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w ! om no 18 e.c er 0 c st 2 ren gi CE fe Re A on r fo icsc t he st ae

VOLUME 5/ISSUE 3 - FEBRUARY 2018

HAS SHE GOT

A SECRET?

r e h d Rea lips

SEE

US

AT

FRI 27 & 28 APR 2018 / LONDON

RES18-01-0025a Date of Preparation January 2018

Restylane, the secret to soft beautiful lips

Tattoo Removal CPD Dr Zohaib Ullah assesses the challenges of treating tattoos with laser

Special Feature: Recognising Skin Conditions

Practitioners explain common skin conditions and treatment options

Pigmentation and Pregnancy

Dr Yusra Al-Mukhtar discusses considerations for hyperpigmentation and pregnancy

The Role of a KOL

Dr Martyn King and nurse prescriber Sharon King detail the role of a key opinion leader


SE E

US

AT

FRI 27 & 28 APR 2018 / LONDON

THE SECRET TO SOFT, NATURALLOOKING LIPS IS OUT...

Read her lips

restylane.co.u

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90% of patients thought the results with Restylane Kysse looked natural 24 weeks after treatment.1 Date of preparation: November 2017 RES17-11-0695f

Reference: 1.Data on file. AMWC Monaco Poster, 2015


Contents • February 2018 06 News

The latest product and industry news

16 News Special: Treating Skin of Colour

Aesthetics investigates the need for a resource for patients with skin of colour

18 ACE Preview: Masterclasses

Discover how to make the most of the free Masterclasses at ACE 2018

20 Advertorial: Meet the Trainer with Rachel Goddard

Learn about Totally Aesthetics training from aesthetic nurse prescriber Rachel Goddard

Special Feature Dermatologic Conditions Page 23

CLINICAL PRACTICE 23 Special Feature: Recognising Common Skin Conditions

Practitioners discuss a range of common dermatological conditions relevant to aesthetics

29 CPD: Effective Tattoo Removal

Dr Zohaib Ullah highlights considerations for removing tattoos with lasers

35 Case Study: Male Facial Rejuvenation

Mr Roger Amar details his technique for treating a male patient using his fat transfer/stem cell procedure

40 Preparing the Skin for Aesthetic Procedures

Dr Rekha Tailor explains how to effectively prepare the skin for facial aesthetic treatments

46 Case Study: Treating Ageing Lips

Aesthetic nurse prescriber Sarah Holness discusses the lip augmentation of a mature patient

49 Acne Management in Patients of Colour

Dr Loredana Nigro considers treatments for acne in darker skin

53 Hyperpigmentation and Pregnancy

Dr Yusra Al-Mukhtar highlights which procedures are safe to use for hyperpigmentation during pregnancy

56 Treating Psoriasis: Part 2

In the second of a two-part article, Dr Priya Patel reviews systemic treatment options for psoriasis

61 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 62 The Role of a KOL

Dr Martyn King and nurse prescriber Sharon King discuss the role of a key opinion leader

64 Using Paperless Medical Records

Dr Brian Franks explains how to transition from paper medical records to digital

67 Selling Skincare Online

Marketing consultant Adam Hampson details how e-commerce can boost profits in aesthetic clinics

In Practice Going Paperless Page 64

Clinical Contributors Dr Zohaib Ullah is the clinical director at My Skin Clinic and a trainer at My Skin Clinic Training Academy. He specialises in non-surgical facial aesthetics, skin rejuvenation and antiageing treatments. He is a member of BCAM and is procuring his Master’s degree in aesthetics. Mr Roger Amar is a plastic surgeon and an assistant professor in anatomy and reconstructive surgery at Marseille University. He is also an active member of the French Society of Plastic and Reconstructive Surgery and the American Society for Aesthetic Plastic Surgery. Dr Rekha Tailor is the founder and medical director of health + aesthetics. She has been a qualified medical practitioner for more than 26 years and an aesthetic practitioner for more than 10. Previous to this she was a fully accredited GP. Sarah Holness is an independent nurse prescriber and has built her own aesthetic business in both injectables and capital equipment. She is the owner and director of the Nightingale Clinic, and Sarah Holness Aesthetics. Dr Loredana Nigro graduated from WITS Medical School in Johannesburg in 2003. She moved into private aesthetic and antiageing medicine in 2010 and is currently a senior aesthetic clinician at Riverbanks Clinic in Harpenden, UK. Dr Yusra Al-Mukhtar is a dental surgeon with experience in head and neck surgery and facial aesthetics. Dr Al-Mukhtar has worked as an advanced injector for Destination Skin and works in private clinics in London and Liverpool. Dr Priya Patel is a core medical trainee at East Surrey Hospital. She is an aspiring dermatologist, and takes an active interest in topics involving allergy and immunology.

70 In Profile: The Mayous

Mr Bryan Mayou and Dr Susan Mayou reflect on their achievements in medical aesthetics

73 The Last Word

Medical director Lesley Spencer debates the use of gift vouchers in aesthetic clinics

NEXT MONTH • IN FOCUS: Patient Experience • Medium and Deep Peels • Reporting Patient Satisfaction

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SEE

US

AT

FRI 27 & 28 APR 2018 / LONDON

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Editor’s letter What do you have in your diary for spring this year? If you haven’t got it in there already, then make sure you add ACE 2018! Taking place on April 27 and 28, this year we wanted to do something very different and Amanda Cameron are excited to be hosting four of the UK’s Editor leading training providers in the Elite Training Experience with Dalvi Humzah Aesthetic Training, Academy 102, Medics Direct Training and the RA Academy. This promises to be an exciting approach to learning with much interaction, so be prepared to come with your ideas and questions for the experts. Each training session is three hours long (worth three CPD points), costs a fraction of the usual price at just £195 +VAT per session, and attendees can benefit from a 10% discount on future courses booked with their chosen trainer. To find out more and to book visit: www. aestheticsconference.com/programme.

So, this month in the journal we focus on dermatology. We speak to four practitioners about skin diagnosis and treatments in our Special Feature on p.23 and we also have an article on skin preparation by Dr Rekha Tailor on p.40. On p.53 Dr Yusra Al-Mukhtar discusses pigmentation management in pregnancy, while on p.56 Dr Priya Patel presents her second article on psoriasis. On p.49, Dr Lori Nigro provides an overview of acne management for patients with skin of colour. Treating skin of colour can be daunting to some practitioners, meaning many patients don’t know who to approach for treatment. This is something the newly-launched Black Skin Directory aims to address, which we explore in more detail on p.16. Don’t forget to check out the array of business topics we cover this month. Learn about the role of a KOL on p.62, how to go paperless on p.64 and utilising e-commerce on p.67. Tell us what you learnt from this issue by tweeting @aestheticsgroup or emailing editorial@aestheticsjournal.com – we look forward to hearing from you!

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the 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 aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 years' experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers.

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions. Bennett has been developing her practice in aesthetics for 25 years.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

Mr Adrian Richards is a plastic and cosmetic surgeon with 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 Maria Gonzalez has worked in the field of dermatology 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.

Dr Sarah Tonks is a cosmetic doctor, holding dual 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.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.

Dr Christopher Rowland Payne is a consultant 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.

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.

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Microbeads

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Annoucement DHAesthetic Training @mdhtraining A warm welcome to leading oculoplastic surgeon & aesthetic doctor @DrMaryamZamani to @mdhtraining, who will bring exceptional expertise to our #multiawardwinningfaculty #Hair Greg Williams @Drgregwilliams Great interview @BessamFarjo @bbc5live – fascinating discussion with other experts about hair loss, hair art, hair 3D printing and future uses for hair! #Presentation Sabrina Shah-Desai @perfecteyesltd Looking forward to presenting alongside Philippe Kestemont #anatomy #periorbital #Restylane #Galderma #WorldTour Dr Daniel Sister @DrDanielSister In Georgia today – lecturing, teaching, training #DraculaPRPTherapy #prp #worldtour2018 #Menopause River Aesthetics @riveraesthetics Great evening supporting @MegMathews with her soft launch #megsmenopause

#Training Innovation Group @InnovationSIG Thanks to all @BAPRASvoice @InnovationSIG team members who delivered a fantastic course on how to #Innovate within your part of #PlasticSurgery #Manchester #NHS #MedTech

UK microbead ban comes into force The first phase of the UK ban on plastic microbeads has been implemented as the government hopes to crack down on marine plastic pollution. The ban states that plastic microbeads can no longer be used in cosmetic and personal care products in the UK, initially barring the manufacturing of such products, with a ban on sales being implemented in July. Environment Minister, Therese Coffey, heralded the ban as a ‘world-leading’ move and an ‘important milestone’ to reduce the amount of plastic entering the world’s oceans. Coffey said, “The world’s oceans are some of our most valuable natural assets and I am determined we act now to tackle the plastic that devastates our precious marine life.” She added, “Now we have reached this important milestone, we will explore how we can build on our world-leading ban and tackle other forms of plastic waste.” Director of medical aesthetics distributor AestheticSource, Lorna Bowes, said, “The ban is official and, as someone who is environmentally conscious, I am pleased that something is being done.” She continued, “Physical exfoliators in our company’s skincare brands are made from professional grade microdermabrasion crystals, so luckily, we don’t have to call any products back or make any changes to existing products. Our customers can feel confident that our products are safe to use.”  Breast implants 

Study suggests breast implant and cancer link A new study published in JAMA Oncology suggests breast implants are associated with an increased risk of a rare form of cancer. According to the authors, the number of women with breast implants diagnosed with anaplastic large-cell lymphoma in the breast (breastALCL) has increased since 2008, and several reports have suggested a link between breast implants and risk of breast-ALCL. The new study claims to be the largest to investigate the link between breast implants and large-cell lymphoma to date. Through a population-based nationwide Dutch pathology registry, investigators identified all patients diagnosed with primary breast-ALCL between 1990 and 2016. From retrieved clinical data, they estimated the odds ratio of ALCL associated with breast implants in a case-control design, comparing implant prevalence between women with breast-ALCL and women with other types of breast lymphoma. Among 43 patients with breast-ALCL (median age, 59 years), 32 had ipsilateral breast implants, compared with one among 146 women with other primary breast lymphomas. The researchers estimated that, for women who get breast implants, the risk of developing ALCL in the breast is one in 35,000 at age 50, one in 12,000 at age 70, and one in 7,000 at age 75. The paper describes that ALCL may be caused by the implant triggering an inflammatory response, or, alternatively, a bacterial species could be carried on the implant’s surface. It is also stated that some women may be genetically predisposed to developing this kind of cancer after breast implantation. Although the absolute risk remains small; the researchers state the results suggest a need for increased clinical awareness, comprehensive registration of implants and complications, and stimulation of alternative cosmetic/reconstructive procedures.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Regulation

JCCP register to open in March 2018 The Joint Council for Cosmetic Practitioners (JCCP) will open its Practitioner Register and Register of Approved Training Providers on March 1. The entry requirements and processes for seeking approval for entry to the register are currently being ‘tested’ with a selected range of education/training organisations.  According to the JCCP, under the leadership of Professor David Sines, it has spent the last two years working with multiple stakeholders to deliver a new voluntary regulatory body, to oversee both patient safety and public protection in the cosmetic sector. In collaboration with the Cosmetic Practice Standards Authority (CPSA), the organisation aims to ensure that a new and comprehensive evidence-based set of practice and education standards is delivered across the sector in England.   The JCCP has now implemented its full governance structure, including the chair of the Board of Trustees, Professor David Sines, and chairs of the Committees for the ‘Practitioner Register’, Professor Mary Lovegrove OBE and Professor Anne McNall.   Professor Sines said, “It is an incredible honour to be able to launch the JCCP after, what is in effect four years of consistent and consolidated work, undertaken by multiple stakeholders, who together have worked tirelessly to co-design the Council’s governance and operating systems. This has only been made possible by the immense range of support provided on a voluntary basis by so many representatives from across the sector.” In addition, new CPSA practice standards for the non-surgical cosmetic and hair restoration surgery sector will be published and endorsed by the JCCP this month. The JCCP and CPSA official launch will take place on February 22. Counterfeit

Galderma safeguards Restylane originality International pharmaceutical company Galderma has launched a new hologram on all packaging across the entire Restylane portfolio to provide further assurance that the products are original. The portfolio consists of NASHA (non-animal stabilised hyaluronic acid) and OBT (optimal balance technology) products, as well as the Skinboosters range. The original hologram sticker is on all boxes and it is hoped by the company that this will work to safeguard all of its fillers’ originality. “At Galderma, we are committed to providing quality products with proven safety and efficacy,” said Toby Cooper, business unit head, aesthetic and corrective sales and marketing at Galderma. “Counterfeit products can put patients at significant risk and, to help combat this issue, we have created an original hologram sticker for all packaging across our entire Restylane portfolio. We are confident the new hologram sticker will help provide additional reassurance to our customers that the Restylane products being distributed in the UK are original.” The new hologram sticker is applied at the Galderma warehouse in the UK.

Aesthetics

Vital Statistics The most common surgical procedure in the US for under 18s in 2016 was ear surgery, whereas eyelid surgery was the most popular for over 65s (The American Society for Aesthetic Plastic Surgery, 2016)

A study by Groupon revealed that British women spend an average of £70,294 on their appearance in their lifetime (Groupon, 2017)

According to the BFA, the UK franchise market for all sectors turns over £15.1 billion annually, with 97% of them being profitable (British Franchise Association, 2016)

Chemical peel treatments are expected to grow by 11.2% globally between 2017-2023 (Market Research Future, 2017)

According to Insulite Health PCOS, hirsutism affects at least 5-10% of women in the US and for women with polycystic ovarian syndrome, incidences are much higher (Insulite Health PCOS, 2017)

As of January 1 this year, there are 330 million active monthly Twitter users (Twitter, 2018)

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Events diary 1 – 5 March 2018 st

th

American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

4th – 7th April 2018 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2018.org

27th – 28th April 2018 The Aesthetics Conference and Exhibition 2018, London www.aestheticsconference.com

15th May 2018 British Association of Sclerotherapists 2018 Conference, Dorney www.bassclerotherapy.com

14th – 16th June 2018 BMLA Laser Skin & Body Conference 2018, Rotterdam www.lasereurope2018.com

1st December 2018 The Aesthetics Awards 2018, London www.aestheticsawards.com

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Conference

New exclusive discount from DHAT Elite Training Experience Dalvi Humzah Aesthetic Training (DHAT) is now offering delegates who attend its session at the Elite Training Experience a 10% discount voucher for TSK Laboratory, and Cosmetic Digital. The TSK voucher, is to be redeemed at the Aesthetics Conference and Exhibition (ACE) 2018 – where the Elite Training Experience will take place – and can be used on all TSK products. The Cosmetic Digital voucher can be used against its Digital Marketing course. TSK is best known for its array of needle products, including the The INViSIBLE NEEDLE, which is said by TSK to be the thinnest needle available to date. A new sponsors has also been announced for ACE 2018. Schuco International will hold a one hour Masterclass on the Princess dermal filler range. The session will feature a panel of leading UK experts, who will be exclusively unveiling and demonstrating latest innovations within the range. The Masterclass promises to have an engaging and interactive format with a mixture of informative presentations, expert panel Q&As and a live injection demonstration. ACE 2018 will take place at the Business Design Centre on April 27 and 28. To register for FREE, and to book an exclusive Elite Training Experience, visit www.aestheticsconference.com/register.

Skincare

Training

Dr Levy introduces new antiageing mask Cosmeceutical brand Dr Levy Switzerland has added the R3 Cell Matrix Mask (Restore, Replenish, Restructure) to its Intense Stem Cell line. The formula is a multi-vitamin A+C+E+B3, retinol, antioxidant and concentrated hyaluronic acid complex, which aims to help the skin to reinforce its natural protective and nutritive eco-system, helping its mother cells fully unleash their rejuvenating collagen-producing powers.  The company claims the product will produce more radiant, silky soft and visibly restored skin that feels firmer and appears more unified.   “The R3 Cell Matrix Mask is the latest product in our series and was invented to be used alongside the other products within the line,” said its creator, dermatologist Dr Phillip Levy. He added, “Our ingredients activate the sirtuin protein family, so you get a very deep epigenetic effect on antiageing in addition to the hydration, glow and antioxidants. Our three aims are to restore, replenish and restructure so that we can basically ‘rescue’ skin.”

AlumierMD launches training academy Skincare developer AlumierMD will provide product education at a new, permanent training facility in Bolton. At the new facility, AlumierMD will hold a two-day professional training course, which comprises theory on homecare products on day one, and chemical peel training on day two; in March this will be extended to three days. Delegates will learn detailed information about the AlumierMD product range, including theory on the homecare and professional products, and will receive chemical peel training and knowledge. The company will also hold a one-day advanced chemical peel training course at the facility. AlumierMD states that this course will explore the art of modern day peeling and will provide detailed chemical knowledge and correct protocols. Product and education specialist Gillian Rafferty will be the permanent trainer at the Bolton venue, and the company says that each course will be CPD verified and have up to 15 delegates. “We opened a permanent training academy to hold our professional and advanced training, which we can invite different clinics throughout the year to, to ensure they have the best knowledge and understanding of our brand,” said Samantha Summerfield, marketing and events manager at AlumierMD. She added, “We are excited to launch this to our clients as we feel that education is key. The Bolton venue will allow us to conduct training all year round.” Training dates have been confirmed until November this year, and can be viewed on the AlumierMD website.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Training

HA-Derma releases 2018 Profhilo course dates Aesthetic UK distributor HA-Derma has released its 2018 training dates for Profhilo. The product, which is a stabilised hyaluronic acid (HA) injectable without any chemical cross-linking agents, aims to improve skin texture, create better skin tone, treat skin laxity and reduce fine lines and wrinkles.  According to the company, there has been a huge demand for training which has led to the decision to branch out from London. Regional centres are now located in Essex, Barnsley, Maghull, Bristol, Leeds, Solihull and Glasgow. The next location to be announced will be in Northern Ireland, with training also planned for Dublin.  Iveta Vinklerova, sales and marketing manager at HADerma, said, “We are delighted to release 2018 dates. We would recommend delegates to contact as early as possible because dates in February are already fully booked for London and Solihull.” She added, “This has confirmed Profhilo’s position, amongst the dermal fillers and toxins, as a third staple injectable treatment. It is becoming a must-have treatment on offer in every clinic in the UK and Ireland.”  Certificates and CPD points will be awarded once training has been completed and practitioners interested in attending the courses are asked to contact HA-Derma directly.  Insurance

Hamilton Fraser makes clear its position on insuring non-medics Cosmetic insurance provider Hamilton Fraser has released a statement regarding its position on insuring non-medics for injectable treatments. The statement, which came in response to ‘a number of incorrect rumours and facts’ regarding who Hamilton Fraser supply insurance to, explains that they do not provide indemnity insurance products to beauty therapists delivering dermal filler or botulinum toxin treatments to the public. Signed by CEO Eddie Hooker and aesthetic insurance and claims manager Naomi Di-Scala, the statement read, “Whilst it remains legal for non-medical practitioners to perform dermal filler injections in the UK, based on the current evidence of skillset and training for beauty therapists, we continue to take the position that they should not be undertaking these procedures – whether previously insured elsewhere or not. With the aesthetic industry now starting to take a much closer look at standards and qualifications (via bodies such as the Joint Council of Cosmetic Practitioners and other registers) there is now an opportunity to improve patient safety for the better and Hamilton Fraser Cosmetic Insurance remains at the forefront of championing suitably qualified and competent practitioners.” The statement also made clear that the company does provide insurance cover for beauty therapists – subject to a minimum qualification of NVQ Level 3 in general beauty or equivalent – for the provision of treatments such as laser hair removal, general beauty treatments as well as public liability and salon insurance for the whole industry.

