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VOLUME 4/ISSUE 1 - DECEMBER 2016

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Botulinum Toxin for Obesity CPD Professor Andy Pickett and Emma Miller explore the use of botulinum toxin for obesity treatment

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HA Fillers in Practice

Non-surgical Rhinoplasty

Going Selfemployed

Practitioners discuss the properties and use of hyaluronic acid dermal fillers

Mr Geoffrey Mullan and Mr Ben Hunter consider anatomy for augmenting the nose

Victoria Vilas explains how to set-up your own aesthetic business


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Contents • December 2016 06 News

The latest product and industry news

16 Conference Preview: IMCAS A preview of the International Master Course on Aging Science

congress 2017

19 News Special: Marketing in Aesthetics Aesthetics investigates the reported practice of unethical marketing 21 ACE Preview: Expert Clinic A look at the sessions taking place at the Expert Clinic

Special Feature HA Fillers Page 23

CLINICAL PRACTICE 23 Special Feature: Hyaluronic Acid in Practice Practitioners discuss the development of HA fillers, their

application, best practice and management of complications

29 CPD: Treating Obesity with Botulinum Toxin Professor Andy Pickett and Emma Miller present research into the

use of botulinum toxin for obesity treatment

34 Non-surgical Rhinoplasty Mr Geoffrey Mullan and Mr Ben Hunter examine the relevant

anatomy for successfully treating noses with dermal filler

39 Managing Male Acne Dr Anil Sharma introduces causes of acne and discusses possible

treatments for men

43 Treating Scars Dr Simon Berrisford outlines possible scar treatments and shares a

case study of treating a hypertrophic scar with platelet rich plasma

48 Breast Augmentation Without Implants

Mr Raj Ragoowansi shares breast augmentation techniques using autologous fat injection

51 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 53 Choosing a Training Course

Dr Tristan Mehta outlines the five questions to consider before booking a training course

57 Patient Testimonials Dr Harry Singh explores how to utilise testimonials from patients

for effective marketing

61 Going Self-employed

Victoria Vilas details the key points to consider when starting your own business

64 Front-of-House Selling Business development director Victor Fieldgrass advises how to

optimise your team for selling

In Practice Going Self-employed Page 61

Clinical Contributors Mr Geoffrey Mullan is a cosmetic surgeon and medical director at Medicetics Clinics and training academy. He has taught anatomy at Guy’s Hospital and worked at the Royal Marsden Head and Neck Unit. Mr Ben Hunter is a consultant facial plastic surgeon and works at St George’s Hospital Medical School, and privately at the Lister Hospital and King Edward VII Hospital. Mr Hunter qualified with the Royal College of Surgeons of England. Dr Anil Sharma is the founder of Sharma Skin & Hair Surgery in Canada and graduated from The University of Glasgow Medical School in 2003. His practice mainly concentrates on tumescent liposculpture, skin surgery, hair restoration surgery, and regenerative medicine. Dr Simon Berrisford has 25 years’ experience in the medical profession and is qualified in aesthetic medicine. He has written and lectured on a broad range of medical topics and runs Select Medical Group in Cheshire. Mr Raj Ragoowansi is a consultant plastic and aesthetic surgeon. He graduated in Medicine and Surgery in 1992 from St Thomas’ Hospital Medical School, London, with the final year elective spent at Harvard Medical School in Boston. Professor Andy Pickett has worked with botulinum toxin for nearly 30 years. He is the director and founder of Toxin Science Limited in Wrexham and an adjunct professor at the Botulinum Research Center, Institute of Advanced Sciences, Dartmouth, US. Emma Miller has worked in the aesthetic industry for 11 years in account management, marketing and product management. Her speciality areas include dermal fillers and botulinum toxin for companies including Merz and Galderma.

67 In Profile: Professor Daniel Cassuto

Professor Daniel Cassuto shares his experiences in teaching, plastic surgery and aesthetics

69 The Last Word Dr Emmanuel Elard debates the issues that surround current clinical

photography methods

NEXT MONTH • IN FOCUS: Contouring • Vaginal rejuvenation • Techniques for non-surgical rhinoplasty • Confident selling

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Editor’s letter The December issue is here and it’s nearly Christmas, meaning party season is upon us with patients asking for youthful, wrinkle-free skin, and bodies in the best condition possible, looking good for little black dresses and little Amanda Cameron black jackets (not to forget the men, of course!) Editor I am sure it is a busy time for you all with the huge variety of treatments now available to plump, smooth, reduce, contour and any other verb you can think of! Hopefully our articles this month will help you to enhance your practice and leave a smile on your patients’ faces. Treatments covered in this issue include non-surgical rhinoplasty by Mr Geoff Mullan and Mr Ben Hunter, which makes for a very interesting read and can be an incredibly successful procedure. In addition, as we are coming to the end of the year, we thought it would be interesting to reflect on the evolution of hyaluronic acid. We interview five practitioners, with a wide range of experiences, to see how we have ended up with the products available today and how they can be used to successfully treat our patients. If you want to learn more, turn to p.23.

Our December CPD article is fascinating – we know BoNT-A has been found to be useful in many indications but who would have thought of this one – obesity! Professor Andy Pickett and Emma Miller inform us of the latest research pointing to this potential new indication on p.29, and it is a MUST read. As always, the whole journal is packed with informative content covering a wide range of topics including back acne, breast lifts, neck treatments and managing scars with PRP. In our business section, Dr Tristan Mehta advises how to choose a training course (p.53), Dr Harry Singh highlights the value of patient testimonials (p.57), Victoria Vilas outlines how to go self-employed (p.61) and Victor Fieldgrass focuses on staff development (p.64). Do let us know which articles you have found useful this month! Finally, you may either be reading this a couple of days before the Aesthetics Awards or just after. For those reading before we wish you the best of luck and can’t wait to see you on the night! For those reading after, congratulations on all your achievements this year – it really is wonderful to see so many people dedicated to making this specialty as professional and rewarding as it is. Here’s to another fantastic year in aesthetics, let’s make 2017 as brilliant as this one!

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 more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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. Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. 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. 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.

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

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Masterclass Medikas @Medikas1 On my way to London but not going home yet, I am delivering a masterclass at the RSM #Restylane

#Dermatology Dr Anjali Mahto @DrAnjaliMahto Looking forward to #scar management day @TheKingsFund with @BritishCosmDerm #London #dermatology #skin #Surgery Reece Tomlinson @reecewtomlinson Spending the day in theatre @weareintraline #plasticsurgery #aesthetics #surgery #Event Dr Stefanie Williams @DrStefanieW Just finished our #acne #blogger event here at #Eudelo. Great to see everybody stay until the end, it was lovely having you all around. #JCCP Dr Tristan Mehta @tris_tweet Contributing on the working party for the #JCCP #regulation #aesthetics

#Smile Dr Galyna Selezneva @DrGalyna I love the sense of satisfaction I get when patients smile, it’s incredibly rewarding. #feelgood #bodyconfidence #CPR River Aesthetics @riveraesthetics Annual CPR training #safetyfirst #resustraining @SaveFaceUK

dermalclinic first to register with HIS An Edinburgh clinic has become the first to register with Healthcare Improvement Scotland (HIS) and be accepted under new legislation designed to safeguard people undergoing cosmetic and aesthetic treatments. The new law requires all private independent clinics, which includes those offering surgical and non-surgical cosmetic procedures, to sign up by April 2017. dermalclinic founding director, Jackie Partridge, said being the first clinic to register sets an important precedent, “The new legislation for independent clinics is vital to ensure the best care is carried out in the safest environment for every patient. While dermalclinic can now provide an added layer of reassurance to our patients, we hope our actions will inspire a stampede of other clinics to go forward and ensure they register.” Registration for HIS opened on 1 April 2016, and since then it is estimated that 258 cosmetic services have began completing their applications. Kevin Freeman-Ferguson, senior inspector for HIS, said, “dermalclinic has not been slow to recognise the importance of registering with us and the benefits this will bring for their clients. We look forward to welcoming many more clinics between now and the end of March.” Surgery

The Private Clinic opens new plastic surgery specialist hospital The Private Clinic has launched a £1.6 million hospital specialising in liposuction and plastic surgery in Fitzroy Square, London. The new facility, which has taken more than a year to construct, includes two operating theatres, enabling a wide range of treatments and procedures to be carried out on the premises including breast surgery, blepharoplasty, liposuction and ear correction surgery. “This has been the most complex project we have embarked on since 2008 when I joined as CEO of the business, but I could not be more proud of what we have achieved,” said Valentina Petrone, CEO of The Private Clinic Group. Established in 1983 in London’s Harley Street area, The Private Clinic has grown to employ more than 140 staff and has 12 locations nationwide. The launch of the Fitzroy Square facility comes just months after The Private Clinic completed the acquisition of Aurora Clinics; Petrone said that the opening demonstrates the company’s commitment to its patients. “Having access to this incredible facility in central London will mean we can offer greater availability to our patients and better care, thereby ensuring that their journey with us is impeccable from beginning to end. We have made it our mission to provide outstanding care and customer service and believe that this new facility will be a unique space within the cosmetic surgery sector, one which will provide patients with the very best experience,” Petrone said.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Distribution

Cosmedic Pharmacy partners with Esthetique Distribution Cosmedic Pharmacy will now be supplying Esthetique Distribution prescription products. The new products will include PDO threads from South Korean manufacturer Grand Aespio, the PQ Age Peel from Italian PromoItalia, and Institute Hyalual injectable products. Business development director for Esthetique Distribution Ltd Magda Krol said, “We’re delighted to be working alongside Cosmedic Pharmacy to offer our customers the very best products and service. Since its inception, Cosmedic Pharmacy has gone from strength to strength and now offers a huge range of cosmetic products and consumables to the single-handed practitioner or large clinic chain. Sharing similar values makes this an ideal union.” Cosmedic Pharmacy founder, Dr Martyn King, said he is pleased to be working with Esthetique Distribution Ltd, “Using the latest technology and clinical specialists they are able to deliver the results that patients want through training and consultation skills, they are the brand that deliver results. We’re delighted to be working with the team.” Skincare

Alumier Labs introduce Intellibright Complex Skincare developer Alumier Labs UK has launched a new serum that aims to brighten the skin’s complexion and reduce the appearance of hyperpigmentation. According to Alumier, the Intellibright Complex contains Azelaic acid, kojic acid, liquorice and niacinamide (vitamin B3) that work to enhance brightening results and create resistance to new pigment formation. Marketing manager at Alumier Labs UK, Samantha Summerfield, said, “The Intellibright Complex will add an additional dimension of lightening and brightening to any professional treatment which will help ageing complexions and post inflammatory pigmentation, especially from acne.” According to the company, for best results the Intellibright Complex should be used with either Alumier’s AHA Renewal Serum or the Retinol Resurfacing Serums, which aim to enhance exfoliation of existing dark spots. Training

AestheticSource announces chemical peel training dates Antiageing skincare company AestheticSource will continue its chemical peel training in December and throughout 2017 to provide delegates with a greater understanding on the science and treatment methods of the products. The NeoStrata Science, Product and Peel Training will discuss how to assess patients’ skin, provide an overview of published clinical data and the science behind the NeoStrata products and will explain how to best use skincare and chemical peels for treatment plans, The courses are CPD accredited and the next session will be in London on December 12, with the 2017 courses taking place on March 17, April 20 and May 17.

THE BUSINESS DESIGN CENTRE / LONDON / 31 MAR & 1 APR 2017

COUNTDOWN TO ACE 2017 AGENDA INSIGHT: MASTERCLASSES With 12 informative Masterclass sessions running across March 31 and April 1 at ACE 2017, you are guaranteed to learn new skills and enhance your product knowledge with talks from industryleading key opinion leaders. Showcased in dedicated rooms in the gallery, the 90-minute Masterclasses will each deliver expert advice on how to best utilise aesthetic companies’ latest treatment and product offerings; covering a range of topics including injectables, lasers and cosmeceuticals. Galderma, Merz Aesthetics, SkinCeuticals, Lumenis UK and Teoxane UK will each host a Masterclass, with more to be announced soon. SPEAKER INSIGHT Dr Raj Acquilla, who will be speaking on the Premium Clinical Agenda, says, “Every year, ACE delivers on its promise to bring together the best speakers, latest innovations and leading aesthetic companies to educate delegates on how to create and enhance a successful practice. I am looking forward to bringing my international experience to the event, teaching delegates how to rejuvenate an ageing face and perfect their techniques for optimum results. I encourage everyone to register and make the most of the hugely educational free content available at the Masterclasses, Expert Clinic and Business Track at ACE 2017, as well as book sessions on the Premium Clinical Agenda for an even more in-depth learning experience.” WHAT DELEGATES SAY “The live demonstrations, the Masterclass sessions, the Exhibition and all of the programme content is good for professional development and ACE is the best conference to attend.” AESTHETIC NURSE, GLOUCESTERSHIRE

“There is a wealth of experience, knowledge and information available at ACE, allowing delegates to pick and choose which is most relevant to them. It is also an excellent opportunity to network with like-minded professionals and share learning experiences.” AESTHETIC DOCTOR, BUCKINGHAMSHIRE HEADLINE SPONSOR

www.aestheticsconference.com

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Vital Statistics

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Botulinum toxin

TSK launches Unit Injector

Enquiries for vampire facials have increased by 67% over the past 12 months (WhatClinic.com data, 2016)

In a survey of 156 US dermatologists, 99% believe that patients don’t apply enough sunscreen (JAMA Dermatology, 2016)

According to a new market research report, the cosmetic lasers market will be worth US $1,132.7 million by 2021 (MarketsandMarkets, 2016)

More than 4,500 men underwent cosmetic surgery in 2015 (British Association of Aesthetic and Plastic Surgeons, 2016)

TSK Laboratory has launched the redesigned TSK Unit Injector to be used in conjunction with the INViSIBLE NEEDLE for botulinum toxin injections. According to aesthetic surgeon Mr Dalvi Humzah, who along with aesthetic nurse prescriber Anna Baker, was the first to use the new product, it allows for more accurate, consistent dosing and easier injection of botulinum toxin. Mr Humzah said this now makes it possible to inject doses from 0.05 to 0.01ml consistently without issues of parallax errors. “It allows me to pay attention to my patients and not get distracted in looking at the graduations on the syringe during the injection process. It makes it easy to inject and have a relaxed patient,” Mr Humzah said. The company claims that this allows for consistent dosing and reproducible results, as it is now possible to accurately inject from 0.05ml to as small as 0.01ml. Mr Humzah and Baker will be demonstrating the TSK Unit Injector and the INViSIBLE NEEDLE in their Practical Cadaver and Advanced Injection sessions run by Dalvi Humzah Aesthetic Training. Post procedure

A survey of 4,000 US women suggested that the average woman owns 40 makeup products (Poshly and Stowaway Cosmetics, 2015)

In a survey of 364 UK residents, 28% admitted to suffering from acne at some stage and of those, 39% admit they don’t know how to handle it (British Skin Foundation, 2016)

Medica Forte releases NuvesseMD Medica Forte has launched US-based skin serum brand NuvesseMD in the UK. The serums aim to accelerate skin healing after aesthetic treatments such as ablative lasers, chemical peels, botulinum toxin injections, microneedling, dermal fillers, intense pulsed light treatments, and to alleviate patient concerns including crow’s feet, lip lines, sagging, puffiness and skin dryness. The company claims the serums do this by delivering hyaluronic acid faster to the skin with the assistance of the company’s Cellulartion Technology (CT). The technology is said to work by allowing the ingredients in the serums to travel through the outer layer of the skin to the inner layers where the collagen and elastin forms. Nurse prescriber Kelly Saynor, clinical lead at Medica Forte, said, “We are thrilled to be able to bring NuvesseMD’s ground-breaking range of skin serums to aesthetic professionals in the UK. We strongly believe the brand is a game-changer for the skincare market and will revolutionise post-care treatment resulting in the very highest levels of patient satisfaction.”

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Hair loss

Fusion GT launches Biofibre Hair Implant Aesthetic distributor Fusion GT has been announced as the exclusive UK distributors of Biofibre Hair Implant. The automatic machine implants artificial fibres, or hairs, that are a medical polyamide with a reversible knot of 0.25mm and can be used in a poor quality donor area, aiming to provide instant, long-lasting results for men and women. According to Fusion GT, the Biofibre Hair Implant works by shooting the artificial hair into the scalp at the correct depth and angle, reducing the risks and complications of incorrect implanted fibres. The Biofibre Hair Implant has 13 different colours that can blend together to make a variety of different shades and the hair can be cut, styled, dyed and treated like real hair. Fusion GT sales manager, Kelly Morrell said of the technology, “It’s ideal for medical practitioners to use on patients they have to turn down for other treatments such as FUE due to lack of donor area or poor quality donor area. Since it gives instant results, it is a massive help to those emotionally affected by their hair loss, which needs to have value. There is minimal downtime and patients can return to normal daily activities.” The procedure is carried out under local anaesthetic and results can last between five to eight years. Training

Advance Aesthetics Training launches new business course Advance Aesthetics Training has launched the Setting up a Skin and Laser Clinic course. The new course, which was launched in November, aims to assist anyone looking to set up a clinic, and covers: legal structure and regulations – opening a business bank account, sole traders, partnerships and limited companies, guidance on choosing a name and information on tax, licences and your business plan; marketing – how to develop a social media plan, PR and advertising, guidance on market research and how to assess competition within the aesthetics industry; and clinic operations – staff contracts, stock control and how to manage day to day tasks. Course leader, Annalouise Kenny, who runs five training centres, said, “This is a great course to help anyone set up and run a business. The course will cover all aspects of setting up a business and delegates will also receive a manual on how to run the business and any paperwork that assists that.” The next three-day course will next take place on January 15-17. Clinic

Juvea Aesthetics introduces surgical treatments Juvea Aesthetics has become Juvea Medical and Aesthetics after it introduced surgical treatments to its offering. As of December, Juvea Medical and Aesthetics on Harley Street will offer breast augmentation, breast reduction, mastopexy, liposuction, abdominoplasty, gynaecomastia, otoplasty and blepharoplasty. “My background in plastic surgery meant that it was always my dream to launch a clinic in Harley Street which offered the highest quality cosmetic and reconstructive surgery, minor surgery and aesthetic procedures with patient care and safety as the main focus,” said medical director Mr Faz Zavahir, who added, “Juvea Medical has hand picked some of the best surgeons in the country who are dedicated to patient care and satisfaction.”

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

BACN CONFERENCE 2017

After the huge success of the BACN 2016 Autumn Aesthetics Conference we are pleased to announce we are going back to the International Conference Centre in Birmingham for an extended 1.5 day conference on 15-16 September 2017. Demand from members and exhibitors has resulted in the conference being extended; it will now start at 2pm on Friday 15th September with sponsored workshops. If any companies are interested in sponsoring these workshops please get in touch.

BACN LAUNCHES 2017 STRATEGIC PARTNERSHIP PROGRAMME

The BACN works with a number of major players within the aesthetics specialty via its Strategic Partnership Programme. In 2016, nine partners worked with the BACN throughout the year, with preferential access to members, regional events and the annual conference, plus a wide range of branding opportunities. These packages have now been upgraded and extended for 2017 and include new social media options, supporting campaign themes and much more. The new programme will start in January 2017 and details are now available for any additional interested partners.

DATES FOR YOUR DIARY The regional meeting dates for early 2017 are: 10th Feb: Cardiff 13th Feb: London 17th Feb: Newcastle 20th Feb: Birmingham 27th Feb: Southampton 3rd March: Manchester 6th March: Belfast 17th March: Bristol 20th March: Cambridge 27th March: Glasgow

MEET A MEMBER Frances Turner Traill is an awardwinning Scotland-based aesthetic nurse practitioner, who is a member of the BACN Board. She is also on the advisory board for Health Improvement Scotland, working towards improved regulation in Scotland. In addition, Turner Traill is a mentor at Northumberland University, where she is studying for her Master’s in Aesthetic Medicine. Her ethos is to provide a safe, clinically excellent environment to achieve optimal outcomes for patients.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Events diary 3rd December 2016 Aesthetics Awards, London www.aestheticsawards.com

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Conference

Early booking discount for ACE 2017 to end this month

26th – 29th January 2017 IMCAS Annual World Congress 2017, Paris www.imcas.com

3rd – 7th March 2017 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

31st March – 1st April 2017 Aesthetics Conference and Exhibition, London www.aestheticsconference.com

6th – 8th April 2017 15th Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2017.org

Skincare

mesoestetic releases festive limited edition gift set mesoestetic Pharma Group has released a gift set for the festive period that includes two antiageing products. The crystal cream, a firming and restorative day and night cream, and the crystal eye cream, that aims to contour the eye and restore firmness, comes in a white case with a leather texture. As well as the two products, the set includes an ion stimulator that aims to improve the microcirculation of the eye contour. mesoestetic claims that using this before applying the eye cream will help to increase the skin’s permeability and enhance the absorption of active ingredients.

A 10% discount for the Premium Clinical Agenda at the Aesthetics Conference and Exhibition (ACE) 2017 is set to end on December 31. Delegates can book to attend up to four sessions over two days, each focusing on treating the face. On the morning of Friday March 31, Mr Dalvi Humzah, nurse prescriber Anna Baker and Dr Beatriz Molina will present The Ageing Female Face, while Dr Kate Goldie and Dr Maria Gonzalez will present The Male Face session in the afternoon. On Saturday April 1, nurse prescriber Lorna Bowes, Dr Uliana Gout and Dr Souphiyeh Samizadeh will present on the Basics of Facial Assessment in the morning, followed by Dr Raj Acquilla, Dr Askari Townshend and nurse prescriber Sharon Bennett’s presentation on The Young Female Face in the afternoon. In each session, speakers will analyse the same patient and share their recommended procedure protocols before carrying out a live demonstration of one of the treatments. They will also provide advice on anatomical considerations to be aware of and how to successfully avoid and manage complications. As well as the 10% Early Booking Discount, further discounts are available to those who book multiple sessions. An extra 10% discount is available when booking two sessions, 15% when booking three sessions and 20% when booking all four sessions. ACE 2017 will take place in London. For more information, or to register for the event, visit www.aestheticsconference.com Skincare

5 Squirrels launches two new hydrating products Private label cosmeceutical supplier 5 Squirrels has launched two new hydrating products in the Your Signature Range. The Lip Hydrating Complex aims to aid optimal lip health and appearance, is fast absorbing and contains natural vitamins B and E. The Hydrate Serum aims to hydrate the skin and reduce the appearance of fine lines and wrinkles, while also improving skin tone. According to 5 Squirrels, the Hydrate Serum has a high concentration of hyaluronic acid, is suitable for all skin types and can be used effectively after treatments such as microneedling. Gary Conroy, co-founder of 5 Squirrels, said the products are designed to hydrate the skin especially in the winter months when outside in cold temperatures and indoor in central heating. “We have had a lot of requests from our existing skincare brands to introduce these products and, with winter in full swing, now it is the time for hydrated skin,” he said. The two new additions bring the Your Signature Range to 11 products, which have all been developed and manufactured in the UK without parabens and animal testing.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Aesthetics

Microneedling

SkinPen Precision launches in the UK

60

Elliot Isaacs, founder of Medik8

The SkinPen Precision device for microneedling has been introduced to the UK by BioActiveAesthetics. Manufactured by US company Bellus Medical, the device aims to enhance the safety of microneedling for collagen induction therapy by incorporating a single-use lock out feature to remove any possibility of cross contamination. According to BioActiveAesthetics, the device ensures a precise depth setting from 0.25-2.5mm and completes 7,000rpm. There are 14 precision sterile needles that can produce 98,000 microchannels per minute, which the company claims is four times faster than any other device. The device also features a wireless charger that allows for an enhanced ease of use and incorporates a battery level monitor. Typically, patients will need between three to six treatments, each taking around 20 minutes for optimal results. Sales

Data suggests Londoners spend most money on beauty products An online beauty store has analysed its most recent product sales and found that Londoners, in particular those in South West London, buy the most face and body skincare products compared to the rest of the UK. The town that spent the least was Lerwick in Scotland and the lowest buying regions were suggested to be Wales and the North-East of England. Suncare sales were reported as lowest in the city of Wigan, and the lowest purchasing region was said to be the East Midlands, making up just 5% of purchases. London, Oxford and Birmingham all spent high amounts on their suncare regimes. Lisa de-la-Plain, co-founder of Beauty Flash has claimed buying habits, around skincare in particular, are changing across the country, “Our latest research is fascinating because it shows how wrong our preconceptions can be and reveals more accurate insights into what the real beauty trends are across the country.” Clinic

Dr Nestor Demosthenous joins PHI Clinic in London Scotland-based aesthetic practitioner Dr Nestor Demosthenous will join the team at PHI Clinic on London’s Harley Street from January 2017. Dr Demosthenous will visit PHI Clinic twice per month and practice a number of aesthetic and skin health treatments, as well as introduce hair restoration surgery to the clinic. “I am very proud to be joining the team at PHI Clinic,” said Dr Demosthenous. “It is an honour to work alongside and further develop my own practice from practitioners, Dr Tapan Patel and Dr Benji Dhillon. I am looking forward to the clinics commencing next year,” he added.

