Aesthetics February 2015

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Contents • February 2015 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month 16 Aesthetics Conference and Exhibition 2015 A comprehensive roundup of all on offer at the highly anticipated ACE 2015, taking place next month

CLINICAL PRACTICE 19 Special Feature: Raising Standards Allie Anderson explores the different mediums and methods

of aesthetic training on offer in the industry today 24 CPD Clinical Article Consultant nurse practitioner Constance Campion-Awwad on using advanced skin procedures with skin of colour 28 Treating Rosacea Dr Daron Seukeran outlines the latest treatments and methods for managing rosacea 33 Infraorbital Rejuvenation Dr Kieren Bong on rejuvenation of the infraorbital region using hyaluronic acid fillers 39 Clinic Study: Interleukin-1 alpha Dr Peter Schoch and Dr Igor Pomytkin present their cosmetic study on collagen disposition and elasticity in ageing skin 43 Upper Eyelid Dermatochalasis Miss Jane Olver addresses the treatment of sagging eyelids 48 The Role of Moisturisers Lorna Bowes, Dr Sandeep Cliff and Dr Jenna Burton investigate the role of moisturisers in aesthetics 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 56 Team Building Mark Tager shares his advice on building and maintaining an effective workforce 59 Skin Health Programmes Jane Lewis highlights benefits of providing your patients with long-term skin programmes 61 Removing Doubt Online Paul Jackson illustrates the best ways to ensure those hesitant online visitors pick your clinic 64 Introducing Retail Alana Marie Chalmers shares her tips on incorporating retail into your practice 66 In Profile: Dr Arthur Swift We talk to esteemed practitioner Dr Arthur Swift about his extensive career in aesthetics 68 The Last Word: Consent Adrian Richards and Dr Natalie Blakely argue for improving methods of consent

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Treatment Focus Upper Eyelid Page 43

Clinical Contributors Constance Campion-Awwad is an aesthetic nurse practitioner, with more than 25 years of experience. A partner of Plastic Surgery Associates, she pioneered the use of a 7-point skin analysis method in 1989.

Dr Daron Seukeran is a consultant dermatologist at the James Cook University Hospital, Middlesbrough, with an interest in laser surgery. He is also the medical director of the SK:N Laser Clinics in Harley Street and Maida Vale in London.

Dr Kieren Bong is trained in both medicine and surgery, combining his creative talents with his scientific, medical aptitude to provide natural and refined aesthetic results for his patients.

Dr Bong lectures in cosmetic dermatology.

Dr Peter Schoch is head of research and development and regulatory affairs at United Cosmeceuticals GmbH. He has a PhD in chemistry and was previously vice-director for pharmaceutical project development at F.Hoffmann-La Roche.

Dr Igor Pomytkin created Dermatopoietin and is the owner of numerous other patents.

He has a PhD in chemistry and is the science director of Buddha Biopharma Oy, Helsinki, Finland.

Miss Jane Olver is a consultant ophthalmologist and oculoplastic surgeon specialising in eyelid surgery. She is the medical director and founder of Clinica London, a private eye clinic located in central London.

Lorna Bowes is an aesthetic nurse and trainer.

With extensive experience of delivering aesthetic procedures, Lorna trains and lectures regularly on procedures and business management in aesthetics. Lorna is director of Aesthetic Source.

Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation.

Dr Jenna Burton is an aesthetic practitioner working between the UK and Dubai. After founding her company ‘Prescribing Beauty’ in 2012, she is now working towards her American Medical Board Specialist Status.

NEXT MONTH • IN FOCUS: The Patient Experience • CPD: Weight Loss • Anatomy of the Eye • The Art of Sharing Knowledge

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

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Editor’s letter With the year now in full swing, time has flown by here at Aesthetics and now we find ourselves at the periphery of the Aesthetics Conference and Exhibition (ACE) 2015. Next month, both UK and international practitioners and exhibitors will descend on the Business Amanda Cameron Editor Design Centre in Islington, London, to experience this year’s very first UK aesthetics conference. Tickets continue to sell fast, so I wholeheartedly encourage you to book your place now. As you will know from reading our exclusive features in the journal over the past couple of months, we have taken a different approach to this year’s event. We have curated the format and content of ACE 2015 based exactly on the feedback we garnered from you, the Aesthetics audience. That is why ACE 2015 will eschew the usual formal lecture model in favour of interactivity, virtual clinic settings and a multimedia method of delivering content. What’s more, you can book one session or all – entirely dependant on what fields are of benefit to you as a practitioner. Practical, hands-on training is the name of the game.

One of the sessions I am very much looking forward to is the ACE 2015 Question Time. Last year’s discussion was a huge success, and

with such a diverse panel this year, ready to answer all your burning issues, we expect a good dose of stimulating debate – I would strongly advise securing this date in your diary.

You will be aware that training and development is an area that we like to focus on, and this month’s issue is dedicated to the topic.

Both the journal and ACE are designed to provide you with the latest information on educational developments. Training standards and recommendations formed a large part of the Keogh report, and we hope to continue to play our part in making aesthetic medicine a safer speciality for all patients and practitioners.

In this spirit, our Special Feature this month is dedicated to exploring the different modes and methods of training available to aesthetic practitioners in 2015 (p. 19). In this issue we were also lucky enough to interview the esteemed Dr Arthur Swift for our regular In Profile slot. In the run up to ACE 2015, where Dr Swift will be presenting at the Merz Aesthetics Education & Demonstration Zone, he tells us about his enthusiasm for educating and entertaining in unison (p. 66).

As an industry and speciality, we cannot give continued education and thorough training enough attention. Tell us what you think about this hot topic by emailing editorial@aestheticsjournal.com or tweeting us @aestheticsgroup.

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Tapan Patel is the founder and medical director of VIVA

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

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

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

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

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

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Talk Aesthetics #Support the cosmetic couch / @CosmeticCouch Talking about (cosmetic) patient safety is not enough. Doing something (independent) and constructive helps. #YourSupportCounts #Survey Aesthetic Society / @ASAPS Make your work in 2014 count by completing the ASAPS 2014 statistics survey. #ACE2015 Dr Saira Vasdev / @DrSairaVasdev Looking forward to ‘Face off’ and ‘Getting into the zones’ sessions on facial aesthetics #neverstopimproving #ACE2015 @aestheticsgroup #Results Dr Stefanie Williams / @DrStefanieW If you do what you have always done, you will get the results that you have always had! #BodyCountouring Fulvio Urso-Baiarda / @MrUrsoBaiarda Looking forward to a great day teaching on body contouring @ royal college of surgeons today #Education Health Ed North East / @HealthEd_NE Being a strong academic is key to being a medic but equally as key to have experience in a caring environment & good comm skills #HeneEdEd #Profession Dr Ravi Jain / @DrRaviJain Looking forward to meeting some great colleagues in Barcelona today!! #lifeofanaestheticdoctor To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com Survey

Survey reveals women prefer to have a youthful face than a youthful body A survey of US women, aged 21 to 65, conducted on behalf of Allergan by Wakefield Research, has shown that nearly 60% would rather have a youthful face than body. The survey also revealed that 44% of respondents believed that there was nothing they could do about lost volume to the face, although 64% noted that the shape of their face has changed as they have aged, and 44% have noticed a decrease in cheek volume or fullness in the past 10 years. US dermatologist Dr Heidi Waldorf said, “My patients often come to see me about a variety of concerns, including sunken, hollowed out cheeks. What they may not realise is that the problem is caused by age-related volume loss.”

Aesthetics Journal

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Industry

Actavis and Allergan announce early termination of waiting period for pending acquisition The US Federal Trade Commission (FTC) has accepted Actavis and Allergan’s request for early termination of their acquisition waiting period. The termination will allow Actavis to acquire Allergan much sooner than expected. The Hart-Scott-Rodino Antitrust Improvements Act 1976 (HSR Act) prevents parties from completing certain mergers, acquisitions or transfers of securities or assets without first making a detailed filing with the FTC. The global pharmaceutical companies had previously filed pre-merger notification and report forms with the FTC on December 1. At the end of December, Actavis voluntarily withdrew and subsequently re-filed these forms, resulting in the permission for early termination.

The companies have further announced that the close of business on January 22 will be the record date for determining the shareholders that will be entitled to vote at their respective Special Meetings, being held in connection with the pending acquisition.

The date, time and location of each Special Meeting are still yet to be announced.

The $66 billion purchase of Allergan by Actavis was confirmed during November 2014 after an uncertain period that saw Allergan battling offers from rival company Valeant.

Training

Aesthetic Business Transformations launches marketing training Aesthetic Business Transformations has launched an online marketing training programme for aesthetic businesses. The 6D Patient Attraction System was designed in response to a survey of more than 200 aesthetic business owners that asked participants to describe their top two marketing challenges.

Founder of Aesthetic Business Transformations Pam Underdown explained that she used the responses, as well as tried and tested marketing strategies, to create the training programme. The 6D Patient Attraction System aims to dispel myths surrounding effective online and offline marketing, teach business owners strategies that will improve their marketing skills, and detail how to achieve a higher return from marketing spend. According to Underdown, the system will help both start-up and established aesthetic businesses focus their marketing efforts and retain patients. She said, “The 6D Patient Attraction System will teach you the essential lessons of marketing and business development, and how to avoid the all too common pitfalls. I have designed the training programme to be as easy to follow as possible, whilst being accessible from home or work at a time that suits you.” Workbooks, downloads, templates and additional support are available. There is also a weekly coaching session available for business owners wishing to fast-track their results.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Aesthetics

Trends

ACE

Open rhinoplasty deemed 2014’s fastest growing surgical trend New statistics show expected treatment and procedure trends for 2015, based on research conducted by private healthcare search engine WhatClinic.com. The study has highlighted which treatments received most enquiries on the website and what treatments were undertaken during 2014. It also predicts aesthetic procedure trends for 2015.

In 2014, open rhinoplasty enquiries increased 1200%, making it the fastest growing procedure last year, whilst nasal tip surgery saw an increase of 763%.

Enquiries for mini-facelifts have also dramatically increased (1006%) in the past twelve months, despite the higher price for the procedure compared to other facial rejuvenation treatments.

WhatClinic.com has now predicted that 2015’s trends are set to be neck liposuction, body-jet liposuction, vaginoplasty and chin implants. Each of these procedures received over 100% increase in queries during the last quarter of 2014. Breast augmentation received the second highest volume of enquiries in the last twelve months, whilst muscle implants were the least sought-after procedure, with queries dropping by 69%.

Emily Ross, director of WhatClinic.com, said, “The cosmetic surgery and injectables market in the UK is expected to be worth as much as £3.6 billion in 2015. Not only is the market huge – it’s growing at a phenomenal rate. With demand so high, it is crucial that patients have access to information about the credentials and qualifications of their chosen practitioner.”

Lasers

Study shows longer wavelength laser is effective in treating keratosis pilaris A study conducted by Northwestern University (US) has shown that treating keratosis pilaris with a longer wavelength laser is effective in dealing with skin roughness and irregularity of texture, although it has little effect on erythema (redness). Keratosis pilaris, a common skin condition that causes rough skin and the appearance of permanent ‘goose pimples’, is often resistant to treatment.

Shorter wavelength lasers used to treat the erythema associated with the condition reportedly do little to treat the textural irregularities, and the aim of the study was to see whether a longer wavelength laser would be more effective overall.

18 outpatients took part in the study over a seven-month period. All were diagnosed as having keratosis pilaris on both arms and were of Fitzpatrick skin type I to III. A randomised selection of patients were treated with the 810-nm pulsed diode laser on either the right or left arm. The procedure was repeated twice for a total of three treatments, four to five weeks apart.

The primary outcome measure was the difference in disease-severity score, including erythema and skin roughness/irregularity between the treated and control sites, with each graded on a scale of zero (least severe) to three (most severe).

Two blinded dermatologists rated the sites 12 weeks after the initial treatment. At follow-up, the blinded raters assigned a 2.0 median redness score for both the treatment and control sides. The median roughness score was 1.0 for the treatment sides and 2.0 for the control sides. The median overall score combining erythema and roughness/textural irregularity was 3.0 for the treatment sides and 4.0 for the control sides. The authors concluded, “Complete treatment of erythema and texture in keratosis pilaris may require diode laser treatment combined with other laser or medical modalities that address redness.”

One month left to register for ACE 2015

There is only one month left to register for free for the Aesthetics Conference and Exhibition (ACE), taking place on March 7-8. Included in the free exhibition registration is access to a huge range of live demonstration Expert Clinics.

Presented by chosen leading practitioners, these sessions will provide invaluable treatment guidance for a range of treatments spanning the field of medical aesthetics. Also included in the free registration are the ACE Masterclasses.

These sponsored sessions will provide valuable tips for achieving the best patient outcomes.

Free access to Business Track, sponsored

by Church Pharmacy, will in addition offer unbeatable practice and commercial guidance from business experts. Delegates will also have the opportunity to meet more than 100 aesthetic suppliers at the ACE Exhibition. Made up of four key sessions, the main Conference programme will offer delegates expert guidance, treatment demonstrations and professional discussion on fat, injectables and aesthetic dermatology. Based in a virtual clinic setting, these sessions will allow delegates to follow patient journeys, watch best practice demonstrations and interact with worldleading speakers through the latest conference technology. Delegates can book single main conference learning modules and are entitled to discounts if multiple sessions are booked.

With an easy-to-access central London location – the Business Design Centre, Islington – ACE is the ideal place to learn from some of the top practitioners in the profession. ACE 2015 is the first UK medical aesthetics event of the year, putting those in attendance in the perfect position to be up-to-date with the latest techniques and technologies early in the year.

See our ACE overview on pages 16 and 17 for more information. Register today at www.aestheticsconference.com

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Acne

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Psoriasis

Bellafill becomes first dermal filler to receive FDA approval to treat acne scars Bellafill, a polymethylmethacrylate collagen filler manufactured by Suneva Medical, has become the first filler approved in the US for the treatment of acne scars. The Food and Drug Administration (FDA) approval of Bellafill was based on the outcomes of a double-blind, randomised, placebo-controlled study in which subjects were treated with the filler at ten US clinical centres. Upon assessing the results of this study, along with other relevant studies, the FDA concluded that Bellafill was proven to be safe and effective for the correction of moderate to severe, atrophic, distensible facial acne scars on the cheek in patients over the age of 21 years. Chairman and CEO of Suneva Medical Nicholas L Teti Jr said, “The results of this rigorous clinical study prove that Bellafill reduces the appearance of acne scars – providing a solution to this widespread skin condition that previously had limited treatment choices. Bellafill can have a transformational effect on a patient’s appearance and, in turn, we hope an improvement in quality of life.”

Business

CoachHouse Medical partner with Merz to market Ultherapy in the UK and Ireland Following Merz Aesthetics’ takeover of Ulthera in 2014, CoachHouse Medical has announced that it is to work in partnership with Merz to promote Ultherapy in the UK and Ireland. As of January 5, Merz Aesthetics has full responsibility for the sale and marketing of all Ulthera products, however, CoachHouse Medical will work with Merz to offer continued business support to Ultherapy customers, along with technical support and training. Merz Aesthetics will satisfy all orders for Ultherapy transducers and hardware. James Backhouse, managing director of CoachHouse Medical, said, “There is significant investment being made in developing Ultherapy in the UK and in supporting you to develop your Ultherapy practice. CoachHouse Medical will of course provide all the necessary support to you, our customers, and Merz Aesthetics in making this transfer a smooth one.”

Skincare

Study confirms SEPITONIC M3 increases cutaneous oxygenation

LEO Pharma submit NDA for plague psoriasis aerosol Danish pharmaceutical company LEO Pharma has submitted a New Drug Application (NDA) to the Food and Drugs Administration (FDA) for an aerosol foam formulation to treat plaque psoriasis. This is the first aerosol treatment for plaque psoriasis and contains a fixed combination of 0.005% calcipotriene and 0.064% betamethasone, which aims to improve the treatment of patients with the condition. President and CEO of LEO Pharma Barbara J. Osborne said, “Psoriasis is a chronic, debilitating disease. Patients with inadequately managed plaque psoriasis can experience the substantial burden of illness, with similar reductions in quality of life to those experienced by patients with diabetes or cancer.” Regulatory filings in Europe and other countries are planned during the course of 2015 and 2016.

Topical

Environ introduces Après CIT Environ, distributed in the UK by skincare distribution company iiaa, has launched a new serum designed specifically for use in conjunction with skin needling treatments. Après CIT (Cosmetic Intensive Treatment) is a serum that contains a blend of three peptide complexes: Matrixyl Synthe 6, Matrixyl 3000 and Trylagen, which the manufacturer claims supports the cutaneous repair process and signals the skin to produce more collagen, elastin and glycosaminoglycans. Après CIT is designed to be used on the face, neck or decolleté immediately after treatment with 1-3mm long needles. Environ recommends that any unused serum should be taken home by the patient and applied twice daily to maximise the effects of skin-needling treatments.

The results of a new clinical study conducted by SEPPIC, manufacturers of SEPITONIC M3, support the company’s claim that the antioxidant agent increases oxygenation to the skin. According to data released by SEPPIC, results of the in vivo test on 30 volunteers showed an almost 10% increase to the skin’s partial pressure of oxygen after two hours of treatment. After 28 days, 76% of participants showed visible effects, with deep wrinkles reduced by 7% on average and skin texture improved by 5%. Yohanna Sander, head of Active Anti-Aging Products at SEPPIC, said, “For SEPPIC, this study reinforces the benefits of SEPITONIC M3 that have already been demonstrated at a cellular level. Its three main targets are the mitochondria, glycation and cellular communication. Acting deep down, it supports the skin at any age. It is recommended for anti-ageing, anti-pollution, vitality, prevention and protection concepts.”

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Question Time

Have your questions answered at ACE 2015 The Aesthetics Conference and Exhibition (ACE) offers delegates an exclusive chance to have their questions answered by a panel of industry leaders.

The ACE Question Time session, sponsored by 3D-lipo, will give attendees the opportunity to engage in debates with a range of aesthetic professionals, who will discuss various industry issues put forward to them via questions asked by you, our readers.

The event will take place on Saturday March 7, following the close of clinical and business sessions in the ACE programme.

Chaired by former BBC presenter Peter Sissons, the board will consist of Health Education England’s Carol Jollie, international aesthetics business expert Wendy Lewis, and renowned cosmetic surgeons Mr Dalvi Humzah and Mr Paul Banwell. British College of Aesthetic Medicine (BCAM) president Dr Paul Charlson, and British Association of Cosmetic Nurses (BACN) chair Sharon Bennett, will also join the expert panel. This invaluable opportunity to challenge leading experts and industry insiders on relevant and current issues within the profession is not to be missed.

To put your question to the panel, email editorial@aestheticsjournal.com.

To register free for ACE 2015 visit www.aestheticsconference.com

Aesthetics

Vital Statistics Enquiries for mini facelifts have risen 1006% in the past 12 months WhatClinic

75% of women who underwent autogolous breast reconstruction surgery were satisfied with their results Journal of American Society for Plastic Surgeons

In a survey, 43.3% said that being told they looked younger than their age was a top reason for feeling good Transform Cosmetic Surgery Group

36% of women want to know more about the safety of Botox

Botulinum toxin

Study shows no significant difference from deeper injections when correcting eyebrow asymmetry A new study has disproved the popular theory that deeper injections will have more effect when treating eyebrow asymmetry using botulinum toxin. During the study, which was carried out by a team from the University of British Columbia in Vancouver, Canada, researchers performed splitface injections on 23 women with eyebrow asymmetry. Identical amounts of drug and injection locations were used on both sides, but deeper injections were administered on the side where a greater lift was needed.

Photographs and evaluation of brow height were conducted at baseline and at four weeks post-treatment.

According to the researchers, the analysis showed no significant difference in the change in brow height over four weeks between the two sides.

The study’s authors have suggested that the diffusion of botulinum toxin between muscle layers precludes accurate targeting of the muscle belly, where the drug would theoretically have the most effect. Lead author Dr Jason Sneath, FRCPC, said, “Although we had not documented that a deeper injection was more effective, we presumed that delivering more botulinum toxin to the belly of the corrugators might weaken these muscles to a greater extent, thereby allowing the brow elevating frontalis to lift the medial brow more.”

SheSpeaks

60% of women aged between 20-65

surveyed said they’d rather have a more youthful-looking face, than a more youthful-looking body Wakefield Research

Last year over one billion was spent on liposuction in the US nationwide The American Society for Aesthetic Plastic Surgery

18% of women are concerned that their face will not look natural after treatment with Botox SheSpeaks

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Events diary 7 - 8 March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com th

th

26th - 28th March 2015 13th Anti-Aging Medicine World Congress, Monte Carlo www.euromedicom.com/amwc-2015/ index.html 27th - 25th June British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 2015, Bruges www.bapras.org.uk 7th - 9th July 2015 British Association of Dermatologists Annual Meeting 2015, Manchester www.bad.org.uk

Aesthetics Journal

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Anatomy

Facial Anatomy Teaching poster presented at BACA Meeting Consultant plastic surgeon Mr Dalvi Humzah and nurse practitioner Anna Baker presented their Facial Anatomy Teaching poster at the British Association of Clinical Anatomists’ (BACA) Winter Scientific Meeting, Bristol, on 8 January. Their poster, ‘21st Century Anatomy: A Bespoke Teaching Model for Non-surgical Aesthetic Practice’, outlines the key components and concepts that underpin their award-winning facial anatomy teaching model. Of the meeting, Baker said, “The calibre of speakers and presentations was extremely high and covered a plethora of anatomical specialties, with engaging audience discussion throughout.” Baker explained that the poster’s content drew the interest of BACA board members, who were particularly interested in discussing the senescent changes analysed in the facial skeleton, as well as the overall concept of their independent teaching. The poster abstract will be published in the Journal of Anatomy later this year.

Clinic

Dr Roger Amar opens FAMI clinic in London

Dermatology

Epionce founder wins dermatology award Founder and CEO of the Epionce skincare line Dr Carl Thornfeldt was presented with the Innovators in Dermatology award at the recent Cosmetic Surgery Forum in Las Vegas.

Dr Thornfeldt has been a practising clinical dermatologist for more than 30 years and created the Epionce line in 2002. He said, “It is an honour to have been chosen for the Innovators in Dermatology award. My first priority has always been to ask the question – ‘What is best for my patients?’

This award acknowledges the dedication and sacrifices that have brought me to this point in time. I am grateful to the Cosmetic Surgery Forum course director, Dr Joel Schlessinger, for recognising these efforts.”

Founder of the FAMI (Fat Autograph Muscle Injection) Lift Dr Roger Amar has opened a clinic specialising in the treatment. The London FAMI Clinic will specialise in his FAMI technique, offering London patients a treatment which Dr Amar claims is safer and produces a longer-lasting and more natural result than HA fillers or other volumising treatments. The FAMI technique involves grafting stem cells from body fat and injecting them into the facial muscles and bones, using patented cannulae developed specifically for the purpose. “We have more and more UK patients asking for the FAMI Lift,” said Dr Amar. “As London is a hub where the Americas meet Europe and Asia, we hope that this London clinic could become a global teaching centre for the FAMI technique.”

Masterclasses

Industry giants to host Masterclasses at ACE 2015 Global healthcare and pharmaceutical companies, Allergan, Galderma and Sinclair IS Pharma will host Masterclass sessions at this year’s Aesthetics Conference and Exhibition (ACE). Each session will provide delegates with key advice from industry leaders sharing their techniques and product expertise. Allergan will host two injectable Masterclasses over the weekend, where key opinion leaders will demonstrate optimum outcomes with the Allergan range, which includes Botox and Juvéderm.

Saturday morning will see Sinclair IS Pharma hold a comprehensive session on their product portfolio, while Sunday afternoon will feature a class from Galderma offering guidance on their wide range of products. Held in central London, 7-8 March, these Masterclasses are just a few of the exclusive sessions and learning opportunities offered at ACE 2015.

To find out more and register visit www.aestheticsconference.com

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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@aestheticsgroup

Aesthetics Journal

Aesthetics

Competition

American Society of Dermatologic Surgery announces winners of writing competition The American Society of Dermatologic Surgery (ASDS) has announced the winners of its 2014 Young Investigators Writing Competition. The annual contest aims to recognise research conducted by younger ASDS members and the winning manuscripts will be published in Dermatologic Surgery, the official journal of ASDS. The 2014 winners included Dr Andrea F Chen, who conducted research into Mohs micrographic surgery; Dr Daniel P Friedman, who wrote a report into the aesthetic treatment of abdominal subcutaneous adipose tissue; and Dr Jared Jagdeo, whose manuscript discussed the inhibition of keloid fibroblast proliferation. As well as publication in the journal, winners receive free registration for the ASDS Annual Meeting, including a travel and accommodation bursary. “Research is an important mission at ASDS,” said ASDS president Dr George J. Hruza. “The Young Investigators Writing Competition is just one of our many efforts to foster, support, develop and encourage investigative knowledge in dermatologic surgery.”

