Aesthetics February 2016

w 16 no 20 E E RE AC er F st gi Re

VOLUME 3/ISSUE 3 - FEBRUARY 2016

Now available from Cosmedic Pharmacy

Understanding Sensitive Skin CPD Dr Tiina Orasmae-Meder discusses the occurence and treatment of skin sensitivities

Hand Rejuvenation

Management of Hirsutism

Top 10 Tips for Interviews

Mr Dalvi Humzah and Anna Baker explain how to augment the hand area

Dr Anita Sturnham details the aetiology of excessive facial hair in women

Julia Kendrick shares her media interviewing techniques to enhance business opportunities

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Contents • February 2016 06 News The latest product and industry news 16 News Special: Dissections and Developments Aesthetics reports on the controversial beauty therapists’ facial dissection

course, the publication of the HEE qualification requirements and the Joint Council for Cosmetic Practitioners

19 Aesthetics Conference and Exhibition 2016 A look at the latest additions to the ACE 2016 Business Track agenda

CLINICAL PRACTICE 21 Special Feature: Using Vitamin A Practitioners discuss the indications, limitations and best practice of vitamin A 27 CPD: Understanding Sensitive Skin Dr Tiina Orasmae-Meder explains the causes and treatment of skin sensitivities

33 The Properties of Skin Peels Lorna Bowes and Jacqueline Naeni review skin peel ingredients and detail

their cosmetic possibilities

39 Hand Rejuvenation

Mr Dalvi Humzah and Anna Baker examine the anatomy of the hand and advise how to successfully augment the area

43 The Role of Supplements, Hormones and Antioxidants in Skincare Dr Daniel Sister explains the importance of supplement intake and hormone

balancing for antiageing

46 Management of Hirsutism Dr Anita Sturnham discusses the causes and treatment of excessive facial

hair in women

52 Reshaping the Axillary Fold Mr Raj Ragoowansi describes his technique for treating the axillary fold 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 56 Top 10 Tips for Media Interviews Julia Kendrick details her effective interview techniques for maximising

your media profile

58 Reaching Social Media Goals Mike Nolan explains different social media strategies and shares his best tips

on how to reach your business development goals

62 On-hold Marketing Mark Williamson discusses how to turn telephone hold time into a business opportunity

66 In Profile: Mr Adrian Richards Mr Adrian Richards reflects on his journey into plastic surgery and the ethos

that has led him to a successful career

68 The Last Word Sharon Bennett argues the dangers of at-home injectable treatment parties

and advises practitioners of the risks they need to be aware of

NEXT MONTH • IN FOCUS: Hair • Eyelash Transplants • Treating the Post-pregnancy Body • Google Reviews and Clinic Reputation

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In Practice On-hold Marketing Page 62

Clinical Contributors Dr Tiina Orasmae-Meder specialises in dermatology and has more than 20 years’ experience in the professional beauty industry. She founded Meder Beauty Science and has been working with Iris Brand Vigilance as a leader in cosmetic safety since 2007.

Lorna Bowes is an aesthetic nurse and trainer.

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

Bowes is director of AestheticSource.

Jacqueline Naeni is an active member of the BACN and the Regional Leader for South Yorkshire BACN Regional Groups. She is also an AestheticSource team member training and supporting other aesthetic practitioners in the north of England.

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director of AMP Clinic in Oxfordshire. He also runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course.

Anna Baker is a dermatology and cosmetic nurse practitioner. She works alongside Mr Dalvi Humzah at the AMP Clinic in Oxfordshire and is the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a post-graduate certificate in applied clinical anatomy.

Dr Daniel Sister is a cosmetic, antiageing and hormone specialist. He received his medical doctorate at the Paris Medical School, and specalises in minimally invasive antiageing procedures. Dr Sister is a published author and appears regularly on television and radio.

Dr Anita Sturnham is a specialist dermatologist and general and aesthetic practitioner. She runs the Nuriss clinic in London, as well as serving an ambassador for Unilever skincare and a medical expert for Superdrug.

Mr Raj Ragoowansi is a consultant plastic and aesthetic surgeon. He graduated in Medicine and Surgery in 1992 from St Thomas’ Hospital Medical School, London, with the final year elective spent at Harvard Medical School, Boston, US.

Register for the Aesthetics Conference and Exhibition 2016 15-16 April www.aestheticsconference.com

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 The Aesthetics year seems to be moving very fast. No sooner have we finished celebrating the Awards than it’s time to learn at the Aesthetics Conference and Exhibition (ACE) 2016. Planning is well underway; we have been overwhelmed with requests for Amanda Cameron speaker slots and the agenda is now almost Editor full. It is such a pleasure to know that ACE is the conference and exhibition everyone wants to attend! As well as the usual Business Track (detailed on p.19), Expert Clinic and Conference agenda, we are launching an exciting innovation called Treatments on Trial, where you will get the opportunity to challenge the manufacturers about their technology, listen to presentations and decide which treatments are best for you and your clinic. Don’t forget to register and benefit from all the educational content – we look forward to seeing you there!

The first week of 2016 was an eventful one for our industry; there was social media uproar at the news that a group of beauty therapists had attended a facial anatomy dissection course, and Health Education England published two reports on the recommended qualification requirements for professionals working within the aesthetic and cosmetic sector. Read our detailed report

on p.16 to find out what went on and how you can practise safely in 2016. I always find February a dismal month, it’s still winter and spring seems some way off, however we can use the time to focus on getting both our patients’ skin and our own in optimum condition for the brighter months. Remember, while there’s no hot sunshine to cause damage, there’s still no excuse not to be using sunblock and antioxidants! To help you along, this issue focuses on skin rejuvenation – we take an in-depth look at the use of vitamin A for topical use in skin preparations on p.21, Dr Tiina OrasmaeMeder shares her dermatologic advice for treating sensitive skin in our CPD article on p.27, and Lorna Bowes and Jacqueline Naeni discuss the use of skin peels on p.33. After reading these articles, there’s no reason why your patients shouldn’t have healthy, glowing skin in time for spring. Enhancing your patients’ experience encompasses every aspect of their journey, starting with their initial telephone call. In our In Practice section this month, sales and marketing director Mark Williamson shares advice on the best methods of marketing your clinic, even when you place a potential patient on hold; turn to p.62 to learn more.

Let us know your thoughts on this month’s news and features, and if you’ll be attending ACE 2016, by tweeting @aestheticsgroup or emailing editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

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

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

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

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Regulation

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Report Emma Davies @daviesemma5 At long last! HEE publishes its report. Excellent document, well worth waiting for. #Clinic InjectAbility Beauty @InjectAbility A lot has changed since this photo and we are so excited to share the new staff members we’ve added! #TBT

#Vitamins Dr. Rabia Malik @DrRabiaMalik From 35 I incorporate vitamin A into my patients’ skincare routine as it’s the number 1 anti-ageing skincare ingredient. #SkinHealth #Safety Dr Kannan Athreya @drathreya Patient safety is so important to us and we keep up to date with regular refresher training for Life Support #Essex

#NewClinic Dr Stefanie Williams @DrStefanieW Sneak preview – just got a mock up of our new clinic front on Bondway – so exciting!

#Contributor Souphiyeh Samizadeh @drssamizadeh Happy New Year! It’s a pleasure writing for @aestheticsgroup #Surgery Barbara Jemec @bjemec Standing back to #teach is hard but necessary if you want to leave permanent skills #ILookLikeAPlasticSurgeon

HEE unveils new qualifications to improve the safety of non-surgical cosmetic procedures Health Education England (HEE) has published two reports aimed at improving and standardising the training available to aesthetic and cosmetic practitioners.

The reports, commissioned by the Department of Health, set out qualification requirements for practitioners in the aesthetic and cosmetic sector, which are aimed at ensuring people are properly trained and patients are safe.

Areas of study that must be incorporated into a detailed curriculum are: general knowledge and skills, speciality specific knowledge and skills, law, policy and ethics, facilities, premises, health and safety.

Part One of the report sets out the qualification requirements, which include guidance on the application of the requirements for different groups of practitioners. Part Two describes the second and final phase of the project, to produce the detailed qualification requirements for delivery of non-surgical cosmetic interventions and hair restoration surgery. The Department of Health will take the work forward as the leaders on the overall programme.

Skincare

Murad launches new Hydro-Dynamic skincare products Skincare manufacturer Murad has introduced the Quenching Essence and Ultimate Moisture to its HydroDynamic skincare range. The HydroDynamic Quenching Essence aims to moisturise and relieve dryness. It is formulated using Mexican blue agave leaf extract that aims to bond to the skin’s surface to restore its ability to attract and retain water. It also contains glycolic acid to exfoliate the skin to open hydration pathways and to encourage cell renewal.

The Hydro-Dynamic Ultimate Moisture uses hyaluronic acid technology, and coconut extract is combined with an antiageing peptide blend that aims to encourage smoother, plumper skin texture. “Hydrated skin functions better, feels smoother and looks younger,” said Howard Murad, founder of Murad. “Longer lasting hydration is a critical component of antiageing and exactly the reason the new Hydro-Dynamic products were created.” All the products in the Hydro-Dynamic range contain RepleniCell, a solution which aims to attract and bind water to the skin to improve skin hydration.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Regulatory body

BACN and BCAM to establish new regulatory body for the aesthetic and cosmetic industry The British Association of Cosmetic Nurses (BACN) and the British College of Aesthetic Medicine (BCAM) have reached an agreement to establish a new oversight/regulatory body for the cosmetic sector in England.

The Joint Council for Cosmetic Practitioners (JCCP) is to be established by the BACN and BCAM, with help from the Department of Health, following the publication of the final Health Education England (HEE) report on January 8, where the principle of establishing such a body was supported.

Patient safety is to be at the heart of the new initiative, which will oversee the delivery of safe treatments for the public. The JCCP’s core principles will include: to be independent and non-profit, industry-led, impartial and objective, and patient-centred.

Sharon Bennett, chair of the BACN, said, “The whole industry has been really concerned about the lack of regulation and the confusion caused to the public when they try to find a reputable practitioner. We are looking to standardise and harmonise the industry and bring together everyone who delivers cosmetic treatments so they’re all working to the agreed standards.” She continued, “The initiative has had huge support and the feedback we have received so far has been fantastic; people are applauding and supporting it. It’s going to take a very long time, this isn’t something that is going to happen overnight, it’s a long-term project, but the JCCP will become the recognised organisation and it can only do good to this industry.”

The BACN and BCAM will work together on the implementation of a framework for the JCCP, with a clear remit, structure and sustainable financial model. They will develop a series of initial options for the proposed JCCP and establish a Professional Standards Board, under the guidance of the newly appointed independent interim chair, Professor David Sines CBE. A summary of the initial thinking and a primary structure has been developed that both organisations believe will be acceptable to the many stakeholders involved. They will be seeking support of both the industry and Government to help finance this development over the next 12 months.

Training

Lou Sommereux launches training courses Aesthetic nurse and independent prescriber Lou Sommereux has launched her monthly Lou Sommereux Training Course, which will begin on February 15 at Cosmex Clinic in Cambridge. The one-day learning experience will allow practitioners to discover the latest on dermal filler complication management, the anatomy and physiology of the face and explore the danger zones; how to avoid these, prevent complications and ensure safe treatments are delivered. The course will also discuss ‘red flag patients’ and explain how to recognise and competently manage a minor and major complication.

Sommereux believes many practitioners are anxious when it comes to calculations and numeracy surrounding hyaluronidase and how much to administer with which filler, so she will explore this and discuss how to use hyaluronidase as an antidote to dermal fillers. Practitioners will be assessed throughout the day and given postcourse work that will be submitted for a certificate of merit.

Sommereux has been in the aesthetics industry for 14 years and was awarded Aesthetic Nurse Practitioner of the Year at the Aesthetics Awards in 2014, while her clinic, Cosmex Clinic, was a finalist in the Best New Clinic catergory.

Countdown to ACE 2016 Latest programme updates Dr Victoria Dobbie will perform a live treatment demonstration using botulinum toxin for facial beautification and rejuvenation.

Dr Chris Blatchley’s Business Track session will provide advice on how to expand a practice offering and patient base by using botulinum toxin to treat migraines.

Insight Consultant plastic surgeon and trainer Mr Adrian Richards says: “I’m delighted to present again at ACE. Last year I discussed fat reduction procedures at the premium Conference and presented on the A-lift method. This year I will run another Expert Clinic, including a live demonstration performed by aesthetic nurse prescriber Mel Recchia, where I will compare surgical and non-surgical procedures for facial rejuvenation.

It’s amazing to see so many colleagues from established clinics keeping themselves upto-date and sharing experiences, as well as new practitioners eager to learn about the latest innovations and best practices. I think that the greatest advantage of attending ACE is the opportunity for practitioners of all levels and backgrounds to enhance their skills and increase patients’ results. You can squeeze so much information into two days so make the most of it!”

What delegates say “I love ACE and I go every year as it really allows me and my team to get valuable information on what’s happening in the industry in one meeting.”

Plastic surgeon, Buckinghamshire

“I go to ACE specifically to listen to certain lectures and see practitioners that I respect, it also offers a good opportunity to network.”

Cosmetic doctor, London

www.aestheticsconference.com HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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

31st March – 2nd April 2016 Aesthetic & Anti-aging Medicine World Congress 2016, Monte Carlo www.euromedicom.com

4th – 6th April 2016 British Society for Investigative Dermatology Annual Meeting 2016, Dundee www.bad.org.uk

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

11th – 15th May 2016 Face Eyes Nose Conference, Coventry www.faceeyesnose.co.uk

29th June – 1th July 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 2016, Bristol www.bapras.org.uk

5th – 7th July 2016 British Association of Dermatologists Annual Meeting, Birmingham www.bad.org.uk

Industry

Skinbrands partner with mybody Cosmeceutical company Skinbrands has announced a partnership with mybody Probiotic Skincare, resulting in the international distribution of probiotic solutions in the UK, Malaysia, Canada and the Netherlands. The mybody Probiotic Skincare range aims to offer solutions for women to treat conditions such as premature ageing, hypersensitivity and acne-prone skin to achieve healthy, radiant skin. “Skinbrands are very excited to launch mybody skincare in the UK,” said education and brand manager for Skinbrands, Sharon Cass. She continued, “At Skinbrands we aim to provide choice for the practitioners we work with and this range provides a fresh approach to treating a range of concerns including ageing, pigmentation, redness and problem skin concerns.” Skinbrands claims the range is free of any known endocrine disruptors including parabens, phthalates, dyes sulfates and gluten.

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Revalidation

Revalidation for nurses to be made compulsory It will be compulsory for all nurses and midwives in the UK to revalidate every three years to maintain their registration with the Nursing and Midwifery Council (NMC) as of April 1. The NMC worked closely with the BACN to build on the existing requirements through introducing new elements that aim to encourage nurses and midwives to demonstrate that they practice safely and effectively.

“These requirements ensure that there will be a culture of sharing, reflection and improvement amongst nurses and midwives, which will ensure that nurses and midwives practice safely and effectively strengthening public confidence in the profession,” said clinical nurse specialist, BACN board member and joint revalidation lead, Sharron Brown. A critical part of the revalidation process is the role of the person who acts as the ‘confirmer’, to which the nurse will need to demonstrate that they have met the revalidation requirements and the role of the ‘reflective discussion’ with another nurse or midwife. The NMC recommends that the ‘confirmer’ should be the individual’s line manager, a NMC registered nurse or a regulated healthcare professional. The aim of this is to provide an additional degree of assurance that the revalidation requirements have been met and to make nurses more accountable for their practice and improvement.

The BACN said that nurses who recently took part in a pilot found the new process and regulations to be achievable and straightforward. “The BACN acknowledges the historical importance revalidation has for nurses and found the revalidation pilot to be a positive experience,” Brown said. “Bringing the speciality of aesthetic/cosmetic medicine to the NMC council chambers has enabled us to consider the needs of our members to help them through the process when it starts in April 2016,” she added.

Laser

Lynton Lasers launches 3JUVE UK aesthetic technology manufacturer Lynton Lasers has introduced its latest antiageing system 3JUVE. The 3JUVE combines three individual non-invasive technologies: ResurFACE Fractional Laser, ReBRIGHT and ReMODEL to target a variety of ageing skin concerns.

The ResurFACE Fractional Laser aims to retexture the skin to increase smoothness, reduce the appearance of lines, tighten pores and treat any textural irregularities. The ReBRIGHT brightening technology is designed to treat discoloured skin by reducing redness, veins, sunspots and sun damage. ReMODEL is the final component of the 3JUVE, which aims to lift and firm the skin to create a more youthful appearance.

Lynton Lasers clinical director, Dr Samantha Hills, said the treatments work to produce a smooth, youthful and glowing skin appearance, “When it comes to ageing skin, there are three key indicators we can all exhibit: discolouration, lines and wrinkles, and a loss of firmness.” She explained, “Our new 3JUVE device has been designed to tackle all three of these symptoms by delivering optimum stimulation of the dermis and epidermis, resulting in unprecedented collagen renewal and even skin tone.

The results achieved through this new 3JUVE treatment will help meet the new, high levels of demand for entirely natural looking antiageing results.”

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Prescribing

Investigation claims UK doctors are breaching botulinum toxin prescribing guidelines According to an investigation by The Times, UK practitioners are breaching guidelines for botulinum toxin prescriptions. The investigation found that some doctors in the UK are providing botulinum toxin prescriptions to third-party beauticians without having face-to-face consultations with patients, which is an industry requirement, set by the General Medical Council (GMC). According to The Times, beauticians are getting prescriptions directly from doctors or obtaining them illegally on the black market.

Undercover reporters from The Times and private accreditation body Save Face discovered several beauty salons in England and Wales that were prepared to inject patients with botulinum toxin in minutes for less than £200, without consulting with a doctor first. In some places, not even a consent form signature was required if the patient said they were ‘not allergic to anything’. Director of Save Face, Ashton Collins, said the body has received several complaints and reports from Save Face members regarding this issue. “Following the changes set out by the statutory medical bodies in 2012 relating to remote prescribing, it is assumed by many within the industry that the issue has been put to bed, which quite simply is not the case.” She continued, “In actual fact, we are receiving increasing reports of this illicit behaviour which is occurring throughout the country both from concerned medical professionals and patients alike. I feel that the current rules do not go far enough to protect the consumer.”

Collins said Save Face is calling for an amendment to the prescribing guidelines to instruct all non-prescribers to disclose the full name and details of the prescriber on their websites to offer the consumer complete transparency. “Enforcement should also be made requiring medical practitioners to provide details of the full names as they appear on their respective statutory registers so that their credentials can be verified,” said Collins, “all too often there are spurious references to doctors and other medical professionals who only make reference to their first names which in reality could be anyone and are often bogus practitioners.”

Aesthetics

Vital Statistics 3%

Psoriasis affects up to of the world’s population

(International Federation of Psoriasis Federation)

29%

of young doctors have depression or symptoms of it (Journal of the American Medical Association)

Prescription drug sales are predicted to reach $1,017 billion by 2020 (EvaluatePharma World Preview 2014 Outlook to 2020)

Botulinum toxin is the most popular non-surgical cosmetic procedure for both men and women, with 4,830,911 procedures performed worldwide (International Society of Aesthetic Plastic Surgery)

19% of men

admit that they would use their partner’s face care

(American Society for Aesthetic Plastic Surgery)

Acne

SkinMed launches addition to Tebiskin range Dermatological distribution company SkinMed has introduced the new OSK Chest and Back to its Tebiskin range. The Tebiskin range aims to combat resistant acne on the face and neck. The new addition to the range is a spray that aims to treat chest and back acne and to reduce inflammation.

SkinMed claims the spray is easy to apply and absorbs without rubbing in, making it easy for the patient to use at home. The company claims the key ingredients act to kill acne bacteria faster than prescription combinations and helps to restore the skin’s lipid balance. The Tebiskin OSK Chest and Back does not contain any antibiotics, benzoyl peroxide or retinoids and can also be used in combination with EnerPeel 30% Salicylic Acid Chest and Back.

In a survey of 1,000 UK customers, 54% of callers believe a company sounds more professional if they use bespoke music and voice messaging (PH Media Group)

A 2015 report suggests that 45% of companies don’t have a clearly defined marketing strategy (Managing Digital Marketing in 2015 from Smart Insights)

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Skincare

Exuviance releases new oxygen facial treatments Skincare company Exuviance has launched two new oxygen facials, The Exuviance Resurfacing and Oxygenating Treatment and the Exuviance Oxygenating Instant Brightening Treatment.

The treatments have been created by skincare professional Debbie Thomas, who, according to Exuviance, has incorporated pure molecular oxygen delivery with special laser techniques, which aim to resurface, rebalance and brighten dull skin. The Exuviance Resurfacing and Oxygenating Treatment aims to increase skin hydration and revitalise skin, prior to resurfacing it using a light fractional laser peel to smooth fine lines. The Exuviance Oxygenating Instant Brightening Treatment incorporates hydra-dermabrasion and red light therapy and aims to provide a ‘pre-party’ oxygen facial with no downtime. According to Exuviance, the treatment stimulates collagen and elastin and infuses the skin with oxygen, polyhydroxy acids (PHAs), antioxidants, amino acids and essential lipids to leave the skin energised, radiant and smooth.

Conference

3D-lipo Ltd announced as ACE 2016 Networking Event sponsor Delegates are invited to attend the free Networking Event at the Aesthetics Conference and Exhibition (ACE) 2016, which will be supported by aesthetic manufacturer and distributor 3D-lipo Ltd on Friday 15 April.

The event provides attendees the opportunity to liaise with colleagues and business partners, as well as meet leading industry figures at 5:30pm at the conference venue in Islington, London. “3D-lipo Ltd are proud to be supporting the Networking Event because it is the ideal way to interact and get to know your fellow industry personnel and practitioners in the field, which is what ACE is all about,” said Roy Cowley, managing director of 3D-lipo Ltd. “The first day of the conference will be jam-packed so we are encouraging delegates to finish the day with a relaxing catch-up and a glass of prosecco. We are especially looking forward to getting to know more professionals throughout the aesthetic industry.”

The Networking Event is free for all ACE 2016 registered delegates, who can benefit from the free Masterclasses, Expert Clinics, Treatments on Trial, Business Track sessions and Exhibition Floor over the two days, which are also included in the free registration. Practitioners can also choose to purchase the premium Conference Pass for a full and comprehensive learning experience, including access to presentations from leading industry experts.

For more information and to register for ACE 2016, visit www.aestheticsconference.com

NeoStrata release ProSystem Professional Backbar range

Skincare company NeoStrata has released a new range of products aimed at optimising skin health in patients before and after clinical treatments. The ProSystem Professional Backbar products aim to enhance the results of treatment and can be applied immediately after non-ablative procedures. The range includes: Facial Cleanser, Aminofil Complex, Firming Collagen Booster, Bionic Face Serum, Bionic Face Cream and Daytime Protection Cream, Sheer Hydration SPF35. According to AestheticSource, the UK distributor of NeoStrata, the ingredients in the products benefit the skin by soothing and conditioning, eliminating redness, evening pigmentation, firming and volumising and strengthening the skin’s natural barrier. Ingredients include gluconolactone, lactobionic acid, NeoGlucosamine, aminofil, matrixyl and phytostem gardenia extract.

The products are said to be ‘ideal’ following microdermabrasion, non-ablative laser treatments, IPL, medical facials, hair removal, radiofrequency and LED treatments.

Training

Mr Dalvi Humzah launches new advanced courses Consultant plastic surgeon Mr Dalvi Humzah has announced his new Aesthetic Clinical Training Course will take place on June 8 and July 6 at Wigmore Medical in London.

In addition to Mr Humzah’s award-winning Facial Anatomy Teaching course on March 7 and Management of Non-surgical Complications teaching course on May 23, the new sessions will offer advanced bespoke injectable training.

Medical aesthetic practitioners have the opportunity to learn from Mr Humzah in an intimate group of four delegates per session, allowing for close supervision and optimal practical experience.

“Practitioners will spend the day with me discussing treatment options, analysing the face and applying the practical aspects of the treatment,” said Mr Humzah. “They will observe the treatments and then be able to perform them with advice and guidance that will be unique for a small group. This will enable them to quickly advance their skills level – I will have to try and hold off getting my hands into the practical during that part of the session!”

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Melanoma

KEYTRUDA gains FDA approval for first-line treatment of metastatic melanoma The Food and Drug Administration (FDA) has expanded the approval of KEYTRUDA, the anti–PD-1 immunotherapy pembrolizumab, to include first-line treatment of metastatic melanoma.

The endorsement is the second indication to be FDA-approved for KEYTRUDA in the use of advanced melanoma. The treatment is also used to treat a certain type of non-small cell lung cancer.

The approval follows the results of a phase III trial, which included 834 patients with unresectable or metastatic melanoma. Researchers provided 279 patients with pembrolizumab 10mg/kg every two weeks and 277 patients with pembrolizumab 10mg/kg every three weeks until disease progression or unacceptable toxicity.

The other 278 patients received ipilimumab, an anti–CTLA-4 antibody that is used as a standard first-line treatment for the condition. Patients in this group were given 3mg/kg every three weeks for up to four doses.

All patients involved in the trial had no prior treatment using ipilimumab and had undergone prior therapy with no more than one other systemic treatment.

Results indicated improved overall survival among patients assigned the everythree-week and every-two-week dose of pembrolizumab. Researchers also reported a higher response rate, longer durations of response, longer progressionfree survival and fewer side effects among pembrolizumab-treated patients.