You’ve recently launched r-Retinoate, a breakthrough innovation in Vitamin A skincare, please tell us more? Consumers desire a powerful retinol that does not irritate. r-Retinoate is the culmination of eight years of research by scientists around the world. The active ingredient retinyl retinoate is a hybrid molecule of retinol and retinoic acid offering properties of both. Research has been published in respected journals including the British Journal of Dermatology. Studies show retinyl retinoate is more powerful than retinol, yet less irritating and photo-stable – so can be used day and night. We are very excited about this new class of retinoid. Medik8 has an exclusive agreement with the patent holders. What is the core Medik8 focus for 2017? Aside from r-Retinoate, our focus is always Vitamin A. Our core anti-ageing philosophy is simple. A stable vitamin C and broad-spectrum sunscreen during the day, with vitamin A at night. We consider retinoids the most important class of anti-ageing active, having the most scientific evidence behind their effectiveness. We are focussed on being the world leaders in Vitamin A technology. Lots of skincare brands are talking about retinol (vitamin A), how do you differentiate from your competitors on the market? We offer simple uncluttered formulas, in a wide variety of formats and strengths. New Retinol 1TR has world-beating stability as proven in a double-blind HPLC trial. We don’t just use any old encapsulated retinol. New regulations mean it is more important than ever to ensure maximum stability/potency, and also to explore retinoids with higher efficacy than retinol eg. retinyl retinoate. How important is being innovative today and how does Medik8 keep ahead of the curve? Innovation is everything at Medik8. We are a nimble British company with the passion for invention baked-in to our culture. Our in-house team of researchers constantly refine and make incremental improvements to our technologies. We are certified ISO 9001 & ISO 22716 and we collaborate with universities and other research groups to make sure we are ahead of the curve. This column is written and supported by

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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News in Brief Medical Aesthetic Group appoints new business development manager Aesthetic product supplier Medical Aesthetic Group (MAG) has welcomed Judith Nowell as its new business development manager. Nowell has worked closely with large corporate companies and has experience in the financial sector for more than 12 years, managing a number of accounts. Nowell said, “With the ever increasing awareness and access to aesthetic treatments, it is such a fantastic opportunity to join the specialist team at Medical Aesthetic Group who are consistently leaders in providing the most innovative products and clinical treatments to the UK.” Dr Peter Grossman joins Oxygenetix’s Board of Advisors Aesthetic brand Oxygenetix has welcomed plastic surgeon Mr Peter Grossman to its Board of Advisors. According to Oxygenetix, Mr Grossman’s 21 years of experience in cosmetic, reconstructive surgery and burninjury patients has led him to be a good addition as an advisor for the company. Mr Grossman said, “I am often asked to endorse or back products, and it is important to have a sense of credibility. I not only use Oxygenetix on my patients but on myself as well. I am delighted to sit on the Board of Advisors for a product I truly believe in.” French Skincare brand Ixxi released in the UK Health and beauty product supplier Vital Life International has launched French skincare brand Ixxi in the UK. According to Vital Life International, the Ixxi extract aims to protect and repair the skin, reduce the signs of ageing and produce a healthy, revitalised glow. The products contain a native French maritime pine bark extract, hyaluronic acid, samphire extract, provitamin B5, sodium hyaluronate and salicylic acid. Skin Philosophy launches new patient membership scheme Skin specialist clinic Skin Philosophy has launched a new membership option designed to suit each patient’s needs. The service is broken down into three options to cater for individual patient requirements. “We’re delighted to see the Skin Membership come to fruition,” said Annalouise Kenny, director of Skin Philosophy Ltd. “The client’s needs underpin everything we do here at Skin Philosophy and with no two clients the same, the prescriptive treatments included in Skin Membership, are the perfect option for your individual skincare needs.”

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Laser training

Mapperley Park sees demand for laser courses double The demand for laser training courses has doubled in the past two years, according to Mapperley Park Aesthetics Training Academy. The training provider, based in Nottingham, offers training in laser and light therapies for practitioners of every level. Glenda Bailye-Bray, head of learning and development at Mapperley Park, said, “The general public’s awareness of the often life-changing results that laser can bring is growing. In turn, demand for quality training has also grown. From specialist units in hospitals to private clinics and beauty salons, qualifications in laser are in demand across the aesthetics industry.” Mapperley Park recently launched three accredited BTEC qualifications that they claim provide ‘credible, quality training and development in lasers’. They also offer a progression route for BTEC qualifications in Lasers and Light Therapies enabling learners to progress to a BTEC Level 5 Certificate. Skincare

Murad launches limited edition gift sets Skincare company Murad has launched limited edition gifts sets to celebrate the Christmas season. There are four gift sets to choose from, each incorporating three of the company’s products that aim to treat different indications. The products in the Merry & Renewed gift set aim to reduce the appearance of medium to deep wrinkles and renew youthful firmness, the Merry & Beautiful gift set aims to polish, plump and smooth fine lines to restore elasticity, the Merry & Glowing set aims to protect against environmental aggressors to restore youthful radiance and a healthy glow and the Party Perfect hopes to maintain healthy skin throughout the festive season. Ambassador

Dr Leah Totten announced as UK brand ambassador for Obagi Medical Dr Leah Totten has been chosen to be the UK brand ambassador for skincare brand Obagi Medical. Karen Hill, managing director of Obagi UK distributor Healthxchange Pharmacy said that Dr Totten was an obvious choice. “We are delighted to announce Dr Totten as the UK Medical Ambassador for Obagi. Dr Totten’s enthusiasm, deep understanding and belief in Obagi Medical Products made her a natural choice. Dr Totten will be an integral part of our plans to ensure that the Obagi brand in the UK is represented in the best way possible to connect with healthcare professionals and patients alike.” Dr Totten has already lectured on behalf of Obagi Medical at recent conferences and has presented live demonstrations of the Obagi Blue Peel Radience treatments. She said she is excited to be working more with Healthxchange and Obagi, “I am thrilled to be the Medical Ambassador of Obagi in the UK,” said Dr Totton, who added, “I have been prescribing Obagi to my patients for quite some time now and it is the skin care regime that I’ve seen the best clinical outcomes from and for me it’s the industry leader delivering the best transformative results for a patient. As an ambassador I am really looking forward to supporting Healthxchange Pharmacy as they continue to develop and grow the Obagi brand in the UK.”

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Hair

Aesthetics Company launch

Facial hair transplants on the rise according to WhatClinic.com Private healthcare search engine WhatClinic.com has released data indicating the most popular treatments of 2016. The search engine has seen a 144% increase in email enquires regarding facial hair transplants compared to the previous year. It also reported an increase in enquires on the ‘vampire facelift’, which was up 67% on 2015. Philip Boyle, head of consumer matters for WhatClinic.com, said, “When it comes to image alterations, it’s important for patients to be realistic about both the risks and the outcomes of any procedure. With medical tourism and the increasing availability of finance options, costs are less of a barrier to treatment. It’s important to think carefully before making a final decision, and to read reviews and check the surgeon’s qualifications before choosing a clinic.” Microneedling

Syneron Candela’s Profound handpiece receives FDA approval Aesthetic device company Syneron Candela has received Food and Drug Administration (FDA) approval for the Profound handpiece. The Profound, a minimally invasive, fractional radiofrequency microneedling device, has approval for the SubQ handpiece and cartridge for improving the appearance of cellulite. The FDA-clearance was based on positive data from an institutional board-reviewed multi-centre study of 50 women with Fitzpatrick skin types I-III with undulation regularities in the thighs. They were treated with Profound using the SubQ cartridge and handpiece. There was improvement reported in cellulite severity in dimples and/or undulation irregularities in 94% of treated thighs at a three month follow-up. At the six-month follow-up, sustained improvement was observed in 93% of the treated thighs. There were similar results per patient, with 88% of the treated patients displaying improvement in the appearance of cellulite at the three month follow-up, and 86% of the treated patients experiencing improvement at six months. “There has been an increased demand for treatments that can impact the appearance of cellulite over the past few years as it’s a driver of insecurities in both men and women,” said Dr Macrene Alexiades, associate clinical professor at Yale University School of Medicine, and director and president of the Dermatology & Laser Surgery Center of New York. “Profound is an optimal treatment for patients with cellulite who are apprehensive about invasive procedures, as well as for those who are looking to improve the appearance of areas impacted by cellulite in a single treatment. Some subjects showed improvement starting at one month after treatment.” she added.

STADA Aesthetics to launch in the UK New aesthetic distributor STADA is set to launch in the UK in January 2017. STADA Aesthetics aims to offer practitioners a ‘onestop-shop’ for antiageing products; for loss of volume and sagging, the company offers the Princess Hyaluronic Acid fillers and Princess Lead Fine Lift PDO threads, whilst for skin ageing, a range of cosmeceuticals, nutritional drinks and supplements can be obtained to address concerns. The company claims that its UK launch represents its commitment to the consistent expansion of its brand portfolio in the areas of skin and hair health, fitness and aesthetics. Katrina Ellison, country manager for STADA Aesthetics UK, said, “I’m thrilled to be launching the STADA Aesthetics products in the UK as it offers aesthetic customers a comprehensive product portfolio. The 3D concept encompasses a variety of innovative treatment options to provide patients with a combination of unique fillers, threads, skincare and supplements.” She continued, “STADA Aesthetics UK will focus on extensive training in order to achieve the best outcomes for patients. Training is vitally important to the company as it combines the skills of the physician, along with the excellent product range to ensure that today’s patients achieve a natural and beautiful result.” The STADA Aesthetics 3D portfolio includes the Princess HA Filler with 0.3% Lidocaine, cross-linked hyaluronic acid; Princess HA Filler without Lidocaine, Princess Volume with 0.3% Lidocaine, cross-linked hyaluronic acid. Princess Lead Fine Lift PDOs and the Princess Skincare. Training

New dates announced for The Training Aesthetic Trainers course Dalvi Humzah Aesthetic Training has announced the 2017 dates for The Training Aesthetic Trainers course. The course, which aims to further the skills of aesthetic trainers and enable them to develop successful presentations, will take place on June 12 and 13 at The Crowne Plaza Birmingham NEC. Facilitating the course will be consultant educators Ms Lisa Hadfield-Law and Ms Hayley Allan, as well as nurse Anna Baker and Mr Dalvi Humzah. The first Training Aesthetic Trainers course took place on October 17 and 18 and received positive feedback from delegates. Aesthetic nurse Pam Cushing said of the course, “Thanks for a fantastic two days. Brilliant learning experience and I have learned a huge amount. Thank you all.”

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Pigmentation

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Laser

Medical Aesthetic Group launches pigmentation treatment Aesthetic product supplier Medical Aesthetic Group (MAG) is now distributing ME LINE in the UK. Manufactured in Barcelona by the formulator of the Innoaesthetics product line, Fernando Bouffard, the ME LINE is a treatment that aims to address pigmentation issues on all skin types over the face and body, such as melanic-hematic pigmentation and hyperpigmentation lentigines. As well as pigmentation, ME LINE also aims to treat dermatitis and signs of ageing including lines, wrinkles and acne. The treatment regime consists of cleansing the skin and applying a ME LINE chemical peel mask followed by a programme of aftercare at home, which aims to control pigmentation, decrease melanin production, promote renewal of skin cells, improve sun damage and even out the tone and colour of the skin. Bouffard said, “The ME LINE is non-aggressive treatment that provides good results against pigmentation. It is the first pigmentation removal system in the world that works on specific types of pigmentation that can be used to treat most skin types, including pale skins, darker skins, sensitive and acne-prone skin.” To teach practitioners about the science and application of the treatment, Glow Aesthetic Training has launched a training course conducted by Dr Zunaid Ali, which includes live demonstrations. Glow Aesthetic director of training Morag Hague said, “We are delighted to collaborate with MAG and launch these new training courses in the pharmaceutical formulations from Innoaesthetics. Our training courses deliver targeted professional learning in small groups, allowing time for each delegate to feel confident in the technical and scientific knowledge and performing the treatments in the practical sessions.”

Fotona Lasers launches new training institute Global device manufacturer Fotona Lasers has launched a new laser training and research institute in Europe. The Fotona Institute, in Ljubljana, Slovenia, has 500m2 of workspace for educational and training activities, a large lecture hall that can sit 90 participants, a room for live patient laser treatment demonstrations and a room for hands-on ex-vivo trainings. The facilities are to be equipped with state-of-the-art audio and visual equipment. Fotona hopes the institute provides a place for regular research and education on new medical laser applications, allows for connecting and coordinating international Fotona training centres, conducting advanced workshops and seminars, organising meetings to exchange ideas and methodology, improving treatment standards, and improving treatment efficacy and efficiency.

On the Scene

On the Scene

Cynosure Advanced Symposium, London The Andaz Hotel in London played host to two days of learning at the Cynosure Advanced Symposium on October 15-16. The Advanced Symposium aimed to educate delegates on applications for hair removal, body contouring, laser skin renewal and injectable fillers and also provided business tips such as how to increase clients and profits. During the training sessions, cosmetic laser surgeon and aesthetic physician Dr Dianne Quibell provided delegates with insightful presentations on different aesthetic indications, which included live demonstrations of treatments. President and owner of cosmetic clinic Dr Flo Foshgarian supported Dr Quibell’s clinical presentations by providing her business advice to enable delegates to understand how to make the most out of their treatment offerings. Rory McNicholl, Cynosure UK manager, said of the event, “The Advanced Symposium was an informative weekend led by Dr Dianne Quibell who is a world renowned cosmetic laser surgeon, and aesthetic physician. With a mixture of live demonstrations, presentations and networking, attendees gained valuable insight into Cynosure’s technology and how to boost their practice. This event demonstrated Cynosure’s continued dedication to education and support for its customers.”

Inspired Cosmetic Training Masterclass, Glasgow Delegates attended the Inspired Cosmetic Training Masterclass on Advanced Facial Volumisation Assessment on the evening of November 21 at the La Belle Forme Clinic, Glasgow. Attendees were introduced to consultant plastic surgeon from La Belle Forme Clinic and Inspired Cosmetic Training, Mr Taimur Shoaib, who during the workshop, explained how to assess a face for rejuvenation requirements. He then discussed how to deliver treatments, including large volume treatments, and presented a live demonstration. The workshop also included a session by Teresa Da Graça, chief executive of Pure Swiss Aesthetics, exclusive distributor for SWISSCODE, on the role of skincare within a business. Da Graça explained how to market skincare for increased revenue, how to choose the right skincare for a business and how to get the most out of a skincare range. Mr Shoaib said he was pleased with the response from the delegates, and was glad that he could help further their learning, “I strongly believe in life-long learning and our programme of masterclasses help aesthetic practitioners at new and advanced levels to keep up to date with the latest clinical and business knowledge out there.” The next masterclass will be on January 1 next year and a full 2017 programme is currently being worked on, covering clinical and business aspects as well as live demonstrations.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


WIN N E R Best Anti-Ageing Treatment


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IMCAS Preview Aesthetics outlines the varied scientific agenda for the International Master Course on Aging Science (IMCAS) World Congress in Paris For the 19th year, IMCAS will return to Paris to bring together world leaders in medical aesthetics to discuss best practice techniques and present the latest innovations in the specialty for 2017. Taking place from January 26-29 at the Palais des Congrès, the event aims to collate scientific research, clinical experience and industry insight in a cohesive programme, covering aspects of successful medical aesthetic practice with a strong emphasis on cosmeceuticals and clinical dermatology. The programme will feature multiple aesthetic topics, including anatomy, body shaping, cosmeceuticals, face surgery, breast surgery, genital treatments, hair restoration, injectables, lasers, peeling, mesotherapy, business development and regenerative medicine. Delegates can also learn about research and development, new technologies, practice management, market analysis and medical affairs. In addition, there will be a day dedicated to cadaver workshops featuring live satellite links to Australia and Indonesia, which will aim to enable practitioners from across the world to benefit and contribute to the sessions. According to IMCAS, with 250 learning hours available, the expected 7,000 delegates attending will have the freedom to choose from a variety of sessions to suit their learning requirements in an ‘à la Carte’ approach to the content on offer. Amongst the 500 speakers confirmed to present at IMCAS, practitioners from the UK include Dr Raj Acquilla, who will perform a live demonstration and outline what’s new in injectables, covering anatomical basis and physiopathology; Dr Olivier Branford, who will share advice on managing your online communication, as well as lead an interactive course on lipofilling; Professor Andy Pickett, who will present the latest clinical data on toxins and lead a session discussing whether acne psoriasis inflammation can be treated with toxins; and Dr Stefanie Williams, who will detail how to attract and retain patients in her first session, and explore the level of evidence supporting cosmeceutical use in her second session. Experienced speakers from abroad include Dr Philippe Kestemont, who will share advice on how to avoid vascular complications with injectables; Dr Marina Landau, who will present six lectures, covering topics from hyperpigmentation to dealing with vascular complications associated with nasolabial fold treatment; Dr Hema Sundaram, who will, amongst other sessions, chair a discussion on

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filler and soft tissues; Dr Heidi Waldorf, who will lecture on avoiding lip treatment complications; and Dr Sabine Zenker, who will perform live demonstrations on using injectables, cosmeceuticals and mesotherapy. IMCAS claims that in their innovative sessions, the speakers will each provide delegates with tips and

techniques to ensure optimal outcomes for their patients. Delegates will also be able to explore 200 exhibition stands, which will allow them to discover technologies, products and devices. In addition, thanks to IMCAS’s new academic and social e-learning platform, IMCAS Academy, IMCAS is now able to offer a digital anytime, anywhere approach to the congresses, offering aesthetic learning at your fingertips. The online service aims to support practitioners in their training and development, whilst also allowing them to socialise, share and discuss specialty news with a global aesthetic community. Delegates can access more than 1,000 video lectures collected from all the IMCAS congresses, join live webinar discussions and explore scientific publications and worldwide events associated with IMCAS. With 15 different themes to choose from, IMCAS claims there is something for everyone to learn, whether it is related to clinical or business development. At the annual IMCAS Beyond talk show, leading practitioners will discuss the future of science in aesthetics. Topics will include the value and challenges associated with incorporating robotics and simulators in both invasive and minimally-invasive treatments, as well as the use of a biochip implant, detailing Evgeny Chereshnev’s experience of living with a biochip implanted into his left hand for the past two years. To celebrate the congress, the annual IMCAS gala dinner will take place on the Saturday evening, aiming to allow speakers, exhibitors and delegates to relax and network. According to IMCAS, a percentage of all proceeds will be given to charity. Delegates will also be able to gain continuing medical education (CME) accreditation from sessions attended, which, IMCAS suggests, ensures that the educational content on offer is of the highest quality at the congress.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Marketing in Aesthetics Aesthetics investigates reports of unethical marketing tactics in the specialty and whether practitioners believe the hard sell is commonplace In October this year, the Royal College of Surgeons (RCS) launched online safety information for patients considering cosmetic interventions that according to the association’s vice president, Mr Stephen Cannon, will help protect patients from, “Aggressive marketing and ruthless sales tactics of some unscrupulous companies.”1 But just how common are ‘aggressive’ and ‘ruthless’ marketing methods in the aesthetics industry? And can ethical standards in marketing and advertising be maintained? Guidance and regulations In the UK, the Committee of Advertising Practice (CAP)2 creates the advertising code of practice that is enforced and regulated by the Advertising Standards Authority (ASA), which has the ability to ban advertisements that fall short of the guidelines.3 According to the ASA, more than 3,000 ads relating to cosmetic and aesthetic surgical and non-surgical interventions received complaints in the last five years, with just over 400 resulting in a ban.4 However, health communications and marketing specialist Tingy Simoes says, “The ASA has very openly admitted that they can’t police everything – they can only do what they can when someone brings a complaint and look into it.” Rulings and advertisements banned by the ASA this year include one advert published in February in The Metro for labia reshaping that stated that patients could ‘achieve a more natural appearance’ and ‘relieve the discomfort caused by enlarged labia’. The reason given for the ban was that it encouraged women to be dissatisfied with their bodies.5 Aesthetic practitioner, Dr Harry Singh, who regularly presents talks on aesthetic marketing, acknowledges that there are lots of practitioners who aim to promote themselves and their clinics ethically, but he also believes that many are unaware of the effect their marketing has on the patient. “I don’t think people do it on purpose – I think many are not educated enough in terms of regulation and guidelines,” he says, adding, “It’s all about education.” Issues surrounding cosmetic marketing In 2013, the Keogh Review highlighted the role of advertising and marketing information in regards to cosmetic medical providers.6 Mr Cannon agrees with Keogh’s views, saying important points raised in the review, “Highlighted how some unscrupulous providers make financial offers, time-limited deals and use celebrity endorsements to encourage people to sign up for procedures without properly informing them of the risks.” He believes that this type of marketing is inappropriate and irresponsible because it, “Trivialises the risks of procedures and preys on people’s vulnerabilities, misleading them into believing they may be able to achieve unrealistic outcomes.” Simoes says that she believes that marketing in this way is fairly common in both the surgical and non-surgical industry, explaining,

Aesthetics

“By ‘not appropriate’, we mean incentives like time-linked deals, or buy one get one free – where you are being, in a way, pressured to have more procedures than you originally came in for. I also think a lot of marketing that goes on is unethical because it targets vulnerable people, such as young people and people going through difficult life changes such as divorce, adding to their insecurities.” Aesthetic nurse prescriber Frances Turner Traill agrees that some marketing tactics are ‘aggressive’ and ‘ruthless’ and says that marketing can be especially problematic on social media, where medical treatments are often ‘beautified’. She says, “I see it more on social media than anywhere else – it’s beautified through marketing – there are a lot of stock photos used where they have absolutely perfect lips which are not realistic, real transformations.” She adds, “The way treatments like botulinum toxin and fillers are sometimes advertised is similar to a facial or waxing, and there is no mention of the complications, no mention of cooling-off periods or the risks that can occur.” What needs to change? Many practitioners agree that change is necessary when it comes to marketing and advertising in aesthetics. Turner Traill says, “I think people need to be made aware that aesthetic medicine is not beauty and that should be underlined in any marketing.” She emphasises that, “Practitioners need to educate patients and make them aware of the risks associated with the treatments.” Simoes says that the lead up to Christmas and the New Year often prompts people to market limited seasonal time offers. She believes practitioners need to, “Stay away from anything that is related to time-linked offers. A medical procedure is not something that should ever be time-linked because it’s a very personal choice and it deserves consideration,” she says. Turner Traill suggests that providing disclaimers on marketing materials, such as before and after images, may help maintain an ethical standard that abides by the guidelines, “On advertising, I think it’s important to use language such as, ‘terms and conditions applied’, ‘subject to a medical consultation’ and ‘results vary from person to person’,” she says. Summary Dr Singh welcomes the RCS’s new safety information and thinks initiatives such as this can help to protect patients, “It’s definitely a good idea. Patients are unaware of a number of factors such as who can legally do the treatment, complications, expected results and safety.” Dr Singh adds that points such as these are not often disclosed in marketing, but should be. Turner Traill says marketing and advertising that does not offer these disclosures, and downgrades a medical treatment to appear as a simple beauty treatment is, “Just selling – there is no marketing to it, it’s just hard sell.” She adds, “There is often no respect to the actual treatment and what it incurs. Practitioners should 100% be responsible for their patients and should adhere to their codes of practices.” REFERENCES 1. Royal College of Surgeons, RCS launches new cosmetic surgery information to protect patients from ‘aggressive marketing’ and ‘ruthless’ sales tactics’, (2016) <https://www.rcseng.ac.uk/newsand-events/media-centre/press-releases/rcs-launches-new-cosmetic-surgery-information-toprotect-patients/> 2. Committee of Advertising Practice, ‘Cosmetic interventions’, <https://www.cap.org.uk/~/media/Files/ CAP/Help%20notes%20new/CosmeticSurgeryMarketingHelpNote.ashx> 3. Advertising Standards Authority, ‘Health and beauty’, (2015) <https://www.asa.org.uk> 4. Advertising Standards Authority, data on file (2016). 5. ASA, ‘ASA Ruling on London Bridge Plastic Surgery Ltd’, (2016) <https://www.asa.org.uk/Rulings/ Adjudications/2016/5/London-Bridge-Plastic-Surgery-Ltd/SHP_ADJ_335126.aspx#.WBxgu7TccTs> 6. Keogh, B, Review of the Regulation of Cosmetic Interventions (2013) <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_ of_Cosmetic_Interventions.pdf>

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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KOL for the company will discuss patients’ sensitive skin following a peel and will also showcase how to perform ‘mindful’ application and removal techniques to create a much better overall experience for patients.