Poll

New poll reveals Glasgow most honest about aesthetic procedures A new poll of 200 patients from cities around the UK has found that Glasgow is the UK’s most open city when admitting to undergoing aesthetic treatment to partners.

Conducted by The Good Surgeon Guide, the survey further revealed that Londoners were the least likely to admit to having cosmetic surgery, with Manchester second least likely. Bristol was announced as the second most honest city in the poll, highlighting no geographical split in terms of honesty trends regarding the procedures. Edinburgh placed third, further showing that the higher rates of people telling their partners about procedures was not isolated to the Scottish region. Christiana Clogg, managing director at The Good Surgeon Guide, said, “We were fascinated by the results of this poll which show that attitudes and openness about cosmetic surgery vary from region to region.”

She added, “It’s clear that, for many, cosmetic surgery is still a private and personal choice and not something that a partner should necessarily know about. This is often the case with smaller procedures like liposuction and fillers.”

App

New app launched to identify skin issues A free app launched as ‘Skinstamatic’ is working with dermatologists to analyse images of skin issues posted by consumers. The medical information technology company behind the app, SkinPhotoTextMatch Inc, claims to be the first to use the gamified collective intelligence engine (GCIE) of a Professional Board of Advisors (consisting of board-certified dermatologists, dermatology residents and dermatology physician extenders) to identify a variety of skin conditions in submitted photos.

Once posted, the board indicates what they collectively believe are the top two skin conditions that best identify the image, whilst the app then directs users to the nearest available clinics for confirmation. The app further provides information on these conditions, and refers users to WikiskinAtlas, a skin textbook created by Skinstamatic’s board of dermatologists. The app then invites users to join forums and blog discussions to enhance their understanding of the skin condition.

60

Steve Joyce, director of marketing and business development at Healthxchange Pharmacy Tell us about the new Healthxchange Academy The new training academy in Manchester has been developed to deliver CPD-accredited product and business training using the latest technology and dedicated clinical facilities.

It forms part of our comprehensive programme of training for products like the Obagi® skincare range, INTRAcelTM RF microneedling and the AQUALYX® fat dissolving solution.

Why are you focusing on training?

Lifelong learning, quality training, outstanding facilities, leading products, patient care and a commitment to CPD are the cornerstones of our new Academy. These areas underpin professional standards upheld by the industry; not least the need for doctors to show CPD as part of their revalidation. Our training and ongoing support gives delegates the means to be successful commercially and clinically, developing and refining their skills to offer patients more choice and improved treatment outcomes.

What makes your training different?

Take our award winning Obagi® products for example; we run workshops which cover the fundamentals of skin health, explaining how Obagi® works, how it is integrated into treatment protocols and identifying where Obagi® should be used clinically once introduced into your practice. However, we also offer further advanced training in specific areas of the Obagi® range which gives attendees hands-on experience using the products and can learn the art of patient consultations, combining Obagi® with other treatments in your clinic, marketing advice and consultation days.

How do you see the future of aesthetic training?

As more practitioners undertake training to fulfil CPD needs or learn about new treatments and technologies, the standard of training will continue to improve as providers develop syllabuses which better reflect the needs of medical professionals.

With technological advances, more content will be delivered online and via interactive channels such as video, animations, and simulators. As we move from chalk to computer to virtual reality, the underlying core values of relevant, engaging, CPD approved training will endure.

This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

@aestheticsgroup

News in Brief Dermagenica join charity scheme Distribution company Dermagenica has partnered with the Global Giving Initiative to provide aid to children in Africa. As part of the Buy One Give One (B1G1) scheme, Dermagenica will donate the equivalent of a client’s purchase to the charity. For every packet of Vitamins A or C bought, one packet will be sent to Africa, and, through the purchase of one serum, consumers can provide a year’s access to clean water for a child in need.

Episciences Europe opens practical training centre in Poland Skincare company Episciences Europe has opened its first practical training centre in Dietl University in Krakow, Poland. Epionce products will be used by students enrolled on the university’s Cosmetology degree course to enhance their understanding of the science behind skincare. The course, which covers microdermabrasion, IPL and laser training, is designed specifically for students hoping to work in medical aesthetics.

Skinceuticals UK appoints RKM Communications L’Oréal award-winning advanced cosmeceutical brand, SkinCeuticals, has announced the appointment of RKM Communications to handle their PR. The skincare company provides cosmeceuticals for aesthetic practitioners across the industry. Chairman of RKM Communications Robert Montague said, “It is an absolute privilege to be appointed by an iconic brand like SkinCeuticals to manage their PR. SkinCeuticals are at the very forefront of the cosmeceutical market and lead the way in science-backed skincare.”

Model Sophie Anderton is new face of Perfectha Supermodel Sophie Anderton has been named as the new face of Perfectha dermal fillers. Anderton, who first rose to fame as a model aged 18, says that her gruelling schedule has taken its toll on her skin and claims that Perfectha helps her to maintain a youthful appearance. Perfectha is a cross-linked hyaluronic acid gel filler, distributed by Sinclair IS Pharma.

Aesthetics Journal

Aesthetics aestheticsjournal.com

Dermal filler

New study indicates improved longlasting efficacy in nasolabial folds treated with PCL filler A recent study has found that patients with nasolabial folds (NLFs) treated with a novel biostimulatory polycaprolactone (PCL)-based dermal filler may see improved long-lasting efficacy in comparison to treatment with non-animal stabilised hyaluronic acid (NASHA)-based fillers. The study, published in the Journal of Cosmetic Dermatology, was conducted by researchers at the United Arab Emirates University in Al Ain, where colleagues studied 40 patients in a randomised split-face study, in order to compare a novel PCL-based dermal filler with a NASHAbased dermal filler. Factors measured included comparison of the safety, efficacy and duration of cosmetic corrections for the treatment of NLFs. According to the researchers, results implied that NLFs treated with the PCL-based dermal filler statistically showed significant improvement in the appearance of wrinkles, measured on the Wrinkle Severity Rating Scale, and also on the Global Aesthetic Improvement Scale, at six, nine and 12 months post-treatment. However, in terms of safety and tolerability, the products were both found to be equal. Dr Hassan Galadari and his team wrote, “Our results suggest that PCL-based dermal fillers offer longer-lasting performance over NASHA-based dermal fillers in NLFs treatment.”

Industry

BBC investigation culminates in 12-month ban for Harley Street aesthetic doctor A Harley Street doctor has been suspended for 12 months following a BBC investigation and subsequent Medical Practitioners Tribunal Service (MPTS) hearing that found the doctor to have acted ‘dishonestly’. The MPTS has further imposed an immediate order of suspension to cover the 28-day appeal period. The BBC reports that Dr Mark Harrison, director of Harley Aesthetics, authorised nurses to perform procedures by speaking to them via telephone, despite the fact that the laws at the time stated that this should only be done in exceptional circumstances. Since the investigation, under new guidance from the GMC, doctors are now banned from prescribing botulinum toxin by phone, email, video-link or fax.

Dr Harrison was first exposed by an undercover BBC London investigation in July 2012, to which he initially denied wrongdoing, but later received an interim suspension immediately following the investigation. Of the recent hearing, MPTS Panel chair Dr Janet Nicholls said, “The panel has determined that his misconduct is serious, wide-ranging and included dishonesty.” The materials from the BBC investigation involved secret footage taken by an undercover nurse, posing as a trainee in Dr Harrison’s introduction to Botox course, and phone recordings from undercover researchers. This evidence showed Dr Harrison instructing nurses to use Botox on a patient even though it had been prescribed for someone else. Commenting on the news, aesthetic doctor Dr Vincent Wong said, “Botulinum toxin injections can cause serious damage in the wrong hands, hence it is really important that patients are assessed by doctors or other prescribers before being injected by a trained practitioner.” Dr Tamara Griffiths, consultant dermatologist for the British Association of Dermatologists, added, “This story highlights probity issues and poor practice which plague the aesthetic sector. Clear guidance defining “adequate supervision” for those who delegate procedures is required. It is high quality training and education, combined with the regulatory power to eradicate poor practice, which will drive standards forward for patients and the public.” Dr Nicholls said, “Suspension is a serious sanction and the panel is satisfied that it sends out a signal to Dr Harrison, the profession and the public about how seriously the panel views Dr Harrison’s misconduct.”

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Dermatology

London-based private practice offers dermatology preceptorship programme for registrars The London Skin and Hair Clinic in Central London offering a oneday Dermatology Preceptorship to current dermatology registrars.

The programme enables registrars to enhance their medical knowledge on how to diagnose and treat skin by bridging the gap between their theoretical and public healthcare training with private practice experience, covering medical laser treatments and aesthetic dermatology concerns. Previously, trainees would experience little practical exposure to laser treatment, aesthetic dermatology and private practice. This new practical programme aims to provide training dermatologists with valuable knowledge and hands-on education. Dr Tony Downs, consultant dermatologist and laser lead at The London Skin and Hair Clinic, said, “Private practice only forms a small part of their training and is mostly theory based. We are giving these doctors an opportunity to spend a series of days shadowing dermatology consultants in private practice, who are already experienced in delivering a broad range of procedures from toxins, to fillers to lasers.” He continues, “We believe this will assist trainee dermatology registrars to appreciate the business mechanics of private healthcare and patient management, as well as providing valuable practical exposure to a variety of common office-based laser treatments and aesthetic procedures.”

On the Scene

The Dermatology Preceptorship aims to allow registrars to be exposed to ‘real-life’ private dermatology practice, and enable them to see how practitioners and their patients interact within that environment. The one-day shadowing opportunities are scheduled on Fridays from 8:45am to 6pm. Whilst there is no charge for the programme, candidates must have a registrar training number and have also completed at least one year of clinical experience in dermatology, enabling them to expand their knowledge based on a sound understanding of skin. By partaking in this programme, participants will be awarded a certificate of attendance, which can be used towards building CPD points and will further add to registrar portfolio requirements. Current Dermatology Registrars who are interested in participating in the programme can find further information online.

On the Scene

Syneron Candela Body Beautiful Event, London Aesthetic device manufacturer Syneron Candela held a treatment presentation at PHI Clinic, Harley Street on January 14. The Body Beautiful Event featured presentations on the latest Syneron Candela technology from aesthetic practitioners Dr Tapan Patel, Dr Grant Hamlet, Dr Sabika Karim and Jo Martin.

Prior to the event, Syneron Candela conducted a survey that asked 1,000 British women to reveal what they disliked about their body.

The topics covered at Body Beautiful reflected the key findings of the research, and speakers presented treatment options to reflect these results. According to the research, problem areas included fat, cellulite, scars, stretch marks and broken veins. Dr Sabika Karim, who presented treatment options for scars and stretch marks, said, “I’m very privileged to have been invited to speak today. It has been a really well organised and informative event that has detailed how far machines and devices have come to be able to offer aesthetic treatments for body issues women really care about.” Dr Tapan Patel, medical director of PHI Clinic, added, “When we first opened the clinic, we were very keen to dedicate some of the facilities to research, education and information. A day like today – where we are packed out to capacity – is a real testimony to what we want to do at PHI.”

Alma Impact Expert Launch, London ABC Lasers hosted a launch for the new Alma Impact Expert on January 16, at The May Fair hotel in London. The ultrasound device is designed to rejuvenate and hydrate skin, emitting gentle acoustic waves aiding the path of active skincare ingredients into the skin’s layers. The device is designed to treat fine lines and wrinkles, sun damage, redness, dehydrated skin, and oily or congested skin. Alma sales and marketing director Lior Dayan began proceedings with a presentation on the technology behind the device, and its potential impact on business. Leading skin health practitioner Mimi Luzon later took to the stage to provide attendees with a lecture and live demonstration. In a joint venture with Alma, Mimi Luzon skincare products will be used in conjunction with the device. Director of ABC Lasers, Guy Goudsmit, said, “Today we are launching what is widely considered the next generation in skin hydration. The Impact Expert is a great addition to our database, and I am delighted to see so many familiar and new faces here today.”

Attending the event, Jackie Atkinson, owner of Medi-Laser Solutions, said, “I have dealt with ABC lasers and Alma lasers for many years, and I’ve always found them to be a very progressive company. I’m keen to learn more about this product as I really enjoy working with the company.”

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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The Aesthetics Conference and Exhibition 2015 is set to open its doors to aesthetic practitioners next month; we take a look at the vast array of benefits being offered at one of the year’s most eagerly anticipated industry events

ACE 2015: The final countdown HEADLINE SPONSOR

With more than 2,000 aesthetic professionals expected to attend in March, the Aesthetics Conference and Exhibition (ACE) 2015 promises to deliver a variety of opportunities for drastically increasing clinical and business skills and expertise. Throughout the weekend, aesthetic practitioners will experience live demonstrations at the Expert Clinics, increase their knowledge at the product and treatment Masterclasses, and sharpen their tools for success at the comprehensive Business Track workshops – complementing an interactive Conference programme of a calibre to rival any international congress. The very first conference of the year, ACE 2015 will give attendees access to every new product and launch, providing them with the opportunity to be the first to know about the latest developments and the chance to truly be above the fold in this competitive market. With more than 100 exhibitors, delegates can absorb the latest information all in one place, whilst making informed decisions on what to include in their clinic offering in the coming year. As a CPD-accredited conference, with 50 points available over the weekend, ACE 2015 will provide a variety of valuable CPD-accredited sessions covered across all agendas. Free registration includes entry to the Expert Clinics, Masterclasses and Business Track, plus an unmissable chance to network with thousands of aesthetic practitioners and industry leaders.

journeys will follow patient concerns and treatments in an interactive style from consultation through to complication management and follow-up care. State of the art technology will enhance the delegate experience, allowing for audience participation and open forum discussion.

This unique setting will also give delegates the opportunity to see internationally renowned speakers Dr Tapan Patel, Mr Dalvi Humzah and Dr Raj Acquilla speak and demonstrate on stage together for the very first time in the Injectables Expert Sessions (Parts I and II), taking place on Saturday afternoon and Sunday morning. Delegates will be invited to learn about the best and most innovative techniques for body sculpting, with leading practitioners Mr Taimur Shoaib, Dr Mike Comins, Dr T Vetpillai and Dr Samira Yousefi discussing and debating important issues related to weight-loss, and comparing key fat reduction and replacement treatments during Saturday morning. For Sunday’s final session, garner instrumental experience and information at the Aesthetic Dermatology Clinic chaired by leading dermatologists Dr Christopher Rowland-Payne and Dr Stefanie Williams, also featuring Dr Daron Seukeran, Lorna Bowes and Anna Baker.

Expert Clinics Conference Programme Delegates can make the most of their attendance by choosing one or more sessions from the premium content Conference programme. The flexible format allows visitors to book single sessions that are particularly relevant to their interests and professional needs. This brand new structure allows attendees to either choose individual three-hour learning sessions, featuring dynamic presentations and talks from international speakers, or book the full two-day package for an incomparable learning experience in medical aesthetics. Rather than simply watching isolated presentations, delegates will be able to learn from expert speaker panels exactly how to treat a patient from start to finish. Virtual clinic patient/practitioner

Included in the free exhibition registration alongside the Masterclasses and Business Track, the live demonstration Expert Clinic sessions will provide outstanding guidance from highly-respected industry practitioners, covering a huge range of areas and learning objectives. The agenda will include topics such as advanced injectables, treatment of filler complications, botulinum toxin for the lower face and neck, bio-generative skin rejuvenation, the evolution of hyaluronic acid, nonablative soft surgery, multiple indications for radiofrequency, forehead rejuvenation, combination treatments, facial anatomy, lasers, chemical peels, micro-needling, LED phototherapy, cosmeceuticals and more. Sponsored sessions will be provided by Skinceuticals, Sinclair IS Pharma, Aesthetic Source, Healthxchange, BTL Aesthetics, Lynton Lasers, Medico Beauty,

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

Aesthetics Journal

Rosmetics, Fusion GT and 10 Lasers. Presented by respected key opinion leaders, these sessions will help delegates to advance their understanding of how to use particular products to their best potential by watching and hearing from successful practitioners.

Aesthetics

Question Time

duction Fat Re

@aestheticsgroup

Saturday evening will see attendees embrace the ultimate opportunity to challenge leading industry professionals Why choose 3D-lipo? at the ACE Question Time debate, sponsored by 3D-lipo.

The panel will include British Association of Cosmetic Nurses (BACN) chair Sharon Bennett and president of the British College of Aesthetic Medicine (BCAM) Dr Paul Charlson, as well as Health Education England’s (HEE) performance and delivery manager Carol Jollie and international aesthetic business expert Wendy Lewis. Attendees can expect to debate topics ranging from industry regulation to business practises across the board. Top practitioners Mr Dalvi Humzah and Mr Paul Banwell will also be on the panel to support a range of perspectives from aesthetic professionals. Regarding the questions expected on HEE’s recommendations, Carol Jollie said, “I am very much looking forward to answering questions about the recommended qualification requirements for delivery of cosmetic procedures which Health Education England has developed in collaboration with experts working across the industry.” Representing professional body perspectives, Sharon Bennett said, “I look forward to answering the questions from the audience during Question Time at ACE in March. Last year the event was such a success and we all enjoyed it enormously.” Dr Paul Charlson concurred, adding that “it is always useful for delegates to question those involved in the industry.” “It is refreshing to offer delegates an opportunity for an open exchange of ideas in this ‘no holes barred’ forum, and to pose their questions to a board of industry insiders and leading practitioners, like Dalvi Humzah and Paul Banwell,” said Wendy Lewis. “I expect to hear some interesting issues raised and discussed. We can all learn from each other.” Mr Dalvi Humzah agreed. “The ACE Question Time session is a great chance for delegates to air important topical subjects and allow the board to be controversial and challenging in their responses,” he said.

“Being on the board with diverse experts provides a range of ideas and opinions to be discussed.” g

Skin Tightenin

A Powerful Three Dimensional Alternative to Liposuction

Cellulite

aestheticsjournal.com

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

Cavitation

Masterclasses Treatment Masterclasses at ACE will educate through live, practical demonstrations, providing invaluable tips and technique advice to enhance product effectiveness. Each Masterclass will take place over 90 minutes, allowing practitioners to build on their skills and understanding through succinct and effective guidance. Dr Elisabeth Dancey, aesthetic doctor and founder of Bijoux Medi-Spa, will lead the Masterclass sponsored by Medical Aesthetic Group, demonstrating the technique behind the V Soft Lift, using PDO threads to accomplish a complete face lift. Other Masterclasses will include expert demonstrations by high-profile industry companies Allergan, Galderma, Sinclair IS Pharma and Institute Hyalual.

Business Track

Complete start up and support package available from under £400 per month

Cavitation is a natural phenomenon based on low frequency

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

Cryolipolysis

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

Radio Frequency Skin Tightening

Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology

Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

What the experts say...

‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients.

Before

After

3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

www.3d-lipo.com www.3d-skintech.com

Offering two whole days of unparalleled learning, the Aesthetics Conference and Exhibition 2015, taking place over the weekend of March 7-8 in Central London, is the ideal platform for aesthetic professionals looking to perfect their skills and enhance their business in 2015 and beyond.

Book your place now.

Visit www.aestheticsconference.com for the full agenda and to register today.

WITH THANKS TO OUR SPONSORS HEADLINE SPONSOR

duction Fat Re

The Business Track will host a wideranging agenda, ensuring that all visitors can further their skills and knowledge to enhance their aesthetics business, whilst simultaneously making their practice more cost-efficient. Run alongside the clinical sessions, these presentations are aimed at the whole clinic, allowing front-of-house staff and business owners the opportunity to integrate exclusive marketing tips into practice, and the addition of new skills and ideas into your clinic. Church Pharmacy, pioneers of the new e-prescribing system DigitRx and sponsors of the Business Track, will lead three sessions on the advantages of switching to online prescribing, providing attendees with the opportunity to ask any questions they may have about switching to the new method. In today’s communication climate, social media and online skills are crucial, and Wendy Lewis will explain how these assets can be utilised to enhance your business to attract new customers and increase patient retention. Customer relations advice will be provided by experienced consultant Gilly Dickons, with sales tips from trainer Annalouise Kenny and marketing and branding guidance from Gary Conroy. Numbers and finance will be addressed by business advisor Dan Travis and VAT expert Veronica Donnelly, whilst regulation and professional associations will be covered by Carol Jollie of HEE and Brett Collins of Save Face.

• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Contouring • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required

g

Skin Tightenin

Cellulite

A Powerful Three Dimensional Alternative to Liposuction

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

Why choose 3D-lipo?

Cavitation

• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Contouring • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required

Complete start up and support package available from under £400 per month

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

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

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015 as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology

Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

What the experts say...

‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients.

Before

After

3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration

www.3d-lipo.com

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Aesthetics Journal

Aesthetics

Raising Standards Training in aesthetics is a hot topic. With ACE 2015 just around the corner and tighter regulation on the horizon, Allie Anderson discusses education and training options to boost your skills as well as your business It’s been almost two years since the Department of Health published its Review of the Regulation of Cosmetic Interventions,1 which sets out recommendations for safeguarding patients and practitioners in the largely unregulated industry.

The review, led by Professor Sir Bruce Keogh, also highlighted important issues about who may perform non-surgical cosmetic procedures and what qualifications they should have as a minimum.

As a consequence of the report’s key recommendations for high-quality care, which included the development of accredited qualifications for providers of aesthetic procedures and standards for practice and training, the focus is more sharply fixed on training than ever before. In the landscape of tighter regulation of an industry that is forecast to be worth £3.6bn this year,2 practitioners now have to better their services – and undertaking new, innovative and more advanced training is one way forward.

The Academy of Advanced Beauty is just one training provider working to improve training standards. Provided by a medically qualified lecturer, their method allows practitioners to gain CPD points. “For us, the most important aspect is to take training more seriously, and to make ‘core knowledge’ a more important part of the training, rather than just machine operation,” says Academy founder Barbara Freytag. But, as Freytag highlights, how can practitioners objectively judge the quality of the courses available?

There are numerous types of training on offer across the industry. From oneday broad-spectrum courses, to high-level, formal qualifications and interactive workshops, it’s far from a one-size-fits-all approach – but whatever format training takes, the consensus is that it’s essential.

Duty of care?

According to Steve Joyce, director of marketing and business development at Healthxchange Pharmacy, practitioners must maintain their skills through training to, “underpin the industry both in terms of the professionalism of those working hard in it, and the desire for excellent and consistent patient outcomes”. When things go wrong, Joyce says the ramifications can be far-reaching, especially if incidents are played out in the public eye. “This affects the whole industry, and there is a collective responsibility upon everyone in the profession to undertake appropriate training, so they can best advise their patients and deliver the expected outcomes from treatments.”

Last year, Healthxchange capitalised on this and opened its own academy in Manchester, providing product and business-focused training programmes suitable for a range of skill and experience levels, from practitioners new to the industry, to experienced doctors wanting to develop new techniques and master specific products.

Education in such a diverse industry differs immensely. While the Healthxchange concept focuses on a wide audience, other providers instead concentrate on specific skill levels. Dr Raj Acquilla delivers training only at ‘masterclass’ level, explaining that “typically, people achieve masterclass level after a year of practice, sometimes longer.” He adds, “Ideally, they’d have performed between 50 and 100 procedures in these areas, to achieve competency with a needle.” His face-to-face training sessions in botulinum toxin and dermal fillers comprise in-depth study of the anatomy from the skull, up through the fat compartments, muscles and skin, including blood and nerve supply and lymphatic drainage.

The one-day courses cover risks and complications and how products interact with tissue in their various compartments, leading into a technical strategy for injecting in each anatomical region. Attendees are certified following a successful practical assessment, overseen by Dr Acquilla.

Practise makes perfect Many concede that practical training is paramount, and should be carried out under the watchful eye of an experienced course leader before the student performs in clinical practice. “The old technique of seeing a treatment, then going to practise on friends before carrying it out for real can no longer be sustained,” comments Mr Dalvi Humzah, cosmetic surgeon and founder of Facial Anatomy Teaching. Of his training, he says, “We go through tutorial-based teaching before doing demonstrations and a hands-on practical, using unembalmed specimens. Practitioners have a chance to inject, and you can see where the injection is in terms of the underlying anatomy.”

From an initial course designed for practitioners with a non-surgical background, Mr Humzah developed a second, separate course focusing on complications.

