the dermis.

To create structure, shape and lift be aware of the danger areas.

These include: 1. Supra trochlear 2. Supra orbital 3. Superficial temporal The supra orbital and trochlear run deep from the orbital rim and move above the muscle to the dermis at approximately 2cm above the rim. The safest plane to inject is deep or very superficial and not in the dermis where intra vascular injection is possible.7 Figure 4: Arterial and venous supply forehead6

I use a dermal filler that has elastic, cohesive properties, in order to lift the brow without distorting the skin excessively whilst allowing it to be moulded.

I place the dermal filler under the frontalis muscle into the galea space. This can be achieved with a sharp needle on to bone.

My preferred method is to use a micro-cannula – as the muscle in this area is tight to the bone, you get a very distinct restriction on the micro-cannula when you are in the correct plane. It is uncomfortable for the patient, due to the restricted space, but this technique avoids dermal filler Figure 5: Soft tissue augmentation from being placed sub dermally above the muscle. Dermal filler that is placed sub dermally can shift and sit above the eyebrow, and so should be avoided. Small deposits of dermal filler will give a good mechanical lift that raises the brow.

7

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Aesthetics aestheticsjournal.com

Top tip: For those who employ an aesthetician, booking patients in to have unruly brows shaped after their two-week review will enhance the patient’s results and impression of the clinic.

Skin tightening Ultrasound skin tightening devices can be used to contract the muscle to lift the brow and promote collagen production to firm and plump the skin.1 A single treatment can achieve a 2mm brow lift for 89% of patients.9 The treatment is quick and the discomfort tolerable for most patients. Treatment can be done to tighten the muscle layer before placing dermal filler to correct any asymmetry. The upper eyelid can be treated because the device is ultrasound and not laser. Suh et al9 demonstrated by biopsy two months after ultrasound or radiofrequency (RF) treatment, that there was significant neocollagenis deeper in the reticulate dermis and SMAS layer with ultrasound. The neocollagenis induced by radiofrequency was more superficial in the papillary and mid to deep dermis. Consequently, I believe that RF cannot achieve similar results to ultrasound and Bassichis et al 10 demonstrated in 2004 that 24 patients treated with monopolar RF had no decipherable change in brow elevation. RF has FDA indication to treat lines for moderate facial wrinkles and rhytides.10 A series of 6-12 RF treatments, depending on the device, will increase collagenisis leading to skin plumping; but this does not contract and lift the underlying muscle layer.

Summary Ageing is multi-factorial and, as our patients age, a single modality cannot be relied upon to continue to achieve good results. The upper third of the face is especially challenging due to skin laxity and brow ptosis. Treatment planning for the upper third of the face requires combination treatments to regain balance and harmony of the brows, because they are the strongest feature on the forehead and are more prominent then any wrinkle.

Dr Victoria Dobbie has 13 years experience in aesthetics and has carried out more than 20,000 treatments. She is the director of the Face and Body clinic in Edinburgh, and previously ran her own dental clinic with the Royal Army Dental Corps.

Dr Victoria Dobbie will discuss off-label uses of botulinum toxin on the Expert Clinic agenda at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more.

REFERENCES 1. Carruthers J, Lowe N, Menter M, et al. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol. 2002;46(6):pp.840–849 2. Swift, Remington Beautiphication a global approach to facial beauty. Clin Plastic Surg 38 (2011) pp.347-377 3. Vleggaar D, Fitzgerald R Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation. J Drugs Dermatol. 2008 Mar;7(3):pp.209-20 4. Matarasso A, Endoscopic surgical correction of glabella creases, Dermatol Surgery (1995) 6:p.695 5. Huiligol S Carruthers JA Carruthers JDA, Raising eyebrows with botulinum toxin Dermatol Surg (1999) 25:pp.373-376.

6. Allergan, inc. (2014). Beneath the Skin of Beauty (Version 3.0) [Mobile application software]. Retrieved from https://itunes.apple.com/za/app/beneath-the-skin-of-beauty-za/id911962831?mt=8 7. Jean Carruthers, Alistair Carruthers, Jeffrey S. Dover, Murad Alam, Materials, injection site, and injection techniques, Soft Tissue Augmentation (2013) Saunders; China (3) pp.53-104 8. J.N. Witherspoon, MPH; L. White; D.P. West; S. Ortiz, BA; S. Yoo, MD; J. Havey, BS; R. Agha; N. Martin, MD; M. Alam, Procedure for evaluating change in eyebrow, Northwestern University, Department of Dermatology, (2012),<http://www.wrinkless.nl/wp-content/uploads/2012/01/Poster-Proced-for-EvalChange-in-Eyebrow-Position-Induced-.pdf> 9. Suh DH et al, Comparative histometric analysis of the effects of high intensity focused ultrasound and radiofrequency on skin J Cosmet Laser Ther 2015 Oct 17(5) 10. Bassichis BA1, Dayan S, Thomas JR. Otolaryngol Use of a nonablative radiofrequency device to rejuvenate the upper one-third of the face, Head Neck Surg. 2004 Apr;130(4):397-406.

11. Sabrina Guillen Fabi, NCBI, Noninvasive skin tightening: focus on new ultrasound techniques (2015) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327394/>

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

EMERVEL – MORE CHOICE AND CONFIDENCE IN MID-FACE FILLER SOLUTIONS Volume is key to maintain facial balance and restore the faces natural contours. Emervel has gel textures especially designed for lifting capacity and volume restoration, optimised especially for the mid-face regions.

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Aesthetics Journal

Copper in Skincare Dr Charlene DeHaven details the uses and benefits of copper in advanced skincare Copper is one of the essential ‘trace metals’ required in small amounts for proper functioning of the human body and its various macro and microsystems, including enzyme systems. Other necessary trace metals include zinc, selenium, magnesium, and manganese. Minimum dietary requirements must be met for each trace metal. These requirements are small, but if deficient amounts are ingested, many systems fail to work properly.12 In addition, copper is involved with energy creation via its role in cytochrome oxidase, a superfamily of proteins, which act as the terminal enzymes of respiratory chains. All living cells in the human body generate energy in order to function. Copper is required in mitochondria, the tiny energy factories within each cell that are responsible for metabolism and energy creation.1 For skin, copper is perhaps best known as a required cofactor in collagen synthesis. It is also a necessary metal in a number of other biochemical reactions occurring in the skin, as listed in Figure 1.3 Copper-Containing Enzyme

Enzymatic Function

Superoxide Dismutase

Antioxidant (superoxide degradation) Collagen, elastin synthesis Collagen synthesis Energy production Melanin formation

Lysyl Oxidase Collagen Proline Dioxygenase Cytochrome Oxidase Tyrosinase

Figure 1: These enzymes in the human body require copper for proper functioning. The copper becomes incorporated into the molecular structure of each of these enzymes.

Copper may exist in a metallic form or an ionic form. The metallic form of copper is the type many think of when visualising this metal – however, copper in metallic form cannot be used by biologic systems. In order for humans and other organisms to benefit from copper, it must be present in ionic form. Ionic copper can be joined to enzyme systems via chemical bonds and is the only form that is active in the human body.4 Ionic forms of copper look very different from copper metal; these have no ‘metallic’ appearance because the copper in them is chemically bound to other substances. Medical literature details uses of copper ions as antimicrobials with potential to combat a variety of possible infectious processes including; bacteria,5 herpes viruses,6 leishmaniasis,7 and other conditions where infectious processes are implicated such Propionibacterium acnes.8

The role of copper within cosmeceuticals There are numerous potential applications for using copper in aesthetics; the key factors are outlined below: Potentiating effects on collagen synthesis Collagen is the most prevalent protein in the body and most collagen is found in the skin (Figure 2). Collagen serves as the structural

Aesthetics

framework for numerous tissues including skin, bone, teeth, tendons, and all other connective tissues.9 Since both vitamin C and copper are necessary for the formation of healthy collagen, combining both ingredients in a single formula would be ideal. Studies have indicated that combining copper and vitamin C together results in a chemical reaction between the two substances, causing a decrease in antioxidant activity,10 although, one product claims to have combined the two successfully.11 Growth factors such as copper tripeptide-1 also increase collagen synthesis.12 This growth factor is a tripeptide composed of the three amino acids; glycine, histidine, and lysine. This natural molecule, found in human skin and other tissues, mediates its effect of encouraging collagen synthesis via decorin,13 a molecule intimately involved with the architecturally correct synthesis of collagen.

Copper tripeptide-1 Figure 2: The triple helix of collagen, composed of two alpha1 strands and one also affects matrix alpha2 strand metalloproteinase (MMP) enzymes.14,15 This growth factor belongs to a group of emergency response molecules that come to the body’s aid in times of stress, including wound healing,16 tissue remodeling,17 stem cell antisenescence,18 ageing,19,20 post-procedure,21,22 inflammation and oxidative stress,23 and infection. Copper tripeptide-1 also has antitumorigenic properties, while at the same time encouraging the growth and normal development of healthy cell lines.24,25 Wound healing Copper metal ions have been found in higher concentrations around healing wounds and thus are implicated in wound healing and inflammatory processes.26 The topical application of copper ion-containing ointments has been associated with improved wound healing.27 In addition there is a huge body of scientific evidence supporting the essential role of copper tripeptide-1 growth factor in the acceleration of wound healing (Figure 3).10,12,13,17 This compound is released during tissue injury to signal repair processes to begin.

3 months control

3 months

6 months control

Copper serum applied twice daily

6 months

Copper serum applied twice daily for three months, then once daily for three months

Figure 3: Two identical full-thickness incisions were made in the thighs of a 54-year-old female, sutures removed at seven days, application of copper serum began, digital photos taken at three months and six months post treatment.

Antioxidant support system Copper, in particular copper tripeptide-1 growth factor, has shown significant impact in optimising antioxidant protection within formulations (Figure 4).

Equally it has shown to provide a pivotal role in a new wave of antioxidants. Superoxide dismutase (SOD), which previously required intravenous administration for delivery, is now available in topical form. SOD is one of three enzymatic antioxidants made by the human body. All were designed through evolutionary processes to neutralise free radical damage.24 This group of antioxidants is unique in several aspects; they are effective in very tiny amounts and are not inactivated during the redox process. Furthermore, they

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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ORAC TOTAL (umole TE/g)

700

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Aesthetics aestheticsjournal.com

683.43

Testing independently performed by Brunswick Labs

600 500

Product containing Copper tripeptide-1 growth factor

400

Product containing C, E and Ferulic

300

Product containing CoffeeBerry

200

Cosmeceutical containing 10% vitamin C

206 157

Product containing 1% ldebenone

100 53 14

0

Figure 4: ORAC (Oxygen Radical Absorption Capacity) measures total lipophilic antioxidant capacity. Testing independently performed by Brunswick Labs. Image provided courtesy of INNOVATIVE SKINCARE.

are not used up while combating free radical processes and persist in the body for long periods of time, unlike other non-enzymatic antioxidants, such as vitamin C.28 A study has shown that copper assists SOD for proper functioning in its antioxidant role.29

firmness and wrinkles.13,15,16 Through the effects of decorin, new collagen made in injured tissue assumes the correct anatomical configuration and structure rather than a disorganised scar.31

Conclusion: All good things in moderation Role in melanin synthesis Melanin is designed to give some protection against photodamage.

Copper is necessary for melanin synthesis within melanocytes, which are found scattered along the Dermal-Epidermal Junction (DEJ) in the basal layer of epidermis.1 Equally tyrosinase, the enzymatic partner for copper, is the most crucial enzyme required in melanin synthesis, as its action is the rate-limiting step in melanin production.30 Tissue remodelling Copper tripeptide-1 and other forms of copper are active for tissue remodelling, which is the return of injured tissue to normal architecture and function. It increases keratinocyte proliferation and normal collagen synthesis, improves skin thickness, skin elasticity, REFERENCES 1. de Romaña DL, Olivares M, Uauy R, Araya M. J, Risks and benefits of copper in light of new insights of copper homeostasis, Trace Elem Med Biol. 2011 Jan;25(1):pp3-13 2. Gambling L, Kennedy C, McArdle HJH. Semin, Iron and copper in fetal development. Semin Cell Dev Biol. 2011 Aug;22(6):pp637-44 3. Stipanuk MH & Caudill MA Biochemical, Physiological, and Molecular Aspects of Human Nutrition, eds. Zinc, Copper, and Manganese. Grider A. 2013. Elsevier: USA. p830 4. Günter J, Konrad J. A. Kundig Copper: Its Trade, Manufacture, Use, and Environmental Status, Copper in the Environment, ASM; USA p378 5. Dlewell A, Barnes M, Endres JR, Ahmed M, Ghambeer DK. J, Walkenhorst WF, Sundrud JN, Laviolette JM. Additivity and synergy between an antimicrobial peptide and inhibitors ions Biochim Biophys Acta. 2014 Sep. 1839(9):pp2234-42. Epub 2014 6. Drugs Dermatol. Efficacy and tolerability assessment of a topical formulation containing copper sulfate and hypericum perforatum on patients with herpes skin lesions: a comparative, randomized controlled trial. 2012 Feb. 11(2):pp209-15 7. Peniche AG, Renslo AR, Melby PC, Travi BL, Antileishmanial activity of disulfiram and thiuram disulfide analogs in an ex vivo model system is selectively enhanced by the addition of divalent metal ions. Antimicrob Agents Chemother. 2015 Aug 3. Epub ahead of print 8. Stephens TJ, McCook JP, Herndon JH Jr. J Pilot study of topical copper chlorophyllin complex in subjects with facial acne and large pores, Drugs Dermatol. 2015 Jun. 14(6):pp589-92.

9. Diegelmann RF, Medscape, Wounds, Collagen Metabolism 2001;13(5) <http://www.medscape. com/viewarticle/423231> 10. HACIŞEVKĐ, A. An Overview of Ascorbic Acid Biochemistry, Ankara Ecz. Fak. Derg., 38 (3) 233 255, 2009 <http://dergiler.ankara.edu.tr/dergiler/24/1716/18327.pdf> 11. iS Clinical, Super Serum Advance, n.d, <https://www.isclinical.co.uk/super-serum-results> 12. Maquart FX, Pickart L, Laurent M, Gillery P, Monboisse JC, Borel JP, Stimulation of collagen synthesis in fibroblast cultures by the tripeptide-copper complex glycyl-L-histidyl-L-lysine-Cu2+.

FEBS Lett. 1988 Oct 10. 238(2):pp343-6.

13. Kinsella MG, Bressler SL, Wight TN. The regulated synthesis of versican, decorin, and biglycan: extracellular matrix proteoglycans that influence cellular phenotype. Crit Rev Eukaryot Gene Expr. 2004. 14(3):pp203-34.

14. Simeon A, Monier F, Emonard H, Gillery P, Birembaut P, Hornebeck W, Maquart FX, Expression and activation of matrix metalloproteinases in wounds: modulation by the tripeptide-copper complex glycyl-L-histidyl-L-lysine-Cu2+. J Invest Dermatol. 1999 Jun. 112(6):pp957-64.

15. Simeon A, Emonard H, Hornebeck W, Maquart FX, The tripeptide-copper complex glycyl-Lhistidyl-L-lysine-Cu2+ stimulates matrix metalloproteinase-2 expression by fiboblast cyultures.