27 & 28 APR 2018 / LONDON

COUNTDOWN TO ACE 2018 EXPERT CLINIC 17 Expert Clinic sessions will take place at ACE 2018. Held on the 2,500m2 Exhibition Floor, delegates will have the opportunity to gain invaluable skills in all aspects of aesthetics including in-depth analysis, live demonstrations and practical advice on areas including injectables and skin peels. At the Expert Clinic, attendees will learn about the newest treatments from leading industry professionals. Confirmed session sponsors include; Teoxane UK, Thermavein, Needle Concept, Church Pharmacy, AestheticSource, Naturastudios, Cutera Medical, Cynosure UK, HA-Derma, Rosmetics and Unique Skin, with more to be announced soon. SPEAKER INSIGHT AestheticSource will be sponsoring a session on Creating ‘The Slim Face’ with RRS Injectable Biorevitalisation. Director of AestheticSource and aesthetic nurse prescriber, Lorna Bowes, says, “ACE is a must-attend for delegates of all experience levels. It provides the perfect opportunity for aesthetic professionals to keep up-to-date with the latest innovations, treatments and techniques to help benefit their practice. AestheticSource’s sessions will include lectures by international speakers including Dr Philippe Deprez and Dr Evgeniya Ranneva on skin and body rejuvenation.” WHAT DELEGATES SAY “ACE is always well structured and it’s good to find out about some new products. An absolutely amazing conference on both days.” AESTHETIC NURSE, ESSEX “ACE is so good for networking and to share experience with other peers. It’s also great to see the latest treatments and technologies.” AESTHETIC NURSE PRESCRIBER, LONDON ACE HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Skincare

Exuviance releases Detox Mud Treatment Aesthetic distributor AestheticSource has added the new Exuviance Detox Mud Treatment to its portfolio. According to the company, the treatment is a deeply purifying mask that aims to decongest the pores and detoxify the skin to produce a refined, smooth complexion. The formula combines Japanese activated Binchotan charcoal, French clay, and patented non-acid NeoGlucosamine – an exfoliator that aims to help build hyaluronic acid and activate enzymes. Exuviance states that Japanese activated Binchotan charcoal has strong absorptive properties that act like a magnet, which aims to draw out impurities and toxins within the skin that can be caused by environmental factors. Patients are instructed to apply twice-weekly to a cleansed face and décolletage and leave on for 15 minutes, before rinsing off with warm water. Industry 

Colgate announces acquisition of PCA Skin and EltaMD Global consumer product organisation Colgate-Palmolive Company has announced the acquisition of PCA Skin and EltaMD skincare brands.  According to the company, these acquisitions, which will be in two separate transactions, will enable Colgate to enter the professional skincare category while complementing its existing global personal care businesses.   The company states that PCA Skin is a leader in medical-grade skincare products targeting a range of indications including acne, discolouration, ageing and sensitive skin, and has strong support from aesthetic professionals. EltaMD is a physiciandispensed skincare brand, which offers sunscreen, cleansers and moisturisers, among other products.  Both brands are distributed in the US, China and other international markets. CEO of PCA Skin, Michael Larrain, said, “For PCA Skin, the immediate plan is to remain a separate brand within Colgate, and to remain based in Scottsdale, Arizona, with the same great products, education and customer service. We will remain committed and dedicated to skincare professionals.” Academy

Wigmore Medical to launch ZO UK Academy Aesthetic distribution company Wigmore Medical is set to launch the ZO UK Academy. Wigmore Medical is responsible for developing the academy and states it will allow aesthetic practitioners to find out information on products, treatments and protocols associated with ZO Skin Health, which they can then pass on to patients. The academy aims to present delegates with Dr Zein Obagi’s philosophy on maintenance and prevention in terms of skincare, and the idea of dermal stabilisation and stimulation.

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Dr Harry Singh, Dental Surgeon and Aesthetic Practitioner Can you tell us about your experience? I have been carrying out facial aesthetics since 2002 and have performed more than 4,000 cases. I have published numerous articles on the clinical and non-clinical aspects of facial aesthetics and spoken at dental and facial aesthetics conferences on these topics. Do you have any advice for dental surgeons who want to make the move into facial aesthetics? In my experience, this was a natural move to make. I’ve always thought cosmetic dentistry and facial aesthetic procedures go hand-in-hand; if a patient has spent a significant amount of money on straightening or whitening their teeth, then it makes sense to complement their new look with a perfectly symmetrical pair of lips! Proper training is key – ideally at a workshop that provides a mix of theory and hands-on experience. It’s important to feel comfortable with the products you are using and to get a lot of practise with the effects of different brands; I’ve found Restylane products to be reliable and would recommend them to those getting started in the industry. What are your ‘golden rules’ for administering lip fillers? Lip fillers are not a ‘one size fits all’ procedure; all sorts of factors, such as your patient’s ethnicity, age, face shape, and personal preference will play a part in determining the right look. That’s why I like to use a combination of Restylane LypsTM and Restylane KysseTM to create a unique look tailored to the individual, that is ultimately in harmony with the rest of their face. What are the other benefits of the Restylane portfolio? The portfolio is broad and is very much a ‘one-stop shop’ for me; it gives me all the tools I need to develop personal treatment plans for my patients that restore, enhance and refresh their appearance. The variety offered by the combination of technologies within the Restylane portfolio is ideal for offering my patients treatments that complement and highlight their existing look. RES18-01-0045 Date of Preparation: January 2018 This column is written and supported by

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Laser

Fusion GT introduces the K-Laser Blue to the UK Aesthetic distributor Fusion GT has made the K-Laser Blue available to the UK aesthetic market. The company states that the product provides a safe and accurate surgical laser for a range of aesthetic applications, with the blue laser targeting; removal of skin blemishes, vascular lesions, facial rejuvenation, stretch marks and onychomycosis, among other areas. According to the company, the K-Laser Blue weighs less than 1.5kg, making it portable and compact, suitable for small clinics or professionals working between multiple sites. The red and infared beams in the laser aim to achieve minimal scarring, accelerated tissue healing and pain relief for post-surgical healing, acne, diabetic and chronic wounds, as well as oedema and inflammation. The company states that the laser, which is manufactured in Switzerland and Italy, comes with a lifetime warranty of diodes and software updates, as well as a complete set of accessory heads.  Clinical director of K-Laser, Dr Stephen Barabas, said, “The blue laser technology and wide range of applications will open up markets for diverse professionals; from aesthetic plastic surgeons and vascular surgeons, to dentists, podiatrists and multiprofessional medical clinics.”  Partnership

Totally Derma appoints Harpar Grace as distributing partner Nutraceutical collagen drink company Totally Derma has appointed Harpar Grace as its distributing partner. Totally Derma states it is the only collagen skin drink currently on the market that also contains high, therapeutic levels of patented hyaluronic acid, with more than 210mg per daily serving. In addition, the company claims that Totally Derma contains high levels of key antioxidants, anti-inflammatories and minerals for collagen production and repair.   Alana Chalmers, director at Harpar Grace, said, “We have been reviewing the nutraceutical market for some time to find the right addition to complete our offering. Totally Derma marries with our portfolio perfectly, meeting our very specific selection criteria that we pride ourselves in offering our clients. It boasts clinically-proven, best-in-class performance, using the highest-grade ingredients in therapeutic dosages. I’m thrilled, after many months of discussions, to be able to partner with the company to cement Totally Derma’s position in the market.” Anita Eyles, director of BOLEY Nutraceuticals, co-developed Totally Derma via the company’s manufacturing and exclusive distribution agreement with the Allergy Research Group (ARG) in the US. She said, “I am delighted to be working closely with Alana and am impressed with the successful growth of Harpar Grace; notwithstanding she and her team share the same work ethic and vision for the Totally Derma brand.” 

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

BACN REGIONAL LEADER MEETING The BACN HQ team, Paul Burgess MBE – BACN CEO, Sharon Bennett – BACN Chair and the BACN Regional Leaders, met in London in January to evaluate the BACN events to ensure they grow and become more successful. The different BACN regions, from Scotland to the South Coast were each represented, and Tara Glover, the BACN events manager led the meeting, working with Regional Leaders to confirm dates and agendas. More information will be available to BACN members in the next newsletter. Many forthcoming events are now on the website to book onto, which can be accessed at www.bacn.org.uk/events. Following the meeting, Sharon Bennett informed members that, “The Regional Leaders are here for all the members. They work so hard outside of their clinic and family hours for us all. Make 2018 the year when you attend your regional meetings – they are fabulous opportunities to have your say, engage in peer-group learning, discover case studies, learn new tricks and make new friends.”

REGULATIONS The BACN’s position on regulation is that the association will continue to work hard towards, and campaign for, higher level aesthetic treatments to only be carried out by medical professionals. The BACN will continue to represent nurses in all major policy areas including regulation and standards. It will engage with the existing public registers and those bodies developing public registers and standards. Without representation, the BACN has no voice.

BACN START-UP PROGRAMME Representatives of the BACN met with interested partners to look at launching the BACN Start-up Programme by April, an initiative where nurses new to aesthetics can attend formal introduction sessions on entering aesthetics, with tips, information and advice before starting their new venture. With more nurses than ever enquiring about setting up businesses, this is a reaction of the increasing interest and demand for a structured session. More info can be found by contacting Gareth Lewis, BACN Membership Manager, at glewis@bacn.org.uk.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Masque

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Conference

Environ releases new masque Global skincare brand Environ has added the new Youth+ BioBotanical Revival Masque to its product portfolio. The masque aims to create visibly luminous, younger and revitalised skin through a combination of ingredients; Asiatic, mandelic and lactic acids. According to the company, the formulation lowers the pH of the skin to help promote growth and hydration, rather than peeling. The Asiatic acid, derived from plant Centella, aims to stimulate growth factors in the skin for regeneration: lactic acid targets uneven skin tone and, according to the company, the mandelic acid has been included in the product for its antiageing properties. Environ founder, plastic surgeon Dr Des Fernandes, said, “My research has shown that, by using selected, less aggressive acids, that function at the surface and cause only mild exfoliation, one can leave them in contact with the skin for prolonged periods and, in that way, cause a pH change in the epidermis.” He added, “This stimulates the keratinocytes to release various growth factors which causes a reduction of fine wrinkles, tightening of the skin, more youthful looking skin and reduction of pigmented marks.” Training

New dates added to DH Aesthetic Training Dalvi Humzah Aesthetic Training has released more dates for 2018. Due to the anatomy training session in Amsterdam now being fully booked, the company has announced a new international date, with anatomy training taking place in Poland on June 20. More UK anatomy training days have also been confirmed and will take place at King’s College London on May 21 and July 30. A complications workshop will also be running at Cliniva Cosmetic Training in Barnsley on April 16. Train the Trainer sessions taking place in June are now fully booked, but more dates will be released for 2018 soon. Dalvi Humzah Aesthetic Training advise interested practitioners to contact them promptly to secure their place. Skincare

RSM to hold Aesthetic 10 conference this month The Royal Society of Medicine (RSM) will hold the RSM Aesthetics conference, which is now in its 10th year, on February 23. This year’s theme is ‘multidisciplinary, evidence-based and patient-centred aesthetic care’ and will aim to bring together a multi-professional faculty to identify and discuss options for aesthetic care. The format will include short presentations, panel discussions, case presentations and clinical demonstrations, while promoting peer-to-peer interaction. There will also be two sets of one hour workshops running concurrently with the main scientific conference, which will include sessions on fillers and threads for beginners. Among the topics covered at this year’s conference will be stem cell technology and cosmeceuticals with Dr Mitchel Goldman, skin tightening with Dr Julia Sevi, chemical peel protocols by aesthetic nurse Shannon Lister, as well as ethical marketing by consultant plastic surgeon Mr Paul Harris. Dr Harryono Judodihardjo, who is president elect designate on the committee, said he really enjoys the RSM because of the high-quality of speakers. “Delegates can expect unbiased sharing of experience from the lecturers. The lectures will cover both surgical and medical treatments to correct aesthetic problems that will be delivered by experts in their field,” he said, adding, “On the day, doctors and nurses who are interested in aesthetic treatment can also join the beginners course. The conference is only one day long so it cannot cover every subject, therefore a new topic will be chosen for each year. This year there is a section on ethical marketing and how to identify, avoid and manage doctor-patient relationship break-downs.” Biotech company CellResearch Corporation will also be unveiling its stemcell based cosmeceutical range CALECIM at a breakfast symposium which delegates can attend.

Post procedure

Heliocare releases 360° Color Cushion Compacts Skincare company Heliocare has added a new oil-free tinted foundation to its Heliocare 360˚ range. According to the company, the new product provides maximum protection against UVA, UVB, visible light and infrared-A. It contains the fern-derived antioxidant Fernblock FC, which the company claims fights and neutralises harmful free radicals in the skin, defending key skin tissues and cells such as fibroblasts and collagen. The 360˚ Color Cushion Compacts includes a sponge for easy application that can be used throughout the day. Heliocare is distributed in the UK through AesthetiCare.

macom expands its product line Compression garment manufacturers macom medical has added the ULTIMATE Brazilliant to its product range. The ULTIMATE Brazilliant is a high-back compression garment with an adjustable eye hook fastening. It has a non-compressive light lycra over the buttock area, with an open gusset for underwear use. The garment is said by macom medical to be ideal for use after buttock fat transfer or implant procedures. macom will also launch its new Comfort Line this year, which will include garments with stretchier fabrics and a silky touch, with the hope it will bring more comfort to the recovery process. As well as this, the company’s new Plus Size Line will launch, which will include garments for the bust and body.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Sclerotherpy

BAS confirms lymphoedema speaker for conference Lymphoedema specialist Monica Smith has been confirmed to speak on the condition and its treatment at the British Association of Sclerotherapists (BAS) annual conference on May 15. The conference will feature industry specialists sharing tips and insights into the latest developments, whilst live demonstrations will enable delegates to refine their injection techniques and improve patient outcomes. Also at the conference, delegates will be able to choose a break-out session to update resuscitation and anaphylaxis skills, and obtain a Basic Life Support certificate. Dr Martyn King, BAS board member and aesthetic practitioner, said, “The event will attract sclerotherapy practitioners, drawn from the ranks of vascular surgeons and nurses as well as doctors and nurses, specialising in aesthetic treatments. 50% of the population suffer from unsightly leg veins, and with no treatment available on the NHS; sclerotherapy is a safe and effective treatment now offered by many vascular and aesthetics practices.” A New Year Initiative is offering free membership of the BAS until March 31, which includes member discounts at the annual conference. Skincare

mesoestetic launches AOX Ferulic Pharmaceutical company mesoestetic has released a new antiageing and antioxidant concentrate. AOX Ferulic aims to combat the effect of oxidation of the cells by inhibiting the oxidative cascade produced by external aggressions. It is said to protect fibroblasts and improve the synthesis of collagen in the skin, as well as prevent photoageing, while offering biological protection against UVB, UVA, IR-A radiation, and blue light. Ingredients in the product include; ascorbic acid, ferulic acid and the ‘protech-cell complex’, which contains vitamin E and a latest-generation peptide. The company states that the product has a light and smooth texture, and can also be used as a base for any aesthetic treatment. mesoestetic claims the product is suitable for all skin types and can be used at any age, on a daily basis. Smoking

Study suggests non-smokers more attractive than smokers Researchers at the University of Bristol have published a study which suggests smokers are deemed as less attractive than non-smokers. The study, published in the Royal Society Open Science journal, presented more than 500 participants with the faces of 23 sets of identical twins, plus a male and female prototype. The research explored two aspects of smoking and facial appearance. Firstly, does facial appearance alone provide an indication of smoking status and, secondly, how does smoking affect the attractiveness of faces? The male and female participants were able to correctly identify which of the male and female prototype faces was the smoker, 70% of the time. Both men and women also predominantly chose the non-smoker prototype faces as the more attractive of the two. The researchers believe that their findings could be instrumental in promoting changes in smoking behaviour, especially among young people. Study researchers said, “Young people are particularly sensitive to the potential negative effects smoking has on their attractiveness as they age. The findings, particularly those for the prototypes that represent the characteristic facial features of smokers and non-smokers, have the potential to be of utility in developing and improving smoking behaviour change interventions.”

News in Brief ZENii releases Beauty Fusion liquid beauty supplement Skincare and supplement company ZENii has added a new liquid beauty supplement to its product portfolio. Beauty Fusion is a liquid beauty supplement designed to strengthen hair, skin and nails. The company states that the key ingredients used include; hydrolysed marine collagen, hyaluronic acid, methylsulfonylmethane (MSM), biotin, vitamins A, B7, C, D and E, as well as zinc and magnesium. According to ZENii, Beauty Fusion provides cellular micronutrient support with high bioavailability because of its liquid formulation, and rather than being a liquid drink, it’s instead a quick, 14ml liquid shot that can be taken on its own or added to a drink. New iCLINICIAN app now available Patient management software solution iCLINICIAN is now available on Apple’s App Store. iCLINICIAN aims to allow aesthetic practitioners to go paperless and manage all aspects of their business from one app. The app can be used to create treatment plans, take before and after photos, manage appointments, manage stock levels, invoicing, produce prescriptions, write notes, record expenses, send SMS texts and emails, fill in timesheets, and more. Eudelo clinic hires new manager London skin clinic Eudelo has hired new clinic manager Iwona Widger. According to the company, Widger has in-depth experience in the medical sector, particularly in optometry and dermatology and has worked in management, patient co-ordination and sales. Widger’s main responsibility at Eudelo will include managing all aspects of Care Quality Commission compliance, clinic operations and staff management. Correction regarding Aesthetic Response In the Aesthetics Awards supplement, which subscribers received with their January journal, it stated that Aesthetic Response was ‘The UK’s first enquiry management software company dedicated solely to aesthetics’. This was an error made during the editing process and should have stated, ‘The UK’s first enquiry management support service dedicated solely to aesthetics’. Aesthetic Response offers enquiry handling and customer service support to aesthetic practitioners. The company won The e-MASTR Award for Best Clinic Support Partner at the Aesthetics Awards 2017.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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more about treating darker skin. “It’s important that I am up-to-date with all the treatments and products available to my patients,” she says, explaining, “There is a lot of study on treating ethnic skin, but I find that it’s not promoted in this country enough. I get a lot of my education from reading articles and journals from the US, India and Korea.” Ayodele agrees, noting, “I think skin of colour isn’t focused upon enough in education. In America, there are very specific textbooks on treating skin of colour but we don’t always see that here in the UK.” In addition, Ayodele argues that not enough clinical trials for new products and treatments are conducted on darker skin, saying that when she has asked companies for their results on higher FSTs, the usual response is that they haven’t been done or are US-based. While having results from abroad is better than no results, Ayodele Aesthetics investigates the challenges patients with suggests that it would be more higher Fitzpatrick skin types face in finding a suitable marketable to have results from the UK. In her role as a beauty writer for practitioner and explores how this can be improved the black female beauty market, as This month sees the launch of a new research into how many others felt this way. well as an aesthetician, Ayodele says that not online resource dedicated to helping She conducted an online survey and spoke having data specific to her audience limits patients with skin of colour find a to women at the Afro Hair and Beauty Show her enthusiasm to report on new products skincare professional who can address 2017, which found that out of 125 women and treatments. “There’s no point in me their concerns. Created by Londonwith skin of colour who have attempted to harping on about something which I can’t based aesthetician Dija Ayodele, who find a skincare professional, 92% said they give relevant details about,” she says. From predominately treats women of colour, found it challenging, very difficult or that a practitioner’s perspective, she suggests the Black Skin Directory is a website that they have never been able to find someone that more studies would get the attention of aims to provide users with information suitable to treat their skin.2 other clinicians and build their confidence in on experienced skincare professionals, So, Aesthetics asks, why might it be difficult offering such treatments. cosmeceutical treatments and products, as for men and women with skin of colour to To help improve the data available on well as events and roadshows that users find a suitable practitioner? And what can products and treatments for higher FSTs, may be interested in. practitioners do to improve this? Ayodele has established the Black Skin According to the 2011 UK census, out of Directory Council, in which patients with skin the 56.1 million people living in England Knowledge of colour will test and review products. “The and Wales in 2011, 4.2 million were Asian/ Before an aesthetic practitioner can treat aim is to give brands the opportunity to have Asian British and 1.9 million were Black/ any patient, they must learn how to do so their product tested on a higher FST so they African/Caribbean/Black British. In addition, appropriately and safely. As there is no one have more data to promote,” she explains. the White percentage of the population route to becoming an aesthetic practitioner Dr Kaur believes that the type of education had decreased from 91.3% in 2001 to 86% in the UK, each will learn skills based on their and the way in which it is delivered could also in 2011, while the number of people from patient demographic and the type of training be adjusted. She says, “When I go to talks Pakistani and Indian heritage increased by they undertake. Treating darker skin is widely on treating higher FSTs, they never seem to around 0.4 million each in the 10 years since acknowledged as more challenging due to take place in the main conference room and the 2001 census.1 So, with a rising population the increased risk of hyper/hypopigmentation they often only focus on laser treatments, of people with higher Fitzpatrick Skin Types and potential for scarring,3 which may however not all practitioners have a laser. If (FSTs), the demand for aesthetic treatments influence practitioners’ hesitation to focus we are to educate people, we should start is only going to increase. Yet, after many their education on higher FSTs. with skincare and chemical peels. Even conversations with her patients, Ayodele For aesthetic practitioner Dr Bhavjit Kaur with laser treatment, the skin needs to be found that they all emphasised how difficult who practises in Greenwich, however, 75% prepared beforehand, so the appropriate it was to find a practitioner able to treat their of her patients have a FST between IV-VI. options and protocols should be stressed skin. As a result, she decided to conduct As such, she has actively sought to learn upon more.”