As such, the ‘technical’ aspects of anatomy are central to both. “The result is that, because students know about the anatomy and how to assess it carefully – as well as the complications that can arise – they can perform their treatments safely and reduce the risk of any major adverse events,” he adds.

The depth of content often varies depending on the student – and as independent educator and practitioner Pam Cushing points out, this can be difficult to balance. She delivers one-day training in botulinum toxin, dermal fillers, peels, mesotherapy, platelet-rich plasma (PRP) injections and derma roller, largely to audiences with different backgrounds, but believes less can be more. “We don’t go into

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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too much muscle detail – I think the problem with doing so is that those are unfamiliar with it can get frightened, and people who already have that knowledge will get bored,” Cushing explains. “It’s much better that they understand the different types of toxin, their indications, the correct injection sites, doses, dilutions, and patient selection. More than anything, I aim to give people a broad-base understanding.”

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already working in the industry, to learn by incorporating practical and theoretical practise within a multidisciplinary programme.

Clinical programme director Dr Tamara Griffiths says, “The most effective form of training will encompass both knowledge as well as practical exposure. Educational programmes can deliver a solid and comprehensive foundation of knowledge to students, but the safe development of practical skills will require an apprenticeship or mentorship form of training.”

Consulting the experts

Pam Cushing preparing a model for a peel at a training session, November 2014

Evaluation methods Assessment and accreditation methods are as diverse as the training available – an inevitable consequence (for good or bad) of lack of regulation. All courses provided by the European College of Aesthetic Medicine and Surgery (ECAMS), for example, culminate in an exam, which delegates must pass to receive their certificate of completion. Similarly, courses delivered by Innomed Training Academy, which are CPD accredited, incorporate a formal, marked assessment. For others, like Dr Acquilla’s masterclasses and Mr Humzah’s Royal College of Surgeons-run courses, successful completion is determined by delegates’ skills being tested under the subjective supervision of the highly qualified and experienced course leader.

Arguably, the difficulty with formal assessment in such training is that it would imply a level of competency on the part of the trainee in delivering that treatment: yet, with no industry-wide, nationally recognised standards for education and training, ‘levels of competency’ can be fairly open to interpretation. Moreover, as stated in the Keogh report, “In the absence of accredited training courses, anyone can set up a training course purporting to offer a qualification”.3 However, some assurance is accumulated by courses offering a recognised general qualification, such as national vocational qualifications (NVQs). An example is the NVQ Level 4 course in laser and IPL/light treatment, offered by Advance Clinic, Training and Consultancy and accredited by international awarding organisation VTCT. Advance’s founder, Annalouise Kenny, testifies that the nature of the ever-changing aesthetics industry has resulted in an abundance of self-accredited training. “When I started up, there were very few private training centres, but even in the last three years it’s expanded,” she says. “You used to have medical on one side, and beauty on the other, but aesthetics is still separating itself as a sector on its own.” In doing so, it is attracting ever more beauty practitioners, which is perhaps where validation of training and education is most pertinent. In this way, an NVQ provides a qualification whose content, though not overseen by an industrywide body, is endorsed by a recognised accreditor of skills and training. This option can be further supported by the Skin Ageing and Aesthetic Medicine Masters at the University of Manchester. This three-year part-time degree allows training practitioners, and those

More providers are anticipating a regulatory training framework, as outlined in draft in the Health Education England (HEE) report: Review of qualifications required for delivery of non-surgical cosmetic interventions,4 commissioned in response to the Keogh report.

Following a stakeholder consultation in December, a final version of this report will be published in April this year. At Sally Durant Training and Consultancy, a range of Level 4 qualifications have been developed “to address the concerns of the HEE”. “We designed the courses to be competency-based and nationally accredited,” explains managing director Sally Durant, “and the competencies we’ve put in place are those reflected in the HEE report.” This training uses assessment via a competency framework, testing practical application, consultation and verbal skills.

“Educational programmes can deliver a solid and comprehensive foundation of knowledge to students, but the safe development of practical skills will require an apprenticeship or mentorship form of training.”

Dr Tamara Griffiths

For Durant, it pays to be ahead of the curve, and others are taking similar steps in the spirit of HEE’s work. Exemplary of this foresight is the CPD-accredited Advanced Consultation Training (ACT) course, devised by micropigmentation specialist Anouska Cassano alongside Professor Glenn Callaghan, a psychologist and director of clinical training at San Jose State University. Cassano explains that the course aims to minimise patient dissatisfaction – and therefore potential litigation – by providing a framework for the consultation process. “There is no standard format for consultation – even on the surgical side, where there are very robust guidelines for practice,” she says. The training comprises a one-day interactive course and workshop, assessing delegates via written and practical elements, providing a raft of pre-course literature and online resources, which practitioners may refer back to in clinic. “The key to successful treatment outcomes is transparency,” Cassano adds. “ACT is designed for the practitioner to determine whether someone is likely to be happy with the outcome of the treatment.

The framework is there to manage expectations, for the protection of clients and patients.”

Getting out what you put in One tangible outcome of ACT certification is the potential for discounted insurance. Similar offers may be a particular attraction for practitioners who are comparing the value of different courses, especially if new to the industry. “We’ve negotiated special offers

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Dr Xavier lecturing in dermal fillers at a conference, April 2014

with key suppliers for our delegates, which includes discounts on products to help them stock up more easily as they start,” comments Innomed’s Martin MacKenzie. “We can also offer sources of other support and professional advice – such as industry publications and journals as well as professional industry associations that they should join, such as BCAM [British College of Aesthetic Medicine] and BACN [British Association of Cosmetic Nurses].” These incentives may well be a consideration when cost of training is an issue, which, according to Dr Elisabeth Dancey, is sometimes the case. Dr Dancey offers specialist one-to-one training in PDO thread lifts and PRP, and says that while such techniques that demand mastery and dexterity require a personal approach, it is not always financially attractive. “Training provided by larger companies will be less expensive, maybe free of charge, and this is the way I see training developing in the future,” she adds. “Relatively simple procedures or those with a lot of theory content can be effectively taught in relatively large groups – and it also makes economic sense for the practitioner and trainee alike.”

But Dr Dancey urges caution when it comes to training in advanced and complex techniques, like PRP, suspension thread lifts and injectable lipolysis ‘en masse’. “These are best taught one to one – or at the very least one to two. Supervision or further training should also be offered,” she says, adding that one-to-one training enhances one’s CV in an increasingly competitive profession.

Continuing education Under the General Medical Council (GMC)’s Good Medical Practice (GMP),5 medical doctors are duty-bound to “develop and maintain [their] professional performance”, which includes the obligation to maintain competency, professional knowledge and skills, and to take part in regular activities and “structured support”.6 Arguably the best way to satisfy this requirement is to undertake training and education that’s certified as continuing professional development (CPD). CPD points or hours are a benefit of a great number of training options, and are an essential part of a practitioner’s portfolio in a changing sector, says Rachel Gofton from the Royal Society of Medicine, whose courses are all CPDcertified. “Such training is important to ensure good practice, as the industry is rapidly developing,” she says. “As products, technology and needs develop, the training will have to change and new guidelines and laws will mould the way training is delivered.” In its very nature, good-quality CPD is perfectly placed to reflect these changes and developments. It can also make training transferrable

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internationally, in a climate where practice and regulation varies from one country to another. ECAMS is one provider addressing this, explains its president, Dr Peter Prendergast. “Many of our injectable training courses in the past included CPD points,” he says. “And due to the requirements now for doctors in most countries to accumulate adequate CPD points, we intend to apply to the European Accreditation Commission for Continuous Medical Education (EACCME) to offer CPD points for all future ECAMS courses, as well as for our annual Congress in Barcelona.”

The advantage of CPD is its variety of forms – as structured/ active learning, reflective learning and self-directed learning7 – making it accessible and flexible: it can often be accrued at an individual’s own pace, for example, by reading journals and articles such as those in Aesthetics (see page 24 for this month’s CPD article). However, more interactive training is, for many, the most essential form of ongoing education. According to Cushing, the best route is live conferences and exhibitions, and she suggests that practitioners should invest in attending at least two of these events – like the Aesthetics Conference and Exhibition (ACE) – every year to make sure they’re up to date. “I think these conferences are vitally important: I can’t see how any practitioner who works in aesthetics – however long they’ve been in it – can’t gain something from going to a presentation or a workshop,” she affirms. “Every single person who presents will always have some nugget of information or clinical experience that you’ve not thought of before.” Similarly, Joyce’s top tip for successful training is to “make it interactive: there is nothing more disengaging than having to sit for hours trying to absorb reams of content. Involve delegates in activities, get them to interact and show videos, demonstrations or role play”. ACE 2015, taking place next month, fully embraces this interactivity, offering delegates the chance to participate in the main sessions through virtual clinics and multi-screen demonstrations, for example. Moreover, the main Conference sessions, Masterclasses, Expert Clinics and Business Track elements all offer one CPD point per hour and, with sessions that are 0.5 to 3 hours each,8 there is a total of 50 CPD points available. Whilst aesthetics is still a largely unregulated industry, there is clearly a good variation of safe, reliable and professional training courses available to practitioners from a wide range of backgrounds and fields of experience. Qualified professionals are on-hand to offer training and support to newcomers to the industry as well as to some of the most experienced practitioners in need of advice. Until the findings of the Keogh review and the following HEE draft guidance are fully implemented and embraced, this is at least a step in the right direction.

REFERENCES 1. Department of Health, Review of the Regulation of Cosmetic Interventions (London: gov.uk,

2013) <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/ Review_of_the_Regulation_of_Cosmetic_Interventions.pdf> [accessed 15 January 2015] 2. Cosmetic Surgery, Market Intelligence, Mintel, 2010, cited in Review of the Regulation of

Cosmetic Interventions (Ibid) 3. Department of Health, Review of the Regulation of Cosmetic Interventions (London: gov.uk,

2013) <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/ Review_of_the_Regulation_of_Cosmetic_Interventions.pdf> [accessed 15 January 2015] 4. Health Education England, Review of qualifications required for delivery of non-surgical

cosmetic interventions (London: NHS, 2014) <http://hee.nhs.uk/wp-content/blogs. dir/321/files/2014/09/Non-surgical-cosmetic-interventions-Report-on-Phase-11.pdf> [accessed 15

January 2015] 5. General Medical Council, Good medical practice (2013) (London: GMC, 2013) <http://www.gmc- uk.org/guidance/good_medical_practice.asp> [accessed on 15 January 2015] 6. General Medical Council, Develop and maintain your professional performance (London:

GMC, 2013) <http://www.gmc-uk.org/guidance/good_medical_practice/maintain_performance. asp> [accessed on 15 January 2015] 7. The CPD Certification Service, CPD Learning Types (London: The CPD Certification Service <http://www.cpduk.co.uk/index.php/what-is-cpd/types-of-cpd> [accessed on 15 January 2015] 8. Aesthetics Conference and Exhibition, Gain CPD accreditation by attending ACE (London:

Aesthetics Conference and Exhibition) <https://aestheticsconference.com/cpd/> [accessed on

15 January 2015]

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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How to minimise risks when using advanced skin procedures in skin type Fitzpatrick III or above (or skin of colour) Constance Campion-Awwad examines innovations in cosmetic chemistry that have significantly minimised the risk of Post-Inflammatory Hyperpigmentation (PIH) and Hypo Pigmentation associated with the use of chemical peels on skin type Fitzpatrick III or above.

The first step when carrying out an advanced skin treatment is to identify the patient’s skin type and diagnose their primary and secondary skin concerns. This analysis provides information to enable a final decision on treatment, and to assess the risk involved with carrying out a chemical peel treatment. This also establishes whether customisation of the treatment application is necessary. An in-depth knowledge of anatomical and physiological skin function also provides a useful insight into the ways in which healthy skin function may already be compromised on a cellular level. This understanding, coupled with accurate assessment, effectively manages risks associated with the procedure, such as PostInflammatory Hyperpigmentation (PIH).

SKIN ANALYSIS USING THE FITZPATRICK SCALE Dr Thomas Fitzpatrick, a Harvard Medical School dermatologist, developed this scale in 1988 in order to provide a standard method of classifying different skin types according to colour, and their reaction to ultraviolet (UV) light from sun exposure. Since melanin is thought to have photoprotective effects, the skin’s classification of colour is representative of it’s natural tolerance, or lack of tolerance, to exposure to UV. The Fitzpatrick Scale, shown in Table One, addresses skin type from the lightest colour, a Fitzpatrick I that is most susceptible to sunburn and photodamage, to the darkest skin colouring, a Fitzpatrick V, the most resistant to sunburn and cumulative photodamage.

Ethnic skin is usually classified in the spectrum between types IV-VI. Surprisingly, there are no differences in the number of melanocytes

between a Fitzpatrick I through to VI. However, variations do exist in the number, size and production of the pigment granules, melanin and the distribution of melanosomes.1 The Fitzpatrick scale not only indicates sun damage susceptibility, depending on the amount of melanin pigment in the skin, but also serves as a scale of intrinsic sensitivity and ethnic origin. Professionals refer to the Fitzpatrick scale prior to performing ablative, wounding procedures that affect the skin’s temperature, since this information serves as an indicator for determining the treatment selection, the tolerance level of the patient’s skin and the final healing results.2 Learning the Fitzpatrick scale is part of the programme of education in the ‘core of knowledge’ training as recommended by the Medical Device Agency, Guidance on the Safe Use of Lasers in Medical and Dental Practice, and the Royal College of Nurses, Competencies for Aesthetic Nurses. Detailed questioning regarding the patient’s tendency to tan or burn is necessary to gain a better understanding of the patient’s phototype. Previous history of colour change after minor injuries is another way to assess the patient’s phototype. It is more likely that a Fitzpatrick III or above will experience Post-Inflammatory Hyperpigmentation (PIH) following a burn injury. The Fitzpatrick skin type is currently the only universal means to classify skin phototype, however, this scale can be inaccurate when applied across the board to all Caucasian patients. Some Caucasian patients will have a mixed heritage – where one parent, for example, is a Fitzpatrick II skin type and the other a Fitzpatrick V skin type. This can result in a patient having what is referred to as a ‘deviated’ skin type III.

Table 1: The Fitzpatrick Scale

Skin Type

Skin Colour

Hair and Eye Colour

Reaction to Sunlight

Common Ethnic Considerations

Type I

White

Blond hair and green eyes

Always burns, has freckles

English, Scottish

Type II

White

Blond hair and green or blue eyes

Always burns, has freckles, difficult to tan

Northern European

Type III

White

Blond or brown hair and blue or brown eyes

Tans after several burns, may freckle

German

Type IV

Brown

Brown hair and brown eyes

Tans more than average, rarely burns, rarely freckles

Meditarranean, S. European, Hispanic, American Indian

Type V

Dark Brown

Brown or black hair and brown eyes

Tans with ease, rarely burns, has no freckles

Asian, Indian, some African

Type VI

Black

Brown or black hair and brown or black eyes

Tans, never burns, deeply pigmented, never freckles

African

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Despite appearing Caucasian, when exposed to UV, the deviation in heritage results in melanocyte activity being the same as a skin type III (they usually tan and sometimes burn).

DISTRUPTIONS TO THE BARRIER FUNCTION A vital step in assessing the risk of causing PIH with a chemical peel is to closely examine the mechanisms that are present to reduce inflammation. The barrier function impacts a number of crucial parameters that can vary such as the level of tolerance to chemical peel solutions, its application, the risk of wounding the skin with a solution that causes excessive wounding and PIH. The skin is the body’s largest organ and maintains a number of complex functions to defend against bacterial invasion and regulate inflammation. The barrier function of the skin is located throughout the granulosum and corneum layers. As the kerantinocytes move into this area many alternations occur within the cells. The granular layer becomes less flexible as the keratin filaments harden within the cells, completing the kerantinization process.

The chief barrier function takes place between the intercellular spaces appearing as bricks and mortar. Initially formed by the Glogi apparatus, lamellar (Odland) bodies found within the granular cells are responsible for forming a bi-polar lipid barrier (mortar), one layer water, one-layer lipids, forming the Natural Moisturising Factor (NMF). This dense structure creates a highly impermeable matrix of cells, and prevents water loss and invasion of foreign substances such as bacteria and other injuring materials. The acid mantle supports the formation and maturation of the epidermal lipids and hence the maintenance of a healthy barrier function. The first line of defence is the acidic environment created in the upper layers of the epidermis, courtesy of a protective outer coating called the acid mantle. This is formed from free fatty acid secretions by the sebaceous glands, lactic acid from the body’s eccrine sweat glands and microbial metabolites in the stratum corneum. Enzymes and specialised proteins are also involved in the formation of this essential acidic environment. The skin’s pH level changes over time, and becomes slightly elevated with age.3 The excessive use of alkaline soaps also disrupts the physiological balance of the skin.

In a healthy skin the acid mantle’s slightly acidic pH of 4.5-5.5 wards off harmful bacteria, preventing bacterial growth on the skin. If it is compromised and a more neutral pH develops, bacteria such as staphylococcus and fungi such as candida may proliferate. Bacterial flora is nonpathogenic and thrives in the acidic environment created by the acid mantle. It benefits the maintenance of healthy skin by balancing the acidic environment.4 THE ROOT CAUSE OF POST-INFLAMMATORY PIGMENATION Disruption to the skin’s acid mantle is caused by the application of topical skin treatments that destroy the essential balance of lipids that from a protective bilayer lipid membrane and balance pH levels. When a chemical peel solution is applied an inflammatory response takes place. The stratum corneum releases inflammatory cytokines in an attempt to trigger more lipid production and restore the acid mantle’s natural pH.5 Post-inflammatory Hyperpigmentation (PIH) results from an overproduction of melanin following inflammation of the skin. Inflammatory mediators have been demonstrated to directly effect melanocyte pigment production that controls the development of PIH and Hypopigmentation. Cytokines and inflammatory mediators can have a stimulatory effect on melanocytes, which results in increased melanin production.6 In order to improve the skin’s tolerance to changes in pH levels it

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is possible to treat patients with a pre-peel skincare regime that uses a range of active ingredients. A homecare plan is sometimes referred to as a ‘conditioning’ step and used pre-treatment as it works synergistically in combination with the peel treatment.

The use of active ingredients on a daily basis gradually adjusts the skin’s tolerance. As a result the wounding effect of the peel treatment is less severe, and the risk of PIH is reduced.

The patient’s acid mantle may already be disrupted through the use of alkalizing soaps with a pH of 7.00 or more, or through the use of skincare that contains alcohol. When a patient presents with this history it is important to take into consideration that their skin could already be ‘sensitised’ because of this disruption to the acid mantle. To reduce the risk of a chemical peel causing more inflammation, prescribe a homecare plan that contains a blend of active ingredients such as AHAs and a Vitamin A derivative beforehand. The increased cell renewal causes cells to become denser and more compact, making skin a more effective barrier to outside irritants and holding moisture inside to keep skin pliable.

By providing enough time to prepare the skin, the risk of PIH could be significantly reduced. Always ensure to follow the manufacturers guidelines on the pre-peel period and, when combining treatments, leave an appropriate amount of time in between to allow for the proper recovery and restoration of the barrier function.

CHEMICAL PEEL SOLUTIONS The term ‘peel’ refers to a wide range of exfoliating procedures using an acid. In order to reduce the risk of causing PIH with a chemical peel when treating skin type III or above, the specific properties of different peeling agents must be considered. The two most popular peels are made from Alpha Hydroxy Acids (AHAs) and Trichloroacetic Acid (TCA). The solutions vary in intensity depending on the depth of penetration. Because of the risk of the treatment causing PIH, deep chemical peels are generally reserved for Fitzpatrick I and II. This is particularly limiting for patients that suffer from pigment disorders, as it is more than likely that their skin type is a Fitzpatrick III or above7 – with Hyperpigmentation developing more frequently in Fitzpatrick IV-VI, compared to lighter skin types.8 Superficial peel treatments include exfoliation with AHAs and this can be carried out on all skin types, from Fitzpatrick I-VI. These are naturally occurring compounds that are watersoluble and can be found in many foods, including Glycolic acid (sugar cane), L-lactic acid (milk), Citric acid (citrus fruits), and L-malic acid (apples), among others. The acid works in the upper layers of the epidermis by reducing the thickness of the stratum corneum.

AHAs disrupt the stratum corneum, decreasing corneocyte adhesion, dissolving the desmosomes (the protein connections between corneocytes) and cause the eventual shedding of these cells. Studies have demonstrated that AHAs also restore hydration and plumpness through an increase in the production of hyaluronic acid. AHAs work to increase the promotion of the gene expression of hyaluronic acid in the dermis and epidermis.9 An early study reported four weeks of treatment of 12% lactic acid resulted in a 19% increase in epidermal thickness and increased amounts of glycosaminoglycans which directly improves hydration in the dermis.10 Concentration of AHAs will directly contribute to the outcome of a treatment and a higher concentration of acids left on the skin for longer have more potent anti-ageing effects.11 However, AHAs lose their effectiveness as a product’s pH goes up or the concentration of the ingredient goes down. A study comparing

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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5% versus 12% L-lactic acid found that while 5% effectively causes epidermal changes it did not reach the dermis, whereas the 12% solution was found to influence both the epidermis and the dermis.11 The pH of the formulation also determines the reach of the peel and depth of the wound. AHAs are more bioavailable and work best at their native lower pH.12 However, the pH of Glycolic Acid – at a very high concentration of 70% – must be above 2% in order to be effective. An early study demonstrated that the risk of wounding was much higher when using a 70% Glycolic peel solution with a pH below 2, causing crusting and necrosis. 13

the penetration of the acid is staggered and other actives such as stimulating Vitamin A derivative Retinol can then filter through the skin. The larger acids, like citric and tartaric, make the skin’s surface more permeable, allowing the smaller acids, like lactic, to penetrate.16 Retinol is encapsulated by an amino acid complex that creates a time-release system. Retinol metabolically converts from retinol to retinaldehyde and finally, to All Trans Retinoic Acid. A study conducted in 1997, demonstrated that Retinol at concentrations of 0.25% and Retinaldehyde at concentrations of 0.01% were the equivalent to Retinoic Acid 0.01% - 0.05% in terms of skin rejuvenation, without causing any irritation.17 A more recent POST-INFLAMMATORY PIGMENTATION development in cosmetic chemistry includes the use of active The risk of causing PIH in Fitzpatrick III increases with a ‘deep’ ingredients that are selected and used in the correct ‘molecular’ chemical peel such as Trichloroacetic Acid (TCA). Derived from fit. Most biomolecules, including active ingredients, are chiral. This chlorinating Acetic acid, a component of vinegar, TCA softens means they have a ‘left’ and a ‘right’ chemical orientation, much fine lines, smoothes rough texture, reduces hyperpigmentation, like our hands. Chiral molecules are identical mirror images of each and improves skin tone.14 When the protein in a skin cell other.18 When an active ingredient is chirally correct, it means that (keratinocytes) reacts with acid at a low pH, it denatures through it contains only the molecules with the ability to give the desired a process called coagulation. The skin appears ‘frosted’ and results (either the D or the L form). An example of a ‘chirally correct’ the protein cannot be normalised again because the proteolytic AHA is L-lactic acid, which comes in three forms, L-lactic, D-lactic and enzymes have destroyed the keratinocytes. As the solution DL-lactic. L-lactic is the correct enantiomer because it correctly fits reaches the level of the papillary dermis and separates the the skin cell receptor and is therefore optimally biologically active. epidermis from the dermis, to cause ‘epi-dermal sliding’15 it makes L-lactic is known to be ‘chirally-correct’, as opposed to D-lactic acid, the skin more prone to injury and PIH. which is not mirrored by the skin cell receptor.

This reaction has led to the opinion, shared by a number Chirally correct acids allow for the combination of AHAs (excluding of clinicians, that if hyperpigmentation is an indication of a Glycolic) and BHA in one solution. Instead of a liquid, the peel is compromised barrier function, then the use of chemical peels that formulated as a cream or gel that is massaged into the skin. This cause irritation and wounding, as well as an acute inflammatory kind of solution can be left on the skin for longer as ‘self-neutralising’ response, increase the risk of PIH and aren’t the most favoured acids do not cause inflammation. In contrast, Glycolic acid penetrates course of treatment. the epidermis quicker than the other AHAs due to its small molecular size. The skin does not metabolise Glycolic acid, which is why a NEW INNOVATION IN CHEMICAL PEEL SOLUTIONS neutralising solution is applied to stop severely wounding or burning In response to complications arising from treatments using chemical the patient’s skin. A comparative study carried out in 1996 explained peels, American biochemists in the 1990s carried out research the effect of AHAs and reported that at the same concentration, to create new formulations that caused less inflammation without L-lactic was found to be less irritating than glycolic acid.19 The compromising on the treatment efficacy. This was achieved by study done by Walter Smith, PhD, a biochemist and independent using a lower concentration and buffered pH. This new approach researcher, demonstrated that the therapeutic index measuring the to peel formulation included combining a blend of AHAs that rate of cell renewal, compared to irritation received from glycolic and vary in molecular size: L-lactic, L-Malic and L-Tartaric Acid, Beta lactic acids was extremely close, 5% lactic acid measured in at 12.7 Hydroxy Acid (BHA) Salicylic acid, and vitamin A derivative Retinol. whilst the same percentage of glycolic acid was 12.6.19 AHA combined in one formulation offer a number of benefits as L-lactic acid is produced naturally within the body and there is a specific cell receptor site found on the skin cell membrane. All cells within the human body Figure 1: Before treatment Four weeks after After third treatment chemical peel for PIH have receptors; these are places in, or on, the cell where an active ingredient can interact with the cell. Receptors are often compared to a lock, with the active ingredient being a key.