Life Sci. 2000 Sep 22. 67(18):pp2257-65.

16. Pickart L, Published studies on tissue and skin remodeling copper-peptides: copper peptide studies on skin renewal, wound healing, and hair growth. Skinbiology.com (2014). <http:// skinbiology.com/copperpeptideregeneration.html> 17. Pickart L, The human tri-peptide GHK and tissue remodeling. J BiomaterSciPolym Ed. 2008.

Although copper is required for human life and for many biologic processes, too much of a good thing is not positive. Ingesting large amounts of copper as a supplement can be harmful and even toxic.32 Both copper and iron have the potential to act as pro-oxidants and increase free radical damage if found in excess.10 However, providing copper in correct amounts can certainly assist many aspects of skin functionality, improve skin health, and maintain youthful vitality of skin appearance.

Dr Charlene DeHaven is a board-certified physician in both Internal Medicine and Emergency Medicine, with an emphasis on age management and health maintenance.

She currently serves on the lecture faculty for the University of Washington Department of Family Medicine.

19(8):pp969-88.

18. Choi HR, Kang YA, Ryoo SJ, Shin JW, Na JI, Huh CH, Park KC, Stem cell recovering effect of copper-free GHK in skin, J Pept Sci. 2012 Nov. 18(11):pp685-90.

19. Leyden J, Stephens T, Finkey MB, Appa Y, Barkovic S, Skin care benefits of copper peptide containing facial cream. Amer Academy Dermat Meeting. 2002 Feb. Abstract pp68-69.

20. Pickart L. Klatz R, Goldman R (eds.) The human tripeptide GHK (glycyl-L-histidyl-L-lysine), the copper switch and the treatment of the degenerative conditions of aging. Anti-Aging Therapeutics Vol XI. American Academy of Medicine:Chicago IL. 2009. pp301-3012.

21. Miller TR, Wagner JD, Baack BR, Eisbach KJ, Effects of topical copper tripeptide complex on CO2 laser-resurfaced skin. Arch Facial Plast Surg. 2006 Jul-Aug. 8(4):pp252-9.

22. Miller TR, Wagner JD, Baack BR, Eisbach KJ, Effects of topical copper tripeptide complex on CO2 laser-resurfaced skin. Arch Facial Plast Surg. 2006 Jul-Aug. 8(4):pp252-9.

23. Miller DM, DeSilva D, Pickart L, Aust SD, Effects of glycyl-histidyl-lysyl chelated Cu(II) on ferritin dependent lipid peroxidation. Adv Exp Med Biol. 1990. 264:pp79-84.

24. Matalka LE, Ford A, Unlap MT, The tripeptide, GHK, induces programmed cell death in SH-SY5Y neuroblastoma cells. J Biotechnol Biomater. 2012. 2:p144.

25. Hong Y, Downey T, Eu KW, Koh PK, Cheah PY, A ‘metastasis-prone’ signature for early-stage mismatch-repair proficient sporadic colorectal cancer patients and its implications for possible therapeutics. Clin Exp Metastasis. 2010 Feb 9.

26. Miratschijski U, Martin A, Jorgensen LN, Sampson B, Agren MS, Zinc, copper, and selenium tissue levels and their relation to subcutaneous abscess, minor surgery, and wound healing in humans. Biol Trace Elem Res. 2013 Jun. 153(1-3):pp76-83. Epub 2013 Apr 18.

27. Frangoulis M, Georgiou P, Chrisostomidis C, Perrea D, Dontas I, Kavantzas N, Kostakis A, Papadopoulos O, Rat epigastric flap survival and VEGF expression after local copper application. Plast Reconstr Surg. 2007 Mar. 119(3):pp837-43.

28. Fukai, T. Ushino-Fukai, M. Antioxidants & Redox signaling, Superoxide Dismutases: Role in Redox Signalling, Vascular Function, and Diseases, 2011 Sep 15; 15(6): 1583–1606 <http://www.ncbi.nlm. nih.gov/pmc/articles/PMC3151424/> 29. Abreu IA, Cabelli DE, Superoxide dismutases – a review of the metal-associated mechanistic variations. Biochim Biophys Acta. 2010 Feb. 1804(2):pp263-74.

30. Casanola-Martin GM, Le-Thi-Thu H, Marrero-Ponce Y, Castillo-Garit JA, Torrens F, Rescigno A, Abad C, Khan MT, Tyrosinase enzyme: 1. An overview on a pharmacologic target. Curr Top Med Chem. 2014. 14(12):pp1494-501.

31. Kinsella MG, Bressler SL, Wight TN. The regulated synthesis of versican, decorin, and biglycan: extracellular matrix proteoglycans that influence cellular phenotype. Crit Rev Eukaryot Gene Expr. 2004. 14(3):203-34 32. Araya, M; McGoldrick, MC; Klevay, L M.; Strain, J.J.; Robson, P; Nielsen, Forrest; O, Manuel; Pizarro, F; Johnson, L; Poirier, K A. (2001). Determination of an Acute No-Observed-AdverseEffect Level (NOAEL) for Copper in Water. Regulatory Toxicology and Pharmacology 34 (2): 137–45. doi:10.1006/rtph.2001.1492. PMID 11603956.

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Recognising Body Dysmorphic Disorder in Aesthetic Practice Dr Dimitre Dimitrov and Dr Anthony Bewley advise practitioners on how to best manage patients with Body Dysmorphic Disorder and detail appropriate methods of assessment Body Dysmorphic Disorder (BDD) is a common problem in aesthetic practices, yet the condition still remains under-recognised and under-diagnosed.1 People suffering from BDD are concerned with minimal or non-existent defects, develop social avoidance and may become housebound or even suicidal.2,3,4,5 BDD is primarily a psychiatric health problem and patients usually consult dermatologists, plastic surgeons, other specialists or general practitioners, but not mental health specialists,6 as patients firmly believe that their disease is a physical problem. Even when their problem is recognised as BDD, it is important to be aware that patients may be resistant to engage with mental health professionals and seek psychiatric help. Instead, they may simply consult other dermatologists or plastic surgeons in the battle to achieve the image of ‘perfection’. However, once diagnosed, a holistic psychodermatological approach, focusing not only on the disease, but also on his/her psychological, emotional, physical, and social needs has to be taken into account and be treated.

The prevalence of BDD varies in different studies, but all have found that a high percentage of patients with the disorder presented in aesthetic practices. According to previous studies, the prevalence of BDD is 1.7-2.4%, but in the setting of general dermatology and aesthetic procedures, the population can reach 7-20.3%.7,8,9

The patient should be informed that this is a recognised problem and there is successful treatment, however some may not be ready during the first consultation to accept that idea

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Symptoms of BDD The fundamental issue with BDD is that the patient is preoccupied with a real (often objectively trivial) or an imagined defect in his/ her appearance. The main areas of patient concern are the face and facial features, skin, breasts, genitals and buttocks.10 Patients can present signs of this disorder at any age, but most patients have noted that symptoms started to develop in adolescence and even childhood.10 Most patients with BDD spend considerable amounts of time in selfreflective, time-consuming and unproductive rumination. Ritualistic behaviours such as mirror checking are common, as are camouflage, covering ‘defects’ and ideas of reference (some patients believe that others have noticed their ‘defect’ and are acting on that knowledge). Affected individuals often need constant reassurance from others, but still continue repeatedly to seek dermatologic or cosmetic referral for correction of the ‘defect’.11 Co-morbidities such as social avoidance, depression, anxiety and suicidal ideation are common lifetime prevalences, with 24-28% for suicide attempts.3,4,5,9 In an observational study of 200 people with BDD, followed up for almost five years, the rate of completed suicide was 22 to 36 times higher than the general population.9 It is important to recognise patients with BDD in aesthetic practice for the following reasons: The prime pathology is psychological rather than physical.2 • Psychosocial co-morbidities and suicidal ideation are common.4 • Patients with BDD are rarely satisfied with the results of their aesthetic procedures.3,12 • Patients quite often become litigious after ‘failure’ to resolve their ‘defect’.13 • Special attention should be paid to the problem with informed consent in BDD patients undergoing plastic surgery/ dermatological procedures. The question that practitioners should address is: do the patients with BDD have full capacity to give a truly informed consent for cosmetic procedures?14 Violent behaviour toward practitioners can also become a possibility. For example, 2% of BDD patients threaten their practitioners and surgeons physically and at least two cosmetic surgeons have been murdered by patients with BDD.15 According to one survey, 12% of plastic surgeons said that they had been threatened physically by a dissatisfied BDD patient.15 Once the diagnosis of BDD has been •

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Assesment Recognition of the condition may be achieved with proper screening with validated questionnaires.16 There are a number of questionnaires available from various organisations, such as: • The Cosmetic Procedure Screening Questionnaire (COPS)17 • The Body Dysmorphic Disorder Questionnaire (BDDQ)18 • The Yale Brown Obsessive Compulsive Scale Modified for Body Dysmorphic Disorder, (BDD-YBOCS)19 • Body Dysmorphic Disorder, NICE Guidance20 • Body Dysmorphic Disorder, Five Questions Psychiatric Evaluation for Cosmetic Procedure by Veale21 In busy aesthetic practices, the following questions can be a quick and helpful tool to help you gauge whether a patient may be suffering from BDD:16

1. Are you worried about how you look? (Yes/No); if you are, do you think about your appearance problems a lot and wish you could think about them less? (Yes/No)

2. How much time per day, on average, do you spend thinking about how you look? (a) Less than 1 hour a day. (b) 1-3 hours a day. (c) More than three hours a day.

3. Is your main concern with how you look that you aren’t thin enough or that you might become too fat? (Yes/No)

4. How has this problem with how you look affected your life? (a) Has it often upset you a lot? (Yes/No) (b) Has it often gotten in the way of doing things with friends, your family, or dating? (Yes/No) (c) Has it caused you any problems with school or work?

(Yes/No) (d) Are there things you avoid because of how you look?

(Yes/No) As practitioners, you should suspect BDD if the patient answers yes to Question 1; (b) or (c) to Question 2; yes to Question 3 and yes to any part of Question 4.16 The following is a more detailed screening questionnaire for BDD patients with skin concerns.22 1. Do you currently think a lot about your skin?

2. On an average day, how many hours do you spend thinking about your skin? Please add up all the time that your feature is on your mind and make your best estimate.

3. Do you feel your skin is ugly or very unattractive?

4. How noticeable do you think your skin is?

5. Does your skin currently cause you a lot of distress?

6. How many times a day do you usually check your skin, either in a mirror or by feeling it with your fingers?

7. How often do you feel anxious about your skin in social situations?

Does it lead to you avoiding social situations?

8. Has your skin had an effect on dating or on existing relationship?

9. Has your skin interfered with your ability to work or study, or your role as a homemaker?

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established, sympathetically discussing this with the patient is crucial, however it is important to still acknowledge that there is a visible difference in their appearance, (if there really is one). Dismissing the concern, trying to reassure the patient that they look fine, or telling them that they should not worry is usually ineffective. Do not argue about the diagnosis; listen carefully and with sympathy to the patient’s story, but allow enough time for discussion. One technique is to ask the patient to allocate a severity score for their ‘defect’, (this is usually 10 out of 10 for most patients), and then compare that with your own assessment of the severity of the ‘defect’ (which can be considerably less than the patient’s numeric severity assessment). A discussion about the ‘gap’ between the patient’s and the practitioner’s assessment can then be a way to open the discussion about the diagnosis of BDD. Referral Referral to a mental healthcare specialist or a psychodermatology clinic may be necessary in the management of BDD. The role of a dermatologist, surgeon or practitioner is to prepare the patient for potential psychiatric help. Without necessary preparation, the patient will usually refuse to seek psychiatric treatment and may continue their journey with other doctors. Discussing the distress caused by their concerns may help patients to understand the need for mental health referral.

The patient should be informed that this is a recognised problem and there is successful treatment, however some may not be ready during the first consultation to accept that idea. Do not force them; just allow them enough time; keep a good professional relationship and ask if they would like to come again. Referral to local or regional psycho-dermatology clinics may be easily accepted by the patient as they may feel more comfortable to be seen in a dermatology clinic by a dermatologist and psychiatrist, as many patients may not want other people to know that they need psychiatric help and may feel ashamed to be seen going to a psychiatric department.

The recommended treatment for BDD is cognitive behavioural therapy (CBT) that is specific to this disorder.20 Patients with moderate or severe BDD may require treatment with a selective serotonin reuptake inhibitor, often at the maximum tolerated dose for at least three months.11 Two randomised controlled clinical trials have proven their efficacy. The first trial found that fluoxetine hydrochloride, an antidepressant drug, is more effective than placebo in patients with BDD. The second trial compared clomipramine, a potent serotonin reuptake inhibitor, and desipramine, a selective norepinephrine reuptake inhibitor and results found clomipramine to be more effective in the treatment of BDD.23,24 Patients with severe problems should have continuing access to multidisciplinary teams with specialist expertise in BDD. Conclusion Based on our personal experience treating patients with BDD, the majority may be driven by media pressure in a ‘celebrity’ culture, together with greater availability and popularity of cosmetic procedures. But early recognition of BDD may help to prevent progress of the disease, to improve quality of life of the patient and of their family and may even help to save the life of the patient and the reputation and wellbeing of the practitioner.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Dr Anthony Bewley is a consultant dermatologist at Whipps Cross University Hospital and the Royal London Hospital. He is an honorary senior lecturer at the Universities of London and Hertfordshire and has trained in all aspects of adult and child dermatology, but has a particular interest in psychodermatology and inflammatory dermatoses.

REFERENCES 1. Dyl J, et al. Body dysmorphic disorder and other clinically significant body image concerns in adolescent psychiatric inpatients: prevalence and clinical characteristics. (Child Psychiatry & Human Development, 2006);36, <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613832/?report=reader> [Accessed 27th October 2015].

2. Helwick C, ‘Body Dysmorphic Disorder Can Be Lethal’, (Medscape Medical News > Psychiatry, 2011) <http://www.medscape.com/viewarticle/740015> [Accessed 2nd September 2015].

3. Veale D, Boocock A, Gournay K et al, ‘Body dysmorphic disorder: A survey of fifty cases.’, (Br J Psychiatry.1996), (168), pp.196-201.

4. Phillips KA, ‘Suicidal Ideation and Suicide Attempts in Body Dysmorphic Disorder’, (Journal of Clinical Psychiatry, 2005), (66), pp.717-725.

5. Phillips KA, Diaz SF, ‘Gender differences in body dysmorphic disorder’, (Journal of Nervous and Mental Disease. 1997), (185) (9), pp.570-7.

6. Phillips KA, ‘The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder’, (Oxford University Press; Oxford, 1996).

7. Haas CF, Champion A, Secor D, ‘Motivating factors for seeking cosmetic surgery: a synthesis of the literature’, Plastic Surgical Nursing, 2008, Oct-Dec; 28 (4), pp.177-82.

8. Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC, ‘Rate of body dysmorphic disorder. in dermatology patients’, J Am Acad Dermato,.2000 Mar; 42(3), pp.436-41.

9. Helwick C, ‘Body Dysmorphic Disorder Can Be Lethal’, (Medscape Medical News > Psychiatry, 2011) <http://www.medscape.com/viewarticle/740015> [Accessed 2nd September 2015].