Treating Skin of Colour

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


Experience Dentist, and aesthetic practitioner Dr Rikin Parekh is working with the Black Skin Directory to host educational events for practitioners to improve knowledge, awareness, patient care and safety on treating darker skin at his training base, The Avanti Aesthetics Academy. He says, “I don’t think it’s so much a lack of knowledge; practitioners know the differences in skin physiology, it’s more a lack of practical experience which then affects confidence. If you are not treating many people of colour, it becomes harder to treat them as you don’t have the hands-on experience to deal with the issues presented or if a complication develops.” Ayodele adds, “There are practitioners who don’t have the experience in looking after darker skin tones because of where they’re based and because there is a lower population of people with skin of colour. However, in larger towns and cities there are so many people with higher FSTs that it shouldn’t be an issue.” For practitioners to increase their confidence in treating these skin types, Dr Parekh advises, “Training and refresher courses together with specific education at conferences and journals can help.” Ayodele adds, “If you are hesitant, there’s lots of good training out there but, likewise, there’s lots of self-education you can do as well. If anything, the main thing to remember is not to rush and to ensure you administer treatment in a step-bystep process.” Dr Kaur emphasises that education is key and practitioners should understand the associated risks of treating darker skin and know what to do if any complications do occur. Marketing The practitioners interviewed agree that if the clinician has the knowledge and experience to treat darker skin types, then they should ensure that this is being communicated effectively to potential patients. “After speaking to my patients, I have noticed that there seems to be misinformation, myths and misconceptions around what sort of treatments black skin can have – for a time it was regarded as dangerous to use certain products and peels on darker skin due to the risk of scarring. However, the technology is so much more advanced now,” says Ayodele. To promote accurate and positive messages on treating higher FSTs, Ayodele suggests that as well as engaging more with black publications and bloggers, “Stronger web presence from clinics highlighting that they treat all skin colours would be a positive first step.” She adds that using more explicit key words in their online content for search engine optimisation purposes such as ‘black skin, dark skin, brown skin, women of colour, people of colour’ could also help. To further break down misconceptions around treating higher FSTs, Dr Parekh advises that even something as simple as providing treatment imagery of a person with skin of colour on your marketing, website and social media could make a difference. Ayodele concludes, “In this day and age, no one should be able to walk away from a clinic feeling that they can’t be catered for. Having open and honest conversations is so important – if you don’t have the appropriate knowledge or feel you can treat them, then refer them to someone who can.” REFERENCES 1. GOV.UK, Ethnicity facts and figures (UK: GOV.UK, 2011) <https://www.ethnicity-facts-figures.service. gov.uk/ethnicity-in-the-uk/population-by-ethnicity> 2. Black Skin Directory (UK: 2018) http://www.blackskindirectory.com 3. Dr Mayoni Gooneratne, Treating Asian Skin, (UK: Aesthetics, 2017) <https://aestheticsjournal.com/ cpd/module/treating-asian-skin>

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Learn About the Latest Technologies in Aesthetics! Discover the newest products and innovative clinical techniques at ACE 2018 From practical demonstrations held by expert KOLs, to insights into the latest technologies – there is so much to learn on the Masterclass agenda at the Aesthetics Conference and Exhibition (ACE) 2018. On April 27 and 28 at the Business Design Centre in London, delegates can join up to 12 Masterclasses, showcasing the latest pioneering products from leading aesthetic companies. Delegates can learn from highly respected industry professionals who will share their tips and demonstrate innovative ways to use injectables, lasers and skin peels, as well as much more! Every one-hour session is worth one CPD

point and each will have a unique learning outcome, where delegates will have the exclusive opportunity to see new products, some of which have never been seen before at any other conference. At the Masterclasses, attendees can ask questions to company representatives and KOLs about the latest products and techniques, learn about effective protocols from industry experts, and discover new ways to expand product offerings. Confirmed on this agenda are: • Aesthetic device company BeamWave Technologies, which has a wide portfolio of aesthetic and dermatological devices

Maximise your Masterclass experience! Follow our five top tips so you can get the best learning outcomes from the ACE 2018 Masterclasses: 1. REGISTER – Visit www.aestheticsconference.com and click the orange ‘Register Now’ button. Registration is FREE and gives you access to the 12 Masterclasses, 17 Expert Clinic sessions, 18 Business Track sessions and the 2500m2 Exhibition Floor. 2. READ THE PROGRAMME – There is so much going on at ACE 2018, so we recommend being organised by viewing the programme, available on the ACE website. Simply click on each session to learn what topics and speakers are of most interest to you. 3. ADD TO YOUR AGENDA – Once you’ve read the programme and decided on which sessions to attend, click on the ‘Add

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• Global cosmeceutical skincare company SkinCeuticals, which aims to improve the appearance of ageing and skin concerns through its products • Aesthetic device company Lumenis, which specialises in IPL and CO2 laser skin resurfacing • International pharmaceutical company Galderma, which specialises in the research, development and marketing of corrective and aesthetic solutions • Global distributor and ACE 2018 headline sponsor, Schuco International, which specialises in skin imaging, electrosurgery, and medical equipment for minor surgical procedures • AestheticSource, a company that distributes a range of products, from peels to injectables • Global pharmaceutical company Almirall, who research, develop, manufacture and market propriety medicines and licensed products With more companies yet to be confirmed, there is so much to learn at the Masterclasses!

Learning outcomes Attend the Lumenis Masterclass to improve your understanding of laser and light technology so your patients are getting the best results possible. Presenting at the Masterclass, taking place at 3pm on April 27, will be laser specialist Kevin Williams, who will discuss the benefits of using the M22 Advance IPL system as an alternative to Pulse Dye Laser (PDL) technology. Williams will provide case studies to inform delegates of new technologies that allow concentrated energy at the correct wavelengths, to maximise clinical effectiveness for indications such as facial veins and redness.

to My Agenda’ button, where you can create your own personalised timetable. You can access this on your mobile devices or print and bring it along to the event. Adding sessions to your agenda enables you to stay on track of everything you want to attend and ensures you don’t miss any valuable training opportunities available. 4. ARRIVE EARLY TO GUARANTEE YOUR SEAT – There is limited space available in sessions, so arrive early to get a prime seating spot. 5. COLLECT CPD POINTS – Don’t miss out on the free CPD points available at ACE! Each one-hour Masterclass is worth 1 CPD point – to get yours, make sure the barcode on your badge is scanned upon entry. Your CPD points will then be added to your Training Record on the Aesthetics website which you can access at any time.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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2018

SATURDAY APRIL 28… If you offer peels at your clinic, attend the AestheticSource Masterclass and educate yourself on different ingredients included in chemical peels in a session led by Dr Philippe Deprez, who will present on the ‘perfect’ balance of trichloroacetic acid (TCA) and phenol. During this session, which will take place at 11am on April 28, the new Skin Tech Easy Phen Very Light (EPVL) Peel will be exclusively launched. Dr Deprez will highlight how the new peel can benefit aesthetic practitioners by providing a comfortable, convenient treatment with easy application and minimal complications. Director of AestheticSource, Lorna Bowes said this Masterclass is one not to be missed, “Delegates will have the opportunity to gain an in-depth overview of the new peel, indications, patient type and expected results. The speakers will share their experiences of both this peel and other peels in addressing concerns such as photo-damage, acne, acne scarring, hyperpigmentation, stretchmarks and solar lentigines.” Galderma will host two Masterclass sessions; the first will take place on April 27 at 2pm, focusing on ‘Lips Through the Ages’, which will demonstrate how beauty ideals for the lips have changed over the years, so you can stay up-to-date with the latest lip trends. If you would like to learn about creating successful aesthetic outcomes whilst considering individual patient expressions for injectable treatments, attend Galderma’s second session, taking place on April 28 at midday. At this session, entitled ‘Beauty Through Expressions’, a yet-to-be-confirmed KOL will present on how practitioners must consider each patient’s individual expressions during consultation and treatment. The Schuco International Masterclass will feature a panel of leading UK aesthetic professionals, who will unveil and demonstrate the latest innovations in the Princess Dermal Filler portfolio. Delegates will have the opportunity to learn how this latest treatment can offer a valuable new approach to facial contouring and volumisation. Also featured in the session will be an interactive Q&A session with an expert panel, as well as a live injecting demonstration. Speakers representing BeamWave Technologies, SkinCeuticals and Almirall will also share their expertise over the two days, with more details to be released soon! Register now to stay updated with the latest developments at ACE 2018 by visiting www.aestheticsconference.com ACE HEADLINE SPONSOR

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Tell us about your experience. How did you become an aesthetic trainer?

Meet the Trainer Aesthetic nurse prescriber Rachel Goddard is the clinical director and founder of Totally Aesthetics training in Ramsbottom, Greater Manchester. She talks training days and aftercourse support. What are the main training opportunities available at Totally Aesthetics? Our main focus is on small group teaching, ensuring that delegates have plenty of hands-on training. We offer a wide range of courses from basic to advanced, and cover a range of areas, including injectables, microsclerotherapy and chemical peels, to name a few. We facilitate a relaxed training environment at a nice, steady pace, so delegates can feel comfortable and ask any questions from the offset. We also offer bespoke training, so if there is an area that a delegate wishes to cover, which isn’t on one of our standard courses, we can tailor a course to fit around them on a one-to-one basis. In addition, we offer a mentoring service, where we provide external support for practitioners and visit them at their clinics. There, we watch them perform procedures in their own environment and provide guidance on treatments they may not be fully confident in.

Who would benefit most from attending your training sessions? We will only train nurses, doctors and dentists with valid UK registration numbers. All levels can benefit from attending our training courses because we offer such a variety. We can take those who have already had basic training to the next level, by updating them on techniques in injectables and improving their practical skills with our masterclasses.

How is a typical training day structured? We start off with introductions and beverages, so everyone is put at ease as soon as they arrive. It also provides the opportunity to get a feel for the delegates’ previous experiences and find out exactly what they want to gain from attending the course. The morning consists of theory – our trainers use PowerPoint presentations and all delegates get handout copies, alongside pens and notebooks so they can make their 20

Aesthetics | February 2018

I’ve now been in aesthetics for 13 years and I opened my clinic Rachel Goddard Aesthetics in 2004. I’ve always been passionate about aesthetics and another passion is sharing my Rachel Goddard knowledge with others, so getting into training happened quite naturally for me. I was approached by a few nurses who were looking to train in aesthetics 11 years ago, so I started offering training courses, and it went from there. I’m currently a mentor at Northumbria University for nurses and doctors studying their Master’s degree in Aesthetic Medicine, and I’m also part of the Allergan medical faculty and do a lot of training and conferences for them. I have a postgraduate certificate in Clinical Education, and that has definitely helped me when training others in aesthetics, as I understand the importance of using a range of training methods to suit the needs of all delegates. I also recently won the Aesthetic Nurse of the Year Award at the Safety in Beauty Campaign Diamond Awards in 2016.

Who else supports your training? Andrea Riscatti is the course co-ordinator and has a really important role in our team, as she’s everybody’s point of contact. Andrea advises delegates on course content, dates, will take down their details and registration numbers, and will provide them with general support. Mr Keith Rose runs the microsclerotherapy training for delegates. He has specialised in the treatment of venous disease for 24 years and, as his course is such an intense focus day, it’s in more of an intimate setting, with no more than three delegates. The course covers both theory and injection technique demonstrations. Sue Robinson is an independent nurse prescriber and came on board to assist Totally Aesthetics in our basic, introductory courses, in 2017. Sue has more than 30 years’ experience in clinical nursing and is a member of the British Association of Cosmetic Nurses (BACN) and the Association of Nurse Prescribing.


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TESTIMONIALS “Courses are always split into theory and practical sessions, giving delegates the opportunity to ask valuable questions, and there is lots of hands-on experience. Rachel is very patient and supportive and I really believe it’s thanks to Totally Aesthetics and Rachel that I am where I am today.” Sally Frank, aesthetic nurse practitioner

“I choose to train with Totally Aesthetics as I gain confidence in knowing Rachel is extremely experienced, competent and fully supportive of delegates learning new treatments or techniques.” Dr Nick Sinden

“Rachel is fantastic. Her knowledge about aesthetics is extensive and her kindness and patience is second to none. She’s that friendly ear who is always willing to help and advise.” Carley Tomlinson, aesthetic nurse practitioner

own notes. Topics covered in the theory session can include anything from different injectable brands and their ingredients, to the anatomy and patient consent, as well as risks and complications. The afternoon involves hands-on, practical sessions, where delegates can watch the trainers provide demonstrations on models, and then perform procedures themselves, supervised by us. We source and

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attending, which should be assessed in more detail for beginners, and be done to refresh the memory of more experienced delegates. We will also provide information on what the course will entail with contact details prior to the training course.

What will delegates take away from the training course? Successful delegates are presented with a certificate at the end of the day which can be used to validate insurance. We also provide them with useful contact numbers of local product suppliers, pharmacists and manufacturers. Additionally, delegates on the dermal filler courses are given a copy of the hyaluronidase protocol and we always encourage our delegates to join the Aesthetics Complications Expert (ACE) Group for information and support on complications.

What support do you offer once a practitioner’s training has been completed? We provide a range of support following the training course. We have a delegate support email address, which is separate to the general enquiry address, so we can find out straightaway if a delegate needs advice. We also offer telephone support. In addition, we have a closed group on Facebook where delegates, or those who are interested in our courses, can join. It creates a safe, relaxed environment where delegates don’t feel silly posting questions and provides peer support between a range of medical professionals. We do monitor this however and, if there are any inappropriate/negative messages, people are warned and removed if necessary. Our course co-ordinators and marketing team also post information on our social media platforms about upcoming training dates and events.

UP COMING TR A INING DATES Rachel Goddard with delegates of the Lip Masterclass course

provide models who we know are healthy, have no contraindications for treatment and who have also been treated before, to ensure they are relaxed and comfortable as, if you have a nervous model, you will also have nervous delegates. The training concludes with a test paper, to identify areas where delegates maybe need to come back and revise things with us, or areas where they may need to do some home study/reading to develop their knowledge further. Delegates are constantly assessed throughout the day and, at the end of the training course, I speak to each person on a one-to-one basis to gather their thoughts on how they thought the training went and to answer any questions they maybe didn’t want to ask in front of colleagues.

• • • • • • • •

Basic Dermal Fillers: 9th March, 11th May Basic Botox: 10th March, 12th May Dermal Filler and Cannula: 2nd February, 4th April Advanced Botox: 3rd February, 5th April Periorbital Masterclass: 23rd March, 18th May 8 Point Lift: 16th March, 25th May Lip Masterclass: 9th February, 13th April AestheticSource Skin Tech Peel Training: 7th February, 20th April • Microsclerotherapy: 18th March

Is there anything delegates should do prior to attending the course?

www.totallyaesthetics.com Tel: 0161 669 4630 Email: info@totallyaesthetics.com www.facebook.com/TotallyAesthetics

We send out prior reading for some of our courses and always recommend our delegates look at the facial anatomy before

For a comprehensive range of facial aesthetics training, look out for the new Med-fx training portal – at medfx.co.uk Aesthetics | February 2018

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Recognising Common Skin Conditions Four practitioners share their preferred treatment methods for common dermatological conditions presenting in clinic

It is well-known that the patients who are commonly presenting to aesthetic clinics have skin concerns associated with ‘ageing’. However, other skin concerns are not beyond the remit for many practitioners working in private aesthetic practices. Around 25% of the UK population will consult a GP each year because of a skin complaint. With only around 650 consultant dermatologists currently practising in the UK, it is likely that some of these patients will turn to private medical aesthetic practitioners for guidance on

Keratosis pilaris with dermatology and cosmetic nurse practitioner Anna Baker Characteristics: redness, bumps, rough skin Can be confused with: folliculitis, ichthyosis vulgaris, atopic eczema Keratosis pilaris (KP) is a common skin condition presenting in at least half the UK population.3 Known as ‘chicken skin’, it is completely benign and non-contagious. It can manifest early on in childhood, going through into adulthood. KP may uncommonly present on other areas of the body, but is most common on the back of the arms or the sides of the thighs, and appears as very red, rough, bumpy skin. Interestingly, KP is usually symmetrical, affecting both sides of the body. KP can be more common in women than in men and has quite a strong genetic component.3 There is no ‘quick fix’ and people often get it more in the winter months, possibly because the skin is dryer

Figure 1: Patient presenting with keratosis pilaris.

their dermatology issues too.1,2 As aesthetic professionals regularly perform all kinds of skin treatments, they are in a prime position to ensure their patients are getting the best skin advice possible. In this article, Aesthetics asks four practitioners who specialise, or have experience, in dermatology to discuss a skin condition that they believe is important for medical aesthetic practitioners to be able to diagnose and treat. The practitioners also recommend when the time is right for a referral.

and produces less sebum.3 ‘Keratosis’ refers to a build-up of keratin, the most abundant protein in the epidermis, and ‘pilaris’ comes from the Latin word for ‘hair’. Therefore, it refers to an excessive build-up of keratin, resulting in an overkeratinisation in the skin’s hair ducts.4 There are two factors in dermatology that are really important for diagnosis: pattern recognition and good history taking. With KP, I believe it’s all about taking a thorough history as other conditions may occur at the same time, such as ichthyosis vulgaris – accumulation of dead skin – and atopic eczema, so it’s imperative that practitioners are 100% sure it’s only KP before administering treatment. There are other types of KP that aren’t as common, such as on the face and neck, but the most common types that we see tend to be on the body, so I will be focusing on that. KP on the body is usually something that can be managed by a patient at home. Universal recommendation for treatment involves an exfoliating topical ingredient. So, that could be something such as salicylic acid, which is a very effective keratolytic agent, urea or alpha hydroxy acids such as glycolics or citric acid.4 Personally, I find that a very cost-effective option for patients is to give them a multi-purpose glycolic and citric acid body lotion to use twice a day. In my experience, these ingredients are

very good at de-plugging and reducing the amount of keratin production of the skin, while still giving some hydration. I use NeoStrata Ultra Smoothing Lotion, which is an 8% glycolic and 2% citric acid homecare product. I would say that in 90% of my cases, just using the lotion at home will produce an improvement within three to four weeks. However, if the case is quite stubborn, or if a patient wants a quicker result, I would look to combine a 20% glycolic peel with the body lotion. It’s important that the patient has been using the body lotion for a few weeks first so that their skin acclimatises to the pH of the peel. The course of peels would range from four to six, every two to three weeks, or thereabouts. I would recommend reassessing the area after each peel to determine whether you need to treat again. If, for whatever reason, the KP wasn’t responding, I wouldn’t hesitate to tell patients to stop treatment and refer them to a dermatologist. In terms of other measures, I’d tell patients to avoid taking very hot showers, which can irritate skin, or over-manually exfoliating, because that can make the area tender, sore and uncomfortable. KP treatment is generally not a ‘quick fix’. The overarching aim is to try and give a nice superficial exfoliation without irritating and drying the skin out. As a nurse, I recommend that others get involved with the British Dermatological Nursing Group (BDNG), which runs great CPD courses in all aspects in dermatology, if they would like more information on this and other conditions.4-6

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Atypical naevus syndrome with Dr Christopher Rowland Payne, consultant dermatologist to The London Clinic Characteristics: many and various moles of different sizes, shapes, colours Can be confused with: ordinary moles, seborrhoeic warts

Aesthetics

brown, but they also burn, and if people have the third inheritance, a large number of moles, then when they burn the moles will rise a few years later. Typically, the skin types that present with ANS are usually Fitzpatrick II-III rather than I, as they only burn; the individual must also have the mole inheritance.7,8,9 Due to its association with melanoma, it is very important that every medical aesthetic practitioner knows how to recognise ANS. If you see it in a patient, which you will often because it’s very common, then you have a responsibility to mention it to the patient, advise them about sun avoidance and always ask the question, ‘Have any changed?’ If there are reported changes in shape, size, number or especially if one becomes blacker in colour, it is vital that they are referred to a dermatologist for mole removal. Removal is traditionally achieved through cutting it out in an elipse excision, which leaves unattractive scars. The other way is to do a superficial excision, which produces a better cosmetic outcome, where you split the skin by holding the scalpel in almost a parallel way and leaving the deeper part of the skin in place. The mole will then be sent for microscopic examination and, if it is found to be a melanoma, then the doctor may need to do another larger excision of the area. So, ANS itself is not dangerous – it’s the potential for the moles to change which is dangerous. Practitioners should never attempt to remove these moles using lasers or chemical peels as they absolutely must be studied microscopically to determine whether it is benign atypical naevus, or one that has evolved into a melanoma due to sun exposure. Encourage patients to seek expert advice, check their moles and body regularly and, if there is any change whatsoever, then this needs to be reported to a dermatologist.7-9

Atypical naevus syndrome (ANS) is common in young adults and is a major risk factor for the development of melanoma, which affects one in 50 of the British population.7 ANS is characterised by many and various naevi (also known as moles) and is usually easy to distinguish. There are variations in shape, size, colour and pattern of pigmentation but the moles are flat to the touch, unlike ordinary moles which are usually slightly raised. It is defined when an individual has more than 50 moles in total and, typically, these are scattered over the trunk and limbs, especially at the edge of clothing sites, where people have had sunburn in the past.8 ANS will present in patients, years after they have been sunburnt earlier in their life, usually during childhood or as a teenager, and the diagnosis will typically be made in their 20s or early 30s. The number and variety of the moles indicate how susceptible the patient is to changes in their ANS – they can also become very unstable if they are burnt again, which increases the risk of irritation and the likelihood of it becoming a melanoma. However, the people who are most at risk of melanoma are people who have what’s called a ‘triple inheritance’.8 This is the ability to tan from one ancestor, Before After ability to burn from another ancestor and the ability to produce moles from a third. So, the types of people who get ANS are people who go out in the sun and go Figure 2: Patient presenting with ANS on the trunk, before and after superficial excision.