The skin requires the correct active to interact with each type of receptor. The L-lactic receptor specifically interacts with the L-lactic molecule.

L-lactic acid self-neutralises and induces the synthesis of the most important component of the cell membrane – the ceramides – reenforcing the epidermal barrier function.20 This Treated with a L-lactic, Following treatment with has a number of benefits for all skin types and Resorcinol and Salicylic Acid a self-neutralising peel chemical peel formulation. formulated with 10% Retinol for the treatment of pigmentation, as restoring PIH occurred on both sides and 20% L-Ascorbic Acid barrier function naturally reinforces the skin’s of the chin. combined with LED Therapy. immunity and protection against UV damage.

The patient had three PIH treatments over the course of Naturally occurring Salicylic acid, a Beta Hydroxy 11 months.

Acid (BHA), is also appropriate for ethnic-

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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skinned patients with melasma or existing PIH in all skin types I-VI. Glycolic acid is less favourable in darker-skinned patients as it can induce PIH in skin types V and VI.21 SUMMARY Advances in peel formulations have reduced the level of risk associated with carrying out chemical peel treatments on all skin types. To ensure the safe treatment of Fitzpatrick III+, a comprehensive skin analysis should be carried out to determine and measure the factors that affect the depth of penetration, wounding and recovery of the skin. Today, chemical peels are highly complex solutions that can be used to treat a vast variety of skin types, when considered against the patient’s unique skin function, their Fitzpatrick skin type, and other factors such as oiliness and hydration. It is necessary to customise the application accordingly, finding the balance between achieving the best possible outcome from treatment and minimising the risk associated with all acids.

Constance Campion-Awwad is an aesthetic nurse practitioner, with more than 25 years’ experience in the speciality. She is a partner of Plastic Surgery Associates, BUPA Cromwell Hospital Kensington, and pioneered the use of a 7-point skin analysis method in 1989. Campion aims to integrate advanced skin health and well being to all her patient treatments.

REFERENCES 1. Thong HY, Lee SH, Sun CC, Boissy RE, ‘The patterns of melanosome distribution in

keratinocytes of human skin as one determining factor of skin colour,’ British Journal of Dermatology, Volume 149(3), 2003, 498-505, p. 503 2. Irwin M. Freedberg, (Editor), Arthur Z. Eisen (Editor), Klauss Wolff (Editor), K. Frank Austen

(Editor), Lowell A.Goldsmith (Editor), Stephen Katz (Editor), Fitzpatrick’s Dermatology in General Medicine, (New York: Mcgraw-Hill, 2003) p.2972-2979 3. Monika Hildegard Schmid-Wendtner, Hans Christian Korting, ‘The pH of the skin surface and its

impact on the barrier function,’ Skin Pharmacology Physiology, Volume 19, 2006, 296–302, p. 297 4. Monika Hildegard Schmid-Wendtner, Hans Christian Korting, ‘The pH of the skin surface and its

impact on the barrier function,’ Skin Pharmacology Physiology, Volume 19, 2006, 296–302, p. 301 5. A. M. Kligman, ‘ Corneobiology and Conrneotherapy - a final chapter, International’, Journal of

Cosmetic Science, 2011, 1 – 13, p. 3 6. Joseph G Morelli, David A Norris, ‘Influence of inflammatory mediators and cytokines on

human melanocyte function,’ Journal of Investigative Dermatology, 100(2 Supplement) (1993),

p. 191-195S, 193S 7. Erica C. Davis, Valerie D. Callender, ‘Post Inflammatory Hyperpigmentation, A Review of

the Epidemiology, Clinical Features and Treatment Options in Skin of Color, Clinical Aesthetic Dermatology, Volume 10, 2010, p. 20 – 31 8. Susan C Taylor, ‘Skin of color: Physiology, Structure, Function, and Implications for

Dermatologic Disease,’ Journal of the American Academy of Dermatology, 2002, Volume 46

(2 Supplement), p. S41-S62 9. Cherie M Ditre, Griffin TD, Murphy GF, Sueki H, Telegan B, Johnson WC, et all, ‘Effects of alpha

hydroxy acids on photoaged skin: a pilot clinical histologic and ultrastructural,’ Journal of

American Academy of Dermatology, 1996, Volume 34, p. 187-195 10. Robert Lavker, Kays Kaidbey, James Leyden, Journal American Academy of Dermatology,

‘Effects of topical ammonium lactate on cutaneous atrophy from a potent topical

corticosteriod’, (1992) 26(4), p. 535-44 (p. 539) 11. Walter P Smith, ‘Epidermal and dermal effects of topical lactic acid’, Journal of American

Academy of Dermatology, (1996) 35(3), p. 388–391, (p.390) 12. Jason Rivers, ‘Cosmeceuticals in Anti Aging Therapy,’ Skin Therapy Letters, 13 (8) (2008), 6-9 (p. 8) 13. Ferdinand. F. Becker, Francis Langford, Mark G Rubin, Patricia Speelman, ‘A histological

comparison of 50% and 70% glycolic acid peels using solutions with various pHs’,

Dermatologic Surgery, 22(5) (1996), 463–465 (p. 464) 14. Gary D. Monheit, ‘The Jessner’s + TCA peel: A Medium Depth Chemical Peel’, Dermatologic Surgery, (1989) 15, 945–950 (p.948) 15. Zen Obagi, Obagi S, S Alaiti, MB Stevens, ‘TCA-based blue peel: a standardized procedure

with depth control’, Dermatology Surgery, (1999) 25(10), p. 773-780 16. Walter P Smith, ‘Epidermal and dermal effects of topical lactic acid’, Journal of American

Academy of Dermatology, (1996) 35(3), p. 388–391, (p.390) 17. E Duell, Sewon Kang, John J. Voorhees, ‘Unoccluded retinol penetrates human skin in

vivo more effectively than unoccluded retinyl palmitate or retinoic acid’, Journal Investigative Dermatology, (1997) 109(3), 301-5 (p. 303) 18. Uwe Meierhenrich, Amino Acids and the Asymmetry of Life: Caught in the Act of Formation,

(Berlin: Springer, 2008), p.17 19. Walter Smith, ‘Comparative effectiveness of alpha-hydroxy acids on skin properties,’

International Journal of Cosmetic Science, 18 (2) (1996), p. 79 20. A.V. Rawlings, A. Davies, M. Carlomusto, S. Pillai, K. Zhang, R. Kosturko, P. Verdejo, C. Feinberg,

L. Nguyen, P. Chandar , ‘Effect of L-lactc Acid Isomers on Kerainocyte Ceramide Synthesis,

Stratum Corneum Lipid Levels and Stratum Corneum Barrier Function,’ Archives of

Dermatology Research, 288(7) (1996), 383-390 (p. 384) 21. Paula E. Bourelly, Angela J. Lotsikas- Baggili, Cosmetic Dermatology, (Berlin: Springer, 2001), p. 60

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An update on the management of rosacea and its complications

The second type is papulopustular rosacea. These patients often have central facial erythema with transient papules and pustules in a central facial distribution. This type of rosacea accounts for just over 20% of patients,1 and this is the sub-type that most closely resembles acne vulgaris without comedones.

Rhinophymatous change is where the patient experiences a thickening of the skin, particularly over the anterior aspect of the nose. This is a combination of fibrosis, sebaceous hyperplasia and lymphoedema. This affects just over 3% of male patients and about 1% of female patients.5 The last type, ocular rosacea, is when rosacea affects the eyes, causing a burning or stinging sensation.1

Aesthetics Conference and Exhibition speaker and presenter Dr Daron Suekeran outlines methods for treating rosacea

The aim of treatment is to alleviate the signs and symptoms such as reddening of the skin, flushing and irritation, and to reduce papules and pustules. In terms of the papulopustular component, this has often been treated with topical agents such as Metronidazole or Azelaic acid, often combined with an oral antibiotic such as a tetracycline or erythromycin. The drugs are often taken for at least four months. Although topical and oral treatments are effective for inflammatory lesions, they have limited effect on diffuse facial erythema and telangiectasia.6

Rosacea is a chronic inflammatory disorder of the skin primarily affecting the central face (cheeks, chin, nose and central forehead). The primary symptoms are often flushing with transient erythema, fixed erythema, papules and pustules and telangiectasia. Secondary symptoms may be a burning or stinging sensation, ocular manifestations and rhinophymatous changes.1 Rosacea more commonly affects patients with fair skin, particularly those of Celtic or Northern European origin. It is rare in patients of less than 30 years of age, and is generally thought to be more common in women, especially in the age group 36-50 years.2 Rosacea can often be a socially stigmatising disease, since facial flushing and skin changes can be mistakenly attributed to alcohol abuse. Patients with rosacea experience more stress than healthy individuals and the embarrassment and lower esteem caused by rosacea can result in social and professional isolation, which may often be underestimated by physicians.3 The precise aetiology of rosacea remains largely unknown.

Numerous theories have been proposed including age, immunity, vascular changes, reactive oxygen species (ROS), ultraviolet radiation and microbes. Many factors seem to trigger or lead to a flare of rosacea symptoms and these triggers vary from patient to patient. The common factors tend to be sun exposure, hot environments, alcohol consumption, spicy foods and caffeine, emotion and stress.4 Since the aetiology of rosacea is poorly understood, treatment targets the disease symptoms rather than the underlying cause.

Types of rosacea Rosacea is often classified as erythematotelangiectatic, papulopustular, rhinophymatous and ocular.1 Erythematotelangiectatic rosacea consists predominantly of telangiectasia, which are small dilated blood vessels on the face associated with flushing â&#x20AC;&#x201C; central facial erythema. This is the most common form of rosacea affecting roughly 70% of patients with the Red facial appearance caused by rosacea condition.1 Patients often report a long history of a flushing response to a variety of stimuli. Often, patients get a characteristic sparing of the peri-ocular region also.

Treatment

Since the aetiology of rosacea is poorly understood, treatment targets the disease symptoms rather than the underlying cause It is advised to use sun protection, protective sunscreens if sunshine is a precipitating factor and to avoid other trigger factors through lifestyle changes. Medical treatments for flushing have proven difficult. Betablockers and other drugs such as clonidine have been used to try and reduce flushing find these often lead to a partial response and I have not found them to be effective in most patients. A new topical treatment, brimonidine tartrate, to treat facial erythema has been developed. This is a highly selective alpha-2 adrenergic receptor agonist with potent vaso-constrictor activity. The alpha-2 adrenergic receptor is found in vascular smooth muscle and induces vasoconstriction in the peripheral blood vessels.7 This targets areas of persistent facial erythema. It normally is applied to the affected areas of the face and usually has an effect within 30 minutes of its first application. This can last for up to twelve hours,8 and can be very helpful in reducing erythema, but is not a cure for rosacea symptoms. The most frequent related adverse effect included worsening of erythema and flushing, pruritis and skin irritation in one third of patients, though no serious adverse effects were observed.8 Patients may still induce flushing by exposing themselves to factors which they would normally avoid.8 In recent years, however, the use of lasers has led to significant advances in the treatment of rosacea.

Laser treatment of rosacea Vascular lasers and intense pulsed light systems are capable of reducing both erythema and telangiectasia.9 The aim is to reduce the superficial vasculature which leads to a reduction in redness as well as the secondary symptoms of flushing, and the burning

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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or stinging sensations.10 The pulsed dye laser was first successfully used by Tan et al in 1989 for the treatment of port wine stains. The pulsed dye laser emits a pulsed beam of a yellow light at 595nm. This is absorbed by oxidised haemoglobin in superfical blood vessels.

It’s important to note that, Purpura caused by laser treatment the brief pulse duration can cause vascular rupture which leads to purpura.9 This was one of the limitations of the pulsed dye laser treatment. Now, however, one can use increased pulsed durations which I have found can reduce purpura and avoid the need for “down time”, making this treatment much more acceptable. Other lasers such as the Potassiunm Titanyl Phosphate laser (KTP) are useful particularly for linear telangiectasia on the nose and rarely lead to any bruising.11 The Neodymium:Yttrium- Aluminium- Garnet (Nd:Yag) laser 1064nm can also be used for erythetemato-temngiectatic rosacea particularly for larger calibre vessels.12 Individuals treated this way can become asymptomatic. It cannot be considered a cure in that the underlying aetiology has not been addressed and the individual may get an exacerbation of rosacea in the future, but from my experience I have found it does lead to long periods of remission.

Before

After

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Aesthetics aestheticsjournal.com

Simply removing the erythema can lead to a significant improvement psychologically removed layers of skin in a more controlled manner.

The whole epidermis and a variable thickness of dermis is ablated.

Ablative lasers can be used for incisional surgery and have the advantage of non-contact with the skin, haemostasis, reducing post-operative pain, and the sealing of lymphatic channels.

The goal of surgical management of rhinophyma is to debulk the hypertrophied tissue and leave an adequate glandular reserve to allow reepithelialisation with a relatively low risk of scarring.

CO2 continuous wave laser ablation allows for precise ablation of the hyperplastic tissue, and haemostasis during the procedure allows visualisation of the treated areas and greater control over contouring.15 Reepithelialistion often takes about two weeks.

Rhinophymas have also been treated with fractionated ablative CO2 lasers, which has achieved good results in early to moderate cases of rhinophyma using relatively aggressive parameters.16 This still retains the benefits of a fractionated treatment such as faster healing times and fewer adverse events.16 In summary, laser technology continues to improve and has led to a significant improvement in our ability to treat the erythema, telangiectasia, flushing and secondary symptoms of rosacea as well as the complications of rhinophyma.

Dr Daron Seukeran is a consultant dermatologist at the James Cook University Hospital, Middlesbrough, with an interest in Laser surgery. He is also the medical director of the SK:N laser Clinics in Harley Street and Maida Vale in London. Dr Seukeran has a wide range of expertise in laser surgery, particularly in the treatment of vascular lesions, laser resurfacing for acne scarring and other forms of laser ablation.

Treatment of rhinophyma using lasers

Simply removing the erythema can lead to a significant improvement psychologically, particularly in terms of the perception that a red face is associated with alcohol consumption.

This effect is highly desirable as a red face can be a source of personal embarrassment, emotional distress, and social isolation.13 Shim et al demonstrated that erythemato-telangiectatic rosacea impairs quality of life as measured by the DLQI (disability life quality index). The authors have also shown that laser treatment significantly produced a reduction in DLQI score and reinforced the effectiveness of PDL in the treatment of rosacea and the disease impact on the psychosocial aspect of rosacea.14

Ablative Lasers: The use of the CO2 laser ablation has led to a significant improvement in the treatment of rhinophyma.

During the 1980s and 90s, continuous wave carbon dioxide lasers were used for laser resurfacing the skin, which meant removing the skin layer by layer with a view to allowing the growth of new smoother, more evenly toned skin.

To reduce the thermal damage that occurred in the skin tissue pulsed CO2 (10600nm) laser systems were developed. These

REFERENCES 1. Wilkin J, et al., ‘Standard classification of rosacea: Report of the National Rosacea Society Expert

Committee on the Classification and Staging of Rosacea’, J Am Acad Dermatol, 46(4) (2002), pp.

584–7.

2. Powell FC, ‘Clinical Pratice. Rosacea’, NEJM, 352 (2005), pp. 793-803.

3. Belivosky C, Ilhe F, Pernet AM, ‘Equale study: impact of rosacea on quality of life on affected patients’, J Am Acad Dermatol, 56 (2007).

4. National Rosacea Society, ‘Rosacea Triggers Survey’, (National Rosacea Society) <http://www. rosacea.org/patients/materials/triggersgraph.php> 5. Kyriakis KP, et al., ‘Epidemiologic aspects of rosacea’, J Am Acad Dermatol, 53 (2005), pp. 918–9.

6. Van Zuuren EJ, Kramer S, Carter B et al. (2011) Interventions for rosacea. Cochrane Database Syst

Rev 3:CD003262.

7. Tong LX1, Moore AY, ‘Brimonidine tartrate for the treatment of facial flushing and erythema in rosacea’, Expert Rev Clin Pharmacol, 7(5) (2014), pp. 567-77.

8. Fowler J Jr et al, ‘Efficacy and Safety of once daily topical Brimonidine Tartrtate gel 0.5% for the

treatment fo moderate to severe facial erythema of rosacea: Results of two randomized

doulble blind , vehicle –ccontrolled pivotal studies’, J Drugs Dermatol, 12(6) (2013), pp. 650-656.

9. Neuhaus IM, Zane LT, Tope WD., ‘Comparative efficacy of nonpurpuragenic pulsed dye laser and

intense pulsed light for erythematotelangiectatic rosacea’, Dermatol Surg, 35 (2009), pp. 920–928.

10. Clark SM, Lanigan SW, Marks R., ‘Laser treatment of erythema and telangiectasia associated with

rosacea’, Lasers Med Sci., 17 (2002), pp. 26–33.

11. Becher GL et al., ‘Treatment of superfical vascular lesions with KTP 532nm laser: experience with

647 patients’, Lasers Med Sci, 29(1) (2014), pp. 267-71.

12. Salem SA et al., ‘Neodymium-yittrium aluminum garnet laser laser versus pulsed dye laser in

erthemt-telangiectatic roseacea: comparison of clinical efficacy and effect on cutaneeous

substance (P) expression’, J Cosmet Dermatol, 12(3) (2013), pp. 187-94.

13. Menezes N, Moreira A, Mota G, Baptista A., ‘Quality of life and rosacea: pulsed dye laser impact’, J

Cosmet Laser Ther, 11 (2009), pp. 139–141.

14. Shim TN, Abdullah A, ‘The effect of pulsed dye laser on the dermatology life quality index in erythe

matotelangiectatic rosacea patients: an assessment’, J Clin Aesthet Dermatol, 6(4) (2013), pp. 30-2.

15. Moreira A et al, ‘Surgical treatment of rhinophyma using carbon dioxide (CO2) laser and pulsed dye laser(PDL)’, J Cosmet Lase Ther, 12(2) (2010), pp. 73-76.

16. Serowka KL1, Saedi N, Dover JS, Zachary CB, ‘Fractionated ablative carbon dioxide laser for the

treatment of rhinophyma’, Lasers Surg Med, 46(1) (2014), pp. 8-12.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Aesthetics Journal

Aesthetics

Anatomy and pathogenesis of ageing Sound understanding of the anatomy in this region is absolutely essential for safe and effective rejuvenation of the infraorbital region. The anatomy of this region over the bone (figure 1) consists of:5 1.

2.

3.

4.

5.

Infraorbital Rejuvenation Dr Kieren Bong details his technique for successful rejuvenation of the infraorbital region using hyaluronic acid (HA) fillers Introduction The ageing process of the infraorbital area is typically characterised by bone resorption, muscle atrophy, fatty tissue volume loss and thinning of the skin. Traditionally, infraorbital rejuvenation involves surgical excision of excess skin, muscle and fat, with the philosophy that facial ageing is characterised by excess tissue. Rejuvenation of this region has evolved considerably over the past decade and we now better understand the anatomy and pathogenesis of ageing in this area. It is generally accepted that volume restoration of the infraorbital region should form part of a comprehensive rejuvenation strategy and, historically, this was achieved through the use of collagen (bovine or human), hyaluronic acid (HA, animal or nonanimal based), autologous fat and poly-Llactic acid.1 Though our understanding of these anatomical concepts has evolved, these various volume replacement methods have presented challenges, limitations and complications.2 Today, patients appear more interested in a less invasive approach. The advent of HA dermal fillers, especially those specifically formulated for this facial area, offer a viable option to rejuvenate mild to moderate deformities in the infraorbital region, providing patients with what I believe is a safe and effective treatment option, without the down time and costs normally associated with surgery.

The skin Superficial fat compartment Orbicularis oculi muscle (OOM) Suborbicularis oculi fat (SOOF) Periosteum

The bony orbit forms the foundation for the peri-orbital complex. Orbital fat is held in place and contained by the orbital septum, which runs from the orbital rim to the tarsal plate. The OOM is a broad sphincteric muscle, which covers the tarsus, septum and bony orbit. It is a pivotal supporting structure for the eyelid and inferior orbital fat. Deep to the inferior OOM lies the SOOF. Inferior to the OOM lies the malar fat pad.6 Ageing may cause pseudoherniation of inferior orbital fat, secondary to weakening of the orbital septum. This results in a protuberance of the lower eyelid.1 Loss of volume in the mid face, coupled with translocation of malar fat pad inferiorly, causes increased exposure of the inferior orbital rim and subsequently relative surface depression and an apparent increase in lower eyelid length.1 The loss of osseous support through bone resorption, muscle atrophy, loss of fatty tissue volume and thinning of the skin all contribute toward the formation of tear trough in infraorbital hollows.1 Also known as the nasojugal groove, the tear trough is a depression extending

What makes HA dermal filler appropriate for the periorbital area?

HA is a molecule that naturally occurs in the extracellular matrix of connective tissues, interstitial membranes, skin, joints and the vitreous body of the eye.

It is a glycosaminoglycan disaccharide and it has the ability to bind 1,000 times its molecular weight in water, which makes it the perfect substance for adding volume to the tissue.1 Its biocompatibility across species, which reduces the risk of immunologic reactions and rejection,1 is one of HAâ&#x20AC;&#x2122;s essential features.

Once injected, HA undergoes a slow process of isovolumetric degradation by enzymatic action of hyaluronidase, offering a longer duration of correction.3 HA dermal fillers now encompass the majority of the temporary dermal filler market..4 I believe this is due to the advantages of HA, finding it to have longer duration (618 months), no need for skin testing, relatively low risk of product-related side effects, and better pliability. Another major advantage is the option of dissolving the HA filler in the event of over-correction, or too Figure 1: Anatomy of the infraorbital region (courtesy of Teoxane data source) superficial a placement.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

@aestheticsgroup

infero-laterally from the medial canthus. It is demarcated superiorly by the infraorbital fat protuberance. The inferior border is formed by the skin of the upper cheek, suborbicularis oculi fat, and portions of the malar fat pad.3 Technique Infraorbital rejuvenation with HA dermal fillers is challenging. Apart from understanding the anatomy and pathogenesis of ageing in this region, clinicians should have considerable experience with injectable fillers and familiarity with the behaviour of the HA being used.

Identifying the correct indication is the key to success. Physical examination and history should ascertain signs of oedema and fluid retention. If the patient describes noticeable swelling in the morning, this is usually indicative of fluid retention or localised lymphatic drainage impairment. Careful preprocedural photography is vital.

Procedure The chair’s backrest is reclined 30° from the upright position and the patient’s head should rest firmly against the headrest. A ‘snap test’ is performed to ensure there is no excessive palpebral laxity. I advocate marking out the treatment area, delineating the upper and lower borders of the tear trough. The infraorbital rim should be actively palpated and marked out.

The HA dermal filler may be administered with a hypodermic needle, although I prefer the use of a blunt micro-cannula in this region. I tend to use a 27G microcannula for a more homogeneous placement of filler. Despite having a blunt tip, a 27G micro-cannula is capable of lacerating blood vessels with excessive force.

Placement of the filler should be just above the periosteum, beneath the OOM and immediately inferior to the orbital rim.

Small aliquots of filler are precisely injected along the infraorbital rim to help soften the transition between orbital fat and malar fat, and, accordingly, the appearance of infraorbital hollows. With a hypodermic

Before treatment

Aesthetics Journal

needle, aspiration prior to each injection is advisable to minimise the risk of intravascular injection, and I recommend a serial puncture technique. Bruising may occur when the needle passes through the OOM. The infraorbital rim gives clinicians an idea of where the orbital septum lies, and care should be taken to avoid injection through this structure because this will exacerbate the pseudoherniation of orbital fat.1 Exerting mild pressure with the index finger of the contralateral hand at the orbital margin helps to avoid injection through the orbital septum.