Gain more from the Expert Clinic at ACE 2017 Aesthetics reveals what to expect from the free Expert Clinic sessions at the Aesthetics Conference and Exhibition (ACE) 2017 On March 31 and April 1 2017 the Business Design Centre in London will open its doors to the UK’s leading educational event in medical aesthetics – ACE 2017. In 2016, the Expert Clinics were immensely popular, remaining consistently full for the two-day event and, with exciting new changes planned for 2017, it is certain to remain a highlight of the comprehensive agenda. The sponsored programme will be presented in one large space located in the Exhibition Hall, with improved seating, sound quality and access, ensuring that delegates have the best experience and opportunity to benefit from the advice and guidance on offer. Each session will encompass practical workshops and demonstrations performed by worldrenowned aesthetic practitioners on a variety of topics from injectables to lasers and cosmeceuticals. Aesthetic companies supporting the Expert Clinic agenda will feature their most knowledgeable speakers, including those representing AesthetiCare, AestheticSource, AlumierMD, Church Pharmacy, Cynosure UK, Fusion GT, HA Derma, Lynton Lasers, Merz Aesthetics, Mesoestetic, Neocosmedix, Rosmetics, Naturastudios and Teoxane UK, with more to follow. An exclusive preview Planning for the sessions and live demonstrations is well underway, and we are thrilled to provide some exclusive details of what to expect. Aesthetic technology manufacturer Lynton Lasers will sponsor the session: The Truth Behind the Picosecond Laser Phenomena, which will include a discussion on the number of picosecond laser technologies released into the industry alongside multi-million dollar marketing campaigns over the past three to four years. In particular, the session will explore how campaigns promote devices’ clinical benefits for the reduction in the number of treatments required for clearance of unwanted tattoos and pigmented lesions. The speaker will aim to uncover the clinical data and financial benefits of the rapidly evolving technology, and will deliberate findings from a number of case studies carried out in clinic. Skincare developer AlumierMD will sponsor the session Mindful Peeling, which will include a live demonstration of an AlumierMD Radiant chemical peel. A leading

Aesthetic distributor HA Derma will support two Expert Clinic sessions at ACE 2017. On Friday afternoon Dr Irfan Mian will present an introduction to Profhilo, for practitioners looking to learn more about the new hyaluronic acid injectable, which aims to treat skin laxity without the use of 1,4-butanediol diglycidyl ether (BDDE). On Saturday morning, Dr Ravi Jain will give an advanced presentation, which will include discussion on a new indication for Profhilo, and new advanced protocols for soft tissue filler Aliaxin. Laser and light-based aesthetic treatment and manufacturing company Cynosure will also sponsor an Expert Clinic session on Saturday morning, which will focus on the SculpSure laser for body contouring, a treatment area which has been a huge trend in 2016, and looks set to continue in 2017. Consultant plastic surgeon Mr Adrian Richards, who presented at ACE 2016, said, “Attending the Expert Clinic is a great way to see many practitioners and experts discuss a variety of topics which you often don’t get the opportunity to see at many other events. There is a wealth of experience, knowledge and information available at the clinic for delegates to pick and choose which is most relevant to them. It is also an excellent opportunity to network with like-minded professionals and share learning experiences.” All of the 17 Expert Clinic sessions will last 30 minutes and will be worth 0.5 CPD points each. Those who register for ACE 2017 will not only have free access to the Expert Clinic sessions, but will also be able to attend the Masterclasses, which will comprise presentations and live demonstrations from leading industry KOLs; and the Business Track sessions, which will be situated on the ground floor of the Exhibition, with talks from experienced practitioners, consultants and advisors, all aimed at helping practitioners to improve the running of their aesthetic business. Delegates can also book to attend up to four Premium Clinical Agenda sessions, which will feature independent clinical presentations and demonstrations from the most prominent aesthetic practitioners within the specialty, all aimed at treating different types of ageing faces. One Premium Clinical Agenda session costs £109 + VAT and discounts will apply if multiple sessions are booked at the same time. In addition, a 10% booking discount is available until December 31. To attend ACE 2017, register for free at aestheticsconference.com

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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causes the skin to lose elasticity, making it prone to lines and wrinkles. HA fillers, therefore, have many applications in antiageing treatments. Since HA is also biodegradable and does not elicit an immune response,9 it is now regarded by many as the most effective dermal filler substance.

Hyaluronic Acid in Practice Allie Anderson explores the development of HA fillers, their application, best practice and management of complications When it comes to beauty, people these days really are trying to keep up with the Kardashians. Last year, some aesthetic clinics reported that enquiries about lip fillers increased by as much as 70% after Kylie Jenner of the famous family confirmed she’d had the treatment.1 It’s no surprise then, that dermal fillers remained the most popular non-surgical treatment in the UK in 2015, with a 113% surge in enquiries.2 Of course, people don’t just turn to fillers for plumper lips. They can be used to treat several facial aesthetic concerns, including: scars, crow’s feet, nasolabial folds, marionette lines, loss of volume in the cheeks, frown lines;3 as well as the ears, hands and the vaginal area. One of the most popular substances used in filler treatments is hyaluronic acid (HA), owing to its temporary nature and the fact that it can be reversed. But dermal fillers have not always been as sophisticated as they are today. For decades, the go-to substance for soft tissue augmentation was silicone, which enjoyed huge popularity throughout the 1950s and 60s. But silicone fillers were associated with numerous severe adverse events, including granuloma, nodules, tissue necrosis, infection, pain and migration of the injected substance.4 Moreover, the fact that silicone gave the fillers a lasting outcome made it attractive to consumers, but this also meant that any complications were especially difficult to manage, and silicone was banned by the US Food and Drug Administration (FDA) in 1991/1992.5 In the early 1980s, the FDA approved bovine collagen as a filling agent,6 and it enjoyed many years of popularity worldwide. However, derived from the hides of cows, bovine collagen required double skin testing before treatment, meaning it was not the quick fix many hope for, and was associated with a 3-5% risk of delayed hypersensitivity.7 One solution emerged in the mid-1990s in the form of HA. The substance occurs naturally in the body’s cells and tissue fluids, and is a key molecule involved in maintaining the skin’s moisture.8 It is this moisture-retaining capacity that makes the skin pliable and plump, and hence, the loss of moisture associated with ageing

The right product for the job Aesthetic practitioner Dr Ravi Jain is a proponent of non-animal stabilised hyaluronic acid – known as NASHA, used in Restylane filler products. “The NASHA technology is the most widely studied technology globally,” he claims. “It’s been around for more than 20 years and, in my opinion, is the gold standard in treatment; I find it delivers excellent results when you’re looking at efficiency of product and maximum lift.” The NASHA products come in the form of a firmer, gel-like substance, which aims to give rise to a more pronounced lifting capacity. “I use this when I want a more targeted projection and lift in someone with thicker skin, or when I’m trying to alter the contour of the face, for example, the nose, chin, jawline and cheekbones,” Dr Jain adds. For older patients with thinner tissue coverage who would benefit from restoration as well as volumisation, Dr Jain advocates another HA technology, also used in Restylane. “I would turn to OBT – Optimal Balance Technology – because these products have a more distributed rather than targeted tissue integration and give a softer, more even look.” One of the main differences between types of HA fillers, says Dr Jain, is the degree of cross-linking and tissue integration. Better cross-linking – the process by which molecule chains are bonded together – means the substance integrates much better with the tissue, giving rise to a more effective result.9 This cross-linking also determines the longevity of the product, says Dr Ayad Harb, who uses a hyaluronic acid product based on supreme monophasic and reticulated technology (SMART) properties called Princess by CHROMA-PHARMA. “The manufacturer has developed a way of very cleverly manipulating the HA chains so that they are aligned very closely together to optimise their reticulation,” Dr Harb explains. “The HA gel is then cross-linked in the usual way with a very low concentration of the non-HA constituent – 1 ,4-butanediol Before

After

Figure 1: Before and after treatment with dermal filler. Images courtesy of Dr Ayad Harb.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ deviceapprovalsandclearances/pmaapprovals/ucm439066.htm

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Before

After

Before

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Aesthetics Journal

Figure 2: Before and after mid-face volumisation with dermal filler. Images courtesy of Dr Ayad Harb.

diglycidyl ether (BDDE) – which binds the HA chains together to give them more resistance and greater longevity.” The product is also homogenised to make it smoother, which, Dr Harb adds, “Means it’s very easy to inject with minimal force, making it much more comfortable for the patient.” Many years of data support the use of BDDE-cross-linked HA fillers as a safe and highly effective choice of treatment;10 but some evidence – both empirical and anecdotal – suggests that the substance’s integrity can begin to decline within six months.11 For this reason, Dr Kathryn Taylor-Barnes opts to use Neauvia, a range of fillers that, rather than being cross-linked with BDDE, contain the biodegradable substance poly ethylene glycol (PEG). Neauvia not only gives immediate hydration and structural support of the hyaluronic acid, but also the calcium hydroxyapatite helps to stimulate collagen in the longer term,” she comments. Molecular size is also important in choosing an effective HA filler, as Dr Milvia Di Gioia highlights. “I use a family of cross-linked monophasic HA, Regenyal Idea. The molecules are as small as 1-3 microns – where the average with monophasic fillers is 40-50 microns, and the biphasic around 200 microns – and this allows the filler to integrate with the tissues where it is implanted and progressively diffuse all around,” she says, adding, “In my experience, the homogeneous distribution results in a very natural effect of the treatment, which also does not alter the facial expressions.” A patient-focused method Taking a holistic approach is key to Dr Di Gioia’s treatment protocol. This involves looking at the patient’s concerns in the context of the entire face with the aim of maintaining proportion. “We call this the 3D facial volumisation. We start with a full consultation about all the facial problems and the patient’s desires, and go through a full-face analysis with the aid of the full-face imagery; we offer a comprehensive treatment plan able to address all the different aspects,” she explains, adding, “The aim is to create new balance and harmony in the facial proportion and appearance.” To this end, Dr Di Gioia employs a nine-point injection technique to lift and reshape the middle and lower thirds of the face and to give a wellproportioned, natural result.

Aesthetics

According to the practitioners interviewed, this method reflects a shift in the general approach to dermal fillers over the last decade or so, where the focus now tends to be on the overall face and the causes of the patient’s concerns, rather than on tackling a specific problem in isolation. As Dr Harb says, a patient who seeks to remedy their problematic nasolabial folds or lower face jowls will ultimately be disappointed if you only consider that concern. “It’s easy to fill a line or fix a shadow or crease, but that’s not addressing the underlying problem so it’ll recur pretty quickly. I always try to appreciate the ‘whys’ in facial aesthetics: why is the skin sagging, why are there fine lines, and why have the lips thinned out?” Treating the causes of these problems in combination tends to yield better outcomes and happier patients, he adds. Aesthetic nurse prescriber Amanda Robertson commonly performs mid-face HA fillers, mainly treating the cheeks and lips. She says a thorough appreciation of the patient is an important consideration in selecting the type and amount of product, as well as how and where you inject it. “I look at the person and their size, as well as their lifestyle,” she comments. “With someone tall, everything about them is slightly bigger – their face, head and hands – so they tend to be able to take more filler than someone smaller. I would therefore often use more product for a taller person than someone shorter to achieve the same result; perhaps two 1ml vials instead of one to define the lip border.” A light-handed approach is best, Robertson adds, with patients sometimes opting to return for a repeat treatment weeks later if, when the product has settled and initial swelling has subsided, the result is less pronounced than they had hoped. Difficulties One of the potential pitfalls with HA fillers, practitioners note, is the propensity to over-inject, leading to a puffy and sometimes lumpy appearance in the treated area. To combat this, Dr Taylor-Barnes and Robertson both advise that the practitioner must take time to massage the area after it’s been injected, to shape the product and ensure it disperses rather than clumps together. “It’s important not to rush the procedure and certainly spend time moulding the product,” says Dr Taylor-Barnes. “The quality of the products today should mean it’s robust enough to withstand a degree of moulding and massaging without harming its integrity.” A filler that contains anaesthetic is advantageous in this regard because thorough post-injection massage can be painful and hard for patients to tolerate, adds Robertson. “I prefer an injection with lidocaine in it,” she says, “And if you take your time and allow the lidocaine to take effect, at the end you can give a really good massage to eliminate any lumps and bumps and improve the result.” Of course, the added benefit of HA is that it has a neutralising agent in the form of hyaluronidase. Administered via injection, it dissolves the HA thereby reversing its effects. So, in the event that a patient is unhappy with the outcome of their filler treatment, or if they experience any adverse reaction – such as allergy, infection or lumping – it can be easily managed. Refining treatments The evolution of HA fillers over the years has enabled the industry to develop a wider range of applications for a diverse patient cohort. Dr Taylor-Barnes, for example, has among her armamentarium a HA product specifically aimed at men, Intense Man from Neauvia, which has a higher concentration of HA (28mg/ml) and is more viscous. It can therefore be considered more suitable for men’s thicker skin and can

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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April 2016

Looking ahead According to Dr Di Gioia, the future of facial rejuvenation remains firmly at the door of HA fillers, thanks to, “Its excellent performance in terms of results and biocompatibility.” She comments, “Companies are working hard to lower the amount of the crosslinking agent, giving rise to an even more biocompatible product.” Dr Jain adds that further developments are likely to result in the inclusion of more additives, such as antioxidants. While many ranges are nowadays formulated with analgesic, this is not standard – something that could Figure 3: Before and after treatment with Biorivolumetria and Biorevitalization over three years at an average of three sessions a year plus botulinum toxin every six months. Images courtesy of Dr Milvia DiGioia. improve the usability of the product and the be used to restore volume in areas of sagging, as well as to fill areas tolerability of the treatment. But Dr Taylorof skin depression, including deep wrinkles and nasolabial folds.12 But Barnes believes that manufacturers will develop more HA-based as important as the formulation of the product itself, says Dr Taylorproducts to treat different anatomical areas. “There’s a big trend Barnes, is the branding and packaging. “It’s nice to have a product towards vaginal rejuvenation, so I would expect there will be more that’s recognised for the male market, because when a male patient ranges targeting the female genital area,” she concludes, adding, “I comes into an aesthetic clinic, everything is female-orientated,” she also think there is room for improvement in the products available comments, adding, “These fine touches help your patient to be more for the periocular region.” While HA fillers continue to be outside receptive to treatments.” As products have advanced and become the jurisdiction of prescription-only medicines, there remains more sophisticated, so have practitioners’ skills, enabling many to the risk of sub-standard treatments performed by unqualified develop signature treatments. One such treatment is the ‘three-point practitioners. But in the right hands, and with full understanding rhinoplasty’, designed by Dr Harb using HA fillers to alter the contour of treatment protocol and, crucially, complication management, of the nose. This non-surgical nose correction involves an injection of HA fillers are sure to retain their place in aesthetic practice as HA filler at three points – the top, the bridge and the tip – to smooth a top treatment for many ageing concerns for a wide patient out bumps, correct droopy tips and crooked profiles, and give a demographic. straighter, more proportioned nose. “I have used my experience as REFERENCES: a plastic surgeon and knowledge of the nasal anatomy to rationalise 1. Emma Akbareian, ‘Kylie Jenner lip filler confession leads to 70% increase in enquiries for the procedure’, The Independent, Thursday 7 May 2015. <http://www.independent.co.uk/ this non-surgical treatment of the nose, which is able to correct 90% of life-style/fashion/news/kylie-jenner-lip-filler-confession-leads-to-70-rise-in-enquiries-for-thenoses that present in my clinic,” says Dr Harb. “The procedure gives procedure-10232716.html> predictable, consistent results, without the complication of surgery and 2. WhatClinic.com, ‘Cosmetic Trends Roundup UK - Jan 2016.pdf’. <http://www.whatclinic.com/about/ press/> in a treatment that takes all of just 10 minutes.” Dr Harb uses a HA filler 3. Plastic Surgery, ‘Hyaluronic acid treatment results’, 2016 <https://www.plasticsurgery.org/cosmeticprocedures/dermal-fillers-hyaluronic-acid?sub=Hyaluronic+acid+treatment+results#section-title> that typically lasts between 12 and 18 months, with the potential to last 4. Andrew Styperek, Stephanie Bayers, Michael Beer and Kenneth Beer, ‘Nonmedical-grade longer when placed in the nose, because, he explains, “It is not an Injections of Permanent Fillers: Medical and Medicolegal Considerations’, J Clin Aesthet Dermatol. 2013 Apr; 6(4): 22–29. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3638855/> area that is prone to rapid deterioration, since the nose doesn’t move 5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740603/Kontis TC, Rivkin A, ‘The history of in the same way as other parts of the face.” injectable facial fillers’, Facial Plast Surg. 2009 May; 25(2): 67-72.<https://www.ncbi.nlm.nih.gov/ Before

After

Before

After

pubmed/19415573> 6. Vanessa Ngan, ‘Collagen replacement therapy’, DermNet New Zealand, 2004. <http://www. dermnetnz.org/topics/collagen-replacement-therapy/> 7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686337/ Eleni Papakonstantinou, Michael Roth, and George Karakiulakis, ‘Hyaluronic acid: A key molecule in skin aging’, Dermatoendocrinol. 2012 Jul 1; 4(3): 253–258. < https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583886/> 8. Lee H, Jeong S, Baek J, Song J and Kim H, ‘Hyaluronic acid hydrogels cross-linked by polyethylene glycol diglycidyl ether (PEGDE) for long-lasting dermal filler applications’, Front. Bioeng. Biotechnol. Conference Abstract: 10th World Biomaterials Congress, 2016. doi: 10.3389/conf.FBIOE.2016.01.01809. <http://www.frontiersin.org/10.3389/conf. FBIOE.2016.01.01809/2893/10th_World_Biomaterials_Congress/all_events/event_abstract> 9. Koenraad De Boulle, Richard Glogau, Taro Kono, Myooran Nathan, Ahmet Tezel, Jean-Xavier RocaMartinez, Sumit Paliwal, and Dimitrios Stroumpoulis, ‘A Review of the Metabolism of 1,4-Butanediol Diglycidyl Ether–Crosslinked Hyaluronic Acid Dermal Fillers’, Dermatol Surg. 2013 Dec; 39(12): 1758–1766. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264939/> 10. Galadari H, et al, ‘Polycaprolactone dermal filler outlasts nonanimal stabilized hyaluronic acid filler’, J Cosmetic Derm. 2015 Mar; 14(1): 27-32. <http://www.healio.com/aesthetics/injectables-and-fillers/ news/online/%7Bed16a686-7ebf-4a8a-9ad6-ade429816d6a%7D/polycaprolactone-dermal-filleroutlasts-nonanimal-stabilized-hyaluronic-acid-filler> 11. Neauvia, Intense Man. <http://www.neauvia.com/products-1/fillers/intense-man-1>

Figure 4: Before and after non-surgical rhinoplasty with HA filler. Images courtesy of Dr Ayad Harb.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


NOW APPROVED FOR

UPPER FACIAL LINES Now Available in 100u Vial

Botulinum toxin type A free from complexing proteins Bocouture® (incobotulinumtoxinA) 50/100 unit vials. Prescribing information: M-BOC-UK-0033. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet Lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected

PURIFIED1,2 • EFFECTIVE3 • CONVENIENT4

into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with Botulinum neurotoxin products. Upper Facial Lines: very common: Headache. Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent postinjection. Legal Category: POM. List Price: 50 U/vial £72, 50 U twin pack £144.00, 100 U/vial £229.90 Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: November 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz. com or on +44 (0) 333 200 4143. 1. Bocouture® 50U Summary of Product Characteristics (SPC). April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 Last Accessed: 27/10/16 2. Bocouture® 100U Summary of Product Characteristics (SPC). October 2016. Available from: https://www.medicines.org.uk/ emc/medicine/32426 Last Accessed: 27/10/16 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 4. BOC-DOF-012_03 Bocouture® Convenient to Use, August 2016 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0038 Date of Preparation November 2016

PURIFIED1,2• EFFECTIVE3 • CONVENIENT4

Botulinum toxin type A free from complexing proteins


1 oint

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Aesthetics Journal

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Treating Obesity with Botulinum Toxin Professor Andy Pickett and independent aesthetic business consultant Emma Miller discuss research into the use of botulinum toxin for the treatment of obesity The use of botulinum toxin (BoNT) in aesthetic treatments is now firmly established. The patient population receiving regular injections for the treatment of wrinkles is growing steadily as people find out how simple, quick, relatively painless and effective the treatments can be. Accurate data on the extent of usage in the UK is difficult to come by, but the information from different societies paints an interesting picture of worldwide use in an extensive range of patient groups. For example, the American Society for Plastic Surgeons (ASPS) each year publishes figures canvassed from their members (Figure 1), which indicates a 65% increase in BoNT treatments in the last decade.1 A new indication for BoNT? Over the years, enterprising clinical investigators have undertaken a wide range of tests for the different uses of BoNT, driven by both their therapy interests and their wish to give patients further satisfaction with the treatments. This has built a growing body of clinical data for the use of BoNT in many different ways and in different areas of the body, not just the face. For example, the latest trend in BoNT use is for the treatment of conditions such as rosacea,2 skin conditions3,4 and rare skin diseases.5 Sometimes, these clinical investigations are controversial. The treatment area, the dose, and the technique can all influence debate. A press release from an investigator or a society can lead (and certainly has led in the past) to an extraordinary rush of interest that, regrettably, is often poorly researched before publication. BoNT can be an easy target, given its ‘colourful’ history and misguided comments about the risks that the molecule carries. Published research that attracts the interest of both clinicians and patients combines the use of BoNT with positive results, especially 7 6.1 6

6.67

6.76

2014

2015

6.3

5.7

Number of treatments (millions)

5.4 5

5

4.8

4.5 4.1 4

3

2

1

0

2006

2007

2008

2009

2010

2011

2012

2013

Figure 1: Number of BoNT treatments in the US reported by members of ASPS

results that are not expected. One such concept is the use of BoNT-A for weight loss in obese patients. The very idea that something as potent as a toxin could actually help weight loss may seem fairly illogical. Yet, in 2014, a UK national newspaper reported work being carried out at St Olav’s Hospital in Trondheim, Norway, which indicated exactly that – BoNT can positively affect obesity.6 The article reported that the effect of the BoNT injections into the stomach wall by using an endoscope was to apparently slow the passage of food through

the stomach, making patients feel fuller for longer. Earlier this year, the same Norwegian team reported further data, now with information on repeat Botox treatments (every six months, unspecified dose).7 After one year, some 70% of their 20 patients were reported to have lost 17% of their body weight and, after 18 months, this result increased to 75% of patients (p<0.05), losing an average of 30% body weight. History of BoNT use for weight-loss Obesity is a major health problem in many countries. According to Public Health England, a quarter of men and women in England are obese.8 Methods to treat obesity need to be developed to support this epidemic, and further research in the area of BoNT may indicate that it could be one method to help. The possibility that BoNT treatments could be of weight-loss benefit to obese patients was first proposed in 1995 by an Italian group based in Rome. Their first publication outlined a very small study in rats which apparently was dose-ranging and identified that 20 Botox units, distributed over six sites in the distal stomach, gave weight loss that lasted for about one month.9 They commenced a second, slightly larger study based on this finding, which subsequently showed similar results, whereas a placebo comparator group lost weight for only two weeks. No additional data were provided in their second publication of the same year.10 Several years later, in 2000, the Italian group reported their work in rats in more detail.11 They injected BoNT in four places in the antral wall of the stomach with a total of 20 units, which would be equivalent to some 2,000-3,000 units for an adult human – a very high dose. For comparison, a normal aesthetic treatment for patients (upper third of the face) might use some 20-50 units. As with all such BoNT animal studies, these results and doses can be misleading since most animals are less sensitive to the toxin than humans and have different metabolism, therefore higher doses are often required to see any effects.12,13 In the study, however, the doctors discovered a significant reduction in mean weight and in the percentage weight reduction of the treated group when compared to a sham (treated but no toxin) group.11 Studies have been conducted around the world, which have investigated the potential effects of BoNT on obese patients. All the relevant studies are shown in Figure 2. They range from small, single dose assessments to placebo-controlled, dose-ranging studies and with varying results from no effect to a significant weight loss. Two important points must be noted from these studies, as shown in Figure 2. Firstly, the studies have generally used small numbers of patients, especially considering that several also included a placebotreated patient group. Some patients responded and some did not, indicating that patient selection may be an important part of successful treatment. Secondly, the majority of the studies were only of relatively short duration (maximum six months) and only used a single BoNT treatment. The Norwegian study7 stands out amongst them as the only study to have a repeat treatment (two injections, six months apart) and be long term, with 12 months follow-up (up to six months after

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Highlighted studies demonstrated improvements for patients Study (1)

No. of patients (2)

Dose (3)

Number of injections and site area

Effect on gastric emptying

Effect on weight loss

Rollnik et al 200333

1

500 D

10 sites Prepyloric antral gastric wall

+ 4 months

9 kilos 4 months

Albani et al 200534

8

500 D

10 sites Prepyloric antral gastric region

ND

+ 4 months

Garcia-Compean et al 200535

12

100 B

8 sites Prepyloric antral gastric wall

X 12 weeks

X 12 weeks

Gui et al 200636

18

133 B 200 B

8 sites Gastric antral wall

X 5 weeks

X 5 weeks

Junior et al 200637

12

200 B 200 B 300 B 300 B

8 16 16 24 sites Antropyloric region

X 12 weeks

X 12 weeks

Foschi et al 200738

24

200 B

20 sites Antrum and fundus

+ 8 weeks

+8 weeks

Mittemair et al 200739

10

200 B

16 sites Antrum and distal gastric body

ND

X 6 months

Foschi et al 200840

30

200 B

20 sites Antrum and fundus

+ 8 weeks

+ 8 weeks

Topazian et al 200841

10

100 B 300 B

5 sites Gastric antral muscularis propria

X 2 weeks

X 16 weeks

Li et al 201242

20

200 C 300 C

20 sites Gastric body and fundus

+ only at 1 week

+ 12 weeks

Topazian et al 201343

42

100B 300B 500B

15 sites Gastric antral muscularis propria

+ 2 weeks 300 B only

X 16 weeks

Chen et al 20167

20

NS

Antral region (repeated after 6 months)