Rosacea with consultant dermatologist Dr Daron Seukeran Characteristics: facial redness, flushing, spots, pustules Can be confused with: acne, seborrheic dermatitis, facial weathering Rosacea is a relatively common, chronic inflammatory condition that usually occurs in patients in their

middle ages between 30-50. It’s found in both men and women, although men are considered to get it more severely.10 Rosacea is a condition that is localised on the face and its characteristic features are often associated with a flushing or a burning sensation, sometimes with spots or pustules. Practitioners must first identify if patients are experiencing redness and if it is triggered by any environmental factors. These factors can be different among individuals but can include sunlight, hot drinks, spicy food,

alcohol, going from a cold to a hot room, or other lifestyle factors. In men, sometimes there is a thickening of skin on the nose that makes it look quite deformed – called rhinophyma.11 Once someone has rosacea, it tends to be a chronic condition that works in waves and relapses with time. Although there is much research, the cause is still unknown. Theories have suggested it may be due to an overgrowth of the demodex mite that lives in the pilosebaceous follicles.12 We also know

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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(PDL) or intense pulsed light (IPL) in my experience. By removing the superficial blood vessels, light technologies Figure 3: Patient presenting with rosacea, before and after treatment with laser. do two that it runs in families and those with things, they reduce the redness and very fair skin seem to have a higher the symptoms of flushing or burning. I instance of rosacea.10 personally prefer the PDL as I find it is Treatment depends on the type of quite precise in removing the vessels, rosacea the patient has. If the patient has active lesions with spots and pustules, they will need to be treated medically. This involves using a combination of topical treatments and creams – such as metronidazole gel, 1% ivermectin cream or azelaic acid – and often combining these with oral antibiotics, such as oral tetracycline.10,12 However, if the patient has rosacea which is just associated with a bit of redness and flushing without the spots and pustules, they can respond very well to three to six light-based treatments such as pulsed dye laser Before

After

but IPL can also be useful. At sk:n clinics, we either use the VBeam pulsed dye 595 nm laser. It’s vital that aesthetic practitioners are careful when giving aesthetic treatments to patients with rosacea, you don’t want to use anything that’s going to irritate the surface of the skin because the skin is so sensitive and you can make it worse if you treat it inappropriately. Practitioners also need to be wary of giving the patient inappropriate advice and should refer to a consultant dermatologist if they don’t have specific knowledge in this area.10,11,12

Once someone has rosacea, it tends to be a chronic condition that works in waves and relapses with time

Acne vulgaris with aesthetic practitioner Dr Dev Patel, who has completed the Postgraduate Diploma in Practical Dermatology Characteristics: comedones, papules, pustules, nodules, cysts Can be confused with: rosacea, seborrheic dermatitis, steroid related dermatitis, tinea barbae, perioral dermatitis, keratosis pilaris, adenoma sebaceum, pityrosporum folliculitis Acne vulgaris is a very common, long-term inflammatory skin condition that involves the pilosebaceous unit, which consists of the hair follicle, the cells lining the hair follicle and the associated sebaceous gland. The general pathophysiology components to acne include: increased sebum production, follicular hypercornification and proliferation of propionibacterium (p.) acnes bacteria, resulting in a T-cell mediated anti-inflammatory response. It’s these collectively, which are hormonally driven, that give the various clinical manifestations of acne as we know it.13 There are many potential consequences of acne, such as scarring and post-inflammatory hyperpigmentation, which may be secondary to the inflammatory lesions or due to increased photosensitivity from retinoid therapy. Another consequence

that is rarely discussed is acne’s impact on ageing of the skin. Inflammation leads to the presence of free radicals such as reactive oxygen species (ROS), which can have a deleterious effect on vital components such as telomerase, mitochondrial DNA and cell walls.14,15 The relationship between inflammation and ageing give us even more reason to successfully treat inflammatory acne Before

After

Figure 4: Patient presenting with mild inflammatory acne before and after four treatments of 30% salicylic acid peel.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Every aesthetic practitioner needs to be confident in their diagnosis before treatment in an individual. Acne is almost always clinically diagnosed through history and medical examination. Practitioners must look for the presence of comedones, which may be open (black heads), or closed (white heads). There will usually be some papules – red spots – and pustules, which are spots containing puss; and in more severe cases, nodules, which are papules that are bigger than 1cm in diameter; and cysts, which affect the deeper layers of the skin. There are more than 25 different grading systems for acne; I use the EU Acne Classification Scale, which grades from 1-4. Grade 1 involves comedonal acne, Grade 2 presents papules and pastules, Grade 3 is severe papulo-pustular that may or may not be combined with moderate nodular acne, and patients with Grade 4 will usually present with nodulo-cystic acne.13 It’s very important that the practitioner also completes a psychological assessment questionnaire to understand how the acne is impacting the patient, as it may have very strong psychological implications. As acne is a huge topic, I will be focusing on my treatment methods for mild Grade 1-2 acne, which are the grades that

Summary According to the practitioners interviewed for this article, the conditions discussed are common among patients who may present in aesthetic clinics, so clinicians should investigate such skin concerns thoroughly to ensure a correct diagnosis is made. The treatment approaches discussed are not the only possible methods, and each patient should be consulted and given treatment on an individual basis. Whether practitioners have the knowledge and experience to treat themselves or not, they should be true to their limitations and know when is best to refer if necessary.

Aesthetics

medical aesthetic practitioners are likely to be treating. I have not covered topical therapy that a GP may prescribe. When a patient presents to me in clinic, the first thing I do is ensure they are on a good skincare regime and introduce ingredients that will help with their overall skin health, as well as their acne. I am looking for ingredients such as java tea, which we know reduces 5-alpha reductase and sebum production16 and linseed extract, which is anti-inflammatory.17 Other ingredients that are good to help inhibit some of the enzymes or pathways that lead to the worsening of the acne include: oligopeptide 10, vitamin B3, B5 and salicylic acid. Hydration is a key aspect for acne, so I will always give them a good moisturiser and/or serum, as well as a cleanser – I use the AlumierMD Acne Clarifying Cleanser and Acne Balancing Serum. I will get patients to use skincare for at least six weeks, before considering in-clinic treatments. I would also ensure they do not overuse exfoliates and retinol or over-wash their skin. In my clinic, the mainstay treatment for Grade 1-2 acne is four to six sessions of a salicylic acid, which is a beta hydroxy acid (BHA) skin peel. In moderate to severe cases I use a 30% salicylic acid peel by Enerpeel or Radiant 20/10 or Glow Peel by AlumierMD. Salicylic acid is fantastic because it’s a lipophilic acid, which is a small molecule that will drive down into the follicles and go into the sebum. It’s a comedolytic and it loosens the keratinocytes and unclogs the pores – I call it my ‘gutter cleaner’. Of course, you can also use lasers; we have the Harmony XL Pro system (ClearSkin) that can give quite good results, however I usually prefer peels because they offer a more cost-effective treatment. Every aesthetic practitioner needs to be confident in their acne diagnosis before treatment, and they must work like a detective to make an accurate diagnosis. Be honest with the patient and make it clear where the limits of your knowledge lie; if someone has mild acne, you can give them some good skincare that you know will help. If they require further treatment that is beyond your remit, or if you suspect a different condition, give them the details of a colleague you know can help.18

REFERENCES 1. Health Committee, ‘Written evidence from the British Association of Dermatologists (LTC 89)’, 2014. <https://publications.parliament.uk/pa/ cm201415/cmselect/cmhealth/401/401vw78.htm> 2. Julia Schofield, Douglas Grindlay, Hywel Williams, ‘SKIN CONDITIONS IN THE UK: a Health Care Needs Assessment’, Centre of Evidence Based Dermatology, University of Nottingham, 2009. <https://www.nottingham.ac.uk/research/groups/cebd/documents/ hcnaskinconditionsuk2009.pdf> 3. Ann L. Marqueling, Amy E. Gilliam, Julie Prendiville, et al. ‘Keratosis Pilaris Rubra’, Arch Dermatol. 2006;142(12):1611-1616. 1. <https://jamanetwork.com/journals/jamadermatology/fullarticle/410006> 4. British Association of Dermatology, KERATOSIS PILARIS. <http://www.bad.org.uk/shared/get-file.ashx?id=217&itemtype=document> 5. Amanda Oakley, ‘Keratosis Pilaris’, Derm Net New Zealand, 2015 <https://www.dermnetnz.org/topics/keratosis-pilaris/> 6. NHS, Keratosis pilaris (‘chicken skin’), 2015. <https://www.nhs.uk/conditions/keratosis-pilaris/> 7. British Association of Dermatology, ATYPICAL MOLE SYNDROME <http://www.bad.org.uk/shared/get-file. ashx?id=152&itemtype=document> 8. Christopher Rowland Payne, Royal Society of Medicine, ‘2017 Stevens Lecture: Sun addiction and skin cancer’, 2017. <https://videos.rsm. ac.uk/video/2017-stevens-lecture-sun-addiction-and-skin-cancer> 9. D. A. Burns, et al., Rook’s Textbook of Dermatology, 2010. 10. British Association of Dermatology, ROSACEA. <https://www.bad.org.uk/shared/get-file.ashx?id=229&itemtype=document> 11. Dr Amanda Oakley, Rosacea, DermNet New Zealand, <https://www.dermnetnz.org/topics/rosacea/> 12. Rios-Yuil JM, Mercadillo-Perez P. Evaluation of Demodex folliculorum as a risk factor for the diagnosis of rosacea in skin biopsies. Mexico’s General Hospital (1975-2010). Indian J Dermatol2013;58:157. 13. A. Nast , B Dréno , V Bettoli, Z. Bukvic Mokos et al., ‘European Evidence-based (S3) Guideline for the Treatment of Acne’, 2016. <http:// www.euroderm.org/edf/index.php/edf-guidelines/category/4-guidelines-acne> 14. S Briganti, M Picardo, ‘Antioxidant activity, lipid peroxidation and skin diseases’, What’s new, 2003. <http://onlinelibrary.wiley.com/ doi/10.1046/j.1468-3083.2003.00751.x/full> 15. Thornfeldt CR, ‘Chronic inflammation is etiology of extrinsic aging’,  J Cosmet Dermatol, 2008. 16. <https://www.ncbi.nlm.nih.gov/m/pubmed/18254816/> 17. B. Vogelgesang & N. Abdul-Malak et al., ‘On the effects of a plant extract of Orthosiphon stamineus on sebum-related skin imperfections’, International Journal of Cosmetic Science, 2010. <http://onlinelibrary.wiley.com/doi/10.1111/j.1468-2494.2010.00581.x/full> 18. Renata Dawid-Pać, Medicinal plants used in treatment of inflammatory skin diseases, Postepy Dermatol Alergol. 2013 Jun; 30(3): 170–177. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834722/> 19. British Association of Dermatology, ACNE, <http://www.bad.org.uk/shared/get-file.ashx?id=65&itemtype=document>

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Effective Tattoo Removal Dr Zohaib Ullah discusses the challenges and limitations of treating tattoos with Q-switched laser technology With the tattoo industry booming and sales worldwide reaching nearly $2 billion a year and climbing,1 it is obvious that the market for the ever-increasing removal of such artwork is in high demand. Survey findings presented at the British Association of Dermatologists showed that around one-third of people regret their tattoos and a total of around 10% eventually do opt for tattoo removal.2 Given this, and the ever-evolving desire for speedy and painless results, the market for tattoo removal has come far from its true inception in the 1960s when laser usage became the norm. Prior to laser use, many different methods, including chemical peels, abrasion techniques with ablative treatments, excisions, microneedling and various other remedies were used, often with poor results, and high complication rates.3 Due to these complications, the gold standard for tattoo

removal has been Q-switched lasers. To understand why lasers are able to help in tattoo removal, we must first understand how they work. For the purposes of this article, we will focus purely on Q-switched lasers and upto-date methods, rather than historic usage of lasers, such as CO2 or argon-related. Although CO2 is still used today, for example in resurfacing treatments, it is not commonly in the scope for tattoo removal; CO2 took a back-seat due to the risks of unwanted complications, including post-inflammatory hyperpigmentation, burns and scarring, not to mention longer downtime.4

Q-switched lasers Q-switched lasers emit nanosecond pulses with a high peak power. These pulses are calculated based on the thermal relaxation time of a pigment, thus leading to less surrounding tissue being traumatised by the

532 nm Nd:YAG Frequency-

694 nm Ruby

doubled Light

1064 nm Nd:YAG Near infrared light

Red

Red (weaker)

Green and dark

Green but less on

pigments

dark pigments

High

Very high

High

Poor

Pigmentation

Pigmentation and

Pigmentation

concerns

vascular issues

issues

Low risk

Low risk

production Best targeted pigment Melanin absorption

Green

755 nm Alexandrite

Red/yellow/orange

Figure 1: Table shows which lasers are most suited to tattoo colours9

(not visible) Dark pigments

resultant burst of energy itself. This allows the pigment to be broken down into smaller fragments, whereby the bodyâ&#x20AC;&#x2122;s natural immune system can clear up the remaining pigment particles.5 The range of Q-switched lasers are 532 nm (frequency doubled Nd:YAG), 694 nm (ruby laser), 755 nm (alexandrite) and the 1064 nm (Nd:YAG). The most efficient laser in tattoo removal in recent times is the 1064 nm (Nd:YAG), given its ability to switch between the 1064 nm and the 532 nm, thus covering the largest light spectrum for tattoo pigments.6 This is demonstrated well in Figure 1. Although the other two wavelengths, 694 nm and 755 nm, have very good outcomes for specific colours in those ranges (Figure 1), having different laser devices for just one type of aesthetic treatment is not usually a viable business model. This would add to initial costs of supply vs. demand and they also have the highest risk of adverse events, when compared to the 1064 nm, such as pigment changes and or vascular/localised damage.7 This is why the 1064 nm is a viable option as a single device, as it is able to cover the largest spectrum, with most tattoos being in the darker range, thus giving the best overall outcomes. To understand how the tattoo is broken down, we must understand the theory of selective photothermolysis, which works on the basis that, in order to effectively treat tattoo pigment, the wavelength of light used must correspond to that which is maximally absorbed by that tattoo pigment.8 This depends generally on a few factors. The colour of the laser light must penetrate the skin; it must be highly absorbed by the target chromophore, but less than the surrounding tissues; the time or pulse duration must be very short so that the heat is dissipated before the surrounding tissues are affected, and that sufficient energy can be sent down to ensure effective pigmentation fragmentation.7 Several colours of laser light (quantified by light wavelengths) are used for tattoo removal (Figure 1). Subsequently, different lasers are better for different tattoo colours to a certain degree. The four types or lasers used interact very differently with pigment dependent on their parameters.9 Given the above, and looking at the light spectrum (Figure 2), it is easy to see why it is preferable to use Nd:YAG over the other choices, given its ability to target a larger area safely. If you follow the tattoo ink colour ranges at the bottom of Figure 2, and the corresponding level above, it shows that the

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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1064 nm Wavelength

Efficacy

532 nm Wavelength

Aesthetics Journal

Tattoo ink colour Figure 2: Efficacy of Nd: YAG laser wavelengths, defined by clearance of tattoo ink.10

level of efficacy remains high, apart from the very white-based colours. Pulse width/duration (total time of laser beam activation) is also a critical laser parameter as well as spot size/width of the laser beam. Light disperses once in the skin, hence the larger the spot sizes, the increased effective penetration depth of the laser light, enabling more effective targeting of deeper tattoo pigments. Larger spot sizes also help make treatments faster; this also works the other way â&#x20AC;&#x201C; when more superficial pigments need targeting, then a smaller spot size would help. Fluence (energy density) is another important consideration as this dictates how well the fragmentation will occur.7 Black ink has shown to be the easiest to work with when it comes to tattoo removal. This, with the combination of a lighter skin type, is the ideal environment for tattoo removal.11 Conversely, white ink has the lowest absorption over the visible light spectrum and hence is hardest to remove. Given this, whites/yellow and flesh tone colours are typically the most difficult to remove.12 It is also worth noting that white and lighter inks have a tendency to darken post-laser irradiation, but this is usually transient.13 This was

demonstrated in one study via an electron microscope, which showed post-irradiation white tattoo particles were still a mixture of large and small particles, whereas the black particles showed overall reduction in number and size, as well as some that were nonexistent after treatment.14 There is also Level 1 evidence to suggest that Nd:YAG lasers treat the most common colour, black, with excellent results.15 Bright colours are harder to deal with in the 1064 nm spectrum, but higher doses and repeated treatment is very well tolerated in this case.15

Complications There are a number of factors that determine how many treatments will be needed and the level of success one might experience. Age of the tattoo, skill of the tattooist, ink density and amount, colour and even where the tattoo is located on the body, all play an important role in how many treatments will be needed for complete removal. Nevertheless, complications and side effects can result from laser treatment and include scarring, hypopigmentation, hyperpigmentation, partial removal, infection, bleeding and tattoo ink darkening.

Some tattoo pigments contain metals that could theoretically break down into toxic chemicals when exposed to lights

Aesthetics aestheticsjournal.com

Although minimised in the advent of Q-switched lasers, complications can still occur at a rate of around 5%.16 Immediate complications include pain, blisters, crusting and pinpoint haemorrhage. These are more common in darker skins, using a higher fluence17 and can be easily minimised if topical anaesthetic is applied earlier or, in the case of crusting, blisters or infection, topical preparations to help soothe and treat. The most common complication is pigmentation issues, either hypopigmentation or hyperpigmentation. These occur four to six weeks after laser treatment and most of them are transient.18 However, longer lasting changes can occur, especially in darker or tanned skin, with up to 20% reported in those with darker skins.18 There are also Level 2 studies that suggest Nd:YAG is far superior in terms of not only outcomes, but also in reduction of complications such as hypopigmentation, which is much more common when using ruby and alexandrite lasers.19 There is some Level 3 evidence to even suggest a complication rate nearing 10% in patients when using ruby.20 Local allergic reactions, particularly to the red and yellow pigment, can occur in the form of pruritic papules, nodules or scaly plaques.21 Systemic reactions rarely occur, but have been reported.21 These local reactions may be early or delayed after several months or even years following tattoo removal.22 It is sometimes difficult to remove the tattoo in the first place, especially those with multi-layered or multi-coloured tattoos. This can sometimes leave a residual ink print, which can look like faded tattoos, which may also become unsightly. Alongside this, the skin texture can be affected, worsening this appearance. Also, newer inks have now begun to contain titanium, and with its highly reflective properties, can be hard to remove given the lasers being unable to fully penetrate them.20 Scarring is now less common given the introduction of 1064 Nd:YAG lasers, but is still a possibility if others are used at high fluences and with darker skins. In one such large level 2 study, adverse effects were observed in only 6.2% of patients with hyperpigmentation being the most common issue.23 It is thus important that the laser in question should be chosen according to the colour of the tattoo pigment and the patient's skin type. Generally, Q-switched 1064 nm Nd:YAG laser is safer in darker Fitzpatrick skin types, V-VI. The spot size, the fluence and the pulse duration are important and should be

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Topical imiquimod is also another favourable option, with effects of tattoo removal destruction almost twice as improved carefully selected. Some tattoo pigments contain metals that could theoretically break down into toxic chemicals when exposed to light.24 These are usually found from tattoos that have been done abroad, in unsafe environments or unregulated parlours. Although this has not yet been shown in vivo, it has been demonstrated in laboratory tests.24 Laser removal of traumatic tattoos may similarly be complicated depending on the substance of the pigmenting material. In one reported instance, the use of a laser resulted in the ignition of embedded particles of firework debris.25,26 Combatting complications These tattoo treatment limitations have led to some prevailing techniques to try to combat them and have shown some good progress. The ‘multi-pass’ technique (essentially overlapping an already treated area on the same sitting) has been found to be of good use,27 with Level 3 evidence suggesting that even by the introduction of increased passing over in the same session (around three to four, rather than the conventional one pass) helps to remove tattoos in a smaller number of sessions in total.27 Although there was an increased chance of epidermal injury, there were no adverse events or scarring. Dispersion of the tattoo inks was also much higher than via the conventional one pass method.27 Added to this, there is also some Level 2 evidence to suggest that the multi-pass technique, combined with topical agents, can improve immediate outcomes, more specifically related to the whitening effect made after the initial pass (multiple or single, the whitening effect is spontaneous after the first pass). A study by Reddy et al. evaluated the safety and efficacy of topical perfluorodecalin in facilitating rapid effective multiple-pass tattoo removal, and found it to be as equally effective as treatment without the topical agent.28 Topical imiquimod is also another favourable option, with effects of

tattoo removal destruction almost twice as improved, and with no adverse reactions, according to one study.29 Also, there is the obvious fact that some wavelengths cannot be reached by the current lasers on the market. These are usually related to the lower spectrum and thus harder to treat. Picosecond lasers – as assumed by the name – may well help in this field and the future for tattoo removal.30 They work by delivering pulsed energy in picoseconds, which is faster than the traditional nanosecond. This means that higher energy can be delivered, in a shorter period of time, resulting in maximal pigmentation removal and minimal damage to surrounding tissues.31 In my opinion, this would mean that removal would be faster, safer and above all much more directed and colourfriendly than ever before.