Some patients may require concurrent volume replacement in the mid-face in order to achieve satisfactory results, which should be established and discussed prior to the procedure.

Post-injection, gentle massage may be necessary to minimise surface irregularity, although this should not be necessary if the clinician has decided on the correct HA dermal filler for the patient. Gently place ice packs on the area to promote vasoconstriction. I discourage patients from carrying out any deep tissue massage of the area for three weeks.

Avoid depositing large volumes of the filler in one location, if possible. In fact, I always under-correct procedures and schedule a review appointment for possible touch up four weeks post-treatment.

Possible adverse events and how to avoid these Although rare, from my experience I find that complications occur mostly as a result of a clinician failing to choose the correct product, poor technical skills or a combination of the two. The most common side effect associated with the use of hypodermic needle in this area is bruising – rates ranging from 13-75% depending on the studies.7 This risk can be minimised through the use of blunt micro-cannula and, if appropriate, I would advise the patient to stop anti-platelet-aggregating medications such as NSAIDs, vitamin E, and over-the-counter medications such as ginger, ginseng and ginkgo biloba a few days prior to the treatment.1 The patient should refrain from consuming alcohol and caffeinated drinks a few days before undergoing the procedure.

Application of ice After treatment to the infraorbital area tment packs and gentle

Aesthetics aestheticsjournal.com

pressure for several minutes immediately after injection may further minimise the risk of bruising. Lumpiness or surface irregularity is a complication which can occur with any filler, although more prevalent with HA fillers of high viscosity.8 Thinner skin atrophy of OOM secondary to ageing in this area means any filler should be injected deep beneath the OOM. The risk can be further minimised with the use of non-particulated HA dermal fillers of lower viscosity.

I have found that transient side effects such as injection site inflammation, including erythema and discomfort, are generally associated with the use of hypodermic needle. These typically resolve within one or two days and can be minimised with extra care during injection and with the use of a blunt micro-cannula. I believe that the use of non-particulated HA dermal fillers with a relatively low percentage of crosslink may help too.

Post-treatment, mild oedema is another known adverse event and can occur between 6% - 26% of injections.8 Although tissue trauma can cause mild swelling, post-procedural oedema in this area is usually caused by using incorrect HA filler.

HA is intrinsically hydrophilic and, as such, I think the risk of this adverse event may be minimised with the use dermal fillers of relatively low HA concentration.

The ‘Tyndall effect’ may occur with too superficial a placement of HA and is more commonly observed when particulated dermal fillers are used in this region.2 This presents as a bluish hue just beneath the skin and can be corrected very easily with the injection of hyaluronidase.9 If indicated, the treatment may be repeated within one to two weeks by re-injecting the filler at a deeper plane, beneath the OOM. Infection is possible although the risk can be minimised through judicious use of antiseptic prior to the treatment and observing a strict protocol for infection control.10 Injection necrosis is a rare but clinically significant complication. This may present as vascular interruption at the treatment site with subsequent localised tissue necrosis or intra-arterial injection of filler resulting in distal embolic events.3 Localised vascular interruption is more likely associated with more viscous fillers.1 I would advise minimising the risk with the use of a blunt micro-cannula.

Product migration can also occur, caused

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

Clinical Practice News

by the migration of product from the deep plane through the dissociation of the OOM or too superficial a placement of HA dermal fillers. Apart from injecting the filler supra-periosteally beneath the OOM, I always under-correct and advise against aggressive massaging after the treatment, especially in older patients. Choosing a product that has the correct balance between reticulated HA and free HA is beneficial.

I would describe free HA as like a lubricant – it makes the injection process easier and smoother, but equally too high a concentration of free HA means the product has the propensity to spread and migrate.

Although technically bacteria-derived HA dermal fillers are non-immunogenic, there is a theoretical risk of hypersensitivity against the impurities, which remain after the purification of HA.11 In essence, it is my opinion that an ‘ideal’ HA dermal filler for the purpose of infraorbital rejuvenation should possess the following features: • • • • • •

Relatively low HA concentration Relatively low % of crosslink Relatively low % of free HA Non particulated Healthy balance between viscosity and elasticity Healthy balance between crosslinked and non-crosslinked HA

Conclusion The approval of HA dermal fillers for the treatment of lines, wrinkles and volume replacement has considerably expanded the cosmetic armamentarium. Despite our evolving understanding of the anatomy in the infraorbital region, treatment of the tear trough and infraorbital hollows remains a challenge. The wide variety of dermal fillers available to treat different areas of the face have allowed clinicians to optimise their results and individualise treatment plans to suit the patient’s needs. The appropriate selection of filler, correct injection techniques and patient selection are keys to success.

Dr Kieren Bong runs the Essence Medical Cosmetic Clinic in Glasgow and is an international speaker for Teosyal. He lectures extensively in cosmetic dermatology and has recently secured a position as clinical lecturer at Buskerud University College in Norway. Dr Bong has recently pioneered a treatment technique for peri-orbital rejuvenation.

REFERENCES 1. J. Charlie Finn, ‘Fillers in the Periorbital Complex’, Facial Plastic Surgery Clinics of North America,

2007; 15:123-132.

2. David Funt, ‘Dermal Fillers in Aesthetics: An Overview of Adverse Events and Treatment Approaches’ Dove Press Journal: Clinical, Cosmetic and Investigational Dermatology, 2013; 6:295-316.

3. Giovanni Andre Pires Viana, ‘Treatment of the Tear Trough Deforemity with Hyaluronic Acid’,

Aesthetic Surgery Journal, 31(2011), 225-231.

4. Inja Bogdan Allemann, ‘Hyaluronic acid gel ( Juvéderm™) preparations in the treatment of facial

wrinkles and folds’, Clin Interv Aging, 2008; 3(4): 629–634.

5. Rohrich R., ‘Compartments of the face: anatomy and clinical implications for cosmetic surgery’,

Plast Reconstr Surg, 2007; 119:2219-2227.

6. Peter M. Prendergast, Cosmetic Surgery (Berlin: Springer-Verlag Berlin Heidelberg, 2012), p. 29-45.

7. Rzany B et al, ‘Correction of tear troughs and periorbital lines with a range of customized

hyaluronic acid fillers’, J Drugs Dermatol, 2012; 11:27-34.

8. Goldberg RA et al, ‘Filling the periorbital hollows with hyaluronic acid gel: initial experience with

244 injections’, RAG Ophthal Plast Recons Surgn, 2006; 22:335-343.

9. Airan LE et al, ‘Nonsurgical lower eyelid lift’, Plast Recons Surg, 2005; 116:1785-1792.

10. Indy Chabra, ‘Severe site reaction after injecting hyaluronic acid based soft tissue filler’, < http:// www.cosderm.com/fileadmin/qhi_archive/ArticlePDF/CD/024010014.pdf>.

11. Busso M et al., ‘Reengineering Injectable Hyaluronic Acid Fillers: The Science’ PRIME North America 2014; 2(2): 42-8.

12. David Funt, ‘Dermal Fillers in Aesthetics: An Overview of Adverse Events and Treatment Approaches’ Dove Press Journal: Clinical, Cosmetic and Investigational Dermatology, 2013; 6:295-316.

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With its innovative mode of action EVENSWISS offers a worldwide unique approach in anti-aging care. The patented active ingredient Dermatopoietin® (a full equivalent of the human epidermal cytokine interleukin-1 alpha) affects the dermal skin layer without penetrating skin by triggering a cascade of reactions which propagates from the surface to the depth of skin. This way it stimulates the natural production of collagen and elastin.

53- YEAR OLD SKIN COLLAGEN LOSS

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Skin rejuvenating effects of interleukin-1 alpha: A cosmetic study on collagen deposition and elasticity in ageing skin Peter Schoch, PhD (Zürich), Igor Pomytkin, PhD (Moscow)

METHOD: Skin density (collagen content) was measured by ultrasonography at 20 MHz using a DermaScan scanner. Bright pixels on ultrasonograms represent high echogenic areas rich in protein; dark pixels represent low echogenic areas composed primarily of proteoglycans, lipids and water. Skin elasticity was measured with a Cutometer SEM 575, a non-

Figure 1.

Schematic representation of the cutometric measurement of Ua ‘gross skin elasticity’ (parameter R2). ‘Extension’ is the deformation Uf of skin upon applying suction.

Upon release of suction the skin R2=Ua/Uf relaxes and eventually returns to the original shape by multiple Time processes at different velocities.

The suction and relaxation phases lasted 1 s each. Uf is the extension after 1s of suction, Ua is measured after relaxation for 1s.

Ua represents the elastic component of the relaxation process of skin. The larger R2 = Ua/Uf the higher the skin’s elasticity. Green: aged skin; red: young skin.

Extension

IL-1a, a cytokine of 159 amino acids, is best known for its role in the regulation of the immune response. Due to its pleiotropic nature, it has, however, other functions. In skin, IL-1a acts as a messenger regulating skin homeostasis,1,2 and it is highly and constitutively expressed by keratinocytes in the epidermis.3 The epidermis, in particular the stratum corneum, is the tissue which contains by far the highest content of IL-1a in the human body.4 The target cells of epidermal IL-1a are dermal fibroblasts.8 IL-1a does not only stimulate their proliferation but also activates, in a concentration-dependent manner, the production of procollagen and collagenase, as well as the expression of several growth and differentiation factors for epidermal cells.5,9,10,11,12 Only at low concentrations does IL-1a also induce the expression of the tissue inhibitor of metalloproteinase (TIMP), a potent inhibitor of collagenase, thus shifting the balance between the production and degradation of collagen towards production.8 Therefore, only low doses of IL-1a are beneficial for collagen replenishment in skin. Furthermore, keratinocyte-derived IL-1a induces fibroblasts to express growth factors which act back on the epidermis and stimulate its regeneration.13 The expression of IL-1a by keratinocytes2,14 and the production of collagen15 have been shown to decline in ageing skin. The resulting deficit of IL-1a has been hypothesised to be at least partially responsible for the signs of skin ageing. The study detailed below shows that topical administration of a cosmetic formulation containing IL-1a on ageing skin improves structure and function of ageing skin by increasing its density (collagen deposition) and improving its elasticity.

invasive suction/relaxation device to measure the kinetics of rapid and slow movements of skin deformation. Suction and relaxation periods lasted 1 s each. The parameter R2 (‘gross skin elasticity’, Figure 1) is measured during the relaxation phase. It measures the ratio of the rapidly relaxing skin deformation at the end of the 1 s-relaxation phase over the total skin extension at the end of the 1 s-suction period. It is the portion of the relaxation phase with elastic characteristics. The parameter R6 is measured during the suction period. It is the ‘viscoelastic to elastic portion’ of skin elasticity (Figure 2) and is measured by determining the fraction of the extension from 0.1 s to 1 s over the initial rapid extension during the first 0.1 s after applying suction.

Figure 2.

Schematic representation of the cutometric measurement of the viscoelastic portion of the skin extension process (parameter R6).

The application of suction lasts 1s. Ue represents the fast elastic R6=Uv/Ue Ue component of skin extension that Time occurs during the first 0.1s. Uv is the slow viscoelastic portion between 0.1s and 1s. R6 = Uv/Ue = [extension at t = 1s – extension at t = 0.1s] / extension at t = 0.1s. Green: aged skin; red: young skin.

Uv

Extension

ABSTRACT Objective: The aim of this study was to test the efficacy of interleukin-1 alpha (IL-1a – trademark name Dermatopoietin) on skin renewal, in volunteers with signs of skin ageing. Method: A placebo-controlled and randomized clinical study on skin renewal was conducted in 21 healthy female volunteers (51 ±6 years) by administering a cosmetic formulation with and without IL-1a twice daily upon either the right or left forearm for eight weeks.

Results: Ultrasonograms of all 21 volunteers at baseline and after 28 and 56 days of treatment with a cosmetic formulation containing IL-1a showed improvement of skin density and the partial disappearance of SLEB in all volunteers. The verum formulation containing IL-1a increased elasticity by 20.7% and 15.2% after 28 and 56 days, respectively. Verum-treated skin showed less viscoelasticity than placebo-treated skin.

Conclusion: The results show experimental evidence for a structural (density) and functional (elasticity) improvement of skin by topical administration of a cosmetic formulation containing IL-1a.

RESULTS: Ultrasonography at 20 MHz frequency Ultrasonography is a visualisation technique for skin architecture (Figure 3). Light pixels indicate high echogenic areas containing lots of protein, e.g. collagen, keratin and elastin. Dark pixels, on the contrary, are low echogenic due to their scarcity of proteins and abundance of proteoglycans, lipids and/or water. A typical marker of skin ageing, in particular of photoageing, is SLEB, the subepidermal low echogenic band.16

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Before treatment

After treatment with IL-1a

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Figure 4.

Day 0

SLEB: subepidermal low echogenic band, a reliable marker of skin (photo-)ageing.

Figure 3.

Ultrasonography at 20 MHz is a technique to visualise skin architecture. Light pixels reflect skin proteins, dark pixels proteoglycans, lipid and/or water. The dense structure on the left side is the epidermis (keratin). Underneath the epidermis is the dermis with the main protein collagen. The SLEB, which partially disappears after treatment with IL-1a, is part of the dermis.

Figure 4 (right) shows the ultrasonograms of 20 volunteers at baseline and after 28 and 56 days of treatment with a cosmetic formulation containing IL-1a. Striking is the clear improvement of skin density and the partial disappearance of SLEB in all volunteers.

Skin elasticity Skin elasticity is a functional parameter of skin which slowly deteriorates with ageing.17 Figure 5 shows that the verum formulation containing IL-1a has a skin rejuvenating effect by increasing elasticity by 26.8% and 15.2% after 28 and 56 days, compared to placebo, respectively. The placebo formulation was without effect. A related skin parameter is called R6, which denominates the ratio between the viscoelastic and the elastic deformation of skin upon applying a mechanical force (suction). The portion of viscoelastic processes in skin deformation increases with age. Figure 6 shows that verum-treated skin exhibits 21.4% less viscoelasticity than placebo-treated skin after 28-days treatment.

25% 20% 15% 10% 5% 0% -5% -10%

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Day 28

Day 56

Day 0

1

11

2

12

3

13

4

14

5

15

6

16

7

17

8

18

9

19

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20

Day 28

Day 56

20.7% * 15.2% Placebo Verum 0.0%

-6.1% Day 28

Day 56

Figure 5.

Change of gross skin elasticity (R2) after 28- or 56-day treatment with either verum or placebo. R2 indicates the elastic portion of skin relaxation after its mechanical deformation.

Only the formulation containing IL-1a improved skin elasticity.

The difference between verum and placebo at Day 28 was significant with a p-value of 0.03.

Figure 4.

Ultrasonograms of the forearm skin of 20 subjects out of the 21 volunteers participating in the study at baseline and after 28 and 56 days of treatment with a formulation containing IL-1a, respectively. All subjects showed clear improvement of skin structure.

CONCLUSION: IL-1a is shown to be an innovative active ingredient for cosmetic products with skin rejuvenating (anti-ageing) properties. It acts on the surface of skin by stimulating keratinocytes, the main cells of the epidermis, to produce and release endogenous IL-1a. The physiological function of this cytokine is to stimulate the fibroblasts in the dermis to increase the expression of collagen and elastin which leads to denser and tighter skin, and eventually to an improved skin elasticity and reduced wrinkles (not shown). Topical IL-1a thus affects deep skin structures without penetrating skin by triggering a cascade of

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

aestheticsjournal.com 25% 20% 15% 10% 5% 0% -5% -10%

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16.7% Placebo

9.4%

Verum 1.1%

* -4.7% Day 28

Day 56

Figure 6.

Change of viscoelasticity (R6) of skin after a 28- or 56-day treatment with verum or placebo, respectively. The difference between verum and placebo at Day 28 was significant with a p-value of 0.0008. reactions, which propagate from the surface to the depth of skin. In the present paper we show experimental evidence for a structural (density) and functional (elasticity) improvement of skin by topical administration of a cosmetic formulation containing IL-1a.

This study was conducted by the Skin Test Institute, Neuchâtel, Switzerland, under the guidance of Dr Alain Béguin.

Dr Igor Pomytkin created Dermatopoietin and is the owner of numerous other patents. He has a PhD in chemistry and is the current science director of Buddha Biopharma Oy, Helsinki, Finland. Dr Pomytkin previously worked as a senior research scientist at the Institute of Chemical Physics, Moscow.

Dr Peter Schoch is head of research, development and regulatory affairs at United Cosmeceuticals GmbH.He was previously vice-director for pharmaceutical project development at F.HoffmannLa Roche, and managing director of the European Society of Clinical Microbiology and Infectious Diseases in Basel, Switzerland.

V-SOFT LIFT is an innovative and less invasive alternative to traditional cosmetic surgery and dermal fillers. V-SOFT LIFT is performed using fine threads that “lift” your skin, increase elasticity and are completely absorbed. The threads are made of polydioxanone (PDO) which is known to be extremely compatible with the natural tissue in our dermis and has been used for over 30 years. An added benefit is that the material, PDO, stimulates the body’s natural production of collagen making your skin healthier and thicker.

REFERENCES 1. Barland C O et al. ‘Imiquimod-induced IL-1 alpha stimulation improves barrier

homeostasis in aged murine epidermis’, J Invest Dermatol (2004), 122: 330.

2. Ye J et al. ‘Alterations in cytokine regulation in aged epidermis. Implications for

permeability barrier homeostasis and inflammation’ Exp Dermatol (2002), 11: 209 3. Gahring L C et al. ‘Presence of epidermal-derived thymocyte activating factor/IL-1 in

normal human stratum corneum’ J Clin Invest (1985), 79: 1585.

4. Hauser C et al. ‘IL-1 is present in normal human epidermis’ J Immunol (1986), 136: 3317 5. Luger T A and Schwarz T. ‘Evidence for an epidermal cytokine network’ J Invest Dermatol (1990), 95: 100S 6. Wood L C, et al. ‘Cutaneous barrier perturbation stimulates cytokine production in the

epidermis of mice’ J Clin Invest (1992), 90: 482.

7. Lee S W et al. ‘Autocrine stimulation of interleukin-1 alpha and Transforming Growth

Factor-alpha production in human keratinocytes and its antagonism by glucocorticoids’ J Invest Dermatol (1991), 97: 106 8. Postlethwaite A et al. ‘Modulation of fibroblast functions by IL-1: Increased steady-

state accumulation of type I procollagen mRNAs and stimulation of other

functions but not chemotaxis by human recombinant IL-1 alpha und IL-1 beta’ J Cell Biol (1988), 106: 311 9. Duncan M R and Berman B. ‘Differential regulation of collagen, glycosaminoglycan,

fibronectin, and collagenase activity production in cultured human adult dermal

fibroblasts by IL-1 alpha/beta and TNF alpha/beta’ J Invest Dermatol (1989), 92: 699.

10. Goldring M B and Krane S M. ‘Modulation by recombinant IL-1 of synthesis of types I

and III collagens and associated procollagen mRNA levels in cultured human cells’ J

Biol Chem (1987), 262: 16742 11. Veli-Matti K et al. ‘IL-1 increases collagen production and mRNA levels in cultured skin fibroblasts’ Biochim Biophys Acta (1987), 929: 142 12. Werner S and Smola H. ‘Paracrine regulation of keratinocyte proliferation and differentiation’ Trends in Cell Biol (2001), 11: 143 13. Maas-Szabowski N et al. ‘Keratinocyte growth regulation in defined organotypic

cultures through IL-1-induced keratinocyte growth factor expression in

resting fibroblasts’ J Invest Dermatol (2000), 114: 1075 14. Dae Hun Suh et al. ‘Effects of 12-O-tetradecanoyl-phorbol and sodium lauryl sulfate

on the production and expression of cytokines and proto-oncogenes in photoaged

and intrinsically aged human keratinocytes’ J Clin Dermatol (2001), 117: 1225 15. Varani J, et al. ‘Decreased collagen production in aged skin’ Am J Pathol (2006), 168: 1861 16. Gniadecka M. ‘Effects of ageing on dermal echogenicity’ Skin Res Technol (2001), 7: 204 17. Ryu HS et al. ‘Influence of age and regional differences on skin elasticity as

measured by the Cutometer’ Skin Res Technol (2008), 14: 354

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aponeurosis. It may cause a pseudo-ptosis because of the weight of tissue pushing the upper eyelid down.4 There can also be associated eyebrow ptosis (droop) and compensatory eyebrow elevation to lift the skin and soft tissue.

Upper Eyelid Dermatochalasis Consultant ophthalmologist and oculoplastic surgeon Miss Jane Olver discusses the cause and treatment of sagging of the eyelid What is eyelid dermatochalasis?

Periocular dermatochalasis is the medical term for excessive loose skin and eye bags. It most commonly affects the upper eyelids where the skin fold loses elasticity and drops both outwards and down onto the eyelashes, also known as ‘hooding’.

The excessive or redundant upper eyelid skin and subcutaneous tissue is caused by either recurrent episodes of swelling (blepharochalasis) or, more commonly, by involutional changes with age and for hereditary reasons. Medical causes of dermatochalasis, include thyroid eye disease, renal failure, trauma, Ehlers-Danlos syndrome, amyloidosis, hereditary angioneurotic edema and xanthelasma.1,2 Cutis laxa (CL), or elastolysis, is a rare, inherited or acquired connective tissue disorder in which the skin becomes inelastic and hangs loosely in folds. The orbital fat, especially the medial fat pad of the upper eyelid, can prolapse through the thin attenuated orbital septum and appear as an unsightly bulge. These are involutional age changes.3 Symptoms of dermatochalasis Cosmetic versus medical Patients may request blepharoplasty to resolve dermacholasis, which is vital in facial rejuvenation and can be both a functional and cosmetic procedure designed to restore a more youthful, bright, and energetic appearance to the eyes. Dermatochalasis can cause a sensation of heaviness and affect the visual field, especially if it is severe with lateral hooding.

The condition can also disturb the normal upper eyelid pretarsal show, sometimes interfering with the application of eye makeup. For patients it can cause mascara to run due to the skin touching the upper lid lashes, and further cause watering eyes from the exfoliation of skin cells and debris dropping into the eyes from excess skin. With lateral hooding, this can cause tears to form at the lateral corner of the eye.

Associated peri-orbital changes Dermatochalasis may be associated with upper eyelid ptosis (drooping) secondary to disinsertion or dehiscence of the levator

Indications for Surgery 1. Cosmetic 2. Functional Indications for surgery can be either cosmetic or functional. A report by the American Academy of Ophthalmology in 2011 showed that significant improvement in the patients vision, visual field and quality of life is obtained with blepharoplasty surgery for dermatochalasis in patients with preoperative symptoms from the dermatochalasis including; superior visual field defect, visual strain, down-gaze ptosis and a reduced upper margin reflex distance (distance central pupil reflex to edge upper lid margin).5

Management of dermatochalasis Assessment Assessment is key to choosing the correct surgical approach to ensure success. It is crucial to ascertain the patient’s concerns, assess their eyelids and prepare a clear surgical plan.

The patient sometimes complains about tired eyes, sad eyes, or extra tissue around the eyes.6 Ask how the eye bags affect them to determine whether the problem is cosmetic or whether it also affects vision. The patient should provide photographs taken prior to the eye bags becoming noticeable.

Does dermatochalasis run in the family? Do they have a dry eye and have they had corneal refractive surgery? Patients attending for a revision blepharoplasty are a dissatisfied patient requiring additional attention and careful listening. Outline a realistic plan to meet their goals.7

Physical examination of the eyelids, periorbital area and eyes The patient’s entire face and eyelids are examined during the consultation, and an ophthalmic assessment is carried out. Assess the amount of loose tissue to determine if there is co-existent eyelid or eyebrow ptosis, or brow compensatory elevation. Look for fat herniation or protrusion. Medially, the small medial fat pad often herniates forwards. Centrally, the pre-aponeurotic fat pad forms a gentle fullness and helps maintain the skin fold. Also centrally, the sub-brow fat or ROOF (retro-orbicularis oculi fat pad)8 can descend because of loose connective tissue and can contribute to the heaviness and bulging.9 Ptosis is detected by measuring the vertical palpebral aperture in mm though the level of the pupil, and also the upper margin reflex distance in mm, between the light reflex on the cornea and the upper eyelid margin. Normally the upper eyelid margin rests 3.5 to 4.5mm above the centre of the pupil. If there is less than 2.5mm, the ptosis may require correction at the same time as blepharoplasty surgery.10 A simple test with a drop of 2.5% phenylephrine placed on the eye will help unmask a small ptosis on one side as it will raise the eyelid and show the “normal” position in many patients. Measure the visual function and examine the eyelid and ocular surface on the slit lamp. Test for eyelid and eye surface conditions such as blepharitis, dry eye, horizontal eyelid laxity or any other conditions that could be exacerbated by a blepharoplasty. The height of the supra-tarsal crease where the levator aponeurosis pull is exerted is an essential landmark usually 7-9 mm

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above the lid margin in women, and 6.5-8 mm in men.