10. Rhode Island Hospital; Centers & Services, ‘Body Dysmorphic Disorder Program’ <http://www. rhodeislandhospital.org/psychiatry/body-image-program.html> [Accessed 2nd September 2015].

11. Phillips AK, Pagano ME, Menard W, Stout RL, ‘A 12-Month Follow-Up Study of the Course of Body Dysmorphic Disorder’, (American Journal of Psychiatry, 2006), 163, (5); pp.907-912.

12. Crerand CE, Franklin ME, Sarwer D, ‘Body dysmorphic disorder and cosmetic surgery’, (Plastic Reconstruct Surg, 2006) (118), pp. 167-80.

13. Francis TE, ‘Informed Consent in Body Dysmorphic Disorder’, (Medscape Plastic Surgery, 2012). <http://www.medscape.com/viewarticle/758800_1> [Accessed 2nd September 2015].

Aesthetics Dr Dimitre Dimitrov is a specialist in dermatology and venereology. He has worked in the field in his native Bulgaria, Libya and UAE. In 2011, he received full registration with the General Medical Council and is an honorary consultant in Whipps Cross Hospital and London Royal Hospital.

14. Millard LG, ‘Millard J in Rook’s Textbook of Dermatology’; Eighth edition (eds Burns T et al), (WileyBlackwell, 2010), pp.64.17 – 64.21.

15. Sarwer DB., ‘Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of American society for aesthetic plastic surgery members’, Aesthet Surg J, 2002 (22), pp.531–535.

16. Ahmed I, ‘Body Dysmorphic Disorder, Medscape’, (Updated 2014), <http://emedicine.medscape.com/ article/291182-overview> [Accessed 2nd September 2015].

17. Veale, D et al, ‘Development of a Cosmetic Procedure Screening Questionnaire (COPS) for Body Dysmorphic Disorder’ (J Plast Reconstr Aesthet Surg. 2012), <http://www.ncbi.nlm.nih.gov/ pubmed/22000332#> (4) [Accessed 27th October 2015].

18. Body Dysmorphic Disorder Foundation, ‘Questionnaires’, <http://bddfoundation.org/helping-you/ questionnaires/>, [Accessed 27th October 2015].

19. Phillips, KA et al, ‘A severity rating scale for body dysmorphic disorder: development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale’, (Psychopharmacology Bulletin, 1997), (1) <http://www.ncbi.nlm.nih.gov/pubmed/9133747#> pp.17-22. [Accessed 27th October 2015].

20. National Institute for Health Clinical Excellence, ‘Core interventions in the treatment of obsessivecompulsive disorder and body dysmorphic disorder’ <https://www.nice.org.uk/guidance/cg031 >, [Accessed 27th October 2015].

21. David Veale, ‘Body Dysmorphic Disorder, Five Questions Psychiatric Evaluation for Cosmetic Procedure’, (Cambridge University Press, Advances in Psychiatric Treatment, 2001) (7) pp.125-132.

22. Bewley, A, Veale D et al, ‘Practical Psychodermatology’, (London, J Wiley & Sons, 2014).

23. Phillips KA, Albertini RS, Rasmussen SA, ‘A randomized placebo-controlled trial of fluoxetine in body dysmorphic disorder’, Arch Gen Psychiatry, 2002 , (59), pp.381-8.

24. Hollander E, Allen A, Kwon J, et al, ‘Clomipramine vs desipramine crossover trial in body dysmorphic disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness’ (Arch Gen Psychiatry, 1999), (56), pp.1033-9.

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Treating Birthmarks with Laser Dr Salinda Johnson details the different types of birthmark and how to effectively treat them using laser As an aesthetic practitioner, I treat adults who bear the constant reminder of symptoms first seen within one month of them being born. Today’s younger patients with birthmarks enjoy the benefits of a science that has nearly come of age; however, many adult patients still suffer the trauma of looking different from their peers, and are often reluctant to return to the hospital environment, that sometimes dismisses their concerns as being only cosmetic. This article therefore focuses on the treatment of birthmarks in adults. Specifically it will cover the classification, treatment and expected results of a number of common types of birthmark.

The progression of treatment options Vascular laser treatments originated with the treatment of port wine stain (PWS), using an Argon laser in the mid 1960s.1 It was successful in reducing the colour of the PWS, but the pulse length (a repeated pulse of 0.2s) and small spot size (1mm), tended to result in a more general ‘bulk’ heating with resultant burning followed by scarring.2 The use of laser in medicine changed when a major breakthrough occurred in 1983, following publication of the paper ‘Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation’ by Anderson and Parrish.3 This paper set out the principle that has been used in the subsequent 30 years of treating of birthmarks – if you can select a wavelength that is absorbed predominantly by haemoglobin or melanin, and use that in a pulse that is sufficiently powerful and timed to match the size of the target, you are able to selectively damage that target while having little or no negative impact on the surrounding tissue.3 In practice, lasers target a specific chromophore – haemoglobin in vascular lesions or melanin in pigmented ones. The chromophore heats up in the presence of light of certain wavelengths while the surrounding tissue does not. Heat radiates from the target into surrounding tissue at a given rate (thermal relaxation time).4,5 But because different wavelengths are required, and the depth to which the laser can penetrate the skin depends on the wavelength, multiple lasers are required. In the 1990s Intense Pulsed Light (IPL), which is produced by a halogen flash lamp, was introduced.6 Rather than use one specific wavelength, the Before After raw broadband light of IPL covers a wavelength of 4001200nm, which non-selectively targets haemoglobin, melanin and water. Early lasers and IPL had standard pulse lengths Male patient in his 50s before treatment imposed by the limitations of and one month after treatment for PWS, using 3 TX with Ellipse PR 530 applicator the light sources concerned, (PWS setting) but advances in electronics

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mean that today’s models are not so restricted. For example, the first Pulsed Dye Laser (PDL) had a pulse of only 0.45ms – too short for adult vessels. Now, the ability to create a range of pulse lengths gives the capability of treating adults. This is important, as the thermal relaxation time of the target is proportional to its size. For deeper vessels (the venous component of some lesions) a longer wavelength is required, and Nd:YAG laser meets these requirements. Many lasers can treat pigmented lesions, but Q-Switched lasers have been suggested to be more successful in treating dermal-pigmented lesions,7 as the energy used is delivered in a pulse measured in nanoseconds, effectively pulverising rather than heating the pigment. With the exception of many epidermal naevi, where lack of chromophore restricts treatment, all of the birthmarks mentioned below (or their residual effects) are treated using light-based technology.

Vascular Conditions Diagnosis in adults is a question of looking at the colour and size of the lesion to determine vessel diameter and depth – larger vessels that are a dark colour (purple/blue) could suggest a deeper cause.8 Use a dermascope to gain more detail where required.

Infantile hemangiomas These benign vascular neoplasms often involute naturally; 70% of cases do so by the age of seven.9 The drug propranolol is the current treatment of choice for children, and given as either systemic medication or topically,10 with the possible adjunct of PDL or IPL. However, more than 30% of adult patients who as children had natural involution by age six, and 80% of patients where this occurred after the age of six, have residue, scarring or develop telangiectasias.11 I tend to treat resultant redness with IPL, using a short (5ms) pulse.

Naevus simplex (Stork Bites) These are present in almost half of newborns as bright patches of skin.12 Most resolve naturally with no residue within the first year of life, but 50% of those on the nape of the neck persist into adulthood.13 Again, the vessels are very small, and a 2 x 2.5ms pulse or single 5ms pulse can reduce the redness.

Naevus flammeus (Port Wine Stains) This form of birthmark is found in 0.3% of babies.9 They persist and develop through the life of the patient. Initially bright pink or red in appearance, as patients age, the vessels dilate and the lesions darken through purple to a blue colour. In later life it may become nodular, and bleed spontaneously.14 A longer pulse (8ms) is more beneficial in adults. Success of treatment is in part determined by the location of the PWS itself; the forehead responds well, followed by the remainder of the face and neck, but results are not quite so good on the trunk and extremities, due in part to the depth and flow-rate of the vessels, and in part to the greater likelihood of hypertrophy.15 Pigment Conditions Epidermal naevi are present in 0.1% of children who are under one year old.16 There are many subtypes depending on the cell type contained;16 keratinocytic or nonorganoid epidermal naevi typically contain only keratinocytes, whereas organoid epidermal naevi may involve additional types of epidermal cells, such as the cells that make up the hair follicles or yellow and pebbly sebaceous naevis; the wart-like verrucous epidermal naevus. While historically these were removed surgically as some feared the development of basal cell

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carcinoma,17 most today are removed for aesthetic reasons via a short surgical procedure performed under local anaesthetic.

Café au lait macules (CALM) 14% of adults have one or more café au lait macules, which can occur anywhere on the body.18 While IPL can work in some cases, Q-Switched Nd:YAG is treatment of choice, as the much faster pulse can shatter the pigment, rather than heating it.

Dermal melanocytoses These are a group of deeper dermal pigmented lesions including Mongolian spot (affecting the lumbrosacral area and often not persisting into adult life), Nevus of Ota (affecting the face) and Nevus of Ito (back and shoulders). All tend to present as a blue-brown lesion requiring Q-Switched Nd:YAG. Conclusion Before treating the patient, it is vital to ensure that they have a realistic expectation of the treatment result and are aware that treating an adult for a birthmark is likely to involve several sessions and result in skin that looks better, but is not totally perfect. A patch test to determine the suitability of the patient for treatment is essential, as is a full medical history. The rewards of such treatments are not just skin-deep; it is possible not only to change the appearance of the patient, but also to change their entire outlook on life, and the way in which they are viewed by society.

Aesthetics

Dr Salinda Johnson is an aesthetic practitioner and has lectured and trained in the specialty for many years.

Dr Johnson completed a specialist fellowship programme in cosmetic dermatology in 2000 and has continued to hone her techniques and expertise in the field ever since, incorporating up-to-date procedures and best practice as they develop.

REFERENCES 1. Solomon H, Goldman L, Henderson B et al. Histopathology of the kaser treatment of port-wine lesions: biopsy studies of treated areas observed up to three years after laser impacts. J Invest Dermatol 1968; 50: 141-146 2. Dixon JA, Huether SE, Rotering SH. Hypertrophic scarring in argon of port-wine stains, Plast Reconstr Surg 1984;73:771–779 3. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation, Science 1983;220:524–527 4. Altshuler GB, Anderson RR, Manstein D, Zenzie HH, Smirnov MZ. Extended theory of selective photothermolysis, Lasers Surg Med. 2001;29(5):416-32 5. Ross EV. Extended theory of selective photothermolysis: a new recipe for hair cooking? Lasers Surg Med. 2001;29(5):413-5 6. Goldman MP, Eckhouse S, Photothermal sclerosis of leg veins, Dermatol Surg. 1996 Apr;22(4):323-30 7. Chan HH, Kono T, The use of lasers and intense pulsed light sources for the treatment of pigmentary lesions Skin Therapy, Lett. 2004 Oct; 9(8): 5-7 8. Cleveland Clinic, Vascular Disease, (2015) <https://my.clevelandclinic.org/services/heart/disorders/vascular-disease> 9. Pratt, A G Birthmarks in Infants, Arch Dermatol 1953: 67:302 10. Beth A, Drolet P, Frommelt P et al. Initiation and Use of Propanolol for Infantile Haemangioma, Report of a Consensus Conference, Paediatrics: 2013: 131, 128 11. Finn MC, Glowacki J, Mulliken JB, Congenital vascular lesions: clinical application of a new classification, J Pediatr Surg. 1983 Dec. 18(6):894-9 12. Alexander K. C. Leung, MD Port-Wine Stain Versus Salmon Patch: How to Tell the Difference (2011) <http://www. pediatricsconsultant360.com/content/port-wine-stain-versus-salmon-patch-how-tell-difference> 13. Juern AM, Glick ZR, Drolet BA, et al. Nevus simplex: a reconsideration of nomenclature, sites of involvement, and disease associations, J Am Acad Dermatol 2010;63:805–14 14. Nie JM et al, Port Wine Stains and the response to argon laser therapy; successful treatment and the predictive role of color age and biopsy Plast Reconstr Surg; 1980: 65,130 15. CR Srinivas, M Kumaresan, IJDVL, Lasers for vascular lesions: Standard guidelines of care, Volume 77 Issue 3, (2011) <http://www.ijdvl.com/article.asp?issn=0378-6323;year=2011;volume=77;issue=3;spage=349;epage=368;aula> 16. Justin J Vujevich, MD, Anthony J Mancini, MD. The epidermal nevus syndromes: Multisystem disorders, JAAD: Volume 50, Issue 6, June 2004, pp. 957-961 17. Nevus Outreach, Nevus Removal, (2015) <http://www.nevus.org/nevus-removal_id599.html> 18. Kopf AW, Levine LJ, Rigel DS, Friedman RJ et al, Prevalence of congenital-nevus-like nevi, nevi spili, and café au lait spots, Arch Dermatol. 1985 Jun; 121(6):766-9

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Assessing the Lips for Successful Rejuvenation Dr Souphiyeh Samizadeh provides an overview of lip-treatment trends and shares advice on clinical evaluation techniques Lip aesthetics Throughout human history, we have ornamented our lips in many ways for various reasons, including cultural beliefs, beauty and aesthetics, courtship and social status (Figure 1).1 As well as being one of the key aesthetic units of the face, lips play a significant role in phonation and swallowing, so for practitioners aiming to augment or enhance lips, successful treatment is essential.2 Studies examining the profiles of Caucasian female models in the late 20th century found that fuller and more anteriorly positioned lips were more fashionable.3,4 For 65 years from 1930, Nguyen and Turley studied male model profile changes from photographs collected from leading fashion magazines in order to analyse the way that the male profile had changed through time. They reported significant changes in the ideal

lip aesthetics, which included:5 • Increasing lip protrusion • Increasing lip curl • Increasing vermilion display As a result, and with the evolution of treatments available, lip augmentation has become progressively popular in recent years, reflecting the cultural trends in youth and beauty. It has been reported that lip augmentation is one of the most popular and requested aesthetic procedure since the introduction of modern dermal fillers.1, 6

What makes an ‘ideal’ lip?

Beauty ideals and aesthetic standards vary across eras and cultures. In Western culture, plump and well-defined lips tend to be preferred.1, 7 In the early years of medical aesthetics, despite cultural preferences for plump lips and admiration of models with voluptuous lips, no actual guidelines existed

Figure 1: Examples of various ideal lip aesthetics in different cultures and time periods

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for assessment and enhancement of the lips.8 Following research, however, studies suggest that the ‘ideal lip’ should have the following characteristics: • Fullness and volume1 • Correct balance between the upper and lower lips1 • Well-defined vermilion border1,8 In my opinion, lips should also be harmonious with other facial features of the individual. Enlarged, full lips in a very petite face will not be aesthetically pleasing as this would be out of proportion with the rest of face. Sexual dimorphism should also be kept in mind when treating lips, as men have a larger mouth width, philtrum width, total lip height, and lip volume compared to women.9,10 Techniques for augmentation and enhancement of the lips have evolved with advances in biotechnology and the various temporary, semi-permanent and permanent fillers and implants available on the market. In order to be able to use these different products and techniques successfully, an understanding of lip anatomy, terminology (Figure 2), assessment and aesthetics is essential.