Conclusion Laser tattoo removal has come a long way since its inception in the 19th century, and continues to evolve. Although complications are becoming less frequent, with better controlled systems, it is likely to improve further with the first advent of the picosecond lasers. With this in mind, the only limitations continue to be the light spectrum in which to target different pigment colours, especially the white and lighter colours. With the tattoo industry itself booming, the ever more fluorescent/glitter and otherwise metallicbased pigments will be the next type of pigment removal that will need to be investigated. Dr Zohaib Ullah is the clinical director at My Skin Clinic and also a trainer at My Skin Clinic Training Academy, educating other medical practitioners in the field of aesthetic medicine. He specialises in non-surgical facial aesthetics, skin rejuvenation and antiageing treatments. He is a member of the BCAM and is procuring his Master’s degree in aesthetics.

REFERENCES 1. How big is the tattoo industry in the US and the world? Quroa <https:// www.quora.com/How-big-is-the-tattoo-industry-in-the-US-and-theworld> 2. Amanda L. Chan, Nearly one-third of people with tattoos regret getting one: study, Huffington Post, (2012) <http://www.huffingtonpost.co.uk/ entry/tattoo-regret_n_1654959> 3. Remove a tattoo, The history of tattoo removal, (2016) <https:// milwaukeeremoveatattoo.com/the-history-of-tattoo-removal/> 4. Fractional CO2 Laser Resurfacing Complications, William M. Ramsdell, M.D. Semin Plast Surg. 2012 Aug; 26(3): 137–140. 5. How Laser Tattoo Removal Works, Aztanza, <https://astanzalaser.com/ treatments/laser-tattoo-removal/technology/> 6. Kabir Sardana et al. Optimising Laser Tattoo Removal, J Cutan Aesthetic Surg. (2015) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411587> 7. Kilmer SL. Laser treatment of tattoos. Dermatol Clin. 1997 Jul;15(3):409– 17. 8. Natalie Kita, Selective Photothermolysis for Skin Conditions, <https:// www.verywell.com/what-is-selective-photothermolysis-2710175> 9. Beyer, Victor. “Laser Parameters Within Tattoo Removal”. Rethink the Ink. 10. Sacred Laser, Our Tech, <http://sacredlaser.co.nz/our-tech/> 11. Laser Tattoo Removal: A Clinical Update. Stephanie GY, Goh CL. J Cutan Aesthet Surg. 2015 Jan-Mar; 8(1): 9–15. 12. Vasold R, Naarmann N, Ulrich H, Fischer D, König B, Landthaler M, et al. Tattoo pigments are cleaved by laser light-the chemical analysis in vitro provide evidence for hazardous compounds. Photochem Photobiol. 2004;80:185–90. 13. Peach AH, Thomas K, Kenealy J. Colour shift following tattoo removal with Q- switched Nd-YAG laser (1064/532). Br J Plast Surg. 1999 Sep;52(6):482-7. 14. Leu FJ, Huang CL, Sue YM, Lee SC, Wang CC. Effects of tattoo ink’s absorption spectra and particle size on cosmetic tattoo treatment efficacy using Q-switched Nd:YAG laser. Lasers Med Sci. 2015 Jan;30(1):303-9. doi: 10.1007/s10103-014- 1657-6. Epub 2014 Sep 24. 15. Kirby W, Koriakos A, Desai A, Desai T. Undesired pigmentary alterations associated with Q-switch laser tattoo removal. Skin and Aging. 2010;18:38–40. 16. Kilmer SL, Lee MS, Grevelink JM, Flotte TJ, Anderson RR. The Q-switched Nd:YAG laser effectively treats tattoos. A controlled, doseresponse study. Arch Dermatol. 1993 Aug;129(8):971-8. 17. Anderson RR, Geronemus R, Kilmer SL, Farinelli W, Fitzpatrick RE. Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment. Arch Dermatol. 1993;129:1010–4. 18. Liu XJ, Huo MH. Permanent leukotrichia after Q-switched 1064 nm laser tattoo removal. Indian J Dermatol Venereol Leprol. 2011;77:81–2. 19. Kilmer, SL; Anderson, RR (Apr 1993). “Clinical use of the Q-switched ruby and the Q-switched Nd:YAG (1064 nm and 532 nm) lasers for treatment of tattoos”. J Dermatol Surg Oncol. 19 (4): 330–8. doi:10.1111/j.1524-4725.1993.tb00354.x. 20. Mankowska A, Kasprzak W, Adamski Z. Long-term evaluation of ink clearance in tattoos with different color intensity using the 1064-nm Q-switched Nd:YAG laser. J Cosmet Dermatol. 2015 Dec;14(4):302-9. doi: 10.1111/jocd.12162. Epub 2015 Jul 2 21. Bernstein EF. Laser tattoo removal. Semin Plast Surg. 2007;21:175–92 22. Anderson RR, Geronemus R, Kilmer SL, Farinelli W, Fitzpatrick RE. Cosmetic tattoo ink darkening. A complication of Q-switched and pulsed-laser treatment. Arch Dermatol. 1993;129:1010–4. 23. Bencini PL, Cazzaniga S, Tourlaki A, Galimberti MG, Naldi L. Removal of tattoos by q-switched laser: Variables influencing outcome and sequelae in a large cohort of treated patients. Arch Dermatol. 2012;148:1364–9. 24. Rashid A. Ganeev, Opthalmology and Advanced Laser, Laser-Surface Interactions, Springer Science + Business (2014) 25. Mankowska A, Kasprzak W, Adamski Z, Long-term evaluation of ink clearance in tattoos with different color intensity using the 1064-nm Q-switched Nd:YAG laser. J Cosmet Dermatol. 2015 Dec;14(4):302-9. doi: 10.1111/jocd.12162. Epub 2015 Jul 2. 26. Charles R Taylor, Laser Ignition of Traumatically Embedded Firework Debris, Lasers in Surgery and Medicine (1998) http://v21.io/files/lasersfirework-tattoos.pdf 27. Kossida T, Rigopoulos D, Katsambas A, Anderson RR. Optimal tattoo removal in a single laser session based on the method of repeated exposures. J Am Acad Dermatol. 2012 Feb;66(2):271-7. doi: 10.1016/j. jaad.2011.07.024. Epub 2011 Oct 27. 28. Reddy KK, Brauer JA, Anolik R, Bernstein L, Brightman L, Hale E, Karen J, Weiss E, Geronemus RG. Topical perfluorodecalin resolves immediate whitening reactions and allows rapid effective multiple pass treatment of tattoos. Lasers Surg Med. 2013 Feb;45(2):76-80. doi: 10.1002/ lsm.22106. Epub 2012 Dec 19. 29. Elsaie ML1, Nouri K, Vejjabhinanta V, Rivas MP, Villafradez-Diaz LM, Martins A, Rosso R. Topical imiquimod in conjunction with Nd:YAG laser for tattoo removal. Lasers Med Sci. 2009 Nov;24(6):871-5. doi: 10.1007/ s10103-009-0709-9. Epub 2009 Jul 15. 30. Torbeck R et al. Lasers in tattoo and pigmentation control: role of the PicoSure laser system. Med Devices (Auckl). 2016 May 2;9:63-7. doi: 10.2147/MDER.S77993. eCollection (2016). 31. Picosecond Lasers, Photonics Encyclopaedia <https://www.rpphotonics.com/picosecond_lasers.html> [Accessed 31/05/2017]

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Illouz reinjection of raw material, in the French publication Annals of Plastic Surgery in 1999. I emphasised the importance of the instrumentation and the underlying anatomy to prevent the main complications of the Coleman technique, which include the unpredictability associated with painful bruising and the necessity of additional graft sessions to touch up the inconclusive outcomes.5

The FAMI technique

Case Study: Male Facial Rejuvenation Mr Roger Amar presents a case study of a male patient who was successfully treated using his facial autologous muscle injection fat transfer/ stem cell procedure As we age, many patients choose to undergo aesthetic treatments to address facial wrinkles and folds. Regularly, these patients opt for hyaluronic acid filler injections and, while they do often offer successful results, their benefits are temporary. It’s therefore often necessary for patients to come back to the needle, again and again. Fat transfer, on the other hand, can offer permanent solutions without the downtime associated with traditional plastic surgery. The first report on autologous fat grafting was published in 1893 by Neuber,1 who described implantation of small quantities of adipose tissue to correct adherent scars from

osteomyelitis. The technique continued to be widely utilised in plastic and reconstructive procedures to augment breasts and for the correction of chin and nose deformities. However, it was the advent of liposuction in the 1980s that opened new horizons for autologous fat transplantation. French plastic surgeon Mr Yves Gerard Illouz, who invented the mechanical liposuction, first described the reinjection of non-purified fat into other parts of the body in 1983.2 A few years later, French plastic surgeon Mr Pierre Fournier proposed the syringe liposuction technique and reinjection of the aspirated fat in the face using the same simple syringe.3 Fat transfer techniques became very popular in the medical Frontal fat pad world in 1995 when New York surgeon, Sydney R Coleman, Temporal fat pad released two harvesting Eyebrow position Luer-Lok cannulas (non-leaking cannulas), a small electrical lab Eyelids centrifuge and two injecting Levator Luer-Lok cannulas to make fat transfer easier.4 After building Labii superiors experience in each of the techniques, I wrote on the Malar eminence advantages of Coleman’s purification of fat before Figure 1: Pre-procedural planning of the patient showing areas that will benefit from the procedure. injection, over the Fournier and

To overcome the disadvantages associated with the Coleman system, in 1998, I introduced the idea of putting purified graft closer to, or inside tissue with maximum vascularity; the red muscles.5

The FAMI technique targets the individual muscles of facial expression, from their bone origin, to engraft the mesenchymal cells with the help of curved cannulas, which duplicate the skull curvatures The graft is placed behind or inside flat muscles or the round red mimic muscles. Mesenchymal tissues in contact with highly vascularised tissues immediately develop a neo-vascularity that guarantees the graft retention, which is the benefit. This was the beginning of the Facial Autologous Muscular Injection (FAMI) technique. In 2001, biologist Patricia Zuk from the University of California, Los Angeles, isolated the mesenchymal stem cells (MSCs) from adipose tissue and called them ‘adipose-derived stem/stromal cells’ or ‘ADSCs’. She stated that mesenchymal stem cells from fat have the same properties as embryonic stem cells. With this

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Aesthetics Journal Before

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Before

After

Figure 2: Patient before, and one year after, one session using the FAMI procedure. Notice the new position of the nose with an apparent columella supporting a smaller nasal tip. Nasolabial folds are less deep and the wrinkling less obvious.

scientific background, the FAMI technique experienced an important development in the quality of results, which hadnâ&#x20AC;&#x2122;t been found in other kinds of fat transfers.6 Fat grafting, as performed by Coleman, is conducted inside the subcutaneous fat plane with a straight cannula and the micro-graft is placed to have maximum contact with the recipient tissue.3,4 The FAMI technique, however, targets the individual muscles of facial expression, from their bone origin, to engraft the mesenchymal cells with the help of curved cannulas, which duplicate the skull curvatures.7

Case study A 50-year-old male patient sought a rejuvenation procedure to make him appear younger. Due to ageing, the patient had a narrowed frontal region, hollow temporal areas, flattened malar bones and orbital rims, causing a sagging of the eyebrow, lids, cheeks and lower face. He did not want an invasive procedure that involved incisions and scarring; however, he said that he would accept a rhinoplasty to reduce his nose size because there is a generally low risk of the procedure resulting in a visible scar. Consultation During the consultation, it was explained to the patient that undergoing the FAMI procedure could correct the frontal and temporal fat compartments, the eyebrow position, the eyelid wrinkling, the lateral nose depressions, and restore the malar eminence with slight effect on the nasolabial folds (Figure 1). As this patient was concerned with the relative size of his nose, he was happy to learn that reshaping the mid-face would make his nose less prominent, avoiding nose surgery. I explained that his nose would look smaller after restoration of the suborbital lid support by injection of the levators labii alaeque nasi muscles, filling the lateral nose depressions.8

The patient was notified that ecchymosis around the eyes could occur and would last for three weeks after the procedure and that there would be a slight swelling for 10 days. He was also informed that there was a possibility of an unsuccessful outcome due to the quality of his fat stem cells. Unfortunately, it is not possible to test the stem cell quality before the procedure. The age, lifestyle and medical history are the only objective indicators. It is difficult to find in the literature contraindications to the FAMI procedure since few papers have been written within the last ten years. Based on my experience of more than one thousand cases, patients who must be dismissed include those with

these procedures donâ&#x20AC;&#x2122;t touch the bone structure, muscle function and/or deep fat pads, the FAMI procedure is still possible. Multiple sessions of botulinum toxin to the frontalis can cause muscle atrophy with poor vascularity that could endanger the survival of the transplant.9 The patient was also notified of the possible side effects, which include: swelling, slight bruising and temporary asymmetries. Some photos of immediate follow up of other patients, with their authorisation, were shown to the patient to reiterate the possibilities. I have so far not reported any nerve or vessel damages, but the possibility should also be discussed with the patient. I recommend using 17 gauge cannulas

The injection of stem cells has restored the orbital contours, malar, zygomatic bone and maxillary bone surfaces, and given fullness to about 15 upper and mid-face mimics muscles and filled the frontotemporal fat compartments solar elastosis, hidden depressive disorder with anhedonia, smoking or alcoholism addiction or general pathologic conditions, such as high blood pressure, diabetes, and tumour history.8 Previous facial surgeries or cosmetic filler injections could influence some superficial deformities and can complicate the approach; however, since

so the injections avoid blood vessels and motor branches of the facial nerve, which is the cause of the main complications of classic face-lifting. The procedure I advised the patient to come to my clinic one hour before the two-hour procedure

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


@aestheticsgroup

with an empty stomach except for the oral premedication of 7.5mg midazolam. Preparation The face is prepared with chlorhexidine solution and draped to show the face and neck from the frontal hairline to the clavicles. Harvesting In the consultation the best harvesting area was discussed with the patient, which was determined as the abdomen and flanks. For women, the anterior abdomen and ‘love handle’ regions are preferred. This is because the fat in these areas are generally abundant with mesenchymal cells at any age, which are the first to make new adipocytes during weight gain.10 Klein’s anaesthetic solution, which contains lidocaine, is infiltrated within the subcutaneous space and the deep supra-aponeurotic plane. The fat deposit core remains relatively free of anaesthetic solution, which has been found to significantly harm the stem cells.10 The harvesting was conducted using 10ml, Luer-Lok syringes which are then taped and put in the centrifuge. A maximum of 200ml can be harvested for a net quantity of 80120ml for engraftment. In my experience, most cases require around 60ml. Anaesthesia A trigeminal nerve block was then performed using Bupivacaine 0.5%, lidocaine 1% with adrenaline 1:200,000. Oral sedation alone can be sufficient for some patients; however, I find that most of them require intravenous sedation for better comfort. Centrifugation The 10ml Luer-Lok syringes are put in up to 12 tubes of centrifuge, specially designed for the FAMI technique. The role of the mechanical purification is to concentrate the adipose stem cells by destruction of fat lobules. The very high speed centrifugation or ultra-centrifugation of the harvested fat, is spun at 3,000-5,000G or 14,000G to get different concentrations of stem cells. The speeds are chosen according to tissues to inject; 3,000G for the fat pads, 5,000G for muscles and 14,000G for subperiosteal injections. Inside the syringe the processed fat is separated into three layers. The supernatant layer containing lipid is poured off and the lower layer containing blood, tissue fluid, and local anaesthetic is ejected from the base of the syringe, leaving the middle part

Aesthetics Journal

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containing ADSCs, stromal cells, vascular cells, endothelial cells, and mural cells, termed as the stromal vascular fraction (SVF). The transfer to 1ml syringes is then carried out with the help of a special Luer-Lok transfer hub.

mimic muscles and filled the fronto-temporal fat compartments. This case illustrates the benefits FAMI can have, showcasing the absence of scars, bumps, deformities, asymmetry or uneven discoloured skin textures.

Injections Ten 1cc syringes and four 3cc syringes were used for this procedure. The appropriate cannula was attached to a 1ml Luer-Lok syringe. The injection began at the bone with 15ml in this case, spun at 14,000G. Then, the muscles are injected. Practitioners not familiar with muscle injections regularly ask, “How are you sure that your cannula is inside the muscle?” The answer I give is, “A correct intramuscular placement, after entrance of the muscle sheath, is characterised by little or no resistance when the cannula is moved. During the injection.”8 I believe that the sensation of injecting muscle becomes familiar to any experienced surgeon who has practised on cadavers.

Conclusion

For each muscle, the injection was performed in a reverse mode. Each withdrawal injects the SVF in one to three passes, always in the direction of muscle fibres. The three muscle planes of the mimic muscles were injected symmetrically as follows: • 9ml to the deep plane (corrugators, levator anguli oris, mentalis, buccinators) • 15ml to the middle plane (levator labii superioris, levator labii superioris alaque nasi, zygomaticus major, depressor labii inferioris, platysma commissural origin, rysorius) • 17ml in the superficial plane (frontalis, procerus, orbicularis oculii, zygomaticus minor, depressor anguli oris, orbicularis oris)

REFERENCES: 1. Neuber GA. Fetttransplantation. Chir Kongr Verhandl Deutsche Gesellschaft für Chirurgie. 1893;22:66 2. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72(5):591-597. 3. Fournier P. Therapeutic megalipoextraction or megaliposculpture. Obes Surg. 1996;6(2):167-179 4. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24(2):347-367. 5. Roger E. Amar. “Adipocyte micro infiltration in the face or tissue restructuration with fat tissue graft”. Ann Chir Plast Esthet 1999; 593–608. 6. Zuk PA, Zhu M, Mizuno H, et al. Multilineage cells from human adipose tissue: implications for cell-based therapies.Tissue Eng. 2001;7(2):211-228. 7. Amar, R.E.; Fox, D.M.; Balin, A. “Cannulation and injection of the muscles of facial expression: a cadaver study”. Dermatol Surg. (19 January 2010) doi:10.1111/j.1524-4725.2009.01438.x. 8. Amar, Roger; Fox, Donald. “The facial autologous muscular injection (FAMI) procedure: an anatomically targeted deep multiplane autologous fat-grafting technique using principles of facial fat injection”. Aesthetic Plast Surg. (August 2011) 35: 502–10. doi:10.1007/s00266-010-9645-0. PMID 21298265. 9. Joseph Niamtu III. Complications in Fillers and Botox. Oral Maxillofacial Surg Clin N Am 21 (2009) 13–21 doi:10.1016/j. coms.2008.11.001 10. Anne-Claire Girard, Michael Atlan, Karima Bencharif, Manoj Kumar Gunasekaran, Pierre Delarue, Olivier Hulard, Christian Lefebvre-d’Hellencourt, Regis Roche, Laurence Hoareau, Franck Festy. New Insights into Lidocaine and Adrenaline Effects on Human Adipose Stem Cells. Aesth Plast Surg (2013) 37:144–152.