Visual Field Analysis and Photography A computerised visual field test is required to determine the extent of visual impairment. The visual fields of both eyes together are examined using a Humphrey Field Analyser test such as the Binocular Esterman. This measures functional scores of whether the patient sees tiny dots of light in different parts of their peripheral visual field. This test is well known to the DVLA as it is the current gold-standard for testing binocular visual fields for driving used by

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many national driving authorities. Binocular Esterman visual fields will show pre-operatively whether the upper eyelids are interfering with the superior visual field and if the dermatochalasis is causing a functional problem. Photographic documentation should also be taken in primary gaze, 30 degrees downgaze, oblique and side views both before and after the procedure.

Goals of upper eyelid blepharoplasty The goals of upper eyelid blepharoplasty are to create a sculpted upper lid with a visible pre-tarsal strip and subtle fullness along the lateral upper lid-brow complex. There is an Table 1: Information that should be given to patients on potential increasing trend towards volume preservation and complications of upper eyelid blepharoplasty.12, 13, 14 creating a very natural look compared to 15-20 years ago. Then the emphasis was on creating high skin Mild bruising and swelling This can last for up to three weeks. creases, with a skeletonised and hollow upper lid due to overaggressive fat resection. The aesthetic Blurred vision This can occur for a few hours or overnight. It is usually due to surface ocular drying from effect benefits of preserving periorbital fat are now valued.11 of the anaesthetic. If this persists for more than In Asian blepharoplasty the aims are different in that 24 hours, you should inform your oculoplastic the pre-tarsal show is minimised and more soft tissue surgeon. (fat) removed, unless requiring a Westernisation type Watery eyes Reflex tearing commonly occurs for one to blepharoplasty.12 two days following surgery due to mild ocular discomfort and surface dryness.

Dry gritty eyes

This can last for two to three weeks due to reduced blinking. You will be prescribed artificial tears to take during the day (e.g. Hypromellose, Systane, Viscotears or Celluvisc 0.5%) and an ointment at night (e.g. Lacrilube or ‘Simple Eye’ Ointment) to ease this. Topical antibiotics such as Chloromycetin are used for one week if surgery has been done from inside the eyelid.

Scratched surface of the eye (corneal abrasion)

Even minor injury to the eye surface during surgery can result in a small abrasion and pain lasting twenty-four hours. If it persists or is severe, the oculoplastic surgeon must be informed.

Marked bruising

Marked eyelid bruising or haematoma may occur and is easily visible. Bleeding behind the eye, however, occurs rarely and is not always visible.

Haematoma is characterised by severe pain and it may cause loss of vision if not dealt with urgently by lateral canthotomy and cantholysis.

Blindness

This is very rare and is thought to be due to bleeding deep behind the eye, see above.19

Wound infection

This may occur during the first seven to ten days after blepharoplasty surgery.

Incomplete eyelid closure

The eyelids may feel stiff for one to two days and be unable to completely cover the surface of the eye when closed. This usually settles in a few days. If it does not, most likely too much skin was removed.

Asymmetry

There may be a minimally uneven skin crease or lid height. Asymmetry may be noticeable if there is swelling. If the asymmetry persists after three weeks, it is possible that it can be corrected with later surgery.

Scarring

This is rare in the periocular area. Scarring can usually be later revised with ‘Z-plasty’ type surgery to break up and conceal the scar.

Repeat surgery

Patients should be warned of the need for further surgery if an optimum result is not achieved.

Consent for surgery and patient expectations An information sheet about the surgery and potential complications must be given to the patient at the assessment, and a consent form signed before surgery, showing the surgeon understands the patients’ expectations and reinforcing realistic goals.13 Treatment Very early dermatochalasis with a slight brow ptosis can be managed in certain cases with botulinum toxin A brow elevation.14 However, the treatment for more severe upper eyelid dermatochalasis is eyelid blepharoplasty, a delicate oculoplastic surgery.

Associated eyelid should be corrected, and if there is brow ptosis causing a secondary dermatochalasis, then brow surgery is performed first or simultaneously to the blepharoplasty.

Upper eyelid blepharoplasty Mark the skin crease The skin crease is marked with the patient sitting up prior to administering local anaesthetic. The height of this varies between six and eight millimetres and is commonly lower in Asian patients who have a naturally low skin crease, unless ‘Westernisation’ is requested, and is always lower in men than women. After mark-up, a minimum of 20 mm of skin should remain.

Local anaesthesia A mixture of long acting and short acting local anaesthesia is injected, with weak adrenaline 1 in 400,000. Approximately 5ml are required each side, with top ups available throughout the surgery. Topical anaesthetic drops are placed on the eyes at the start and throughout the surgery. A protective contact lens is advised.

Incision The incision is made along the natural eyelid skin crease a few millimetres above the eyelashes and

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Upper lid blepharoplasty Figure 1a

Figure 1b Skin +/muscle

Skin incision closed with stitches

Skin marking

Firstly the surgeon marks with a pen the amount of skin that is required to be removed.

After an injection of local anaesthetic the excess of skin is removed

The skin is always removed. Usually a bit of the underlining muscle is also removed.

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Complications of Upper Eyelid Blepharoplasty Surgery Complications occur because of inadequate assessment, poor surgery decisions and patients’ expectations not being met. It is imperative that the patient be fully informed of the potential risks of upper eyelid blepharoplasty surgery.17,18,19 (See Table 1).

The skin incision is closed using fine stitches that usually are removed after 7-10 days.

Results of upper eyelid blepharoplasty These are both subjective and objective. Photographic analysis and Before and after upper eyelid blepharoplasty a patient satisfaction questionnaire following an upper eyelid Before Dermatochalasis, After upper and lower lid wrinkles, orbital fat prolapse etc, blepharoplasty blepharoplasty surgery shows that give the eyes and eyelids an Eyes and eyelids look most patients are highly satisfied aged appearance upper lid skin younger with lighter and sags, there is lower lid puffiness, softer skin are more open with their results.18 Blepharoplasty eyelashes point downwards with better eyelid position surgery should be performed by an and visual problems occur fewer wrinkles and fewer ophthalmologist trained in eyelid when looking up. visual problems. surgery, known as an oculoplastic surgeon. Plastic surgeons, follows the pre-marked lines. maxillofacialsurgeons, and entsurgeons also include blepharoplasty Excision in their curriculum and may choose to include it in their repertoire, An elliptical piece of skin and muscle is removed in two separate however, I would recommend an occuloplastic surgeon as they layers using a blade or a Colorado needle, which greatly reduces are very familiar with all the structures around the eye and are best bleeding and helps keep the surgery very neat. Great care is trained to manage complications. made to avoid damage to the underlying thin levator aponeurosis.

Miss Jane Olver is a consultant ophthalmologist Sit the patient up and oculoplastic surgeon specialising in eyelid surgery.

She is the medical director and founder of Clinica The patient is sat up several times during the surgery in order to London, a private eye clinic located in the heart of check the eyelid appearance.

London. Since stepping down from her NHS consultant Managing the upper eyelid fat post in August, Miss Olver has dedicated her full time to the practice.

The underlying medial fat pad may be reduced to lessen its bulge.

REFERENCES The medial fat pad can also be repositioned into the medial 1. Jacobs LC, Liu F, et al ‘Intrinsic and extrinsic risk factors for sagging eyelids’, JAMA Dermatol,

150 (8) (2014) 836-43 compartment thus aiding central sulcus volume.15 2. Nagi KS, Carlson JA, Wladis EJ., ‘Histologic assessment of dermatochalasis: elastolysis and Bipolar coagulation-assisted orbital (BICO) septoblepharoplasty is

lymphostasis are fundamental and interrelated findings’, Ophthalmology, 118 (2011), pp. 1205-10.

3. Hornblass A., ‘Ptosis and pseudoptosis and blepharoplasty.’, Clin Plast Surg, 8 (1981)pp. 811-30. where the exposed orbital septum (unopened) is treated with bipolar 4. Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, Mawn LA., ‘Functional coagulation, as opposed to excision. This “shrinks” the fat pads in.16

Indicators for upper eyelid ptosis and blepharoplasty surgery: a report by the American

Academy of Ophthalmology’, Ophthalmology, 118 (2011), pp. 2510-2517.

TIP: If possible preserve fat otherwise the eyelid may have an A 5. Hwang SH1, Hwang K, Jin S, Kim DJ. ‘Location and nature of retro-orbicularis oculus fat and frame deformity (deep central sulcus) with loss of a soft skin crease

suborbicularis oculi fat’, J Craniofac Surg, 18(2) (2007) 387-90.

6. May JW Jr1, Fearon J, Zingarelli P. ‘Retro-orbicularis oculus fat (ROOF) resection in aesthetic fold, which looks ageing.

blepharoplasty: a 6-year study in 63 patients’, Plast Reconstr Surg, 86(4) (1990) 682-9.

Closure 7. Castro E, Foster JA., ‘Upper lid blepharoplasty’, Facial Plast Surg, 15 (1999), pp. 173-181.

8. Stanciu NA, Nakra T., ‘Revision blepharoplasty’, Clin Plast Surg, 40 (2013), pp. 179-189.

The skin incision is then closed using delicate absorbable or non9. Martin JJ, Van de Lei B, Timmerman IS, Cromheecke M, Hofer SO., Ann Plast Surg, 59 (2007), absorbable sutures and /or fibrin adhesive.

pp. 263-267.

10. Pepper J-P, Moyer JS., ‘Upper blepharoplasty: the aesthetic ideal’, Clin Plast Surg, 40 (2013), Post-operative management

pp. 133-138.

After surgery the patient is advised to instil lubricant drops between 11. SM Lam, ‘Asian blepharoplasty’, Facial Plast Surg Clin North Am, 22 (2014), pp. 417-25.

12. Lieberman DM, Quatala VC., ‘Upper lid blepharoplasty: a current perspective’, Clin Plast Surg, two hourly and four times a day for at least one week, use ice packs

40 (2013), pp. 157-165. over the eyelids and sit up or use added pillows when sleeping, in 13. Massry GG., ‘Nasal fat preservation in upper eyelid blepharoplasty’, Ophth Plast Reconstr Surg,

27 (2011), pp. 352-355. order to reduce swelling. Removal of sutures should be 7-10 days 14. Steinsapir KD, Rootman D, Wulc A, Hwang C. ‘Cosmetic microdroplet botulinum toxin A after surgery. If fibrin adhesive is used, patients should use plastic

Forehead Lift: A New Treatment Paradigm’, Ophthal Plast Reconstr Surg, (Sep 11 2014)

[Epub ahead of print] shields to protect the eyelids at night.

15. Van de Lei B, Timmerman IS, Cromheecke M, Hofer SO., ‘Bipolar coagulation-assisted Adjunctive surgery

orbital (BICO) septoblepharoplasty: a retrospective analysis of a new fat-saving upper-eyelid

blepharoplasty technique’, Ann Plast Surg, 59 (2007), pp. 263-267.

A drooping brow ptosis or eyelid ptosis may be operated on during 16. Whipple KM, Lim LH, Korn BS, Kikkawa DO., ‘Blepharoplasty complications’, Clin Plast Surg, 40 the same procedure. A brow ptosis can be corrected before or at the

(2013), pp. 213-224.

17. Raschke GF, Bader RD, Rieger UM, Schultze-Mosgau S., ‘Photo-assisted analysis of same time. Less brow lifting surgery is being done now than it was

blepharoplasty results’, Ann Plast Surg, 66 (2011), pp. 328-333.

10 years ago when there was an enthusiasm to do more invasive 18. Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast

Surg Int 2012;2012:252-68 endoscopic forehead and eyebrow lifts.

19. Goldberg RA, Marmor MF, Shorr N, Christenbury JD. Blindness following blepharoplasty: two

case reports, and a discussion of management. Ophthalmic Surg;1910,:85-9

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The Role of Moisturisers in Skincare Aesthetic nurse Lorna Bowes and consultant dermatologist Sandeep Cliff detail the importance of understanding the role and properties of moisturisers when recommending products to patients An Introduction from Dr Jenna Burton As cosmeceutical companies continue to charge a premium for luxury brand moisturisers, how often do the public consider the scientific evidence supporting why moisturisers actually work and which type of moisturiser is most appropriate for them?

The UK female population is estimated to spend, on average, £131.95 on cosmetics annually.1 The reality being that many individuals will spend more than this amount on any one single ‘anti-ageing’ cream or serum. Moisturisers may be infused with gold, contain almond extracts or simply demonstrate luxurious packaging and design. Yet moisturiser is defined as ‘A cosmetic preparation to prevent dryness to the skin.’ In reality what patients are really seeking from moisturiser is, quite simply, water.

One 2010 study,2 funded by Olay, found that skin hydrated with daily moisturiser aged objectively less over the course of eight years than those who did not maintain adequate methods of skin hydration. The demand from consumers and the experience and results from dermatologists agree that the hydrating qualities of moisturisers make them a worthwhile and beneficial product to use on patients for anti-ageing.

Yet, despite the population’s readiness to part with significant sums of cash in exchange for this ever-popular, ever-used daily routine, many admit to knowing little about the mechanism of action of their favourite preparation. Do they appreciate the difference between why they are purchasing a daily serum as opposed to a thicker, more occlusive night cream? Do they understand what the term ‘occlusive’ means to their skin? Should they purchase the same moisturiser as their friend or should they consider their own skin type?

Lorna Bowes and Dr Sandeep Cliff will now explain how we can educate patients to make more sensible, scientific decisions As practitioners, our patients need us to fully understand the structure and function of the skin to correctly diagnose and prescribe pharmaceutical and cosmetic preparations. We also need to be able to explain the concept of moisturisation and clearly differentiate between humectants, occlusives and emollients, as

well as being able to explain the difference between ‘carrier’ or ‘vehicle’ ingredients and ‘active’ ingredients. In this article we will define these differences and review some of the popular topical ingredients that may lead to increased water content within the skin – essential in maintaining effective skin barrier function and a healthy skin appearance.

Definitions Moisturiser: According to the Oxford English Dicitionary (OED) a moisturiser is a cosmetic preparation used to prevent dryness in the skin. In short, it is a substance that when applied to the skin adds water and/or existing levels of water in the stratum corneum (SC).

Humectant: Again, according to the OED, a humectant is a product retaining or preserving moisture. For example, natural humectants in the SC absorb moisture from the atmosphere, increasing the hydration levels in the outer SC. Occlusive: The OED medical definition of occlusion is: The blockage or closing of a blood vessel or hollow organ. The word ‘occlusive’ is the adjective derivative and is described as ‘of or being a bandage or dressing that closes a wound and keeps it from the air’. In cosmetics, it is the covering and keeping from the air that is relevant.

Emollient: Defined as, “having the quality of softening or soothing the skin”, by the OED.

Water in the skin The outer layer of the skin is the stratum corneum; it comprises mature keratinocytes and on average is 15 cell layers thick.3 The structure of the stratum corneum has frequently been described as similar to ‘bricks and mortar’; the keratinocytes being the ‘bricks’ and lipids and amino acids making up the majority of the ‘mortar’.3 As well as amino acids, other osmolytes in the stratum

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corneum such as glycerol, lactic acid, taurine and urea act as humectants.4 The stratum corneum layer, sometimes known as the ‘horny layer’, contains natural moisturising factor (NMF). NMF is a combination of low molecular weight, water-soluble metabolites of filaggrin, lactic acid and urea. NMF is osmotically active with strong humectant properties and its precise composition varies between individuals and different environments.5 The role of NMF is to prevent transepidermal water loss (TEWL). TEWL was described by Kligman as insensible water loss through the skin via diffusion and evaporation, making it therefore different to perspiration.6 Due to it’s considerable humectant properties (it is composed of the aforementioned water-soluble chemicals), NMF allows the SC to remain hydrated even in very dry environments.3 The lower layers of the skin, including the layers of the stratum compactum, are hydrated by body fluids rather than the humectant properties of the SC.4 What are the roles of lipids in maintaining hydration in the SC? NMF is water soluble; therefore, by it’s nature of being very superficial, is prone to being literally ‘washed away’.6 The ‘mortar’ layer of lipids, such as diglycerides, triglycerides, fatty acids, cholesterol and wax esters, is essential to seal the keratinocyte layer and in turn reduce TEWL.6 It has been clearly shown that inherited lipid metabolism deficiencies lead directly to dry skin conditions such as ichthyosis.7 The lipid ‘mortar’ serves a dual function, also preventing entry of bacteria and water-soluble agents. Sebum production is also important here, as sebum produces glycerol, which is vital for maintaining the skin barrier function.8 Excess sebum certainly leads to oily skin and contributes to acne, however we need to remember the vital function of sebum in treating patients with all skin types, and make skincare choices that work with the natural biology of the skin for best results.

Why is water so important to the SC? Proper hydration of the stratum corneum as a key factor in the maintenance of soft, flexible, healthy skin was reported by Blank in the 1950’s.9 Continuous loss of water through evaporation on the surface of the stratum corneum – at a speed faster than it can be replaced – leads to xerosis (dry skin).10 Add to this the frequent use of hot showers and baths (worse with hard water) along with foaming cleansers, bath salts, gels and body and face scrubs, as well as soaps and detergents, it is easy to see how we frequently wash away the healthy barrier function. Xerosis is a symptom of many dermatological conditions, but is of particular cosmetic and functional importance in the treatment of photoageing and promotion of skin health. It is possible to reduce dehydration in the epidermis by creating an oil film that reduces evaporation, as well as using ‘chemical sponges’ that absorb and hold water within the SC. Moisturisers are a key therapeutic component in topical treatment of various skin conditions such as eczema, lamellar ichthyosis, psoriasis etc.11 A very positive side effect of increased hydration is the reduction in apparent fine wrinkles that a hydrated skin exhibits.10 It is not surprising that ‘moisturisers’ are extremely popular.

There are three main categories of moisturiser – occlusives, emollients and humectants. Although the aim of all moisturisers is to increase moisture in the skin by increasing water content in the SC, they achieve this in very different ways

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What is the difference between ‘carrier’ or ‘vehicle’ ingredients and ‘active’ ingredients?

A carrier or vehicle ingredient is the base in which the ‘active’ ingredients are delivered. In the case of moisturisers, the vehicle is often also an active moisturiser. The group of cosmetic topical preparations that are known as ‘cosmeceuticals’ tend to comprise active ingredients in a vehicle base. By selecting the appropriate base with the ideal active ingredients it is possible to tailor skincare to patients individual needs, for example providing a ‘moisturising base’ with active humectant ingredients to address both water dry and lipid dry skin.

Types of moisturiser There are three main categories of moisturiser – occlusives, emollients and humectants. Although the aim of all moisturisers is to increase moisture in the skin by increasing water content in the SC, they achieve this in very different ways. The key effects required to increase water content are to reduce evaporation, increase the integrity of the skin barrier, and increase levels of NMF and other humectants.

Most moisturiser products are a combination of different moisturising agents, and are designed to be ‘cosmetically elegant’. This is not an easy task as many of the moisturising agents available are sticky and ‘heavy’ in consistency. A key to effective moisturisation is to produce a product that is both effective and tolerable and therefore encourages compliance i.e. regular topical application – a product that stains clothes, leaves skin sticky or prevents the patients applying make-up will not be used regularly.

Moisturisers therefore come in different vehicle formulations (the vehicle usually being one of the moisturising ingredients) known as: Ointment (approx. 80% oil, 20% water) Cream (approx. 50:50 oil: water) Lotion (approx. 70% water 30% oil) Serum (water based) Gel (water based emulsion) For cosmetic preparations creams, lotions and gels are the most commonly used moisturisers; serums tend to be carriers for active ingredients such as antioxidants.12 Occlusives: The main function of an occlusive is to trap water on the surface of this skin, reducing TEWL. Occlusives also act as emollients, because they smooth the skin, filling in the gaps and cracks in the SC between the corneocytes.13 The occlusive effect of these

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ingredients ends as soon as the ingredients are removed from the skin, so any effect is temporary. Petrolatum has been in use as a skin care product since 1872, and is frequently cited as the gold standard against what other moisturisers are compared due to it being one of the most effective occlusives reported.14 The ‘grease’ effect of petrolatum may not be tolerable, petrolatum is a highly effective occlusive but its greasiness can prevent it being an acceptable ingredient in cosmetic products. It is important to note however that petrolatum is also known to be non-comedogenic.19 Other occlusives frequently listed are mineral oils (a liquid mixture of hydrocarbons obtained from petroleum), squalene, beeswax and cannuba wax, silicones such as dimethicone and cyclomethicone, lanolin and shea butter.15 Increasingly, natural oils such as grapeseed, olive and sunflower are being added to this list. Linoleic acid, found in these natural oils, is an omega-6 fatty acid, which is able to provide structural lipids to improve skin barrier integrity.16 Humectants: Humectants are ingredients that are able to draw water into the upper layers of the epidermis either from the atmosphere or from the underlying dermal/ epidermal layers. As well as the direct effect of hydration, the increased water content of the SC leads to reduction in fines lines. This has led to many humectants being labeled as ‘antiageing’ or ‘anti-wrinkle’ – which is misleading, as the humectant effects are simply temporary.16 However, there are humectants that have other properties that are ‘antiageing’ or ‘anti-wrinkle’ in addition to the straight increase in local, temporary hydration. Commoly used humectants are glycerin (glycerol), urea, hyaluronic acid and sodium hylaronate, sorbitol, propylene glycol (also an occlusive), and hydroxyacids. The hydroxyacid group of humectants is particularly interesting, as they also have widely reported antiageing properties. Lactic acid is an AHA found in milk, and is a component of the skin’s natural moisturising factor.17 The polyhydroxy acid gluconolactone is made up of multiple hydroxyl groups, as opposed to a single hydroxyl group like earlier AHAs (e.g. glycolic acid), this attracts water, providing enhanced moisturisation.18 Lactobionic acid, a bionic polyhydroxy acid derived from milk sugar, is a potent antioxidant with humectant properties that strongly attracts and binds water. It is suitable for all skin types19,20 and its unique hydra-film delivers moisture, softness and smoothness to the skin.13 Emollients: Emollients are used to smooth and soften the skin. Many emollients are oils that have an occlusive (air tight) action that provide a barrier against water loss from the skin. They also fill in the gaps and cracks in the SC between the corneocytes.

13 Common emollients are cetyl stearate, glyceryl stearate, octyl octanoate, decyl oleate, isostearyl alcohol.22

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How to choose a moisturiser?

Patients frequently describe their skin as both oily and dry (combination), and this is not illogical.

Dry skin is a result of a lack of moisture in the SC, whereas oily skin is a result of excess sebum production, so it is logical and possible to have dry AND oily skin. Frequently patients will present with oily skin on the face but dehydrated dry skin on the body where there are less sebaceous glands. earlier described, above, the group of emollients, occlusive and humectants, collectively known as ‘moisturisers’, can be chosen specifically to address the different types of ‘dryness’ and to ameliorate dry skin for patients with complex issues such as dehydrated acne prone skin. With an increasing list of single ingredients with multiple clinical indications and skillful formulation of actives in carrier vehicles, our challenge is to find clinically effective moisturising skincare that is tolerable and delivers to our patients multiple skincare needs.

Dr Jenna Burton is an aesthetic practitioner heavily involved in population health promotion (focusing particularly on the promotion of chronic eating disorder management). She has obtained a diploma from the American Academy of Aesthetic Medicine and is currently working towards her American Medical Board Specialist Status. Dr Burton works between the UK and Dubai.

Lorna Bowes is an aesthetic nurse and trainer with an interest in dermatology, formerly a committee member of the Royal College of Nursing Aesthetic Nurse Forum and a founding member of the British Association of Cosmetic Nurses.

With extensive experience of delivering aesthetic procedures, Lorna trains and lectures regularly on procedures and business management in aesthetics.

Lorna is director of Aesthetic Source.

Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation.

REFERENCES 1. Deni Kirkover, ‘The 18,000pound face’ (Daily Mail Online, 2013) http://www.dailymail.co.uk/

femail/article-2434830/The-18-000-face-Women-spend-thousands-beauty-make-lifetime.html

(Accessed 23/08/2014) 2. Fu JJ, Hillebrand GG, Raleigh P et al., ‘A randomized, controlled comparative study of the

wrinkle reduction benefits of a cosmetic niacinamide/peptide/retinyl propionate product

regimen vs. a prescription 0.02% tretinoin product regimen’, The British Journal of Dermatology, 162 (2010) 3. Baumann L, Saghari S, ‘Basic Concepts of Skin Science’, Cosmetic Dermatology: Principles

and Practice, 2nd edn. (New York: McGraw-Hill Professional, 2009), p.4-7.