2

9 3

1 4 8

5

7 6

Figure 2: Lip anatomy and terminology

1.

2.

3.

4.

5.

6.

7.

8.

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Philtrum Philtrum columns White roll Cupid’s bow Vermillion border Oral commissures Upper incisor teeth Upper lip tubercle Cutaneous upper lip

Assessing lips I advocate examining your patients in their natural sitting position as this is a standardised and reproducible position for upright examination.2,11 It is also important to examine lips while relaxed and during animation in order to assess the natural position of lips and symmetry of muscle movement to detect any asymmetry, and to assess action and hyperactivity of muscle groups.2,12 The position of the lips is closely related to the teeth and

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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In my opinion, lips should also be harmonious with other facial features of the individual. Enlarged, full lips in a very petite face will not be aesthetically pleasing as this would be out of proportion with the rest of face alveolar processes,13 yet it is paramount to keep in mind that the lips are only one factor of an attractive smile. Other factors that contribute to the lower face and smile aesthetic, and those that should be assessed (ideally by a dental professional), include:14 The dentitions, gingivae and alveolar bone: • Crown length • Crown width • Incisor crown angulation • Midline • Open gingival embrasure • Gingival margin • Incisal plane • Gingiva-to-lip distance Skeletal components: • The relative position of the mandible to maxilla Soft tissue factors: • Lip and soft tissue morphology • Prominence of chin and nose

Clinical evaluation Systematic clinical evaluation of the lips with assessment of a number of parameters results in a better understanding of the aesthetics of the lips and a more successful treatment planning. The following systematic evaluation can be followed as suggested by Dr Farhad Naini:2 Lip height: • Upper and lower lips • Lower lip/chin height • Ratio of upper lip to lower lip/chin height • Interlabial gap (gaps between the lips at rest) • Upper and lower lip vermilion height Lip thickness: Lip thickness is an important parameter during analysis as it is directly

correlated with lip prominence and can be influenced by ethnic background. Unlike thick lips, thinner lips usually more readily follow the teeth and jaw movements.2 As such, aesthetic effects of loss or movement of teeth in individuals with thinner lips would be more noticeable.

Lip contour: This can be evaluated in frontal and profile views to evaluate lip curvature, lip curl and inclination. Excessive or reduced lip curl could be due to the position and strength of dentoskeletal support for the lips. For example, maxillary dentoalveolar retrusion could result in a flat upper lip.2 Lip inclination: The support of lips is provided by the dentoalveolar. The inclination of the lips provides an indication of prominence of the underlying dentoalveolar. Protrusion or retrusion of the upper and lower incisors will result in protrusion or retrusion of the lips.

When upper incisor teeth impinge in the lower teeth, it can result in eversion of the lower lip.2 Lip posture: Assess lip posture and lip seal in natural head position in repose. The two should be assessed when relaxed with normal muscle tone (without excessive muscular contraction). Each person has a unique characteristic orolabial soft tissue posture (lip posture) and if the lip seal does not occur in the rest position, adaptive postures are used. This means the patient will have a continuous contraction of circumoral musculature.

Lip prominence: In profile, the prominence of the lips can be assessed relative to the prominence of the nose and chin. The prominence of the lip can vary due to soft tissue factors such as lip thickness, dentoalveolar factors such as position of the incisor teeth, or skeletal factors.2

Lip activity and function: Practitioners should assess the patient for hypertonic (hyperactivity or overactivity) or hypotonic (low muscle tone or underactivity) lips. A hypertonic lower lip, also known as a ‘straplike’ lower lip may retrocline the lower incisor teeth.2 A hypertonic upper lip levator muscle can result in a gummy smile. Hypotonic upper or lower lips appear flaccid and may result in overstretching of the lips to achieve lip seal.

This is common in individuals with increased lower-face height.2

Conclusion While this article has hopefully provided readers with a detailed overview of considerations to take into account when treating lips, it is also imperative that practitioners understand how lips age and the anatomy of the perioral region.

Knowing how, where and when to treat the lips should lead to successful rejuvenation and satisfied patients.

Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in medical aesthetics.

She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine.

REFERENCES 1. Niamtu J, ‘New lip and wrinkle fillers’, Oral and maxillofacial surgery clinics of North America, 17 (2005), pp.17-28.

2. Naini FB, ‘Facial Aesthetics: Concepts and Clinical Diagnosis’, Wiley-Blackwell (2011).

3. Auger T, Turley P, ‘Aesthetic soft-tissue profile changes during the 1990s’, Journal of Dental Research, (1994) pp.368-368.

4. Auger TA, Turley PK, ‘The female soft tissue profile as presented in fashion magazines during the 1900s: a photographic analysis’, Int J Adult Orthodon Orthognath Surg, 14 (1999) pp.7-18.

5. Nguyen DD, Turley PK, ‘Changes in the Caucasian male facial profile as depicted in fashion magazines during the twentieth century’, Am J Orthod Dentofacial Orthop, 114 (1998), pp.

208-217.

6. Morris CL, Stinnett SS, Woodward JA, ‘Patient-preferred sites of restylane injection in periocular and facial soft-tissue augmentation’, Ophthalmic Plastic & Reconstructive Surgery, 24 (2008) p.117-121.

7. Bisson M, Grobbelaar A, ‘The esthetic properties of lips: a comparison of models and nonmodels’, The Angle orthodontist, 74 (2004) pp.162-166.

8. Klein AW, ‘In Search of the Perfect Lip: 2005’, Dermatologic Surgery, 31 (2005) pp.1599-1603.

9. Sforza C, Grandi G, Binelli M, et al., ‘Age- and sex-related changes in three-dimensional lip morphology’, Forensic Sci Int, 182 (2010), p181-187.

10. Gibelli D, Codari M, Rosati R, et al., ‘A Quantitative Analysis of Lip Aesthetics: The Influence of Gender and Aging’, Aesth Plast Surg, 39 (2015) pp.771-776.

11. Bansal N, Singla J, Gera G, et al., ‘Reliability of natural head position in orthodontic diagnosis: A cephalometric study’, Contemporary Clinical Dentistry, 3 (2012) pp.180-183.

12. Mani V, ‘Surgical Correction of Facial Deformities’, JP Medical, (2010) p.290.

13. Turley PK, ‘Evolution of esthetic considerations in orthodontics’, Am J Orthod Dentofacial Orthop, 148 (2015) pp.374-379.

14. Burrow SJ, ‘The impact of extractions on facial and smile aesthetics’, Seminars in Orthodontics: Elsevier, (2012) pp.202-209.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Managing Acne

Dr Terry Loong shares her holistic approach to treating acne and advises practitioners on the best guidance to give to patients suffering from the condition Acne is an aesthetic concern that is very personal to me. Both my late mother and I suffered from the condition as adults and, sadly, my mother’s acne-scarred skin hugely affected her confidence. Unfortunately the technology and knowledge we have available today was not present when she was alive, so it inspired me to change the way I utilise skincare and how I treat my acneic patients.

In this article, my aim is to share with you some of the most common advice I give my patients suffering with acne and alternative approaches to acne, aside from skincare, to ensure faster clearance and longer maintenance of good skin.

How widespread is the problem?

According to Yale University School of Medicine,1 acne is the most common skin disorder in the world. Globally, acne has a lifetime prevalence of more than 90% in people of all ages. Around 80% of adult acne cases occur in women and 50% of those women suffer with acne right through to their 40s and older.

Acne is an inflammatory skin disease ranging from mild comedonal forms (blackheads and whiteheads) to severe inflammatory cystic acne of the face.1 According to the Acne Academy,2 facial scarring from the condition affects up to 20% of people and 92% of acne sufferers have felt depressed, with 14% having had suicidal thoughts.

Most sufferers will develop acne during their teenage years (73%) but according to the Journal of the American Academy of Dermatology,3 54% of women over the age of 25 have some facial

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acne. Interestingly, the journal notes that, according to various studies, the average age of having the problem is 31.3 Most adult acne occurs on the cheeks (81%), chin (67%) and jawline (58.3%).

The majority of sufferers have inflammatory papules – red, raised bumpy spots (55%), while fewer have a comedonal problem, which present as black or whiteheads (6%). Research has shown that adult acne is more treatment resistant and prone to relapse, even after the use of antibiotics and isotretinoin (Roaccutane) therapy.

Likewise, adults often have sensitised skin, or a combination of skin conditions in addition to their acne, which makes treatment more challenging than teenagers with acne, who generally have more resilient, uniform, oily skin.3 The skincare industry has seen the global acne market aiming to rise to the challenge with new skin products, new prescriptions, new treatments and new technology being introduced to tackle the problem.4 In 2009, $2.9 billion was spent on this growing market and it is estimated that the global acne market will reach revenues of $3.02 billion by 2016.2 In my practice, I mainly see women with adult acne between their late 20s to mid-40s. My patients typically come to me after having spent a lot of time seeing different doctors who have only recommended skincare or skin treatments, which has not completely resolved the problem. As such, patients tend to be ready to look at alternative options or a more holistic solution to their skin concerns. I also have patients who come to me wanting to avoid going down the Roaccutane, antibiotic or birth-control pill route – again hoping I can offer them a more holistic approach to their treatment.

Advice I give to my patients with acne Before they attend their first consultation, patients will complete a 15-page questionnaire that looks not just at their general medical history, but also takes a deeper look at their gut health, hormonal balance, nutritional status, supplement history, skincare products in current use and their skincare routines. This allows a thorough exploration of all possible aspects of a patient’s life including their nutrition, supplements, sleep patterns, exercise and stress levels, which may contribute to the condition of their skin. We don’t often have the luxury of time in the clinic so by having the patient complete the questionnaire beforehand, we get to know the patient much better before we have even met them.

I find that when patients complete the questionnaire beforehand, it starts the rapport building process right from the very start, which I believe is vital for patients to trust you as a practitioner.

During the first consultation, and after we have discussed their answers to the questionnaire, I typically like to give a mini crash course on the following: What causes acne?5 I draw the patient a diagram explaining how acne is formed, involving the sebaceous follicles, excessive oil production, sluggish skin cell turnover, clogging of the pores, inflammation, Propionibacterium acnes, hormonal fluctuations, some pharmaceutical agents, stress and inappropriate use of products on the skin, heat, friction and humidity.

What are hormones and how do they affect acne?5 This is where my main interest lies as I see a lot of hormonal imbalances in patients due to their modern day lives. I explain the various types of common hormones, e.g. cortisol, insulin, oestrogen, progesterone and testosterone and how they fluctuate

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through the ages, through stress and with the use of prescriptive medication. Imbalanced hormones can cause excess oil gland production, skin inflammation, and an increased number of the acne-causing bacterium.

The gut-skin connection and how to improve it6 The gut contributes to about 70% of our immune system and is involved largely in activities of digestion, metabolism, assimilation, nutrient absorption and detoxification. If all this is not functioning optimally, then this could lead to poor skin healing, skin sensitivity and even breakouts.

Appropriate skincare and routine for oily mature skin types that tend to be more ‘combination’ and can have dry patches prone to wrinkles7 – I like to keep the patient’s skincare routine simple, as, in my opinion, simplicity is the most likely way of achieving compliance and consistency. I try my best to recommend just three

Aesthetics Journal

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products at the first session, as typically patients who come to see me have tried many products and have often lost confidence in them. I like to choose products depending on the patient’s personality type. For instance I assess if they like to try products often but never give it enough time for it to be effective as the products are too slow to act. Or maybe they’re minimalist and don’t normally use products so I recommend the basic essentials to help them build their confidence with skincare and skin routine.

Some patients’ skin is sensitive and they may not be as willing or prepared to go through the dry phases of some acne products.

Some don’t mind; so it really depends on their personality type. If patients can see an improvement in the first three weeks with just three products, their confidence in you as a practitioner will grow.

The typical products I recommend are: a good gentle exfoliator, an acne serum containing at least salicylic acid, glycolic acid and retinol, and a day or night oil-control lotion.1 I also examine patients’ skin and recommend a session with my clinical therapist for a

Alternative solutions for acne While I do believe medication has a role to play, especially in severe cases of acne, due to the possible side effects medicine can have, such as causing damage to the gut, my approach has always been to look at what we can do to facilitate the skin’s repair first, before reaching out for the prescription pad. The most important thing is to educate your patients and create a partnership working with them and their acne. It’s a journey that will leave you with very loyal patients in many years to come.8 15 In my book, The Hormonal Acne Solution,9 I summarised my hormonal adult acne system, where I combined internal solutions (Phase 1) with external options (Phase 2) to control the occurrence or re-occurrence of acne. Depending on what the patient’s budget, goals and commitments are, I encourage them to work on both phases simultaneously.

Here is a summary of the different steps: Phase 1: Take control of acne internally

Phase 2: Take control of acne externally

• Step 1: Reduce inflammation to lessen eruptions: This step is used largely to manage patients’ stress and cortisol levels. Lifestyle changes can help to manage stress and create more balance in one’s life, so I recommend that patients exercise more often, spend time in nature, switch off digital devices after 8pm and have a good night’s sleep. I also encourage patients to take part in an elimination diet to remove common food triggers, e.g. dairy, gluten, caffeine, alcohol, peanuts and sugar. If they are able, they can also opt for a food sensitivity blood spot test, which can accurately check for up to 95 food sensitivities.16 My patients often markedly reduce their skin eruptions within three weeks of the elimination diet.

10

• Step 2: Digestion optimisation and sugar balancing:11 This step restores gut health and flow, maximising the gut’s ability to eliminate ‘used’ hormones and absorb nutrients that affect genes in a positive way. This step also supports the body’s detoxification process and optimises the skin’s repair mechanism through proper nutrition. Sugars can be balanced by eating cleanly and appropriately. I often recommend my patients do a stool test to check for inflammation, microbes or viruses, which, if present, will need addressing through supplementation or medical repair foods.

• Step 3: Hormonal harmonisation:12 Once inflammation is managed and the gut health is optimised, we can then look at balancing the patient’s hormones. I believe hormones naturally balance themselves out with a little help. As such, I like to wait until we complete steps 1 and 2, before recommending anything to address the hormonal imbalance. By this point, hormones should be very much aligned and skin should have improved. Depending on what I find and how the patient’s symptoms have improved, I might recommend specific nutrients and precursors, herbs/supplements or bio-identical hormones that we can introduce to balance and optimise hormonal equilibrium. One in particular is Agnus Castus, a herb that can potentially naturally regulate hormones. 17

• Step 1: Skin Awareness:13 This is one of my favourite steps as patients really get to know their skin and how it works. I aim to educate my patients about how skin changes throughout their monthly cycle and with each special milestone in their life. By knowing and working with their skin, they will begin to understand what products will be most suitable for home use, and which treatment to use during the different stages of their cycle.

• Step 2: Skincare: Often patients come in to the clinic confused about which products to use – this is a great opportunity for you to educate them on effective ingredients and skin routines that they can do at home.