“The growing body of evidence in patients with advanced melanoma supports the expanded indication for KEYTRUDA,” said Dr Omid Hamid, the principal investigator for the pembrolizumab clinical programme. “This approval highlights the importance of KEYTRUDA for advanced melanoma, where we are in need of additional treatment options.”

Acquisition

Allergan acquires Anterios for $90 million Pharmaceutical company Allergan has acquired Anterios, a biopharmaceutical company that is developing next-generation botulinum toxin-based prescription products. Allergan acquired the company for an upfront sum of US $90 million, which also included the New Drug Submission (NDS) technology that Anterios developed that aims to deliver neurotoxins through the skin without the need for injections.

“The acquisition of Anterios bolsters Allergan’s commitment to innovation and maintaining its leadership position in neurotoxin development and commercialisation,” said the executive vice president and president of global brands research and development at Allergan, David Nicholson. “This acquisition demonstrates our ability to apply our tremendous scientific leadership in neurotoxins to further extend our already deep neurotoxin pipeline by advancing a new delivery system and formulations that are appealing to both patients and physicians,” he said.

As well as NDS, Allergan now has the global rights to ANT-1207, a botulinum toxin type A formation currently in development for the potential to treat hyperhidrosis, acne, and crow’s feet lines. “Allergan has a long history in dermatology and aesthetics, a deep commercial and development network across these professional communities, and a strong commitment to innovation,” said Dr Jon Edelson, CEO and founder of Anterios. “They were the natural fit for us as we sought a partner to take our NDS platform technology and ANT-1207 programme to the next stage of development and eventual commercialisation,” he said. The acquisition comes shortly after the $160 billion Pfizer and Allergan merger in November 2015.

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Iryna Stewart, managing director of Institute Hyalual UK Institute Hyalual is a big supporter of aesthetic nurses, why are they so important to you?

We recognise the big contribution nurses make to the industry and want to champion this at every opportunity. Our philosophy is to develop practitioners’ skills and knowledge, and we have found that nurses are always keen to learn, becoming more and more advanced each year. That’s not to say we don’t support other aesthetic professions, everyone is welcome to attend our training and learn about our new products and techniques to benefit their patients.

You have recently launched Xela Rederm, what does this do?

Xela Rederm is a unique formula made up of highly purified biotechnological origin hyaluronic acid. The injectable product has a powerful antioxidant effect and can be used for all types of skin rejuvenation, including hand and neck rejuvenation, wrinkle reduction and skin tightening. We have a number of experienced aesthetic practitioners using and supporting Xela Rederm, who have all reported excellent results and high patient satisfaction.

Medical director of Cosmedic Clinic, Dr Martyn King, stocks Xela Rederm in his pharmacy, Cosmedic Pharmacy.

How do I learn more about Xela Rederm?

All users of Xela Rederm are provided with comprehensive free training to ensure they practise safely and are confident in its use and patient suitability. Depending on user preference, we can either visit you in your clinic or you can attend training at our premises at 1 Harley Street.

Practitioners interested in Xela Rederm can watch live demonstrations and discover more from the Institute Hyalual team at the AMWC congress in Monaco on March 31, and in the UK at the Aesthetics Conference and Exhibition (ACE) on April 15-16.

This month we will also be holding a press day to officially launch Xela Rederm; ensuring consumers learn about its fantastic antiageing effects and are encouraged to find practitioners offering Xela Rederm in their clinics.

This column is written and supported by

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Skincare

Medica Forte launches new skincare products and Perfect Prescription Kit

Aesthetic medical supplier Medica Forte has launched its new Perfect skincare range to prolong the results of The Perfect Peel. The new products aim to help even skin tone, exfoliate, hydrate and regenerate the skin, and destroy blemish-causing bacteria. Included in the range is The Perfect Cleanser, The Perfect Body Wash, The Perfect Body Lotion and Mineral Perfection. Medica Forte has also announced its Perfect Prescription Kit, which is a selection of single patient prescription treatment kits for acne, pigmentation and skin rejuvenation issues, which allows practitioners to order the exact required products in one box. The Perfect Prescription Kits will be available in six different forms: the Acne Kit, the Acne + Kit, the Pigmentation Kit, the Pigmentation + Kit, the Rejuvenation Kit and the Rejuvenation + Kit. A protocol card advising on pre and post-peel regimes that aim to suit specific patient needs will also be included.

Medica Forte has more than 30 years’ experience in medical aesthetics and is the UK distributors of The Perfect Peel, The Perfect Plus Booster and The Perfect C. Laser

Lutronic CLARITY range offered in UK clinic Cotswold Face & Body in Cheltenham has become the first clinic in the UK to offer the new Lutronic CLARITY laser treatment device.

Lutronic CLARITY is a multi-treatment, dual wavelength laser that offers solutions for a variety of skin and antiageing concerns such as hair removal, vein and capillary treatments, pigmented and vascular lesions, rosacea, skin rejuvenation, and skin tightening and firming. “My aim is to offer our patients superlative treatments and we are proud to have a first with Lutronic CLARITY,” said Cotswold Face & Body clinic director Emma Beddow, continuing, “whether clients are after smooth legs for life, would like to rid themselves of veins or to purge pigmentation, CLARITY has a treatment to suit.

The procedures are simple, effective and due to the built-in Intelligent Cooling Device, the treatments are comfortable and come with almost no down-time for clients.” The device’s dual wavelengths permits the treatments of all skin types and gives the user the ability to choose from 755nm or 1064nm wavelengths. The device is distributed in the UK by VENN Healthcare.

Aesthetics aestheticsjournal.com

News in Brief Mr Ash Labib and Healthxchange launch new non-surgical rhinoplasty training Ear, nose and throat surgeon and aesthetic practitioner Mr Ash Labib is to deliver his non-surgical rhinoplasty training at the Healthxchange Academy in Manchester on various dates in 2016. Healthxchange Pharmacy, which won Distributor of the Year at the Aesthetics Awards 2015, opened its academy in Manchester in late 2014 and offers a range of aesthetics courses.

Provisional dates for the training are February 11, March 19, May 5, June 4 and July 17.

World Association of Medical Editors elects new president Dallas plastic surgeon and editor-in-chief of Plastic and Reconstructive Surgery, Dr Rod Rohrich, has been chosen as the new president of the World Association of Medical Editors (WAME). Dr Rohrich will serve as president at the WAME International Conference, to be held on October 1 2016, and will continue to serve his presidential term until January 2018.

Intraline Lifestyle Aesthetics appoints new director of threads, UK Intraline Lifestyle Aesthetics has welcomed Siobhan Cunney to its new UK team as director of threads. Cunney, who has been in the aesthetic industry for 15 years, said, “I am passionate about the aesthetic industry and I am delighted to join Intraline Lifestyle Aesthetics, a company dedicated to clinicalbased products. They are looking to shift the attitude of the aesthetic industry amongst clinicians and consumers by taking a unique and genuine lifestyle approach to their business and marketing.”

Dental Directory launches new website The Dental Directory has launched its new website, dental-directory.co.uk, providing a more user-friendly site for a better customer experience. The new site aims to create an online, flexible resource that responds to the changing needs of the UK dental sector.

The improvements include budget controls, product recommendation tools, offers and promotions, quick shopping, order history and mobile functionality. The site’s homepage also sorts popular products and categories such as ‘facial aesthetics’ and ‘infection control.’

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Awards

QMS Medicosmetics re-formulises skincare range Skincare developer QMS Medicosmetics has re-formulised its collagens and exfoliants, aiming to deliver better product effectiveness. The new formula can be found in the Classic Collagen Set and MED Collagen Set, and aims to deliver improved effectiveness in targeting premature skin ageing, stimulating cell renewal and providing hydration across more layers of the skin. The collagen formula has introduced Neotec A15, which is a combination of collagen and hyaluronic acid of differentiated molecular sizes of lower molecular weight. The formula is designed to penetrate deeper into the skin layers to help the collagen penetrate through. The desired result is to increase the skin’s moisturising capabilities and improve softness and elasticity.

The new formula also includes an anti-irritation complex, hoping to optimise the skin’s tolerability.

QMS Medicosmetics distributes its skincare products internationally and was founded more than 25 years ago by Dr Erich Schulte.

New Sponsors Announced for the Aesthetics Awards 2016 New sponsors have been announced for the annual Aesthetics Awards, taking place on December 3, 2016. Held at the Park Plaza Westminster Bridge hotel, the night will celebrate the aesthetics industry in 2016, with practitioners, professionals, clinics and companies presented with awards for their contribution to the industry. For the second year in a row, SkinCeuticals will sponsor the award for Best Clinic Ireland, while Pure Swiss Aesthetics will once again sponsor the category for Best Clinic Group UK and Ireland (10 clinics or more). Teresa Da Graca of Pure Swiss Aesthetics said “Swisscode and Pure Swiss Aesthetics were delighted to sponsor the 2015 Award for Best Clinic Group, UK and Ireland. The event was a perfect opportunity to celebrate with our clients and peers and to gain exposure and wider recognition for Swisscode Pure and Bionic clinic-only brands. We were thrilled to be given this opportunity and look forward sponsoring the Aesthetics Awards 2016.” Antonia Parsons, product manager at SkinCeuticals added, “At the Aesthetics Awards 2015 it was great to see those at the top of their game rewarded for their dedication to the industry, skill and professionalism. We are truly delighted to be sponsoring the Awards again this year.”

On the Scene

On the Scene

UltraPulse treats UK armed forces, Birmingham Surgeons from around the country visited the Queen Elizabeth Hospital in Birmingham to deliver UltraPulse laser treatments to injured personnel for burn scars on January 11. Led by consultant plastic and reconstructive surgeon Mr Max Murison, the surgeons were taught current techniques for treating burn scars using UltraPulse, providing an opportunity to treat armed forces personnel for the first time. Five patients were treated, one being Karl Hinnett, a regular campaigner for veterans. The charity WoundCare4Heroes was also in attendance and announced on the day it would fund the upgrade to the current UltraPulse system to use on burn scar patients. “It was an interesting day and the first time I have had the opportunity to treat members of the armed forces,” said Mr Murison, “The technique of treating burns scars has been used in Wales for the last five years and makes a remarkable difference to the texture and stiffness of the scars. Over 100 patients in Wales have benefited from CO2 laser treatment of the scars and the improvement is usually immediate, followed by a period of up to eight months when the scar continues to soften.”

Viviscal Professional Hair Growth Programme Brand Launch Viviscal Professional launched new branding for its hair growth supplements at the Ham Yard Hotel, London on January 7. The Hair Growth Programme

by Viviscal Professional contains marine protein complex AminoMar C, and aims to help nourish thinning hair and promote healthy hair growth. The company’s founder and CEO James Murphy believes the products have provided positive results and are a good option for patients who “Have the highest expectations of their hair and will go to any lengths to get what they want.”

The company claims that patients will see an 111% increase in terminal hairs after three months of taking two tablets a day.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Dissections and Developments: industry standards under scrutiny in 2016

days provided an invaluable resource for a small number of practitioners to study, in depth, the nerve structures of the face and to ensure that the highest level of safety and protection is offered to clients undergoing cosmetic procedures.” However, much to the concern of many aesthetic professionals, the anatomist who conducted the dissection and training did not have experience in treating aesthetic patients.

Consultant aesthetic and plastic surgeon, and founder of Facial Anatomy Training, Mr Dalvi Humzah said, “It is important courses are run for practitioners to uphold their skills In the same week as the release of a controversial and knowledge, however the problem lies video discussing beauty therapists training using a with who is teaching it. A person who is cadaver, HEE published its recommendations for the performing a dissection should be qualified not only in the anatomy but also in the safe delivery of cosmetic procedures and the Joint techniques of injection and problems that Council for Cosmetic Practitioners was launched. one may see when performing non-surgical Aesthetics reports on the debates and developments treatments.” Chair of the British Association of Cosmetic Nurses (BACN) Sharon Bennett in the industry so far this year added, “Although I applaud the initiative to expand on education and training, it is of Last month, following the online sharing of a facial dissection grave concern that this course has been taught to beauty therapists course designed to offer training to beauty therapists, a social by someone non-medical.” Consultant plastic surgeon and former media storm erupted amongst aesthetic professionals. The president of the BAAPS, Mr Rajiv Grover, also voiced his concerns, national press quickly picked up the story, extending its reach to stating, “This is not just about teaching how to inject – anyone can the general public as well as the aesthetic community. Cosmetic wield a needle – it’s about those injectors not being equipped to Couture, a company that offers aesthetic training to beauty deal with consequences should something go wrong.” therapists, ran the two-day course in December with the aim of raising the safety standards of those participating in aesthetic HEE: qualification requirements training and increasing the anatomical knowledge of practitioners.

In the same week as the social media furore, Health Education The company later released a YouTube video, which has since England (HEE) published two reports aimed at improving and been removed, in which four beauty therapists and the director standardising the training available to aesthetic and cosmetic of Cosmetic Couture, Maxine McCarthy, discussed their learning practitioners. Commissioned by the Department of Health (DoH) experiences following the training. following the 2013 Keogh Review, the guidelines were developed Alarmed by the video, the Safety in Beauty campaign shared it by a group of industry professionals with advice and support via social media to the medical aesthetic community, which led to from an advisory group and representatives from the regulatory many practitioners voicing their concerns with beauty therapists bodies. The reports set out recommendations for qualification receiving training using a cadaver and subsequently offering requirements for practitioners in the non-surgical cosmetic sector. injectable treatments. Upon hearing the news, president of the The requirements laid out in Part One of the report state that only British Association of Aesthetic Plastic Surgeons (BAAPS) Mr Fazel practitioners of postgraduate level (Level 7), who have successfully Fatah commented, “A cadaver dissection course geared towards completed modality specific training, should administer botulinum non-medics beggars belief. How is a beauty therapist qualified to toxins and dermal fillers, providing an independent prescriber perform invasive treatments that require anatomy training? Nonsurgical doesn’t mean non-medical!”

A bigger issue While many people were quick to criticise McCarthy and the beauty therapists who undertook the training, others recognised that the issue raised a wider concern with the lack of regulation of the aesthetic industry. As there is currently no restriction on beauty therapists administering injectable treatments, providing a nurse prescriber or doctor has written a prescription following a face-to-face consultation, as recommended by the General Medical Council, it could be argued that beauty therapists who are intending to offer treatments should seek thorough and comprehensive training at every opportunity. McCarthy, who has 20 years’ experience as a beauty therapist, explained, “The two

HEE suggests that all practitioners demonstrate that they meet the standards for the treatments they wish to deliver by September 2018

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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oversees their work. Practical skills training for the administration of botulinum toxins and temporary/reversible fillers would begin at degree level (Level 6), again, under the supervision of an independent prescriber and clinical oversight. The requirements suggest that the practitioner should have, amongst others, an indepth understanding of facial and neck anatomy, be able to identify contraindications, have an understanding of the biochemistry and pharmacology of various botulinum toxins and dermal fillers, the ability to recognise and correct suboptimal outcomes using knowledge of facial muscle interactions in the case of botulinum toxin, and be able to recognise and manage complications relating to dermal fillers.

HEE recommends that practical skills training for the administration of botulinum toxins should include 10 treatments to the upper face for 10 different patients, while training for the administration of temporary/ reversible fillers for lines and folds (precluding complex zones) should also include 10 treatments for 10 different patients.

Part Two of the report describes the results of a one-month stakeholder consultation on the draft qualification requirements and HEE’s recommendations for accreditation and implementation.

Eight recommendations are made, of which, HEE suggests that all practitioners demonstrate that they meet the standards for the treatments they wish to deliver by September 2018. The report also recommends that a joint professional council should be established to assume ownership of the cosmetic industry standards for education and training, with lead responsibility for accreditation, further development, future proofing and continuing validity of the qualification requirements.

Aesthetics

The Joint Council for Cosmetic Practitioners: a way forward?

In response to HEE’s recommendation, the BACN and the British College of Aesthetic Medicine (BCAM) announced they would work together on the establishment of a joint council for the nonsurgical aesthetic sector. With support from the DoH, the Joint Council for Cosmetic Practitioners (JCCP) will aim to oversee the delivery of safe treatments to the public. Bennett explained, “We are looking to standardise and harmonise the industry and bring together everyone who delivers cosmetic treatments so they’re all working to the agreed standards.” The president of BCAM, Dr Paul Charlson, added, “The support of the DoH in this area has been fundamental in order to give this initiative credibility. It can only work with the full support of all parties and we will be as inclusive as we can in order to achieve an outcome that will be credible and workable.”

According to the pair, the BACN and BCAM will work together on the implementation of a framework for the JCCP with a clear remit, structure and sustainable financial model. They will also aim to establish a Professional Standards Board under the guidance of the newly appointed independent interim chair, Professor David Sines CBE. Despite the concerns and challenges faced by the growing aesthetic community in recent years, the developments this year offer new hope to those working hard to ensure patient safety is of principal importance to those practising aesthetics in the UK. Speaking of the JCCP, Bennett concluded, “It has been a long time coming and will not happen over night, however it will put an eventual stop to unsafe practice.”

Consultant Plastic, Reconstructive & Aesthetic Surgeon, Mr Dalvi Humzah provides bespoke practical anatomical and injectable teaching. Anatomical research continues to further understanding on emerging concepts and cadaveric teaching using unembalmed tissue remains the only teaching modality to allow aesthetic medical practitioners to appreciate the 3-dimensional aspect of facial anatomy through practical dissection, to visualise where injected product resides.

Dalvi Humzah Aesthetic Clinical Training Courses provide highly specialised small group teaching to develop your skills and provide an understanding of age related changes with specific techniques to treat these areas.

Facial Anatomy Teaching explores the current concepts and literature pertaining to treating age-related changes, with a practical dissection to analyse the current injection techniques using needle and cannula approach.

The Management of Non-Surgical Complications Through Anatomy teaching incorporates a detailed theoretical component on the recognition, diagnosis and current management strategies of toxin and dermal filler complications. This includes a practical dissection and hyalase workshop.

Mr Dalvi Humzah is an internationally recognised tutor who has been performing injectable treatments for more than 25 years. He has been closely involved in the research and development of many injectable products and devices, as well as holding consultancy roles in the management of complications.

Upcoming training dates Dalvi Humzah Aesthetic Clinical Training Facial Anatomy Teaching (Advanced/Intermediate Level Injectables) 11th March: University of Glasgow CASC 8th June, 6th July: Wigmore Medical 23 May: Royal College of Surgeons England rd

The Management of Non-Surgical Complications Through Anatomy 7th March: Royal College of Surgeons England 29th April: University of Glasgow CASC

W: www.facialanatomy.co.uk T: 07739 378 693 E: facialanatomyteaching@gmail.com

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Aesthetics

Growing your practice at the ACE 2016 Business Track Covering the latest in business strategy and development, both practitioners and clinic teams will benefit from the guidance offered at the free Business Track The highly anticipated Business Track sessions will provide delegates with crucial business skills and development strategies at the Aesthetics Conference and Exhibition (ACE) 2016, to be held in London on April 15 and 16. Alongside the free clinical content, the non-clinical sessions will be presented in a dedicated workshop on the exhibition floor by international consultants and successful entrepreneurs who will focus on marketing, patient loyalty, clinic management, taxation, regulation and patient consent.

Practitioners are encouraged to bring their whole clinical team to the Business Track sessions including directors, managers, ancillary staff and marketeers in order to obtain guidance on building, sustaining and growing a practice in medical aesthetics.

Over the two days, the Business Track agenda will cover an array of business related themes, including an in-depth discussion on how to increase sales from registered nurse and successful clinic owner Jane Lewis, and a useful presentation for small business owners and marketing teams on how targeted marketing can build your business by managing director and founder of e-clinic, Mark Lainchbury. Helpful advice on how to increase patient net value and retention will be shared by co-founder of 5 Squirrels, Gary Conroy, while the managing director of insurance provider Hamilton Fraser, Eddie Hooker, will share his specialist knowledge on the history of claims and the progression of insurance within the aesthetic industry. Dental surgeon and Lumley Aesthetics clinic owner, Dr Cheralyn Lumley will provide a stimulating talk on moving from dentistry to aesthetics, while chartered tax advisor, Veronica Donnelly will provide an

industry tax and VAT update. The latest on new consent law for use in practice will be delivered by aesthetic nurse and accredited civil expert Liz Bardolph, and an insightful discussion on how treating migraines with botulinum toxin will help grow a clinic and its patient database will be led by the founder of Capital Aesthetics, Dr Chris Blatchley.

Director and founder of Toxin Science Limited and scientific expert Professor Andy Pickett will discuss his growing concern for the circulation of counterfeit and fake aesthetic products, in particular botulinum toxin and dermal fillers, while also providing advice on how practitioners can reduce the prevalence of the issue in the UK. Aesthetic practitioner and chair of the British College of Aesthetic Medicine, Dr Paul Charlson, will provide an update on industry regulation, following the HEE report released January 8, and consultant vascular surgeon and founder of The Whiteley Clinic, Professor Mark Whiteley, will draw on his vast experience in order to provide key advice on how to grow a successful practice. Vital PR tips for your clinical business growth will be presented by the founder of Kendrick PR Consulting, Julia Kendrick, who will also present on building your clinic’s profile for increased revenue.

Finally, international aesthetic business consultant, Wendy Lewis, will present two talks, providing her expertise on the best online marketing practices in one session and sharing her social media mastery advice in another. Each Business Track session aims to increase the success and productivity of clinics, by providing the latest information on how to ensure daily activities run smoothly, how to enhance your brand, encourage patient loyalty and, ultimately, how to increase profitability.

“Today’s aesthetic practitioners face many challenges as well as opportunities,” says Wendy Lewis, continuing, “at every congress I attend in America and Europe, informative clinic marketing and business sessions are in great demand by delegates. By featuring knowledgeable and professional speakers who are willing to share their expertise, rather than just promote their own services, the ACE 2016 organisers are demonstrating their commitment to listening to what the UK aesthetics industry wants and needs to insure success and growth.”

Zain Bhojani, co-director of aesthetic distributor Church Pharmacy, sponsor of the Business Track, urges delegates to make the most of the free, informative non-clinical content offered at ACE 2016. He says, “Last year the response of the people listening to the Business Track was really good, it was nice to know the delegates were getting something out of it and learning something that is a bit different to the clinical side of things.” Bhojani adds, “ACE is without a doubt my favourite show; I find that we see most of our customers at this show, which is why I am excited to sponsor and contribute to the success of the Business Track again in 2016.”

Bhojani, who spoke at the Business Track last year, says there was a good response from those attending last year and people really benefited from the quality and diversity of the speakers. “I think everybody recognises the speakers, they are all faces within the industry and always have something new, innovative and useful to say,” he says.

Practitioners are encouraged to utilise the opportunity to attend the Business Track by bringing their entire clinic to gain imperative business knowledge. To access the free Business Track, practitioners and clinical staff can register online, which will also give them access to other free clinical content including the Expert Clinics, Masterclasses and Treatments on Trial agendas. Once registered, delegates can also choose to purchase the premium Conference Pass for a full and comprehensive learning experience.

The Business Track at the Aesthetics Conference and Exhibition is an unmissable opportunity to ensure that you and your clinic staff stay up-to-date with the latest industry tools and advice in order to maximise your clinic’s opportunities for success in 2016.

For access to the Business Track sessions and clinical sessions on the exhibition floor, register free at aestheticsconference.com BUSINESS TRACK SPONSOR

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Aesthetics

In their 2015 book Vitamin A skin science: A scientific guide to healthy skin, Dr Des Fernandes and Dr Ernst Eiselen broadly describe four main types of vitamin A:8

1. Retinol: chemically, this is the basic

Using Vitamin A In its numerous formations, vitamin A is used to treat photoaged skin and acne. Allie Anderson explores its indications, limitations and best practice Vitamin A has been used in dermatology since as far back as the 1960s, when it was found to be clinically effective in treating ichthyoses and acne.1,2 It wasn’t until the 1980s that scientists demonstrated that a form of vitamin A led to the production of collagen and regulation of damaged tissue, manifesting in visible improvements in lines and wrinkles, hyperpigmentation, and sallow and rough-looking skin.3,4 This led to the development of vitamin A in various formulations to become a panacea in skincare, found in all the latest products and marketed as a ‘magic’ ingredient for antiageing and dry skin conditions alike.

What is vitamin A? “Vitamin A is a fat-soluble vitamin found in many foods,” says consultant dermatologist Dr Anjali Mahto. “There are two types available in the diet: preformed vitamin A – retinol and its esterified form, retinyl ester – and pro-vitamin A carotenoids, for example, beta-carotene.” Dr Mahto explains that vitamin A has many important physiological roles. “It is necessary for immune function, reproduction, and cellular communication, and is critical for vision as it is an essential component of rhodopsin, a protein that absorbs light in the retinal receptors.” Also known as a retinoid, vitamin A acts to affect the production of a molecule called messenger ribonucleic acid (mRNA), which conveys genetic information

and results in the formation of proteins.

As such, it’s a key element in maintaining the integrity of the epidermis, as well as the neural and eye membranes.5,6 “It also supports cell growth and differentiation, thus playing a vital role in the normal formation and maintenance of the heart, lungs, kidneys, and other organs,” adds Dr Mahto.

Dietary sources of ‘true’ vitamin A include meat – especially liver – and animal products, such as eggs, oily fish, cheese, milk and yoghurt. Beta-carotene can be converted into vitamin A, so dietary intake can be boosted by consuming beta-carotene-rich foods such as yellow, red and green leafy vegetables (spinach, carrots, and red peppers, for example), and yellow fruits such as mango and papaya.7

form of vitamin A, used to transport the vitamin in the bloodstream. It is changed by way of oxidation into retinaldehyde.