4. Draelos ZD, Cosmetic Dermatology: Products and Procedures, Kindle edition. Wiley- Blackwell, (Chichester, 2011).

5. Baumann L, Dry Skin. Baumann L, ed. Cosmetic Dermatology: Principles and Practice, 2nd

edn. McGraw-Hill Professional, (New York, 2009), p.87- 88.

6. Kligman A, Regression method for assessing the efficacy of moisturizing, Cosmet and Toil, 93

(1978), p.27-35.

7. Downing DT, Strauss JS, Poci PE, ‘Variability in the chemical composition of human skin surface lipids’, J Invest Dermatol, 53 (1969) p.322.

8. Webster D, France Jt, et al., ‘X-linked ichthyosis due to steroid-sulphatase deficiency’, Lancet, 1

(1978) p.70.

9. Baumann L, Saghari S, ‘Oily Skin’, Cosmetic Dermatology: Principles and Practice. 2nd edn,

(New York: McGraw-Hill Professional, 2009) p.75.

10. Blank IH, ‘Factors which influence the water content of the stratum corneum’, J Invest Dermatolo, 18 (1952), p.433-439.

11. Marcia Ramos-e-Silva et al., ‘Elderly skin and its rejuvenation: products and procedures for the

aging skin’, Journal of Cosmetic Dermatology, 6 (2007) p.40–50.

12. Gupta AK, Gover MD, Nouri K, et al., ‘The treatment of melasma: a review of clinical trials’, J Am

Acad Dermatol 55 (2006) p.1048-65.

13. Small R, Hoang D, A Practical Guide to Chemical Peels, Microdermabrasion & Topical Products, Lipincott and Williams, Kindle Edition, (2013) p.2503-2516.

14. Draelos Z, ‘Moisturizers’, Atlas of Cosmetic Dermatology, (New York: Churchill Livingstone,

2000) p.85.

15. Morrison D, Petrolatum, Loden M, Maibach H, eds. Dry Skin and Moisturizers, (Boca Raton,

FL: CRC Press, 2000) p.251.

16. ‘American Academy of Dermatology Interventional Symposium on Comedogenictiy’, J Am

Acad Dermatol, 20 (1989) p.272.

17. Baumann L, ‘Moisturizing Agents’, Cosmetic Dermatology: Principles and Practice. 2nd edn.,

(New York: McGraw-Hill Professional, 2009), p.273-275.

18. Ditre CM, Griffin TD, Murphy GF, et al, ‘Effects of alpha hydroxyacids on photoaged skin: a pilot

clinical, histologic and ultrastructural study’, J Am Acad Dermatol 34 (1996) p.187-95.

19. Briden ME, Green BA , ‘The next generation hydroxyacids’, Draelos Z, Dover J, Alam M,

eds. Procedures in Cosmetic Dermatology: Cosmeceuticals. 2nd edn. (Philadelphia: Saunders Elsevier,2006).

20. Green BA, Briden ME, PHAs and bionic acids: next generation hydroxy acids, Draelos Z,

Dover J, Alam M, eds. (2009).

21. PA . Edison BL, Green BA, Wildnauer RH, Sigler ML, ‘Cosmetic Dermatology: Cosmeceuticals’,

2nd edn. Saunders Elsevier, Philadelphia: (2004) A polyhydroxy acid skin care regimen

provides antiaging effects comparable to an alpha-hydroxyacid regimen. Cutis 73(2

Suppl): 14–7 22. Grimes PE, Green BA, Wildnauer RH, Edison BL (2004) ‘The use of polyhydroxy acids (PHAs) in

photoaged skin’. Cutis 73(2 Suppl): 3–13.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL152/1214/DS Date of preparation: December 2014

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Why 3D-Skinmed?

The ultimate multi-technology platform soon to be revealed as the next celebrity secret to uplifted and rejuvenated skin.

Following in the traditionally innovative 3D-format, the NEW 3D-Skinmed offers three of the most up-to-date clinical technologies in one amazing platform.

The 3D-Skinmed machine tackles lifting and tightening for the face and neck, skin refinement to treat acne scarring, scars and stretch marks, plus impact infusion, delivering cosmeceuticals through newly formed channels in the skin.

No other system on the market combines these three technologies, and this unique method ensures the best patient and treatment outcomes when tackling multiple indications for the face, all in one affordable machine.

The Technology 3D-HIFU (High Intensity Focused Ultrasound) Non-surgical skin lifting has become one of the most sought after treatments, and HIFU is the latest non-surgical technology to excel in this area, providing results in just one single session. The technology individually targets and achieves brow lifting, jowl-line lifting, nasolabial fold reduction, periorbital wrinkle reduction and overall skin tightening and rejuvenation. The highly focused acoustic energy creates thermal coagulation zones at three different selected depths. A wound-healing response then aids the formation of new collagen, thus providing a long-term tightening of the skin. A noticeable improvement in the patient’s facial contouring, fine lines and wrinkles will be visible within a four-week period, whilst further improvement in facial skin tightening and wrinkles should be noticeable within six weeks. In addition to 3D-HIFU’s skin lifting and rejuvenation qualities, there is no down time associated with this non-invasive procedure.

3D-Dermaroller RF The 3D-dermaroller RF offers a complete solution in skin refinement indications such as stretch marks, acne scarring, scarring, skin whitening and skin rejuvenation. The skin rejuvenating dermaroller creates micro channels in the skin using a 0.5mm microneedle roller. This action triggers the skin’s natural healing response, which stimulates new collagen production, and in turn leads to firmer, tighter looking skin with diminished lines and wrinkles. By combining radiofrequency energy, we can deliver direct and accurate heating to both the epidermis and dermis with depth control of 0.5mm. This has significant, documented, benefits compared to deeper delivery options. Fiber blast and collagen fibers are stimulated through delivered RF energy; resulting in improvement of wrinkles, skin elasticity and skin problems such as acne scarring. We provide the practitioner with two size options of sterile rollers (15mm and 30mm) to ensure the administration of the 3D-Dermaroller RF is as simple as possible.

3D-Impact To complete the trio of technologies, 3D-Impact increases the acoustic waves of the ultrasound to create pressure that enables cosmeceutical products to have greater mobility and reactivity. This will then increase the amount of product that enters the skin in the areas where it is needed most, thus improving overall effectiveness of the 3D-Skinmed. These three amazing technologies can be used individually to target specific concerns, or layered in a prescriptive fashion to address multiple indications. To enhance this advanced technology platform, we also provide a free starter package of 3D-skintech cosmeceutical products, peels, and full point-of-sale support, as well as delivering our in-house-training programme to your staff.

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Aesthetics | February 2015

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A summary of the latest clinical studies Title: Comparison of different technologies for non-invasive skin tightening Authors: Pritzker RN, Hamilton HK, Dover JS. Published: Journal of Cosmetic Dermatology, December 2014 Keywords: laser, non-invasive, skin tightening Abstract: Facial skin laxity is a bothersome sign of aging. In the past, the only option for treating laxity was surgery. While surgical lifting remains the gold standard, there has been a growing demand among patients for less invasive techniques. Patients are increasingly seeking procedures with little to no downtime, lower risk profiles, and a more natural appearance. The industry has responded to these demands with an emergence of non-invasive skin tightening devices. The rate of development and marketing of these devices has increased exponentially within the last decade. Whereas we previously had no options, now we are faced with many choices. How do we choose which technology is best for our patients? While there is a paucity of comparative trials to date, a critical exploration of these technologies is worthwhile. The underlying mechanism of action of all these treatments is essentially the same: heating of the dermis and subdermal areas while minimizing injury to the epidermis. In this article, we outline the different technologies and highlight the differences to help guide us in selecting the right treatment.

Title: Assessing the rhinoplasty outcome: inter-rater variability of aesthetic perception in the light of objective facial analysis.

Authors: Ozturk K, Gode S, Karahan C, Midilli R. Published: European Archives of Otorhinolaryngology, January 2015 Keywords: dermatochalasis, eyebrow, rhytidosis, upper eyelid blepharoplasty Abstract: The aim of this study was to assess the success of rhinoplasty by evaluating the inter-rater variability in the light of primary indication as functional or cosmetic. Subjective aesthetic perception was compared with objective facial analysis. 45 rhinoplasty patients were included in the study. 25 had cosmetic plus functional reasons with septal deviation (group 1) and 20 had pure cosmetic reasons without septal deviation (group 2). Preoperatively and 6 months postoperatively, four individuals (patient, surgeon, 2 independent surgeons) rated the aesthetic appearance of the nose with visual analogue scale. Facial photogrammetric analysis was applied. The patient’s aesthetic perception score was significantly correlated with the two independent surgeons (p < 0.05) whereas not with the primary surgeons. Regarding the objective parameters, patient’s aesthetic perception was significantly correlated with the dorsal alignment in both groups (p < 0.05). General satisfaction score was significantly correlated with the nasal breathing as well as with the aesthetic perception scores in both groups. This correlation was higher for aesthetic perception in group 1 and nasal breathing in group 2. Interrater variability of outcome perception was higher in cosmetic patients.

Nasal dorsal alignment was the only objective parameter which was correlated with the patient’s perception. Patient’s perception of outcome has better represented the objective photogrammetric analysis rather than the primary surgeons. An interesting finding was the more significant correlation of general satisfaction with aesthetic perception in the functional group whereas nasal breathing in the cosmetic group.

Title: Complications of collagen fillers Authors: Lucey P, Goldberg DJ. Published: Facial Plastic Surgery, December 2014 Keywords: fillers, skin rejuvenation, collagen, complications Abstract: As the skin ages, a deficiency in collagen occurs, thus injectable collagen products have become a sensible and popular option for dermal filling and volume enhancement.

Several types of collagen have been developed over the years, including animal sources such as bovine and porcine collagen, as well as human-based sources derived from pieces of the patient’s own skin, cadaver skin, and later cultured from human dermal fibroblasts. While collagen overall has a relatively safe, side effect profile, there are several complications, both early and late onset, that practitioners and patients should be aware of. Early complications, occurring within days of the procedure, can be divided into non-hypersensitivity and hypersensitivity reactions. The non-hypersensitive reactions include injection site reactions, discoloration, maldistribution, infection, skin necrosis, and the very rare but dreaded risk of vision loss, whereas the hypersensitivity reactions present usually as delayed type IV reactions, but can also rarely present as an immediate type I reaction. Late complications, occurring within weeks to even years after injection, include granuloma formation, foreign body reactions, and infection secondary to atypical mycobacteria or biofilms. This review will give a detailed overview of the complications secondary to cutaneous collagen injections.

Title: Treatment of Early Stage Erythematotelangiectatic Rosacea with a Q-Switched 595-nm Nd:YAG Laser Authors: Goo, BL, Kang J, Cho SB. Published: Journal of Cosmetic Laser Therapy, December 2014 Keywords: erythematotelangiectatic rosacea, skincare, lasers Abstract: Erythematotelangiectatic rosacea presents as persistent erythema and telangiectasia with frequent flushing and blushing on the facial and extrafacial skin. Additionally, papulopustular rosacea shows acneiform papules, pustules, and nodules with persistent plaque-form edema. Despite garnering only grade C or D level recommendations, a 585-nm or 595-nm flash lamp pumped pulseddye laser can be considered as an effective therapeutic modality for the treatment of rosacea in the patients refractory to topical and/ or systemic treatments. In this report, treatment with a Q-switched 595-nm Nd:YAG laser with low non-purpurogenic fluence proved to be safe and effective in treating early stage erythematotelangiectatic rosacea in two female Korean patients. Laser treatment for rosacea was delivered with the settings of a pulse energy of 0.4-0.5 J/cm2, a pulse duration of 5-10-nsec, a 5-mm spot size, 5 Hz, and 500 shots.

Additionally, we found that remarkable therapeutic effects were achieved for both rosacea and melasma by combining Q-switched quick pulse-to-pulse 1,064-nm Nd:YAG and Q-switched 595-nm Nd:YAG laser treatments, which required only the changing of handpieces equipped with solid dye. In conclusion, we suggest that treatment with a Q-switched 595-nm Nd:YAG laser with low fluence may provide an additional therapeutic option for treating early stage erythematotelangiectatic rosacea.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Team building Mark Tager shares his advice on how to improve teamwork amongst staff in aesthetic clinics Each day aesthetic practitioners compete for business.

Savvy and critical consumers demand that all aspects of the patient-professional encounter meet high standards. Patients enter your establishment with a critical eye, not just directed toward the physical aspects of the practice, but also focused on the quality of the interaction among staff. Consciously, or subconsciously, your patients ask themselves questions such as: How happy are the staff members? Do they seem caring and empathetic? Is communication positive? Is the office well organised?

For the patient, the answers provide the best indicator of how well they will be treated. Just as a weak link can break the strongest chain, so too can dysfunctional team interactions disrupt the patient-engagement experience and result in a poor reputation and loss of business. This leads us to question what makes a successful healthcare team? And, how can you enhance the team you have? In this article, I detail six key components to improving team morale whilst simultaneously enhancing your aesthetic business.

1. Identify and improve workplace norms Every workplace has cultural ‘norms’ that reflect the dominant values, attitudes, and behaviours of a group. In attempting to diagnose worksite health, organisational change consultants will often select an aspect of the culture (customer service, accountability, responsibility, etc.) and pose a series of openended questions to the group, asking team members to fill in the following sentence, “Around here it is normal for…” The collection of answers, both positive and negative, provides a starting point for the organisational change effort.

Identifying norms allows issues to surface, but rather than identifying individuals, it has the benefit of spreading the accountability among all group members. This type of culture investigation generally works best in larger organisations and

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trusting environments in which owners/managers seem to be more open to genuine improvement.

In my experience, the best approach is to reinforce the positive aspects of worksite culture that you want to govern day-to-day interactions.

The process can be jump started with ‘The Great Team Exercise’, which is best conducted in an informal setting, such as a staff retreat or extended lunchtime session. One of the team members serves as scribe and asks the group: “What are the ingredients in a great team? Think back to successful teams you’ve been part of – perhaps school sports teams or community service organisations. What words would you use to describe these experiences?”

The scribe then writes down the responses.

Invariably, the group’s list includes terms such as mutual support, respect, caring, fun, a ‘can do’ attitude, fairness, teaching and learning from one another, celebrating accomplishments together, clear-cut goals, good leadership. Selected attributes could be highlighted and subjected to ongoing dialog. It’s important to hold this ideal image in your mind as what you and all your coworkers should aspire to.

2. Replace Bad Apples If an organisation is serious about affirming the values, attitudes and behaviours outlined in the ‘Great Team Exercise’, those members that fail to adhere to positive behaviour standards need to be removed from the team. Such removal should take place within legal guidelines and in accordance with the organisation’s policies on employment termination (which should be in writing and provided at the time of hire). Employees should be given regular performance reviews and opportunities to correct their attitudes and behaviours however, where necessary, removal allows the practice manager to hire an individual with attributes that will benefit the clinic.

How do you assess an applicant’s team-based skills? One popular method is the use of a technique known as behavioural-based interviewing. This process is rooted in the theory that the most reliable predictor of future performance is how an individual has performed in a similar situation in the past. Once you have identified the core competencies or skills required in a job, you can probe for behaviour patterns that represent these attributes.

Behavioural-based questions that revolve around teamwork are exemplified by the following: • Can you provide examples of both pleasant and unpleasant teamwork experiences that you have had and how you managed the situations?

• Describe a situation involving conflict with a difficult client or co-worker and tell me how you dealt with it.

• Tell me about a time when you needed to inspire or motivate your co-worker or subordinates and explain what you did.

• Can you tell me a time when you were able to effectively ‘read’ another person and direct your actions by taking into account their individual needs or values?

• When working on a team, what role do you usually take? Why? Because these queries require plausible, story-based explanations, it is extremely difficult for a person to fake the

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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answers to these questions on the spot. While the answers can’t inform you as to a person’s competency in aesthetics, the answers do reveal a job applicant’s style around teamwork.

3. Recognise the benefits of happy staff Is your establishment a happy place customers enjoy visiting, as well as a place people want to come to work each day? The medical and psychological literature is continuing to document the benefits of happiness, included among them: • Superior work outcomes: greater creativity, increased productivity, higher quality of work, and higher income.1 Happy employees are better problem solvers. Rather than focus on complaining, they are more likely to focus on positive solutions to the issues that patients have.

• More activity, energy and flow.2 Enhancing these traits increases the likelihood that staff will be more present for patients, more sensitive and attentive to their needs, thereby delivering improved customer service.

One method that can be used to encourage a happy, engaged environment amongst staff is to ask each team member to set a positive intention for the day to promote focus, concentration and productivity. Hopefully this will improve team morale, as well as patient satisfaction.

4. Catch a co-worker doing something right One of the best ways to create a healthy team culture is for all staff members to get in the habit of catching a co-worker doing something right. This can reinforce the best practises that you want to maintain and makes the recipient feel good.

Honest feedback boosts self-esteem and fuels the desire for personal improvement. Examples of beneficial feedback include: • Immediate: As close to the event as possible so that it is fresh in peoples’ minds.

• Task specific: When you praise someone for how well they conducted a task such as answering the phone, handling unrealistic patient expectations, or adjusting the treatment parameters for a particular patient, you are reinforcing their competence.

• For them: Don’t just give out praise when you are in a good mood and forget to do so when the situation calls for it.

Remember feedback is for the receiver, not the giver.

5. Be flexible in dealing with others Why is it that you seem to get along so well with one type of person while another constantly irritates you? Despite many possible explanations, one reason relates to the concept of temperament, a psychological term that describes how certain aspects of personality become crystallised in early childhood through a combination of nature and nurture. We tend to like and get along best with people who, from an energy perspective, are more like us.3 The pioneering Swiss psychologist Carl Jung advanced this concept in the early 20th century. Jung described a number of types of groups of individuals who shared a natural tendency to perceive the world and interpret information in a common manner.4 Jung’s work forms the basis for a number of popular style-based assessments, the most well known being the Myers-Briggs Type Inventory.5 In the early 1980’s, I developed the PowerSource Profile (PSP) with psychologist Stephen Willard.6 Our experience of researching individual and group stressors enabled us to create

Aesthetics

this Jungian-based assessment programme that can be applied to worksite groups in a time-efficient manner. The PSP offers users the advantage of being specifically designed to help improve team building and encourage staff members to become more resilient to change.

The profile identifies four specific types: • Creative people: A preference for imagination and intuition, a forward sense of time, and a tendency to become stressed because of fragmentation, lack of attention to detail, and difficulty with follow-through. They value variation and are often drawn to aesthetics because of the many types of activities in which they can participate, and the possibility of helping to transform others.

They are easily bored by routine.

• Grounding people: A preference to use the senses, be practical and realistic, use tried-and-true procedures and rules, are stressed by changes to the predictable and orderly. They thrive on routine, enjoy keeping things neat and organised and will naturally follow through on details. They have a good sense for how long it takes to complete an activity well.

• Logical people: A preference for cause and effect, objective analysis, model building and quantification. Can become stressed by having to make decisions without enough data and situations (and people) with strong feelings. This energy type tends to be represented by physicians, scientists, financial analysts, bankers and business consultants.6 • Relationship people: A preference to interpret information based upon people’s feelings, keen attention to their own emotions; stressors include having to say “no”, getting burned out, and taking criticism personally. They conflict with high-logic types who can disregard their feelings and don’t listen well. Many nurses, of both genders, have this as their dominant energy, drawn to the caring/helping aspects of an aesthetic practice.6 To tailor communication to different types of people, both co-workers and patients, you need to abandon a one-size-fits-all mentality and focus your communication on the recipient.

6. Go for Great When your staff members are happy, they become great team members. They focus on the positive aspects of their work, reinforce this to the rest of the team and are usually flexible enough to manage other members of staff. Each individual’s efforts are key to both personal and commercial success so, as managers and business owners, it is vital that you strive to satisfy your members of staff as much as your aesthetic patients.

Dr Mark Tager is CEO of San Diego-based consultancy company ChangeWell. Tager is co-author of ‘The Art of Aesthetic Practice’, alongside Dr Stephen Mullholland, and is currently interested in the interplay between integrative medicine and skin health and wellness.

Dr Tager has also worked as a chief marketing officer for Reliant Technologies and Syneron.

REFERENCES 1. Tomiyama AJ, Blackburn E, Epel E, Kirschbaum C, Wolkowitz O, Dhabhar FS et al., ‘Does cellular

aging relate to patterns of allostasis?’, Physiology & Behavior, 106 (2012), p.40-45.

2. Harker L, & Keltner D, ‘Expressions of positive emotions in women’s college yearbook pictures and

their relationship to personality and life outcomes across adulthood’, Journal of Personality and

Social Psychology, 80 (2001), p.112-124.

3. Bauer, Jack J, Mcadams D and Sakaeda A, ‘Crystallization of Desire and Crystallization of Discontent

in Narratives of Life-Changing Decisions,’ Journal of Personality 73.5 (2005) p.1181-214.

4. Frager R, Fadiman J, ‘Personality and Personal Growth’, (New York: Pearson Prentice Hall, 2005) p.56.

5. The Purpose of the Myers-Briggs Type Indicator (MBTI Basics: The Myers and Briggs Foundation,

2015) <http://www.myersbriggs.org/my-mbti-personality-type/mbti-basics/> Last accessed: January 8 2015.

6. Tager, M., & Willard, S., Transforming Stress into Power: The PowerSource Profile system (Rancho

Santa Fe, CA: Changewell, Inc., 2014)

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Looking Ahead: Providing on-going skin health programmes Jane Lewis highlights the advantages of curating long-term skin treatment plans for your patients At the turn of the New Year, many of my patients come to me looking for quick-fix skincare solutions to help them start the year renewed and refreshed.

In some cases, a little too much indulgence over the festive party season has taken its toll on the complexion; in others, time spent with friends and family has served to highlight how the ageing process has accelerated since the same time last year.

However, while quick-fix solutions serve a purpose in terms of near-instant gratification and short-term feel-good factor, I like to take this opportunity to work with the patient to develop an ongoing programme that encourages them to think about their skin health as part of a wider lifestyle choice – rather than simply a superficial aesthetic. By building a programme that provides a comprehensive care path to last the year round, I find there are multiple benefits to both the patient and practitioner. The patient experience is greatly improved when we put in place a bespoke treatment plan that ensures that those you treat are fully educated on what to expect at various steps along the path. More often than not, my patients come to me with an end goal in mind and, to some degree, an understanding of how this might be achieved.

They may have friends who have recommended a particular treatment, or they may have read about a certain brand in magazines or online. As practitioners, I believe it is our responsibility to conduct a thorough consultation with each patient to understand exactly what we can do for them. By tailoring a treatment plan to their specific needs and setting realistic expectations in terms of results, the patient will be encouraged to look beyond a ‘quick-fix’ solution and will instead be excited by the benefits of a longer-term treatment plan. For example, a patient looking to improve the appearance of sun spots and hyperpigmentation caused by prolonged sun exposure would traditionally get a good result from one high-level fractional laser treatment early in the year. However, I would want to talk them through the option of several lower-level fractional laser treatments at intervals throughout the year, and to supplement this with a radiofrequency treatment to improve skin laxity and the fine lines that are also ageing effects of sun exposure. I find that with this approach, not only does the patient feel fully informed and therefore more excited about their plan, they will also be more receptive to any additional solutions I

recommend for enhanced results. This might include a topical skincare programme, or injectable toxins or fillers. By creating a treatment plan to span the next 12 months, you can also offer a package at the best possible value to incentivise a block booking and reward loyalty. Developing an ongoing treatment plan has the primary benefit that, in mapping out a year’s worth of treatments, you are guaranteeing patient loyalty through regular repeat custom. It also provides a vehicle to speak to the patient often throughout their journey, ensuring they are happy with their progress, answering any questions or concerns and offering additional aftercare advice. This continuum of care is an easily-executed, added-value service that gives the patient confidence in your expertise and professional recommendations. It also presents opportunities to identify relevant supplementary procedures outside of the original treatment plan to enhance the patient’s results. It might be that a patient who we were originally treating for acne with a course of broadband light and vacuum treatments such as Isolaz might later in the year benefit from a course of laser treatment such as Clear + Brilliant to refine the complexion and erase areas of pigmentation caused by scarring.