NS

+ 9 and 12 months

Figure 2: Table 1: Human studies carried out on the use of BoNT for the treatment of obesity (1) Some studies also used placebo control injections (2) Including patients treated with placebo (3) B = Botox units: C = Chinese toxin BTX-A: D = Dysport units (the units of each product are not interchangeable with each other) + Significant result, X No significant result, ND Not Determined, NS Not Specified.

the second injection). At present, the clinical evidence for an effect in obesity is not conclusive by any means. How might toxin work? How can the effects of BoNT for treating obese patients, with results varying between nothing significant and a major effect, be explained? Is there an effect related to dose or site of injection or even the number of injection points? These are difficult questions to answer from what we know today since the conclusions from the various studies are highly variable. There are several possible actions of BoNT which could explain an effect if injected intragastrically. Firstly, by reducing the muscle activity of the stomach, the rate of gastric emptying slows down, making patients feel fuller for longer.14 The effects of BoNT on smooth muscle have been known from studies carried out more than 20 years15 ago leading ultimately, to the licensed use of the product for the treatment of several urological conditions of the bladder.16 The stomach has three separate smooth muscle layers: the longitudinal, circular and oblique muscles (Figure 3). As muscle activity is governed by nerve impulses, there are plenty of targets for BoNT.17,18 Targeting the nerves which control the muscles in specific areas of the stomach can therefore reduce activity just in those regions. For the smooth muscles of the stomach, like the bladder, the BoNT targets are the visceral (autonomic) efferent neurons, unlike the somatic efferent motor neurons that are attached to skeletal muscles.19,20 BoNT has been shown to down-regulate both acetylcholine and another neurotransmitter, Substance P, in these muscles.20 Injection of BoNT into the three muscular layers will clearly have effects on the stomach with potential impacts, such as the patient’s ability to process food intake or reduce the food requirements. In particular, targeting the pre-pyloric region, at the base of the stomach,

led to a reduction in food intake in the rats, probably through delayed gastric emptying.11 The second effect, related to vagus nerve activity, has been explored in more detail by the Trondheim group and is more specific.7,21 The vagus nerve is the longest of the 12 cranial nerves, extending from the brainstem down to the heart, lungs and digestive system. This nerve controls unconscious body activities such as regulation of the heart rate and food digestion through action on the stomach, and therefore contains both motor and sensory fibres.22 Food interacts with the gut to provide (afferent) information to the brain through the vagus nerve, information such as food quantity and composition. The brain then calculates all the required variables to regulate food consumption and ingestion, and passes the requirements (efferent) back down through the same nerve pathway. Esophagus

Cardia

Fundus

Muscularis externa • longitudinal layer • circular layer • oblique layer

Pylorus

Serosa

Body

Lesser curvature

Rugae of mucosa

Greater curvature Duodenum

Pyloric sphincter (valve)

Pyloric canal

Pyloric antrum

Figure 3: The structure of the stomach and layout of muscles

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Interfering with this pathway in a controlled way could therefore potentially reduce consumption and provide a mechanism for weight loss, notably in obese patients. This concept has been brought into practice in the US through the licensing by the FDA, in January 2015, of a medical device called the vBloc vagal blocking technology for the treatment of obesity.23 The Maestro system implanted device, which is the delivery mechanism for vBloc, functions like a pacemaker, sending an intermittent signal to block vagus nerve activity, which aims to increase feelings of fullness, thus reducing the feeling of hunger.24 The subcutaneous device has electrodes that are placed in contact with the trunks of the vagus nerves just above the junction between the oesophagus and the stomach.24 The Trondheim group has explored this principle of regulating the vagus nerve in both animal and human studies. Results in a comparative study using rats indicated an actual improvement for the use of BoNT over the vBloc system, with total body weight losses of more than 20% and 10%, respectively, for the Possible treatment with botulinum toxin

Pain condition Carpel tunnel syndrome

-

Connective tissue disorder (e.g. rheumatoid arthritis)

Limited

Fibromyalgia

Limited

Gastrointestinal disorders

+

Gout

-

Lower back pain

+

Migraine and headache

+

Neuropathy

+

Osteoarthritis

+

Plantar fasciitis

+

Rotator cuff tendinitis

+

Figure 4: Table 2: Obesity-related pain conditions and the potential for their treatment using botulinum toxin (adapted from reference).44 + indicates clinical evidence available

treatments.21 Separately, human repeat dose BoNT treatments have achieved clearly beneficial results, in a first study of ongoing use, as described earlier (recorded on the main world trials database as NCT02035397). The potentially improved beneficial effects of BoNT, administered by endoscopic injection for obesity, over an implanted vBloc device have yet to be established in any human comparative studies. Further indications During the studies with BoNT, other interesting uses have emerged as treatments for obese patients. Obesity carries the risk of many different pain conditions (Figure 4) and, of these, almost all could be directly treated using BoNT. Clearly, further evidence-based and dose-ranging clinical studies will be necessary in order to validate these applications. Regrettably, no such studies, that might lead to registration of the indications, seem to be underway. There are two other fascinating aspects; in 2006, Dr Erle Lim and Dr Raymond Seet proposed that injection of BoNT into adipose tissue would potentially influence weight loss.25 This was already recognised approximately 40 years ago after being demonstrated in a rat model, which suggested, that adipose fat actually has a nerve supply and, if that nerve supply is physically cut (they did not use BoNT), then the animals lose fat as well as muscle mass.26 In 2010, a group in Iran went further to demonstrate the lipolytic effect of BoNT in rabbits.27 This time, the dose was low at 3-7 Dysport units per animal and a dosedependent effect was demonstrated. Assessed fat cell volume was reduced by up to 77% in the higher dosage group when compared to

Aesthetics Journal

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a control group. No muscular effects were reported in treated animals and their feeding and daily food intake was the same as the control group. To emphasise the possibility that direct treatment of fat with BoNT might be a useful therapy, pharmaceutical company Allergan applied for patents on the treatment method in 2014.28,29 They have not followed these patent applications through with any sponsored clinical trials to date. Finally, as well as affecting the stomach muscles to delay gastric emptying, BoNT has actually found a place as a therapy in the exact opposite clinical condition. Gastroparesis, also known as delayed gastric emptying, has been treated with BoNT in some clinics for more than 15 years (although not yet a standard protocol), and has indicated successful results.30 There are several forms of this disease – idiopathic, occurring after an infection; diabetic; or even post-surgical – and the condition is recognised as being under-diagnosed. The clinical studies to date extend from a small case series through to a large 179-patient retrospective review, which indicated that 51% of treated patients gained benefit.31,32 The likely mechanism of action here is simple relaxation of stomach muscles in spasm which lead to the delayed gastric emptying. Summary Overall, BoNT has been suggested to have a role in relation to obesity and gastric conditions from the clinical data to date. However, more evidence-based clinical studies with larger sample sizes and of a longer duration than previously conducted are definitely needed before this versatile product can be licensed as a new tool in the practice of the aesthetic clinician dealing with the all too common weight issues in the current patient population. Disclosures: Andy Pickett is director and founder of Toxin Science Limited, UK; adjunct professor at the Botulinum Research Center, IAS, USA; and senior program leader and scientific expert, Neurotoxins in Galderma Aesthetic and Corrective Global Business Unit. The opinions and views expressed are those of the authors and Toxin Science Limited only. This article is for scientific information purposes only and is not intended to promote the use of any botulinum toxin product in any use that is not currently authorised by regulatory authorities. Professor Andy Pickett has worked with botulinum toxin for nearly 30 years in a variety of roles including and is an internationally recognised expert in the field. He is the director and founder of Toxin Science Limited, Wrexham, UK and an adjunct professor at the Botulinum Research Center, Institute of Advanced Sciences, Dartmouth, in the US. Pickett specialises in translating basic science to practical, clinical knowledge for everyone using botulinum toxin products. Emma Miller has worked for the past 11 years in the aesthetic industry in roles including key account management, marketing and product management. Her speciality areas include dermal fillers and, in particular, botulinum toxin – both medical and aesthetic applications – for companies including Merz and Galderma. Emma is currently an independent consultant to businesses in the UK.

NOTE: Whist in final preparation, the authors have noted that a new review on use of BoNT for treatment of obesity has just been published (Pero, R, et al., ‘Botulinum Toxin A for Controlling Obesity’, Toxins, 8(10),2016, pp.281). In the present authors’ opinion, this review contains certain errors and issues. Also, the summary of studies to date which has been included is incomplete in comparison to that shown in Figure 2 of the present article. The authors have therefore not cited this new review and do not recommend its use as a reference source.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


BOOK YOUR FREE DEMONSTRATION REFERENCES 1. ASPS, 2015 Plastic Surgery Procedural Statistics <http://www.plasticsurgery.org/news/plasticsurgery-statistics/2015-plastic-surgery-statistics.html> 2. Park KY, Hyun MY, Jeong SY, Kim BJ, Kim MN, Hong CK. Botulinum toxin for the treatment of refractory erythema and flushing of rosacea. Dermatology. 2015;230(4):299-301. 3. Bansal C, Omlin KJ, Hayes CM, Rohrer TE. Novel cutaneous uses for botulinum toxin type A. J Cosmet Dermatol. 2006;5(3):268-272. 4. Akhtar N, Brooks P. The use of botulinum toxin in the management of burns itching: preliminary results. Burns. 2012;38(8):1119-1123. 5. Ho D, Jagdeo J. Successful botulinum toxin (onabotulinumtoxinA) treatment of Hailey-Hailey disease. J Drugs Dermatol. 2015;14(1):68-70. 6. Johannessen H, Olsen MK, Cassie N, et al. Mo2054 Preclinical Trial of Gastric Injection of Botulinum Toxin Type A As Weight-Loss-Surgery. Gastroenterology. 2014;146(5):S-1077. 7. Chen D, Olsen MK, Strommen M, et al. Mo1945 Intragastric Injection of Botulinum Toxin A to Treat Obesity: Mechanism of Action and a Randomized, Double-Blind, Placebo-Controlled Phase II Trial With Open-Label Extension Study. Gastroenterology. 2016;150(4):S823. 8. Public Health England (2016), Slide Sets, <www.noo.org.uk/slide_sets> 9. Albanese A, Bentivoglio AR, Cassetta E, Viggiano A, Maria G, Gui D. The use of botulinum toxin on smooth muscles. Eur J Neurol. 1995;2(1):29-33. 10. Albanese A, Bentivoglio AR, Cassetta E, Viggiano A, Maria G, Gui D. Review article: the use of botulinum toxin in the alimentary tract. Aliment Pharmacol Ther. 1995;9(6):599-604. 11. Gui D, De Gaetano A, Spada PL, Viggiano A, Cassetta E, Albanese A. Botulinum toxin injected in the gastric wall reduces body weight and food intake in rats. Aliment Pharmacol Ther. 2000;14(6):829-834. 12. Martignoni M, Groothuis GM, de Kanter R. Species differences between mouse, rat, dog, monkey and human CYP-mediated drug metabolism, inhibition and induction. Expert Opin Drug Metab Toxicol. 2006;2(6):875-894. 13. Pickett A. Animal studies with botulinum toxins may produce misleading results. Anesth Analg. 2012;115(3):736 14. Bowen, R. (2016), Gastric Motility: Filling and Emptying <http://arbl.cvmbs.colostate.edu/hbooks/ pathphys/digestion/stomach/motility.html> 15. Pasricha PJ, Ravich WJ, Kalloo AN. Effects of intrasphincteric botulinum toxin on the lower esophageal sphincter in piglets. Gastroenterology. 1993;105(4):1045-1049. 16. Jiang YH, Liao CH, Kuo HC. Current and potential urological applications of botulinum toxin A. Nat Rev Urol. 2015. 17. Bowen, R. (2016), The Enteric Nervous System <http://arbl.cvmbs.colostate.edu/hbooks/ pathphys/digestion/basics/gi_nervous.html> 18. Britannica (2016), Human Digestive System <https://www.britannica.com/science/humandigestive-system/images-videos/Structures-of-the-human-stomach-The-stomach-has-threelayers/68634> 19. Apostolidis A, Dasgupta P, Fowler CJ. Proposed mechanism for the efficacy of injected botulinum toxin in the treatment of human detrusor overactivity. Eur Urol. 2006;49(4):644-650. 20. Shao YF, Xie JF, Ren YX, et al. The Inhibitory Effect of Botulinum Toxin Type A on Rat Pyloric Smooth Muscle Contractile Response to Substance P In Vitro. Toxins. 2015;7(10):4143-4156. 21. Chen, D. (2015), Repurposing botulinum toxin A to target the vagus nerve for treatments of gastric cancer and obesity <http://gastroenterologen.no/2015/06/repurposing-botulinum-toxin-ato-target-the-vagus-nerve-for-treatments-of-gastric-cancer-and-obesity/> 22. Tewfik, T.L. (2015) Vagus Nerve Anatomy - Gross Anatomy <http://emedicine.medscape.com/ article/1875813-overview> 23. Maisel, W.H. (2015), P130019 - Maestro Rechargeable System approval letter, US Department of Health and Human Services <http://www.accessdata.fda.gov/cdrh_docs/pdf13/P130019a.pdf> 24. Enteromedics (2016), vBloc Maestro System <http://www.enteromedics.com/international/ vbloc_maestro_system.asp> 25. Lim EC, Seet RC. Botulinum toxin injections to reduce adiposity: possibility, or fat chance? Med Hypotheses. 2006;67(5):1086-1089. 26. Singarachari A, Krishamoorthy RV. Increased fat degradation in the denervated muscle of frog. Indian J Physiol Pharmacol. 1976;20(1):9-16. 27. Bagheri M, Jahromi BM, Bagheri M, et al. A pilot study on lipolytic effect of subcutaneous botulinum toxin injection in rabbits. Anal Quant Cytol Histol. 2010;32(4):186-191. 28. Cernok, K. & Martinez, K. (2014) Botulinum toxins for use in a method for treatment of adipose deposits, patent application WO 201313042 A1 29. Cernok, K. & Martinez, K. (2014) Method for treatment of adipose deposits, patent application US 20140127188 A 30. Lacy BE, Schettler-Duncan VA, Crowell MD. The treatment of diabetic gastroparesis with botulinum toxin. Am J Gastroenterol. 2000;95(9):2455-2456. 31. Coleski R, Anderson MA, Hasler WL. Factors associated with symptom response to pyloric injection of botulinum toxin in a large series of gastroparesis patients. Dig Dis Sci. 2009;54(12):2634-2642. 32. Ukleja A, Tandon K, Shah K, Alvarez A. Endoscopic botox injections in therapy of refractory gastroparesis. World J Gastrointest Endosc. 2015;7(8):790-798. 33. Rollnik JD, Meier PN, Manns MP, Goke M. Antral injections of botulinum a toxin for the treatment of obesity. Ann Intern Med. 2003;138(4):359-360. 34. Albani G, Petroni ML, Mauro A, et al. Safety and efficacy of therapy with botulinum toxin in obesity: a pilot study. J Gastroenterol. 2005;40(8):833-835. 35. Garcia-Compean D, Mendoza-Fuerte E, Martinez JA, Villarreal I, Maldonado H. Endoscopic injection of botulinum toxin in the gastric antrum for the treatment of obesity. Results of a pilot study. Gastroenterol Clin Biol. 2005;29(8-9):789-791. 36. Gui D, Mingrone G, Valenza V, et al. Effect of botulinum toxin antral injection on gastric emptying and weight reduction in obese patients: a pilot study. Aliment Pharmacol Ther. 2006;23(5):675680. 37. Junior AC, Savassi-Rocha PR, Coelho LG, et al. Botulinum A toxin injected into the gastric wall for the treatment of class III obesity: a pilot study. Obes Surg. 2006;16(3):335-343. 38. Foschi D, Corsi F, Lazzaroni M, et al. Treatment of morbid obesity by intraparietogastric administration of botulinum toxin: a randomized, double-blind, controlled study. Int J Obes (Lond). 2007;31(4):707-712. 39. Mittermair R, Keller C, Geibel J. Intragastric injection of botulinum toxin A for the treatment of obesity. Obes Surg. 2007;17(6):732-736. 40. Foschi D, Lazzaroni M, Sangaletti O, Corsi F, Trabucchi E, Bianchi Porro G. Effects of intramural administration of Botulinum Toxin A on gastric emptying and eating capacity in obese patients. Dig Liver Dis. 2008;40(8):667-672. 41. Topazian M, Camilleri M, De La Mora-Levy J, et al. Endoscopic ultrasound-guided gastric botulinum toxin injections in obese subjects: a pilot study. Obes Surg. 2008;18(4):401-407. 42. Li L, Liu QS, Liu WH, et al. Treatment of obesity by endoscopic gastric intramural injection of botulinum toxin A: a randomized clinical trial. Hepato-Gastroenterol. 2012;59(118):2003-2007. 43. Topazian M, Camilleri M, Enders FT, et al. Gastric antral injections of botulinum toxin delay gastric emptying but do not reduce body weight. Clin Gastroenterol Hepatol. 2013;11(2):145-150 e141. 44. Bonakdar, R. A. (2013). Targeting systemic inflammation in patients with obesity-related pain: Obesityrelated pain: time for a new approach that targets systemic inflammation. J Fam Pract 62(9 Suppl CHPP): S22-29.

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Non-surgical Rhinoplasty

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taken and the presence of a graft of any sort should be looked at as a contraindication in most cases.9

What product should be used?

Treatment of this region is well described in literature, historically the use of autologous fat, silicone, poly-tetrafluoroethylene and calcium In the first of their two-part article, Mr Geoffrey hydroxyapatite are commonplace. However, Mullan and Mr Ben Hunter discuss the relevant over the last seven to eight years with anatomy for successful non-surgical rhinoplasty advances in the plastication methods involved in forming longer lasting HAs with more What is rhinoplasty? cohesive structures, HA has become the mainstay of most NSRs.10 Rhinoplasty is the permanent reshaping of a nose using surgical HA has low immunogenicity, is malleable, durable and has the techniques that involve reshaping the nasal cartilages and advantage of being easily reversed with the use of hyaluronidase.11 sometimes nasal bones. Reshaping or trimming these structures in Collagen and calcium hydroxyapatite can also be used and have a reduction rhinoplasty or augmentation rhinoplasty, with cartilage different fluid characteristics compared to hyaluronic acid that can and bone from the ear and ribs, allows for significant restructuring be advantageous in forming a more rigid structure and is favoured of the nasal anatomy.1 by many practitioners. However, they are more difficult to correct if Surgical rhinoplasty procedures are in the top 10 most popular there are complications as they need to be physically removed and procedures for women and men in the UK, with 4,205 procedures cannot be easily reversed by simply injecting a dissolving agent recorded by the British Association of Aesthetic Plastic Surgeons such as hyaluronidase.12 2 in 2015. Although surgical intervention has been indicated as popular Nose anatomy among many patients, non-surgical rhinoplasty (NSR) can offer an There is no perfect nose, as every face is different with features of alternative for those that require revision surgery such as saddle different shapes and sizes. However, there are some proportions deformity, alar cartilage collapse or dorsal unevenness, who do not that are accepted as being the guide to normal features,13 which 3 wish to subject themselves to the risks associated with surgery. can help to assist in assessing the nose in terms of proportions. NSR has many attractions, despite being a temporary treatment. These average proportions hold true with minor variations across The soft tissue augmentation can give a very natural contour, even both sexes and broadly across races also. All attempts to classify in thin-skinned patients, without the complications of surgery.4 racial features or the ‘classic’ European, African or Asian nose have For patients, the main attractions of NSR are that there is very always failed. This is simply due to the variation of any particular little downtime compared to a surgical approach, a lower risk of feature in any group, having too large a range to be statistically complications, as well as its affordability.5 significant. NSR involves the use of soft tissue augmenters such as hyaluronic There is an array of terms to describe specific points of the nose acid (HA).6 These injectable products can be used to correct and a quick revision of these will help practitioners to clarify an deformities that would otherwise require significant surgery, approach to NSR. The nose is roughly divided into the upper, social downtime and a high cost. The use of fillers in the nose is a middle and lower thirds. The upper third is formed by the bony more subtle treatment that allows for a limited augmentation and skeleton, the middle third by the nasal septum and upper lateral correction of some defects and can also give long lasting results of cartilages, and the lower third refers to the nasal tip, which is made an average of 13.5 months, however there are reports of up to 30 up of the nasal septum and the lower lateral cartilages.14 7 months. Below is an overview of terms that must be understood before a An interesting observation in NSR is that by adding volume to the practitioner can undertake NSR.14 nose, an NSR is always going to make the nose slightly larger. It is important that this is acknowledged and explained to the patient in the consultation so that they understand the procedure and Hairline outcomes. In contrast, the majority of surgical rhinoplasties or ‘reduction rhinoplasties’ are performed with the aim of refining 1/3 or removing perceived imperfections or making noses smaller, Glabella although this is not exclusively so. Sellion (radix) Although the nose can be generally treated safely, due to the 1/3 nature of the blood supply in the nasal region, the short direct arteries and the anastomoses involved, it is essential that the Subnasale 1/3 practitioner is well educated on the anatomy and how to avoid 1/3 1 8 complications if they occur. 2/3 Even the best surgeons have experienced contractures and Menton rotational deformities post surgery and injectable products can be useful tools for post-surgery complications. It must be noted 1/5 1/5 1/5 1/5 1/5 that the post-surgery nose has a higher risk of complication due Figure 1: The three thirds of the face to altered anatomy and blood supply, so extra caution must be 14

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Pronasale: is the most prominent part of the nasal tip.14 Trichion Glabella Nasion Sellion (radix) Supratip break Tip defining point Pronasale Infratip lobule Subnasale Pogonion Mention Cervical point

Figure 2: Useful nasal anatomy surface anatomy

Nasal dorsum: also called the nasal bridge, it refers to the superior surface of the nose. It is made up of the upper two thirds of the nose, the middle cartilaginous part and the upper bony part.14 Alar cartilage: provides the structure and support for the lower third of the nose. This pair of cartilages, also referred to as the lower lateral cartilages, form a domed arch. They make up the nasal tip and columella. The perfect width of the nose should correspond to the intercanthal distance, which is the same as the width of the alar base (Figure 1).14 Nasal tip: is formed at the point where the two curved lower lateral cartilages come together to form the most forward point of the nose. The tip is divided into the tip lobule, supra-tip lobule and infra-tip lobule.14 Nasion: represents the median anterior tip of the naso-frontal suture.14 Radix: is the nasal root that correlates with the upper termination of the nasal bridge at the glabellar base and is a soft tissue landmark that correlates with the deepest point of the nasal bone.14 Rhinion: is the region that correlates with the junction of the bony upper nasal vault with the cartilaginous middle and is usually the typical high point of a nasal bridge hump.14

115o-130o

Nasofabial angle 90o110o Nasofacial angle

36o

Pogonion

Figure 3: Angles of the nose

Sellion (radix) Subnasale

Subnasale: represents the junction between the columella and philtrum.14 Septum: the dividing wall between right and left nasal passages, deviation in this cartilage can cause a rotational deformity.14 Nasofrontal angle: this is the angle formed between the nasal angle and the forehead (glabella) when viewed laterally with the apex correlating with the angle of the superior eyelash line (Figure 3). Ideally, it should be 115-130 degrees, however it is often less in Asian patients. It is commonly corrected in NSR and the dorsum should be raised with respect to the apex of this angle.14 Nasolabial angle: is the angle between the columella and the lip assessed in association with the position of the columella. This is usually more open in females at 105-120 degrees compared to a more obtuse angle in men where 90-105 degrees is normal.14 Arterial Anatomy When performing NSR, it is vital that practitioners know and understand the arterial anatomy of the nose (Figure 4).14 The dorsal nasal artery emerges from the orbit above the medial palpebral ligament and divides into two branches:14

An interesting observation in NSR is that by adding volume to the nose, an NSR is always going to make the nose slightly larger

1. First branch crosses the root of the nose and anastomoses with the angular artery. 2. Second branch runs along the dorsum of the nose laterally supplying its outer surface towards the nasal tip and anastomoses with the contralateral dorsal nasal artery and the lateral nasal artery. The lateral nasal artery arises from the facial artery and is superficial at the piriform recess (top of nasolabial fold); deep injections are a danger to this area. It supplies the alar and dorsal of the nose anastomosing with septal and alar branches.14 The superior labial artery gives off the columellar arteries that run up the columella ending and anastomosing in the tip with branches of the lateral nasal artery.

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Hanging columella: is an overgrowth of the nasal septum causing an overly-protruding columella.14

Supratrochlear artery Dorsal nasal artery Angular artery Lateral nasal artery Columellar branch Superior labial branch

Inverted ‘V’ deformity: is also a post-operative appearance and is due to the detachment of the upper lateral cartilages from the nasal bones. This leads to the upside down ‘V’ deformity at the junction of the upper and middle third of the nose.14

Conclusion Non-surgical rhinoplasty is a viable option in the sub-section of patients that do not need a reduction rhinoplasty. Requiring minimal downtime, it is also a useful tool to correct late onset complications following surgery or to treat very minor defects. Achieving treatment goals with NSR requires an in-depth knowledge of nose anatomy and the arterial system.