2. Retinaldehyde (retinal): this is one step away from, and is oxidised into, the metabolically active form of vitamin A, retinoic acid.

3. Retinoic acid (retin A): this works on the DNA of the cell nucleus, and is generally only available by prescription for topical use.

4. Retinyl palmitate: this is a more stable and milder (though still active) form of vitamin A, and is therefore better tolerated by the skin.

According to practitioners, an important factor in the efficacy of vitamin A is its stability: the degree to which it degrades with exposure to oxygen, light and water. The lattermost form, retinyl palmitate, is commonly used in over-the-counter skincare products and cosmeceuticals, because it is more ‘stable’ than other forms i.e. it is less sensitive to exposure. It becomes so by esterification – the addition of palmitic (fatty) acid to the vitamin A molecule – and as such is also referred to as vitamin A ester. Esterification makes vitamin A milder and therefore more tolerable when applied to the skin, but in doing so it also becomes less active. It does, however, metabolise reversibly into retinol, and the conversion process outlined above follows. This cascading effect is called the vitamin A pathway, says Elliot Isaacs, founder and medical director of Medik8 Skincare.

“You have something like retinyl palmitate, and that gets converted to retinol, which then gets converted to another intermediate form

According to practitioners, an important factor in the efficacy of vitamin A is its stability: the degree to which it degrades with exposure to oxygen, light and water

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After eight months

death, or ‘cell suicide’ – which regulates the proliferation of keratinocytes and the formation of the stratum corneum.12 “The other thing that vitamin A does is to have an effect on matrix metalloproteinases (MMPs), the enzymes that break down collagen,” Bowes comments.

“Vitamin A is a significant suppressor of MMPs, reducing After one year, six months After three years, nine months the amount of enzyme produced to break down collagen.13 Therefore you get less collagen breakdown, and the collagen lasts longer, which is brilliant for someone with photodamage.”

Bowes recommends a number of derivations of vitamin A, reporting that tretinoin – the prescription-strength formation Figure 1: Before and after treatment for extensive sun damage with Environ creams and vitamin A and C treatments.

– can be used for patients with Applied with iontophoresis/sonophoresis using the Ionzyme DF machine. Images courtesy of Dr Des Fernandes. very significant photodamage. called retinaldedyde, and then finally it ends skin can be just as cosmetically ageing However, tretinoin is renowned for causing up as retinoic acid, which is transported into as sagging and folds. If my patients are irritation, through burning, scaling or the cell nucleus,” he explains. “Effectively intending to start an antiageing programme, dermatitis.3 “You have to get the balance you’re getting retinoic acid in the end anyway, including injectable and other treatments, absolutely right to give someone sufficient just a lot less than the starting substrate.” He then I explain to them that skin health is vitamin A photodamage correction without likens this biological mechanism to panning equally important, and healthy skin and a causing them so much flaking and redness for gold. “You have to sift through thousands glowing complexion is a youthful component that they won’t comply with the skin care of bits of sand [retinyl palmitate] before you of our appearance.” regimen,” Bowes says. A solution is to end up with one little grain of gold: retinoic This strategy typically involves patients using build up the patient’s tolerance gradually. acid is the pure gold.” vitamin A derivatives as part of their daily Surgeon and founder of S-Thetics, Miss skincare regime, she says. Moreover, White Sherina Balaratnam, recommends starting Vitamin A for skin ageing also uses retinol and tretinoin (a form of by applying the product once a week, Around 90% of skin ageing is photoageing retinoic acid), depending on the patient and and gradually increasing to aim up to caused by sun exposure,9 and this is among their specific concerns. Indeed, a 2015 study using it daily. “This prevents patients from the most common problems seen by

by Babcock et al comparing the efficacy of developing unwanted side effects that might aesthetic practitioners. As nurse prescriber retinol-based and tretinoin-based topical put them off,” she says. “People can drop and founder of Outline Skincare Clinic products suggested that both significantly off their regime if they feel discouraged with Mary White explains, combatting these improved the appearance of photodamaged flaking and redness. Being mindful of this, requires a holistic approach. “While we can skin – including fine lines, wrinkles, skin building up tolerance slowly and making the address signs of sagging and volume loss tone brightness, mottled pigmentation, and regime fit into their lifestyle, is very important.” by the use of dermal fillers and collagen roughness – yet no significant differences in More stable versions of vitamin A are induction techniques (such as dermaroller efficacy between the two product types.10 milder and will elicit less irritation.3 However, and radiofrequency), and we can treat One of the factors that makes vitamin A a patients face a trade-off, sacrificing efficacy dynamic lines and wrinkles with botulinum good ingredient in antiageing products, for tolerability. “The strength of retinol in a toxin treatment, this does not address issues says nurse prescriber and director of product will influence the bioavailability of surrounding the quality of patients’ skin,” she AestheticSource Lorna Bowes, is that it retinoic acid once it converts in the cells,” says. “Dull, lined and sallow or pigmented promotes apoptosis11 – programmed cell says White. “A very low concentration of retinol, for example in a high street product Before After eight months [such as retinyl palmitate] will produce a low retinol cascade and result in less bioavailability of retinoic acid.” She would recommend doses of retinol from 0.5% up to 1.6% depending on the patient’s age and the condition of their skin, adding that a retinol concentration of 1.6% will convert to an equivalent retinoic acid of around 0.025% as Figure 2: Before and after treatment with vitamin A and C oil and lactic acid lotion.

Images courtesy of Dr Des Fernandes. a result of the vitamin A pathway.14

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Before

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Figure 3: Before and after treatment with NeoStrata Skin Active. Images courtesy of Lorna Bowes.

Vitamin A and acne Retinoids – most commonly tretinoin – have been used in the treatment of acne since the first paper demonstrating its clinical efficacy was published in 1969.2 However, the well-publicised adverse effects discussed (irritation, dermatitis etc.) mean that adherence to a treatment regime is often compromised. Non-compliance may be more common in acne patients than in those with photoaged skin, says White, who highlights the importance of persevering through the beginning period of treatment, when side effects are more marked. “You have to get patients through the initial stage and get their skin functioning normally,” she says. “This helps psychologically as, often, acne patients have tried everything, both over-the-counter and from their GP, before they present in our clinic.” Adapalene – a synthetically produced retinoid that was developed to be more tolerable – is available on prescription in gel and cream formulations, and is approved by the Medicines and Healthcare Products Regulatory Agency (MHRA) to treat mild to moderate acne.15 It works by binding to retinoic acid receptors (RARs) to regulate keratinisation and inflammation.3 Miss Balaratnam reports that in her practice, acne is the most common indication for the use of vitamin A. “It decreases the amount of sebum produced by the sebaceous glands, and increases cell turnover, and is a catalyst for exfoliation,” she explains. “This can often cause dryness, which patients don’t like but one that will naturally improve with time as the skin develops its protective barrier function.

Once it resumes its normal cell turnover and the hydration of the skin improves, this will resolve.” Dr Fernandez suggests that taking vitamin A orally can preclude its irritating

effects. “I advise all my patients who want cosmetic surgery to use topical vitamin A and I also suggest that they should use 50,000 IU [international units] of vitamin A orally a day,” he says. “I have been using this dose for 21 years. I suggest the same thing to my patients who come to me for excision of skin cancers.” Whilst a dermal filler treatment will give some lift to sagging skin, the concept of ‘ageing’ will be omnipresent if the skin has indications of photodamage. Using retinols and other derivatives of vitamin A in their daily skincare regime will aim to improve elasticity and firmness, reduce the appearance of fine lines and wrinkles, and improve skin tone and texture.

Considerations One of the main considerations when using retinoids – and one of its drawbacks – is its light instability, leading it to be rendered ineffective by UV light. As a result, most topical applications are recommended for night-time use only. Isaacs comments that this leads to misconceptions about the safety of vitamin A. “People think that, somehow, it’s dangerous to use during the day because of some sort of toxic reaction with sunlight,” he says. “In fact, all that happens is that UV light breaks down the molecules, making it inactive or perhaps sensitising.” To combat this, a newer ingredient – retinyl retinoate – has been developed that is completely stable, non-irritating, more powerful than retinol, and can be used both night and day.16 There are certain patient cohorts who should avoid vitamin A treatment, says Dr Mahto. “Topical retinoids are unsuitable for patients with sensitive skin and during pregnancy, while oral retinoids should also be avoided in pregnancy, as well in women who are breastfeeding, Before After six weeks people with liver disorders, renal impairment, and concomitant use of certain other medications, such as tetracyclines with isotretinoin.”

Sensitivity to vitamin A would also be a contraindication; however, according to Dr Figure 4: 70-year-old patient before and after using iS Clinical skincare Fernandez, some people containing vitamin A, as well undergoing an iS Clinical Fire & Ice resurfacing treatment. Images courtesy of Miss Sherina Balaratnam. mistakenly think they are

allergic to vitamin A, thanks to a deficiency in their retinoic acid receptors. “They are not and are, paradoxically, desperately in need of it to restore their skin to health,” he comments.

Conclusion The merits and drawbacks of vitamin A as a treatment for skin complaints has been the subject of much debate, but currently it is regarded by many as the gold standard in skincare. As well as an effective solution for symptoms of photoageing, some suggest it might be considered as an early intervention for youngsters with oil-prone skin.

“We are in an era where acne and oily skin used to be a problem of the young,” comments Miss Balaratnam. “What I see in my practice now is women in their 20s to 40s presenting with an ongoing problem with acne or oil-prone skin, who could potentially have been managed much earlier with topical vitamin A.” Greater confidence is required from practitioners to embrace the full potential of vitamin A in maintaining a healthy complexion and combating problem skin.

REFERENCES 1. Zainglein A L, ‘Topical Retinoids in the Treatment of Acne Vulgaris. ‘Semin Cutan’’, Med Surg, 27 (2008) pp.177-182.

2. Kligman et al, ‘Topical Vitamin A acid in acne vulgaris’, Arch Dermatol, 99 (1969) pp.469-476.

3. Mukherjee et al, ‘Retinoids in the treatment of skin ageing: an overview of clinical efficacy and safety’, Clinical interventions in Aging, 1(4) (2006), pp.327-348.

4. Kang et al, ‘Long-Term Efficacy and Safety of Tretinoin Emollient Cream 0.05% in the Treatment of Photodamaged Facial Skin: A Two-Year, Randomized, Placebo-Controlled Trial’, J Am J Clin Dermatol, 6 (4) (2005), pp.245-253.

5. Oregon State University Linus Pauling Institute Micronutrient Research for Optimum Health, Micronutrient Information Center (US: Oregon State University, 2015).

6. Belitz HD et al. Food Chemistry, 4th Revised and Extend Version (Berlin: Springer, 2009) p. 403-419.

7. NHS Choices, Vitamins and minerals – vitamin A (UK: NHS, 2015) <http://www.nhs.uk/Conditions/vitamins-minerals/Pages/ vitamins-minerals.aspx> 8. Fernandez, D and Eiselen, E, ‘Vitamin A skin science: A scientific guide to healthy skin’, Fenro Publishing, London, 2015. Chapter 7, The chemistry of vitamin A. p.65-70.

9. Canadian Dermatology Association, What is Photoaging? <http://www.dermatology.ca/skin-hair-nails/skin/photoaging/ what-is-photoaging/> 10. Babcock M, Mehta RC, Makino ET, ‘A randomized, double-blind, split-face study comparing the efficacy and tolerability of three retinol-based products vs. three tretinoin-based products in subjects with moderate to severe facial photodamage’, J Drugs Dermatol. 2015, 14(1), pp.24-30.

11. Nelson AM, Gilliland KL, Cong Z, Thiboutot DM, ‘13-cis Retinoic acid induces apoptosis and cell cycle arrest in human SEB-1 sebocytes’, J Invest Dermatol. 2006, 126(10), pp.2178-89.

12. Kaštelan et al, ‘Apoptosis in psoriasis’, Acta Dermatovenerol Croat, 2009, 17(3) pp.182-186.

13. Varani J et al, ‘Vitamin A Antagonizes Decreased Cell Growth and Elevated Collagen-Degrading Matrix Metalloproteinases and Stimulates Collagen Accumulation in Naturally Aged Human Skin’, Journal of Investigative Dermatology (2000) 114, pp.480-486.

14. Kang et al, ‘Application of Retinol to Human Skin In Vivo Induces Edipermal Hyperplasia and Cellular Retinoid Binding Proteins Characteristic of Retinoic Acid but Without Measurable Retinoic Acid Levels or Irritation’, Soc Investig Drmatol, 105(4) (1995), pp.549-556.

15. Griffiths et al, ‘An in-vivo experimental model for topical retinoid effects on human skin’, Bt J Dermatol, 29 (1993), pp.389-99.

16. Kim, H et al, ‘Improvement in skin wrinkles from the use of photostable retinyl retinoate: a randomized controlled trial’, British Journal of Dermatology, (2010), 162: 497–502.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Understanding Sensitive Skin Dr Tiina Orasmae-Meder shares advice on the aetiology and treatment of skin sensitivities Occurrence Patients frequently tell their dermatologist that they have sensitive skin.

What they actually mean is they have a certain condition that causes varying degrees of discomfort. But what does it mean for a doctor?

First of all it should be noted that ‘sensitive skin’ is not quite a diagnosis, but rather a summary of a certain range of symptoms manifesting in various uncomfortable sensations and specific changes in the skin condition. The patient’s sensations and skin changes may vary and they can appear unexpectedly, as a response to a certain number of factors or contact with certain irritants. Generally the definition of sensitive skin is still rather fuzzy and every particular case requires further examination of the symptoms, their intensity, individual reactions and also of the triggers that provoked the skin’s hypersensitivity.

It is a common notion that sensitive skin is characterised by the following patient complaints – itching, stinging, burning and a tight sensation. It is interesting that such sensations can be present at all times while the skin does not display any objective visible changes.

Many patients who suffer from heightened sensitivity, or have had episodes of hypersensitivity in the past, note that, often, the increase in the skin’s sensitivity was preceded by contact with new cosmetics, soap or a sunscreen. The unpleasant sensations may intensify after overcooling or overheating, after sun-tanning or even a short time in the sun. In addition, the skin’s hypersensitivity can sometimes develop after any manipulation aimed at thinning the skin’s corneal layer – like dermabrasion, laser resurfacing, chemical peeling or using retinoids and hydroxy acid-based cosmetics.

Nonetheless, the nature of the changes in the skin’s sensitivity level and of the appearance of characteristic sensations remain unclear.

It is possible that there is a connection between certain anomalies in the constitution of the skin and the impact of some trigger factors –particularly repeated contact with the substances irritating the skin

Increased skin sensitivity is more commonly found in women, and among them predominantly in premenopausal and menopausal women

or occupational diseases caused by contact with irritants or frequent hand washing (e.g. dish washers, surgeons, hairdressers, etc). Recent research has made somewhat clearer what role the stratum corneum has in the development of the skin’s hypersensitivity and identified the importance of the neuroimmune system in the development of sensitive reactions (in particular the effect on vanilloid receptors in neuronal transmission has been described). According to the research, it is highly probable that the skin parameters, such as the size of corneocytes, the sensitivity of receptor structures, the overall condition of the skin’s barrier layer and its functioning, largely define the characteristics of the skin’s sensitivity.1 Characteristics Subjective sensations are common for sensitive skin, while objective changes may be insignificant or even absent altogether. When the skin changes are actually present, most commonly noted are erythema, skin dryness, sometimes skin eruption or singular urticarial elements (wheals). The skin may also feel hot and sensitive to pain.

In some cases the patients notice the dynamics of the changes in connection with menstrual cycle, seasonal air temperature and humidity changes, conditioned air or contact with certain fabrics (clothes, towels, bed linen).2 Many patients report a high risk of aggravation when using new cosmetics, personal hygiene products or even with the change of tap water on a trip, however objective changes on a microscopic level are not usually present.3 Generally, it can be said that the patients who complain about constant hypersensitivity often have skin prone to dryness, with levels of moisture and elasticity slightly lower than average for their age group. They also often suffer from telangiectatic skin.4 Nonetheless, documenting the changes in the skin condition is problematic due to unstable objective data, the difference in their manifestation and variable corresponding with subjective sensations.

According to research, sensitive skin has become unusually common in recent years. More than half of women asked in the USA, Europe and Japan think their skin is sensitive.5 Researchers used the method of a telephone survey to collate results, conducted in several European countries: France, Italy, Portugal, Germany, Switzerland, Belgium and Greece (n=4506),6 USA (n=994).7 A national representative sample of the Japanese population over 18 years was taken; individuals were questioned by telephone and selected according to the quota method.8 There is a certain correlation with age and gender – increased skin sensitivity is more commonly found in women, and among them predominantly in premenopausal and menopausal women.9 Histological examination rarely shows vasodilatation with an inflammatory infiltrate. In general, there are no histological abnormalities.10 The common absence of an infiltrate demonstrates

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It is difficult to find accurate parameters for categorising the skin as sensitive or non-sensitive because sensitive skin often does not posess visible, physical or histologically measurable signs

that there is no role for innate or specific immunity. Skin sensitivity is more frequently reported by patients with atopic dermatitis or other allergic conditions,11 however most people with sensitive skin do not have atopy of allergic disease. Skin barrier function is altered in certain patients, leading to trans-epidermal water loss (TEWL) that may be promoted by the contact with triggering factors.12 Nonetheless, altered barrier function is not found in all people with sensitive skin, suggesting that sensitive skin and dry skin represent different phenomena. A connection is not inconceivable because skin dryness and alterations in the skin barrier could enhance skin sensitivity by facilitating contact with triggering factors. Alternatively, skin sensitivity could enhance skin dryness. Skin dryness and skin sensitivity could also be consequences of the same pathogenic mechanism when the two conditions are displayed together. The regular use of skin moisturisers seems to improve the sensitive skinâ&#x20AC;&#x2122;s condition.13 Causes Abnormal sensations and vasodilatation demonstrates the involvement of the cutaneous nervous system.14 Neurotransmitters, such as substance P, calcitonin gene-related peptide (CGRP) and vasoactive intestinal peptide (VIP) may induce neurogenic inflammation with vasodilatation and mast cell degranulation. Neurogenic inflammation is defined by the release of neuropeptides (by the nerve endings), which induces inflammation.15 A fascinating and mysterious aspect of sensitive skin is that its sensitivity is triggered by the factors that are very heterogeneous.

Although it has never been demonstrated, the role of transient receptor potential (TRP) channels in skin reactivity is obvious.

Sensitive skin is defined as a response to multiple factors that may be physical and/or chemical, and TRP channels are the only molecules that could be activated by these very different factors.

The abnormal or enhanced activation of TRP channels appears highly probable. In the skin, TRP channels are expressed on nerve endings, Merkel cells and keratinocytes.16 TRPV1 is activated by

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capsaicin, phorbol esters, heat and H + ions. TRPV3 is activated by heat and camphor. TRPV4 activation is due to heat, mechanical stresses, hypo-osmotic stress and phorbol ester derivatives. Cold and menthol activate TRPM8. TRPA1 is activated by the cold, wasabi, mustard, horseradish and bradykinin. TRP channels are most likely activated by other substances that are included in cosmetic products. The activation of TRP channels is followed by Ca2+ influx into cells and then depolarisation. Interestingly, the activation of TRPV4 on keratinocytes induces alterations in the skin barrier.17 To summarise, it is probable that epidermal TRP channels are overstimulated by various factors in sensitive skin or are overexpressed. Consequently, there is a release of neurotrophins and neurotransmitters, which induce neurogenic inflammation in the skin.

Hyper-reactors may have a thinner stratum corneum with a reduced corneocyte area causing a higher transcutaneous penetration of water-soluble chemicals.18 Frosch and Kligman19 suggested that, when testing different irritants, there was a 14% incidence of sensitive skin in the general population, likely correlating with a thin permeable stratum corneum, which makes these subjects more susceptible to chemical irritation. Moreover, the declined barrier function in sensitive skin has already been reported as the result of an imbalance of intercellular lipid of stratum corneum.20 Although impaired barrier function is easily interpreted as a mechanism of sensitive skin, other factors are also possible implications, such as changes in the nerve system and/or the structure of the epidermis.

In this study, detailed characteristics of sensitive skin have been investigated using non-invasive methods. Sensitive skin has been classified into three different types based on their physiological parameters. Type I has been defined as the low barrier function group. Type II has been defined as the inflammation group with normal barrier function and inflammatory changes. Type III has been specified as the pseudo-healthy group in terms of normal barrier function and no inflammatory changes. In all types, a high content of nerve growth factor in the stratum corneum has been observed compared to that of non-sensitive skin. Both in types II and III, the sensitivity to electrical stimuli was high,21 as this data suggests, the hypersensitive reaction of sensitive skin is closely related to nerve fibres innervating the epidermis.

Yamasaki and Gallo22 proposed recently that the innate immune system triggers an abnormal inflammatory reaction that mediates the symptoms of rosacea and sensitive skin. If it is so, flushing and blushing erythema may be caused by chronic inflammation.

In particular, cathelicidin may play a part in inducing the cytokine cascade. Indeed, some forms of cathelicidin peptides have been known to be both vasoactive and pro-inflammatory, which is a unique capacity.23,24 Direct connections were observed between unmyelinated nerve fibres and mast cells; stress in animal subjects induces substance P(SP) in unmyelinated nerve fibres which triggers mast cell degranulation with subsequent histamine release.25 Stress is commonly reported as a trigger for sensitive skin, and mast cell degranulation is supported by the finding that the patients with sensitive skin had higher density of mast cells and a larger lymphatic microvasculature.26 Most often, patients complain about heightened sensitivity of the skin on the face and hands, the most sensitive areas being nasolabial folds, followed by zygomatic region, chin, forehead and upper lip.27,28 Many patients also report increased sensitivity of the skin on the scalp and hands.

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Measuring sensitivity It is difficult to find accurate parameters for categorising the skin as sensitive or non-sensitive because sensitive skin often does not posess visible, physical or histologically measurable signs.

Subjects with sensory irritation tend to have a less hydrated, less supple, more erythematous and more telangiectatic skin, compared to the general population. In particular, significant differences were found for erythema and hydration/dryness.29 Tests for sensitive skin are generally based on the report of sensation induced by topically-applied chemicals. Consequently, the use of a self-assessment questionnaire is a valuable method to identify ‘hyper-reactors’30 and a useful tool for irritancy assessment of cosmetics.31 Psychophysical tests based on the report of sensations induced by topically-applied chemical probes have been increasingly utilised to provide definitive data on sensitive skin. These methods of sensory testing can be validated by the use of functional magnetic resonance imaging (fMRI) which represents one of the most developed forms of neuroimaging. This technique measures the changes in the blood flow and blood oxygenation in the brain, closely related to neural activity manifested as sensory reaction.32 Querleaux et al evaluated two groups according to their selfperceived characterisation using a dedicated questionnaire about their skin reactivity. Event-related fMRI was used to measure cerebral activation associated with the skin discomfort, induced by a simultaneous split-face application of lactic acid and of its vehicle. In both groups, skin discomfort owing to lactic acid increased activity in the primary sensorimotor cortex contralateral to application site and in a bilateral fronto-parietal network including parietal cortex, prefrontal areas around the superior frontal sulcus and the supplementary motor area. However, the activity was significantly higher in the sensitive skin group. Most remarkably, in the sensitive skin group only, activity spread into the ipsilateral primary sensori-motor cortex and the bilateral periinsular secondary somatosensory area.33 The results of this research suggest that the nervous system’s role in the formation of the symptomatic complex of sensitive skin may be more important, if not fundamental, than previously considered. We shouldn’t dismiss the possibility that the activation of different areas of cerebral cortex in response to stimulating the skin with standard irritants is a hereditary reactivity trait rather than a random phenomenon. We can even theorise that some people are born with a specific nervous way of reacting to a number of external factors and irritants, which is more likely to result in uncomfortable sensations. The people who haven’t inherited this trait can be in contact with the same irritants and external factors with only a slight discomfort or none at all. The external manifestations of skin changes can be explained by a specific hereditary reaction of the neuroimmune system.

Differential diagnosis In the case of erythema, the sensitive skin diagnosis could be considered for a high number of skin diseases. However, the association with abnormal sensations, such as prickling and stinging rather than pruritus; the triggering factors; and the transitory nature of the erythema are strong arguments for a diagnosis of sensitive skin. The main differential diagnosis aid that remains are the flushes that are observed in patients who are suffering from rosacea.