Finally, the deep fat pads were filled with 28ml to restore the upper face contours and restructure the mid-face: latero-frontalis, retro-orbicularis oculi fat, temporal, and suborbicularis oculi fat. A total of 84ml of SVF from the abdomen and flanks were injected for this case study. No sutures and no dressing were applied to avoid any compression on the face; only benzoin solution was applied for three days to protect the skin. One year after using the FAMI technique on my patient, rejuvenation around the eyes can be observed (Figure 2). The injection of stem cells has restored the orbital contours, malar, zygomatic bone and maxillary bone surfaces, and given fullness to about 15 upper and mid-face

The FAMI technique was developed to give more predictability and longevity to fat grafting techniques. To make this blind procedure safer, outstanding anatomical knowledge is a necessity, as is training on cadavers that are suitable for injection (frozen or embalmed). Mr Roger Amar is a plastic surgeon and graduate from the University of Paris. He is an assistant professor in Anatomy and Reconstructive Surgery at Marseille University, as well as being an active member of the French Society of Plastic and Reconstructive Surgery since 1980, the American Society for Aesthetic Plastic Surgery since 1985 and the Spanish Society for Aesthetic Plastic Surgery since 2002.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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refined carbohydrates, as well as eating plenty of oily fish rich in omega 3. In order to achieve the best results, diet and nutrition should be addressed several months before a treatment. In the short term, it is important to maintain hydration. As we know, alcohol increases the risk of bruising so it is best to advise patients not to drink the day before injectable procedures. It is also important to check if the patient smokes; smoking can inhibit vascular circulation, hence it can impede healing and increase the risk of infections, so it should be recommended for patients to stop smoking. Smoking also reduces the body’s supply of vitamin A and the absorption of vitamin C, both of which are essential in slowing the ageing process, therefore this should be a standard recommendation to your patients.3 Sleep should be assessed as it allows the body to rehydrate and recover moisture; also, a rise of growth hormone permits damaged cells to be renewed.4,5 Additionally, with sufficient sleep, there is greater circulation and oxygen flow to the skin, and toxins are also expelled. Long-term Dr Rekha Tailor details how to effectively prepare the lack of sleep results in collagen degradation and premature ageing.1 It would be ideal if patients skin for chemical peels and injectable treatments rested well at least one week before treatment, Optimum skin condition is fundamental to enhance the outcome of but as a minimum, a good night’s rest before the day of the a treatment, reduce the risk of complications, and help to enhance treatment is essential. and prolong the results of a treatment, resulting in happier and more satisfied patients. With proper skin preparation, generally Environment both the epidermis and dermis are improved, skin is smoother, It is also important to check whether patients are exposed to pigmentation is more even and barrier function is optimised. The pollution and traffic fumes, particularly if they live and work in a city.6 resulting skin has a healthy glow, is more tolerant and less irritable. Exposure creates free radicals, which damages cells, causes ageing and also affects skin healing.7,8 In a study in 2010, on 400 women, Consultation measurements were made on skin ageing and also how much A comprehensive consultation, thorough assessment and inpollution the women were exposed to. They found that air pollution depth skin analysis is the first step in preparing for any treatment. was linked to signs of skin ageing such as lines, age spots and Fundamental issues such as an unhealthy diet, lack of sleep, and hyperpigmentation. Increased pollution was associated with a 20% poor physical health all need to be assessed before treatment increase of age spots on the forehead and cheeks, as well as more as they can contribute to oily skin, acne, skin dullness, broken pronounced nasolabial lines, demonstrating that there is a connection capillaries, eye bags and dark patches of skin. between pollution and extrinsic ageing. In 2014, there was an analysis It is essential in the process of managing patients’ expectations to of several studies which showed that skin damage due to pollution take a series of photographs to discuss with the patient what can is a global problem; exposure to pollutants contributes to premature realistically be achieved and improved. Photography-based skin skin ageing; ozone depletes antioxidants from the skin; air pollution is analysis systems can take standardised photographs as well as providing a computerised analysis comparing patients’ scores to others of a similar age, which is very useful. It is vital that patients are informed of everything they need to know every step of the way, so a comprehensive treatment plan is developed for this purpose.

An Overview of Skin Preparation

Diet and lifestyle It is important to always ensure patients are well-hydrated and that they have increased their intake of antioxidants by including more vegetables and low-sugar fruits from the current minimum recommendation of five portions per day to ten portions per day. These protect the skin from free radical damage and improve general skin health.1 Dietary protein also helps to maintain a healthy skin structure and should be increased,2 along with reducing the intake of sugars and

As we know, alcohol increases the risk of bruising so it is best to advise patients not to drink the day before injectable procedures

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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damaging to health and diseased skin and people with sensitive skin are more susceptible to pollution damage.9 Health Another crucial element in preparing the skin for treatment is to find out if the patient has any allergies to any substances that are in the injectables or skin peels. This could be ingredients in the peel solution such as glycolic acid, lactic acid or salicylic acid. Reactions to the skin from these products can include changes to the skin colour, itching, a skin rash or hives.10 With regards to fillers, some patients are allergic to local anaesthetics such as lidocaine, however this is rare.11 Signs of allergic reactions can be severe, and even fatal, if the patient were to suffer anaphylaxis.12 Reports of allergic reactions to botulinum toxin are uncommon.13,14 It is also important to check for systemic diseases, for instance, myasthenia gravis (MG), if a neurotoxin is going to be injected. MG is an autoimmune condition that causes muscle weakness and muscle fatigue. Treatment of an MG patient with botulinum toxin could worsen their symptoms.15 Hence, I believe a person with MG should not be treated. Patients on immunosuppressant and chemotherapy medication are more prone to infections and therefore should also not be treated. Practitioners should exclude patients who have a history of cold sores since an injection could precipitate an outbreak. If a person has a history of this then an antiviral medication needs to be prescribed to prevent a breakout.16 Before any treatment begins, patients must also be fully recovered from any illness or surgery. This is important so that patients recover quickly and reduce the risk of complications. Preparation To reduce the risk of infection and a biofilm developing, which can lead to chronic infection,17 it is imperative that the skin is prepared using sterile gloves and an aseptic technique prior to administering injections. This regime is crucial before any aesthetic procedure, as it contributes to optimum results and a speedy recovery time. Specific treatments can be used to reduce the risk of bruising. This includes taking Arnica tablets, a herbal supplement, before injectable procedures, and consuming pineapple, which contains bromelain, before treatment which has been suggested to reduce swelling and inflammation.18 Patients should also avoid taking aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), fish oils, vitamin E and other blood thinners due to the risk of bleeding.

Skincare routine A good place to start, which is both simple and effective, is to introduce patients to a good daily skincare regime. Skincare usage can result in dispersion of pigmentation and hence a more uniform and even skin tone. It can also improve the barrier function of the skin, reduce inflammation and plump and firm the epidermis, hence reducing the risk of bruising. It is best for patients to start this regime six weeks before treatment if possible. Ingredients patients could benefit from in their skincare regime, depending on their individual needs, include: • Hydroquinone: supresses pigment production, however it is important to note that it can only be used for up to four to five months due to the risk of inflammation, rebound hyperpigmentation and reduced tolerance.19 • Vitamin A (retinol): breaks up existing pigmentation and increases cell turnover to brighten and even skin tone.

Aesthetics Journal

Aesthetics aestheticsjournal.com

• Vitamin C (ascorbic acid): exfoliates surface skin pigmentation and helps to brighten skin. • Glycolic acid: helps to exfoliate and remove excess pigmentation from the skin’s surface. • SPF 40+: to guard against UV damage and hyperpigmentation. By improving the skin quality and thickness, the risk of the Tyndall effect from dermal fillers is reduced. The Tyndall effect is a bluish discolouration that appears if hyaluronic acid is injected too superficially in the skin, therefore, by thickening the skin, this is less likely to occur.20

Conclusion For a successful outcome with many procedures, the patient needs to adhere to advice for several weeks beforehand. For some treatments, such as botulinum toxin and filler injections, less preparation is needed by the patient beforehand, but ensuring a good diet, hydration and healthy lifestyle can enhance the treatment results and reduces the chances of side effects. If a patient chooses to have a procedure done, skin preparation helps the skin through the ordeal, and will make it easier for them to see the results they want faster and more safely. Dr Rekha Tailor is the founder and medical director of health + aesthetics. She has been a qualified medical practitioner for more than 26 years and an aesthetic practitioner for more than 10 years. Previous to this, she was a fully accredited GP. Dr Tailor has received specialist training in the use and administration of all products and treatments offered by her clinic. She is a full member of the British College of Aesthetic Medicine (BCAM). REFERENCES 1. V. Lobo, A. Patil, A. Phatak, and N. Chandra, Free radicals, antioxidants and functional foods: Impact on human health, Pharmacogn Rev. 2010 Jul-Dec; 4(8): 118–126. 2. Susan C. Taylor, What to Eat for Glowing Healthy Skin, American Academy of Dermatology, November 15, (2007) 3. Rossi M, Pistelli F, Pesce M, et al. Microvasc Res. (2014) May;93:46-51, Impact of long-term exposure to cigarette smoking on skin microvascular function. 4. Esteé Lauder Clinical Trial Finds Link between Sleep Deprivation and Skin Aging’, University Hospitals, (2013), <http://www.uhhospitals.org/about/media-news-room/current-news/2013/07/esteelauder-clinical-trial-finds-link-between-sleep-deprivation-and-skin-aging> 5. Rachel Leproult and Eve Van Cauter, Role of Sleep and Sleep Loss in Hormonal Release and Metabolism, Endocr Dev, (2011) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065172/> 6. Andrea Vierkotter, et al., “Airborne Particle Exposure and Extrinsic Skin Aging,” Journal of Investigative Dermatology, July 22, 2010; (130):2719-2726, http://www.nature.com/jid/journal/v130/n12/full/ jid2010204a.html 7. Khalid Rahman, Studies on free radicals, antioxidants, and co-factors, Clin Interv Agin, (2007) Jun; 2(2): 219–236 8. Dr Jane Leonard, The Effects of Pollution on Skin, Aesthetics, (2016) 9. Jean Krutmann, et al., “Pollution and skin: From epidemiological and mechanistic studies to clinical implications,” Journal of Dermatological Science, September 13, 2014;1811(14)00193-5/abstract. 10. WebMD, What is Salicylate Allergy? (2017) <http://www.webmd.com/allergies/salicylate-allergy> 11. Dorota Jenerowicz, Adriana Polańska, Olga Glińska et al. Allergy to lidocaine injections: comparison of patient history with skin testing in five patients, Postepy Dermatol Alergol, (2014) <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC4112262/> 12. Emma Davies, Anaphylaxis, ACE group, (2016) <http://acegroup.online/wp-content/uploads/2016/01/ Anaphylaxis-v1.3.pdf> 13. Careta MF, Delgado L, patriota R, Report of Allergic Reaction After Application of Botulinum Toxin. (2015) <https://www.ncbi.nlm.nih.gov/pubmed/26063836> 14. Norbert Brüggemann, Lien Dögnitz, Lutz Harms et al. BMJ Case Report, (2009) <https://www.ncbi.nlm. nih.gov/pmc/articles/PMC3028521/> 15. Ian Wright, Andrea Civitarese, and Richard Baverstock, The use of intra-detrusor onabotulinumtoxinA in patients with myasthenia gravis, Can Urol Assoc J, (2016) <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5065409/> 16. Nestor MS, ‘Prophylaxis for and treatment of uncomplicated skin and skin structure infections in laser and cosmetic surgery’, J Drugs Dermatol, (2005). <http://www.ncbi.nlm.nih.gov/ pubmed/16300226> 17. Souphiyeh Samizadeh, Biofilm, Aesthetics, (2016) <https://aestheticsjournal.com/cpd/module/biofilms> 18. de Lencastre Novaes LC, Jozala AF, Lopes AM, de Carvalho Santos-Ebinuma V, Mazzola PG, Pessoa Junior A, Biotechnol Prog. (2016) Jan-Feb;32(1):5-13, Stability, purification, and applications of bromelain: A review. 19. Rashmi Sarkar, Pooja Arora and K Vijay Garg, Cosmeceuticals for Hyperpigmentation: What is Available? J Cutan Aesthet Surg, (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663177/> 20. Sclafani AP, Fagien S., ‘Treatment of injectable soft tissue Filler Complications’, Dermatologic Surgery, 35: s2 (2009) pp.1672- 1680.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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augmentation currently available, such as; Restylane Kysse, Belotero Balance/Intense and Teosyal RHA to name a few. Some patients will present with a clear idea of the filler they wish to have, alternatively I will offer advice on which I feel is most suitable. After discussion, my patient opted for Belotero Balance + lidocaine, a polydensified crosslinked gel, with both high-density (high levels of cross Aesthetic nurse prescriber Sarah Holness linked hyaluronic acid) and low-density (lighter levels details the lip augmentation treatment of of cross-linked hyaluronic acid) zones, within the same product.5 This enables it to homogeneously integrate a mature patient within the dermis and stay intact for an expected duration Beautification, enhancement and rejuvenation treatments for of six to twelve months, patient depending. Fine lines and wrinkles the lips date back to ancient Egypt. Coloured paste, olive oil, require superficial injection, but careful filler selection is necessary to and beeswax were added to animal fat and applied to the lips avoid visible or palpable product and the Tyndall effect.6 to moisturise and enhance colour. It is also documented that the Full medical history was discussed and documented, and an informed Japanese Geisha reddened their lips with crushed safflower petals.1 consent form completed and signed. Additionally, it’s worth verbally Today, there is a plethora of short duration plumping, moisturising, checking that the patient doesn’t have any recent or planned dental staining and glossing lip applications available; but, for a longer treatments, oral infections or antibiotics. duration and for a lip that is more defined with more volume, a nonPhotography, without makeup, before and immediately after treatment surgical lip augmentation can be offered. is essential, so you can document the patient’s treatment journey and Full, shapely lips, with minimal perioral rhytids are considered refer back to them when needed. attractive.2 However, I personally believe that achieving balance and Pre-treatment topical anaesthesia is my personal choice. Although harmony with other facial features, and resisting the request for an most hyaluronic acids contain lidocaine, the lips are heavily innervated. ‘overdone’ look, is more important. By applying a topical anaesthetic, the lip enhancement experience is more comfortable, although dental infiltration is an option. Anatomy For all my aesthetic treatments, I use a sterile dressing pack, Treating a mature lip, to enhance shape, support structure and add complete with a sterile gauze and gloves. Once the topical volume, can be more difficult than treating a younger patient, due anaesthetic is removed, scrupulous cleansing to the lips and to the natural ageing process, skin laxity, bone remodelling and the surrounding tissues is paramount. In this instance, I used Clinisept+, presence of perioral rhytids. which is a hypochlorous solution that is bactericidal, virucidal, Full examination of the anatomy prior to treatment is essential, sporicidal and has anti-inflammatory effects.7 including dentition. With age, teeth shorten, and bony remodelling of the mandible occurs. Bone density alteration has been attributed to Cannula versus needle; both have their advantages and cannula age, nutrition, hormonal changes, comorbidities, and tooth loss.3 requires fewer entry or pre-hole points, and is considered a safer The main arterial blood supply to the lips is from the superior and technique due to the blunt tip. I feel a needle is more precise, inferior labial arteries, which are branches of the facial artery, that have, however I am comfortable with either technique. I chose the needle in turn, arisen from the external carotid. The facial artery becomes the technique as I would also be using needle for the perioral area. angular artery lateral to the nose, merging with the dorsal nasal artery, Belotero Balance comes packed with 27g and 30g sterile needles. which emerges from the ophthalmic artery, supplied by the internal Using the 27g needle, I initially treated the upper vermillion border, carotid. The infraorbital artery has several anastomoses with the facial commencing laterally, and using a retrograde technique. Generally, artery and tributaries supplying the cheek and lips. The mental artery filler will flow into the potential space. Care should be taken not to supplies the chin and the lower lip.4 The blood supply, both arterial place excessive extrusion force on the plunger. and venous, is complex and has natural variations. With this patient, the Cupid’s bow and philtral columns were not augmented, as the patient felt this may give her an over-done Case Study appearance. Once both sides of the upper vermillion border were My patient was a 74-year-old female, with a previous history of upper augmented, a gentle smoothing of the product was done and face augmentation with another practitioner. On consultation, her symmetry was assessed. Aspirating prior to product placement request was for a lip enhancement, and addressing the fine perioral is important and injection of the upper red lip should be done lines, which she felt made her appear older. She desired ‘a natural gradually. I continued by injecting the lower vermillion border and and fresher appearance’. central lower red lip. In total, 0.7ml of product was used for the lips. With lip augmentation, there is a propensity for swelling, and patients Changing to the 30g needle, the remaining 0.3ml of product was need to be reassured that this is a frequent side effect and will distributed in the perioral lines using the flat blanching technique. resolve within three to four days. I offer an oral antihistamine prior to This requires stretching the skin with the non-dominant hand, placing treatment – unless contraindicated – and apply a single-use ice pack the needle bevel up, at an approximate 10-degree angle to the skin, covered with a sterile gauze prior to injecting, both to reduce swelling and placing a very small aliquot of product, observing the colour of and additional numbing of the lips. Everting the lips and palpating, the skin so that it blanches momentarily. The aliquot should not be and possibly visualising blood supply, plus checking the patient’s raised, but flat. This technique requires some practise to perfect.  natural ‘bite’, can be done at this stage. When undertaking dermal filler injections, the practitioner There are a multitude of hyaluronic acid fillers suitable for lip should be fully versed in the signs, symptoms and subsequent

Case Study: Treating Ageing Lips

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


Before

treatment protocols and management of complications. Fortunately, there are support networks available to join such such as the Aesthetic Complications Expert (ACE) Group, and an excellent reference book, such as After the Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment (second edition). During the treatment, I ask my patients to use a mirror to evaluate the upper lip once augmented, and again with the lower lip; Figure 1: Patient before and after lip augmentation with dermal filler. at this stage more filler can be added. I believe a slightly fuller lower lip is deemed more aesthetically proportionate in Caucasians. Following treatment, the lips and surrounding tissues are cleansed again. Gentle palpating of the injected area checks for any accumulation of product. Post-treatment information is given to my patients, including advice on avoiding applying makeup to the treated area for 12 hours, general hygiene, and my contact details, reiterating the importance of contacting me regarding any concerns or changes, no matter how insignificant they may seem. Posttreatment photos are also taken. The patient was delighted with the results, and a follow-up appointment was arranged for two weeks time, at which time no further filler was required.

Summary Lip augmentation is one of the most popular aesthetic treatments today, providing volume, definition and ultimately a more youthful appearance in a mature patient. Facial assessment and full patient consultation prior to treatment is essential. My personal mantra for all treatments is ‘subtle enhancement; less is more’. Sarah Holness is an independent nurse prescriber, having spent 20 years in the operating room as a surgeon’s first assistant. Holness built her own aesthetic business, while working for a major pharmaceutical company as a clinical aesthetic specialist, in both injectables and capital equipment. She is the owner and director of the Nightingale Clinic, and Sarah Holness Aesthetics. REFERENCES 1. G.Schneider and others, Skin Cosmetics: Ullmann’s Encyclopedia of Industrial Chemistry (Hamburg, Wiley-VCH, 2001) <http://onlinelibrary.wiley.com/doi/10.1002/14356007.a24_219/full>  [accessed 29th December 2017]. 2. Uwe Wollina, Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures Clin Interv Aging, (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3770626/> 3. Cemile Nurdan Ozturk and others, ‘Dentition, Bone Loss and the Aging of the Mandible’, Aesthetic Surgery Journal, 33 (2013) <https://academic.oup.com/asj/article/33/7/967/231073> [accessed 30 December 2017] (p.967-974). 4. Ralf J. Radlanski & Karl H. Wesker, The Face: Pictorial Atlas of Clinical Anatomy (Berlin,Quintessence Publishing Co, Ltd, 2012), 38. 5. Tran C. and others, ‘In vivo Bio-Integration of Three Hyaluronic Acid Fillers in Human Skin: A Histological Study’, Karger Dermatology Journal, 228 (2014) <https://www.karger.com/Article/ FullText/354384> [accessed 29 December 2017]  (p.47-54). 6. Micheels P and others,  ‘Two Crosslinking Technologies for Superficial Reticular Dermis Injection: A Comparative Ultrasound and Histologic study’,  J Clin Aesthet Dermatol, 10(1) (2017) <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC5300731/> [accessed 29 December 2017]  (p.29-36). 7. Shannon Kilgariff, ‘Spotlight On: Clinisept+’, Aesthetics, 4 (10) (2017) 34-35 (p.34).

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Treating Acne in Patients of Colour

Heightened inflammation is obviously a key factor in the development of scarring and pigmentation alteration – the sequelae linked to long-term physical and psychological morbidities associated with acne. Factoring inflammatory considerations into diagnosis, treatment and management is therefore critical.