Of course, over a period of time the patient’s goals and desired outcome are likely to shift; by listening to them and working collaboratively on their treatment plan, you will be able to advise on both proactive and reactive solutions to ensure they get the best possible result. It might be that the patient has a special event coming up, such as a wedding or anniversary, and they would like a little boost to help them feel extra special. I find this way of working helps me to forge great relationships with my patients, many of whom have been coming to us since we first opened.

Generally, patients who have been made to feel completely at ease and confident throughout their treatment journey are often very willing to have their photograph taken and participate as a case study, which is an extremely powerful marketing tool. With a comprehensive on-going skin health programme, the patient will value the time and care taken to develop a bespoke treatment plan that is unique to their needs, and will consequently feel more confident in both your original recommendations and any additional supplementary treatments you might suggest down the line. They will also appreciate the financial benefits you may offer in exchange for their ongoing business. As a practitioner, you will enjoy an open dialogue with your patient that enables you to monitor their progress for best possible results. You will understand their goals and manage expectations, and identify opportunities to recommend additional treatments that will enhance their results and boost your revenue. A satisfied patient will not only remain loyal for years to come, they will also talk openly about their positive experience to friends and associates. And, after all, word of mouth is the single most powerful form of marketing for small businesses. Providing your patients with the opportunity to work with you to look forward and create a long-term treatment plan suited to their needs ensures a steady and loyal patient base. This in turn increases revenue and secures the ongoing success of your practice.

Jane Lewis owns a clinic in Hertfordshire and is a registered nurse with 28 years experience in the cosmetic industry. For 17 years she was the development director for one of the largest laser chains in the UK, before becoming director of clinical training EMEA for Fraxel and Thermage.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Removing Doubt is the Key to Online Success

Marketing consultant Paul Jackson highlights the best ways to boost your online appeal When researching and choosing a clinic for an aesthetic treatment, your clinic’s target audience are increasingly making their decisions based entirely on your clinic’s website and your other online activities, all in comparison to your competitors. Online expectations are skyrocketing and if your website visitors have any doubts about you, it’s easier than ever for them to go elsewhere. The key to making the most of your website is to remove their doubts and to ensure your website visitors have no reasons to leave and have no unanswered questions – just continual motivation to stay on your site and make an enquiry or booking. So how do you remove doubt online, how do you meet and exceed your audience’s expectations, and how do you get more of those all-important enquiries and bookings? The following guide takes you through the actions that will allow you to stay ahead of the game.

Keeping up to date Your website is your online showroom, your online brochure, and your initial sales pitch all rolled in to one. It represents your business, your approach, your culture and your appreciation of customer service. Your website is the perfect opportunity to start off on the right foot. Having the basics in place is the first step, ensuring that your website mirrors what is important to your business. Your website needs to be modern, professional, up to date with the latest treatments available and regularly maintained. Even forgetting to change the copyright date to the current year can send negative signals to your visitors about your attention to detail. Your website absolutely must be mobile friendly. In industries such as aesthetics, clients are even more likely to research clinics and treatments within the privacy of a tablet or smartphone rather than on a shared computer.

With mobile internet usage exceeding PC internet usage for the first time in history1, not having a mobile website or a responsive website is a statement to potentially half of your online visitors that your clinic is outdated and not focused on providing a good customer experience. You’ll find that they will soon be on a competitor’s mobile website instead.

Tailored and personalised website text In an aesthetic clinic you expect the staff to be able to tell you in detail about the treatments offered, their experience of results, and their recommendations and insights to help you make the right treatment choice, as well as explaining the benefits of using their clinic. So the same information should be available on your website.

With many clinics offering a wide range of treatments, it can be a time-consuming task to write unique content about each of your treatments and offerings, especially when many suppliers provide generic content about their products for you to copy and use. However, it is well worth spending the time to do this and to think about what your potential patients will want to know when researching a treatment at your clinic. It’s your chance to stand out and be the clinic that answers all their questions and queries, as well as the one they end their search with.

Putting this into action is nice and simple. Consider rewriting the content on key pages of your website; for example, on a page about a specific treatment you could include the following key treatment details: Suitability, areas treated, treatment duration, number of treatments required, downtime, aftercare, your expertise and experience, testimonials, how to book a consultation or appointment, and imagery such as your treatment rooms, practitioners and before and after photos.

If there’s too much detail to put on a single page of your website, why not create a full guide to each treatment and encourage visitors to view or download it for more information?

What’s obvious in person should be obvious online When a regular patient or new patient comes into your clinic it will be clear to them how you go about booking, they’ll already know how to get to the clinic, what the clinic looks like on the inside and outside, how your staff present themselves and how good your customer service is. After a short conversation with you they’ll know about the treatments you offer, the availability you have, your pricing, your cancellation policy and much more. It is

Your website is your online showroom, your online brochure, and your initial sales pitch all rolled in to one

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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With 88% of people reading online reviews to determine the quality of a local business2, incorporating testimonials, reviews and accreditations into your website can be a highly effective way to remove doubt and help convince your website visitors that you are the clinic for them crucial to replicate this experience online.

Aesthetic clinics need to be clean, welcoming and professional, and so their websites rightly often mirror this. The result can be that important information is hidden away for visitors, and whilst this helps maintain the sleek look of the site, it also prevents visitors from finding the information they need to make the decision to contact your clinic. This leaves these visitors with doubts in their minds, reasons to delay their decision and motives to look elsewhere. This is another simple method to implement improvement that will make a big difference. At all steps in a visitor’s path to making a decision, ensure key details are available to them. For example, on pages about treatments you can show details of how to make a booking or get in touch, and on booking pages you can show details about availability, timings, payment and cancellations.

Sensitivity and courtesy The trend of crisp, clean websites can sometimes come across as being cold and clinical. When visitors to your website may be feeling sensitive or unsure about embarking on a treatment, your website can be the ideal way to reassure them and make them feel comfortable with your clinic and treatments.

Visitors who are new to aesthetic treatments are likely to have many questions but may also be nervous about asking them. Keep note of all the questions you are asked from day to day and add them with answers to an easily accessible FAQ section on your website. Make it as simple as possible to contact you directly via phone or email by having your contact details clearly displayed in the top right hand corner of your website and on every relevant page. Add a friendly call to action, such as ‘if you have any questions, queries, worries or wonderings about this treatment – anything at all – we’d love to talk you through it. Feel free to call us or email us today.’ Show sensitivity, care and interest in your visitors’ concerns and they’ll quickly warm to you and be willing to ask you the questions they want answered in order to remove their doubts.

Show that you are human If a patient or potential patient visits you at your clinic, it can be simple to show your personality and build a rapport with that

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person, and this can be the deciding factor in whether or not they choose you to give them a treatment. Online it can be more difficult to show off your personality, but there are some fantastic methods of providing a more ‘human’ experience and ensuring that your website is not impersonal and overly corporate. This does not mean adding a stock image of an attractive young lady in a call centre headset – which is a surprisingly common response – but do write your website copy with personality, and try to use imagery and video where appropriate. On key pages of your website you can include photos of your team and your clinic, you can have pages with photos and information about each of your practitioners’ backgrounds and you can even drop quotes from your team into the copy on the key pages to help convey the information.

Perhaps the most effective method to convey personality is video. With such high quality video available on smartphones and low-cost digital cameras, there’s no longer a need for a whole production team to record footage. On your homepage you could include an introductory video featuring your team, on pages about specific treatments you could include a clip of a practitioner discussing the treatment, and you could even create videos to respond to your FAQ questions.

Testimonials & accreditations When embarking on an aesthetic treatment, your potential patients are likely to want to read more than just your opinion of your clinic – they want to know what other people thought too. Was your customer service friendly, how was the treatment process, what were the treatment results, was it good value for money, are you recognised in the industry? With 88% of people reading online reviews to determine the quality of a local business2, incorporating testimonials, reviews and accreditations into your website can be a highly effective way to remove doubt and help convince your website visitors that you are the clinic for them.

The tricky part here is gaining those reviews and testimonials, but implementing a system of requesting feedback as a standard process can be very effective. Some clinics send a follow-up email after a patient’s treatment and others have an iPad at the clinic that patients can leave feedback on there and then. Also ensure that any industry accreditations, qualifications and awards are prominently displayed on your website as they go a long way to building a visitor’s trust in you.

With the rest of 2015 ahead of us, now is the perfect time to bring your website in line with best practices and address the needs of your target audience – the outcomes for your business could be worth much more than the small amount of time required to make the changes. To get ahead of the game and exceed your audience’s expectations, consider putting these recommendations into place to remove the unanswered doubts on your website; you’ll be amazed at the difference it makes.

Paul Jackson is senior marketing consultant at Reload Digital and specialises in social media and online marketing for the aesthetics, beauty, cosmetics and fashion industries. As a chartered marketer and Google certified partner, Paul can be seen speaking at marketing events across the country.

REFERENCES 1. Rebecca Murtagh, Mobile Now Exceeds PC: The Biggest Shift Since the Internet Began (US:

Seach Engine Watch, 2014) <http://searchenginewatch.com/sew/opinion/2353616/mobile-now-

exceeds-pc-the-biggest-shift-since-the-internet-began> (Accessed January 13th 2014) 2. Myles Anderson, 88% Of Consumers Trust Online Reviews As Much As Personal Recommendations

(US: Search Engine Land, 2014): <http://searchengineland.com/88-consumers-trust-online-reviews-

much-personal-recommendations-195803> (Accessed January 13th 2014)

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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Retailing in your clinic: can you afford not to?

Business strategist Alana Marie Chalmers details how to successfully integrate a retail portfolio into your practice

Why retail?

Introducing retail into your aesthetic business creates opportunities to unlock vital revenue streams and enhance your customer journey, potentially generating incremental income without expansion. Most methods that a business will usually invest in and deploy in order to generate growth (advertising, SEO, new equipment and exhibitions), are though valid and impactful, cost time and money with no guaranteed return on investment (ROI). In contrast, if integrated effectively, retailing may become the most hardworking asset in your clinic. A correct approach to retailing can work to reinforce existing strategies for responsible and holistic patient care. It is an opportunity to strengthen your customer relationships, and gives your patients a reason to return and buy from you between treatments. Are you maximising floor space and practitioner time? Are your customers satisfied and supported in all areas of their wellbeing? Are you hitting expected profits? If not, then it’s important to consider retailing sooner rather than later.

What are your options?

Whilst your treatment portfolio should always remain at the heart of your business, retail has the capability to augment your clinic offering.

A carefully selected range, complementing existing treatments, further supports your patients in achieving their desired results. Every aspect of your patient’s journey has the potential to be transformed

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into new and improved revenue streams with a carefully selected retail proposition. There are various categories from which you can define your retail portfolio; • Cosmeceuticals • At-home devices • Supplements and vitamins • Nutraceuticals • Cosmetics • Self-enrichment literature • Haircare and hair growth therapies • Homeopathic remedies What are the benefits?

The benefits for your customers are improved satisfaction, loyalty and better patient care, while staff will benefit from greater staff morale, renumeration enhancement and the potential for career progression.

The business will also experience an increased profit turnover and diversified portfolio.

What are the potential profits?

The turnover and profit garnered from retail efforts reflects the level of commitment and integration adopted, as well as the selected portfolio.

FACT: You can create equal turnover from a quick sale of 30ml serum as an advanced facial treatment, which requires therapist’s time.

FACT: For every treatment, there is potential to generate an additional £30-£250 of sales by upselling your retail portfolio.

The table below illustrates a modest calculation of the potential profit involved in retailing, measured against staff commitment levels and based on three possible retail lines. Though in reality each business and product varies, the table below demonstrates the feasibility of generating additional profit with only a small amount of effort from each team member.

It’s important to note that an extensive retail offering or multiple brands does not necessarily equate to higher profits. Based on experience, an integrated retail approach to cosmeceuticals alone can represent as much as 30% of monthly turnover. This can be achieved from simply offering one brand on an exclusive basis.

Illustrating the Potential Profit from Retailing Cosmeceuticals

Units per Wk

Home Device

Units per Wk

HairCare

Units per Wk

No Active Selling

100

4

0

0

12.5

1

Reception Only

200

8

100

2

50

4

Therapists & Reception

800

32

200

4

100

8

Full integrated approach

1600

64

400

8

200

16

Strategic Marketing efforts

2400

96

600

12

300

24

Comittment Level

Revenue Stream

Potential profit Per week

£2,400

£600

£300

Total

Total Profit potential for month

£9,600

£2,400

£1,200

£13,200

Ave Units per staff per day at level 5

4

0.50

1

(5 Day working week) Potential profit indicated at 50% margin selling indicated units per week based on 5 staff/practitioners in clinic Profit ex Vat before Tax Profit Assumption per Unit

£25.00

£50.00

£12.50

Estimates based on low profit assumption per unit sold of each different retail item in relation to clinic efforts

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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How do I make this happen?

Investing time to define a strategy and implementation plan to support the successful introduction of your retail portfolio is crucial.

Strategy: Define the retail portfolio that fits your business. Evaluate every treatment for the pre/post-products that improve outcome and define a range that enthuses your staff and customers.

Sales and Marketing: Develop a communications and sales plan.

Communicate with your customers regularly; how effective are your current protocols from a retail perspective? Can these be adapted to integrate retail, upsell, or develop new packages? Set realistic targets within specific time frames.

Staffing: Ensure the team is equipped, motivated and unified in implementing the plan. Staff members must embrace retail as a vital element of the customer relationship.

Getting it right first time Start simple and small – increase your commitment level once initial targets have been hit.

Ensure the team understand how to sell – this is often overlooked in supplier training.

Make the suppliers work hard – get them to pitch and present the business opportunity, detailing exactly how they will help you roll out the products and grow your sales.

Avoid high minimum orders – order often and smaller whilst your confidence and cash flow grows.

Less is sometimes more – keep your messaging clear. Invest in one brand per area of your retail portfolio.

Build strong customer relationships – this will make selling and

Aesthetics

purchasing a more personal, fluid and mutually-beneficial process.

How do I know if it’s working?

Set targeted income goals – empower relevant team members to achieve them through individual and team targets and regular reviews.

Customer purchases – review weekly and monthly purchases against set targets.

Feedback – garnering feedback from staff and your accountants is essential for assessing retailing success.

The final word Retailing demands a change in strategy and mindset throughout your business. It does not automatically mean more investment in stock and shelves filled with numerous brands, leaving your staff and customers overwhelmed. All retailing efforts should be clear, cohesive and wellcommunicated. Successful clinics are not necessarily those with an extensive offering or designated retail manager; they’re those that have an integrated approach to retailing and a marketing plan that influences the patient journey before, during and after their visit to the clinic. Done well it will enhance and pay dividends to every aspect of your business.

Alana Marie Chalmers is a branding and business strategy expert with a background in the management of global brands across the premium health and beauty sector. Having founded luxury distribution & consultancy outfit Harpar Grace International, Alana specialises in working with clinics and practitioners in the UK aesthetics industry to enhance clinic propositions, grow revenue and fast track profitability.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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“There’s no reason why you can’t educate and entertain at the same time” Renowned aesthetic pioneer Dr Arthur Swift shares his journey into the specialty “It was unusual for a plastic surgeon to get involved with skin care,” recalls Dr Arthur Swift, as he details the integration of aesthetics into his surgical practice in the late 1980s. “To me it made sense; I was pulling and tightening skin but commenting to my colleagues that we weren’t doing anything for its quality.” Dr Swift, now one of the most respected practitioners in aesthetics, continually aims to optimise both the patient’s experience and outcome. Dr Swift’s journey towards plastic surgery began in the trauma unit at Jackson Memorial Hospital, Miami. Due to long hours, a two-month stint in trauma wasn’t recommended, so instead he spent his second month training in plastic surgery. Under the supervision of Dr Ralph Millard, often referred to as a leading plastic surgeon of the 20th century, Dr Swift fell in love with the craft. “I loved the diversity, the creativity and the surgery,” he explains. Completing his plastic surgery residency at McGill in 1986, he returned to Miami to complete an aesthetic fellowship with Dr Millard. Settling in his hometown of Montreal, Canada in 1987, Dr Swift began offering both reconstructive and aesthetic plastic surgery consultation services. Consulting at about 23 clinics, he spent most of the day in his car. The effort paid off and in 1993, after establishing an excellent reputation, Dr Swift opened The Westmount Institute of Plastic Surgery. To better serve his patients, Dr Swift kept up with industry innovations, which soon lead to the incorporation of less-invasive aesthetic treatments to his clinic. Initially he offered these treatments as a free, additional service to his surgical interventions. Soon, however, there was an apparent interest for less invasive therapies as stand-alone procedures. “My one afternoon of doing injectables every two weeks was now becoming more of a demand,” he explains. Dr Swift began dedicating a day a week to non-surgical facial enhancement to complement his plastic surgery practice. Simultaneously, Dr Swift’s reputation began attracting patients disappointed with results from other clinics. He explains, “It seemed as though practitioners were taking up non-invasive approaches but didn’t really have a clear concept of what their goals were. They understood that they had to fill areas that were depleted and soften lines that were dynamic, but they didn’t know when to take their foot off the gas pedal.”

After seeing many over-treated patients, Dr Swift felt he needed to teach restraint and aesthetic ideal. “There has to be a ‘sweet spot’ – where individual attractiveness is optimised – not a different look, just the best version of the patient,” he argues. “I began looking into concepts of beauty and soon discovered a commonality and universal concept of beauty.” Dr Swift looked to the renaissance artist and inventor Leonardo Da Vinci for inspiration. He learnt that Da Vinci, along with other artists and architects, incorporated the ‘Golden Ratio’ – a mathematical quantity represented by the Greek letter Phi – within their work. “Even the Ancient Greeks insisted that mathematics was at the root of all things beautiful,” explains Dr Swift.

He began applying this concept to his work, creating an injectable method called ‘BeautiPHIcation’. Invites to discuss BeautiPHIcation at conferences soon arrived, surprising Dr Swift with the

overwhelmingly positive reaction it received. Today, Dr Swift travels the world during his time off, sharing and exchanging knowledge with other practitioners. For aspiring aesthetic professionals, he emphasises the importance of being adaptable and optimising overall patient experience. Dr Swift is clearly passionate, and makes it his goal to impassion others when speaking at events. He says, “There’s no reason why you can’t educate and entertain at the same time. I constantly remind the attendees that they should be passionate about what they do or stay home.” Regarding the aesthetic profession, he adds, “There is nothing shameful about being in the quality- rather than quantity-of-life business. We are truly blessed to do this day-today – helping individuals, improving self-esteem and making positive changes to their lives.” Dr Arthur Swift will speak at the Aesthetics Conference and Exhibition (ACE) on March 7.

Q&A What treatment do you enjoy giving the most?

BeautiPHIcation is extremely gratifying – patient’s are our easels and their faces our canvas.

What technological tool best compliments you as a practitioner?

I remember during my residency when we tied off every bleeding surgical vessel with suture threads. Cautery technique, which can be taken for granted today, changed my life with respect to operating time. But people will probably say, “Come on, that’s from the dark ages!”

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

Whilst battling through medical school, my dad came into my room and left a piece of paper on my desk. There was a quote on there from Calvin Coolidge (ex-US president), which said, “Nothing in this world can take the place of persistence.

Talent will not; nothing is more common than unsuccessful people with talent. Genius will not; unrewarded genius is almost a proverb. Education will not; the world is full of educated derelicts. Persistence and determination alone are omnipotent.”

Do you have an industry pet hate?

That would be practitioners who hang on aesthetics purely for financial gain. Not because they’re passionate about what they do, but because of the money that can be generated from it. The medical aesthetic field is for the dedicated and is not a profession for dabblers.

What aspects of aesthetics do you enjoy the most?

Probably the teaching – it has truly opened the world to me.

I have made so many friends all over the globe, and the people that I’ve met in the industry have been phenomenal.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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The Last Word: Improving methods of consent Consultant plastic and cosmetic surgeon Mr Adrian Richards and aesthetic doctor Dr Natalie Blakely argue for better standards and streamlining of consent within the speciality of aesthetics Mr Adrian Richards

Dr Natalie Blakely

Unlike other countries, the UK has traditionally had what is generally perceived as low levels of medical litigation. This, however, is changing, and many of us are seeing this change reflected in a rise in our indemnity costs. Many medical litigation cases hinge on the process of consent. They seek to address the following questions: Were the risks of the procedure fully explained to and understood by the patient? Is the risk and the patient’s understanding of the risk recorded accurately in the patient’s notes? During my plastic surgery fellowship in Australia in 2000, I was struck by the detailed nature of the Australian consent forms. In the UK, I had been used to a printed sheet with one line for the surgeon to write the potential complications of the procedure. In Australia, there were specific consent forms for each procedure and five to six pages detailing the pros and cons, as well as the potential risks associated with the specific procedures patients were undergoing. Patients were given the forms two weeks prior to surgery and, after having time to study the forms, were asked to sign their consent on the day of surgery, at the same time as the clinician. In some medical centres they were required to sign after each paragraph to demonstrate that they had read and understood all aspects of the form. Today, Australian surgeons still follow similar stringent consent guidelines. Acquiring consent for photographs is also essential. Under standard medical practice guidelines, practitioners should not show before and after pictures to other patients or publish them on or offline without specific written consent from the patient. We can all learn from this thorough approach. For the patient, a better understanding of the benefits versus risks of any procedure helps them to make a more informed decision on whether to undergo treatment. For the clinician, accurate, detailed and legible consent reduces the risk of litigation. At my clinic I have worked with our team to improve and standardise our consent process. This involves adhering to the following steps: • Prior to the first consultation the patient is sent an information pack detailing the surgical process, likely recover period and a description of possible post-operative complications, as well as contact details for a 24 hour hotline should they have any concerns.

• During the first consultation the pros, cons and potential risks of the procedure are discussed and documented in the patient’s notes.

• If photographs are taken, the patient signs the specific consent form.

• The patient is given a procedure-specific consent form and a CD in which the pros and cons of the operation are discussed. Realising the demand for a simpler way for patients to understand the different aspects of the procedure, I created CDs, typically lasting 40-60 minutes, which provide the relevant information. I would recommend practitioners record their own CDs, as technique, treatment and outcome can vary.

• During the second consultation the patient and clinician both sign the consent form, and the patient is asked to confirm in writing that they have listened to all of the information on the CD. The completion of each stage is recorded in the patient’s notes. At present the consent forms are printed, signed and scanned onto our patient management system. In the future we hope to have a Mr Adrian Richards is a plastic completely digital consent process and cosmetic surgeon with 12 years with patients signing on screen. of specialism in plastic surgery at both NHS and private clinics. He is a In the 12 years I have been member of the British Association of practicing, I’ve been fortunate to Plastic and Reconstructive Surgeons (BAPRAS) and have a very low rate of litigation the British Association of Aesthetic Plastic Surgeons – I believe this is partly due to our (BAAPS). He has won numerous awards and has written a best-selling textbook. robust consent process.

As our society becomes ever more litigious, it is vital that we as clinicians improve our consent process. Litigation rates in private practice and the NHS are reported to be rising at 20% per annum.1 In aesthetics, most doctors use consent forms that are normally provided by the manufacturer of the product. As they are product specific, most practitioners I have spoken to agree that they are more convenient to use. However, I found that I was constantly running out of these consent forms. During my personal research to find out how other practitioners dealt with the critical matter of consent, I came to the following realisations: • Some practitioners had only ever consented their patients once (sometimes as long as five years ago).

• Some doctors did not consent at all, assuming implied consent.

• Most consultation notes did not reflect the detailed discussion that took place before a procedure.

• Consent is often not properly taken, with patients being asked to sign the form whilst the doctor is standing over them.

A signature does not necessarily mean consent. The patient must fully understand every part of the consent form before that consent is valid.

We as a speciality need to ensure that we spend sufficient time educating patients about the risks and benefits of treatment before proceeding.

New technology has allowed us to streamline this process. I founded a patient management app in order to aid this process, and I would love to create an interactive consent form to be used on an iPad. At the moment however, some aesthetic doctors still rely on pen and paper and rushed and incomplete consultation notes that leave us wide open to litigation (warranted or not). Isn’t it time we changed?

REFERENCES 1. http://www.telegraph.co.uk/health/healthnews/10093091/NHS- negligence-claims-rise-by-20-per-cent-in-just-one-year.html

Dr Natalie Blakely is medical director of the Light Touch Clinic in Surrey and founder of the Consentz patient record app. Whilst developing Consentz she became fascinated by the legal issues surrounding consent and how practitioners can improve their consenting processes, helping to protect both themselves and their patients.

Reproduced from Aesthetics | Volume 2/Issue 3 - February 2015

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INDICATION

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Now approved for crow’s feet lines Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection.

Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml).

Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection.

Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness.

Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,

dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251.

2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456.

3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.

5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1180/BOC/OCT/2014/LD Date of preparation: October 2014

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Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014