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In the specific case of a sensitive scalp, the diagnosis must be based on neuropathies, other causes of an itchy scalp and trichodynia. Trichodynia is a painful sensation at the scalp that is localised in the area of hair loss (androgenetic alopecia).34 Treatment The treatment of sensitive skin is still debated. No controlled, randomised and double-blind clinical trial has been performed so far. The use of well-tolerated cosmetics, or cosmetics with soothing effects has been recommended. For example, trans4-tert-butylcyclohexanol, a selective antagonist of TRPV1, has recently been proposed.35 This antagonist is able to inhibit capsaicin-induced hTRPV1 activation with an IC(50) value of 34 ± 5μm tested in HEK293-cells, as well as in electrophysiological recordings performed in oocytes expressing hTRPV1. Notably, in a clinical study with 30 women using topical treatment with o/w emulsions containing 31.6 ppm capsaicin, it was indicated that 0.4% of this inhibitor significantly reduces capsaicin-induced burning (P < 0.0001) in vivo.35 All substances that have a potentially stabilising effect on the epidermal barrier can be recommended. For example, topical application of niacinamide has a stabilising effect on epidermal barrier function, seen as a reduction in transepidermal water loss and an improvement in the moisture content of the horny layer. Niacinamide leads to an increase in protein synthesis (e.g. keratin), has a stimulating effect on ceramide synthesis, speeds up the differentiation of keratinocytes, and raises intracellular NADP levels. It is possible to demonstrate anti-inflammatory effects in acne, rosacea and nitrogen mustard-induced irritation. As such, regular use of cosmetic products containing niacinamide is suitable for patients with sensitive skin.36 We can also suggest a number of new biotechnological ingredients: Rhamnosoft HP is a polysaccharide obtained by bacterial fermentation. It presents a branched structure and a sugar sequence rich in rhamnose (I, III, VI), galactose (II, V) and glucuronic acid (IV). Because of its high L-rhamnose content, a sugar recognised specifically by keratinocyte membrane receptors, Rhamnosoft aims to inhibits cell adhesion and limits the propagation of inflammatory reactions in skin cells following an aggression. Rhamnosoft also stimulates the release of ß-endorphins.37 Skinasensyl is a pure tetrapeptide based on a new mechanism of action, mainly targeting neuro-sensitive skin. The active is able to reduce the nerve response to external stimuli by decreasing the release of pro-inflammatory neuro-mediators CGRP, an action mediated via the activation of the μ opioid receptor.38 Delisens (Acetyl Hexapeptide-46) is a hexapeptide that reduces neurogenic inflammation and itching of sensitive skin. It aims to restore and strengthen the natural skin barrier.39 Telangyn (Acetyl Tetrapeptide-33) is a tetrapeptide that reduces facial redness caused by an inflammatory reaction. It inhibits the inflammatory effect of LL-37 through reducing the release of interleukins (IL-6 and IL-8), caused by over-activation of LL-37. It also has a photoprotective effect that reduces cell damage and the harmful effects of skin inflammation.40

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However, the number of products that have been proposed is very large. It is obviously sensible to recommend the discontinuation of all topical cosmetics, fragrances and sunscreens. Cosmetic formulations with as few ingredients as possible are better.

Pons-Guiraud has recommended a set of guidelines for the prevention and management of sensitive skin:41 • Apply the smallest possible number of cosmetic products.

• Choose fragrance-free formulations • Avoid soaps • Use non-rinsing cleansing lotions or thermal spring water spritzers • Do not forget to thoroughly dry the area by gently patting with a paper tissue (do not use cotton wool) • Choose moisturising creams with a mild texture • In case of exposure to air conditioning or overly heated environments, do not hesitate to reapply these creams several times a day • Choose hair products without irritating tensioactive surfactants • Avoid skin cleansing and exfoliating masks • Avoid applying products containing alpha hydroxyl acid, retinaldehyde or tretinoin • If any cosmetic product application is responsible for burning and discomfort, discontinue use immediately • Protect skin from temperature changes, sunlight, wind and exposure to heat • Consumption of alcohol must be limited as much as possible • Observe whether the skin is more irritable after intake of coffee or spices • If necessary, treat depression and neuropsychiatric signs • After three to six months of avoidance of skincare products, progressively reintroduce cosmetic products one by one at intervals of one or two weeks • Remember that a recurrence is always possible

Without question, any potentially traumatic cosmetic procedures for sensitive skin patients bear a high risk of aggravation and further discomfort. Therefore the recommendation for such patients would be to avoid traumatising the skin and, if the desired effect is unachievable without a trauma, use soothing local therapeutical solutions and ascertain its efficiency.

Acknowledgement: this article has not been supported by any funding.

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Dr Tiina Orasmae-Meder is a specialist in dermatology, having more than 20 years’ experience in the professional beauty industry. She is the founder of Meder Beauty Science, based in Switzerland. Dr Orasmae-Meder has led new product development for many professional brands and since 2007, she has been working with one of the largest independent labs, Iris Brand Vigilance, as a leader in cosmetic safety.

REFERENCES 1. Berardesca E., Farage MA., Maibach HI., Sensitive Skin: an overview (pp2-8) International Journal of Cosmetic Science 35 (2013).

2. Saint-Martory, C., Roguedas-Contios, A.M.,Sibaud, V., Degouy, A., Schmitt, A.M., Misery, L., ‘Sensitive skin is not limited to the face’, Br. J. Dermatol, 158 (2008), pp.130-133.

3. Misery L., ‘Sensitive Skin’, Expert Review of Dermatology, 8(6) (2013), pp.631-637.

4. Seidenari, S., Francomano, M. and Mantovani, L., ‘Baseline biophysical parameters insubjects with sensitive skin’, Contact Dermatitis, 38 (1998), p.311-315.

5. Kligman, A., ‘Human models for characterizing “Sensitive Skin”’, Cosm Derm, 14 (2001), pp.15-19.

6. Misery L., Boussetta S., Nocera T., Perez-Cullel N., Taieb C., ‘Sensitive Skin in Europe’, J Eur Acad Dermatol Venereol, 23, (2009), pp.376-381.

7. Misery L., Sibaud V., Merial-Kieny Ch. Taieb C., ‘Sensitive skin in the American Population: prevalence, clinical data and role of the dermatologist’, International Journal of Dermatology, 50, 8, (2011) pp.961-967.

8. Kamide R., Misery L., Perez-Cullel N., Sibaud V., Taieb C., ‘Sensitive skin evaluation in the Japanese population’, J.Dermatol, 40(3) (2013), pp.177-81.

9. Farage MA., Miller KW., Maibach HI., ‘Textbook of Aging Skin Springer’, USA, 5 (2010), pp.1028-1033.

10. Misery L., ‘Sensitive Skin’, Expert Review of Dermatology, 8(6) (2013), pp.631-637.

11. Farage MA, Maibach HI., ‘Sensitive skin: new findings yield new insights’, In: Textbook of Cosmetic Dermatology, Baran R, Maibach HI (Eds)., ‘Informa Healthcare’, London, 558 (2010).

12. Branco N, Lee I, Zhai H, Maibach HI., ‘Long-term repetitive sodium lauryl sulfate-induced irritation of the skin: an in vivo study’, Contact Derm, 53 (2005), pp.278-284.

13. Kligman A., ‘Human models for characterizing “sensitive skin”’, Cosmet. Dermatol, 14 (2001), pp.15-19.

14. Ständer S, Schneider SW, Weishaupt C, Luger TA, Misery L., ‘Putative neuronal mechanisms of sensitive skin’, Exp. Dermatol. 18 (5) (2009), pp.417-423.

15. Pauly G, Moussou P, Contet-Audonneau J-L et al., ‘New peptidic active ingredient to reduce discomfort and painful sensations in sensitive skin’, IFSCC Mag, 12 (2009), pp.25-30.

16. Boulais N, Misery L., ‘The epidermis: a sensory tissue’, Eur. J. Dermatol, 18, (2008), pp.119-127.

17. Kida N, Sokabe T, Kashio M et al., ‘Importance of transient receptor potential vanilloid 4 (TRPV4) in epidermal barrier function in human skin keratinocytes’, Pflugers Arch, 463 (2012), pp.715-725.

18. Berardesca, E., Cespa, M., Farinelli, N., Rabbiosi, G. and Maibach, H.I. ‘In vivo transcutaneous penetration of nicotinates and sensitive skin’, Contact Dermatitis, 25 (1991), pp.35-8.

19. Frosch, P.J. and Kligman, A.M., ‘A method for appraising the stinging capacity of topically applied substances’, Journal of the Society of Cosmetic Chemist, 28 (1977), pp.197-209.

20. Ohta, M., Hikima, R. and Ogawa, T., ‘Physiological characteristics of sensitive skin classified by stinging test’, J. Cosmet. Sci. Soc. Jpn, 23 (2000), pp.163-167.

21. Yokota, T., Matsumoto, M., Sakamaki, T.et al., ‘Classification of sensitive skin and development of a treatment system appropriate for each group’, IFSCC Magazine, 6 (2003), pp.303-307.

22. Yamasaki, K. and Gallo, R.L., ‘The molecular pathology of rosacea’, J. Dermatol Sci., 55 (2009), pp.77-81.

23. Koczulla R, von Degenfeld G, Kupatt C et al., ‘An angiogenic role for the human peptide antibiotic LL-37/hCAP-18’, J Clin Invest 111 (2003), pp.1665-1672.

24. Braff MH, Hawkins MA, Di Nardo A et al., (2005) ‘Structure-function relationships among human cathelicidin peptides: dissociation of antimicrobial properties from host immunostimulatory activities’, J Immunol, 174 (2005), pp.4271-4278.

25. Kumagai, M., Nagano, M., Suzuki, H. and Kawana, S., ‘Effects of stress memory by fear conditioning on nerve-mast cell circuit in skin’, J. Dermatol, 38 (2011), pp.553-561.

26. Quatresooz, P., Piérard-Franchimont, C. and Piérard, G.E., ‘Vulnerability of reactive skin to electric current perception – a pilot study implicating mast cells and the lymphatic microvasculature’, J Cosmet Dermatol, 8 (2009), pp.186-189.

27. Marriott, M., Holmes, J., Peters, L., Cooper, K. et al, ‘The complex problem of sensitive skin’, Contact Dermatitis, 53 (2005), pp.93-99.

28. Distante, F., Bonfigli, A., Rigano, L., D’Agostino, R. and Berardesca, E., ‘Intra- and Inter-Individual Differences in Facial Skin Biophysical Properties’, Cosmetic and Toiletries, 7 (2002), pp.149-158.

29. Seidenari, S., Francomano, M. and Mantovani, L., ‘Baseline biophysical parameters in subjects with sensitive skin’, Contact Dermatitis, 38 (1998), pp.311-315.

30. Willis, C.M.et al., ‘Sensitive skin: an epidemiological study’, Br. J. Dermatol, 145 (2001), pp.258-261.

31. Simion, F.A. et al, ‘Self-perceived sensory responses to soaps and synthetic detergent bars correlate with clinical signs of irritation’, J.Am. Acad. Dermatol, 32 (1995), pp.205-207.

32. Querleux, B. et al., ‘Specific brain activationrevealed by functional MRI’, 20th World Congress of Dermatology, Paris. Ann. Dermatol. Venereol, 129, 1S42 (2002).

33. Querleux, B., Dauchot, K., Jourdain, R.et al., ‘Neural basis of sensitive skin: an fMRI study’, Skin Res Technol, 14 (2008), pp.454-461.

34. Reich A., Medrek K., Adamski Z., Szepetowski JC., ‘Itchy Hair – Trichokinesis : a variant of trichodynia or a new entity?’, Acta Dermato-Venereologica, (2012).

35. Kueper T, Krohn M, Haustedt LO, Hatt H, Schmaus G, Vielhaber G., ‘Inhibition of TRPV1 for the treatment of sensitive skin’, Exp. Dermatol., 19, (2010), pp.980-986.

36. Gehring W, ‘Nicotinic acid/niacinamide and the skin’, J Cosmet Dermatol, 3(2) (2004), pp. 88-93.

37. Marseglia A., Licari A., Agostinis F., Barcella A., Bonamonte D., Puviani M., Milani M., Marseglia G., ‘Local rhamnosoft, ceramides and L-isoleucine in atopic eczema: a randomised trial’, Pediatr Allergy Immunol, 25(3) (2014), pp.271-5.

38. Pauly G., Freis O., Rathejens A., Danoux L., Benoit I., Contet-Audonneau J-L., Moussou P., ‘Skinasensyl® – A new peptidic active ingredient to reduce discomfort and painful sensation in sensitive skin’, Skin Care Forum BASF, (2010).

39. Delisens Peptide (Barcelona: Lipotec, 2016) <http://www.lipotec.com/en/products/delisens-tradepeptide/> 40. Telangyn Peptide (Barcelona: Lipotec, 2016) <http://www.lipotec.com/en/products/telangyn-tradepeptide/> 41. Pons-Guiraud A., ‘Sensitive skin: a complex and multifactorial syndrome’, J Cosmet Dermatol, 3, (2004), pp.145-148.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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in to the superficial category – epidermal peeling. Medium depth peels affect the papillary dermis, and there are relatively few deep, reticular dermis peels performed in the UK (Figure 1). Deep peels are, however, gaining in popularity following the European model.

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Superficial AHAs up to 50% BHAs Retinoids Jessner’s peel TCA up to 20%

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Medium Glycolic Acid (AHA) 70% TCA 20-40% TCA with Jessner’s peel or with GA 70%

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The Properties of Skin Peels Lorna Bowes and Jacqueline Naeni discuss the cosmetic possibilities of skin peels and conduct a review of their ingredients The concept of skin treatments is certainly not new, stories of peeling go back to the time of Cleopatra in Ancient Egypt, while Ayurvedic skincare and medical traditions can be traced back 5,000 years in South Asia and India.1 Consumer demand for peels is strong, and there are plenty of choices not only for our patients, but also for us as practitioners. This article will review peeling ingredients that have the dual effect of restoring epidermal components and building the dermis. The possibilities of what can be achieved at different depths of peel will also be explored.

Deep Phenol peel Baker-Gordon TCA > 40% Subcutaneous tissue Figure 1: Superficial, medium and deep peeling

Superficial peels Most superficial peeling is achieved by topical ingredients or procedures such as microdermabrasion rather than a peel treatment; we have found that peeling caused by topical ingredients can be perceived as sensitivity or flaking skin and good consultation and explanation is needed to generate compliance in early days of using an effective topical exfoliant. To achieve a true epidermal peel requires treatment in-clinic using a range of topical ingredients.

Popularity of skin peels Since Kim Cattrall’s Samantha Jones had a peel in Sex and the City, there has not only been an increase in awareness, but an increase in demand for skin peels. In May 2014 an article in the Daily Mail2 asked: ‘Could YOU face peeling off a layer of skin to look younger?’ The first four statements in the piece were: • Brutal way to beautify is making a comeback • Cosmetic chemical face peels are coming back into fashion • The skin treatment sees the face covered in a lotion containing acid • The acid burns the skin off, which is then peeled off to ‘reveal’ fresh skin These portrayals of peels and skin rejuvenation do not help consumer understanding of peels, but the demand continues to rise.

Purpose of skin peels What can actually be achieved by peeling? The main aim of peeling is to visibly improve the structure of the skin. This can be achieved by merely accelerating the natural process of exfoliation, by destroying layers of the epidermis and/or dermis or by protein coagulation or lysis.3 Peels are categorised into three depths of skin penetration, with the vast majority of peels performed falling

Hydroxy acids Alpha hydroxy acids (AHAs) have been applied as topical preparations and peeling agents for more than forty years,25 originally being reported at around the same time as vitamin A was first used as a topical preparation for photodamage. Consumers see them as eco-friendly as they are sometimes known as the fruit acids – derived from fruits, nuts and dairy products. According to a study by Beradesca et al, hydroxyl acids increased protection against 5% sodium lauryl sulphate without reducing trans-epidermal water loss (TEWL) by causing a separation of the stratum corneum without compromising barrier function.4 The most commonly used AHA is glycolic acid, many published clinical studies have reported the effects of AHAs in treating photoageing.5 The main mode of action of AHAs is to damage the desmosomal attachments between corneocytes, and reduce corneocyte cohesion.5 It is not just a peeling effect that occurs however, in their studies, Ditre et al and Okano et al demonstrated a 25% increase in dermal thickness, increase in glycosaminoglycans, enhanced collagen density and improved elastic fibre behaviour.7,8 These effects are unique to hydroxy acids and do not occur with other chemical or mechanical exfoliators that simply work by removing outer epidermal layers.9 Glycolic acid peels are formulated in strengths up to 70%, to allow for the ideal balance of efficacy versus safety, but it is the pH of the

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peel that is critical for successful treatment outcomes. This is because penetration, depth and efficacy of the glycolic peel is defined by the pH; many superficial peels are partially neutralised or buffered during manufacture, reducing the sensation of stinging but also reducing efficacy. Glycolic acid peels need to be neutralised to end the penetration and peeling effect, and to allow for greater control of depth and level of peeling for safe and effective clinical results. There are many glycolic peels available including Dermaceutic, SkinTech, as well as the myriad of higher pH ‘high street’ glycolic peels Agera, Murad, NeoStrata (the doctors who discovered the desquamating effects of glycolic acid are the founders of NeoStrata Company) and many other cosmetic and cosmeceutical brands. The AHA lactic acid is sometimes used for chemical peels such as gloTherapeutics lactic 15%, although peel preparations are available up to 50%. Lactic acid is known to be naturally hydrating because the lactic acid converts to lactate, which is a component of natural moisturising factor, hence it is generally considered to be gentler than other AHAs such as the more portent mandelic and glycolic acids.10 Resorcinol Resorcinol is a derivative of phenol and has been used in treatments for peeling for almost 150 years.12 Resorcinol works by disrupting the hydrogen bonds in keratin, so it is primarily used for addressing pigmention.13 Currently, Resorcinol is most commonly used in combination peels such as Jessner’s peels due to the side effect profile. Resorcinol has been associated with side effects such as myxedema, thyroid dysfunction and cardiac arrythmia;14 therefore, it is highly recommended that allergy testing is performed before using resorcinol as a peeling agent.15 Retinoic acid Vitamin A is widely used in topical formulations that vary from mild derivatives to prescription-only high strength formulations. There are three main forms and many manufacturer specific sub-forms: 1. Retinol (vitamin A) 2. Retinal (retinal aldehyde not to confuse with retinal which refers to the retina) 3. Retinoic acid (vitamin A acid or vitamin A1, tretinoin) Topical retinoids are frequently used to treat photodamage and acne.3 Retinoic acid is the bioavailable form of vitamin A, retinol is converted to retinoic acid in the dermis. Studies have reviewed the safety and efficacy of vitamin A peels, with one study showing that a 1% tretinoin peel, applied for six to eight hours performed on 15 women aged 23-40 years with Fitzpatrick Types I to IV, achieved the same result at two and a half weeks as topical tretinoin for a period of four to six months.16 Vitamin A peels may enhance the effects of other peel types; for example, salicylic and glycolic acid peels enhance desquamation.16 Jessner’s solution Jessner’s solution and modified Jessner’s are well-known exfoliators and reports of their uses have been seen for more than a century.26 Originally, Jessner’s was a combination of resorcinol 14%, salicylic acid 14% and lactic acid 14%. Modified Jessner’s contain various combinations, typically salicylic acid 17%, lactic acid 17% and citric acid 8%.17 Jessner’s has been used in combination with AHA and TCA peels, as a thorough skin preparation due to it’s keratolytic properties.18

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Beta hydroxy acids Salicylic acid is the most frequently-cited beta hydroxyl acid (BHA). It is lipophilic, whereas AHAs are water-soluble, which is why salicylic acid is often chosen for oily and acne prone skins.

Salicylic acid is able to penetrate hair follicles and sebaceous glands and exhibits comedolytic properties.11 Manufacturers who use salicylic acid include Epionce, Mene & Moy, Cosmedix, Medik8, NeoStrata, ZO, Priori and Jan Marini. The application of salicylic acid as a peel solution generates a frost on the skin, which is a precipitate and should not be confused with epidermolysis or precipitated dermal protein.

Combinations Many manufacturers now combine ingredients either in protocols or in peels, which are all designed to suit different patients.

Common hydroxy acid combinations include: • Skin Tech Easy Phytic Peels: glycolic, lactic, phytic and mandelic acid • Skin Tech Easy Droxy Versicolour: glycolic, lactic, salicylic, citric and kojic acids • ZO 3Step Stimulation Peel: glycolic, salicylic, and lactic acid • SkinCeuticals protocols: glycolic, salicylic acid and resorcinol • Agera: salicylic, l-ascorbic and lactic acid • NeoStrata: protocols combining glycolic acid with mandelic acid or citric acid and a home daily peel with glycolic acid and N-acetyl Tyrosinamide

Medium peels Also known as trichloroethanoic acid and trichloromethane carboxylic acid, trichloroacetic acid (TCA) first became topical in the 1880s12 and returned to popularity in the 1960s.19 TCA is now widely used in the aesthetic industry, both as a single ingredient peel and in combinations. Unfortunately, TCA is neither homogenous nor stable, and when made up as a simple aqueous solution, the concentration will not be uniform, which will lead to uneven results and adverse events.3 However, manufactures have developed stable adjuvant formulas for ease of use and optimal results. Lowstrength TCA peels (<20%) have been shown to reduce fine lines and wrinkles, but not deep wrinkles and scars, whereas higher strength TCA up to 40% induces dermal necrosis.3,6 However, post-inflammatory hyperpigmentation and scarring are known documented side effects. Therefore, particular care is needed when addressing the needs of Fitzpatrick Skin Types IV to VI.6 TCA causes protein to denature leading to keratocoagulation and keratinocyte death, this presents as a white frost. As the skin re-epithelialises, collagenesis is observed and abnormal keratinocytes are replaced by healthy cells.20,21 TCA can also be supplied by a pharmacist using a weight in volume (W/V) dilution i.e. 15%. TCA is made by adding sufficient water to 15g TCA to make a 100ml solution. TCA peels that are available include Skin Tech Only Touch, Easy TCA and UniDeep; Obagi Blue Peel and ZO Controlled Depth Peel. TCA in peel combinations are available from manufacturers such as gloTherapeutics AlphaBeta, Triplex (TCA with glycolic and salicylic acids); PCASkin Ultra Peel Forte TCA with lactic, azelaic and kojic acids.

Deep peels Phenol and combination peels which include phenol, have been described over the past 200 years, with phenol originally being used as a disinfectant and, from the early 20th Century, as an

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anaesthetic.22 In the 1940s and 1950s, use of phenol peels created a backlash and rejection by medical professionals.23 Recently, work by Deprez in Spain, Vigneron in France and Figureido in Portugal, among others, has reinvigorated use.3 Phenol dissolves the epidermal layers in the first 36 hours after application, the basal layer is restructured and melanin synthesis is reduced.3 In the papillary dermis, the elastotic layer is destroyed and new collagen fibres appear in the Grenz zone, and an effective network of elastic fibres have been demonstrated.24 After the application of a phenol peel, it takes approximately six weeks for normal skin to regenerate. The area will remain red for several weeks, or sometimes even months. Reassurance is needed for patients to tolerate this, and the fact that new blood vessels are developing helps to alleviate some of the concerns post deep peel. Histological changes have been reported 15 years after a phenol peel, so one phenol peel is sufficient in most cases for long-lasting rejuvenation.3 An example of a target phenol peel is Skin Tech Lip and Eyelid Formula and there are others that make their own blend.27 Deep Peel Combinations Many clinics combine peels with other modalities such as medical microneedling, microdermabrasion, laser resurfacing, dermal fillers and boosters, mesotherapy and chemical denervation. Common deep peel combinations include: • Perfect Peel: glutathione, kojic acid, TCA, retinoic acid, salicylic acid, phenol • Vitality Institute VI Peel: TCA, tretinoic acid, salicylic acid and phenol • Skin Tech Easy Phen Light: TCA and phenol

Conclusion This brings us to the question: which peel do you choose for your patients and why? These days we have so much choice of peel products to offer, so which do we choose? In the experience of the authors, we have found that the consultation process is so important to help decide which peel to use. There are many important factors that need discussing with the patient such as: • What is the patient’s key skin concern and expectation of the treatment?

• Is the patient medically suitable for a peel?

• Which Fitzpatrick skin type are they?

• Have they had peels in the past, and if so, were they happy?

• Will the patient comply with the pre and post-peel skincare advice?

It’s very important to discuss the expected results of the treatment, as each patient is different and the outcome will vary from person to person. We need to find out during our consultation process what the patient’s lifestyle/work commitments are like. Does the patient want a peel where they can return to work immediately or the following day, or a peel that may result in them needing more time off work because of the extra downtime? All of these factors need to be discussed during the consultation and the answers will therefore help in the decision process. Financial implications need to be discussed before any treatment plan can begin as prices vary from peel to peel. If the patient’s expectations outweigh what they may be able to afford, we need to highlight this before starting any treatment that may not be the most appropriate for them. We

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must offer our patients choice in our clinics by combining peels with professional skincare and other modalities such as medical microneedling, microdermabrasion, laser resurfacing, dermal fillers and boosters, mesotherapy and chemical denervation. Only the best combinations will help enhance patients’ results.

Disclosure: Lorna Bowes is the director of AestheticSource, the distributor of NeoStrata and SkinTech products. Jacqueline Naeni is a trainer for AestheticSource.

Lorna Bowes is an aesthetic nurse and trainer. With extensive experience of delivering aesthetic procedures, she trains and lectures regularly on procedures and business management in aesthetics. Bowes is a founding member of the British Association of Cosmetic Nurses and is director of AestheticSource.

Jacqueline Naeni is an aesthetic nurse and trainer and active member of the British Association of Cosmetic Nurses (BACN). She is also one of the AestheticSource team members training and supporting other aesthetic practitioners in the North of England and is the director of Face Cosmetic Clinic and Face Cosmetic Training.

Lorna Bowes will present at the Expert Clinics at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more.

REFERENCES 1. Datta HS & Paramesh R, ‘Trends in aging and skin care: Ayurvedic concepts,’ J Ayurveda Integr Med, 1(2010) pp.110-3.

2. Coleman C, Could YOU face peeling off a layer of skin to look younger? Brutal way to beautify is making a comeback, The Mail on Sunday (2014) <http://www.dailymail.co.uk/health/article-2619510/ Could-YOU-face-peeling-layer-skin-look-younger-Brutal-way-beautify-making-comeback. html#ixzz3tqeEawvr> 3. Deprez P, Text Book of Chemical Peels, CRC Press (2007) pp.185-206.