• Step 3: Skin Treatments: My philosophy on treatments is if you can prevent and treat acne at home, in-clinic treatments are only the ‘icing on the cake’. While patients can of course have medical facials in the clinic to enhance their home routine, as well as treatments to help clear their acne scars and pigmentation, providing advice on how they improve their overall health and wellbeing in the long term is more important than offering a one-off skin treatment.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

103758 Dermalux Half_P_Ad Accred:Layout 1 10/11/2015 16:45 Page 1

medical facial with full extractions of comedones (papules) to clear any congestion of the skin and remove superficial sources of inflammation. I explain that, in my opinion, it’s best to properly cleanse the skin in the clinic first, as this should then make it easier to maintain good skin health with home products.

Summary As practitioners working in skincare and aesthetics, we are in a privileged position to be able to gain the trust of our patients and help them manage their acne; not only to treat and hopefully reduce it, but the ability to clear the aftermath in the form of scars and pigmentation. By incorporating holistic solutions into your practice, you will not only help your patients achieve better skin, but also help them feel better in themselves in terms of their energy levels, concentration, confidence and overall wellness – which, in my opinion, is priceless.

The basis for skin beauty and health

Dr Terry Loong graduated from Guy’s and St. Thomas’ Hospital and completed her postgraduate qualifications with the Royal College of Surgeons. Dr Loong’s earlier training was in general and plastic surgery before she began specialising as an anti-ageing doctor.

Disclosure: Dr Terry Loong is the author of The Hormonal Acne Solution and is currently exploring the idea of creating a CPD-accredited training course based on the book. She is actively seeking interest from practitioners looking to learn more.

REFERENCES 1. Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller, ‘Acne Vulgaris: a disease of Western civilization’, J. Arch Dermatol, 138(2002), pp.1584-90.

2. Acne Treatment, Acne: The Facts and Stats. (AcneTreatment.org, 2012) <http://www. acnetreatment.org.uk/acne-facts-and-stats/> 3. Collier CN, Harper JC, Cantrell WC, Wang W, Foster KW, Elewski BE, ‘The prevalence of acne in adults 20 years and older,’ J Am Acad Dermatol, 58 (2008) pp.56-9.

4. Howard D, ‘Why is adult acne on the rise?’, Dermal Institute <http://tiny.cc/5ebz4x> 5. Gary W. Cole, What causes acne (emedicinehealth.net, 2014) <http://www.emedicinehealth. com/acne/page2_em.htm#acne_causes> 6. Whitney Bowe and Alan C Logan, ‘Acne vulgaris, probiotics and the gut-brain-skin axis - back to the future?’Gut Pathog. 3:1 (2011) <10.1186/1757-4749-3-1> 7. Mayo clinic, Choosing an effective acne product (2015) <http://www.mayoclinic.org/diseasesconditions/acne/in-depth/acne-products/art-20045814?pg=2> 8. Dr Mercola, Accutane Acne Drug Widely Overused says UK Dermatologist (mercola.com, 2012) <http://articles.mercola.com/sites/articles/archive/2012/12/12/acne-drug-accutane.aspx> 9. Dr Terry Loong, ‘Chapter 3: The Perfect Dance in The Hormonal Acne Solution’, 1st edition.

Create Space, Amazon, 2014 10. Bowe WP, Joshi SS, Shalita AR, ‘Diet and acne’, J Am Acad Dermatol. 63 (2010) pp.124-41 11. Rachel Reily, Long term links to dairy and high sugar foods to acne (SkinInc.com, 2013) <http:// www.skininc.com/skinscience/physiology/Long-term-Research-Links-Dairy-and-High-SugarFoods-to-Acne-200252611.html> 12. Seirafi H, et al, ‘Assessment of androgens in women with adult-onset acne’, International Journal of Dermatology, 46 (2007) pp.1188-91 13. Raghunath RS1, Venables ZC, Millington GW, ‘The menstrual cycle and the skin’, Clin Exp Dermatol, 40 (2015) pp.111-5 14. Bowe WP, et al. Effective over-the-counter acne treatments, Seminars in Cutaneous Medicine and Surgery. 2008; 27:170 15. Ruth Williams Downside to Antibiotics, The Scientist, <http://www.the-scientist.com/?articles. view/articleNo/36329/title/The-Downside-of-Antibiotics-/> 16. Invivo clinical, IgG4 95 Food Antibodies, <http://www.invivoclinical.co.uk/catalogue_item. php?catID=3010&prodID=83327#.VjTskYSTDFI> 17. Tracy Raftl “Q+A for Vitex Agnus Castus for Female Hormonal Acne” The Love Vitamin, <http://thelovevitamin.com/9662/q-about-vitex-agnus-castus-for-acne/>

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Spotlight On: Radara Aesthetics explores the efficacy of the new microchannelling skincare system aimed at restoring skin quality and reducing the signs of ageing Introduction While ‘Adara’ is the Greek word for ‘beautiful’, Innoture Medical Technology explains that the name ‘Radara’ intends to represent skin radiance and beauty; supporting patients on their journey to improved skin health.

The manufacturer believes that its microchannelling patches and hyaluronic acid (HA) serum offer a unique treatment that targets the signs of ageing, while improving elasticity, hydration and skin support.1 Studies into the efficacy of the product have supported these claims, suggesting that, depending on the starting skin condition, fine lines and wrinkles were reduced by an average of 35% in four weeks, with noticeable improvements in just two weeks.2 But, how does Radara work? And how should it be administered in practice?

Using Radara Transdermal delivery is a commonly used technique for administering a number of therapeutic substances3 – however the key challenge is achieving effective ingredient delivery past the stratum corneum. Innoture claims that Radara patches have been specifically designed to greatly enhance the delivery of the high-purity Radara HA serum, allowing for effective penetration, which should provide maximum skin benefits. The patches are developed using a patented printing technology, which aims to deliver a flexible, ultra-thin design tailored to fit the lateral canthal areas. The patches are coated with microscopic plastic structures, similar to needles, less than half a millimetre in length which when applied to skin, can painlessly create hundreds of tiny micro-channels in the epidermis. These ‘micro-channels’ allow for the Radara HA serum to flow through the skin barrier, directly targeting the deeper layers of the skin.

Study design During February and March 2014, a 32-person, split-face study was conducted to examine the effectiveness of Radara.2 The study was independently verified by an accredited facility in Germany and results were based on both qualitative and quantitative data submitted by a

dermatologist and the study participants.

According to Innoture, the aim of the study was to examine the product for tolerance as well as improvement in wrinkle depth over an eight-week period. Results were measured with the PRIMOS (Phaseshift Rapid In-vivo Measurement of Skin) optical threedimensional measuring device.

Before beginning the trial, the 32 female participants, aged between 35-55 years old, underwent a dermatological examination to assess their suitability. Participants were required to have healthy skin in the test area – ‘crow’s feet’ or the lateral canthal lines – and to not use other skincare products during the study. Women with severe or chronic skin inflammation were excluded, as were those that had used skincare products with active ingredients seven to ten days before the study began. All 32 participants were photographed and evaluated before beginning the trial and at one-week, twoweek and four-week intervals. Then 16 participants were selected for analysis at the end of the rest-period, to provide an eightweek data set. Overall, the study comprised a four-week application period followed by a four-week rest period.

Participants were instructed to apply the Radara micro-channelling patches in combination with the HA serum once daily to the test area on one side of their face.

The patch was initially applied with light pressure to the test area, before being removed to allow serum application and then re-applied for a further five minutes.

On the other side of their face, participants only applied the HA serum.

Assessment of the study All 32 study participants dermatologically tolerated the micro-channelling patch and HA serum during the course of the four-week application period, with the independent dermatologist stating Radara was tolerated “very well”. No undesired or pathological skin reactions in the test area were reported during the study, nor were there any medical interventions or interruptions to the application in any of the participants.

Skin roughness was measured on the 16 participants who were analysed up to week

eight, and showed an improvement in fine lines and wrinkles of up to 35% (with the standard error margin between 20 and 46%) on combined usage of the patch and HA serum at the four-week interval. This measured a 46% greater effectiveness versus application of the serum alone. At week eight, Radara patches and the serum were shown to offer continued results, even after the fourweek rest period, with overall improvement of skin roughness at 19% compared to measurements taken before treatment began. Innoture explains that it must be noted that all the patients’ skin is different and may have had different starting points in terms of skin quality and level of wrinkling.

Skin improvement was also graded by dermatologists and participants at one, two and four-week intervals by means of a questionnaire, tolerability analysis, subject wrinkle assessment using the Facial Wrinkle Scale (FWS), dermatologist-assessed wrinkle assessment and the 3D objective wrinkle assessment using the PRIMOS imaging system. These methods measured the reduction of fine lines and wrinkles, smoothness and firmness. After two weeks, 75% of participants recorded a positive change in skin firmness, rising to 88% at week four. Skin smoothness achieved an 81% positive change over the two and fourweek intervals, whilst 72% of participants saw a positive reduction in fine lines and wrinkles after only two weeks. On the Garnier scale, a two-grade improvement was seen over four weeks. Aesthetic practitioner Dr Benji Dhillon, who peer-reviewed Radara, noted the smaller differences between scores at the four-week period, but believes this is due to the fact it is an early time-point to measure neo-collagenesis. He highlights that the stronger data is actually at the eight-week point, stating that, “Despite the study limitations, such as a lack of statistical powering, the exclusion of males, and lack of Fitzpatrick data, the results from this study are compelling in supporting the efficacy of Radara in combination with HA serum to help improve the appearance of wrinkles within the area.”

REFERENCES 1. Innoture Aesthetics, ‘In vitro penetration studies and biocompatibility of microneedle array-based delivery systems’, Project Report, Queens University, Belfast, Data on File.

2. Innoture Aesthetics, ‘Specialist dermatological report on the optical 3D-Measurement of the surface of the skin Quantitative evaluation of the roughness of the surface of the skin with the calculation of standardized skin roughness parameters according to DIN 4768ff’, Dermatest GmbH I Engelstrasse 37 I 48143, Münster, Data on File.

3. Innoture Medical Technology, Microneedles (UK, Innoture Medical Technology, 2015) <http://www.innoture.co/ microneedles.htm>

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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A summary of the latest clinical studies Title: Histopathological analysis of 226 Patients with Rosacea according to subtype and severity Authors: Lee WJ, Jung JM, Lee YJ, Won CH, Chang SE, Choi JH, Moon KC, Lee MW Published: The American Journal of Dermatopathology, October 2015 Keywords: Rosacea, histopathological, perifollicular, inflammation Abstract: The aim was to evaluate the histopathological features of rosacea according to clinical characteristics such as subtype and severity. We retrospectively analysed histopathological findings in 226 patients with rosacea, which included 52 patients with the erythematotelangiectatic rosacea (ETR) and 174 patients with the papulopustular rosacea (PPR) subtype. The frequency of each histopathological finding was compared between subtypes. Histopathological features were also compared according to the severity, through subgroup analysis within each subtype group. Perivascular and perifollicular lymphohistiocytic infiltration were common dermal findings in both subtype groups, but the intensity of dermal inflammatory infiltration was higher in PPR than in ETR. Follicular spongiosis and exocytosis of inflammatory cells into hair follicles were noted in both subtypes; but these findings were significantly more common in the PPR subtype. The intensity of inflammatory reactions, especially perifollicular infiltration, was higher in PPR patients than in ETR patients.

Title: Development and characterisation of a rapid polymerising collagen for soft tissue augmentation Authors: DeVore D, Zhu J, Brooks R, Rone-McCrate R, Grant DA, Grant SA Published: Journal of Biomedical Materials Research, October 2015 Keywords: Collagen, polymerisation, soft tissue, augmentation Abstract: A liquid collagen has been developed that fibrilises upon injection. Rapid polymerizing collagen (RPC) is a type I porcine collagen that undergoes fibrillisation upon interaction with ionic solutions, such as physiological solutions. The ability to inject liquid collagen would be beneficial for many soft tissue augmentation applications. In this study, RPC was synthesized and characterised as a possible dermal filler. Transmission electron microscopy, ion induced RPC fibrillogenesis tests, collagenase resistance assay, and injection force studies were performed to assess RPC’s physicochemical properties. An in vivo study was performed which consisted of a one, three, and six month study where RPC was injected into the ears of miniature swine. The results demonstrated that the liquid RPC requires low injection force (<7N); fibrillogenesis and banding of collagen occurs when RPC is injected into ionic solutions, and RPC has enhanced resistance to collagenase breakdown.

The in vivo study demonstrated long-term biocompatibility with low irritation scores. In conclusion, RPC possesses many of the desirable properties of a soft tissue augmentation material.

Title: Nasolabial symmetry and esthetics in cleft lip and palate: analysis of 3D facial images Authors: Desmedt DJ, Maal TJ, Kuijpers MA, Bronkhorst EM, Kuijpers-Jagtman AM, Fudalej PS Published: Clinical Oral Investigations, November 2015 Keywords: Cleft lip, cleft palate, imaging, morphology Abstract: 84 subjects (mean age 10 years, standard deviation 1.5) with various types of nonsyndromic clefts were included: 11 had unilateral cleft lip (UCL); 30 had unilateral cleft lip and alveolus (UCLA); and 43 had unilateral cleft lip, alveolus, and palate (UCLAP). A 3D stereophotogrammetric image of the face was taken for each subject. Symmetry and esthetics were evaluated on cropped 3D facial images. The degree of asymmetry of the nasolabial area was calculated based on all 3D data points using a surface registration algorithm. Esthetic ratings of various elements of nasal morphology were performed by eight lay raters on a 100 mm visual analog scale. Statistical analysis included ANOVA tests and regression models. Nasolabial asymmetry increased with growing severity of the cleft (p = 0.029). Overall, nasolabial appearance was affected by nasolabial asymmetry; subjects with more nasolabial asymmetry were judged as having a less esthetically pleasing nasolabial area (p < 0.001). However, the relationship between nasolabial symmetry and esthetics was relatively weak in subjects with UCLAP, in whom only vermilion border esthetics was associated with asymmetry.

Title: Classification by causes of dark circles and appropriate evaluation method of dark circles Authors: Park SR, Kim HJ, Park HK, Kim JY, Kim NS, Byun KS, Moon TK, Byun JW, Moon JH, Choi GS Published: Skin Research and Technology, September 2015 Keywords: Causes, classification, dark circles, evaluation Abstract: It is not easy to classify dark circles because they have various causes. To select suitable instruments and detailed evaluation items, the dark circles were classified according to the causes through visual assessment, Wood’s lamp test, and medical history survey for 100 subjects with dark circles. We performed a randomised clinical trial for dark circles, a placebo-controlled double-blind study, using effective parameters of the instruments selected from the preliminary test. Dark circles of vascular type (35%) and mixed type (54%), a combination of pigmented and vascular types, were the most common. 24 subjects with the mixed type dark circles applied the test product (vitamin C 3%, vitamin A 0.1%, vitamin E 0.5%) and placebo on randomised split-face for eight weeks. The effective parameters (L*, a, M.I., E.I., quasi L*, quasi a* and dermal thickness) were measured during the study period. Result showed that the L* value of Chromameter, Melanin index (M.I.) of Mexameter and quasi L* value obtained by image analysis improved with statistical significance after applying the test product compared with the placebo product. We classified the dark circles according to the causes of the dark circles and verified the reliability of the parameter obtained by the instrument conformity assessment used in this study through the efficacy evaluation.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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patient base. Once your patients arrive for their treatments, you will then need to have highly-skilled clinical staff who can perform procedures at a consistently high level, remaining focussed and attentive to patients at all times.