Figure 4: The arterial anatomy of the nose

Common nasal deformities Tip rotation: refers to the tip position along an arc of rotation in the longitudinal field. An over-rotated tip has the tip rotated towards the nose, making it look perky and what many refer to as ‘Miss Piggy’. An under-rotated tip is rotated in the opposite direction and makes the nose look droopy and appear longer.14 Saddle nose deformity: refers to damage to the middle cartilaginous middle vault that can leave a deep depression and clear step between the bony upper third at the rhinion. The tip in the lower-third structure is supported by the arched alar cartilages, therefore, damage can leave a saddle-like depression between the two highpoints. Common causes of saddle nose deformity are trauma, over aggressive surgery, autoimmune disease and cocaine abuse.14 Tension nose deformity: is an overgrowth of the dorsal part of the nasal septum and can cause a high, narrow appearance of the nose. This overgrowth of the nasal bridge can cause an overprojection of the nose.14 Pollybeak deformity: is a ‘hooked’ appearance of the nose following surgery. This occurs when the bony dorsum has been reduced, but the mid-third has not been lowered to correspond and gives a classic ‘parrot’s beak’ shape to the lower two thirds of the nose.14 Retracted columella: is a common feature found in Asian noses and can be treated successfully with NSR. When viewed laterally, if the columella is not visible by at least 2mm it is deemed to be retracted. It is associated with mid-face hypoplasia and can be caused by over aggressive surgery, trauma or birth defect.14 Pinched lobule: is due to over aggressive treatment of the alar cartilages either by over trimming or over tightening of the sutures in this area, which can cause the domes of the alar cartilages to collapse leaving a pinched nose.14

This article is the first of two on non-surgical rhinoplasty by Mr Geoffrey Mullan and Mr Ben Hunter. Their next article will detail techniques and complications and how to best manage these. Mr Geoffrey Mullan is a cosmetic surgeon and medical director at Medicetics Clinics and Training Academy. He has taught anatomy at Guy’s Hospital and worked at the Royal Marsden Head and Neck Unit, with an advanced understanding of the deep structures of the face. He has been a dermal filler trainer for Allergan and offers workshops in a number of treatments in central London. Mr Ben Hunter is a consultant facial plastic surgeon with extensive experience and expertise in nasal surgery. He works at St George’s Hospital Medical School, and privately at the Lister Hospital, Chelsea and King Edward VII Hospital in London. Mr Hunter qualified with the Royal College of Surgeons of England and holds European Board Certification in Facial Plastic and Reconstructive Surgery. He runs training workshops alongside Mr Mullan and a number of other faculties in central London. REFERENCES 1. Angelos PC1, Been MJ, Toriumi DM, ‘Contemporary review of rhinoplasty’, Arch Facial Plast Surg, 14(4) (2012), pp.238-47. 2. Moss R, ‘Cosmetic Surgery On The Rise, With 51,000 Brits Undergoing Procedures Last Year’, Huffington Post, (2016),<http://www.huffingtonpost.co.uk/2016/02/08/cosmetic-surgery-rising-inbritain-2015-statistics_n_9185180.html> 3. Adamson PA1, Warner J, Becker D, Romo TJ 3rd, Toriumi DM., ‘Revision rhinoplasty: panel discussion, controversies, and techniques’, Facial Plast Surg Clin North Am., 22(1) (2014), pp.57-96. 4. Pontius AT1, Chaiet SR, Williams EF 3rd., ‘Midface injectable fillers: have they replaced midface surgery?’, Facial Plast Surg Clin North Am., 21(2) (2013), pp.229-39. 5. Jasin ME1., ‘Nonsurgical rhinoplasty using dermal fillers’, Facial Plast Surg Clin North Am., 21(2) (2013), pp.241-52. 6. Jasin ME1., ‘Nonsurgical rhinoplasty using dermal fillers’, Facial Plast Surg Clin North Am., 21(2) (2013), pp.241-52. 7. Schuster B1, ‘Injection Rhinoplasty with Hyaluronic Acid and Calcium Hydroxyapatite: A Retrospective Survey Investigating Outcome and Complication Rates.’, 8. Nasal Anatomy emedicine.medscape.com/article/835134-overview Edward W Chang, MD, DDS, FACS Consulting Staff, Department of Cosmetic Services, Head and Neck Surgery, Kaiser Permanente of Northern California at Santa Rosa 9. Adamson PA1, Warner J, Becker D, Romo TJ 3rd, Toriumi DM., ‘Revision rhinoplasty: panel discussion, controversies, and techniques’, Facial Plast Surg Clin North Am., 22(1) (2014), pp.57-96. 10. Tezel A, Fredrickson GH., ‘The science of hyaluronic acid dermal fillers’, J Cosmet Laser Ther.,10 (2008), pp.35-42. 11. Hirsch RJ, Brody HJ, Carruthers JD., ‘Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid’, J Cosmet Laser Ther., 9 (2007), pp.182-185. 12. Smith KC1, ‘Reversible vs. nonreversible fillers in facial aesthetics: concerns and considerations’, Dermatol Online J., 15;14(8) (2008), p.3. 13. Leong, S.C. and Eccles, R., ‘A systematic review of the nasal index and the significance of the shape and size of the nose in rhinology’, Clinical Otolaryngology, 34 (2009), pp.191-198. 14. Papel et al., ‘Facial Plastic and Reconstructive Surgery’ Third edition Thieme.

Bulbous tip: occurs if the alar cartilages are very broad and arched, a cupping depression between the cartilage and the caudal position of the middle cartilage develops.14

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Androgens, including testosterone, lead to the stimulation of a more compact network of collagen fibres than that found in female skin. This firm collagen and elastin network, coupled with the existence of terminal hair follicles, results in the thick skin seen in men.4 As a result of this biological difference, men are more likely to develop acne.4 Acne vulgaris' pathogenesis is multifactorial, with genetics playing a crucial factor, as an individual who is more predisposed is likely to go on to develop the disease.5 Acne develops as a result of the interplay of the following four factors:6

Managing Male Acne Dr Anil Sharma provides an introduction to the causes of acne and outlines treatment methods suitable for men Acne is a result of the action of hormones and other substances on the sebaceous glands and hair roots. These variables lead to plugged pores and outbreaks of acne in varying severity. Acne lesions usually appear on the face, neck, back, chest and shoulders. Although acne is not a serious health risk, it can be a source of considerable emotional distress.1 Severe acne often leads to permanent scarring if not treated quickly. While women are statistically more likely to suffer from acne, men are more liable to develop a more severe form of body acne due to the amount of circulating testosterone.2 It is generally accepted that women are more likely to seek medical help for skin-related issues due to societal norms, whereas men are less likely to present these issues to a professional until the disease is more mature. This is where, as health professionals, we must educate men and make skin health a priority.

Acne and hormones The main difference between male and female skin, apart from the thickness, is the effect that the male sex hormones, known collectively as androgens, have. The primary sex hormone of this group is testosterone. Although amounts vary, adult males secrete ten times the amount of testosterone as women.3 Testosterone acts on androgen receptors, either directly, or by being converted into dihydrotestosterone (DHT), a considerably more potent activator of the androgen receptors. Throughout male childhood, testosterone levels remain relatively constant until puberty. After puberty, men continuously secrete higher amounts of testosterone that result in all the features of an adult male. With middle age, testosterone levels are responsible for the changes in men's hair and skin. In areas sensitive to androgen modulation, such as the face, underarms, and genital area, testosterone triggers the production of terminal body hair. In men, this extends to the arms, legs, chest and back – virtually the remainder of the skin’s surface area – except the soles of the feet and palms of the hands.3 

1. Release of inflammatory mediators into the skin 2. Follicular hyperkeratinisation following plugging of the follicle 3. Propionibacterium acnes follicular colonisation 4. Excessive sebum production Studies indicate that inflammatory tendencies occur before hyperkeratinisation. Cytokines produced by CD4+ T-cells and macrophages activate local endothelial cells to up regulate inflammatory mediators such as vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and human leukocyte antigen (HLA)-DR inside the vessels around the pilosebaceous follicle.7 Follicular hyperkeratinisation entails enhanced keratinocyte growth and reduced desquamation, resulting in sebum- and keratinpacked microcomedones.8 Excess sebum is another factor affecting the progress of acne vulgaris. Removal and production of oil are managed by way of a quantity of mediators and different hormones. In particular, androgen hormones moderate oil production and release.10 The amount of comedonal acne in pre-pubertal females correlates with circulating levels of the adrenal androgen dehydroepiandrosterone sulfate (DHEAS).11 Numerous additional mediators and receptors, including human growth hormone, insulin-like growth factor and peroxisome proliferator-activated receptors manage the sebaceous gland and could give rise to the progress of acne.12,13 Moreover, the sebaceous gland acts as a neuroendocrineinflammatory organ that is triggered via corticotrophin-releasing hormones in reaction to anxiety and typical functions.14

Treatment choices Treatment should be geared toward the known pathogenic factors involved in acne. Included in these are: follicular epidermal hyperproliferation, excessive sebum production, P. acnes, and inflammation. Knowledge in the severity and the grade of the acne

While women are statistically more likely to suffer from acne, men are more liable to develop a more severe form of body acne

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patients experiencing acute headaches, decreased vision, or adverse psychiatric events to stop taking isotretinoin immediately.15

What is P. acnes? P. acnes or propionibacterium acnes pathogens, is an anaerobic organism contained in acne lesions. Inflammation influences the disease process by creating cell mediators that soften through the follicle wall. Research indicates that P. acnes might also reveal why acne vulgaris develops in some people but not others.9

help in ascertaining which of these treatments, in combination or alone, are most appropriate. Current consensus advocates a combination of topical retinoid and antimicrobial treatment as firstline therapy for almost all patients with acne. However, due to the vast surface area of severity that can occur on the body, this may not be practical. Topical retinoids are comedolytic and anti-inflammatory. They normalise follicular hyperproliferation and hyperkeratinisation15 and they may need to be used less frequently if irritation occurs. Topical retinoids thin the stratum corneum, and have been connected with light sensitivity.15 It is essential patients are educated about adequate sun protection with SPF 50 when using retinoids. Systemic treatments Antibiotics Systemic antibiotics are a mainstay in treating moderate-to-severe inflammatory acne vulgaris, especially in male body acne, where it may cover a large surface area and not be responsive to topical treatments.16 Agents that possess anti-inflammatory properties and that are also effective against P. acnes are preferred. The tetracycline group of antibiotics is generally prescribed for acne. The more lipophilic antibiotics, like doxycycline and minocycline, are generally more efficient than tetracycline.16 Greater efficacy may also be due to less P. acnes resistance to minocycline.9 Isotretinoin Isotretinoin treatment should be started at a dose of 0.5 milligrams/ kg/d for four weeks, and increased as tolerated until a cumulative dose of 120-150mg/kg is achieved.16 Coadministration with steroids (prednisolone) at the onset of therapy may be useful in severe instances to prevent initial worsening.16 Some patients may respond to doses lower than the conventional recommended dosage. A lower dose (0.25-0.4mg/kg/d) may be as successful as the higher dose given for the same time period and with greater patient satisfaction as there are fewer systemic side effects and hence a greater patient toleration.17 Lower irregular dosing programmes (one week/month) are not as effective because long term dosing leads to down regulation of the androgenic receptor.17 Some patients only need one course of oral isotretinoin for entire acne remission, while others need isotretinoin therapy. A study of 1,500 acne patients, who were given 1mg/kg per over a six-month period in two divided doses within 24 hours found that 38% had no symptoms of acne at a three-year follow up. The study indicated that among the remaining patients, 17% were controlled with additional topical treatment, 25% with topical and oral antibiotics, and 20% with a second course of isotretinoin.18 Adverse effects of isotretinoin include dry skin, lips, and eyes, as well as muscle aches and headaches. Practitioners must advise

There is also a link between isotretinoin and heighten feelings of depression and suicidal thoughts.19 Acne may create hostility and can alter character development in the adolescent period, anger, and anti-social behaviour. Connected mood changes and depression have also been reported during treatment.19 It is important to therefore not administer isotretinoin to a depressed or suicidal individual. Although a cause-and-effect relationship has not been established, patients should be informed of this potential side effect, and must sign a consent form acknowledging that they are aware of this.20 Diet Although in women the relationship between acne and insulin resistance is well known, it is lesser understood in men. As such, in a study conducted this year by the department of Clinical Dermatology at the University of Naples Federico II, 20 male subjects with an altered metabolic profile were considered and randomised. 10 patients were treated with metformin and a low GI diet for six months (group A), while the other 10 patients were assigned to the control group (group B). All patients of group A, after six months of metformin treatment, had a statistically significant improvement compared with patients in group B. The study identifies a link between diet and insulin resistance in acne pathogenesis, and underlines the possible use of diet and metformin as possible adjuvant treatment for male patients with acne.21,22 Other treatment options As well as the treatments mentioned above, which, as stated may not be suitable for patients with back acne due to the surface area, there are also studies that suggest that the following can be effective in treating the condition. Intralesional steroid injections have already been found to be beneficial for inflammatory lesions. Comedone removal doesn't change the course of the disorder, but it does enhance the patientâ&#x20AC;&#x2122;s appearance.16 Phototherapy (using red or blue light) and photodynamic therapy are being assessed as potential treatments for acne. It is well documented as per the literature that lasers (fractional), blue light and chemical peels are an excellent adjunct therapy once the endogenous sebaceous production is controlled.23

Summary Body acne in men can, at times, present in a more severe form when compared to the female population, mainly because of the increased effect of circulating androgens. Due to the possibility of a more severe disease process and risk of scarring, oral isotretinoin may be the first line treatment of choice. However, many patients are anxious about the possible side effects. In my own practice in both the Canada and the UK, I have found great benefit in combining a low dose of isotretinoin (20mg once daily), in combination with a low strength of topical tretinoin (0.025% in an ointment base). Patients may be on treatments for longer but they are more likely to adhere to the treatment protocol and thus achieve the end goal of symptom control and less psychological

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suffering associated with acne. It is important to treat acne quickly and efficiently to avoid permanent scarring, of which men may be more at risk of developing.15 Dr Anil Sharma is the founder of Sharma Skin & Hair Surgery in Canada and graduated from The University of Glasgow Medical School in 2003. After initial postgraduate surgical training, he trained in a number of specialties within the UK. In 2008 he joined a large private cosmetic dermatology and surgery group where his practice concentrated on tumescent liposculpture, skin surgery, hair restoration surgery, regenerative medicine and aesthetic dermatology. He now splits his clinical time between Europe and Canada. REFERENCES 1. B. Archer, S. N. Cohen, S. E. Baron, and British Association of Dermatologists and Royal College of General Practitioners, ‘Guidance on the diagnosis and clinical management of acne,’ Clinical and experimental dermatology, 37(2012). 2. Haider & J. C. Shaw, ‘Treatment of acne vulgaris,’ JAMA : the journal of the American Medical Association, 292(2004) pp.726–735. 3. Mercè M. Fernández-Balsells, Mohammad H. Murad, Melanie Lane, Juliana F. Lampropulos, Felipe Albuquerque, Rebecca J. Mullan, et al., ‘Adverse effects of testosterone therapy in adult men: A systematic review and Meta-Analysis’, Journal of Clinical Endocrinology & Metabolism, 95(2010) pp.2560–2575. 4. Ana Maria M. Abreu-Velez and Michael S, ‘Howard. Collagen IV in normal skin and in pathological processes’, North American journal of medical sciences, 4(2012) pp.1–8. 5. Goulden V, McGeown CH, Cunliffe WJ, ‘The familial risk of adult acne: a comparison between firstdegree relatives of affected and unaffected individuals,’ Br J Dermatol, 141(1999) pp.297-300. 6. Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al., ‘New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group’, J Am Acad Dermatol, 60(2009) pp.1-50. 7. Jeremy AH, Holland DB, Roberts SG, Thomson KF, Cunliffe WJ, ‘Inflammatory events are involved in acne lesion initiation’, J Invest Dermatol, 121(2003) pp.20-7. 8. Norris JF, Cunliffe WJ, ‘A histological and immunocytochemical study of early acne lesions’, Br J Dermatol, 118(1988) pp. 651-9. 9. Webster GF, ‘Inflammatory acne represents hypersensitivity to Propionibacterium acnes’, Dermatology, 196(1998) pp. 80-1.

Aesthetics 10. Pochi PE, Strauss JS, ‘Sebaceous gland activity in black skin’, Dermatol Clin, 6(1988) pp.349-51. 11. Lucky AW, Biro FM, Simbartl LA, Morrison JA, Sorg NW, ‘Predictors of severity of acne vulgaris in young adolescent girls: results of a five-year longitudinal study, J Pediatr, 130(1997) pp.30-9. 12. Trivedi NR, Cong Z, Nelson AM, Albert AJ, Rosamilia LL, Sivarajah S, et al., ‘Peroxisome proliferatoractivated receptors increase human sebum production, J Invest Dermatol, 126(2006) pp.2002-9. 13. Smith TM, Cong Z, Gilliland KL, Clawson GA, Thiboutot DM, ‘Insulin-like growth factor-1 induces lipid production in human SEB-1 sebocytes via sterol response element-binding protein-1’, J Invest Dermatol, 126(2006) pp.1226-32. 14. Zouboulis CC, Böhm M, ‘Neuroendocrine regulation of sebocytes – a pathogenic link between stress and acne,’ Exp Dermatol, 13(2004) pp.31-5. 15. Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al, ‘Management of acne: a report from a Global Alliance to Improve Outcomes in Acne,’ J Am Acad Dermatol, 49(2003) pp.1-37. 16. Cunliffe WJ, Goulden V, ‘Phototherapy and acne vulgaris’, Br J Dermatol, 142(2000) pp.855-6. 17. Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, et al. ‘Guidelines of care for the management of acne vulgaris’, J Am Acad Dermatol, 74(2016)pp.945-973. 18. White GM, Chen W, Yao J, Wolde-Tsadik G, ‘Recurrence rates after the first course of isotretinoin’, Arch Dermatol, 134(1998) pp.376-8. 19. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L, ‘Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-based study,’ J Invest Dermatol, 131(2011) pp.363-70. 20. Jacobs DG, Deutsch NL, Brewer M, ‘Suicide, depression, and isotretinoin: is there a causal link?’, J Am Acad Dermatol, 45(2001) pp.168-75. 21. Fabbrocini, Izzo, Faggiano, Del Prete, Donnarumma, Marasca , Marciello , Savastano, Monfrecola, Colao, ‘Low glycaemic diet and metformin therapy: a new approach in male subjects with acne resistant to common treatments’, Clin Exp Dermatol, 41(2016), pp. 38-42. <https://www.ncbi.nlm.nih. gov/pubmed/26053680> 22. Hywel C. Williams, Robert P. Dellavalle, and Sarah Garner. Acne vulgaris. Lancet, 379(2012) pp.361–372. 23. Randie H. Kim and April W. Armstrong, ‘Current state of acne treatment: highlighting lasers, photodynamic therapy, and chemical peels’, Dermatology online journal, 17(2011).

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undertaken on 15 patients with scars following cancer surgery suggested that there was no evidence for the efficacy to the cosmetic outcome of vitamin E products and that it might even make some scars worse. Of the patients studied, 33% developed a contact dermatitis to the vitamin E.2 In addition, the Mayo Clinic grades the evidence on scars and vitamin E as grade D, which means there is fair scientific evidence against this use (suggesting it may not work).3

Treating Scars Dr Simon Berrisford outlines a range of scar treatments available and shares a clinical case study of treating a hypertrophic scar with platelet rich plasma Post-operative and traumatic scars can frequently be seen on parts of the body that may be regularly on display. With 24-hour celebrity news suggesting a need for ‘the perfect body’, scars may be viewed as ugly imperfections, which are difficult to disguise. The psychological effect of a scar should also not be underestimated. The NHS does not offer treatment for such matters as they are usually classed as PLCPs (Procedures of Low Clinical Priority) and as such, they are unavailable, unless the patient chooses to go down the private route. Therefore the availability of affordable, effective scar treatment via private clinics is a key service.

Types of scars Two types of scars that are often confused are keloid and hypertrophic.1 The keloid is defined as an abnormal scar that grows beyond the boundaries of the original site of skin injury, whereas the hypertrophic scar is defined as a widened or unsightly scar that does not extend beyond the original boundaries of the wound. Other types of scars include burns, post-operative scars, post-trauma scars, atrophic scars, post-infective or diabetic wound scars, or combinations such as hypertrophied post-op scars or keloided trauma wounds.1

Chemical peels Peels in scar treatment have focused mainly upon acne scar treatment, although they may be used for any type of scar which has an element of hypertrophy, where the aim is to lower the scar to be flush with the skin. Examples would include scars created after burns, surgery or trauma, but not scars that are depressed. Trichloroacetic acid (TCA) peels and salicylic acid peels are frequently used and tend to be combined with other treatments such as microneedling and laser.4 There appears to be no consensus on the best combination, if any, of these elements of treatment, with many practitioners offering their own blend or package. Corticosteroid injections Corticosteroid injections are a mainstay of treatment for hypertrophic scars and keloids.5 Usually triamcinolone is injected in multiple small aliquots along the length of the wound, or, if practical, a linear infiltration technique is used. The result is a reduction in redness of the scar and then slowing of growth, followed in most cases by regression of the bulk of the lesion.6 Silicone sheets Silicone gel sheets, which can be placed on scars to encourage moisture accumulation under the scar to hydrate the skin, have also been shown to be effective for some scars and have led to a wide range of versions being made available for patients to purchase for themselves for self-treatment. Research has suggested they are safe and effective, and also well tolerated for the treatment of hypertrophic and keloid scars.7 Dermal fillers Fillers are particularly suited to a couple of applications, namely pitted scars and acne scarring, such as ice pick scars. When combined with subcision,8 fillers can produce a cosmetically effective result. A single treatment can therefore provide both components of the treatment i.e. the subcision with the needle bevel, followed by the insertion of the filler material through the same needle to fill the space created by the subcision. This is an example of when a needle is more effective than a cannula as the latter cannot be used for subcision. The filler needle’s bevel can be

Scar treatments There are multiple treatment modalities already in use for the treatment of scars. Some, such as corticosteroid injections, aim to reduce the prominence of the scar. Surgery, on the other hand, aims to hide or reposition it. A general recap of these treatments is listed below. Topical treatments Topical treatments include vitamin E creams, gels and oils that claim to help fade the colour of prominent scars.2 These are extensively used and an enormous number of such products are widely available both in pharmacies and online, with some successful anecdotal results reported. However, a double-blinded study

It has been indicated that laser therapy for hypertrophic scars has approximately 70% efficacy

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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inserted below the defect or ice pick scar and moved from side to side in an arc to divide the tissue, anchoring the base of the scar down to the subcutaneous tissue. Injecting the filler material, usually hyaluronic acid, will fill the defect from below and raise the surface of the scar to be consistent with the surrounding tissue, thus reducing its visibility for the life of the filler, which may last between to four to nine months depending on the product. Furthermore, the production of new collagen is stimulated in the same way as microneedling, which may lead to more permanent filling of the defect by the patient’s own tissue. Other types of filler materials such as calcium hydroxyapatite may be more effective for this latter function.9,10 Microneedling Microneedling therapy, also called collagen induction therapy (CIT), and percutaneous collagen induction (PCI), involves making large numbers of punctures into the scarred area using needles which can generally range from 0.5mm to 3mm in depth.11 The devices used can be pen-like or needle encrusted rollers, used under topical anaesthesia. The punctures are repaired by the body’s natural healing process of skin proliferation12 producing collagen and elastin to plug the wounds, which can reduce the appearance of the scar. This treatment is used for most types of scar. Lasers Lasers have been used for scar treatment since their early incarnations and they have benefits based upon multiple modalities. The older and more basic lasers rely on tissue destruction to achieve results. With a raised scar, selective destruction of the raised portion can easily reduce the prominence of the scar tissue rendering it flatter and more amenable to camouflage with makeup. Non-fractional CO2 ablative lasers would be an example of these. The newer, fractional lasers only treat fractions of the skin surface at a time, effectively dividing the target into thousands of fine treatment areas producing perforations in the scar, which then heal in a manner similar to microneedling wounds over multiple treatments.13 Moving on to pulsed dye lasers, the wavelength of the beam allows the pigmentation of the scar to be targeted, helping it to pale back to skin colour, as the redness of the scar is usually caused by its vascular content for which the pulsed dye laser is optimised.14 It is logical that a combination of these technologies can be used to give a superior result over multiple treatments. For example, an ablative laser could be used to resurface an uneven scar by destroying the proud tissue, then a fractionated non-ablative laser could be employed to drill new channels into the scar to promote production of new tissue, followed by a pulsed dye non-ablative laser used to reduce pigmentation. It has been indicated that laser therapy for hypertrophic scars Figure 1: The initial wound, image supplied has approximately 70% by the patient the day after the procedure

Aesthetics

efficacy.15, Another study advised that laser therapy should become an integral part of hypertrophic scar therapy and may reduce the need for surgical excision.19 Clearly there are numerous treatments that rely on similar methods to reduce scarring, which could be viewed as interchangeable depending on the practitioner’s skills and preference. For example, several use tissue destruction (laser, TCA peels) to remove excess scar tissue and others use tissue damage/growth stimulation (fractional laser, microneedling) to promote replacement of scar tissue with healthier collagen.