4. Berardesca E, Distante F & Vignoli GP, et al., ‘Alpha hydroxyacids modulate stratum corneum barrier function,’ Br J Dermatol,137(1997) pp.934-8.

5. Van Scott EJ, Yu RJ, ‘Actions of alpha hydroxy acids on skin compartments,’ J Geriat Dermatol 3(1995), pp.19-24.

6. Bauman L & Saghari S, ‘Chemical peels,’ Cosmetic Dermatology: Principles and Practice, 2(New York: 2009).

7. Ditre CM, Griffin TD & Murphy GF ‘Effects of alpha-hydroxy acids on photoaged skin: a pilot clinical histologuic and ultrastructural study,’ J Am Acad Dermatol 34(1996), pp.187-95.

8. Okano Y, Abe Y & Masaki H, et al., ‘Biological effects of glycolic acid on dermal matrix metabolism mediated by dermal fibroblasts and epidermal keratinocytes,’ Exp Dermatol 12(2003), pp.57-63.

9. Bowes L, ‘The science of hydroxy acids: mechanisms of action, types and cosmetic applications’ Journal of Aesthetic Nursing, 2(2013), pp.77-81.

10. Wehr R, Krochmal L, Bagatell F & Ragsdale W, ‘Controlled two centre study of lactate 12% lotion and a petrolatum based cream in patients with xerosis,’ J Am Acad Dermatol, 37(1986), pp.205-9.

11. Davies M, Marks R, ‘Studies on the effect of salicylic acid on normal skin,’ Br J Dermatol 95(1976), pp.187-92.

12. Brody HJ, Monheit GD, Resnik SS, Alt TH, ‘A history of chemical peeling,’ Dermatol Surg, 26(2000), pp.405-9.

13. Rook A, Wilkinson DS, Ebling FJG, ‘Textbook of Dermatology,’ Blackwell Scientific, (Oxford: 1972).

14. CDCP, ‘National Institute for Occupational Safety and Health,’ Resorcinol, (2011), <http://tinyurl.com/ nnj4qv2> 15. Fromage G, ‘Topical retinoids: exploring the mechanisms of action and medical aesthetic applications,’ Journal of Aesthetic Nursing, 2 (2013): pp.68-75.

16. Cucé LC, Bertino MC, Scattone L, Birkenhauer MC, ‘Tretinoin peeling,’ Dermatol Surg, 27(2001), pp.12-4.

17. Safoury OS, Zaki NM, El Nabarawy EA & Farag EA, ‘A study comparing chemical peeling using modified jessner’s solution and 15% trichloroacetic acid versus 15% trichloroacetic acid in the treatment of melisma,’ Indian Journal of Dermatology 54(2009), pp.41-45.

18. Monheit GD, ‘The Jessner’s + TCA peel: a medium-depth chemical peel,’ J Dermatol Surg Oncol, 15(1989), pp.945-50.

19. Ayres S, ;Superficial chemosurgery in treating ageing skin.’ Arch Dermatol 85(1962) pp.385-93.

20. McCollough EG, Longsdon PR, ‘Roenigk H, Roenigk R Dermatologic Surgery: principles and practice,’ Chemical Peeling with Phenol, (Marcel Dekker, New York, 1989), pp.997-1016 21. Roenigk RK & Roenigk HH, ‘Dermatologic Surgery,’ Principle and Practice, (UK: Marcel Decked Ltd 2edn 1996), pp.1147-60.

22. Landau M, ‘Advances in deep chemical peels,’ Dermatol Nurs 17(2005), pp.438-41.

23. Landau M, ‘Deep chemical peels (phenol),’ Colour Atlas of Chemical Peels, (Berlin: 2edn 2012).

24. Petes W, ‘The Chemical Peel,’ Ann Plast Surg, 26(1991) pp.564-71.

25. Green a & Sabherwal Y, Antiaging Benefit Ingredients: AHAs, PHAs, and Bionic Acids (Elevier 2016).

26. Grimes, Pearl E, ‘Jessner’s Solution,’ Color Atlas of Chemical Peels, (Springer Berlin Heidelberg 2012), pp.57-62.

27. Bensimon R, ‘Croton Oil Peels,’ Aesthetic Surgery Journal, 26(2008) <http://www.coupureseminars. com/media/docs/CrotonOilPeelsAestheticJournal.pdf>

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Hand Rejuvenation Mr Dalvi Humzah and Anna Baker detail the anatomy of the hand and how to successfully augment the area The appearance of the hands, in conjunction with the face and neck, are the most conspicuous parts of the body. In our opinion, the anatomy of the ageing hand has, historically, been poorly conveyed, as more emphasis seems to have been placed on describing the palmar aspect. In our research, there are only a few reports within the literature that describe the dorsal region in relation to technical considerations when rejuvenating.

The practitioner is able to employ a number of rejuvenation strategies to improve the ageing changes of the dorsum of the hand; the safety and effectiveness of these techniques is determined by: an accurate clinical assessment, use of the most suitable treatment, and a sound technique to perform the chosen modality.

In order to augment this area safely and to minimise risk of complication(s), a thorough understanding of the anatomy of this complex region is imperative.

Practitioners must also ensure that they have a detailed understanding of the characteristics of available products when considering non-surgical rejuvenation of the dorsum of the hand.

Clinical studies continue to emerge, analysing the effectiveness of different modalities, including combination treatments. In this article, we shall address some of the studiesâ&#x20AC;&#x2122; findings and discuss the anatomy of the dorsal hand in conjunction with a preferred method of non-surgical augmentation.

Ageing of the dorsum of the hand may be characterised by large intermetacarpal spaces, skin atrophy, dryness, uneven skin tone and solar lentigines, purpura as well as actinic keratosis

Ageing hands A youthful hand comprises smooth, hydrated and firm skin without the presence of visible veins, tendons, or textural changes.1 Hand ageing is a three-dimensional process that involves the bones, soft tissues and skin.2 Ageing of the dorsum of the hand may be characterised by large intermetacarpal spaces, skin atrophy, dryness, uneven skin tone and solar lentigines, purpura as well as actinic keratosis.3 Many of these develop owing to extrinsic factors; yet, some are intrinsically induced through disease processes (arthritic symptoms) as well as bone and soft tissue remodelling. As a consequence, the demand for correcting these changes has been steadily increasing within the last 10 years.4 Options to improve texture and pigment changes can include chemical peels, photodynamic therapy, intense pulsed light as well as lasers.2,3,5 Volume loss may be counteracted through a variety of injectable agents including hyaluronic acid, calcium hydroxylapatite, poly-l-lactic acid and autologous fat.1,3,4,6,7 An ideal injectable substance to contour the dorsum of the hand should be durable to withstand dynamic demand, as well as mouldable with good longevity.8 Dorsal hand anatomy There are key anatomical concepts regarding the anatomy of the dorsum of the hand, which includes the skin, soft tissue, areolar tissue/dorsal laminae as well as intrinsic muscle activity and wasting.9 Bidec et al performed detailed histological and ultrasound analysis of cadaveric hands, in which the authors identified three layers of fat, separated by three facial layers.10 The superficial layer is the first and is located between the dermis and the dorsal superficial fascia which does not contain structures and, in an aged hand, may be adherent to the deep dermis. The intermediate fat layer resides between the dorsal superficial fascia and the dorsal intermediate fascia, 1.

2.

3.

4.

5.

6.

7.

8.

9.

Dorsal superficial lamina (DSL) Dorsal superficial fascia (DSF) Dorsal intermediate lamina (DIL) Dorsal intermediate fascia (DIF) Dorsal deep lamina (DDL) Dorsal deep fascia (DDF) Extensor tendon Visible vein Septum

9 8 1 2

3

4

7 5

6

Figure 1: Anatomy of the hand

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

@aestheticsgroup Dorsal superficial lamina (DSL)

Dorsal superficial fascia (DSF) Dorsal intermediate lamina (DIL)

Dorsal intermediate fascia (DIF) Dorsal deep lamina (DDL)

Extensor tendon

Dorsal deep fascia (DDF)

Figure 2: Illustration demonstrating the different fascial layers and fatty laminae, with an injection cannula placed within the dorsal superficial lamina.

which is also an extension of the antebrachial fascia of the forearm.

The intermediate layer contains the dorsal veins and sensory nerves. The deepest and final fat plane is located between the dorsal intermediate fascia and the dorsal deep fascia, which covers the interosseous muscles and the metacarpal bones. The extensor tendons are located between the dorsal intermediate fascia and the dorsal deep fascia. There is potential communication between the palmar and dorsal vessels through perforators, which pass through the interosseous spaces,11 which lead to the end arteries in the digits. Therefore there is potential for material injected in the dorsum to pass by a retrograde mechanism into the palmar circulation and enter the end artery of the digits.12 In addition, Bidec et al report findings of vertically arranged fibres which transition between the layers from the deep compartments to the dermis, which house the perforating vessels that supply the subdermal

To treat the dorsal aspect of the hand safely, it is crucial to identify the presence of any veins and tendons and to mark these, if necessary

Aesthetics Journal

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plexus from the deep dorsal vessels. Injury to these vessels during cosmetic injection may be the cause of bleeding and bruising.12 To minimise the risk of potentially serious complications, the practitioner must understand the complexity and variability of the dorsal arterial system.13 The dorsal carpal arch is formed by the carpal branches of ulnar and radial arteries, from which dorsal metacarpal arteries arise distally in the intermetacarpal spaces.13 The dorsal metacarpal arteries lie deep to the tendons and all dorsal metacarpal arteries lie deep to the extensor tendon. The dorsal metacarpal arteries at the distal third of the hand supply two to three perforator branches, that travel between the tendons of the back of the hand to reach the skin, dividing proximally.2 The dorsal venous network can be located in the intermediate fat plane and on the radial aspect drains via the cephalic vein, and on the ulnar aspect into the basilic vein. The dorsum of the hand is innervated by the terminal branches of the radial and dorsal ulnar nerve.10

Clinical assessment The dermis and epidermis of the dorsal hand are exceptionally thin with a reduced number of pilosebaceous units in comparison to facial skin.3 Lefebvre et al describe ultrasonographic findings to indicate that the thickness of the dermis has been shown to be between 0.2 to 0.9mm, the fascial plane from 0.3 to 2.2mm and tendon layer from 0.7 to 1.7mm; an approximate total thickness of all layers equals between 2.2 and 4.6mm, which are key measurements in the context of selecting an appropriate plane for injection.4 Aesthetic assessment scales may be a useful tool during the consultation to establish the extent of correction and to manage realistic expectations from treatment.14 To treat the dorsal aspect of the hand safely, it is crucial to identify the presence of any veins and tendons and to mark these, if necessary. An assessment of the motor and sensory activity of the palmar region of the median, radial and ulnar nerves, should be performed. In addition, the arterial supply should also be assessed by utilising the Allen test.15 To assess, the patient is asked to make a fist for approximately five to eight seconds, with pressure applied over the radial and ulnar arteries to occlude them. The hand is then relaxed and opened, which should be pale, as the pressure over the ulnar artery is released and the colour should return within seconds to verify that the ulnar artery is patent. Equally this test can be repeated with pressure over the radial artery.15 Technical discussion In line with all dermal filler treatments, a strict aseptic technique when augmenting the dorsum of the hand is imperative in light of the close communication of the compartmental spaces of the hand.16 While it is accepted that product may be placed safely within the dorsal superficial layer lamina; in an aged hand, it can be too close to the dermis to separate and would be unsuitable for the placement of calcium hydroxylapatite and hyaluronic acid as these would be visible through the skin. Lefebvre et al (2015) consider that raising the skin between two fingers (tenting), prior to injecting a bolus of dermal filler results in the product being placed in the

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Our preferred product choice for dorsal hand volumisation is calcium hydroxylapatite owing to its viscoelastic properties, Food and Drug Administration approval and longevity intermediate plane. This may be due to the tight dermofascial adhesions, whereby the skin and fascia lift together. ‘Tenting’ may not create sufficient space for the product to reside and a needle approach may easily perforate fascia and veins.4 Vessels enlarge from a distal to proximal direction and are more visible proximally; as such may be avoided through proximal injection points.5 Insertion of a cannula and product proximally (at the level of the wrist) is unlikely to damage the dorsal arteries; yet, distal injections to the extensor digitorum communis could damage the perforator vessels, and it is possible for a product to be injected into these vessels, as they have a communication with the palmar and end artery digital vessels. The findings of Lefebvre et al in cadaveric studies suggested that a safe plane for product placement is between the dermis and fascial layer, using either a 22G or 25G, 38mm or 50mm cannula approach, creating a subdermal space for injection.4 Used appropriately, a cannula is less likely to perforate vessels or fascia to ensure that product remains within the desired plane.17 Our preferred product choice for dorsal hand volumisation is calcium hydroxylapatite owing to its viscoelastic properties, Food and Drug Administration approval and longevity.18 The patient’s hands are initially washed to get the area socially clean and then the dorsal surface cleaned with an approved skin antiseptic agent, such as chlorhexidine. Retrograde threads (through a proximal insertion point) may be placed to achieve the desired level of correction. To locate the subdermal plane, the undersurface of the dermis is scraped with the cannula, which appears as ‘tethering’ on the surface of the skin as the cannula is passed through this plane.

After correction, the product is massaged gently to ensure even distribution and the patient is advised to keep their hands clean and dry following treatment, to avoid wearing any creams and abstaining from vigorous activity for 48 hours.

Aesthetics

minimise the risk of bruising. Anatomical literature continues to advance in relation to non-surgical rejuvenation strategies and practitioners are advised to be aware of published studies. The use of aesthetic scales is a valuable tool to assess the pre-treatment condition and the predicted degree of correction. This will enable patients and practitioners to discuss the realistic expectations regarding the possible outcomes of treatment.

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director of AMP Clinic in Oxfordshire. He also runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Mr Humzah worked as a consultant plastic surgeon in the NHS for 10 years and teaches nationally and internationally.

Anna Baker is a dermatology and cosmetic nurse practitioner. She works alongside Mr Dalvi Humzah at the AMP Clinic in Oxfordshire and is the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a post-graduate certificate in applied clinical anatomy, specialising in head and neck anatomy.

Mr Dalvi Humzah will discuss periobital, perioral, mid-face and lower face anatomy and enhancing the eye at the Aesthetics Conference and Exhibition 2016. Anna Baker will also discuss the forehead, temple and brow. Visit www.aestheticsconference.com/programme to find out more.

REFERENCES 1. Leclère F.M.P., Vögelin E., Mordon S., Alcolea J., Urdiales F., Unglaub F., Trelles M. (2012) Nonanimal Stabilized Hyaluronic Acid for Tissue Augmentation of the Dorsal Hands: A Prospective Study of 38 Patients Aesth Plast Surg 36:1367-1375 2. Jackubietz R.G., Kloss D., Gruenert J.G., Jackubietz M.G. (2008) The ageingnhand. A study to evaluate the chronological ageing process of the hand. J Plast Reconstr Aesthet Surg 61(6): 681–6 3. Fabi S.G., Goldman M.P. (2012) Hand Rejuvenation: A Review and Our Experience Dermatol Surg 38:1112-1127.

4. Lefebvre-Vilardabo M., Trevidic P., Moradi A., Busso M., Sutton A.B., Bucay V.W. (2015) Hand: Clinical Anatomy and Regional Approaches with Injectable Fillers Plast Reconstr Surg 136(5s):258-275 5. Butterwick K.J. (2005) Rejuvenation of the aging hand. Dermatol Clin 23(3): 515–27 6. Sadick N.S. (2011) A 52-week study of safety and efficacy of calcium hydroxylapatite for rejuvenation of the aging hand. J Drugs Dermatol.10:47–51 7. Villanueva, Nathaniel L. M.D.; Hill, Sean M. M.D.; Small, Kevin H. M.D.; Rohrich, Rod J. M.D. (2015) Technical refinements in Autologous Hand Rejuvenation. Plastic & Reconstructive Surgery 6: 11751179 8. Marmur E.S., Al Quran H., De Sa Earp A.P., Yoo J.Y. (2009) A five-patient satisfaction pilot study of calcium hydroxylapatite injection for treatment of aging hands. Dermatol Surg 35:1978-1984.

9. Sadick N.S., Anderson D., Werschler W.P. (2008) Addressing volume loss in hand rejuvenation: a report of clinical experience. J Cosmet Laser Ther 10:237-241.

10. Bidec S.M., Hatef D.A., Rohrich R.J., (2010) Dorsal hand anatomy relevant to volumetric rejuvenation.

Plast Reconstr Surg 126(1): 163-8 11. Quaba A. A., Davison P.M. (1990) The distally-based dorsal hand flap. British Journal of Plastic Surgery 43: 28-39.

12. Humzah D., Baker A. (2013) Dorsal hand anatomy: age-related changes, fat planes and vascular considerations, Journal of Aesthetic Nursing 2(1):1-4 13. Park T.H., Yeo K.K., Seo S.W., Kim J.K., Lee J.H., Park J.H., Rah D.K., Chang C.H. (2012) Clinical experience with complications of hand rejuvenation, Journal of Plastic, Reconstructive & Aesthetic Surgery 65:1627-1633 14. Carruthers A., Carruthers J., Hardas B., Kaur M., Goertelmeyer R., Jones D., Rzany B., Cohen J., Kerscher M., Flynn T.C., Maas C., Sattler G., Gebauer A., Pooth R., McClure K., Simone-Korbel U., Buchner L. (2008) A validated hand grading scale. Dermatol Surg. 34(Suppl 2):s179–s183.

15. Cable DG, Mullany CJ, Schaff HA (1999) The Allen Test. Ann Thorac Surg 67(3): 876–7 16. Demir E., Perez-Bouza A., Pallua N. (2013) Adverse late Reactions After Cosmetic Implantation of Hydroxyethylmethacrylate Particles Suspended in Hyaluronic Acid: Clinics and Complication Management Aesth Plast Surg 37:576-586 17. Sundaram H., Weinkle S., Pozner J., Dewandre L. (2012) Blunt-tipped microcannulas for the injection of soft tissue fillers: a consensus panel assessment and recommendations. J Drugs Dermatol.

11:s33–s39.

18. FDA, Radiesse Injectable Implant, (2015) <http://www.fda.gov/medicaldevices/ productsandmedicalprocedures/deviceapprovalsandclearances/recently-approveddevices/ ucm451776.htm>

Conclusion It is imperative for practitioners to have a sound knowledge of the ageing changes of the dermis, deeper tissues, muscles and bony structures of the hand. Knowing the position of the perforating vessels and how the dermis is vascularised will reduce the possibility of retrograde injection into the palmer circulation and

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

New for 2016, 3Juve combination skin treatment fights against the 3 key signs of ageing.

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Aesthetics

The role of supplements, hormones and antioxidants in skincare Dr Daniel Sister details the importance of supplement intake and hormone balancing in holding back ageing I am a ‘pre-Botox baby’, which means I’ve witnessed the evolution of the aesthetics industry over the past 25 years. When I trained as a doctor, I was taught to look at a patient in their entirety – not at their different problems – but as one individual. During my career I’ve always promoted the idea of treating the ‘whole patient’. In practice this means looking at how what is happening on the inside is affecting what we can see on the outside.

The ageing process of the face is a complex chain of events between bone, muscle, fat and skin. But there are other key changes that occur within the body that affect the speed at which this chain of events occurs, which explains why we don’t all appear to age at the same speed. There are, as we all know, two different versions of age: chronological age; the age that is written on your ID or driving licence that you cannot change, and biological age; how one will age depending on factors such as genetics, lifestyle, stress, disease and diet. Biological age is something we can affect. In essence, what you put into your body is reflected in its outward appearance, and the skin is the most obvious place we can see this.

Biological ageing is not just something that happens. As medical professionals, we can help our patients understand that the choices they make and the lifestyles they lead will have an effect on their own specific ageing process. In my opinion, providing patients with advice on supplements, nutrition and hormones is of vital importance and should always be done in tandem with any anti-ageing treatments that we may recommend.

By combining nutritional advice, the addition of supplements to the diet, and hormone testing and re-balancing, I believe we can dramatically increase the effects that any aesthetic medical treatments will have on both a patient’s appearance and their general wellbeing. Not only does the addition of this advice make the patient feel better, but it will also ensure any treatments achieve the maximum effect.

To my knowledge, drips are rarely customised to meet the needs of a specific individual, but rather a ‘ready-made cocktail’ – the equivalent of fast food versus a balanced meal. It’s far more valuable to discuss a patient’s diet in detail and, if necessary, arrange blood tests to identify key areas of deficiency.

Diets high in vitamin C and low in both fats and carbohydrates are associated with good skin. This was indicated in a study of 4,025 American women between the ages of 40 and 74 years old, where dermatologists reported that they had fewer wrinkles and agerelated dryness.2 A 24-hour dietary recall was administered to each respondent by a trained dietary interviewer, with 3-dimensional food models, including household measures, to estimate food portions. A complete clinical dermatologic examination of the skin was undertaken to evaluate variations in texture and colour, certain manifestations of ageing, and all pathologic changes. Women with a wrinkled appearance had significantly lower intakes of protein, total dietary cholesterol, phosphorus, potassium, vitamin A, and vitamin C than women without a wrinkled appearance. Further studies have also indicated that women who eat more vegetables, and less fat tend to have younger looking skin.3 Reducing overall sugar intake is beneficial to both elastin and collagen. Eating too much sugar over time ages the skin, making it dull and more prone to wrinkles. This is due to glycation, where sugar in the bloodstream attaches to proteins and forms advanced glycation end products (AGE).4 AGEs damage proteins,4 making cells stiffer, less flexible, and more prone to both damage and premature ageing. Collagen and elastin are particularly prone to this damage.

The effects start at around the age of 35 and increase quickly thereafter. To clarify, the more sugar a patient eats, the faster their skin is ageing. In addition to the potential for poor diet, as we age the body becomes less effective at extracting key nutrients from what we eat. This is where supplements with the right quantities of key ingredients can make a big difference.

The role of vitamins and mineral supplements Diet I always discuss diet with my patients. Sometimes deficiencies are obvious through a patient’s own description of their diet, but I also use blood tests to identify any issues and to look at specific levels.

The skin and hair reflect what’s happening on the inside, therefore good nutrition is vital. Personally I am not an advocate of IV vitamin drips. To my knowledge, drips are rarely customised to meet the needs of a specific individual, but rather a choice of ‘ready-made cocktails’. I believe that sound dietary advice is much more valuable, and if necessary, blood tests to identify key areas of deficiency.1

Supplements Specific vitamin and mineral deficiencies that cannot be addressed through an improved diet should be tackled through the addition of good quality supplements. I would encourage any practitioner intending to recommend supplements to thoroughly research which brand they suggest to patients, in my opinion, not all supplements are equal. A nutritional supplement I developed contains a combination of amino acids and marine plant extracts, which aims to enhance the production of the patient’s own growth hormone. A double blind placebo controlled study, which used optical three-dimensional invivo measuring, has shown that taking a daily dose of a supplement

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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containing collagen peptides can improve the skin’s procollagen content by 65% after eight weeks.5 Hair is another area that suffers due to the ageing process. Hair growth is divided into three distinct cycles, anagen (the growing stage), catagen (the transitional stage) and telogen (the resting stage). As we age the length of the anagen phase shortens with every hair growth cycle, resulting in the hair becoming weaker and appearing less vibrant. A diet rich in protein is particularly important to the development of keratin, the key structural component of hair and nails.6 A supplement that I often recommend to patients is Viviscal Professional. This hair growth supplement contains the key active ingredient AminoMar C, a marine protein complex, plus biotin (vitamin B7) and apple extract, which aim to promote healthy hair growth without the use of hormones or drugs. I find this useful for patients who complain of hair loss, thinning and/or shedding brought about by hormonal change, ageing, stress, and poor diet.

This supplement is supported by clinical trials, starting in 1992 and continuing to the present day,7,8 with a recent six-month double-blind placebo controlled trial which showed an 80% increase in terminal hairs and a 12% increase in hair diameter (thickness).9 Aside from this supplement, the only other recommendation I would make, that I have found to be is effective, is Platelet Rich Plasma (PRP) treatment.

Of course there is a downside to recommending supplements.

Patients rely on taking a tablet when, in fact, making positive changes to their diet would be a far better option. I also steer patients away from self-medicating with supplements. It is far better to seek a professional opinion on where they may need the addition of a vitamin or mineral, than to take a guess and end up contributing to a general imbalance.

How hormones play their part It is well-known that hormones play a hugely important part in the ageing process. Generally women’s hormones begin to fluctuate at around the age of 40, during the perimenopause. This is when skin changes are often first noticed. Wrinkles, dryness and loss of elasticity can all result from a drop in sex steroid hormone levels. When hormones are balanced they enable the body to work efficiently and create energy, fight disease and regenerate tissue. With age, this balance often goes out of kilter. An imbalance of testosterone, for example, often causes significant skin issues. The correct amount of testosterone, balanced with a dose of oestrogen, will help regulate the skin’s oil gland activity. Women who take hormone replacement therapy (HRT), for instance, have been shown to have skin that is thicker than women who do not take hormones.10 In my opinion, using a blood test to check a patient’s hormone levels is vital, as it will provide information about how to treat them. I only prescribe bio identical hormones as they can be tailor-made for each patient.

The role of antioxidants Despite our awareness of how to reduce the risk, skin cancer is on the rise with at least 100,000 new cases diagnosed every year in the UK.11 We should all be aware that reducing sun exposure will decrease our chances of developing skin cancer, however research shows that the majority of people do not use sunscreen effectively; for example, they do not use enough or remember to re-apply frequently.12 As such, I am interested in the role that antioxidants can play in protecting the skin.