Dr Loredana Nigro provides considerations for acne management in darker skin types Long considered to be a self-limiting disease of adolescence affecting 90% of teenagers, acne vulgaris and its sequelae can continue later in life, with 1% of men and 5% of women reporting ongoing lesions at 40 years of age.1 The physical and psychological morbidity associated with scarring and pigmentation change has significant psycho-social effects and potential remedial costs for patients.1 Acne is a chronic inflammatory disease of the pilosebaceous unit, with multiple causes and manifestations, both short and long-term. The higher propensity for inflammatory involvement, hyper/hypopigmentation and hypertrophic scarring in patients with skin of colour (those with Fitzpatrick skin type III-VI) has specific impacts for diagnosis, treatment and management.2 Lesions may be present anywhere on the body, but may be particularly prevalent in areas with high density of pilosebaceous units – the face, neck, chest and back.

Specific considerations for skin of colour In various studies of patients presenting with dermatological issues, acne is the most common primary diagnosis. Reporting proportions are similar for Caucasian, African and Asian origin patients.3 Skin of colour has different characteristics from those with lighter skin types – Fitzpatrick skin type (FST) I-II, and a differing distribution of the manifestations and sequelae of acne. Skin of colour indicates a greater risk of inflammatory involvement in presentation, and increases patient risk of scarring and pigmentation changes. Concomitant with these risks are some of the lifestyle issues associated with skin of colour – including widespread use of specific hair and skin cosmetics which may be comedogenic (pore-clogging) and/or pro-inflammatory, and lower usage of barrier protection. Observation and histological studies of lesions in skin of colour have shown marked inflammation in all lesion types – even where inflammation is not evident on clinical examination.2,4 Studies observed significant inflammation surrounding papules and pustules, extending into the reticular dermis, and postulated this as a reason behind the development of hyperpigmentation related to clinically observed mild/moderate acne in skin of colour.

Hair Skin Surface Sebum Follicle Sebaceous Gland

Diagnosis Practitioners must know the right questions to ask during the consultation phase. Initial diagnosis in patients should include lifestyle questions to establish inflammation risks, which is important for treatment of acne and sequelae. The causes of acne can include: inflammation, androgen driven increases in sebum production, ductal obstruction through keratinocyte proliferation, ductal obstruction through comedogenic topical products (pomade acne), or the proliferation of Propionibacterium acnes. Scarring and post-inflammatory hyperpigmentation are of particular concern to patients with skin of colour. While the most common differential diagnosis of acne vulgaris for light skin types is rosacea, in FST IV-VI patients, many clinically indistinguishable presentations may involve pomade acne or acne cosmetica.5 Topics should include:

Skin of colour indicates a greater risk of inflammatory involvement in presentation, and increases patient risk of scarring and pigmentation changes • Patient skin type – oily/dry • Beauty products/devices used (including hair) – patient observation of inflammatory effects • Skin changes related to diet or season • Medications used, including any skin lightening products, photosensitising medications, antibiotics, combined oral contraceptive pill (COCP) • Patient and familial medical history (keloid, G6P-dehydrogenase deficiency) • Current use of sunscreen, including regularity/discipline

Clinical progression of acne1 1. Abnormal keratinocyte proliferation and epithelial desquamation leads to follicle obstruction

(microcomedone). 2. Increased subsurface sebum production, causes blackheads/whiteheads and substrate for bacterial growth, leading to proliferation of Propionibacterium (P.) acnes. 3. Finally, P. acnes release chemical mediators that promote inflammation, which is propagated by traumatic rupture of comedones into the surrounding dermis. 4. This inflammation manifests through the development of inflammatory papules, pustules, nodules, and cysts.

Figure 1: Pilosebaceous unit

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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• Correlated hormonal conditions/indicators e.g. polycystic ovary syndrome (PCOS) and hirsutism Treatment of acne outbreaks Treatment of acne in skin of colour should be early, aggressive, and appropriate. It comprises a wide range of modalities, as shown in Figure 2, and there is a large overlap with treatments for other skin types. Additional considerations should include:1-4,6 • Early and aggressive anti-inflammatory intervention (e.g. tetracycline, benzoyl peroxide) to reduce inflammation and longterm morbidity associated with scarring and post-inflammatory hyperpigmentation (PIH) • Management of external factors (elimination of certain cosmetics/introduction of sun barrier regime, which I recommend should be UVA 30+) • Caution/avoidance of treatments with additional risk factors e.g. I would avoid minocycline, which has been linked to increased fatal hypersensitivity in patients of colour7

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• Patch tests for contemplated topical treatments/laser (as many treatments may also cause pigmentation change/scarring in skin of colour) • Use of inflammation mitigating techniques such as cooling during heat-based treatments; for example, cold packs, hyper-cooled air or vapocoolant sprays Fundamentals of treatment Treatments for patients with acne should be individualised, and regularly reviewed to ensure that disease progression is controlled and long-term sequelae are minimised. Ongoing attention should be paid to lifestyle issues such as diet, barrier protection and inflammatory environmental factors. Care should be taken to identify any adverse reactions to medication or treatment which may increase co-morbidity, and especially to control inflammation. Key aspects when tailoring a treatment plan, based upon personal clinical experience: • Detailed history to understand individual pro-inflammatory factors

Treatment Type

Treatment

Considerations for skin of colour

Oral

Antibiotics – tetracycline, clindamycin, doxycycline

• • • •

Anti-androgen medication COCP Anti-seborrheic medication

Isotretinoin

Topical

Benzoyl peroxide

Azelaic acid Salicylic acid Alpha hydroxy acids Retinoids Lifestyle

Cosmetic and hair products Sun barrier protection Diet

Medical

Comedone removal Light therapy (PDT) Laser

Steroids

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Early tetracycline to address inflammation Pregnancy contraindications Doxycycline is a photosensitiser (sunblock) Avoid minocycline

• Cyproterone acetate – acts against testosterone, particularly important for female patients with PCOS

• Avoid androgen-containing brands. Androgens are implicated in acne genesis so combined pills that include androgens must be avoided • Women FST IV-VI show significant correlation between sebum production and acne incidence • Topical dapsone may be used even with G6PD deficiency • Important as a sebum controlling agent – high sebum production/acne correlation in skin of colour • Major complications are psychological including suicidal ideation and biological (anaemia, raised triglycerides and hepatic dysfunction)13 • Major teratogen – test negative pregnancy before commencement

• Long mainstay of treatment, particularly useful in skin of colour • Important to use pharmacological grade product appropriate for patient FST, with patch test • Up to 20% safe in FST I-IV

• Safe up to 20-% in FST I-IV • 10% limit for FST IV-VI (patch test important)14 • Appropriate formulation + patch test • Appropriate formulation + patch test

• Potentially comedogenic or irritating products should be elimination tested

• Barrier protection should be used rigorously during outbreaks, treatment, and for ongoing management • Strong links between high glycaemic load diets and acne prevalence • Useful for controlling localised outbreak • Use in conjunction with anti-inflammatory topical treatments • Blue light for bacterial control • Red light for inflammation reduction

• Study shows significant benefit in Asian patients (FST III-IV)2 • Suction under 400-1200 nm broadband light • Laser treatment of FST IV-VI should be approached with extreme caution following patch testing • Topical or Intralesional injections of steroids may be considered during treatment for analgesia, disease limitation (hypertrophic scarring)

Figure 2: My list for common acne treatment ingredients and skin of colour considerations. Some considerations are common to other FSTs.1-4,6

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Manifestation

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Long term sequelae

• Scars: o Multi-ingredient peels, effecting multi-layer peeling11 o Microneedling or mesotherapy to stimulate collagen production and skin smoothing o Laser – particularly fractionated laser systems – can achieve profound improvement but carry significant risks when treating skin of colour, as heat is a potent stimulator of inflammation. Treatment should be carried out with caution, by experienced professionals12

✓ ✓

Conclusion

Blackheads (open comedones) Whiteheads (closed comedones) Cysts Nodules, papules & pustules Bumpy skin Oily skin Redness Scarring (ice pick, boxcars, rolling) Post inflammatory hyper/ hypopigmentation

Keloid / hypertrophic scar

Figure 3: Manifestations and sequelae of acne vulgaris in skin of colour1

• Examination of all high-risk areas (not just face, but chest and back) • Control P. acnes and inflammation early during break-out (tetracycline, isotretinoin) • Peel treatments as an in-clinic mainstay (subject to patch tests). I have found that combination products containing 20% azelaic acid and 20% salicylic acid are effective • Home-based management centred around benzoyl peroxide and retinoids

Treatment of PIH and scarring The principal causes of acne-related morbidity in skin of colour are the sequelae of hyperpigmentation and scarring, which can be remediated by aesthetic practitioners. While prevention is better than cure, many skin of colour patients will present with existing scars or dyschromia. Concerns include: • PIH:8 o Control of melanocyte response with reversible tyrosinase inhibition. Combination products containing tyrosinase inhibitors, retinoids and botanical adaptogens demonstrate significant MASI score reduction9,10 o Mesotherapy – particularly with antioxidants such as vitamin C o Retinoids for epidermal shedding and diminished melanogenesis Before

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After

In patients with skin of colour, the increased susceptibility to inflammation can lead to long-lasting pigmentation change and scarring. Certain treatments may exacerbate the development and severity of these conditions. When treating acne in patients with skin of colour, treat timeously and with an appropriate level of aggression. Control is essential to limit this chronic disease, and its adverse outcomes. Acne is the most common chronic condition facing aesthetic practitioners and an individual treatment plan is required for each patient. Disclosure: Dr Loredana Nigro is a KOL for mesoestetic, which produces acne treatments and chemical peels. Dr Loredana Nigro graduated from WITS Medical School in Johannesburg in 2003. She worked in internal medicine in South Africa’s public health sector until 2009, and decided in 2010 to move into aesthetic and antiageing medicine in private practice. She is currently a senior aesthetic clinician at Riverbanks Clinic in Harpenden and works with patients of all ages and skin types. REFERENCES 1. Dawson and R. Dellavalle, ‘Acne vulgaris,’ BMJ, vol. 346, no. 5, p.2634 . 2. Davis and V. D. Callender, ‘A Review of Acne in Ethnic Skin: Pathogenesis, Clinical Manifestations, and Management Strategies,’ , 2010. <https://ncbi.nlm.nih.gov/pmc/articles/pmc2921746> 3. M Henderson, J. Abboud, C. M. Cogan, L. M. Poisson, et al., ‘Skin of Color Epidemiology: A Report of the Most Common Skin Conditions by Race,’ Pediatric Dermatology, vol. 29, no. 5, pp. 584-589, 2012. 4. P. Dunwell and A. Rose, “Study of the skin disease spectrum occurring in an Afro Caribbean population,” International Journal of Dermatology, vol. 42, no. 4, pp. 287-289, 2003. 5. Albert M. Kligman, Otto H. Mills Jr., ‘Acne Cosmetica’, Arch Dermatol. 1972;106(6):843-850. 6. Taylor SC, Cook-Bolden F, Rahman Z, Strachan D, ‘Acne vulgaris in skin of colour,’ Journal of the American Academy of Dermatology, vol. 46, no. Supp 2, pp. S98-106, 2002. 7. F. Poli, ‘Acne on pigmented skin.,’ International Journal of Dermatology, vol. 46, pp. 39-41, 2007. 8. E. C. Davis and V. D. Callender, “Postinflammatory Hyperpigmentation: A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color,” , 2010. <https://ncbi.nlm.nih.gov/pmc/ articles/pmc2921758> 9. W. A. Fisk, O. . Agbai, H. . Lev-Tov and R. K. Sivamani, “The use of botanically derived agents for hyperpigmentation: A systematic review,” Journal of The American Academy of Dermatology, vol. 70, no. 2, pp. 352-365, 2014. 10. P. E. Grimes, “Management of hyperpigmentation in darker racial ethnic groups.,” Seminars in Cutaneous Medicine and Surgery, vol. 28, no. 2, pp. 77-85, 2009. 11. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing. The Journal of clinical and aesthetic dermatology. 2010;3(7):32-43. 12. Shivani B. Kaushik & Andrew F. Alexis, ‘Nonablative Fractional Laser Resurfacing in Skin of Color: Evidence-based Review’, J Clin Aesthet Dermatol, 2017 Jun; 10(6): 51–67.  13. Langan SM, et al. Acne, isotretinoin and suicide attempts: a critical appraisal. Br J Dermatol. 2011. 14. Marta I. Rendon, MD, Diane S. Berson, et al. ‘Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing’, J Clin Aesthet Dermatol. 2010 Jul; 3(7): 32–43.

Figure 4: Patient presenting with acne, before and after treatment. Patient was treated with two sessions of the azelan peel, three weeks apart. Images courtesy of ELO LEMOS Clinic.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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by light, thus preventing damage to the underlying hypodermis.8 As such, it is important to remember that, in any pigmentation treatment, we are not looking to remove the capacity of the skin to produce melanin altogether, but simply to lighten its excesses and control its irregular production.

Pregnancy and pigmentation

Considerations for Hyperpigmentation during Pregnancy Dr Yusra Al-Mukhtar provides a background of hyperpigmentation and explains which treatments are deemed safe during pregnancy Background Hyperpigmentation is defined as excess pigmentation in the skin, and can occur secondary to excess sun exposure, inflammation, or endocrinological changes.1 Pregnancy, in particular, increases the risk of hyperpigmentation of the face, hands and body.2 Usual patterns of pigment for pregnant women include linea nigra found on the abdomen, darkening of the areola, and pigmentation that can affect the face, neck and décolletage. Melasma is a common skin condition in adults, in which light to dark brown or greyish patches of pigmentation develop, usually symmetrically. This often occurs during pregnancy, most commonly on the face, and is often referred to as ‘the pregnancy mask’, typically presenting across the mid-face and malar region in a butterfly fashion. When the cause of the pigmentation is gone, the pigmentation may start to fade, though melasma, in particular, can be troubling and in some cases long lasting, and may result in significant psychological distress to the patient. It is also notoriously difficult to treat and there is no one definitive modality of treatment. Understanding the pathology and management is therefore imperative if we are to correct, or control, this condition. The purpose of this article is to assess different

treatments available for hyperpigmentation and will discuss which ones would be suitable for pregnant patients.

Pathology Melanin is produced by melanocytes in the stratum basale via a process known as melanogensis.3 Melanocytes are cells that contain melanosomes, which are small sack-like organelles, in which the melanin is formed. The main chemical reaction is the conversion of the amino-acid tyrosine into melanin pigment, by the action of the enzyme tyrosinase.4 There are essentially two types of melanin made: eumelanin, which gives a red pigment, and pheomelanin, which gives brown pigment. Once synthesised, melanin is moved along arm-like structures called dendrites, to reach the keratinocytes. Over 150 genes have been identified that influence pigmentation5 and the base activity relies on various epigenetic factors which influence the density of pigmentation in the skin, depending on the skin type, which can be identified from the Fitzpatrick scale.6,7 The Fitzpatrick scale is a numerical classification for human skin colour and is based on the patient’s reports of how their skin responds to the sun, as well as skin, hair and eye colour.7 The main function of melanin is to protect the skin from ultraviolet B (UVB) radiation by its ability to absorb the energy generated

In pregnancy, hyperpigmentation tends to develop in the first trimester, though in first pregnancies, its appearance may be delayed until several months into the pregnancy.10 In subsequent pregnancies, pigmentation often appears earlier and can be darker than that experienced in the first pregnancy.11 The exact cause remains unclear, but it is thought to occur due to increased levels of hormones that can instigate increased melanin formation.11 These hormones include: • Melanocyte-stimulating hormone • Oestrogen • Progesterone The increased pigmentation can continue to progress during the pregnancy until delivery. The darkened areas usually fade in the post-partum period, though this may take several months and, in some women, may not completely fade.11 Melasma usually becomes more noticeable in the summer and improves during the winter months.12 Hyperpigmentation in pregnancy can have a significant impact on confidence and self-esteem, and often warrants treatment. It is vital, however, that the aesthetic practitioner counsels the patient appropriately, reassuring them that once the hormonal cause of the pigmentation, i.e. the pregnancy, is over, it is likely the pigment will fade. Nevertheless, there are certain treatments which are deemed safer for pregnant patients to use than others, as mentioned in further detail below.

Treatments There are a number of medicaments that have been reported as useful in the control of melanin production, as described below. The use of medicaments in pregnancy needs to be carefully evaluated by the clinician on a risk-to-foetus vs benefitto-mother basis; taking into account the extent to which they can penetrate the skin barrier and be absorbed systemically, thus potentially having a toxic effect on the developing foetus. Sun protection The use of sunscreens is fundamental in control and prevention of hyperpigmentation,

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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and is recommended during pregnancy and lactation, as in all other times of life. The physical sunscreens zinc oxide and titanium dioxide, which deflect and block the sun’s rays, are considered safe during pregnancy. Chemical sunscreens which absorb the sun’s rays include two general classes – the PABA (para aminobenzoic acid) derivatives and the cinnamic acid derivatives. Both are deemed safe and the actives do not penetrate the skin barrier.9 Sunscreen should be encouraged during pregnancy and beyond as a long-term preventative measure against sun damage. Hydroquinone and tretinoin Hydroquinone is a skin bleaching medicament used topically that works by inhibiting the action of tyrosinase thus preventing melanin deposition.4 This is typically used in a formulation of between 2-4%, and is often used in combination with a retinoid such as tretinoin which acts on different levels; facilitating the removal of pigment by accelerating the keratinocytes’ turnover; enhancing hydroquinone penetration through the stratum corneum; and protecting hydroquinone from oxidation.13 Hydroquinone is a benzene (an organic chemical compound) and its molecular structure allows it to fully penetrate the skin barrier.14 Studies have shown that up to 45% of hydroquinone is systemically absorbed following topical use in humans and, within minutes of application, hydroquinone levels are measurable in urine.15,16 The molecular weight of hydroquinone is small enough that is may cross the placenta,16 which can be potentially damaging for a pregnant woman, though, due to the lack of human studies, this remains unproven. This treatment requires commitment from

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the patient and an understanding that melasma can take months to years to treat, and requires appropriate long-term maintenance to reduce the likelihood of recurrence.17 Redness, peeling and itching is expected during this treatment – dermatitis with hydroquinone is reported in 25% of patients – so I would therefore recommend a patch test prior to initiating treatment. Despite controversy on the potential carcinogenic hydroquinone, at the low doses used cosmetically (2-4%), this treatment remains the gold standard in the management of hyperpigmentation. Hydroquinone should only be used under medical supervision, as long-term use can lead to the condition exogenous ochronosis, a grey-brown or blue-black hyperpigmentation of the skin.18 In pregnancy, both hydroquinone and tretinoin are deemed unsafe to use due to the potential toxic effects on the baby and the reported potential teratogenic effects of retinoids,19,20 so must not be prescribed for use. Skin peels Chemical peeling is the application of a chemical agent to the skin, which causes the controlled destruction of either part of the epidermis, or the entire epidermis, leading to exfoliation and the removal of superficial lesions. This creates the regeneration of new epidermal and dermal tissues.21 In melasma, chemical peels are used to remove unwanted melanin by causing a controlled chemical burn to the skin. Although a wide variety of agents are available for chemical peels, the choice becomes relatively limited when you are treating a patient with a Fitzpatrick skin type IV or above, due to the significant risk of developing postinflammatory hyperpigmentation.22 Glycolic acid is the most commonly used

Melasma is more resistant to treatment during pregnancy because of the persistent hormonal trigger for development of the disease, and treatment is therefore routinely deferred until after delivery

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alpha hydroxy acid (AHA) and is used frequently in treating hyperpigmentation. Animal studies, where relatively high doses of acid were used, demonstrated systemic absorption and resulting toxicity to the developing foetus, though one can argue that these findings cannot be extrapolated to human use, due to the significantly lower doses used in peels.23 Nevertheless, due to the lack of human studies in pregnancy, I would recommend against performing skin peels in pregnancy, particularly given that it is an elective aesthetic treatment that can be deferred post-partum. Other topicals Other topical ingredients that are beneficial in reducing hyperpigmentation include azelaic acid, arbutin, kojic acid, mandelic acid and liquorice extract.24 All of these ingredients are tyrosinase inhibitors and thus pigment suppressors. Salicylic acid is a beta hydroxyl acid, which can also be used to treat superficial pigmentation with good success, though again, salicylic acid use topically in pregnancy is not recommended by medical professionals, despite the low probability of systemic effect with the doses used in chemical peels.25,26 Kojic acid, a product derived from several species of fungi, as well as L-ascorbic acid (vitamin C) are deemed safe in pregnancy and lactation, as is AHA mandelic acid.27 This is because they have a large molecular size so do not enter the bloodstream, creating a systemic effect. This gentle AHA penetrates deep into the skin and breaks up areas of uneven pigmentation.28 Lasers IPL and lasers have been used to treat hyperpigmentation and work by selective photothermolysis, targeting the chromospheres melanin, and can be an effective treatment for stubborn hyperpigmentation or melasma. However, none have been tested for their safety profiles during pregnancy and there is a real risk of post-inflammatory hyperpigmentation being accentuated during pregnancy due to higher levels of melanocyte-stimulating hormones11 and, as such, this procedure must not be performed during gestation.