Case study: hypertrophic scar treatment An alternative treatment for scars is platelet rich plasma (PRP), which is used frequently in my clinic. I will now discuss PRP use in more detail and present a case study. The subject (Patient A) is a 36-year-old female airline pilot who had a cervical discectomy in October 2015 after an injury that occurred whilst reaching for a control in the flight deck that was too far away and blew the disc, losing the use of the arm. Thankfully, she made a safe landing. After surgery she made a full recovery and initially had a very neat paramedian scar on the anterior aspect of the neck on the left side. Figure 1 shows a picture of the wound, which the patient took on her phone the day after the procedure. By February 2016 the wound had begun to show signs of hypertrophy. She attended my clinic in April 2016 with an angry red scar, which had not grown outside the margins of the original wound so was deemed to be a hypertrophic scar. The patient also showed me two scars over her scapula, where two papillomas had been removed before the neck injury. These also showed hypertrophic scarring and had been treated with corticosteroid injection previously with little effect (Figure 2). The decision was made to treat the neck scar with PRP rather than corticosteroids as the scar was in a very visible place on Patient A’s neck. Furthermore, the wound was relatively new, and corticosteroids can thin and pale the skin as well as potentially weaken the scar. PRP has growth stimulation properties and was considered more likely to strengthen, rather than weaken the wound.16 Laser therapy seemed impractical due to the wound being so narrow, so collateral damage was likely.17 Topical treatment and peels were discounted for the same reason. The daily visibility of the scar called for a treatment that would not cause a local reaction making the wound more unsightly during the healing process, thus PRP was deemed, on balance, to be the best option.

Figure 2: Two scars over the patient’s scapula previously treated with corticosteroid injection showing hypertrophic scarring

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Before

Aesthetics Journal

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After first treatment

Figure 3: The scar prior to treatment

After second treatment

Figure 4: The scar eight weeks after first treatment with PRP

PRP Platelet-rich plasma is made from the patient’s venous blood that has been centrifuged to make it especially rich in platelet cells. Platelets contain several different substances including a useful range of growth factors like VEGF (vascular endothelial growth factor), bFGF (basic fibroblast growth factor) and PDGF (platelet derived growth factor), all of which stimulate new growth of tissue and blood vessels. PRP is a relatively old therapy, first developed in the 1970s and used in open heart surgery in Italy in 1987.18 The use of PRP continues to expand into more and more areas. After training with Dr Daniel Sister I have learnt how PRP can be used as a basis for treatment for a wide range of indications, including leg ulcer treatment, gum recession and male and female genital rejuvenation, as well as more obvious aesthetic applications such as facial treatments and, the subject of this article, scar treatment. Treatment Figure 3 shows the wound prior to treatment. Contraindications to PRP would include bleeding disorders, current warfarin or non-steroidal anti-inflammatory drugs (NSAID) usage or evidence of infection in the wound. In the consultation the patient was told of the possible side effects, which include bruising, swelling and infection. The process began by drawing 20ml of blood, along with an anticoagulant, which was then centrifuged. The plasma was activated with calcium resulting in 8ml of active PRP. The wound was injected with aliquots of 0.2ml of PRP using multiple punctures. The wound was also underrun with 1ml of plasma at the level of the deep dermis. Review After eight weeks the patient was reviewed and the wound showed a significant improvement. Figure 4 shows the scar post treatment. There was a reduction in the redness of the scar, apart from a fine border, which remained hyperaemic. Also, the most lateral portion of the scar remained raised, whilst the rest had flattened completely. The patient was delighted with the response, but was keen to see if further improvement could be achieved, particularly in the lateral region and also in the colour, which she felt still drew attention to the scar and was difficult to disguise without a scarf. A second round of plasma therapy was undertaken at this appointment and the patient was reviewed eight weeks later. At the next review, shown in Figure 5, the lateral portion of the scar can be seen to have responded well and flattened. Also the hyperaemic border has resolved and the scar no longer looks active. An appointment has been made to review the patient six months after the second treatment for final follow up, although no further treatment is planned at the moment.

Figure 5: Results eight weeks after second treatment with PRP

The future A new treatment that I am now trialling in my clinic is plasma beam therapy. This treatment is delivered via a small portable machine called the Plasma IQ. There is a similar device called Plexr. It delivers a curved beam of plasma energy created from charged gas, in this case room air. This device can even be used on low power without anaesthesia, which is something I have tested on myself. The main use of the technology is for upper blepharoplasty, although it seems very suitable for some types of scar removal as it is far more subtle in its action than other treatments. The wound is relatively innocuous and the results are encouraging. I plan to report on my results with this new treatment in the New Year. Dr Simon Berrisford has 25 years’ experience in the medical profession and is qualified in aesthetic medicine. He has worked in all types of general practice, been a consultant medical editor at Pulse Magazine and written and lectured on a broad range of medical topics. He opened Select Medical Group in Cheshire and is a full Member of the British College of Aesthetic Medicine. REFERENCES 1. Kokoska M, ‘Hypertrophic Scarring and Keloids’, Medscape (2016) <http://emedicine.medscape.com/ article/876214-overview> 2. Baumann LS, Spencer J, ‘The effects of topical vitamin E on the cosmetic appearance of scars’, Dermatol Surg, 25(1999) pp.311-5. 3. Vitamin E, Evidence (US: Mayo Clinic, 2016) <http://www.mayoclinic.org/drugs-supplements/vitamin-e/ evidence/hrb-20060476> 4. M. C. Annunziata, V. D’Arco, V. De Vita, G. Lodi, M. C. Mauriello, F. Pastore, and G. Monfrecola, ‘Acne Scars: Pathogenesis, Classification and Treatment. Gabriella Fabbrocini’,Dermatol Res Pract, 2010. 5. S Kokoska, MD & Arlen D Meyers, Hypertrophic Scarring and Keloids Mimi, (2016) <http://emedicine. medscape.com/article/876214-overview#a1> 6. Juckett G, Hartman-Adams H, Management of Keloids and Hypertrophic Scars’, Am Fam Physician, 80(2009) pp.253-260. 7. Neerja Puri and Ashutosh Talwar J, ‘The Efficacy of Silicone Gel for the Treatment of Hypertrophic Scars and Keloids’, Cutan Aesthet Surg, 2(2009) pp.104–106. 8. Orentreich N, ‘Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles’, Dermatol Surg, 21(1995) pp.543-9. 9. Jesitus J, Collagen-stimulating fillers provide rejuvenating advantages, naturally (US: Dermatology Times, 2012) <http://www.dermatologytimes.modernmedicine.com/dermatology-times/news/ modernmedicine/modern-medicine-feature-articles/collagen-stimulating-fillers-?page=full> 10. Moers-Carpi M, Vogt S, Santos BM, et al. Dermatol Surg. 2007;33 Suppl 2:S144-S151 11. Lewis W, ‘Is microneedling really the next big thing?’ Plastic Surgery Practice, 7(2014) pp.24-28 12. Liebl H, Kloth L, ‘Skin cell profliferation stimulated by microneedles’, J Am Coll Clin Wound Spec <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3921236> 13. Ngan V, Fractional laser treatment (New Zealand: DermNet New Zealand, 2015) <http://www. dermnetnz.org/topics/fractional-laser-treatment/> 14. Dalton M, Treating vascular lesions (US: The Dermatologist, 2013) <http://www.the-dermatologist.com/ content/treating-vascular-lesions/> 15. Rui Jin, Xiaolu Huang, Hua Li, Yuwen Yuan, Bin Li, Chen Cheng, Qingfeng Li, ‘Laser Therapy for Prevention and Treatment of Pathologic Excessive Scars’, Plastic and Reconstructive Surgery, 231(2013). 16. Coondoo A, ‘Side-effects of topical steroids: a long overdue revisit’, Indian Dermatol Online J, <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4228634> 17. Jean L Bolognia, Joseph J Jorizzo, Julie V Schaffer, Dermatology, (2012) p.2262. 18. Textor J, ‘Platlet-Rich Plasma (PRP) as a Therapeutic Agent: platelet biology, growth factors and a review of the literature’, Springer. 19. Parrett BM, Donelan MB, ‘Pulsed dye laser in burn scars: current concepts and future directions’, Burns., 36(4) (2010), pp.443-9.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Patient suitability Patients who would not be suitable for treatment include those with breast cancer or a family history of it. However, use of fat grafting for reconstruction of post mastectomy and/or post radiotherapy is well established within a multi-disciplinary set up, and as an additional precautionary measure I carry out a baseline MRI scan for patients. The American Society of Plastic Surgeons (ASPS) review recently stated that although fat grafting to the breast can potentially interfere with breast cancer detection, there is no strong evidence to support this.5

Breast Augmentation Without Implants Mr Raj Ragoowansi explains his technique for augmenting breasts using autologous fat injection and details the treatment outcome from a group of 12 patients Since Dr Mel Bircoll first reported the use of autologous fat injections for breast augmentation in 1987,1 several reports of the technique, refinements, reproducibility, results and pitfalls have been reported.2,3,4 Given that implant-based breast augmentation is relatively safe, effective and reliable, yielding consistent and reproducible results, I have been judiciously deploying the fat grafting technique only to those seeking a 1-1.5 cup size enhancement, with good quality, supple skin, and those who have a particular aversion â&#x20AC;&#x201C; physical and/or psychological â&#x20AC;&#x201C; to silicone implants. In this article I will detail my experience in treating patients at my clinic.

Use of fat grafting for reconstruction of post mastectomy and/or post radiotherapy is well established within a multidisciplinary set up

Treatment Over the past 40 months we have treated a limited series of 12 patients, with an average follow up of 14 months. The indications for treatment were mainly breast hypoplasia (10 patients); a condition where there is insufficient glandular tissue, and congenital breast deformity (one patient with Polandâ&#x20AC;&#x2122;s Syndrome and one with a tuberous breast). On average, between 200275 millilitres of fat, depending on the amount of enhancement, were injected into each breast, which was harvested from the anterior abdominal wall, flank and lateral thigh donor sites. Fat is preferentially harvested from firstly the flanks, followed by the periumbilical and lateral thighs, depending on availably of fat and volume required; roughly 100g of fat is needed for each breast for every cup size. Repeat injection to replenish the resorbed fat was carried out in seven patients, mainly in the hypoplasia group. On average the interval between the primary and secondary procedure was 10 months. In my experience, two in every three patients will require repeat treatment, approximately 18 months post the initial treatment. Technique The patient is given a general anaesthesia and is sat in an upright position. The technique involves manual suction harvesting, using a 10ml syringe, a single use, sterile, disposable device (I use the Revolve system) and transfer via an adaptor into 5ml and 10ml syringes. The harvested fat is collected in the disposable device, where it is washed and processed, to separate the fatty tissue from fluid waste contaminates.6 After the fat is processed, I use 5ml and 10ml syringes, which allow for aliquot injection with a blunt cannula into the pectoralis major muscle, the pre-pectoral space and the subcutaneous tissue, avoiding breast parenchyma proper. The volume is built up sequentially, from the base of the breast to the nipple, ensuring symmetry by injecting layer by layer, one breast at a time, with regular inspection from the end of the operating table, with the patient sat up. Throughout this process it is essential to minimise trauma to the adipocytes by using bespoke equipment and delicate handling. The system used in my practice is easy to use, reproducible, efficient, and obviates the need for centrifugation. This is because the three to four washes with normal saline helps to clear the oil droplets and blood, thus freeing the fat from substances that degrade it, such as lipases and proteases. The system we use renders a smooth, uniform and concentrated suspension of fat for transplant, which theoretically increases the density of adiposederived stem cells, thus enhancing graft take. Results Results obtained from a patient questionnaire suggested that the overall satisfaction rate was 72% at a median follow up of 14

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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A comprehensive meta-analysis on data available to date does not show that fat grafting promotes cancer recurrence or a new primary cancer

months, but all patients categorically advocated recommending the procedure to a friend or relative. The overall complication rate was 10-12% and included early recipient site inflammation/infection (one patient) and late formation of cysts/fat necrosis (four patients), none of which required any operative intervention. Infection was treated with antibiotics and inflammation settled after time, up to three months later. Rapid fat resorption was seen in one patient within five months, and two patients in the hypoplasia group were dissatisfied with the final cup size. There are no direct studies that compare fat grafting with implantbased breast augmentation/reconstruction. The majority of studies on fat grafting for breast augmentation have low numbers of patients,2,3 with what I believe to be significant bias due to variation in technique, patient population and indications. Current studies do indicate high patient and surgeon satisfaction at 18 months median follow up with an average of 1.9 sessions. Overall, post-operative complication rate in the studies was 7.3%, with fat necrosis being the most common indication. A comprehensive meta-analysis on data available to date does not show that fat grafting promotes cancer recurrence or a new primary cancer.1

Aesthetics

Figure 2: Fat being injected into the breast. Image courtesy of Mr Raj Ragoowansi.

Conclusion Breast augmentation using implants is relatively safe and effective but can potentially carry rare but real risks of capsular contracture, rupture, leakage and displacement.7 Also, of recent, cases of anaplastic large cell lymphoma (ALCL) associated with breast implants has been reported, albeit numbers are very low compared to the total number of implant-based augmentations/ reconstructions carried out worldwide – 200 cases reported since 1997 versus up to 10 million implants sold/inserted during this period worldwide.8 In our experience, fat grafting for primary breast augmentation has yielded favourable results in carefully selected and counselled patients who are seeking only a moderate enhancement. On average, two sessions are required (12-18 months apart) and the overall cost of the completed episode generally exceeds that of an implant-based augmentation – both factors playing an important role in the decision making process. Mr Raj Ragoowansi is a consultant plastic and aesthetic surgeon. He graduated in Medicine and Surgery in 1992 from St Thomas’ Hospital Medical School, London, with the final year elective spent at Harvard Medical School, in Boston, US. REFERENCES 1. Riaz A Agha, Tim Goodacre, Dennis P Orgill, Use of autologous fat grafting for reconstruction postmastectomy and breast conserving surgery: a systematic review protocol (2013) <http://www. ncbi.nlm.nih.gov/pmc/articles/PMC3808755/#R21> 2. Fa-Cheng Li, Breast Augmentation With Autologous Fat Injection, Annals of Plastic Surgery (2014) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219534/> 3. Riaz A Agha, Use of autologous fat grafting for reconstruction postmastectomy and breast conserving surgery: a systematic review protocol, BMJ Open, (2013) <http://bmjopen.bmj.com/content/3/10/ e003709.full> 4. Melvin A. Shiffman, History of Breast Augmentation with Autologous Fat, Autologous Fat Transfer, (2010) Springer; USA 5. ASPS, Fat Grafting Techniques for Breast Reconstruction Are Commonly Used by US Plastic Surgeons, Study Provides Benchmark, but Highlights Need for More Research, (2013) <http://www. plasticsurgery.org/news/2013/fat-grafting-for-breast-reconstruction-commonly-used.html> 6. Revolve, What does the Revolve System do? (2016) <http://www.revolvegrafting.com/about-revolvetmsystem/> 7. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/ BreastImplants/ucm259296.htm 8. BAPRAS, ALCL Risk from Breast Implants, British Association of Plastic Surgeons, (2016) <http://www. bapras.org.uk/professionals/clinical-guidance/alcl-risk-from-breast-implants>

Figure 1: Fat being harvested from the patient. Image courtesy of Mr Raj Ragoowansi.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


A PAR TNERSHIP THAT REALLY WORKS LASER HAIR REMOVAL + VANIQA ® The hair-removing combination more effective than laser alone*

VANIQA® is licensed for the treatment of Female Facial Hirsutism *Complete or almost complete hair removal was achieved in 93.5% (29/31 subjects) in eflornithine-laser treated sites vs 63.9% (21/31 subjects) in placebo-laser treated sites.1

Available from Wigmore Medical Limited

Reference: 1. Hamzavi I et al. J Am Acad Dermatol 2007; 57(1): 54-59. Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing). Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women. Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects. Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product. For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application. The condition should improve within eight weeks of starting treatment.

Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on

UKEFL3585b Date of preparation: August 2016.

the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain. Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500. Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk. Date of Revision: 10/2015. Item code: UKEFL3336

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Almirall Ltd.

For more information please go to: www.medicines.org.uk/emc/medicine/21243


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A summary of the latest clinical studies Title: A Clinical Study on the Usefulness of Autologous Plasma Filler in the Treatment of Nasolabial Fold Wrinkles Authors: Choi YJ, Kim HS, Min JH, Nam JH, Lee GY, Kim WS Published: Journal of Cosmetic Laser Therapy, November 2016 Keywords: Autologous plasma filler, nasolabial fold, wrinkle Abstract: Recently, the efficacy of autologous plasma filler for the reduction of facial wrinkles has been demonstrated. The aim of our study is to validate the efficacy and safety of autologous plasma filler in treating nasolabial fold wrinkles. Twenty Korean patients with moderate to severe nasolabial fold wrinkles were enrolled. The patients were treated in one session of autologous plasma filler. The wrinkle improvement effects were evaluated at 1-week, 4-week, 8-week, and 12-week after the treatment. Three assessment methods were applied. First, two independent dermatologists assessed cosmetic results using a 5-point wrinkle assessment scale. Second, global aesthetic improvement score was used for assessment of final cosmetic results. Third, patient satisfaction was surveyed. And, adverse effects associated to treatment were observed. Mean age of the patients was 44.5 years. The average 5-point wrinkle assessment scale score was significantly improved at 1-week, 4-week, 8-week, and 12-week after treatment, comparing to before treatment (p < 0.01). The patients’ average GAIS also indicated better cosmetic outcomes. The clinical improvement with sufficient patients’ satisfaction and no significant adverse events demonstrated that novel autologous plasma filler could be considered as efficient and safety treatment option for nasolabial fold wrinkles. Title: Curative effects of microneedle fractional radiofrequency system on skin laxity in Asian patients Authors: Lu W, Wu P, Zhang Z, Chen J, Chen X, Ewelina B Published: Journal of Cosmetic Laser Therapy, November 2016 Keywords: Microneedling, radiofrequency, Asian skin Abstract: To date, no studies have compared curative effects of thermal lesions in deep and superficial dermal layers in the same patient (face-split study). The objective of this study was to evaluate skin laxity effects of microneedle fractional radiofrequency induced thermal lesions in different dermal layers. 13 patients underwent three sessions of a randomized face-split microneedle fractional radiofrequency system (MFRS) treatment of deep dermal and superficial dermal layer. Skin laxity changes were evaluated objectively (digital images, two independent experts) and subjectively (patients’ satisfaction numerical rating). 12 of 13 subjects completed a course of 3 treatments and a 1-year follow-up. Improvement of nasolabial grooves in deep dermal approach was significantly better than the superficial at three months (P=.0002) and 12 months (P=.0057) follow up. Effects on infraorbital rhytides were only slightly better (P=.3531). In conclusion, the microneedle fractional radiofrequency system (MFRS) is an effective method to improve skin laxity. The thermal lesion approach seems to provide better outcomes when applied to deep dermal layers. It is necessary to consider the skin thickness of different facial regions when choosing the treatment depth.

Title: Long-term Analysis of Lip Augmentation With Superficial Musculoaponeurotic System (SMAS) Tissue Transfer Following Biplanar Extended SMAS Rhytidectomy Authors: Richardson MA, Rousso DE, Replogle WH Published: JAMA Facial Plastic Surgery, September 2016 Keywords: SMAS, lip augmentation, tissue transfer Abstract: The objective was to evaluate the efficacy, longevity, and safety of lip augmentation using SMAS tissue transfer. A retrospective single-blind cohort study was designed to evaluate all patients who underwent surgical lip augmentation using SMAS following rhytidectomy. Preoperative photographs of each patient served as controls and were compared with postoperative photographs at three months, one year, and five years after lip augmentation. A total of 104 images (from 26 individual patients) were reviewed by 12 blinded observers using a validated lip augmentation grading scale. Median lip volumes of all patients at each postoperative interval were compared with preoperative lip volumes. Secondary outcome measures included postoperative complications. Both the superior lip and the inferior lip showed statistically significant increases in volume at three months, one year, and five years (P ≤ .004 for the superior lip after 5 years; P ≤ .001 for all other comparisons) after SMAS lip augmentation. The greatest median increase was observed in the superior lip at three months, while the smallest median increase was observed for the inferior lip at five years. The degree of increase in median volume seemed to weaken slightly over time, but remained statistically significant even at five years. SMAS lip augmentation is an effective and safe method for lip augmentation that can yield natural, long-lasting results with minimal risk. Title: Intense pulsed light (IPL) treatment for the skin in the eye area; clinical and cutometric analysis Authors: Augustyniak A, Rotsztejn H Published: Journal of Cosmetic Laser Therapy, October 2016 Keywords: Intense pulsed light, eye area, skin rejuvenation Abstract: This study included 24 women, aged 38 to 63 years (mean age was 48.04) with Fitzpatrick skin type II and III who underwent five successive treatment sessions with an IPL in twoweek intervals. The Cutometer (Courage; Khazaka electronic) reference test was an objective method for the assessment of the biomechanical properties of the skin. The measurements were made in three places around the eye. The photo documentation was used to compare state of skin before and after three months of treatments. Additionally, patients filled in a questionnaire, which contained questions concerning self-assessment of the procedure effects. The Cutometric analysis showed significant improvement of skin elasticity (statistical significance level is mostly (p<0.0001). The comparison of clinical changes in the therapy, based on photo documentation, showed a 25% improvement. In conclusion, this treatment was used in order to improve skin elasticity and decrease the amount and depth of wrinkles. It is a non-invasive treatment, with low risk of complications.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


What is redermalization™? redermalization™ [ri-dur-muh-luh-zey-shun n] verb (used with object) redermaleyes™, rejuvenate, succinate A unique technique to improve the quality of skin health through: hydration oxygenation and collagen & elastin stimulation. 1. My eyes and skin looked tired and grey before redermalization™ 2. I now have perky peepers after my redermaleyes™ treatment

FREE advanced redermalization™ training available with CPD accreditation. For more information on redermalization™ contact us on: 07506 517 274

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2. How robust is the training course and qualification gained at the end of it?

Choosing a Training Course Dr Tristan Mehta outlines the five questions to consider before booking a training course Training is a significant investment in your career in medical aesthetics. Courses can start at approximately £700 for just one day of training, but can go up to £10,000-30,000 for a three year master’s degree.1 There is likely no such thing as ‘the best course’. So, whether you are new to aesthetic medicine, or looking to improve your current practice, the most important question to ask yourself before investing in further education or training is, ‘where will this take me?’ Do you want a broad overview of injectables? Or are you looking to enhance your ability to manage complications? Would you like to deliver medium-depth peels? There are varied education and training opportunities available for all requirements. Whilst there are many good places to start or advance your training, one of the most common realisations that I see people make after investing in courses is that they did not think far enough ahead into the future and understand what they wanted to get out of it. Those who did not get what they were trying to achieve out of training often find that this easy, yet myopic, mistake has been an expensive one. How can you ensure that you don’t fall into this trap? I would advise that before booking a particular course, you ask yourself the following questions.

1. Is my aim academic or vocational? This question relates to an often overlooked distinction that we can make between education and training. Whilst training is

generally vocational, and therefore provides tangible skills, in some cases education might offer less measurable forms of skill acquisition. Educational courses can tend to centre on improving learners’ more abstract, academic abilities. Short training courses often necessarily neglect the development of these deeper skills in favour of immediately applicable talents. Both approaches have their merits, but it is worth reflecting on your ambitions. If your interest in a new field of aesthetics is at all academic, then the most appropriate route is likely a master’s degree at a university. Although these are typically relatively lengthy and costly, master’s degrees are not only designed to ensure clinical proficiency, but also to equip you with an ability to critically engage with, and potentially contribute to, aesthetics research in the future. On the other hand, practical proficiency and continued knowledge can be enhanced through vocational routes such as those offered by independent academies. These options range from weekend courses to distance-learning programmes. If you want to offer a number of core procedures, or update a subset of your overall knowledge, then these may be suited to your needs. Realistically consider whether you want education or training before enrolling on a course. Ideally, however, you should find a way to incorporate them both. This could be through an academic and vocational course, or a course that blends the two.

Some courses may seem to provide a convenient shortcut into the aesthetics industry by implying that if you attend a oneday course then you will be well equipped to perform those procedures independently from then on. However, as the old adage goes, ‘If it seems too good to be true, then it probably is’. How realistic is it that a one-day course will equip you with the skills you need to successfully enter a new medical specialty? To quote some advice from the British Association of Cosmetic Nurses (BACN), “These [one-day] courses usually (and should) only offer certificates of attendance, rather than proficiency, since it is not possible to become proficient within a day.”2 Medical aesthetics is a highly competitive field. Only those who can demonstrate true proficiency, rather than just competency, will succeed in the long run. Short courses might ‘top-up’ your skills with a niche procedure such as treating the tear troughs, provided they take place in small enough groups for in-depth one-to-one feedback. However, those who are completely new to the aesthetics industry should be wary of spending significant amounts of money on one or two-day courses in the hope that it will leave them fully proficient. A foundation of knowledge is the most stable basis for advanced learning. For newcomers it is especially important to find a course that favours depth of learning, with a full theoretical and practical curriculum that includes topics such as dermatology, skin ageing, and the mechanisms of action of any pharmaceuticals such as botulinum toxin type A. Aesthetics is a specialty typically entered after undergraduate training. So, ensure that your chosen course delivers theoretical and practical training to that postgraduate standard, and provides you with a nationally recognised qualification at the end of it.