When recruiting new staff members, don’t just look at their skills and experience, think about personality, too. Look for the passion and enthusiasm that will translate into the motivation to do a great job.

After hiring a team of exceptional staff, you then need to keep them motivated in order to reach your business goals.

Team Motivation Victoria Vilas explains how staff incentives can motivate your team and boost trade A modern and stylish clinic based at a prestigious address, innovative technology and high-end products are not the only elements necessary for a prosperous aesthetics business. Without a dynamic and productive workforce, your clinic is unlikely to reach its full potential to become an acclaimed name in the industry. As such, a team of dedicated, enthusiastic and skilled staff members are needed to deliver an exceptional service.

Managing competition The treatment menu that you provide may match other clinic offerings in your region, so in order to stand out from the competition, you must deliver those treatments at the highest possible standard. It is important that you also focus on the customer journey that begins the moment a potential patient first gets in contact, whether by phone or in person. For this reason, it is essential that you pay the same attention to non-clinical staff members as you do to practitioners. Your receptionist or patient coordinator is likely to be the first point of contact for patients, and the quality of that experience could attract or discourage a new

Look for the passion and enthusiasm that will translate into the motivation to do a great job

Attainable targets and tangible benefits Practitioners and clinic staff are likely to be on a basic salary with the chance to increase their earnings through commission or bonuses gained from selling additional treatments or retail products to patients. When setting out the terms of individual commission rates or team bonuses, it is a good idea to think about realistic targets that are achievable. If targets are set so high that your staff members fail to reach them on a regular basis, your team will become disheartened and you will probably find it becomes harder to maintain their enthusiasm for the work in hand.

This doesn’t mean you have to set targets so low that you end up paying out more than the business can afford in bonuses. Take time setting out your commission or bonus structure, taking into account both your business profits and the value you should place on high-performing staff.

However, the benefits you provide for your staff don’t have to just be financial. Offering a package that can make staff members feel valued and supported, and a working week that takes into account a healthy work/life balance, will also help to keep your team happy and productive. Don’t overwork your staff with schedules that leave them very little free time, and be fair with their holiday allowance and the flexibility they have to book time off. Pension contributions will soon be a necessity for businesses,1 but you could also consider benefits such as private health insurance and childcare vouchers, or even negotiate discounted rates for the local gym.

After all, benefits that help to keep your staff fit and healthy can only benefit the performance of your clinic.

A pleasant working environment The environment your staff work in, and the other team members they share their day with, will have a big impact on their happiness, and in turn, their productivity. While it may be a rather simple element to consider, try and make sure that all staff members have a comfortable space to work in. You should provide a space for your staff to relax during their breaks as it isn’t always convenient for them to go out of the clinic for their lunch, depending on location and bad weather.

A comfortable, quiet space will allow your staff to recharge during their break times, which will help them to be consistently productive throughout the working day. Also remember to make sure that your staff members do take their breaks, even if you run a very busy clinic.

It can become quite common for staff to work through their breaks if they have a heavy workload, however, remember, staff members who become tired and irritable are unlikely to stay motivated and provide the level of service you require of them.

In regards to putting your team together, unfortunately, there is no magic formula for putting a group of people in one place who all get on fantastically well. This doesn’t mean you have to single people out and think about letting them go; instead, try and think of ways to encourage inclusion in your team. Try holding group meetings where every staff member can actively share their opinions, and think about

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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organising group activities or social events you can all enjoy together.

If staff members get to know each other away from the stresses of the working day with some fun activities, you’ll probably find that they get on better at work, too.

Effective management and clear communication The most crucial element to building and maintaining a motivated workforce is how you manage your team. An effective manager will be able to lead and inspire, even if there are no financial incentives or exciting benefits to offer staff. An excellent, communicating manager should stay in touch with their team, holding regular one-to-ones to check on staff performance and ensuring that the team are happy with the workload. Managers don’t have to be best friends with their team, but good communication will ensure that small issues can be identified and dealt with before they become big problems. When staff members understand the importance of a task and exactly how it needs to be carried out, they are likely to be more receptive to your requests. A good manager will explain tasks carefully – if they are simply giving orders to their team, a lack of understanding could make staff members feel unsure of what they are supposed to be doing, and this may not just make them worry, it could also lead to mistakes being made. Make sure your staff members are fully trained in every aspect of their role, and understand your clinic’s protocols and procedures.

Empower your staff with the knowledge they need to do their job well, and they will feel far more confident and enthusiastic to carry out set tasks. Good communication isn’t just about informing your staff of the clinic’s performance, it’s also important to make sure you listen to what they have to say. Medical staff and front-of-house teams will have the most contact with your patients, therefore they are likely to have valuable insights into your patient’s likes and dislikes. Your staff can help develop your business and keep it up-to-date with the latest trends. You don’t have to agree with everything they say, but you may find that you can learn as much from your team as they do from you.

Remember to recognise employees when they have done a good job.

Don’t just assume that staff members know when you are happy with their performance – put it into words. You may offer financial incentives for good work, but offering praise will also give your staff a confidence boost, and will make them feel like a valued member of the clinic team. Praise shouldn’t only be given to those who have made big achievements, as team members who may not be the top performers probably need a morale boost more than the high achievers. Think of ways you can encourage all team members equally. You will also have to offer some constructive criticism to your team at certain points, so this praise will help to balance that out, and keep morale up.

Continuing development and staff promotion opportunities If you want to make sure that your team remains motivated, and that they stay loyal to your clinic as long-term staff members, you must consider their individual career progression, not just the future of your business. Think about where you can offer training that helps your staff members develop their skills, and what opportunities you could offer for promotion. Young, ambitious practitioners and sales staff will not want to stay at the same level forever – they will want to progress to a more senior position and a higher salary. If your clinic has a structure that makes progression impossible, you are likely to have a high turnover of staff, as your team will more than likely look for opportunities elsewhere. This could harm your business, as a constantly changing workforce doesn’t suggest that your business offers any stability or long-term prospects to new team members, and the cycle could continue.

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If you want to make sure that your team remains motivated, and that they stay loyal to your clinic as long-term staff members, you must consider their individual career progression, not just the future of your business Retaining your best staff members is crucial to your clinic’s success.

Would you rather give an employee a small salary increase, or lose them and their regular patients to a competitor? Think carefully about what you can offer your employees before it becomes too late. While some staff members will be looking for financial rewards, others will be looking to progress to a more senior level, perhaps taking on management responsibilities. Even if you have a clinic manager in place, this does not prevent you from giving others more responsibility. For example, if you have a high-performing aesthetic nurse who appears to have the professionalism to manage others, think about making that person a senior practitioner in title, and giving them the task to train and supervise their juniors. The more staff you have in your clinic, the bigger the workload for your clinic manager, so promoting others to junior management positions could also help your clinic to run more smoothly.

Conclusion Whether you are running a startup or a well-renowned clinic, remember that keeping up the level of staff happiness and motivation is an ongoing task that you must consider on a regular basis. The most successful clinics are those that are run by business owners and managers who keep in touch with their staff, so it is imperative to give praise where praise is due, and reward your team for a job well done. With effective and intuitive management, a happy working environment, and a business structure that allows good employees to stay in their positions long-term, you are more likely to have the loyal, professional and enthusiastic team you desire.

Victoria Vilas is the operations and marketing manager at ARC Aesthetic Professionals, a recruitment consultancy specialising in the medical aesthetics and cosmetic surgery sector. Since 2008, the team have aimed to help numerous organisations within the industry grow their businesses by hiring the most talented aesthetic professionals in the UK. REFERENCES 1. Government Digital Service, Workplace pensions – employers’ obligations (London: GOV.UK, 2015) <https://www.gov.uk/workplace-pensions-employers>

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Finding the Funding Key to Business Growth Peter Nolan offers advice on finance options for your clinic According to this year’s Key Note Market Update report,1 the UK cosmetic surgery industry is expected to grow in the coming years to a total value of £913 million, up from £725 million in 2014.

Non-surgical procedures are also becoming increasingly popular. Less invasive practices, such as microdermabrasion and laser treatment, now account for 85% of the market,1 meaning medical aesthetic practitioners can look to the future with a sense of justified optimism about business success. A significant problem, however, still remains with regards to weak bank lending. Difficulty in obtaining funding from the banks has shown to be a challenging hurdle for businesses to overcome, potentially putting the brakes on growth and expansion.

This can prove detrimental. Rapid technological advancement in the cosmetic industry has meant that continual investment in expensive equipment could be necessary in order to stay ahead of competitors and become more business efficient. The good news is that if it’s not possible to obtain funding from the more traditional routes, there are alternative options available.

Option 1: Lease don’t buy Equipment such as laser and IPL devices can cost a clinic well into the tens of thousands and can easily put a strain on company cash flow.

Buying equipment upfront affects the company balance sheet as it means money having to leave the cash flow straight away. Leasing, on the other hand, allows owners to spread the cost over a three to five-year period through regular payments, freeing up money to be invested elsewhere across the business and helping to build a strong credit history. Today’s customers are becoming ever more discerning and there is an increasing appetite for advanced cosmetic procedures, which can cost upward of £100. Microdermabrasion treatments using low-cost consumables, for example, can not only deliver fantastic results for image conscious consumers but can also deliver strong profit margins. Just a couple of treatments a month over a three-year period can be enough to cover the equipment finance costs.

How leasing agreements work Leasing is effectively a fixed or minimum term rental, where the leasing company (lessor) buys the asset on behalf of the customer and agrees to lease it back to them for a specified period of time. At the end of the minimum term, the customer can return the equipment or continue to use it, but this gives them the opportunity to frequently upgrade equipment in a rapidly developing market like medical aesthetics.

You don’t ‘own’ any of the asset during the term, but there is usually an opportunity to effectively take ownership at the end of your agreement if you wish to do so. Most customers upgrade their equipment, meaning that they can have brand new kit for the same regular instalment as their old kit. This helps them to stay one step ahead of their competitors and offer services that keep clients

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returning to their clinic. Interest rates are entirely dependent on the financial performance of the proposed lessee; new start clients inevitably pay a higher interest charge than that paid by businesses with a strong track record and good credit history, as the lessor is taking a significantly greater risk. With some flexible leasing arrangements, you can also include equipment servicing in the lease cost or choose to vary your monthly payments.

Benefits of leasing Leasing partners with experience in the sector and good contacts with medical aesthetic equipment suppliers are more likely to look favourably on offering asset finance for equipment they are familiar with. They can recognise the potential returns-on-investment a piece of equipment can generate and are more likely to provide approval on the back of it. They will also know which suppliers provide the most reliable and robust technology. Paying a fixed monthly amount over an agreed term can also make it easier to control finances and plan ahead and can help create a strong credit history for your business. There are also tax benefits to be enjoyed. Capital allowances on the equipment you lease can be claimed and interest on the finance payments is tax deductible. If equipment is hired under an operating lease, you can also write off the total amount of your leasing agreement against corporation tax by using Operational Expenditure (OPEX).

Option 2: Borrow against hard assets Did you know your existing equipment can be used to release working capital? If your cash flow has been left at breaking point due to money being used up elsewhere, a reputable finance specialist might offer to lend money against your hard assets, for instance IPL systems, which have a clear monetary value. The lender will base the loan terms and conditions on a fair evaluation of the equipment while considering other outstanding debts the company may already have, to check that business revenues can cover the new cost comfortably.

As long as the specialist believes the business plan demonstrates a considered strategy, further securities may not be needed. For medical aesthetic practitioners, this might mean proof of realistic sales forecasts, based on past performance, or for new operations, detailed competitor research with audience segmentation and affordability studies, to check demand in the area for aesthetic services. An individual’s financial stability will also be taken into consideration, as a strong fallback position will give the lender greater confidence in your ability to pay back financed capital. If assets are already subject to existing lease finance terms, payments can sometimes be spread over a longer term, helping to reduce monthly outgoings and providing more financial flexibility.

Conclusion Ultimately, a well-structured finance package should minimise your risks while maximising your return. And with a heady mix of drive, determination and financial support in place, the road to business success should prove that little less rocky – and all the more rewarding.

Peter Nolan is the chief underwriter at Academy Leasing and has several years’ experience working within the finance and leasing industry. His work involves offering advice on responsible lending decisions, as well as analysing clients’ business plans and predicting the potential risk and return on investment on leased equipment.

REFERENCES 1. Lauren Davidson, Have we reached peak plastic surgery? (London: The Telegraph, 2015) < http://www.telegraph.co.uk/finance/newsbysector/retailandconsumer/11569454/Have-wereached-peak-plastic-surgery.html> [accessed 7 October 2015]

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Introducing Laser and IPL Hair Removal to Clinics Christine Clarke details the benefits of introducing hair removal to your clinic portfolio and advises on how to do it successfully Introduction: history, demand and the opportunity to upsell The aesthetic industry today offers more exciting business opportunities than ever before in regards to expansion, innovation and setting trends. Ensuring that ‘permanent hair reduction’ is an easily accessible clinic treatment could pay dividends to the clinic as a solid investment in your services and treatment offerings. The desire for smooth, hair-free skin can be traced as far back as ancient Egyptian times with evidence of hair removal methods such as sugaring, the use of clam tweezers and flint razors been found dating back to 1900BC.1,2 In today’s society, tweezing, threading, depilatory creams, buffing, waxing, shaving, sugaring, electrical epilation (electrolysis), laser and intense pulsed light (IPL) treatments ensure that the demand for hair removal is ever present.

According to Statista, in 2014 a reported 1.12 million women in the UK admitted to using hair removal products once a day or more.3 Providing the best possible service at your clinic is crucial to success, as is maintaining a solid business core that can bring a consistent financial return. In this article, I shall explain how a ‘bespoke’ permanent hair reduction service can be a valuable asset to an aesthetic clinic.

Patient demand I personally work with a multi-platform device offering both IPL and 1064LP Nd:YAG which in my experience has proven to offer permanent hair reduction opportunities for all Fitzpatrick Skin Types (FST) I to VI (Figure 1),2 alongside a variety of equipment offering electrical epilation.

The device offers hair removal on the face, areola, underarm and bikini line throughout the year, and from my personal experience, turnover varies between 25% during the summer months and 45% in the winter months. The quieter summer months can be put down to the fact that when skin has colour in the form of an active tan, it cannot be treated using existing laser/IPL equipment, as use of both modalities is restricted by the amount of melanin present in the skin.

If implemented, there is a potential risk of skin scorching/burning, which can result in possible blistering, scarring and hyperpigmentation.4 The societal change in attitude toward unwanted forms of hair growth such

In 2014 a reported 1.12 million women in the UK admitted to using hair removal products once a day or more

as hypertrichosis,5 means an increasing number of consumers openly seek solutions. You need only to look at the advertising and treatment menus in the high street windows of beauty salons, medi-spas, aesthetic clinics and the plethora of hair removal products available on the shelves to see this change in society. Although, statistically, the average turnover from hair removal as a stand-alone procedure appears to be undocumented here in the UK, making it harder to gauge.