While we know that antioxidants should not replace the role of sun protection (in the form of SPFs), we do know there is benefit in taking them alongside traditional methods. Research has indicated that

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taking 1g of vitamin C and 500 IU of vitamin E, for more than three months, can lead to a reduction in the effects of UVB damage.13 Supplements containing polypodium leucotomos, which comes from a Central American fern-plant, have also been reported to offer additional protection. A study in early 2015 conducted by the International Society of Dermatology found that this supplement provided ‘significant advantages’ such as a more uniform protective coverage over the whole body.14 I would suggest that patients who are prone to sun damage take an antioxidant supplement, such as Heliocare Oral Capsules. As far as I am aware, these are suitable for all patients.

Conclusion In my personal experience I have seen many ‘miracle treatments’ come and go because they did not live up to their promises. I don’t rely on clever marketing from sales people, I believe in science and evidence-based research with case studies of large groups of patients, followed for a number of years. Crucially I focus on doing my research before using a treatment (whether it’s new or old).

In conclusion, when I’ve correctly tested my patients and they have stuck to the programme they are given, they come back to me happy with their results. Most importantly they come back without being prompted, because they like how they feel. Much though we try, we cannot stop the ageing process. What we can do, however, is ensure that we age as well on the outside as on the inside.

Treating one without the other is like applying cream to hide a wound; it’s no longer visible, but neither will it heal. Remember, your chronological age is not relevant if your biological age means you look and feel great.

Dr Daniel L Sister is a cosmetic, antiageing and hormone specialist. Since receiving his medical doctorate at the Paris Medical School, he has specialised in minimally invasive anti-ageing procedures. Dr Sister appears regularly on television and radio and has written a number of books including Your Hormone Doctor, with Leah Hardy and Susie Rogers.

REFERENCES 1. USA National Academy of Sciences, Dietary Reference Intakes: A risk assessment model for establishing upper intake levels for nutrients. 1999, National Academy Press; Washington 2. Cosgrove, MC, et al. Dietary nutrient intake and skin aging appearance among middle-aged American women. Am J Clin Nutr 2007;86:1225-1231.

3. Chisato Nagata, Kozue Nakamura, Keiko Wada, Shino Oba, Makoto Hayashi, Noriyuki Takeda and Keigo Yasuda (2010). Association of dietary fat, vegetables and antioxidant micronutrients with skin ageing in Japanese women. British Journal of Nutrition Volume 103 / Issue 10 / May 2010, pp 1493-1498 4. Alison Goldin, BA; Joshua A. Beckman, MD; Ann Marie Schmidt, MD; Mark A. Creager, MD, Basic Science for Clinicians - Advanced Glycation End Products 2006; 114: 597-605 5. Proksch E, et al, Oral intake of specific bioactive collagen peptides reduces skin wrinkles and increases dermal matrix synthesis. PubMed (2013) <http://www.ncbi.nlm.nih.gov/pubmed/24401291> 6. Sinclair, R & Joliffe, V 2013, Fast Facts: Disorders of the hair and scalp. Ed 2, Oxford: Health Press 7. Hornfeldt, C & Holland, M. (2015). The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments. The Journal of Drugs in Dermatology. 14 (9), s14-21.

8. Lassus, A & Eskelinen, A 1992, A comparative study of a new food supplement, Viviscal, with fish extract for the treatment of Hereditary Androgenic Alopecia in young males, The Journal of International Medical Research, vol. 20, no. 6, pp. 445-453.

9. Glynis Ablon, MD, Ablon Skin Institute Research Center, Manhattan Beach, CA; Steven Dayan, MD, A six-month randomized, double-blind placebo-controlled multi-center study evaluating the efficacy of a new oral supplement in women with self-perceived thinning hair. DeNova Research, Chicago, IL. 10. Vaillant L1, Callens A, Hormone replacement treatment and skin aging PubMed, Jan-Feb;51(1):67-70.

11. British Skin Foundation, Skin cancer, 2015, <http://www.britishskinfoundation.org.uk/SkinInformation/ SkinCancer.aspx> 12. British Association of Dermatologists, Sunscreen fact sheet, 2015 13. <http://www.bad.org.uk/for-the-public/skin-cancer/sunscreen-fact-sheet#applying-sunscreen> 14. Placzek M, et al. PubMed, Ultraviolet B-induced DNA damage in human epidermis is modified by the antioxidants and ascorbic acid and d-alpha-tocopherol. (2005) <http://www.ncbi.nlm.nih.gov/ pubmed/15675947> 15. El-Haj N, Goldstein N, PubMed, Sun protection in a pill: the photoprotective properties of Polypodium leucotomos extract, (2015) <http://www.ncbi.nlm.nih.gov/pubmed/25040452>

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Management of Hirsutism Dr Anita Sturnham discusses the causes of excessive facial hair in women and explains her methods of treating patients with this concern

Our skin contains hair follicles over almost the entire body, apart from the palms of the hands, soles of the feet and on the lips. Throughout one’s life, hair follicles will produce varying types and quantity of hair.

The subject of too much or too little hair amongst aesthetic patients is therefore commonplace.

As a skin specialist, I often advise patients with hair-related conditions.

Whether it be too much or too little hair, the concerns one sees are often subjective. Patients are influenced by cultural factors and society’s idea of the ‘norm’. Modern-day women are often under pressure to have no or reduced facial/body hair, to conform with the ‘ideal’ image portrayed in the media, of flawless, hairless supermodels. Sadly, for some women, being ‘too hairy’ can have a devastating affect on body confidence and even result in an increased incidence of anxiety and depression.1 Hair growth For the purpose of this article I will focus on ‘excessive’ facial hair (hirsutism) in women. To simplify my thoughts on the management of excessive facial hair, it is useful to understand the hair growth cycle and the types of hair present on the body. Hair growth goes through three main phases, the anagen or growing phase, the catagen or transition phase, followed by the Anagen

Catagen

(active growth phase)

(transition phase)

Lasts 2-6 years.

Early anagen starts with emergence of new hair, which replaces the old hair.

Around 90% of hair follicles are normally in this phase.

Typically lasts two to three weeks but can last up to six weeks.

Hair growth stops and the hair shaft detaches from the dermal papillae in the follicle.

Figure 1: The phases of hair growth1,2

Telogen

(shedding/ resting phase) Lasts six to eight weeks. Hair no longer attached.

As new anagen phase starts, it pushes the old telogen hair out.

telogen shedding or resting phase. Patients with excessive facial hair, tend to have a disturbance in this pathway, resulting in a prolonged or altered anagen phase.1,2 Hair types Lanugo: downy hair, without pigment, found on fetuses and is usually shed in the womb. It can be found on malnourished children and adults.1,2 Vellus: soft, short hairs with very little pigment. Found on most parts of the body. It appears after lanugo hair is shed. When a person reaches puberty some sites of vellus hair are concerted to terminal hairs, such as hair in the armpits and pubic regions.1,2 Terminal: longer, thicker, darker and coarser hairs.1 Identifying a cause If a patient presents to my clinic with excessive facial hair, my first task is to establish whether there has been a sudden increase in the growth of hair, a change in its character (more likely to have an underlying medical cause) or whether it has always been that way (more likely to be genetic). If the case is the latter, although an underlying medical aetiology is unlikely, it is still important to understand why the patient is suddenly presenting with this complaint and not to dismiss it.

The second task is to ascertain the underlying cause. If the hair in question is thick, dark terminal hair, in a male distribution, this is likely to be hirsutism.4 If the patient has generalised excessive hair growth all over the body then this is more likely to be hypertrichosis.4 Hirsutism is thought to be either the result of an increase in production of the androgen hormone testosterone or an increased sensitivity of the androgen receptors at the level of the hair follicle.5 Up to 80% of a female’s androgen production comes from the ovaries or the adrenal glands,5 the rest comes from the conversion of

Causes of hirsutism Ovarian: polycystic ovarian syndrome (PCOS), ovarian tumour Adrenal: congenital adrenal hyperplasia (CAH), adrenal tumour Idiopathic (IH): no identifiable cause Figure 2: The hair growth cycle

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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precursors dehydroepiandrosterone (DHEA) and androstenedione in peripheral organs such as the liver, adipose tissue and also in the skin.5 Polycystic ovary syndrome (PCOS) and idiopathic hirsutism account for approximately 90% of hirsutism, a condition that effects up to 10% of women.6,7 PCOS typically presents around puberty, however the exact aetiology is unknown.7 PCOS is a common endocrine condition, which can affect up to 10% of women of childbearing age.6 Females with this condition may present with weight gain, irregular periods and menstrual abnormalities. Hormonal imbalance is generally a feature, with raised insulin and testosterone levels.

As such, PCOS is linked to the pathophysiology of hirsutism.6,7 Not all testosterone is ‘biologically active’. For it to be active it needs to be in its ‘free form’ and this typically accounts for 1-2% of our testosterone.6 The rest in its ‘inactive’ form is bound to steroid hormone binding globulin (SHBG) albumin and other proteins.3 As such, we may question how this free testosterone causes hair growth. An enzyme called 5-alpha reductase is present in the sheath of hair follicles. This enzyme converts testosterone to dihydrotestosterone (DHT). DHT prolongs the anagen hair growth phase and results in lanugo and vellus hair being converted into thicker, coarser, darker and longer terminal hairs.4,6 Hirsute women typically present with concerns about increased growth of terminal hair in a male distribution. These tend to be the sites of androgen dependent hairs such as the chin, jawline, upper lip, shoulders, upper back and abdominal regions. There are no standardised assessment tools to assess the severity of hirsutism, however many practitioners find the Ferriman and Gallwey score helpful.8 This score was utilised in their study of 161 women aged 18 to 38 years old,3,4 in which the density of terminal hair was graded in nine body areas, with a rating score from 0 (absence of terminal hairs) through to 4 (extensive terminal hair growth). The study concluded that hirsutism was represented by a score of 8 or more.3

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Managing the hirsute patient The importance of taking a good history and examination is key. Examination should consist of a general physical examination, including hair, skin, cardiovascular system, abdomen and urine. Practitioners should then establish the following before offering treatment: • Onset of hair growth.

• Other associated symptoms such as weight gain, skin changes including acne, changes in menstrual cycle, deepening of voice, changes in libido.

• Drug history; some medications can affect hair growth, such as some antiepileptic drugs.3 • Family hair growth patterns: genetic causes.

• Past medical history, including thyroid disease and diabetes. Thyroid disease can cause weight gain and irregular menstruation and must therefore be excluded. Diabetes is strongly associated with PCOS. Blood tests • Testosterone: may be normal/increased in case of PCOS and CAH if significantly raised (>200ng/ml) consider malignant ovarian/adrenal tumour.3 • Dehydroepiandrosterone sulfate (DHEAS): >700μg/do indicates adrenal cause.3 • 17-hydroxyprogesterone (take between 7-9am): raised in cases of CAH.4 • 24-hour urinary free cortisol (measured if clinical signs of Cushing’s syndrome).4 • LH/FSH >3 indicative of PCOS.4 • Prolactin raised in hyperprolactinemia (hypothalamic disease or a pituitary tumour).4 • Thyroid function tests (TFTS).4 • Glucose: metabolic syndrome associated with PCOS.8 Other tests • Pelvic ultrasound: to assess ovarian follicles. The ‘string of beads’ sign reflects a line of pearl-like follicles in the peripheral region. PCOS sufferers are likely to have at least 12 visible follicles and this may increase up to 25 in some cases.7,8

Treatment options For the purpose of this article I am focusing on the management of excessive facial hair secondary to PCOS or IH. For any other underlying conditions Figure 3: Terminal hairs in a hirsute female patient before and 12 weeks after four identified at this stage I would seek advice from treatments with the Soprano diode, fluence mode II, 38j. Images courtesy of Dr Dhepas, an endocrinologist. For those with patients with Skin City. Postgraduate Institute of Dermatology, India.

PCOS, I start by advising them to follow a diet and exercise plan, which can help to reduce their BMI and also lower at drug treatments for confirmed hyperandrogenism. Below I other health disease risk factors. have summarised the medical treatment options that should be Studies have identified a directly proportionate relationship considered at this stage. between raised BMIs and raised free testosterone levels.7 The same link applies for reduced Sex Hormone Binding Globulin Oral contraceptives: These are recommended first line and are a (SHBG) levels. Both factors are thought to contribute to hirsutism.7 popular choice for women who are also looking for contraception.4 I often advise a three to six month programme before looking The combined pill (COC) containing oestrogen and progesterone,

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Female patient presents with excess growth of hair Check the sites for excess growth of hair

Increased growth of hair in male pattern distribution

Generalised increase in growth of hair on all body

Hirsutism

Hypertrichosis

Find the cause, take complete history and do physical and systemic examination

Features of hyperandrogenism

History of drugs prior to onset oral contraceptives, danazol, testosterone, anabolic steriods, metoclopramide, methyldopa, phenothiazines, reserprine

If yes, stop the drug and replace it with some other drug

Evaluate the patient on follow up for the regression of hirsutism

If no If yes, ask the rate of onset

Gradual onset with no virilisation Benign

IH

Rapid onset with virilisation Malignant

PCOS

CAH

Ovarian tumour

Adrenal tumour

testosterone-N/Inc. DHEAS-N cortisol-N 17-0HP-N LH/FSH-N/Inc.

testosterone-N/Inc. DHEAS-Inc. cortlsol-N/dec.

17-0HP-Inc. LH/FSH-N

testosterone-N./Inc. DHEAS-N cortisol-N 17-0HP-N LH/FSH-N/Inc.

testosterone-Inc. DHEAS-Inc. cortlsol-Inc. 17-0HP-N LH/FSH-N

Figure 4: Summary of assessment protocol for patients with hirsuitism3

works by inhibiting adrenal androgens and reducing ovarian androgens. The COC also increases levels of SHBG, resulting in lower levels of free androgens.4 Patients should be warned of common side effects such as: mood changes, breast tenderness and weight gain.4 Spironolactone: Most will know of this as an antihypertensive, but it is also acts as an androgen blocker, by competing with DHT for androgen binding sites.3 It also has an inhibitory effect on 5-alpha reductase.7 It should be emphasised that it may take four to six months before patients start to see any benefits so it is important to advise the patient of this to encourage compliance. Patients should be warned of common side effects such as: tiredness, increased thirst and constipation.3 Cyproterone acetate: This has anti-androgenic properties too; it works by reducing luteinizing hormone (LH) levels.3 Patients should be warned of common side effects such as: tiredness, hot flushes and breast tenderness.3 Finasteride: 5-alpha reductase inhibitors inhibit DHT production.4 Patients should be warned of common side effects such as: mood swings, weight gain and breast tenderness.3 Hair removal While the medical management is initiated, patients generally do not want to wait for prolonged periods of time to treat their excessive facial hair, so it is important to address this issue at an early stage. Simple at-home options include waxing, shaving and plucking.6 These are somewhat time-consuming methods and can leave redness, inflammation and irritation. In my experience, most patients will have already tried these options before coming to see

a specialist and are generally seeking alternatives at this stage.

At my clinic, we offer electrolysis as a solution for hair removal.

During this process a fine disposable sterile needle is introduced into the individual hair follicle to the correct depth and a small amount of current is released. This destroys the root of the hair by cutting off the blood supply.6 This â&#x20AC;&#x2DC;old-fashionedâ&#x20AC;&#x2122; method is great for hair removal, however it is time-consuming if large treatment areas are required.

Studies have identified a directly proportionate relationship between raised BMIs and raised free testosterone levels. The same link applies for reduced Sex Hormone Binding Globulin (SHBG) levels

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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regimen, using cosmeceutical grade products using the actives alpha arbutin, ascorbic acid 20% and retinol 2-3%, for a period of six weeks. The importance of daily SPF 30 is also emphasised, as part of the skin preparation phase. The main reasoning for this skin preparation phase is to reduce post-inflammatory hyperpigmentation that one can see in darker skin tones following laser treatments.

At the time of treatment, designated settings are used as per skin type, hair type and body area. To achieve the best results with hirsute facial hair, low-fluence, rapidpulse width and multiple passes with the Soprano ICE 755nm and 810nm dual wavelength laser seems to be the best approach. As well as noticing this in my practice, a study by Ganesh et al, which compared this strategy Figure 5: Treatment of facial hair using Soprano Alexandrite laser. Fluence mode III. 28J. with a traditional high-powered, single-pass, Soprano 10 weeks after first treatment. Images courtesy of Dr Dhepas, Skin City. Postgraduate 755nm and 810nm dual wavelength laser system, also Institute of Dermatology, India. suggested this method was more effective.9 Laser hair removal Once we have achieved the desired end point, we advise our Lasers have gained wide popularity in recent years. They work to patients to return two to three months later for a review. At this reduce hair by causing selective photothermolysis, which aims to stage, we may recommend additional treatments. Most patients destroy the hair follicle.3 The laser target or chromophore is the return for several maintenance treatments every 12 to 18 months. melanin pigment in the hair. The best clinical results tend to be achieved with a light-skinned patient with darker hair.9 The laser Conclusion energy acts on only anagen hair follicles, we therefore need to Hirsutism is a condition that all aesthetic practitioners are likely to treat the patients every four to six weeks for facial hair and every be presented with. It is important to assess each patient carefully six to eight weeks for body hair to achieve significant reduction.3 and ensure that underlying medical causes are addressed and There are many different lasers on the market for hair removal. treated accordingly. As discussed, PCOS and IH are the most likely These include 1064nm Q-switched, 694nm ruby, 755nm longcauses.3 If pharmacological therapy is required, the combined 9,10 pulsed alexandrite, Nd: YAG Lasers. oral contraceptive pill may be a good first line pharmacological At my clinic, Nuriss, we use the Soprano ICE, a high fluence therapy.3,4 This should be reviewed at the six-month stage, where dual wavelength laser, with contact cooling, hence the ‘ICE’. one may consider adding an anti-androgen if necessary.3 The Soprano’s sapphire cooling system allows the energy to be Most women will also want advice and/or treatment for hair removal. delivered into the hair follicle without damaging the epidermis.9 In my experience I have found that laser photoeplilation is often This allows for more comfortable treatments but also helps to the preferred choice.10 The darker skin types may benefit from reduce the risk of hypo or hyper pigmentation, secondary to a period of skin preparation with melanocyte-stabilising active inflammatory changes in the skin.10 skincare products before commencing laser therapy, to reduce the There are many laser hair removal devices on the market. I chose risks of adverse effects secondary to the laser.

Soprano ICE for my clinic, as I have worked with it for several years Dr Anita Sturnham is a GP and specialist dermatologist. and have achieved outstanding results. Many of my colleagues use She is an ambassador for Unilever skincare and a medical other devices such as the Gentle Pro systems and Lightsheer. expert for Superdrug, previously appearing on television to share her expertise. She currently works as a general At Nuriss, suitability for laser is assessed and risk factors are and aesthetic practitioner, combining NHS duties with screened for at the initial consultation. Those with a Fitzpatrick skin private practice, recently opening her own clinic, Nuriss, in London. type IV-VI are prepped with a melanocyte-stabilising homecare

It is important to assess each patient carefully and ensure that underlying medical causes are addressed and treated accordingly

REFERENCES 1. Di Prospero, F, ‘Hypertrichosis and Hirsutism’, Aesthetic Medicine, Endocrinology, (2014) <http:// womanhealthgate.com/hypertrichosis-hirsutism/> 2. Hair Loss: The Science of Hair, WebMD (US: American Hair Loss Association, 2010) <http://www. webmd.com/skin-problems-and-treatments/hair-loss/science-hair?page=2> 3. Sachdeva S, ‘Hirsutism: evaluation and treatment’, Indian J Dermatol, 55(1) (201), pp.3-7.

4. Rosenfield RL, ‘Clinical practice. Hirsutism’, N Engl J Med, 353 (2005), pp.2578-88.

5. Martin KA, Chang RJ, Ehrmann DA, Ibanez L, Lobo RA, Rosenfield RL, et al., ‘Evaluation and treatment of hirsutism in premenopausal women: an endocrine society clinical practice guideline’, J Clin Endocrinol Metab, 93 (2008), pp.1105-20.

6. Hunter MH, Carek PJ, ‘Evaluation and treatment of women with hirsutism’, Am Fam Physician, 67 (2003), pp.65-72.

7. Chang RJ, Katz SE, ‘Diagnosis of polycystic ovary syndrome’, Endocrinol Metab Clin North Am, 28 (1999), pp.397-408.

8. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group, authors, ‘Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome’, Fertil Steril, 81 (2004), pp.19-25.

9. Ganesh et al., ‘Safety and Efficacy of low-fluence, high repetition rate versus high-fluency, low repetition rate 810-nm diode laser for permanent hair removal- a split-face comparison study’, Journal of Cosmetic and Laser Therapy, 13 (2011), pp.134-137.

10. Sanchez LA, Perez M, Azziz R, ‘Laser hair reduction in the hirsute patient: A critical assessment’, Hum Reprod Update, 8 (2002), pp.169-81.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Reshaping the axillary fold Mr Raj Ragoowansi presents his technique for treating the axillary fold to restore patient comfort and confidence The axillary fold is an often uncomfortable and unsightly excess of volume between the outer aspect of the breast and the inner arm, which can become more prominent when wearing tightfitting clothes and push-up brassieres. The fold can also fluctuate with body weight, and if it consists of breast tissue (the axillary tail), it can alter in size in conjunction with the menstrual cycle and other hormonal imbalances.1 From a functional point of view, it can be uncomfortable and not only restrict comfortable arm adduction, but can also harbour intertrigo and eczematous rashes, especially in warm climates. Aesthetically, it disturbs the natural superolateral contour of the breast, as it blends into the anterior axillary fold and, at worst, can appear as an unsightly irregularity both within and out of the brassiere.

Patient assessment Before the procedure, patients must be fully examined, which includes a thorough assessment of the fat and breast tissue components, together with tone, texture and turgor of the overlying skin. A clear appreciation of the adjacent aesthetic units of the axilla/ upper arm and breast is also paramount. Using ultrasound can be useful to determine the relative proportions of breast and adipose tissue, and also to ascertain the consistency of breast tissue, thus determining it’s suitability for liposuction or liposuction-assisted removal. Practitioners should assess the skin quality; is it thin with stretch marks or thick; loose or firm? Is the fat consistency soft or fibrous? Is the volume minimal, moderate or in excess?

Left side before

Right side before

Figure 1: 24-year-old woman before treatment for axillary folds Left side after

Right side after

Figure 2: Six months post treatment

Treatment options In the majority of cases, especially if the skin excess is mild to moderate, bespoke liposuction under local anaesthetic is carried out, both at a deep level, to remove the soft tissue ‘fill’, and at a superficial level, to encourage the skin to adhere to the underlying chest wall and muscle. In my experience, this procedure avoids leaving the patient with scars. The breast tissue is then chemically and mechanically softened with hyaluronidase within the infiltrate, and a bespoke, truncated liposuction cannula is deployed to remove the excess tissue. If breast tissue is firm/nodular then the cannula needs to be truncated and these cannulas are especially designed this way.2 If there is reasonable skin excess, in addition to the liposuction, the skin is surgically removed through a well-hidden scar in the valley of the axilla. Small openings in the flesh are closed using dissolvable sutures over a soft drain. This is then removed within six hours, to remove any exudate, but mainly to encourage skin adherence.

A compression dressing is applied and remains in situ for five days, followed by a compression garment for three weeks. During this initial recovery period, arm exercises are restricted, including lifting, carrying and reaching out, in order to prevent swelling and seroma. Lymphatic drainage massage is encouraged for six weeks thereafter to drain tissue oedema and to facilitate skin redraping.

Before the procedure, patients must be fully examined, which includes a thorough assessment of the fat and breast tissue components, together with tone, texture and turgor of the overlying skin Results My personal assessment of the 45 patients I have treated over the past five years indicates that 92% have been satisfied with the outcome and were discharged between four to six months post treatment. A complication rate of 7-8% occurred in these patients, which includes:

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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After

After

Figure 3: 34-year-old woman treated for axillary fold on both sides. Images show before and four months after treatment

• Intolerance to the local anaesthetic during surgery. This had to be converted to sedation/general anaesthetic.

• Seroma, which occurred within 10-14 days. This was drained percutaneous.

• Persistent breast tissue, necessitating open removal via an axillary scar extension.

• Minimal skin retraction, necessitating revision skin excision.

• Asymmetry was found in one patient, in whom the procedure was repeated with a favourable outcome.

Aesthetics

Side effects I have noted the following side effects: • Early (within 48 hours) – discomfort, swelling.

• Intermediate (between 48 hours and two weeks) – seroma.

• Late (after two weeks and thereafter) – asymmetry, skin excess, manifesting as a fold.

Conclusion I believe the key tenets to a satisfactory outcome are: careful assessment of the axillary tissue, liposuction, and post-operative compression and diligent massage/lymphatic drainage. Patients also need to be seen again at three to four months post procedure before the final outcome is apparent. Overall, this is an effective technique, tolerated well by most patients under local anaesthetic. With downtime of four to six weeks, this treatment can comfortably treat a problem that can be functionally and aesthetically debilitating.