3. Does the course meet the latest Department of Health guidelines? You need to know whether your training will withstand upcoming changes to the regulatory landscape. In 2015 and 2016, Health Education England (HEE) laid out the Qualification Requirements for Delivery of Non-surgical Cosmetic Procedures.3 This is one of the most comprehensive guides to what level of training you should be aiming for in order to deliver non- or minimally-invasive cosmetic procedures, from dermal fillers to

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


Specialist insurance for cosmetic practitioners

Clinic Insurance for Medical Professionals Whether you run one cosmetic clinic or a chain of clinics, it is important to make sure you have adequate insurance in place should the unexpected happen. We can provide tailor made insurance to protect your cosmetic clinic, drugs and equipment against loss or damage caused by insured events such as storm, flood, escape of water and theft.

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Hamilton Fraser Cosmetic Insurance | 1st Floor | Premiere House | Elstree Way | Borehamwood | WD6 1JH Hamilton Fraser Cosmetic Insurance is a trading name of HFIS plc. HFIS plc are authorised and regulated by the Financial Conduct Authority

Specialist insurance for cosmetic practitioners

Medical Malpractice Insurance Our medical liability insurance policies have been created to protect cosmetic practitioners against allegations of malpractice and negligence in their performance of cosmetic treatments. We offer policies that are affordable and flexible and designed to grow as your cosmetic business develops.

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Hamilton Fraser wish you a Happy Christmas and a successful 2017!

www.cosmetic-insurance.com

Hamilton Fraser Cosmetic Insurance | 1st Floor | Premiere House | Elstree Way | Borehamwood | WD6 1JH. Hamilton Fraser Cosmetic Insurance is a trading name of HFIS plc. HFIS plc is authorised and regulated by the Financial Conduct Authority.


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Whether you are a new or experienced practitioner, familiarity with the HEE recommendations is essential chemical peels. HEE guidelines were also endorsed by the General Medical Council (GMC) in the recently released guidance for cosmetic doctors.4 Whether you are a new or experienced practitioner, familiarity with the HEE recommendations is essential. HEE signpost what level of training you will be expected to meet in the future. I believe these higher expectations will possibly become the minimum standards for accrediting bodies, as well as for cosmetic insurers, employers at clinic chains, and the general public. Consider some important points outlined for training in botulinum toxin injections: • Qualifications should be at a Level 7 for the administration of botulinum toxins (subject to oversight of an independent prescriber).3 • Practical skill requirements: students must perform ‘10 treatments for 10 different patients/clients (observation) [and] 10 treatments for 10 different patients/clients (under supervision) for each treatment type’.3 • Training courses must have their own degree awarding powers, or be regulated by the government’s Office of Qualifications and Examinations Regulation, Ofqual.3 HEE gives practitioners until 2018 to meet the new, higher standards.3 So take this opportunity to get ahead of the curve: read the HEE guidelines, and make sure that your chosen course allows you to comply with them.

4. Will you gain enough clinical experience? Practical experience is obviously vital for both confidence and proficiency. With injectable treatments, for example, hands-on training is essential for understanding how to achieve good outcomes and how to minimise the risk of complications. That said, the kind of hands-on practise that is on offer varies wildly. For instance, on a one-day course you may get to partly treat several pre-selected models who are shared between delegates.

This means that you get to experience parts of several procedures. Although informative, it is important to distinguish this from what it is like to assess and deliver entire aesthetic treatments in a real clinic. By sharing patients, some teaching methods minimise hands-on time, and fragments the training. This might be useful for the refinement of skills, but for initial training, at least, it is vital to perform entire treatments. By contrast, full treatments include the consultation, treatment planning, entire and uninterrupted procedures, aftercare and follow-up. Before delivering botulinum toxin injections independently, HEE recommend that practitioners observe ten and deliver ten full treatments under expert supervision.3 If you know someone who can supervise you, who has more than three years of experience in the procedure you are learning, then you can gain this clinical experience independently. However, if you do not know someone who is able or willing to supervise you then make sure that your training provider offers real clinical mentoring.

5. Who is accrediting or regulating the course? Accreditation is one of the most contentious issues surrounding aesthetic training. This is because, although many courses claim to be accredited, the important question is, ‘who is the course accredited by?’ If you want formal Continued Professional Development (CPD) points then CPD accreditation is useful. However, there are other important accreditations that a course can have. For example, the aforementioned HEE requirements specify that qualifications in aesthetic medicine should be regulated.3 There are only two ways of gaining a regulated qualification in the UK: through a university, or through an awarding body that is regulated by Ofqual. In light of the potential need for compliance with HEE guidelines, my advice would be to check who your course is accredited or regulated by. One useful tool for doing this is the Ofqual register (register.ofqual.gov.uk).5 Other accreditations to look out for include those from independent professional

bodies such as the British College of Aesthetic Medicine (BCAM), or the emerging regulatory body the Joint Council of Cosmetic Practitioners (JCCP), which is due to become operational in Spring 2017.6 These accreditations mean that the course meets certain stringent requirements and testify somewhat to the quality of the course, even if they aren’t mandated by HEE requirements.

Conclusion The JCCP is, in part, being set up to counteract the proliferation of training standards in aesthetics. However, sadly it is still the case that choosing an aesthetic training course can be somewhat of a minefield. Until aesthetic medicine is successfully self-regulating, vigilance is key for prospective students looking to start or continue training. Fortunately, however, the recent guidelines from organisations like the GMC4 and HEE3 provide a reliable baseline of objective information. By armouring yourself with the facts, examining different courses, and clarifying your aims, you can benefit both yourself and the aesthetics specialty more broadly with wise investments in your education and further training. Disclosure: Dr Tristan Mehta is the director and founder of Harley Academy. Dr Tristan Mehta is a medical doctor, entrepreneur and founder of Harley Academy. He is studying for an MSc in Skin Ageing and Aesthetic Medicine and is passionate about developing better standards in medical education through novel approaches and the implementation of state-of-the-art technology. REFERENCES 1. University of Central Lancashire, ‘Msc Non-surgical Cosmetic Interventions’, (2016), <http://www.uclan.ac.uk/courses/msc_ pgdip_non_surgical_cosmetic_interventions.php> 2. BACN, ‘What is Aesthetic Medicine? <http://www.bacn.org.uk/ content/566058da818644.79319286.pdf> 3. HEE, ‘New qualifications unveiled to improve the safety of non-surgical cosmetic procedures,’ (2016) <https://hee.nhs. uk/news-events/news/new-qualifications-unveiled-improvesafety-non-surgical-cosmetic-procedures> 4. GMC, Guidance for doctors who offer cosmetic interventions, (2016) <http://www.gmc-uk.org/guidance/ethical_ guidance/28687.asp> 5. Ofqual, ‘Welcome to the Register of Regulated Qualifications’, (2016), < http://register.ofqual.gov.uk> 6. BCAM, Standrads and Criteria for Aesthetic Medicine Continuing Professional Development Activities Regulations (2012) [available upon request] 7. Joint Council for Cosmetic Practitioners (JCCP) and Clinical Standards Authority, (2016) http://www.bacn.org.uk/ documents/jccp/JointCouncilforCosmeticPractitionersJCCPCSAGenericPresentationV1.pdf

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Patient Testimonials Dr Harry Singh discusses how to gain and utilise patient testimonials to effectively market a clinic Testimonial In promotion and advertising, a testimonial consists of a person’s written or spoken statement extolling the virtue of a product or service. The term ‘testimonial’ most commonly applies to the pitches attributed to ordinary citizens, whereas the word ‘endorsement’ usually applies to pitches by celebrities or prominent figures.1

Why are testimonials important? The importance of patient testimonials has been highlighted by numerous studies.2,3 Many suggest that patients are more trusting and hence more willing to uptake your services if they know other patients have had a positive experience and that the service they have received has resulted in an optimistic impact on their lives.4 Patients want reassurance and confidence that they have made the right decision in seeking your services, and evidence from their peers will greatly help this. Personally, I have found that many patients feel privileged to be asked to give a testimonial and it therefore generates a feeling of goodwill with those patients. They might feel special and proud that out of all the patients, you have asked them to share their experiences. They are likely to act congruent to what they have put on paper or said in a video; I have found within my own practice that the patients that have given me a testimonial will remain with me longer than those patients that have not. Social media is an important communication tool that patients use to connect to other patients or to your business. Patients will use social media to share their experiences, reviews, testimonials, information, advice, warnings and tips. This information may influence other patients’ decision-making. Some studies suggest that people use information on social media as the guideline for their own future purchases. In one study, it was indicated that 53% of consumers look at information from forums, social accounts and company websites before a purchase.5,6 Therefore, social media, via reviews and testimonials, can be successfully used as advertising for your business.

journey before patients will be willing to give any form of testimonial. Some of the processes you need to consider to make the patient journey exceptional are, but not limited to; how the initial enquiry was handled (whether this be by phone, email or face to face), the ambience and décor of your clinic, friendliness of the team, the assessment process, rapport building, comfort of the procedure, the treatment itself, the anticipated results obtained and follow-up care. As previously discussed, my team and I wait for that moment when the patient shows gratitude or has a positive comment on any aspect of our business. It is at that time that you should kindly ask the patient if they’d be willing to provide a formal testimonial. The law of reciprocation7 is inbred within all of us and when we have a positive experience we want to return the favour. It is imperative that you ask for the favour to be returned as soon as the patient recognises that they have benefitted. The longer you leave your request for a testimonial (i.e more than a week), generally the less conversions you will have for your testimonial request.7

Different formats of testimonials You will need to generate various formats of testimonials, such as written or video, and choose the platform, such as social media channels and Google reviews. Generating different formats is important because your patients giving the testimonials will each have a certain personality/learning profile8 and will likely prefer one format compared to others. Similarly to this, potential new patients will prefer to receive information via one particular platform, which may influence them to book a consultation or treatment more than others. Platform Social media: use of the various formats of testimonials across the different social media platforms such as Facebook and Google Plus. Written testimonials on your Google Business Page is a good idea because it will add credibility to your page and is one of the many ways to improve your search engine rankings.10

Asking for testimonials It is valuable to create methods that will increase the probability of your testimonial requests being approved. I don’t have a rigid system where I ask every patient I have treated. If I did, then the patient will feel it has been rehearsed and they are just a number. My approach is to wait until the patient shows gratitude and thanks, which indicates that they may be ready to give a testimonial. The advantage of this is that it is more natural and in my experience you get a greater uptake for your request. So, how might you increase the chances of your patients presenting themselves to give a testimonial? The production of a testimonial is usually the last and final part of the patient journey. There needs to be a seamless and enjoyable patient

Format Written: you can either use a template document, where the patient writes their testimonial according to a set of questions, or a testimonial/visitor’s book, they can fill in. Video: this is a visual recording of the patient’s experience. Make sure you have good lighting, sound and a well-presented

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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area to undertake the recording. In my experience a large majority of my patients are not too comfortable with video testimonials and you need to tread carefully when requesting this and don’t be surprised with the low uptake for this form of testimonial. Content Stories: personal stories of their journey from their initial aesthetic concerns to how the treatment provided has been beneficial. Case studies: more for your professional peers, but can be adapted for patients too. This will be in the format of before and after images accompanied by text on how you achieved the results, what materials were used, your injection technique, and anything you would have done differently. This can also be supplemented with patients’ comments. The above forms of testimonials can be published anywhere and everywhere, such as newsletters, websites, social media channels and around the clinic.

Learning types People will, broadly speaking, fall into three learning types – visual, auditory and kinaesthetic.8 We have all three of these learning styles present in ourselves, but one is normally more dominant than others. This will be the preferred route for learning and thus more likely to influence buying decisions. There are various online tools where you can discover which learning type you are.9 Visual patients will learn and decide via images, videos and drawings. Therefore, with visual personality types, it is essential that you show before and after images of results and video testimonials similar to what they are looking to achieve. If you show a visual learner written testimonials, you are less likely to interest them and provoke a positive response to uptake your services. Auditory patients will learn and decide via hearing facts and figures. Therefore, with auditory personality types, it is essential that you go into detail about the procedure and services and you use written testimonials and case studies that emphasise the details of the procedure carried out. Kinesthetic patients will learn and decide via their feelings and emotions. They want to know how your services have transformed patients’ lives and how the patients felt afterwards. Therefore, with kinesthetic personality types, it is essential that you show personal stories.

Scripted testimonials For my written testimonials I let the patients write free flow with no script to follow. For video testimonials, it is important to have some structure to it. The reason is that most patients are more comfortable undertaking the written format compared to the video, so you can help patients by letting them focus on two to three points. I have a list of around a dozen questions and out of those, I’ll pick three different questions for each of the patients to talk about as you don’t want all videos to be the same or too long. Questions to use could be, ‘what was your main concern?’, ‘why did you choose us?’, ‘how was your experience of the service?’, ‘how was the procedure?’, and ‘would you recommend us to others?’

Potential pitfalls It may sound obvious, but it is vital that you don’t make up testimonials.

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As well as breaching professional standards that could land you in trouble with your relevant medical body, you’ll be breaking the law in relation to The Consumer Protection from Unfair Trading Regulations 200811 (which covers marketing aimed at consumers) and/or the Business Protection from Misleading Marketing Regulations 2008.12 Secondly, you will need to obtain express consent from the patient for the use of the testimonial for promotional material. This is critical for medico-legal issues and the Data Protection Act.13 It is also recommended that you make sure that the patient is aware of where the testimonial could possibly be published, for example online, on social media or maybe playing on the televisions in clinic.

When testimonials are not appropriate We cannot advertise prescription only medicines (POM) to the general public.14,15 This means that you cannot use any format of testimonial (such as written, video and before/after images) that is accessible by the public (newspaper ads, leaflets, posters on shop windows, website, social media etc.) that is showing the use, results obtained and patients’ experience of botulinum toxin treatments or other procedures that have used POMs.

Summary There is a clear benefit to asking for and receiving different formats of testimonials in terms of adding extra value to your existing patients and allowing new patients to experience what others are saying about you. You may need to ‘coach’ your patients in expressing the value and emotional benefit of your services, not just the product side. For example, saying ‘the service was great’, will be more of a benefit as we tend to buy on emotion and justify later with logic. However, you do need to make sure you comply with your professional guidelines, such as insuring that you do not advertise POMs, any off label usages and most importantly ensuring that you have patient consent. Dr Harry Singh has been carrying out facial aesthetics since 2002. Alongside dental and aesthetic work he has a strong interest and experience in marketing. He has published numerous articles on the clinical and nonclinical aspects of facial aesthetics and spoken at dental and facial aesthetics conferences on these topics. REFERENCES 1. G Belch, ‘Advertising and Promotion, An Integrated Marketing Communications Perspective’, Facts 101, Cram101 Text Book Reviews 10(2016). 2. Medical Decision Making, The Inclusion of Patient Testimonials in Decision Aids, (2016), <http://mdm. sagepub.com/content/21/1/60.short> 3. Robert Alan Bonakdar, Herbal Cancer Cures on the Web: Noncompliance With the Dietary Supplement Health and Education Act, (2002) <http://umass.stfm.org/fmhub/fm2002/july02/ awardpaper4.pdf> 4. LD Pruitt, LA Zoellner, NC Feeny, D Caldwell, R Hansona, The Effects of Positive Patient Testimonials on PTSD Treatment Choice, Behav Res Ther, (2012) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3519362/> 5. Forbes, LP & Vespoli, EM, ‘Does social media influence consumer buying behavior? An investigation of recommendations and purchases’, Journal of Business & Economics Research,11(2013) pp.107-111. 6. Vinerean S, Cetina I, & Tichindelean M, ‘The effects of social media marketing on online consumer behavior’, International Journal of Business & Management, 8(2013), p.66. 7. Cialdini R, ‘Chapter 2: Reciprocation’, Influence: the psychology of persuasion, (2011). 8. Tanner K & Allen D, ‘Approaches to Biology Teaching and Learning: Learning Styles and the Problem of Instructional Selection—Engaging All Students in Science Courses’, Department of Biological Sciences, University of Delaware, (2006) <http://www.lifescied.org/content/3/4/197.short 9. Fleming N & Baume D, Learning Styles Again: VARKing up the right tree!, Educational Developments, 7(2006), p4-7. 10. Moz, The 2015 Local Search Ranking Factors, (2016) <https://moz.com/local-search-ranking-factors> 11. The Consumer Protection from Unfair Trading Regulations, (2008), <http://www.legislation.gov.uk/ uksi/2008/1277/contents/made> 12. The Business Protection from Misleading Marketing Regulations, (2008) <http://www.legislation.gov. uk/uksi/2008/1276/regulation/3/made> 13. Data Protection Act 1998, <http://www.legislation.gov.uk/ukpga/1998/29/contents> 14. MHRA, The Blue Guide; ADVERTISING AND PROMOTION OF MEDICINES IN THE UK, (2014) <https:// www.gov.uk/government/uploads/system/uploads/attachment_data/file/376398/Blue_Guide.pdf> 15. GMC, Prescribing guidance: Prescribing unlicensed medicines, <http://www.gmc-uk.org/ mobile/14327>

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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• Take into account the costs you may incur, consider the potential opportunities and problems you may encounter and think of how you could hypothetically deal with them. • Make a list of the legal requirements for operating your business and the paperwork you need to complete. • Start your administrative set-up, including a calendar with dates for tax returns and payments, insurance premium and regulatory body renewals, as well as potential patient consultation and treatment slots.

Going Self-employed Operations and marketing manager Victoria Vilas details the points to consider when starting your own business The private healthcare industry offers medical professionals the chance to develop a career in specialisms outside of the NHS remit. It allows them to setup independent practices and develop a personal or company brand, and to move into an industry where earnings are not subject to public sector bandings or caps. Aesthetic medicine is an area of private healthcare that is growing substantially, and one that offers many opportunities for talented and enterprising clinicians. Working as an aesthetic practitioner gives you the chance to continue medical practice, but also perform treatments that require more of a personal touch and artistic flair than conventional medicine. The independence and earning potential of being self-employed may appeal if you think you have the drive to develop and manage your own business, and the skills and experience to grow a loyal patient base. Having the freedom to choose when and where you work, and taking home the profits of your hard work, can make for a prosperous career with a great work/life balance, but if you don’t take the care needed to manage all elements of your business efficiently and legally, then you may never realise that dream. In a competitive market, it is essential to get off on the right foot if you want to develop a solo career that flourishes. If you get the details right when you first set up, you will find it far easier to get into a regular working routine, and create your own structure and schedule that helps you to manage your workload efficiently, prioritise effectively, and satisfy patients while staying on top of administration and operational tasks. Define the career you want and make a business plan To be a self-employed worker in any field, even if it is not full time, you must define your employment status, notify HMRC, and then comply with the regulations associated with that status. Working independently can take more than one form, and the tax office will expect you to declare how you work, and what you earn from it. So, the first thing to do is to decide what your self-employment will involve. Do you want to be a sole trader, performing toxin and filler injections on your own patients from a treatment room that you will hire in a multi-disciplinary medical practice? Would you prefer to be a freelance contractor, visiting clinics in your area to perform treatments on their clients? Do you want to set up your own business, perhaps with a partner, find premises and hire other staff members to create a company? Your decision is likely to be based on the funding you have available, the existing network of patients and colleagues you could take with you, and the time and effort involved in working out the logistics. Once you have an idea of what is both possible and realistic, you can start your business plan. Make some calculations to work out how many hours or days you need to work, and at what rate, to get to the income level you require.

Register your status with HMRC If all you know is that you want to work for yourself, then setting up as a sole trader1 is the quickest and easiest way to start a business on your own.2 It is essential to register as self-employed3 with HMRC and follow the rules for declaring your taxable income and submitting your own National Insurance (NI) contributions4 as soon as you start working for yourself, because you may be subject to penalty charges if you submit late tax returns, or fail to make payments on time.5 If your employment status changes from being another company's employee to being self-employed, you must notify HMRC so they can make sure you are paying the right levels of Income Tax6 and NI.7 When you are self-employed, paying your contributions is solely your responsibility, and you will be liable for penalty charges for late or incorrect payments, not your employer.8 Once your business is established, you may wish to set up as a limited company,9 meaning you pay less personal tax, and will be able to take additional money out of the business as dividends.10 You will need to register your business at Companies House, which is the UK companies register;11 appoint directors, which may be yourself or a business partner; complete company accounts, your annual tax return and pay corporation tax. You may decide not to this for reasons including, more complex, time consuming accounting and administration requirements, more expensive accountancy costs, and information relating to the owner of the company and the company itself that are displayed on public record.12 If you do wish to set up your own limited company, then HMRC does not consider you ‘self-employed’ as such, but rather the director and employee of your own company (Figure 1). After registering your business at Companies House, you must also register

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Self-employed Sole Trader

Limited Company

Your role

You are the business; you are the owner.

The business is a separate legal entity; you are a shareholder, and company director.

Legal disputes

In the event of any legal dispute you will be sued personally unless you have suitable insurance.

In the event of any legal dispute the company will be sued unless it has suitable insurance cover.

Employment status

You are self-employed; you cannot be your own employee.

For Income Tax and NI purposes directors/company officers are treated as employees. The company pays corporation tax on its taxable profits. Company tax rates are lower than higher rates of Income Tax.

Tax on profits

You pay Income Tax and NI on the taxable profits of your business, or your share of profits, if you are in partnership.

Insolvency

If the business fails you will be personally liable for its debts. You may go bankrupt.

There is no requirement that you prepare accounts for tax purposes. Accounts

Paying yourself

The company pays Income Tax and NI contributions on the earnings and some benefits of employees, including directors. Shareholders are subject to income tax on dividends.

If the company fails, your liability is limited to the amount unpaid on your shares (if any) unless you have made a personal guarantee for the company’s borrowing.

You must prepare annual accounts under the provisions of the Companies Act.

You may need annual accounts to complete your personal tax return, which includes a balance sheet section.

HMRC require full accounts for Corporation Tax.

You can withdraw any amount of profits, but it is not classed as remuneration as you are not an employee.

There is no restriction on the size of your salary, but it is subject to PAYE and NICs.