Unless one has fair hair or has no wish to embark on the route of permanent reduction, in my opinion, these treatments seem to be on most people’s to-do lists, both male and female, resulting in open discussion among friends socially – which can be considered as the best form of marketing.

Fitzpatrick Scale I.

White, always burns, never tans

II. White, usually burns, difficulty in tanning, may freckle

III. White, sometimes burns, average tan IV. Moderate brown, rarely burns, tans easily V. Dark brown, rarely burns, tans easily VI. Black, tans/darkens easily Figure 1: Fitzpatrick Scale

Choosing the right device(s) The consumer can be easily confused by the choice of treatment modalities on the market, as can sometimes the professional. A sound understanding of not only the treatments you wish to introduce into your practice, but also what options are available, will guide you in selecting the right machine. Practitioners can do this by attending major aesthetic exhibitions and taking time to collect the various literature available and speak in depth with the staff at the stands; there will often be a trainer present who can answer any queries you may have and advise you of the most appropriate devices and equipment for your clinic.

I recommend that practitioners go armed with a list of ‘prior to purchase’ questions, as well as an idea of both budget and method of payment. These could include: • Costings of the annual financial outlay for maintaining the equipment after the warranty period is over, including consumables such as flash lamps in the IPLs. • Whether the company offers a monthly payment scheme to help manage cash flow for on-going service maintenance contracts and consumables.

• Investment in attending online and classroom-based courses, which are designed to provide practitioners with the basics of using lasers and IPL systems, prior to purchasing, as this should give you a valuable step forward into starting to understand laser and IPL equipment.

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Enhancing your clinic profile and increasing footfall There are some essential considerations to make for your clinic, which will hopefully enhance the clinic profile and increase footfall. One consideration is the staff – employ practically skilled practitioners, who are also empathetic and people-friendly. In addition, qualityassured equipment is vital in order to achieve the safest results possible. Make sure you have an excellent support service contract with the equipment supplier, which can include policies such as 24hour emergency phone line incase of equipment failure, quarterly maintenance visits and regular customer updates. A demographic profile can be of assistance in the choice of equipment; for example, if your clinic is located in a predominantly FST IV patient area, then you might consider investing in a laser specific to the needs of those patients or a combination of more than one modality.

Other pre-purchase considerations include: • Members of staff obtaining substantial knowledge.

• A member of staff to acquire a Level 4 NVQ in the provision of laser and light treatments.

• Consumables required, such as disposable gloves, postprocedure cooling product, tissues and cotton wool.

• Location of the equipment, the space available and ventilation needed.

• Layout of treatment room; can this room be multifunctional? If so, the machine in situ could be a marketing tool in itself.

• Acquisition of referrals and developing a clientele; for example, working with or employing an electrologist who should be the ideal candidate to further train in the use of IPL or lasers.

Clinical and financial success lies in the skill of bringing them all together. The patient who comes to your clinic for hair removal is a loyal, trusting staple of any aesthetic business, as they both need and rely on the service offered. However, one of the mistakes made by many clinics is the lack of continuity in the provision of the same practitioner performing the treatment on the same patient; building a valuable relationship between the practitioner and patient can increase trust and encourage the patient to return to your clinic for future treatments. This is where the smaller, more bespoke clinic can benefit when considering competition with the larger aesthetic clinics.

Pricing of treatment Competitive pricing is crucial. Undercutting your competitors’ prices may initially increase your footfall, but in the long-term can negatively impact on your profit margin, cash flow and, inevitably, the reputation of the clinic. As with all procedures a clinic may offer, it is essential to conduct market research on your local competitors to carry out a price comparison, alongside the cost of the initial investment to determine the financial return. For example, if the clinic is located where the demographic is predominantly FST IV-VI and investment has been made in the latest combined laser of Alexandrite and long-pulsed Nd:YAG, then the pricing and advertising should reflect the uniqueness of both the equipment and the forward thinking of the clinic’s investment. On the other hand, to over price oneself in a market where there is a lot of choice available is not a constructive approach to business.

Consultation Including a test patch in the consultation is a vital part of any procedure and this is where you could gain or lose a potential

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patient. It is the first point of contact and must be charged for; I charge £50 and will provide up to an hour of my time to educate, reassure and perform the treatment to a small area of the body requiring the procedure. In my experience, this practice often ensures a returning patient who is then booked in at reception prior to leaving for their first full treatment. The unsure patient must always be given time to consider their decision; persuasion should never be part of the package.

For the aesthetic clinic the ‘test patch consultation’ will always be the area of least financial return, but this time is your investment in the patient returning for consecutive treatments often paid for upfront as a course.

Courses of treatment Courses of treatment are an excellent way of ensuring treatment continuity, but it is important to remember that not every patient is a suitable candidate for the procedure.

‘Payable in advance’ is always a good source of income for any aesthetic clinic with typical packages such as: • Eight treatments for the price of six • Six treatments for the price of five The above are constructive packages; in my experience, however, body hair usually requires eight treatments for both IPL and lasers, with back areas on average requiring twelve sessions or more.

Treating facial hair growth requires truly bespoke treatment planning.

The cause is a variable as is the problem area specific to each patient. A comprehensive consultation exploring the advantages, expectations and realistic outcomes will facilitate a mutually agreeable and affordable hair reduction management plan.

Conclusion As with all laser and IPL applications, the equation is simple; the equipment is the physics, the presenting condition to be treated is the physiology and the practitioner is the active element between the two.

Ideally, the correct application of the appropriate light therapy, plus ideal target chromophore/presenting condition will equal successful outcomes, which will in turn increase customer satisfaction. In return, you will recoup word-of-mouth, advertising and testimonials alongside a ready-made patient base for other procedures and products your clinic may offer. Ideally, one multi-functional hair removal machine, with perhaps two part-time practitioners who both offer electrical epilation alongside the laser/IPL would provide your clinic with a solid core of hair removal options.

Christine Clarke is the owner and lead aesthetic practitioner of the Christine Clarke Clinic. She delivers NVQ Level 4 in the application of laser and light therapies at her premises in Sheffield, along with bespoke basic and advanced skin analysis and treatment.

REFERENCES 1. Tannir, D. and Leshin, B, Sugaring: An Ancient Method of Hair Removal. (American Society for Dermatologic Surgery, 2001), (27), < http://www.ncbi.nlm.nih.gov/pubmed/11277903> [Accessed 16th September 2015] pp.309-311 2. Fernandez, A. A., França, K., Chacon, A. H. and Nouri, K, ‘From flint razors to lasers: a timeline of hair removal methods’. (Journal of Cosmetic Dermatology, 2013) (12) < http://www.ncbi.nlm.nih.gov/ pubmed/23725310> [Accessed 16th September 2015] pp.153-162 3. Statistica, ‘Number of women using hair removers, shavers and razors in the United Kingdom (UK) in 2014, by frequency of use (in 1,000)’ (2015) <http://www.statista.com/statistics/302795/women-s-hairremoval-product-usage-frequency-in-the-uk/> 4. S Vano-Galvan, ‘Laser Hair Removal: A Review’, (College of Family Physicians of Canada, 2009), <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628842/> [Accessed 28th October 2015] pp. 50-52 5. The Trichological Society, ‘Hair and its Growth Cycle’ (2015) < http://www.hairscientists.org/humanhair/growth-cycle> [Accessed 27th October 2015]

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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undergraduate, it is not surprising at all.

However, the necessity of doing so is important and becomes clearer when patients start defaulting on their payments. From cheques bouncing to credit cards failing and counterfeit notes being used – if you have been in business for long enough you will have experienced all of these issues. If you haven’t experienced such problems, the system you operate clearly works so don’t change it!

Patient Cancellations Professor Bob Khanna shares advice on managing late or cancelled clinic appointments Deposit systems When I set up my first clinic in Ascot in 1997, I remember having a conversation with my receptionist about a ‘great’ idea that I had – to take a deposit from each new patient to secure a booking. Jackie thought I was joking when I said this and, when she realised I wasn’t, told me that it would never work as, “no one else does this!”

I replied, “In that case, there is even more reason to do it!” To this day I have maintained this policy and my Failure To Show (FTA) rates are extremely low.

My belief has always been that we must get commitment from the patient and a simple deposit system can be a very powerful tool to help us do so. Patients are very unlikely to miss an appointment if they are aware that they may be charged and that they have left a deposit with the clinic. The ideal amount for securing a new patient booking should be high enough for them to want to turn up, but not too high that it becomes a deterrent for booking. Ironically, I set the consultation price at £45 in 1997 and this has remained the same ever since. I only see this price as a holding fee and an FTA deterrent, so it is not something the clinic is aiming to profit from. Let us not forget that it is of course in everyone’s interest for the patient to actually attend rather than miss an appointment.

Following a new patient consultation, a patient will need to be booked in for a subsequent appointment for the appropriate length of time, depending on the procedure. I think it is wise to take at least 25-50% (or more) of the full fee of the treatment to secure such bookings. Again, this will commit the patient to treatment and facilitate cash flow for the clinic in order to purchase the appropriate materials required for the case. One should not be hesitant with taking deposits or money upfront as this concept is endemic in today’s society. From ordering a Big Mac at McDonalds to booking a flight, we would be required to pay upfront. Why then, are practitioners so reluctant to operate a deposit system? I suspect it has something to do with an inbuilt duty of care we all have. Being too business-like can make many practitioners feel uneasy. In view of the fact that we receive absolutely no training in business skills as an

Cancellations There is nothing like a last-minute cancellation to sour your mood as a practitioner, especially if it is for an appointment of more than one hour. However, one has to also realise that certain life circumstances are unavoidable and practitioners must, therefore, be flexible too.

The problem occurs when you encounter the ‘serial offender’. This is the patient that is frequently late or, more often, cancels at the last minute, usually on the day, citing, “I’ve been called into work”, “I feel ill”, or that classic… “My car didn’t start up!” So, how do we prevent patients taking us for a ride?

Firstly one must have a clear written practice policy that states the cancellation ‘rules’ that each patient has to sign on registering with the practice. Ideally, this should be updated every year to allow clarification of any changes for your patients. As a deterrent, staff should make it very clear that cancellations inside of 48 hours may incur a late cancellation fee. This fee can either be the full treatment fee or a pay-per-minute fee, for example, £2 per appointment minute missed.

Since it is more beneficial to retain a patient, from a long-term perspective, one must exercise a degree of discretion. Hence, a firsttime offender may be granted a pass, so long as they are informed that, on this occasion, they narrowly missed being charged the cancellation fee. The reception team should document this fee and the reasons for cancellation so you can check how many times it has happened. A fee ought to be taken from the deposit if the patient repeats this activity again. If you are too lenient, the patient may become complacent and keep re-offending.

It works both ways All of the above is designed to make the patient respect our clinical time. As I have mentioned previously, rather than for profit, any such fees should act as a deterrent and send a clear message that FTAs and late cancellations are not acceptable.

However, practitioners and clinic staff must therefore appreciate that for this to be fully respected, then it has to be a two-way process.

For example, if one is running substantially late (more than 30 minutes) or if a clinic day has to be cancelled at short notice then I think it is only fair that the patient is compensated. Rather than offer a monetary fee, a gift voucher towards treatment at the clinic could be a better idea so you retain their custom. The mere gesture of this will alleviate most of the patient’s anxiety and annoyance, serving as a reminder of how valued they are at the clinic. Retaining patients is a key aspect to a successful business; achieving patient loyalty and respect is a testament to how well they are treated by the whole team, in all aspects of their care, and must not be taken for granted.

Professor Bob Khanna is a cosmetic and reconstructive dental surgeon and runs clinics in Ascot and Reading, carrying out a full spectrum of treatments from aesthetic dentistry, surgical implantology and bone regeneration procedures. He has also trained thousands of aesthetic practitioners, dentists and plastic surgeons in non-surgical facial rejuvenation procedures.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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How do you target men?

Whilst marketing to female patients is commonplace, successfully reaching men to promote treatments can prove to be more difficult. We also have the added job of needing to widen men’s knowledge of what treatments they can have outside of botulinum toxin and fillers.

Marketing to Men Charlotte Moreso shares advice on how to entice male patients into your clinic According to the British Association of Aesthetic Plastic Surgeons, surgical procedures for men dropped by 15% in 2014.1 Practitioners interviewed for this article, however, suggest there has been a rise in popularity of non-surgical treatments such as fillers, botulinum toxin and body treatments. Some proof of this lies in the results of a nationwide survey commissioned by Syneron Candela that indicated a third of men would now consider laser hair removal in a clinic.2 So where is the business coming from if it’s no longer just women funding this segment of the market? Various factors could have an influence, including: • Workplace: Marc Moreso, CEO of Leisurejobs.com says, “Men are increasingly under pressure to look younger for longer in the boardroom due to competition from younger recruits in the work environment. Youthful looks equal energy, ideas and a go-getting attitude in the minds of employers.”

• Rules of Attraction: Men now know that there are ways, other than a new haircut, in which they can make themselves look more attractive to a potential partner. These can include both surgical and non-surgical treatments.

• “If it’s good enough for her...” In the same way as men started using, or rather ‘borrowing’ their partner’s skincare at home before realising they can buy their own, men have witnessed women having non-surgical treatments for so long that it has paved the way for men wanting and having them too.

• Media: According to Ben Isaacs of ShortList magazine, “Advertising and men’s grooming pages within mainstream press has increased dramatically within the last five to 10 years, meaning men are more likely to find it acceptable to look after their looks in the same way women do.”

• Celebrity and the ‘David Beckham Effect’: This ‘real’ sportsman and his groomingbased advertising, alongside his overall appearance, has made being a beautiful male acceptably manly. More recently, celebrities such as Simon Cowell and Gordon Ramsay have admitted to having botulinum toxin treatments.4 It has been reported in the US that the most popular non-surgical treatment for men is botulinum toxin.3 Harley Street-based dermatologist Dr Ariel Haus comments, “I have seen a real increase in the number of men coming for treatments over the last three years.

More and more men are increasingly interested in botulinum toxin to give them a ‘fresh’ or ‘less tired’ look. Men now realise that it does not have to result in a frozen look, and that appeals to them.”

The male market is a huge opportunity to expand your patient base, but we know we cannot market to men the same way you would to women. Males and females are, of course, very different socially, biologically and psychologically. However, both genders tend to want to gain attention and look attractive – we just need to talk to them in different ways and through different mechanics.

From my experience, I believe there are four main ways to reach male patients: 1. Partners: Reach men through the wives and girlfriends with in-clinic materials and newsletters. Most women will confess to having been the prime purchaser of their partner’s toiletries in the past, especially during the weekly shop, and women are key influencers with their partners. So let the ladies do the talking. Even if you don’t have a large male patient base, you can still create a male menu for women to read and take home.

2. Online: Ensure you have a mix of search engine optimisation (SEO) and pay-perclick (PPC) tactics to market your clinic and treatments for men within the search results.