Mr Raj Ragoowansi is a consultant plastic and aesthetic surgeon. He graduated in Medicine and Surgery in 1992 from St Thomas’ Hospital Medical School, London, with the final year elective spent at Harvard Medical School, Boston, US. REFERENCES 1. Laor T, Collins MH, Emery KH, Donnelly LF, Bove KE, Ballard ET, (2004), MRI appearance of accessory breast tissue: a diagnostic consideration for an axillary mass in a peripubertal or pubertal girl, AJR Am J Roentgenol. Dec;183(6):1779-81 2. Melike Erdim, Ayhan Numanoglu, Aydin Sav, The effects of the size of liposuction cannula on adipocyte survival and the optimum temperature for fat graft storage: an experimental study, Journal of Plastic, Reconstructive & Aesthetic Surgery, September 2009 Volume 62, Issue 9, pp. 1210–1214

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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

Premium content education at the ACE Conference agenda Focused Conference sessions Everything you need to perfect your skills from consultation guidance, treatment options, case studies and complication management advice on key facial and body anatomical areas • What to do with the Mid-face • Treating the Buttock and Thigh Area • From Neck to Breast • Enhancing the Eye • Forehead, Temple and Brow • Vaginal Rejuvenation • Perioral, Chin and Submental Area • Lower Facial Contouring

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A summary of the latest clinical studies Title: Fractional Microneedling: A Novel Method for Enhancement of Topical Anesthesia Before Skin Aesthetic Procedures Authors: El-Fakahany H, Medhat W, Abdallah F, Abdel-Raouf H, Abdelhakeem M Published: Dermatologic Surgery, December 2015 Keywords: Microneedling, acne, scars, topical anesthesia Abstract: The authors evaluated the efficacy of skin microneedling, using an automated device, to enhance the numbing effect of topical anesthesia, used before minimally invasive aesthetic approaches.

Fifteen patients, looking for treatment of atrophic acne scars, were subjected to randomized split-face study comparing automated fractional skin microneedling (0.5 mm depth) followed by application of topical anesthetic cream (Lidocaine 2.5% + Prilocaine 2.5%) on one side of face, with topical anesthesia alone on the other side, followed by full face fractional microneedling treatment for postacne scars (2.5 mm depth). The treated sides (fractional needling + topical anesthesia) had significantly lower pain scores when compared with the nontreated sides (topical anesthesia alone). The scores of pain sensation, during the whole procedure, were statistically significantly (p < .0001) less on the treated sides (3.10 ± 1.09) of the face when compared with the nontreated sides (5.37 ± 0.99). There was also a statistically significant (p < .0001) difference in pain sensation scores between the 2 sides of the face after horizontal passes, as the mean scores of the treated and nontreated sides were 3.93 ± 0.59 and 6.20 ± 0.41, respectively. The small number of patients, yet the results show a significant difference. Application of topical anesthesia for minimally invasive aesthetic procedures can be enhanced with fractional microneedling pretreatment.

Title: Novel Polydioxanone Multifilament Scaffold Device for Tissue Regeneration Authors: Kim H, Bae IH, Ko HJ, Choi JK, Park YH, Park WS Published: Dermatologic Surgery, December 2015 Keywords: Ageing, regeneration, wrinkle, tissue augmentation Abstract: Facial aging is the result of intrinsic and extrinsic factors that lead to gradual reduction of dermal extracellular components and skin elasticity and wrinkle formation. A novel stent-shaped biodegradable and biocompatible scaffold device braided with absorbable polydioxanone (PDO) multifilaments was recently marketed for tissue suturing and augmentation. To explore tissue regeneration profiles following implantation of the stent-shaped hollow scaffold in rats and mini-pigs. The scaffold device was implanted under the panniculus carnosus of rat dorsal skin and in the subcutaneous layer of mini-pig dorsal skin. Tissue samples were harvested and histologically evaluated after 3 days and 1, 2, 4, and 12 weeks for rats and after 1, 2, 4, 8, and 12 weeks for mini-pigs. Type III collagen was slowly replaced by Type I collagen in the scaffold.

Cells from the surrounding tissue infiltrated the hollow space of the scaffold, which induced de novo tissue regeneration in this space. The novel stent-shaped scaffold used here may be useful for stimulated tissue remodeling of aged skin, collagen synthesis, and partial restoration of dermal matrix components. The cosmetic purpose of this novel soft tissue augmentation device should be clinically investigated in long-term studies.

Title: Short-Scar Mammaplasty in Severe Macromastia Authors: Akyurek M, Chappell AG Published: Annals of Plastic Surgery, December 2015 Keywords: Scarring, breast reduction, liposuction, mammaplasty Abstract: This report presents our experience of reduction mammaplasty greater than 1000 g per breast using a short-scar technique. The procedure is based on the following: a) modified breast marking method with conservative placement of the nipple-areola complex, determined not only by the level of the inframammary fold but also degree of upper pole volume loss; b) use of liposuction for contouring the inferior pole; c) vertical design dermoglandular resection; d) superomedial pedicle; and e) skin closure without undermining or gathering. A total of 69 patients were identified (n = 138 breasts). Mean age was 38.0 years with average BMI of 36.4 kg/m. Mean weight of breast removed was 1333.8 g (range, 1002-3275). New nipple position was determined to be inferior to the inframammary fold at a mean distance of 4.6 cm, as predicted by the degree of flatness of upper pole. Complications included delayed healing (7.2%), fat necrosis (10.1%), infection (5.8%), hematoma (2.9%), and seroma (1.5%). There were no instances of nipple-areola complex necrosis.

Revision of dog-ears was necessary in 7 patients (10.1%). The authors conclude that in using a modified short-scar mammaplasty approach in cases of severe macromastia, the outcomes can be improved with reduced scar burden, pleasing breast shape, and a low complication rate.

Title: Ameliorating Effect of Akebia quinata Fruit Extracts on Skin Aging Induced by Advanced Glycation End Products Authors: Shin S, Son D, Kim M, Lee S, Roh KB, Ryu D, Lee J, Jung E, Park D Published: Nutrients, November 2015 Keywords: Ageing, natural compounds, antioxidants, antiglycation, skin, anti-ageing Abstract: The accumulation of free radicals and advanced glycation end products (AGEs) in the skin plays a very important role in skin aging. Both are known to interact with each other. Akebia quinata fruit extract (AQFE) has been used to treat urinary tract inflammatory disease in traditional Korean and Chinese medicines.

In the present study, AQFE was demonstrated to possess antioxidant and antiglycation activity. AQFE protects human dermal fibroblasts (HDFs) from oxidative stress and inhibits cellular senescence induced by oxidative stress. We also found that AQFE inhibits glycation reaction between BSA and glucose. The antiglycation activity of AQFE was dose-dependent. In addition, the antiglycation activity of AQFE was confirmed in a human skin explant model. AQFE reduced CML expression and stimulated fibrillin-1 expression in comparison to the methyglyoxal treatment. In addition, the possibility of the extract as an anti-skin aging agent has also been clinically validated.

Our analysis of the crow’s feet wrinkle showed that there was a decrease in the depth of deep furrows in RI treated with AQFE cream over an eight-week period. The overall results suggest that AQFE may work as an anti-skin aging agent by preventing oxidative stress and other complications associated with AGEs formation.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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• What format will the interview take and how long will it be? You need to adapt your preparation and delivery techniques for print versus broadcast interviews, and knowing the interview length helps you to hone your messages.

Know Your Audience As with all PR and communications, it is vital to understand your audience and make your responses relevant to them.

Is your interview for a trade journal? A radio show? A glossy magazine?

Make sure you adapt your style and messages, keeping your points relevant and tailored to the audiences’ needs and expectations. This approach gives you the framework to prepare your responses and map out additional questions or situations that may also come up – minimising the chances of you being ‘caught out’. As the old saying goes, ‘forewarned is fore-armed!’

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Top 10 Tips for Media Interviews Julia Kendrick shares her effective interview techniques that can maximise your business Media interviews are the Holy Grail for your PR efforts. You have the time and attention of a journalist who wants to hear your opinions, which is a huge opportunity to raise your profile and get your messages out. However, many practitioners regard interviews with a sense of dread – fearing they will be misquoted, ‘tripped up’ by difficult questions or come out of the process in worse shape than they went in. Whilst this is a possibility, it is much less common than you’d think and with some simple preparation, you can mitigate this risk. This article will guide you through my top 10 tips to get the best possible result for your business and increase your chances of being interviewed again.

Do Your Homework Much of the ‘fear factor’ around media interviews revolves around fear of the unknown: what questions will they ask?

What if I don’t know the answer? What if my mind goes blank? To tackle this, make plenty of time to prepare for your interview and practise your techniques. Whether it’s a two-minute telephone interview or an hourlong TV slot, your preparation efforts should be the same. Bear in mind, journalists also want the best possible results and will welcome your efforts to prepare ahead of time. Make sure you find out:

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• What do they want to talk to you about? Get as much detail as possible on what they’re looking for and what information they already have.

• What questions do they plan to ask you? Ask for these on an email so you have a written record and can plan out your responses.

• Are they speaking to anyone else? If so, research their backgrounds and anticipate what their angles/points of view might be.

• What is the broader context for the interview? It’s always essential to know the broader context within which your opinion is being framed.

Hone Your Messages – The Power of 3x3 First thing’s first: you shouldn’t do an interview just to answer a journalists’ questions – it’s also about getting your own messages across. In order to do this successfully, you need to be crystal clear on what your key messages are. A key message is the most important point you want your audience to know now, and remember later. The most effective method for getting key messages to stick in the audience’s mind is to keep them short, relevant and REPEATED. The more you try to cram into your interview, the less likely people will remember anything at all – so stick to no more than three key messages, and aim to repeat each one three times (irrespective of the interview length). This is known as the power of 3x3 – it is much more effective for audience retention than rushing out five to 10 individual messages which only get mentioned once and are likely to be forgotten instantly.

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Your key messages should be described in brief and powerful sentences which set out your position on the issue at hand. Keep them short, relevant to the audience and jargon-free: • They should tell the audience something they don’t already know.

• It’s good to include a key fact or figure that underpins or supports your position.

• Include an action that you are doing, or an action that you want your audience to do e.g. ‘speak to your doctor,’ ’visit this website’ or ‘sign this petition.’

Bridging Technique Naturally, you have to weave the key messages into your interview answers – which can be tricky if the journalist asks a negative question or one that is unhelpful to your own agenda.

This is where bridging technique comes in – using a variety of ‘bridging phrases’ to move the conversation on and then introduce or restate your key messages.

Be warned – this does not mean you should ignore a journalist’s question and just keep making your points regardless! Answer the question – yes or no – and then quickly bridge to steer the conversation back to the points you want to make. Examples of bridging phrases include:

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• • • • •

What’s important to understand here is that…

The key issue is…

Let me tell you the facts…

What really matters to [insert audience] is…

What we do know is…

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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• What I can tell you is….

• What my patients tell me is that…

• From my own experience, I can say….

Then follow with one of your three key messages, to keep your power of 3x3 going.

Keep Calm During your interview, try to relax. Be confident in yourself and your expertise – this is why you are being interviewed in the first place. Breathe deeply and take your time to answer to the questions – this also helps avoid ‘umming and aahing’. Be aware of your tone – if discussing a contentious issue, or receiving ‘negative’ questions, make sure you respond with a calm, considered approach. Try not to ramble on once you’ve answered the question – you will likely get off topic and dilute your message.

Silence or, as it is commonly known, ‘dead air’ is the cue for the journalist to ask more questions.

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Watch Your Body Language 6 We all know the importance of body language and how much non-verbal communication is delivered unconsciously. Regardless of the interview format – TV, radio, face-to-face or telephone – be aware of your body posture, hand movements and facial expressions. You need to portray confidence and authority – so sit comfortably, but keep movement to a minimum; jiggling hands or feet look nervous and are distracting.

Hand gestures can help you make a point but don’t overdo it – if you tend to ‘talk with your hands’ try keeping them folded in your lap. Plant yourself firmly – sitting up straight, shoulders back, head up – definitely no slouching! Some of my clients prefer to stand up on telephone interviews – it makes them feel more confident and helps them focus, so do what works for you in this scenario.

What Not To Wear This mainly relates to TV interviews where camera optics play a part – but it is also useful for face-to-face interviews.

Try to avoid:

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• Uncomfortable clothes – you need to feel confident and smartly turned out.

• Fussy patterns or small prints e.g. dog tooth, geometric shapes – these play havoc with the TV cameras. Instead, wear bright singular colours that ‘pop’ or complementary colour tones.

• Black or white – it drains colour from your face.

• Bulky or excessive jewellery/accessories as this will be distracting.

• Anything too short (skirts or trouser legs) – you may be sat on a low sofa or seat and nobody needs to see the flashy statement socks you got for Christmas!

• Hair hanging over your face – it will distract you, and the viewers.

Make It Your Comfort Zone 8 Being comfortable in yourself and your surroundings will help boost your confidence and make for a successful interview experience. To help establish your comfort zone: • Bring a change of clothing in case of any last-minute accidents.

• Get to the studio early to familiarise yourself with the set and calm your nerves.

• Don’t forget time needed for hair and makeup on set (even the men).

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• Don’t be afraid to ask silly questions – like where the toilets are.

• Make sure you have a glass of water on hand just in case.

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Common Pitfalls and How to Manage Them This point could fill another whole article! Some key ‘watchouts’ to consider are:

• Repeating negative language: journalists may try to put words in your mouth for example, asking, “Is this a disaster?” Counter by saying, “No I don’t agree”, “that isn’t accurate” or “that is untrue” – don’t repeat the word disaster, even to disagree.

• Don’t get drawn into speculation: respond with a factual overview: “Let me give you the facts...”

• No such thing as ‘off the record’: remember that cameras and microphones stay on. Don’t do a Gordon Brown and say something indiscreet as soon as your interview ends, maintain your concentration and composure throughout.

Be Honest, Credible And Trustworthy To me, this is the most important point of all. Lying (whether intentional or not) is the quickest way to destroy your reputation and be blacklisted by the press. No journalist will risk their professional integrity if they can’t rely on you. If you make a mistake or speak an untruth, correct it quickly and clearly. It is better to backtrack now and remain firm than be found out later. Another part of being honest and credible is not offering an answer to something you don’t know – just bridge to what you DO know. Saying ‘no comment’ is never an option – it just fuels speculation and allows someone else to decide what the story is.

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Conclusion You should now have a good understanding of the basics of media interview preparation and feel more confident about tapping into this approach to boosting your media profile and business opportunities.

I would encourage clients doing more regular interview work to invest in good media training from an experienced professional – this is a skill you can develop and grow constantly which can deliver huge value to your business. Good luck!

Expert Opinion Nicola Hill, veteran journalist and managing director of media training agency NC Media Ltd, says: “Preparation and practice are the most important factors for successful media interviews. A media interview is not the same as a presentation, nor is it a consultation or a conversation – remember to listen carefully to the questions posed, and use those questions to inform the audience and share your expertise. My clients all have refresher media training on a regular basis to hone their interview skills and prepare themselves for media opportunities.”

Julia Kendrick has more than 11 years’ experience within the PR industry. She recently founded Kendrick PR Consulting: a bespoke strategic consultancy service specialising in medical aesthetics and healthcare PR. A previous winner of the Communiqué Young Achiever Award, Kendrick’s ethos is to deliver excellence for clients with impactful campaigns and high-calibre results.

Julia Kendrick will present on PR for business growth and profile-building for increased revenue at the Aesthetics Conference and Exhibition 2016.

Visit www.aestheticsconference.com/programme to find out more.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Reaching Social Media Goals PR consultant Mike Nolan shares social media strategies and provides his best tips on how to reach your business goals Few of us would doubt that social media has taken a significant role in our lives in recent years – not just in the way that we communicate at a personal level but also in the way that businesses communicate with their audiences. If used correctly, social media can help you create a strong personal connection with your potential patients. However, too often many businesses merely pay lip service to social media – posting the odd comment without much thought as to what they are sending. They can make the mistake of diving into social media without a clear strategy. At best, this is a waste of time, at worst, it can lead to a PR catastrophe – someone misinterpreting a post could threaten your reputation. To benefit from social media, you need a clear plan that takes into account what you’re trying to achieve, who your patients are and what your competition is doing. The bottom line is that your target audience is online and very socially aware (Figure 1). 1 Prospective

patients are also more likely to get their news online rather than in print. The benefits of reaching your patients amongst such a huge audience should therefore be obvious, but how do you go about it?

Your social media strategy Create a plan to determine what your social media goals are and what you want to achieve. Do you want to attract more traffic to your website? Raise awareness, build your audience or maybe increase sales? Of course, it’s easy to say ‘yes’ to all of these but if you spread yourself too thinly, then the chances are you won’t achieve much. Be specific and measurable, and your social media strategy will be much more successful. If your goal is to increase brand awareness, then you may want to set a goal to increase your followers by 20%. However, don’t leave it for six months, set a time related goal, so you can see if what you are doing is working.

There are now 7.2 billion people on the planet and of those: 45% of the world’s population are active internet users 3.65 billion mobile users access the internet via smartphones and tablets Close to 1.7 billion people have social media accounts Figure 1: Social media statistics. Source: Digital, Social and Mobile in 2015 report, We Are Social

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The audience Understanding your audience is key – target the right people, at the right time with the right content. There’s no point in targeting everyone on every social media platform when your ideal patient probably isn’t in their 80s, male, and retired. They are more likely in their 30s, female and living near your clinic, so brainstorm with your team and think about who they really are and how you can find them. As a starting point, look at your current patient list to help find any useful data to put together your target profiles. Specifically, look for things like gender, age group and geographical location.

The message Once you’ve determined your target audience, think about how you communicate with them – speak in a language they will understand and relate to. Create your voice, be true to your brand, but do not be boring – social media is ‘social,’ it’s meant to be fun and engaging. The essential thing here is quality and relevance. Perhaps, if your target audience are female and aged 30-50, then they’ll probably be very conscious of lifestyle, health and appearance, so talk to them as if you are one of them. Get into the mind set of that group – even if that means speaking to a handful of current patients as a focus group to gather their thoughts or even friends or colleagues in this age bracket. It is also important to note that the way you get your message across is through building engaging content for your social channels. Be it a video, tip sheet or a simple Tweet, they should be linked to your objectives.

Focus on channels your patients’ use Choose the right platform(s) for you. You don’t have to use all of them; try to focus on the ones your target market is more likely to use. Just because a certain network has millions of users, it doesn’t mean it will aid your marketing objectives. It is vital to focus your efforts on the social media channels that hold the key to your target audiences.

Each has pros and cons, so choose the networks that will work best for you. In my experience, the best-known channels for Business to Customer (B2C) business are Facebook and Twitter but you are obviously not limited to these.

Facebook As of the last quarter of 2015, Facebook had 1.55 billion users.2 For aesthetic professionals, you can be sure your target audience is most likely represented in some way on this

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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platform. However, can Facebook contribute to your overall goals? Facebook continually changes which means businesses must stay on top of it. For instance, in March 2015, Facebook started making page ‘likes’ more meaningful.3 The result of the new algorithm change guarantees that data is reliable, up-to-date and also gives updated audience insights on the people who actively follow your page. This makes it easier for you, as a business owner, to find a new viewership that’s similar to your target audience through tools like lookalike audiences, i.e. audiences that will be similar to your current patient base. As well as this, news from your friends is now pushed to the top of your timeline, higher than news from brand pages. Even if your patients ‘like’ your page and want to hear the latest information from you, chances are they are less likely to do so. Successful use of Facebook for businesses is now less about post ‘likes’ and more about ‘reach’. If you analyse ‘reach’ statistics you may see declining numbers because many of your followers aren’t getting your updates. The best way to get around this unfortunately means spending some money to boost posts. Facebook claims you will see more engagement, traffic and sales.

It might be a bit galling to have to spend on something that used to be free, but it does mean that you can target the people you want to reach, including age, gender and geographical location. In terms of marketing, it can be very effective. However, if you are limited with budget, then ask your fans to add your page to their ‘preferred’ list. Facebook will always put a friend’s content first, so the more you can get fans to share your posts the better. Saying this, don’t keep asking them to ‘like’ your posts, as Facebook frowns upon this. Remember that content is king – Facebook values and promotes good quality, original content so really make the effort to post interesting things.

Twitter Latest statistics show Twitter has 307 million users posting more than 500 million messages each day.4 With all those Tweets, it is likely that someone is either mentioning your company or starting a conversation that you would be keen to add to. I believe it is best to use Twitter as a customer service and business development channel. Look for messages from dissatisfied patients, and quickly turn them into happy interactions. It’s essential to reply quickly, and to be honest and upfront. The majority of people looking at your page will appreciate that and so will

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the disgruntled patient. Do everything you can to appease them but try not to get into an argument online. If the complainant is not happy with your response, then offer to speak to them offline on the phone or in person. At the same time, look for prospective patients – perhaps from unhappy patients of competitors.

Consider the competition It is likely that you and your competition are both targeting the same audience, so see what platforms they are using and how successful they are. Look to see what their content is like and what works – posts, videos or infographics? A word of caution though, always remember your own voice and stay true to your brand.

Consider the time commitment The keyword in social is ‘social’ which is probably the most understated and forgotten part of the equation. You should aim to use social media as a source of twoway communication with your audience, regardless of the platform. Interact with your audience on a regular basis through articles, videos, and other relevant posts and encourage them to ‘like’ and ‘share’ your content. Don’t feel pressured to be on every platform, start with one that connects you with your audience that you can regularly manage.

If you really feel that you can’t commit the time to social media, then you can opt to get professional help.

Keeping happy patients According to most marketing analysis, it costs between four and 10 times more to acquire a customer than to keep an existing one,5 so keep your existing patients through effective communication and engagement. A good social relationship with your patients should translate into a better perception and offline relationship with your brand. By building a bond, patients will be more likely to stick with you. People turn to social media for business engagement, so it is important your staff have the knowledge and authority to respond to patient questions and be ready to help customers in any channel they contact you through. By doing this you’ll be equipped to respond to your patient accurately and timely.

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Customer service and complaints Social media is an easy and very public way for customers to voice their grievances. If you don’t respond, it can hurt your reputation and patient relationship. Most people are reasonable enough to know that occasionally there will be negative feedback on social media, but audience are unforgiving if it is ignored. Deal with problems professionally and courteously as it shows you care, and minimises any damage to your brand.

Research and development Your customer base is highly engaged with what you do. Requesting customer feedback on social media and listening to it is vital.

This can also help expose any problems in products or service.

Measuring your progress Finally, track how your social media journey is going by studying your Google analytical reports, Twitter or Facebook analytics to give you an idea of which kinds of content and posts are working best. Make sure you are continuously aligning with your social media objectives. Reaching your goals can be challenging and sometimes overwhelming, but just remember that you have to start somewhere. If you commit to social media now, you’ll be surprised just how far you get in 12 months’ time, and hopefully you’ll have some fun along the way.

Mike Nolan has been involved in PR for more than a decade and is the founder and director of Nolan PR. Since he started his company in 2009 he has helped a broad range of clients, from many different industries, design and implement successful social media marketing campaigns. Nolan also has news editing and journalistic experience at a daily newspaper.

REFERENCES 1. We are Social, Digital, Social and Mobile in 2015, (2015) <http://wearesocial.sg/blog/2015/01/digital-socialmobile-2015/> 2. Statista, Number of active Facebook users worldwide as of 3rd quarter 2015 (in millions) <http://www.statista.com/ statistics/264810/number-of-monthly-active-facebook-usersworldwide/> 3. Beck, M, Facebook’s News Feed Algorithm: A Guide To Recent Changes (2015) <http://marketingland.com/21news-feed-updates-that-have-changed-how-pages-usefacebook-126066> 4. Statista, Number of monthly active Twitter users worldwide from 1st Quarter 2010 to 3rd Quarter 2015 (in millions) <http:// www.statista.com/statistics/282087/number-of-monthlyactive-twitter-users/> 5. Kingwill I, What is the cost of Customer Acquisition vs Customer Retention? (2015) <https://www.linkedin.com/ pulse/what-cost-customer-acquisition-vs-retention-iankingwill>

Business function Social media lives within the marketing department, however it can have a hand in almost every business function, from human resources to research and development:

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

CLINIC FOR SALE •

5 Surgery Medical Aesthetic Practice in affluent Dublin 2, City Centre.

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Situated in Dublin 2 off Merrion Square, Harley Street of Dublin in area of Ballsbridge (environs akin to Knightsbridge).

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EBITDA €125,000. Turnover €500,000 in Botox and Dermal Filler alone, private patient list. Huge opportunity for add on adjunct services. Current turnover solely on Botox & Filler. No skin care sold. Huge gap in Irish market for Weight Loss Clinics/Vitamin Infusion Clinics.

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Recent acquisition of adjoining building and 3 new surgeries, fully fitted out and can be used as minor ops, laser, aesthetician rooms and/or Dental surgeries/ Dermatology rooms or consulting rooms for surgical procedures.

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Huge potential to grow existing Medical Aesthetics practice alongside other services such as laser, surgical consults, dentistry and dermatology.

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Brand originally included Dentistry but was sold, now non-compete clause is finished, this practice is ripe for reintroduction of Dentistry, Dermatology and/or Plastic Surgery.

Huge Gap in market for Surgical procedures.

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Huge gap in Irish market for private Dermatology.

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Principal is dual qualified dentist and medical aesthetician, but her practice currently limited to Facial Aesthetics.

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3 additional associates performing Medical Aesthetics (2 doctors and 1 dentist performing Botox & Filler Tx).

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Private clinic - high end/high spend patients. No Nurse practitioners allowed inject in Ireland, no driving down of prices.

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Abundance of disposable income in Dublin - Average spend in excess €1,200 per patient per quarterly visit.

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In Dublin2/Dublin 4 area which is ABC1/ demographic equivalent Knightsbridge or Kings Road, Chelsea, London.

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Republic Of Ireland market same as London market 10 years ago, and is NOT supersaturated. No Nurse BTX injectors.