You obtain tax relief for expenses that are incurred for the purposes of the trade. Expenses An adjustment must be made for tax to add back the proportion of any expense that relates to ‘private use’.

for Corporation Tax.13 As a director, you will need to fill in an annual selfassessment form which includes information on all sales or takings, and purchases and expenses,14 and you will pay your income tax and NI as an individual and employee of your company, using the PAYE system.15 If you are not sure whether you should set up as a sole trader or limited company, accountants who deal with small businesses will be able to offer you advice.16 If you do not think you can manage to keep on top of your business records, returns and accounting, then consider using the services of a bookkeeper or accountant.17 Check you have the right certifications and get insured Though this may be stating the obvious, to work as an independent aesthetic practitioner in the UK, you must be registered with regulatory bodies, have completed certified training courses, and have professional indemnity insurance that includes medical malpractice cover. Doctors and surgeons must be registered with the General Medical Council (GMC), nurses with the Nursing and Midwifery Council (NMC) and dentists with the General Dental Council (GDC). If you have been a medical practitioner abroad, and do not yet have UK registration, you must apply for and receive this to practise legally in the UK.18 If you are an NMC registered nurse who has trained in injectable procedures, you will also need to have completed the V300 Non-Medical Prescribing course to be able to prescribe and use prescription-only medications such as botulinum toxin legally, without the presence of another qualified prescriber.19 Though you may be a highly skilled clinician, you cannot guarantee that you will never face a complaint or claim against you, whether it is justified or otherwise. If you have professional indemnity insurance then

The company obtains tax relief for its expenses if they are incurred for the purposes of the trade. If a director incurs private expenses through the company, they may be treated as earnings, if they are a shareholder, the amounts are treated as distributions.

you will be covered for a range of scenarios, including mistakes and negligence, breach of confidentiality, and more. If you are not covered, you could face having to pay thousands of pounds in legal fees and compensation to defend a claim. When working for yourself, there are other scenarios to consider with regards to insurance cover. Professional indemnity may protect you against a malpractice claim, but it does not cover you for unfortunate personal circumstances. If you are a sole trader and fall seriously ill or have an accident that prevents you from working, then you could end up in financial difficulty at the same time as having to deal with the stress of your situation. It is wise to arrange Income Protection Cover to give you peace of mind, so you know that you and your family will be covered if you are unable to work for a long period.20 Market your services and develop your patient list As a self-employed practitioner, you will be responsible for your own PR and marketing, and generating your own business. You may already have patients, but it’s likely that you’ll need to increase your patient base if you are giving up a permanent job to go self-employed. A huge number of potential patients are likely to search for practitioners and clinics online, so digital marketing is very important. This doesn’t mean that you have to allocate funds for an expensive multi-functional website and online advertising, as you can have an online presence even with a small budget. It is a good idea to launch your own website, as this will give you the space to list your services and prices, supply your contact details and address, display patient testimonials and treatment images, and add an air of professionalism. Sites such as Wix.com and Moonfruit.com

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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offer the tools to build a basic website for free, and to host your site and keep it online for as little as £3 per month. You will need to pay for a domain name to give your site its own unique title, but these can be less than £10 for a whole year. If you enlist the help of a professional to get your website designed, built and online, you may be looking at costs of £500 to £3,000, but this can be a worthwhile investment if you're not tech-savvy and want a professional-looking site.21 As many potential patients are likely to be social media users, it’s also wise to have a business page on Facebook, a Twitter account, and perhaps an Instagram account for any before-and-after pictures that your patients have consented to you using for marketing communications. Social media accounts are a great way to advertise your business for free, and collect positive reviews and comments from patients. Dedicating just a few hours per week to posting on your social media accounts can be an easy way to market your services and stay in touch with trends. Despite the prevalence of digital marketing, never underestimate the power of word-of-mouth advertising. If a patient has a fantastic treatment experience with you, they are likely to share their feelings and recommend your services, but also return to you as a regular patient. You may have a great technique, but in order to gain and keep patients, you will also need to ensure your customer service is flawless from start to finish. Keep a check on your budgets and expenditure When you are self-employed, you are responsible for generating your own business, and your own income. There is no basic salary to fall back on, or a redundancy payout if your work dries up. Being self-employed can be daunting as your income may fluctuate. Make sure you have insurance that covers the worst eventuality, but also try and budget carefully. Create a budget document on paper, on a spreadsheet, or with online bookkeeping tools, and track all of your revenue and expenses.22 Include projected cashflow, fixed and variable costs, and revenue forecasts, and most importantly, be realistic with your estimations.23 When you have your own private patients, there is no doubt that you will need certain stock and equipment in order to do your job. You may not have the funds to invest in a multi-use laser device right now, but if you are performing injectable treatments, skin peels, or microneedling, then you will need the relevant products in stock, and supplies for preparing your treatment room to create a hygienic, comfortable environment for your patient. When it comes to training, even if you work freelance in other clinics, you also should expect to pay for your own training, be it in new treatments, or advanced courses to further develop existing skills. Clinics may invest in training for permanent members of staff, but they cannot guarantee that contractors will stay long enough to make paying for expensive training courses worthwhile. Make contingency plans There is no employment contract allocating you annual leave, and no employer to take responsibility for covering your work when you are away when you are self employed. It will be up to you to schedule holiday at a time when it is convenient for your business, but if you get ill, you may have to cancel bookings. It’s not all negative though. If you’re feeling unwell, you don’t have to worry about whether your employer will be understanding, and you don’t have to ask for anyone’s permission to book a holiday on certain dates. With some thought on scheduling and good communication with your patients, you’ll be able to take breaks without too much hassle. If you’re concerned about undertaking everything on your

Aesthetics

own, you could also consider going into official partnership with another practitioner, so you have each other to bounce ideas off, to cover one another during holidays or illnesses, and to be able to increase your capacity for patient bookings. It is always a good idea to have a back-up plan, or to at least think about putting aside funds to cover your essentials if you happen to have a lull in custom at any point. Whichever route you choose, despite the daunting set of tasks required to set up your solo endeavour, once you have completed the administration and started on your new path, working for yourself can be incredibly rewarding and worthwhile. 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. Set up as a sole trader (UK: GOV.UK, 2016) <https://www.gov.uk/set-up-sole-trader> [31.10.2016] 2. How to register as a self employed sole trader or freelancer (UK: Startups, 2016) <http://startups. co.uk/how-to-register-as-a-self-employed-sole-trader-or-freelancer/> 3. Working for yourself (UK: GOV.UK, 2016) <https://www.gov.uk/working-for-yourself> 4. Register for and file your Self Assessment tax return (UK: GOV.UK, 2016) <https://www.gov.uk/log-infile-self-assessment-tax-return/register-if-youre-self-employed> 5. Help with your Tax Return: Deadlines and Penalties (UK: TaxAid, 2016) <http://taxaid.org.uk/guides/ taxpayers/tax-returns/late-tax-returns> 6. Tax for the self-employed (UK: Which?, 2016) <http://www.which.co.uk/money/tax/guides/tax-for-theself-employed/self-employed-income-tax/> 7. Self-employed National Insurance rates (UK: GOV.UK, 2016) <https://www.gov.uk/self-employednational-insurance-rates> 8. Tax and National Insurance when you’re self employed (UK: The Money Advice Service, 2016) <https://www.moneyadviceservice.org.uk/en/articles/tax-and-national-insurance-when-youre-selfemployed> 9. 10 advantages of running your business as a limited company instead of being self employed (UK: Bytestart, 2016) <http://www.bytestart.co.uk/limited-company-advantages.html> 10. Should I be self-employed or a limited company? (UK: ihorizon, 2014) <http://ihorizon.co.uk/selfemployed-limited-company/> 11. Companies House: About Us (UK: GOV.UK, 2016) <https://www.gov.uk/government/organisations/ companies-house/about> 12. Advantages and disadvantages of limited company formation, (UK: Company Formations, 2015) <https://www.yourcompanyformations.co.uk/blog/advantages-and-disadvantages-of-limitedcompany-formation/> 13. Corporation Tax (UK: GOV.UK, 2016) <https://www.gov.uk/corporation-tax> 14. Business records if you’re self-employed (UK: GOV.UK, 2016) <https://www.gov.uk/self-employedrecords> 15. PAYE and payroll for employers (UK: GOV.UK, 2016) <https://www.gov.uk/paye-for-employers> 16. I’m starting up my first small business. Should I hire an accountant or do my own sums? (UK: This is Money, 2013) <http://www.thisismoney.co.uk/money/smallbusiness/article-2438577/Im-starting-smallbusiness-Should-I-hire-accountant-sums.html> 17. How much do accountants charge? (UK: Ainsworth Accountants, 2013) <http://accountant-prestonlancashire.co.uk/accounting-tax-bookkeeping-services/how-much-do-accountants-charge> [31.10.2016] 18. Information for overseas doctors (UK: Health Careers, 2016) <https://www.healthcareers.nhs.uk/i-am/ outside-uk/information-overseas-doctors> 19. Information for Nurses interested in entering Aesthetics (UK: British Association of Cosmetic Nurses, 2016) <http://www.bacn.org.uk/education/entering-aesthetics> 20. Do you need income protection insurance? (UK: The Money Advice Service, 2016) <https://www. moneyadviceservice.org.uk/en/articles/do-you-need-income-protection-insurance> 21. How much does a website cost in 2016? (UK: Expert Market, 2016) <http://webdesign.expertmarket. co.uk/how-much-does-website-cost> 22. The five minute business ready budget guide (UK: QuickBooks, 2016) <https://www.quickbooks. co.uk/r/business-planning/the-five-minute-business-ready-budget-guide/> 23. James Caan, How to budget for startup success (UK: QuickBooks, 2016) <https://www.theguardian. com/small-business-network/2013/aug/14/how-to-budget-business-startup-success> 24. Sole trader v. limited company: key tax & legal differences (UK: Ross Martin, 2016) < http://www. rossmartin.co.uk/starting-in-business-77750/140-sole-trader-v-limited-company-key-tax-a-legaldifferences> Further reading • Set up a business (UK: Gov.uk, 2016) <www.gov.uk/set-up-business> • Working for yourself (UK: Gov.uk, 2016) <www.gov.uk/working-for-yourself> • Self-employment (UK: RCN, 2016) <www.rcn.org.uk/get-help/rcn-advice/self-employment • Self-employment: checklist (UK: Citizens advice, 2016) <www.citizensadvice.org.uk/work/selfemployed-or-looking-for-work/self-employment-checklist/> • Self-employment (UK: Money Advice Service, 2016) <www.moneyadviceservice.org.uk/en/categories/ self-employment>

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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Front-of-House Selling

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important qualities in front-of-house team members, as is showing an interest in the patient so they feel the clinic cares about them personally; going that one step further can improve patient retention. For these reasons, the skills of front-of-house staff go beyond that of the regular receptionist, who may simply have a meet and greet function or a telephonist who is not customer facing. In order to have a successful front-ofhouse environment, you need to pay close attention to how the staff interact with customers both over the phone and in person, as well as their ability to do administration work. However, one thing that is sometimes not considered is for front-ofhouse staff to take responsibility for selling, which is a lot more important in private practice and can be seen as a low priority in training. This is not surprising, when many practice managers would not consider the receptionist to have a sales role.

Importance of selling

Private medical practitioners and aesthetic clinics are operating in a competitive business environment, and a business owner who fails to understand that will feel the impact on their profitability. It is quite common for practitioners to complain of wasting money on marketing campaigns, when a simple analysis of the results of the campaign may indicate that the failure was not in generating the ads, but rather in converting the leads to consultations. The expectation was that the prospective patient phoning in response to an advert or an internet search would simply book an appointment without questioning the front-of-house staff, who had been ill-prepared to handle anything beyond booking the consultation into the system. In order for an aesthetic business to profit from marketing campaigns, all clinic staff must be well equipped to handle the enquiries, and, to do this, staff must make the connection between the front-of-house responsibilities and business generation. The aesthetic clinic that realises the importance of its front-of-house team in client acquisition and retention will understand that training needs to be an ongoing part of that team’s development, and not simply viewed as a chore for new recruits.

Business development director Victor Fieldgrass discusses the importance of front-of-house staff and advises how to optimise teams for selling in aesthetic businesses The old adage, ‘you never get a second chance to make a first impression’ should be the mantra of all front-of-house staff. The first point of contact with new patients will invariably be by way of phone contact, yet, for many clinical practices, training on the use of the phone often comprises going through the manual, learning what buttons to press to transfer calls, rather than how to deal with the basis of the patient call and how to turn a call into a consultation. This article explains why clinic owners and practice managers need to consider their approach to front-of-house staff management if they wish to optimise in the competitive world of medical aesthetics, and how they can use their front-of-house staff to turn queries into consultations.

Front-of-house staff in aesthetics Similarly to the reception staff working in the NHS, front-of-house staff in aesthetic clinics will have administrative competence, such as phone answering, booking appointments, record keeping and accurate filing of patient records, regulatory compliance, knowledge in patient privacy and Care Quality Commission compliance. However, a good front-of-house staff member working in an aesthetic clinic should also possess certain qualities, such as good communication skills, a background in customer service, as well as familiarity with the products and procedures available at the clinic. Multi-tasking skills are a must and the staff member needs to be able to cope under pressure, which can only be accomplished if they know their job thoroughly. If they are struggling, it presents very unprofessionally to the patient, and also places extra stress when other tasks are waiting to be performed. As well as this, engaging the patient and being courteous are

Training how to sell The amount and type of training provided to front-of-house staff will vary according to the precise role that the staff member has in a particular clinic. Where front-of-house is also responsible for retail sales of, for example, skincare products, the staff need to be well versed in the products, have personal experience of using the products, and have specific training in how to sell the products. Often the product distributors will be able to provide training support. Where the clinic only expects their front-of-house to book appointments for the physician, the training is easier, since the only thing to be ‘sold’ is the consultation. It is not within the receptionist’s skill set, nor job specification, to make any recommendation regarding the procedure that the

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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patient is requesting nor should they propose a medical solution to the patient’s issues. The only ‘solution’ that the receptionist has available to offer is booking a consultation to see the practitioner. To ensure that your front-of-house staff are equipped to turn leads into consultations, sales training is vital. Selling the consultation In order to ‘sell’ the consultation successfully, a receptionist at a medical clinic does not need to be medically qualified, but they do need to have the ability to understand the services being offered in considerable detail. Those with no medical training can project a professional approach if they have a thorough knowledge of the non-medical side of the procedure, for example, the length of the procedure, post-operative issues, aftercare and follow up regime. Their training may involve observing procedures, and even, if indicated, having the procedures themselves so that they have a full understanding of the patient journey to confidently describe the purpose of the consultation and the process that the patient will go through from the moment they arrive through to when they attend a follow up appointment after the procedure. The objective of the training is NOT for the receptionist to recommend the procedure, but they need to be able to talk confidently and provide non-medical information that the prospective patient may require before booking the consultation. The patient who is comfortable that they are talking to an experienced professional is much more likely to book a consultation. In my experience, when it comes to selling, as well as clinic knowledge and the correct manner, it is also important to note that personal appearance, personal hygiene and smiling are all obvious aspects of presenting well and helping with the ‘selling’ aspect. The staff must also be trained in presenting the clinic itself; too often clinic waiting rooms display outdated magazines, an untidy waiting room with dirty cups, and receptionists on their mobile phones; even evidence of a desk-side lunch are not uncommon occurrences. Over the phone As stated above, the phone is generally the first point of contact between the patient and the clinic after they may have seen your clinic’s services online. Showing the receptionist how to book and ‘sell’ a consultation goes far beyond the mechanics of the appointment booking system. For new or less experienced front-ofhouse staff, teaching them to follow a carefully-crafted script is the one way to ensure that incoming calls are handled professionally, competently, and stay compliant within the regulatory framework and the clinic’s local rules. An experienced receptionist may well be able to handle calls efficiently, but a less experienced call handler, without a well rehearsed script, can create a very poor impression of the clinic, and a failure to book the patient in for the consultation. The training starts with showing the staff member how to engage with the patient, by asking questions and finding out more about their condition and the reasons why they wish to have the consultation. The staff member is then able to describe the benefit of the consultation in a way that relates to the personal issues raised by the client/patient. The inquirer may want to know how many sessions they are likely to need, how long the procedure may take and if there are any contraindications that would prevent them from having the treatment. The inquirer will sometimes list a whole series of previous ailments to see if that poses a problem. The difficulty with answering these questions is that the receptionist ends up delivering a mini-consultation, which they are not qualified to conduct, and

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which, even for the practitioner, should not be conducted over the phone. Part of the training for front-of-house is to explain how to re-direct the question. The receptionist cannot keep repeating the mantra, “You’ll have to ask the doctor”, but should be trained to respond with, for example, “The procedure normally takes less than half an hour, but it will vary on a case by case basis, and the doctor will be able to give you a precise answer once they have reviewed your medical history.” Both answers ultimately refer to the doctor, but the second response leaves the enquirer with the feeling that their question has been answered. Often, a patient who is interested in a cosmetic procedure will ask staff the price of the procedure before considering booking a consultation. The receptionist should not be surprised if the potential patient fails to book after the price is quoted, as the enquirer may simply be ‘price shopping’. How to respond to the ‘price question’ is the subject of a whole training module, but as an example, the patient who is price shopping for botulinum toxin, may think that they are looking for the cheapest clinic. In my experience, a well-trained front-of-house staffer who can engage with the enquirer, find out whether they have any concerns about the procedure and explain the benefits of being treated by a well-qualified physician, is more likely to book the consultation than someone who responds, “£175 for one area and £225 for two areas.” In person Selling is mostly about engagement. We buy from people we like. When the patient is in the clinic, it provides an ideal opportunity to sell. But too often, junior or inexperienced staff look at selling as a transaction where money changes hands. For example, “I must remember to offer the patient a skincare product to buy.” There is no harm in that, as long as it is a natural consequence of the patient’s interaction with the physician, but if the patient walks out of a consultation for a breast augmentation, and the receptionist chips in with, “Why don’t you try our new skincare line,” it will just come across as pushy and will make the patient feel uncomfortable. Now compare this with the receptionist who engages with the patient before the consultation, the patient mentions that they will shortly be going on a beach vacation. After the consultation, the receptionist wishes the patient a nice holiday, and follows up with, “Do you want to pick up some SPF before you go?” All good sales must be a winwin. Selling is an art. The artfulness is being able to sell, without the buyer noticing that you are actually selling.

A final message The competitive environment of private medical practice and the wide choice of aesthetic clinics available to the consumer means that the receptionist has to focus on ensuring that new patients phoning in end up booking an appointment rather than ‘taking their business’ elsewhere. Training your front-of-house staff in managing these initial patient enquiries and encouraging them to turn these queries into consultations as well as selling products in-clinic is key to providing the business with an adequate return on investment. Victor Fieldgrass is the business development director at EF MEDISPA and has been involved with training front-of-house personnel since the clinic chain was established in 2006. He has previously held senior managerial positions within international banking where he also developed sales training programmes for financial executives.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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“Seeing patients come back with tears in their eyes after a successful treatment is the most beautiful part of what I do” Professor Daniel Cassuto shares his experiences in teaching, plastic surgery and aesthetics Born in the picturesque Italian city of Livorno in Tuscany, Professor Daniel Cassuto explains he always knew he wanted to be a surgeon. “Being able to treat patients who’ve previously been told nothing can be done to help them is the favourite part of my job,” he says, adding, “Seeing patients come back with tears in their eyes after a successful treatment is the most beautiful part of what I do.” After qualifying with a degree in Medicine and Surgery from the Hebrew University of Jerusalem in 1984, Professor Cassuto underwent plastic surgery training in Jerusalem and Beer Sheva, Israel. “I went back to Italy to practise as a private practitioner, establishing my clinic in Milan in 1999, before also becoming a contract professor and training residents at the University of Catania in Sicily from 2004 to 2010,” he explains. Professor Cassuto then went on to establish a unit within the Modena Department of Plastic Surgery, dedicated to the management of complications associated with permanent fillers. “A colleague of mine, Dr Ovidio Marangoni, found a way of treating them, however he unfortunately passed away after only treating one or two patients so he barely had time to speak about it,” Professor Cassuto explains, noting, “I picked up the system and we can now efficiently remove permanent fillers without open surgery. It takes up a lot of my practice and occupies a lot of my time but we can’t abandon these patients – they are usually neglected and rejected because no one knows what to do.” Once a physician has undergone appropriate training, many treatments are relatively straightforward to perform, according to Professor Cassuto. “Of course, there are a few procedures that you need to learn in more detail but they’re not that complicated,” he says, adding, “I’ve trained a few colleagues around the world – I wish

that there was a trainer in every country who could establish a referral centre and treat theses complications.” Within the past ten years, Professor Cassuto has also developed a successful non-surgical aesthetic practice within his clinic. “About ten years ago we started to see evidence of the diminishing facial bone volume and the study of facial fat compartments in the literature,” he says, continuing, “Until then we just thought that there was skin excess and we had to fight gravity. When I realised this was not the case, I started thinking we have to give back more than just excising – I looked at ways we can abandon the knife for many complaints, yet still improve the appearance of the face.” To achieve this, the role of hyaluronic acid dermal fillers is increasingly important, according to Professor Cassuto. “They are not just space-occupying fillers, they are really improving tissue quality,” he says. “This is why I don’t like the word ‘filler’ anymore, I don’t want to fill, I don’t want to inflate, I don’t want swelling – I want to restore, I want a patient’s tissues to be healthier. A better face shape for my patient is a good by-product, but it’s not my goal. The same way that money should be a by-product of good work, not the other way around,” he adds. Along with international presenting and training commitments, Professor Cassuto continues to run his successful clinic in Milan, which is virtually untraceable to those who don’t already know about it. “I don’t have a website and I don’t advertise anywhere, although 90% of my patients are referred on the internet,” he says, explaining, “I usually refuse to be interviewed in my country as I don’t want it to appear like I’m promoting myself. I think my referrals come through blogs and forums where patients talk to each other.” Rather than finding promotional material when they type his name in a search engine, Professor Cassuto explains he prefers

that potential patients can learn about his expertise and professionalism by finding his publications and presentations online. “My main complaint is that it’s difficult to find a phone number and get hold of me,” he laughs, adding, “I’ve got a waiting list of a few weeks though so it’s okay!” For practitioners new to the specialty, Professor Cassuto advises, “Whenever you’re in doubt, always choose a way in that, if you’re wrong, you will know how to fix it.” In addition, he says, “At the end of every procedure I always think of how I could have done better. There’s no way to go back but it’s a moral imperative to apply those thoughts to the next case – this is how you improve.”

What’s your favourite treatment? My favourite treatment depends on the patient’s face when they see the result. It may be the most boring procedure to perform but if the patient wants to hug you because they’re so grateful, it turns it into the most pleasant one. Do you have an industry pet hate? I think medical education should only be provided by medicallytrained practitioners and scientific organisations. Unfortunately this is not common. Also, there are often too many conflicts of interest associated with trainers and companies and this is not beneficial to the industry. What part of the industry is exciting you most right now? It’s encouraging to see that some companies in the industry are beginning to design their marketing on science, instead of designing their science on marketing, which we have seen too much of so far.

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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The Last Word Dr Emmanuel Elard discusses the importance of standardised photography and debates the issues that surround current clinical photography methods Practitioners regularly use images to demonstrate successful treatment results and market their services to prospective patients. However, we are often criticised for before and after photographs due to the differences in factors such as lighting and angles, which alone, can change an individual’s appearance. Consistency in imagery is not only demanded by the patient, there is also pressure from the industry and media to produce photographs that are transparent and depict the patient without interference from the surrounding environment. This is shown at congresses, where images are often scrutinised, and in press events, where media often argue that many before and after photographs do not show a true comparison. It is my belief that consistency is an integral part of our aesthetic practice, yet, unfortunately, it seems many practitioners do not understand the importance of photography standardisation. Images in aesthetics Photography plays a major role in the everyday lives of aesthetic practitioners, not only in consultations to demonstrate work to new patients, but also in sharing our learning with peers. During consultations, using before and after photographs or videos can help patients to determine a treatment’s quality. As medical practitioners, we need to be able to explain the procedure in detail, noting how a treatment works, as well as manage a patient’s expectation of results. It is essential to have a range of photographs, taken at multiple angles, to do this successfully. Otherwise, how is it possible to reassure patients concerned with losing facial animation following a botulinum toxin procedure if you can’t show them dynamic before and after photographs of your current patients? Another concern is that patients often forget how they looked before treatment, so photographs are useful for making comparisons and demonstrating successful results. For example, I once conducted a dermal filler procedure to correct a patient’s jawline – results were wonderful. However, in the follow-up consultation the patient accused me of creating a lateral

deviation in her chin. I showed her a standardised before video and she could clearly see that her chin was deviated before the procedure. My patient was finally happy, apologised, and I did not face a risk of being sued. Importance of standardisation Standardising photographs or videos would require factors such as the temperature, exposure, lighting, angles and patient positioning in each image to be exactly same every time.1 These must be kept consistent to allow for a true comparison. Although image standardisation is optimal, aesthetic practitioners are not photographers and many do not have the know-how to achieve standardisation. It is also something that can be very time consuming to get correct. There are also cost implications; so many clinics rely on a smartphone with a blank background and judge factors such as the position and lighting to replicate pictures taken prior to procedures, when there are other points to consider. The main concern for a business hoping to implement standardised photography/videography would come with the cost of equipment such as a good quality camera, tripods, a dedicated room with no windows (just artificial light), specific lights, specific software to classify and edit all photographs and team training. While some practitioners may not have the knowledge or facilities to achieve complete standardisation, we have to remember that we are in a connected era – patients are rightfully more demanding about information and evidence following procedures and clinics must react accordingly. Certain parameters can be achieved through costfree ways including phone apps such as Teoxane Aesthepics Premium and Allergan Face to Face that can produce standardised patient positioning. However, to achieve a completely standardised image, business owners can choose to invest in technology that uses a motorised device to travel around a patient with the same background and lighting, producing standardised photographs and videos with consistent light, temperature,

shadows, patient positioning and angles, producing much more consistent results. I believe practitioners have a responsibility to become knowledgeable in this area and understand or invest in technology that allows them to take before and after photographs that are as consistent as possible. What needs to be done There is a lack of official guidance mentioning patient photography. However, some associations such as the BAAPS, recommend that photographs should be taken for all patients undergoing aesthetic medical procedures and that they should be standardised where possible.2 However, declaring that practitioners must adhere to a set standard of imagery is something I feel most people would welcome from an ethical standpoint. Set legislation, requiring clear photographic or video evidence pre and post treatment, could help monitor inadequate practice, improving the reputation of aesthetic practitioners as a whole. It is also my opinion that photographs are not enough – I feel that pictures only tell half the story and clinics should consider video logs to better show the movement and dynamic results of a treatment. We need to be able to restore harmony of the moving, expressive face and, for this, we need a moving reference point. While new regulation is never going to be quick and easy to implement, I believe standardised photography is a vital step forward for our industry and every practitioner must do their best to ensure that their photographs are as consistent as possible. It will help us as medical professionals to communicate an achievable outcome with patients, while improving transparency within the relationship and creating a clear record of the patient journey. Disclosure: Dr Emmanuel Elard is the founder of Next Motion, photographic technology for aesthetic clinics. Dr Emmanuel Elard has a clinic in Paris and is a specialist in antiageing and aesthetic medicine, with specific experience and knowledge in injectable and laser procedures. He obtained his MD at the Faculty of Pitié-Salpetriere in Paris, then IUD of aesthetics and antiageing medicine in Lyon. REFERENCES 1. Dayan SH, Ashourian N, ‘Considerations for Achieving a Natural Face in Cosmetic Procedures’, JAMA Facial Plast Surg, (2015). 2. BAAPS, ‘Code of Conduct’, The British Association of Aesthetic Plastic Surgeons, <http://baaps.org.uk/baapsmedia/docs/ code_of_conduct.pdf>

Reproduced from Aesthetics | Volume 4/Issue 1 - December 2016


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1. Raspaldo H. J Cosmet Laser Ther. 2008;10:134-42. 2. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167–172. 3. Callan P et al. A 24 hour study: Clin, Cosme and Investig Derm, 2013. 4. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147-58. 5. Jones D et al. Dermatol Surg. 2013;1–11. UK/0721/2015

Date of Preparation: October 2015

Aesthetics December 2016  

EVOLUTION