SEO provides search engines with relevant information and keywords to rank your site higher organically in search results. PPC utilises search engines’ paid advertising platforms (such as Google Adwords) to list a website in search results.5 According to Paul Handley of SEO Copywriter UK, “If you are looking to run PPC advertising, males will click on brand search terms over generic keywords. However, although PPC can be a good ‘quick fix’ for page one results, organic SEO will yield far more traffic to your site.” He explains, “In recent studies, it has been suggested that natural rankings in search results leads to 94% of clicks (the remaining 6% allocated to PPC).6 Organic search positions (as opposed to PPC listings) also receive far more clicks from males than females. To demonstrate the importance of natural SEO further, the top three organic search positions in Google account for 79% of all clicks, leaving just 21% for all other listings.”6 Also be sure to use your social media accounts

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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to deliver male-targeted messaging and treatment options. Even consider placing digital adverts and banners on local sites they may use, for example local sports clubs. Contact the sites directly through the contact tab on their websites to enquire about prices directly, and ensure you negotiate as there is often room for movement in price.

Double chin: Entice men to reclaim the face of their youth with underchin treatments using radiofrequency or similar technology.

3. Promotions: Create ‘his and her’ treatments around Valentine’s Day. Develop a couple’s promotion to entice patients to come and experience treatments together. Why not focus on treatments like body shaping for the abdomen or ‘love’ handles, or develop a ‘dinner date facial’. It’s important to note, however, that botulinum toxin cannot be promoted or discounted in any deal as it is a drug.

Once you have the male half of the partnership in your clinic, it’s the perfect opportunity to let him know about the range of treatments available.

4. Local Businesses: Look in your local area surrounding the clinic.

There are likely to be some small and larger businesses such as wine bars and social clubs that you could target with treatment materials. Offer free consultations to men looking to enhance their appearance. Create a flyer with a menu of treatment options. Don’t blind them with too much information though, just include enough to peak their interest.

• Lunchtime Light Treatments: Blue and red light treatments that fit into the lunch-break.

• The 30-minute Man-Peel: A range of peels to rejuvenate in just half an hour.

• Workaholics Reviver Treatment: Combination treatments to refresh the skin and restore youthful looks. Typically, a course of three to six treatments would ensure they return to the clinic for optimal results.

Creating the ‘Man Menu’ It’s often the case that men won’t realise the variety of aesthetic options open to them, so ensure you create a very specific menu of treatments for men. Divide them clearly into face and body treatments for clarification.

I have successfully run male-specific marketing campaigns for a large aesthetic company in recent years using imagery of toned men and catchy strap lines such as ‘Fit & Firm’ and language that they can relate to such as ‘turbo charge your torso’ and ‘high-tech solution’. This successfully captured their attention and encouraged them to try the latest body treatment to rid them of concerns such as love handles and abdominal ‘over-load’. Ideas include: Body Men’s body treatments could include those targeting: • Love handles: Ultrasound, radiofrequency, fat freezing.

• Laser hair removal: Back, abdomen, chest and buttocks.

• Gynaecomastia: Radiofrequency, ultrasound and fat freezing treatments are all options for this area of concern.

Dr Anita Sturnham, founder of the NURISS clinics, says, “With the increasing popularity of advertising campaigns that employ perfectly honed male celebrities such as David Beckham, it is no wonder that many men feel under pressure to improve their appearance. I am sure that the media drives both men and women’s insecurities with their perfected appearance. I am personally noticing more and more male patients coming to see me at my clinic with concerns about their stomach region. It is typically a difficult area to lose weight from, even with a strict diet and exercise regime, so stomach toning treatments and non-surgical body contouring treatments are becoming popular.”

Face Line erasers: Filler, botulinum toxin, laser and radiofrequency all work well to decrease facial lines and wrinkles.

Eradicate redness: Older men can suffer from broken capillaries, so promote your skincare and treatment options for this.

Men tend to like things to be quick, clear and direct, but also appealing. Here are a few ideas to implement that might work:

Also look into male specific treatments you may not offer already.

This is something that Dr Sherif Wakil, founder of SW Clinics, has had great success with. Dr Wakil says, “I have introduced the P-Shot (male sexual rejuvenation with PRP) to Europe and the UK last year and since then I have seen quite an increase in the number of my male patients interested in the treatment, not only from the UK but also from Europe and the Middle East.”

He continued, “Looking back, there was definitely an increase in male patients coming to my clinic over the past few years, especially after the recession period. I believe this could be explained by the fact that a lot of middle-aged men have been made redundant and were forced to apply for jobs along with other candidates in their twenties, obviously they had to take care of their looks to give a good impression on an interview. I believe, since then, they have seen what positive effect procedures could have on their lives.”

Summary Devise your man menu and create a clinic flyer for distribution at local businesses, always being mindful of using ‘man-friendly’ language and imagery they can relate to. Lastly, note that it is always worthwhile writing a press release detailing all the treatment options for men and sending this to your local newspapers and magazines, with an invitation for them to try a treatment in their lunch-break in return for editorial coverage.

Charlotte Moreso is managing director of True Grace PR. Charlotte has worked as a PR and marketing consultant in the health and beauty industry for more than 20 years, running highly successful campaigns for global commercial brands, smaller UK beauty brands and in more recent years, creating news for the UK’s leading aesthetic treatments, doctors and clinics. Her work has won several industry awards.

REFERENCES 1. British Association of Aesthetic Plastic Surgeons, ‘New statistics show extreme surgery’s gone bust – surgeons welcome more educated public’ (2015), <http://baaps.org.uk/about-us/press-releases/2039auto-generate-from-title> [Accessed 28th October 2015] 2. Censuswide Survey of 1,000 UK consumers March 2013 for Syneron-Candela Gentle Lasers. Data on file via Syneron Candela.

3. American Society for Aesthetic Plastic Surgery, ‘The American Society for Aesthetic Plastic Surgery Reports Americans Spent More Than 12 Billion in 2014; Procedures for Men Up 43% Over Five Year Period’ (2015), http://www.surgery.org/media/news-releases/the-american-society-for-aesthetic-plasticsurgery-reports-americans-spent-more-than-12-billion-in-2014--pro [Accessed 30th October 2015] 4. Vicki-Marie Cossar, ‘The rise of Brotox: plumbers and businessmen copy Simon Cowell’s Botox look’ (London: Metro.co.uk, 2013) < http://metro.co.uk/2013/02/25/the-rise-of-brotox-plumbers-andbusinessmen-copy-simon-cowells-botox-look-3510335/> [Accessed 28th October 2015] 5. Silverwood-Cope, S, ‘Natural Search accounts for 94% of Search Engine clicks, PPC 6%’ (Intelligent Positioning, 2012), <http://www.intelligentpositioning.com/blog/2012/08/natural-search-accounts-for94-of-search-engine-clicks-ppc-6/>, [Accessed 30th October 2015] 6. David Towers, ‘PPC accounts for just 6% of total search clicks’, (Econsultancy, 2012), < https:// econsultancy.com/blog/10586-ppc-accounts-for-just-6-of-total-search-clicks-infographic/>, [Accessed 30th October 2015]

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“You don’t just say goodbye to patients who have a problem, you help them and hold their hand the whole way through” Mr Nigel Mercer details his experiences of the plastic surgery and aesthetic industries and the valuable skills he has learnt along the way As the president of the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), Mr Nigel Mercer’s devotion to plastic surgery and aesthetic medicine is clear. He explains that he has aspired to work in medicine ever since he was a child, “I wanted to be a doctor since I was four, as I was fascinated by biology and how the organs of the body worked – I was very focused from an early age.” But it wasn’t until he saw one of the first colour supplements in a newspaper that he developed a curiosity for plastic surgery. “When I was 11, I picked up a supplement from a Sunday newspaper and it had some images of children from France who’d had a bony disfigurement of the skull and face treated; I remember seeing one child who went from looking very strange to completely normal after surgery, and I thought ‘wow, that’s fantastic’ and then the rest of my life was really programmed to go into medicine.”

Mr Mercer gained his medical degree from the University of Bristol in 1980 and, from then on, was determined to work in plastic surgery; however, he found it a tough industry to break in to. “Plastic surgery was just as popular as a profession then as it is now, so you had to go off and do something else for about 18 months while you waited for an opening. You’d do your training, get your surgical qualification, then the people in charge would say ‘great, lovely to have you… but come back in two years time’.”

Subsequently, Mr Mercer spent around 18 months working in orthopaedics; treating backs, hips and carrying out arthroscopic surgery. “I remember sitting there thinking ‘how is this making me a better surgeon?’ But in fact, it got me used to looking after sick patients, improving my manual dexterity and stitching, so it actually did make me a better surgeon and I appreciate that.”

Over the years, Mr Mercer spent time perfecting his surgery skills in centres of excellence in London, Glasgow, Bristol and Canada.

Today, he divides his time between his private practice Bristol Plastic Surgery, and his NHS practice in Bristol, where he is the senior consultant.

Although a specialist in surgery, Mr Mercer also acknowledges how non-invasive medicine complements his practice. “The world of aesthetic medicine has moved forward dramatically, and it’s not just ‘a bit of botulinum toxin and a bit of filler’; its complete facial skin rejuvenation. I can do a great facelift but if the skin looks as though it’s 200 years old, then it doesn’t look right. So we’ve incorporated aesthetic treatments into our practice.”

Appointed president of BAPRAS this year, Mr Mercer is also a member of several associations, which are very important to him.

“Next year, I’ve taken almost all my annual leave for the BAPRAS meetings!” he comments. “I was at a conference in Lisbon recently and when I got back to the airport to travel home, the passport officer said ‘Did you like Lisbon?’ and I had to unfortunately reply,

‘I haven’t even seen it!’ But these meetings are so important. It’s fantastic to have the opportunity to work with practitioners from around the world. You get to meet some really interesting people; it’s an enormous privilege.”

For Mr Mercer, treating patients isn’t just a one-off procedure; it’s a process, and to him, every conversation with a patient is a psychological intervention. He feels its important to correct surgery if patients aren’t happy and make sure they know he’ll be there to help them whenever they need it. “You can do a facelift and have a fantastic result, but if the patient is a smoker or sun-worshipper, then it’s likely that in a year’s time, the skin’s dropped; and that’s disappointing. But, metaphorically, you hold their hand and say, ‘I don’t like this either, lets do something about it.’ If revision surgery is needed, you do that. You don’t just say goodbye to patients who have a problem, you help them and hold their hand the whole way through.”

What treatment do you enjoy giving the most?

I love treating noses and faces. There’s a degree of natural variation in noses and you never quite know what you’re going to find when treating one. I have a mental image of what I think is normal for that patient and then try and create it – that’s the challenge!

What’s the best piece of career advice you’ve ever been given?

Mr Douglas Harrison, who was one of my main trainers, said to me, ‘The one thing you need to make sure of is that you sleep well in your bed at night – so don’t take risks.’ If I have a complication, I feel terrible about it and can lose sleep over it.

So minimising complications and risk is terribly important for me.

Do you have an industry pet hate?

I really don’t like the profit motive involved with aesthetics – some people come into it just because they think they can make a lot of money. When I teach students I say, ‘You’re never going to be rich! You’ll be comfortable, but you’re never going to be rich.’ And that’s true.

What aspects do you enjoy most about the industry?

I love the people! The industry is full of such nice people and a lot of us have ‘grown up’ together in the specialty. I’m lucky to have developed lifelong friendships. The patients can be exacting but it’s great to get to know and help them.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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The Last Word Dr Asim Shahmalak argues why it’s time to end the hard sell in aesthetic practice Patients quite rightly expect us to put their interests first, regardless of whether it benefits our practice or not. In my work as a hair transplant surgeon I have treated some big names in show business, but for every celebrity that has had a hair transplant, there is another that I have had to turn away. While my practice may have benefited enormously by the global publicity, I had to say ‘no’ as, if I treated them, I would not be acting in the patient’s best interests and, thus, I would have been failing in my duties as a medical professional.

Unfortunately, not every clinic has the same ethics. In my opinion, it has become apparent that hard-sales tactics are being used to the detriment of the patient. Patients will be told, ‘If you book today, you can have 25% off’ – pressuring them into making a decision quickly.

Other clinics will offer price matches on foreign clinics, in the same way you see supermarkets matching its competitor’s prices on branded goods. I’ve also seen botulinum toxin offered as part of a ‘3 for 2’ deal, like tubes of toothpaste at the chemist.

I have spent more than 30 years building my reputation as a successful practitioner and establishing my hair transplantation clinic, which, to my knowledge, is one of only four such clinics in UK that is doctor-owned and run. While many other clinics have

Patients seeking repairs have come to me blaming foreign hard sells; they are lured by the cheaper prices abroad but bitterly regret cutting corners on cost

Aesthetics

excellent doctors working in them, it is not always the medical professionals who are in charge of running the business.

To my knowledge, a sales team or ‘consultants’ (as they are often described to perspective patients) are running some clinics.

Their primary interest is not always that of the patient – and can be, instead, focused on making a sale and generating profits for the business. This can mean patients are being treated too early or when there is little chance of a successful treatment because they are not suitable.

I often see the results of this recklessness as around 10% of my workload is what we could call ‘repair work’ – fixing the poor surgery provided by other clinics. Most of my repair jobs arise from patients who have gone abroad for treatment. The most popular locations tend to be Greece, Turkey and Spain, and increasingly India and Pakistan, too. In each case, the regulation in these countries is not as strict as it is here; patients can have a hair transplant without ever seeing a fully qualified surgeon – a technician rather than a doctor will do the grafts. Patients seeking repairs have come to me blaming foreign hard sells; they are lured by the cheaper prices abroad but bitterly regret cutting corners on cost. If you buy cheap, you buy twice.

Clinics pushing patients into undergoing a treatment too quickly is not just an issue in hair transplantation surgery – the issue is prevalent right across the aesthetics industry. From breast implants to filler injections, there are rogue procedures taking place that are damaging the reputations of us all, and making some patients wary of seeking treatment that has the potential to transform their lives.

Moving forward It pains me to see the hard-sell tactics being used so blatantly. There have been significant developments in the aesthetics industry within the last 10 years, and while technologies have advanced right across the board, offering patients highly sophisticated treatments which produce far better results than ever before, the principles and values underpinning some of the clinics in our field leave a lot to be desired.

I think the way forward is to put more power into the hands of doctors and clinicians who are experts in their field and to rely less on sales people and consultants, who may put profit ahead of their patients’ best interests. I believe the best way to do this is to bring in tighter regulation in the UK. The British Association of Hair Restoration Surgery (BAHRS) is keen to liaise more closely with the General Medical Council and the health sector to bring in even tougher laws, as are other bodies such as the British Association of Aesthetic Plastic Surgeons (BAAPS).

In the hair transplantation sector, we are now moving towards a system where you would not be able to operate unless you were a member of the BAHRS, which insists on the highest ethical standards.

The most important thing we are all working for in aesthetics is our reputation as medical professionals. As such, it is vital that we do not feel pressurised into focusing on sales and profit instead of the care of our patients. People pay for quality so, remember, your reputation doesn’t need to be built on how many sales you make, more so, it should reflect the high level of care and successful treatments you offer your patients. It’s time to end the hard sell.

Dr Asim Shahmalak is a hair transplant surgeon and gained his medical degree from the University of Karachi, Pakistan in 1988. He founded the Crown Clinic in Manchester eight years ago and also has consulting rooms in Harley Street. He is a hair loss expert on Channel 4 show Embarrassing Bodies.

Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015

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Date of Preparation: October 2015