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Turnover generated on BTX and Dermal Filler only. Currently not even skin care sold. Huge potential for growth.

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Price point 3 areas of BTX €550/€700 and 2 Tubes of Juvéderm 4 = €850, 2 Tubes Juvéderm Smile = €700 due to lack of competition/monopoly of market. Filler always sold in dual boxes.

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Nurse Practitioners are NOT allowed administer BTX in Ireland. It is illegal for Nurse Practitioners, and it is also illegal for Nurse Prescribers to administer Botox in Republic of Ireland, hence no supersaturation of market. No driving down of prices with discounted Nurse led treatments.

Clinician (Doctor or Dentist) led market/ treatments ONLY. Only GMC & GDC registered clinicians can administer Botox in ROI.

For Sale

Enquiries should be directed in strictest confidence to premiummedicaldentalsale@gmail.com

Specialist insurance for cosmetic practitioners

Clinic Insurance for Medical Professionals Whether you run one cosmetic clinic or a chain of clinics, it is important to make sure you have adequate insurance in place should the unexpected happen.

We can provide tailor made insurance to protect your cosmetic clinic, drugs and equipment against loss or damage caused by insured events such as storm, flood, escape of water and theft.

Call free on 0800 63 43 881

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found 70% of callers will hang up within 60 seconds if faced with silence on hold,3 it spells danger for clinics if no consideration is given to what a customer hears when they ring the business. This is where on-hold marketing – a highly-targeted voice and music solution – comes in.

On-hold Marketing Sales and marketing director Mark Williamson discusses how businesses can turn telephone hold time into a golden business opportunity For medical aesthetics clinics, the telephone is often the first point of contact between the business and a potential customer. Whether the caller is ringing to book a laser hair removal appointment or to enquire about the price of a microdermabrasion facial, the phone is an important tool for communicating key messages and ultimately converting leads into sales. But what if the clinic provides a poor telephone experience?

When a potential patient picks up the phone to a clinic, their ears are their only tool for forming an initial judgement, so being faced with an unhelpful employee or being left on hold with only automated beeps could forge a lasting negative impression of the company. I work for PH Media Group, an audio branding specialist that recently conducted research of 1,000 British consumers. We discovered 73% of respondents wouldn’t do repeat business with an organisation if their first call wasn’t handled to expectations.1 This could mean a huge threat to profitability. For clinics, this could result in missing out on a potential inbound lead before the patient even steps through the door.

Training staff to provide a consistent, professional telephone service represents a good start in ensuring a high level of customer service. Providing such training ensures leads aren’t wiped out at the first hurdle, instead fostering a best-practice approach to enhance the caller experience and instil a good brand image in the caller’s memory. However, shaping employee

behaviour isn’t the only thing to consider when looking to improve the patient’s telephone experience.

Raising the customer engagement bar Hold time remains a source of irritation throughout the world. Sitting in an automated queue for hours on end isn’t a consumer’s idea of good customer service. However, for businesses, leaving a customer on hold is almost inevitable. While clinics will endeavour to answer every telephone query within a matter of seconds, unfortunately this isn’t always possible. Perhaps the caller needs to speak to the practitioner who specialises in botulinum toxin, but they’re with another patient, or maybe information on laser treatments is required but isn’t to hand. Regardless, it doesn’t have to be a negative experience. On the occasions when customers do need to be put on hold, it is essential to ensure the caller is engaged and entertained to prevent them from switching off and hanging up.

A study of 3,630 UK businesses by PH Media Group discovered that non-surgical cosmetic clinics put customers on hold for an average of 33.55 seconds per call before their query was answered.2 While this does not seem like a long time on paper, consider the typical television advert. Lasting around 30 seconds, the advertisement manages to convince – or not convince – the viewer of the value of the product within a short space of time. Similarly, imagine if the patient was left listening to repetitive beeps, poor music or even silence while on hold. Given that further research has

Defining your audio brand Rather than focusing on how your business looks, have you thought about how it sounds?

Most companies spend the majority of their marketing budget on visual branding, such as signage, websites and letterheads, without giving any thought as to what people hear when they come into contact with the business. On-hold marketing works by transforming the previously ‘dead air’ heard over the phone, offering an ideal chance for highly-targeted advertising conducted in a completely unobtrusive manner and speaking directly to an attentive audience.

The messages can be tailored specifically to reflect your existing brand values and help to create a more professional company image.

Using on-hold marketing There are a number of ways a medical aesthetic clinic can use on-hold marketing to benefit its business strategy. Considering clinics are putting customers on hold for more than 30 seconds per call,2 it serves as a golden opportunity to up-sell, cross-sell and communicate highly-relevant information to attentive customers. For example, a caller could ring the company to book in for a microdermabrasion facial, only to be made aware of the new advanced intense pulsed light system, which has recently been installed in the clinic. The listener could then enquire and book in for both treatments after being notified of the additional service through the audio messaging, leading to increased revenue for the business. Equally, the messages could advertise current price promotions for certain services. For instance, in summer, there could be a seasonal offer on for laser hair removal, or around Mother’s Day, there might be an offer on antiageing or skin rejuvenation treatments.

The messages, however, don’t just work to inform patients of the company’s services and products as they can also help to portray the clinic’s professionalism and improve brand image. By notifying callers of a practitioner’s qualifications or the accreditation of a certain medical device, it can help build patient trust and provide reassurance that they are in safe hands.

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Using the wrong voice and music can communicate the wrong brand image or values, influencing a customer’s thoughts and feelings and creating an unwanted lasting perception of your company in the caller’s mind

the customer so it is important to make it clear that callers can rely on the company with their new look, especially when it comes to non-surgical medical treatments.

Implementing tailored messages also helps to explain to callers why they should buy into the clinic’s ethos in a highly competitive and concentrated market. By introducing members of staff via the phone system and informing callers of their specialisms, it makes the business more approachable and the service more personal, giving patients another reason to trust your company over another.

Messages can also be used to tell callers of opening hours or even direct them to an online booking service, boosting traffic to the clinic’s website while also improving customer service by making their experience easier and more convenient. Audio can also be aligned with existing marketing strategies by encouraging callers to follow the business on social media channels. This gives another opportunity for the brand to connect with their customer at a different level, advertising new services and offering exclusive promotions to their followers.

As an example, a Cambridge beauty salon Stilo, which offers a range of beauty treatments and therapies, such as IPL, would hold a similar outcome to aesthetic clinics when it comes to on-hold marketing. At Stilo, on-hold marketing has led to a valuable increase in sales enquiries – both from new and existing customers. What’s more, they receive a consistently positive reaction from their clients, with callers commenting that they enjoy listening to the production while they wait on-hold. “Our on-hold marketing production gives us a creative point of

difference that really sets us apart from our competitors,” says Stilo owner, Laki Boulieris.

Difficulties with on-hold marketing When it comes to on-hold marketing, there are a few difficulties a business can encounter both before and after installing the solution. Firstly, it’s important to consider the company’s phone system before implementation. It is recommended that your appliances are checked prior to installation to ensure they are well suited to the system; an audio branding company should be able to help with this as a number of tests on the line and devices is required. There are also a number of variables to contemplate when choosing the voice and music for your business. Many companies believe that playing a generic, popular track or having an employee read a script as their on-hold recording is satisfactory, but that isn’t the case. Using the wrong voice and music can communicate the wrong brand image or values, influencing a customer’s thoughts and feelings and creating an unwanted lasting perception of your company in the caller’s mind. When choosing a voice for your business, the number of variables to consider may make it seem like a daunting task. Should the voice be old or young? Male or female? Is an accent required? Ultimately, it boils down to what perception each attribute communicates. Consider what your existing branding says about your company and work forward, rather than choosing a voice that doesn’t really match your organisation’s brand image.

The same goes for music. I believe that using a piece of commercial music in your on-hold messaging is another square peg, round hole

Aesthetics aestheticsjournal.com

scenario; taking a track and trying to make it fit a new purpose to convey a meaning it was never supposed to. The customer could also have attached feelings to existing song, which could be either positive or negative – it’s purely a lottery of their previous experience. If negative, this could have a detrimental effect and the caller could end up switching off and hanging up. Physical attributes, such as volume, tempo and pitch should all be take into consideration to create a new tune which comes without preconceptions and instead works from scratch to shape the company’s image in a positive manner.

By tailoring the messages to the customer base, it minimises the risk of a bad caller reaction while helping to improve engagement. In fact, 49% of consumers don’t feel as valued as a customer if they hear generic on-hold messages,4 meaning with bespoke voice and music messages, customer service levels are boosted.

However, it is important to keep the content fresh and up-to-date as sound can induce fatigue if not deployed correctly.

Audio messages can have a powerful effect on the subconscious and help to warm customers up to make a buying decision.

Nevertheless, if a customer hears the same messages every time they ring a clinic, they will reach a point where they simply switch off. By updating the content on a regular basis, it not only keeps customers in the loop with changes to the business and its services, but it also helps to hold the caller’s attention and ensure they won’t get bored.

A boost for the bottom line The implications for profitability are clear.

By transforming hold time into a key communication tool, medical aesthetic clinics can take action to reduce caller hang-ups, improve customer service and strengthen the marketing mix.

Mark Williamson is the sales and marketing director of audio branding consultancy, PH Media Group. With more than 12 years’ experience of working in the industry, Williamson manages the global brand strategy of the company and advises businesses on how best to implement onhold marketing and design an audio brand.

REFERENCES 1. TNS UK Business Onlinebus Survey (S6477 - 260121843), Call Handling Standards, September 2014, p11-13 2. PH Media Group, Call handling study among UK businesses, 2013 3. Assad A, The Importance of On-Hold Messages (Houston: Houston Chronicle) http://work.chron.com/importance-onholdmessages-4665.html

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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“That’s the beautiful thing about medicine, whatever you are interested in, there’s an area for you” Mr Adrian Richards shares his journey into plastic surgery and the ethos that has led to a successful career “When I left medical school aged 23, I wasn’t sure exactly what I wanted to do,” explains consultant plastic surgeon Mr Adrian Richards. Although Mr Richards was sure he would become a medic, after been brought up in a medical family, it took him a little longer to discover his niche. “I wasn’t really sure what type of surgeon I wanted to be until I saw a plastic surgery operation for the first time. It was the simplest operation, a skin graft, but as soon as I saw the surgeon do the procedure, I knew straight away that’s what I wanted to do. That’s the beautiful thing about medicine, whatever you are interested in, there’s an area for you.”

Mr Richards trained for 15 years in plastic surgery, which began at the Queen Victoria Hospital in East Grinstead, a specialist reconstructive surgery infirmary. He then went on to train in a number of plastic surgery units, including the Stoke Mandeville Hospital in Buckinghamshire and divisions in Oxford, London, the US and Australia. He finally became a consultant plastic surgeon at the age of 38, in 2002. After initially working three and a half days a week in the NHS and a day and a half privately, Mr Richards made the decision to focus purely on private work, and set-up his training programme Cosmetic Courses in 2002, followed by his practice Aurora Clinics in 2006; these are achievements he is particularly proud of. “Doctors are generally rubbish business people! A lot of my plastic surgeon friends have started hospitals and got involved in business ventures that they have come to regret. So I am really proud of not only having a good medical background but also creating a sustainable, growing, vibrant business that runs alongside our medical principles.”

But as well as being a good surgeon and a good businessperson, Mr Richards believes it’s important to be able to have good people skills. “If you’ve got good social abilities, like people and get along with people, then you are likely to be successful. What we really emphasis on our course is the importance of the ‘three As’: availability, affability and ability; the ability to work hard, to be able to get along with people and to be able to do the treatments well. Those are the really important things if you want to be successful.”

Mr Richards gets a lot of job satisfaction from his work, despite feeling that members of the public sometimes misunderstand the plastic surgery industry and assume it is purely about vanity. “The reality is that these patients are real people with real issues. You get these really young, fit and healthy people that have real physical issues that have a real impact on them, and, with a relatively simple procedure, you can correct that and let them get on with their normal life.”

For anyone looking to get into the aesthetics industry, Mr Richards advises, “It’s not for everybody. Some people may have slight issue with the fact you’re not treating ill people, you’re treating well people.

You are making a big difference to their life, but they’re not ill. So if you have an issue with that, this is probably not the right industry to get into,” adding, “But you are changing people’s lives.”

Mr Richards explains that he works by a humble ethos, and believes

a simple and honest formulae leads to success, “If you treat people well, make the whole experience positive, make sure the treatments are effective and do it in a nice environment, near where they live, at a reasonable price, you don’t need to do anything else.”

What treatment do you enjoy giving the most?

I’m mainly a breast surgeon and we have a new operation which I really enjoy doing. I have put two of my surgeon friends’ techniques together and created a new solution for people who have descended breasts, after having breast implants in for a long time. Technically it’s a very clever operation and it has been very successful.

What technological tool best compliments you as a practitioner?

It sounds a bit pedestrian but I’ve started using a ‘funnel’ to put breast implants in. Normally, when you put the implants in they touch the skin, but now there is this ‘funnel’ we use, which is lubricated and ensures the implants don’t touch the skin. This means a smaller scar, no bacterial contamination, and it is much better for the patient.

Do you have an industry pet hate?

There are people in the industry who over-hype things and make claims that are untrue that easily mislead people. It’s usually when there is a new trend or craze, but people need to wait until they know the facts and not make decisions based on these claims.

Looking back, is there anything you would have done differently?

I’ve probably been too trusting of some people. As a very busy plastic surgeon, I tended to trust people, and perhaps some of them I shouldn’t have done. The thing I perhaps regret is not getting trusted business advice sooner.

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

If you’re in the aesthetics industry, you need somebody who can give you simple advice and for me, that’s my dad. Years ago I was working in a hospital and had a very small slot to operate, between 7pm and 9pm, and the plastic surgeon before me would often overrun. So I said to my dad, ‘I’m trying to build-up a practice but I’ve only got this small window in which to work.’

And he said, ‘Well, is there anywhere else you can operate?’ It was so simple, yet I hadn’t really thought about it. I ended up going elsewhere and it became really successful.

Mr Adrian Richards will present on surgical vs. non-surgical options for face and breast treatments at the Aesthetics Conference and Exhibition 2016 as well as chairing the Breast session on the Conference agenda.

Visit www.aestheticsconference.com/programme to find out more.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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The Last Word Sharon Bennett argues the dangers of at-home injectable treatment parties and why practitioners need to be aware of the risks Tupperware, Avon, Ann Summers – home parties are common across the globe and millions of people enjoy the comfort of socialising, sampling and shopping in a relaxed home-setting.

Nowadays, however, you don’t have to look very far to find a socalled ‘Botox party’. These events appear to be a growing trend; a trend that has many medical aesthetic practitioners furrowing their own brows with worry. Many critics are stressing that those offering these ‘parties’ are walking a fine line of medical ethics. I don’t believe any other landmark drug has had such a high public profile as botulinum toxin, and its 20-year journey has taken it from the ophthalmic clinic to the X Factor stage.

Naturally, there are many ‘for’ and ‘against’ arguments, however I think it is imperative that we, as medical professionals, make a concerted effort to bring an end to this growing concern.

Bad practice If you surf the internet for ‘Botox parties’, you will find pages of articles, links and advertisements on the subject. Even though the common theme of the search appears to be that of a negative view of ‘at-home’ parties, there does appear to be marginally fewer objections to parties of patients being treated in a medical environment, such as a clinic. Group treatments held in medical

Group treatments held in medical clinics might seem a more appropriate setting, but patients should be consulted and consented individually, something that doesn’t appear to happen at these parties

clinics might seem a more appropriate setting, but patients should be consulted and consented individually, something that doesn’t appear to happen at these parties. The British Association of Cosmetic Nurses (BACN) does not support their members in this area of practice. As all healthcare professionals should know, botulinum toxin is a prescription medication and it is prohibited to advertise it in the UK. The Medicines and Healthcare Regulatory Agency (MHRA) guidelines specifically state, “Advertising materials such as magazine advertisements and flyers distributed to the public, must not mention product names such as ‘Botox’ or ‘botulinum toxin’.”1 The Committee of Advertising Practice (CAP) also echoes this guideline.2 If those offering this service are breaking these rules, then it makes me wonder if other rules are being broken behind closed suburban doors. The concept of ‘Botox parties’ or ‘filler parties’ is wholly incompatible with the Royal College of Surgeons (RCS) Professional Standards for Cosmetic Practice.3 The college rightly, in my opinion, argues that treatments should be carried out in licensed premises where practitioners have access to professional equipment for use in the event of an emergency.

However, licensing of medical premises in this country is the remit of the Care Quality Commission (CQC), which does not cater for cosmetic treatments such as dermal fillers and botulinum toxin.

I recall some years ago a TV programme in which actress Leslie Ash, following her own sub-standard treatment experience, arranged a Botox party with a phony doctor pretending to be a cosmetic practitioner.4 She wanted to see how much information the women sought out, and whether they would opt to go ahead with treatment. Ash was shocked by their lack of knowledge and interest in who was carrying out the treatment. The women, without question, assumed they were in the hands of an expert and, therefore, seemed quite prepared to go ahead with the treatment.

In a group setting, with peer pressure, it appears to be easy to get carried away in the moment.

I’m sure you will agree that these women should have asked for and seen evidence of the practitioner’s qualifications. They should have been examined and consulted alone, without distraction or coercion from other members of the party, and asked to provide a complete medical history. They should have been advised on alternative treatments and discussed the risks and potential complications; thereby allowing them to make an informed decision and give consent to treatment.

Reproduced from Aesthetics | Volume 3/Issue 3 - February 2016

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Conflict of interests Some may say that it is less intimidating and more comfortable to be with a group of friends for a treatment, as well as more convenient.

Of course, there is also the unspoken fact that the hostess is likely to receive treatment at a reduced price or even free-of-charge. In addition, reduced overheads may allow favourable prices to be offered to the host’s guests.

Medical ethics and consumer desires can conflict frequently in the cosmetic and aesthetic industry. We are a consumer-driven specialty, working in the private sector and offering a service to the fee-paying public. It is enticing for some practitioners to ‘follow the buck’, but perhaps they do not see the bigger picture of the risks with doing so. Downgrading the procedure from a professional medical environment to a more social party setting moves it seamlessly into the beauty therapy treatment arena, and almost on par with a facial to many patients. Although botulinum toxin has less potential serious complications than dermal fillers, it may also set a precedent to introduce other non-surgical treatments into a party/group domestic setting, giving even more fuel to my argument.

Safety first Cosmetic injectable parties may also affect any medical indemnity policies. Two of the leading insurance providers have told me that they would not wish to cover a practitioner who practices in this way.

Claims arising from a ‘Botox party’ are not specifically excluded from an insurance policy, but they say it is highly unlikely they would pay a claim, as they would have breached their terms with their governing body. And going forward, it is unlikely they would obtain cover with a reputable insurer following a claim of this nature.

Keeping botulinum toxin in a clinical environment ensures the procedure remains firmly in the medical domain, where the practitioner will have all the necessary equipment and personnel to hand, and the patient will be afforded a safety net and a point of reference to return.

If, as some patients may argue, they really do feel intimidated by entering a clinic, perhaps it is more a failing on the part of the medical professional and their staff. It is our duty as medical professionals to ensure patients feel safe, comfortable and cared for when considering an aesthetic treatment.

Most of us lead busy lives and convenience is always attractive, be it supermarket home delivery, mobile hairdressers or beauticians.

Nevertheless, we don’t have dental procedures carried out at home, so why should we have aesthetic ones?

Aesthetics

I hope that 2016 will put the spotlight on the new overseeing body for non-surgical practice – the Joint Council for Cosmetic Practitioners (JCCP) I hope that 2016 will put the spotlight on the new overseeing body for non-surgical cosmetic practice – the Joint Council for Cosmetic Practitioners (JCCP). The BACN and British College of Aesthetic Medicine (BCAM) have worked at the request of Health Education England, and with approval from the Department of Health (DoH), on the establishment of the JCCP. With support from the DoH, MHRA, the regulatory medical bodies, colleges and other stakeholders, our commitment to ensuring patient safety could be realised.

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standards.

Bennett has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).

REFERENCES 1. MHRA, (2012) The Blue Guide, Advertising and Promotion of Medicines in the UK, 7.3, <https://www. gov.uk/government/uploads/system/uploads/attachment_data/file/376398/Blue_Guide.pdf> 2. CAP, (2014) Rule 12, Medicines, Medical Devices, Health-Related Products and Beauty Products, <www.cap.org.uk/News-reports/Media-Centre/2014/~/media/Files/CAP/Codes%20CAP%20 pdf/12%20-%20Medicine%202014-09-04%20CAP.ashx> 3. RCS, (2013) Professional Standards for Cosmetic Practice, 5.1 <www.rcseng.ac.uk/publications/docs/ professional-standards-for-cosmetic-practice> 4. The Sun, TV Leslie is sharp at botox, (2015) <http://www.thesun.co.uk/sol/homepage/showbiz/ tv/1686980/TV-Leslie-Ash-learns-how-to-inject-botox.html>

Sharon Bennett will present on treatments for the lips and perioral area at the Aesthetics Conference and ExhibitIon 2016.

Visit www.aestheticsconference.com/programme to find out more.

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Merz Aesthetics +44 0333 200 4140 info@merzaesthetics.co.uk

HA-Derma IBSA Italia’s aesthetic portfolio UK Contact: Iveta Vinklerova 0208 455 48 96 info@ha-derma.co.uk www.ha-derma.co.uk Services: Distributor of IBSA’s Aliaxin, Viscoderm, Skinko Hamilton Fraser Contact: Stephen Law 0800 63 43 881 info@cosmetic-insurance.com www.cosmetic-insurance.com

MACOM Contact: James Haldane +44 02073510488 james@macom-medical.com www.macom-medical.com

Pure Swiss Aesthetics Contact: Sarah-Jayne Tipper info@pureswissaesthetics.co.uk 0203 6912375 www.pureswissaesthetics.co.uk

Med-fx Contact: Dyan Williams +44 01376 532800 sales@medfx.co.uk www.medfx.co.uk

Harley Academy 0203 129 5756 www.harleyacademy.com enquiries@harleyacademy.com

Medical Aesthetic Group Contact: David Gower +44 02380 676733 info@magroup.co.uk www.magroup.co.uk

Healthxchange Pharmacy Contact: Steve Joyce +44 01481 736837 / 01481 736677 SJ@healthxchange.com www.healthxchange.com www.obagi.uk.com

Medico Beauty Contact Name: Andy Millward +44 (0) 844 855 2499 training@medicobeauty.com www.medicobeauty.com & www.medicobeautyblog.com

Syneron Candela UK Contact: Head Office 0845 5210698 info@syneron-candela.co.uk www.syneron-candela.co.uk Services: Syneron Candela are Global brand leaders in the development of innovative devices, used by medical and aesthetic professionals.

t TEOXANE UK 01793 784459 info@teoxane.co.uk www.teoxane.co.uk

Thermavien Contact: Isobelle Panton isobelle@thermavein.com 07879 262622 www.thermavein.com

z Hyalual UK 1 Harley Street Tel. 02036511227 e-mail : info@hyalual.com web: www.hyalual.co.uk

MedivaPharma 01908 617328 info@medivapharma.co.uk www.medivapharma.co.uk Service: Facial Aesthetic Supplies

Aesthetics | February 2016

Zanco Models Contact: Ricky Zanco +44 08453076191 info@zancomodels.co.uk www.zancomodels.co.uk

EMERVEL – MORE CHOICE AND CONFIDENCE IN MID-FACE FILLER SOLUTIONS Volume is key to maintain facial balance and structure. Emervel gel textures are specifically designed to lift and restore volume in the mid-face regions.

EMERVEL DEEP FOR SHAPE REDEFINITION

EMERVEL VOLUME FOR VOLUME RESTORATION

Emervel Deep for patients who require mid-face shape redefinition due to flat zygomatic bones or mild-to-moderate facial asymmetry.

Emervel Volume for patients who require midface volume restoration due to volume loss caused by ageing.

INTRODUCING EMERVEL VOLUME 1ML SMOOTHER FLOW • Optimized gel texture: Homogenous gel particle calibration enables smooth and regular extrusion • 27 G Ultra-thin-wall needles improve flow rate and reduce extrusion force

GREATER WORKING COMFORT • Lightweight, ergonomic syringe for more comfortable handling • Lower extrusion force for reduced fatigue

OPTIMISED CHOICE • Emervel Volume available in 1ml or 2ml - Your choice of comfort and flexibility depending on your patients’ needs.

Galderma (UK) Ltd Meridien House, 69-71 Clarendon Road, Watford, Hertfordshire WD17 1DS Tel: 01923 208950 Email: info.uk@galderma.com For more information visit www.galderma-alliance.co.uk EME/030/0714 Date of prep: July 2014

You can sign up to receive email & text message alerts through Galderma (UK) Ltd’s A&C subscription service for Healthcare Professionals and Non-Medical Aesthetic Clinic Staff. Scan here, or visit www.galderma-mail.co.uk

The VYCROSS™ Collection is the latest generation of CE-marked Juvéderm ® HA dermal fillers, building on the strong heritage and benefits of the Juvéderm ® Ultra range, helping to create natural-looking results and high patient satisfaction.1-5

The VYCROSS™ Collection includes:

JUVÉDERM® VOLBELLA® with Lidocaine

JUVÉDERM® VOLUMA® with Lidocaine

JUVÉDERM® VOLIFT® with Lidocaine

JUVÉDERM® VOLIFT® Retouch® with Lidocaine

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

UK/0721/2015

Date of Preparation: October 2015