Summary When formulating treatment plans, patients should be informed that due to the limited data on the safety of many of the treatment modalities for hyperpigmentation, and the relatively short duration of wait in pregnancy,

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that the risk of treatment may not be justified. Melasma is more resistant to treatment during pregnancy because of the persistent hormonal trigger for development of the disease, and treatment is therefore routinely deferred until after delivery. Moreover, treatment may be unnecessary because melasma in pregnancy may be a transient affair; removal of the hormonal trigger after parturition may result in significant improvement.29 Emphasis should be made on prevention of pigment through appropriate sun protection including the use of sunscreens, hats, and staying out of the sun. Dr Yusra Al-Mukhtar is a dental surgeon with experience in head and neck surgery and facial aesthetics. She is a lead trainer for injectable courses with Oris Medical. Dr Al-Mukhtar has worked as an advanced injector for Destination Skin and works in private clinics in London and Liverpool. REFERENCES 1. AOCD, ‘Hyperpigmentation’ American Osteopathic College of dermatology’, <http://www. aocd.org/?page=Hyperpigmentation> 2. Miller M & Lee R. ‘Medical Care of the Pregnant Patient’, 2008; 729 3. Weedon, D. ‘Weedon’s Skin Pathology (ThirdEdition)’, 2010; 282 4. Cichorek M, Wachulska M, et al. ‘Skin Melanocytes: Biology and Development’ Postepy Dermatol Alergol. 2013 Feb; 30(1): 30–41. 5. Y Yamaguchi, V Hearing ‘Physiological factors that regulate skin pigmentation’ Biofactors. 2009; Mar–Apr; 35(2): 193–199. 6. Fitzpatrick, T.B. ‘The validity and practicality of sun-reactive skin types i through vi’, Archives of Dermatology, 1998; 124 (6): pp.869–871 7.  ‘The Fitzpatrick Scale’ Skin Cancer. New Insights for the Healthcare Professional. Scholarly Editions (2012) p.55 8. D’Orazio J, Jarrett S, et al. ‘UV Radiation and the Skin’ International Journal of Molecular Science, 2013 Jun; 14(6): 12222–12248. 9. DermaMedics professional, ‘An Overview of Human Pigmentation’ <https://www.dermamedics. com/hyperpigmentation_id60.html> 10. Winn H, Hobbins, J, ‘Dermatologic diseases’, Clinical Maternal-Fetal Medicine (2000) p. 386 11. Adekunie OG, Olaylwala BS, et al. ‘The Incidence of lower mid-trunk hyperpigmentation (linea nigra) is affected by sex hormone levels’, Journal of the National Medical Association 2005; 97: 685-688. 12. BAD, ‘Melasma’, British Association of Dermatologists (2009) <http://www.bad.org.uk/for-thepublic/patient-information-leaflets/melasma/?showmore=1&returnlink=http%3A%2F%2Fwww. bad.org.uk%2Ffor-the-public%2Fpatient-information-leaflets#.WjpaOt9l9PY> 13. K Godse, ‘Triple Combination Of Hydroquinone, Tretinoin And Mometasone Furoate With Glycolic Acid Peels In Melasma’ Indian J Dermatol. 2009 Jan-Mar; 54(1): 92–93. 14. National Center for Biotechnology Information. PubChem Compound Database; CID=785, <https://pubchem.ncbi.nlm.nih.gov/compound/785> 15. GG Briggs, RK Freeman, et al. ‘Drugs in pregnancy and lactation. Hydroquinone’ (2014) 16. P Bozzo, A Chua-Gocheco, et al. ‘Safety of skin care products during pregnancy’, Can Fam Physician, (2011) 17. Prignano F, Ortonne JP, et al. ‘Therapeutic approaches to melasma.’ Dermatol Clin. 2007;25:337–42.  18. ‘Exogenous ochronosis: case report and literature review’ Anais Brasileiros de Dermatologia. (2012) <http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962012000400021> 19. L Shapiro, A Pastuszak, et al. ‘Is topical tretinoin safe during the first trimester?’ Canada Fam Physician. (1998) Mar. 44:495-8. 20. Veraldi S, Rossi LC et al. ‘Are topical retinoids teratogenic?’ Ital Dermatol Venereol. 2016; 151(6):700- 705 21. Khunger, N. ‘Standard Guidelines of Care for Chemical Peels.’ Indian Journal of Dermatology, Venereology and Leprology 2008, p.74 22. Sarkar S, Bansal S, et al. ‘Chemical Peels for Melasma in Dark-Skinned Patients’ J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 247–253. 23. ROACCUTANE ‘Patient Information Leaflet’, (2017) http://www. leeclinicdermatology.ie/userfiles/ Roaccutane%20Patient%20 Information%20Leaflet.pdf 24. Davis E, Callender V. ‘Postinflammatory Hyperpigmentation, A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color’, The Journal of Clinical and Aesthetic Dermatology 2010, 3(7) pp.20-31. 25. James AH, Brancazio LR, Price T, ‘Aspirin and reproductive outcomes’, Obstet Gynecol Surv, 2008;63(1):49–57. 26. P. Bozzo, A. Chua-Gocheco, A. Einarson, ‘Safety of skin care products during pregnancy’, Can Fam Physician, 57 (2011) pp.665–667. 27. Shiffman M, Prendergast P, ‘Cosmeceutical Treatment of the Ageing Face’ Aesthetic Medicine: Art and Techniques (2011) p.79 28. Board of Directors of the American Society of Hospital Pharmacists, ‘American Hospital Formulary Service Drug Information’, Drug Information 84 (1984) p.560 29. D Bandyopadhyay, ‘Topical Treatment Of Melasma’, Indian J Dermatol. 2009 Oct-Dec; 54(4): 303–309

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Treating Psoriasis

blood pressure checks (two per week for the first two months, then monthly thereafter) to monitor for adverse reactions; if they occur, ciclosporin must be discontinued.10,11-13 The risk of hypertension In the second of a two-part article on treating and nephrotoxicity increases with increased dose and duration of ciclosporin and generally desists psoriasis, Dr Priya Patel reviews the systemic on discontinuation.12,13 Additionally, ciclosporin treatment options available for the disorder metabolism is influenced by cytochrome p450 and discusses some novel modalities enzymes; therefore, many drugs can interfere and interact with it, such as steroids, amiodarone, In part one of this article, which was published in the January erythromycin, phenobarbital, orlistat and the herbal remedy, St 2018 issue of Aesthetics, I discussed the topical treatment Johnâ&#x20AC;&#x2122;s Wort.9 This would limit ciclosporin use in elderly populations, options that are available for the chronic inflammatory disorder, given their comorbidities and polypharmacy. As ciclosporin psoriasis. Generally, patients are initiated on topicals and those is an immunosuppressant, patients have an increased risk of with more severe or refractory symptoms may need dermatological malignancies, with trials showing an estimated 2.2-3.8% increased assessment and systemic treatment, then biologics, depending on risk.9,14 These risks were at the higher end if patients had a past their disease severity and efficacy of the treatment. Many of these history of psoralen and ultraviolet A (PUVA), methotrexate or other therapies have been used for years and are known to be safe and immunosuppressants.10,14 Therefore, ciclosporin is contraindicated effective in most cases. However, newer therapies are emerging in patients with malignancies, renal dysfunction, and uncontrolled that are focusing on immunological pathways, which are showing hypertension or during lactation.9 Relative contraindications include promise and with time may be more cost-effective and safer than active infections, immune-deficiencies, chronic organ failures or traditional systemics. pregnancy.9

Systemic therapies Across Europe, treatment of moderate to severe psoriasis varies, as there is limited data comparing therapies. One study from 1977-2000 demonstrated that only 8% of randomised control trials compared different systemics, with merely two trials comparing more than two systemics (ciclosporin vs. etretinate).1-3 The limitations to most of the trials are due to inconsistent data regarding doses, length of treatment, incomplete outcomes, short follow-up times and small patient samples.1,4,5 However, although many studies do not allow for effective comparison of treatments, they do demonstrate efficacy of systemics, as discussed below. Systemic therapies include ciclosporin, methotrexate, retinoids, hydroxyurea and fumaric esters. Although many of these therapies have shown to be effective, they have increased toxicities compared with topicals, limiting their long-term use.6 Additionally, many are utilised in rotations to minimise the side effects. However, the difficulty with this is that psoriasis can flare or return whilst off treatment or during transition. In many countries, there are discrepancies between which systemic should be used as a firstline treatment. Ultimately, therapies should be chosen based on an individualâ&#x20AC;&#x2122;s comorbidities, psoriasis severity and patient choice after the benefits and risks are fully explained by the practitioner. Ciclosporin Ciclosporin has been used throughout Europe since the early 80s because many clinical trials have found it to be effective.4,7-9 It primarily acts as an immunosuppressant, with doses ranging between 2-5mg/kg in divided doses and gradually incremented by 0.5-1mg/kg over two to four weeks.9,10 After six to 12 weeks, if no response is seen, then therapy should be discontinued. If effective, patients should remain on treatment for one to two years as ciclosporin cannot be used long-term due to its cumulative side effects. It does however, achieve remission quickly, hence therapy can then be switched to longer-term agents such as retinoids, fumarates and methotrexate.4,9,10 The side effect profile includes hypertension, nephrotoxicity and immunosuppression. Patients need regular blood tests and

Studies One randomised control trial with 85 patients (43 in the methotrexate group and 42 in the ciclosporin group) with moderate to severe psoriasis showed 60% and 71% PASI-75 responses for methotrexate (discussed below) and ciclosporin respectively.1,15 Therefore, both were effective with ciclosporin having higher clearance rates, but not at a statistically significant level (p value=0.29).15 However, the sample numbers were small and therefore small differences could be missed. Another trial indicated methotrexate potentially has a faster clearance rate compared to ciclosporin, but the efficacy of both drugs was similar, with the limiting factor being a small sample size of 30 patients.16 Trials demonstrate clinical inconsistencies due to varying patient sizes, disease severity and follow-up periods.4,7 No one trial has used very large sample sizes, making the true efficacy harder to estimate. Nonetheless, ciclosporin is known to be effective in treating psoriasis, but patients should be warned about variable responses.6 Methotrexate Methotrexate is a known immunosuppressant, which has been used to treat psoriasis successfully for more than 40 years, despite the exact method of action remaining unclear and with no largescale randomised control trials conclusively proving its effects.4,17 Methotrexate is commonly given once per week as an oral dose based on weight, but can be given intravenously or intramuscularly, with a maximum dose of 30mg/week.18,19 However, the side effect profile is extensive; common side effects include gastrointestinal disturbance, headaches, bone marrow/blood dysfunction, fibrosis (pulmonary and hepatic are most common), hepatotoxicity, skin reactions or hypersensitivity and conditions associated with immunosuppression, such as malignancies or infections.7,18,20-22 Deaths have been reported with the use of methotrexate in the treatment of psoriasis due to fatal toxic reactions,18 however it is my understanding that these are uncommon. Similar to other systemics, the side effect profile increases with dose and duration, although this does not occur in all cases. Generally, side effects reverse with cessation or reduction of therapy.18,21 As the risks are

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extensive, it should only be considered in severe psoriasis that is refractory to topicals and the lowest doses possible should be used.21 It is contraindicated in patients with severe hepatorenal dysfunction and relatively contraindicated in bone marrow dysfunction, immunodeficiency and acute infections.18,20 Additionally, methotrexate is teratogenic and secreted during lactation; hence, patients must undergo pregnancy prevention schemes prior to drug administration.18 Furthermore, women should avoid pregnancy until one month post-discontinuation and men should not impregnate their partners until three months post-discontinuation.18,19 Alongside pregnancy prevention, patients must also have regular bloods tests – full blood count (FBC), urea and electrolytes (U+E) and liver function tests (LFT) – with additional liver biopsies if hepatotoxicity is suspected (note that this may not always show on routine blood tests).18,19,22 An additional test that can be performed is Type III procollagen aminopeptide (PIIINP), as normal levels indicate a lower risk of hepatic fibrosis and raised levels could warrant biopsy.23-25 Non-steroidal anti-inflammatories and salicylates can interact with methotrexate metabolism, increasing the risk of toxicity, thus concomitant use should be avoided, especially with existing renal dysfunction and folate deficiency.18,20,21,26 Overall, methotrexate patients should be carefully selected and monitored; however, it has been shown to be a relatively safe, well-tolerated and cost-effective medication.7,19,26-28 Studies Smaller case series, reports or retrospective studies have suggested methotrexate can reduce psoriasis severity by 50% in more than 75% of patients.4 One small study of 85 patients with moderate to severe psoriasis showed a 50-60% reduction in PASI scores after four months of using 15mg methotrexate.15 Comparatively, another small study with 30 patients demonstrated faster clearance in one month using an average of 27.7mg/week of methotrexate.1,16 Retinoids Retinoids are vitamin A derivatives, for which several formulations exist, but acitretin is widely approved in the US and Europe.29 Similarly to other systemics, its exact method of action has not been fully established; however, it acts as an anti-inflammatory, immunosuppressant and affects epidermal growth and differentiation.22,30 It has pharmacokinetic variability, thus the dose needs adjusting per patient but is usually given once/day at 2550mg.29,31 Retinoids are often used in combinations, such as PUVA, as they demonstrate poorer disease control as a monotherapy.6 Retinoids demonstrate variable half-lives, which is dependent on patient lifestyle and alcohol intake as this can prolong the half-life. The longest documented elimination half-life is 168 days, with three years for complete elimination of longer-acting retinoids.1 The major side effect is teratogenicity, hence it is contraindicated in pregnancy; it’s also contraindicated in women of child-bearing age as it interferes with oral progesterone contraception.29 Additionally, liver and lipid function can be affected, with clinical trials demonstrating 66% of patients developing hypertriglyceridaemia.1 Thus, patients with existing renal or liver failure or hypercholesterolaemia should not be given retinoids. Monitoring involves blood tests (FBC, U+E, LFTs, glucose and lipids) at least monthly during treatment.29 More commonly, retinoids cause mucocutaneous drying (xerosis, cheilitis and pruritus)7,30,31 with 75% of patients also experiencing drug-induced alopecia, which resolved on discontinuation.1,17 Some studies also demonstrate muscle and joint dysfunction with long-term therapy.7,31

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Overall, retinoids are effective, but given their side effects, are poorly tolerated by patients, with 10-20% discontinuing treatment.32 They seem to have greatest benefit when used as maintenance for immunosuppressed patients or patients achieving clearance with other medications like ciclosporin, as it is cumulatively less toxic than other systemics.30,33 Studies Clinical trials have shown retinoids to be effective. However, overall the data of trials is limited by variability in patients assessed (disease severity at baseline), retinoid dose and duration, use of other topical therapies and outcomes.4 Many trials collated into systematic reviews also have small patient numbers and short follow-up (two to four months).4 However, effective results have been seen in subtypes of psoriasis such as pustular and erythrodermic.33 Combinations with PUVA, discussed in Part One of this article, have shown good results whilst reducing the side effect profile of both therapies.4,34 One study of 135 patients utilising PUVA and retinoids demonstrated significant reduction in squamous cell carcinomas from 196 to 302 (p=0.002), although no difference in basal cell carcinomas was observed.35 Combination with narrow band UVB also showed efficacious treatment.4,34,36 Fumaric acid esters (FAEs) FAEs are chemical compounds that are only approved in a few European countries, such as Germany or the Netherlands, and are not used as a first-line treatment given their side-effect profile.6,4,37 They can be utilised in the UK, but only on an individual basis, usually with refractory psoriasis and contraindications to other therapies.6 Additionally, doses and recommendations appear to vary across the world with no clear consensus.6,37,38 Hydroxyurea can be used to manage psoriasis; however, haematological abnormalities can occur with hydroxyurea, but will generally improve with dose reduction or cessation. Overall, it is a favourable drug to use, although it should be used as a last-line agent and larger studies with longer follow-ups are needed.39,40 FEAs are marketed as Fumaderm or Dimethyl fumarate, which immunomodulates peripheral T-cells and reduces keratinocyte proliferation.37,41 Side effects for FAEs include gastrointestinal disturbance, which occurs in 67% of patients, and flushing, which occurs in 33%.37 The side effects tend to be delayed and occur four to 12 weeks into therapy, but improve after a few weeks or can be alleviated with other medications such as antacids, anti-emetics or antispasmodics.37,38,42 However, if symptoms persist, either dose reduction or discontinuation should be considered, this occurs in approximately 30-40% of patients.32,37,38 Generally, FAE are monitored via blood tests, every two weeks for three months, then monthly, as they can cause high or low white blood cell count and eosinophilia as well as increased LFTs, U+Es and lipids.37,38,42 FAEs need to be gradually increased and not used with other FAEs, as there have been previous reports of renal failure (acute and chronic) when both oral and topical FAEs were used or were used for prolonged periods.37,38,43-46 It can be used with gradual increments as both short and long term therapy for less than two years, although smaller studies have used it in patients for 14 years.37,47 It is contraindicated in patients with severe hepatorenal syndrome or gastrointestinal disease or an abnormal blood profile.37,38 There have been no safety trials to assess FAE in pregnancy or lactation; hence it’s currently contraindicated in these groups. Currently, guidelines also advise against combination therapies with other systemic agents as there is an increased risk of organ dysfunction.37,38

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Studies FEA has shown efficacy in a systems review using pooled data from five randomised control trials.4 One study showed a statistically significant (P<0.01) reduction of body percentage of psoriasis from 21% to 6.7% after 16 weeks of treatment, with 50% of patients achieving complete clearance.4,48 However, the number of patients used in this study was small (12). For it to be applied to a wider population, further studies are needed, particularly comparing FEA with other systemics. Other studies have shown FEA used in combination with topical therapies such as calcipotriol have better outcomes compared to isolated use.49 This combination showed 50% reduction in PASI in 143 patients after three weeks compared to nine weeks when used as a monotherapy.49

Novel modalities Newer agents, such as biologics, are a growing area for psoriasis treatment.6,50 Biologics are protein based chemicals cultured in laboratories from living cells.51 Many patients can be started on these if traditional methods have failed and their psoriasis is clinically and psychologically severe to warrant novel therapies.6,52 Some newer agents include tumour necrosis factor-α (TNFα) inhibitors (such as infliximab, etanercept or adalimumab).53-59 Anti-TNFα’s reduce the inflammatory process associated with psoriasis and have been shown to be comparable or better than ciclosporin.60 Other options include secukinumab, a human anti-interleukin-17A monoclonal antibody. A Taiwanese study of 51 patients showed 75% improvement in PASI after 12 weeks in 87.5% of patients compared to 0% of placebo.61 This has shown efficacy and safety during 52 weeks of follow-up and further trials are being conducted. Other newer agents emerging include itolizumab, an anti-CD6 humanised monoclonal IgG1 antibody, which has recently been used in seven Indian patients, refractory to other therapies.62 In this study, five patients responded positively to therapy with a PASI-90 and the remaining two responded well to PASI-7.62 Lastly, apremilast has emerged. This is an oral phosphodiesterase inhibitor, which has anti-inflammatory properties and has a favourable safety profile seen in two to three year data analysis.63 However, it appears to be better in those with a lower PASI score (<20) and with a lower BMI as those with larger BMIs endured more gastrointestinal side effects.64 Apremilast has shown efficacy with PASI-75 being achieved in patients after 16 weeks and participants even demonstrated small improvements in psoriatic arthritis.65 Overall, the advantages of biologics are they have longer remission periods and are effective for refractory psoriasis and some have been effective in psoriatic arthritis.60 However, they are very costly and the long-term safety profile has not been fully established; although, more therapies are continually emerging with further evidence being produced.60

Conclusion Generally, for mild to moderate psoriasis, emollients and topicals can be administered and managed in the community. However, complex cases will likely need dermatological assessment and review for possible systemics. Ultimately, failing all of the above, biologics can be considered in certain patients. At all times, a patient’s comorbidities and systemic disease associated with psoriasis must be assessed; with lifestyle recommendations given to prevent further complications. Lastly, the psychosocial impact

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of disease should not be overlooked and these burdens must be addressed for patients to feel valued and treated as a person not a disease. Dr Priya Patel is a core medical trainee at East Surrey Hospital. She is an aspiring dermatologist, and takes an active interest in topics involving allergy and immunology. REFERENCES 1. Naldi L; Svensson A; Diepgen T et al. Randomized clinical trials for psoriasis 1977-2000: the EDEN survey. Journal of Investigative Dermatolology. 2003;120: 738-41. 2. Mahrle G; Schulze HJ; Farber L et al. Low-dose short-term cyclosporine versus etretinate in psoriasis: improvement of skin, nail, and joint involvement. Journal of American Academy of Dermatology.1995; 32: 78-88. 3. Finzi AF et al. Italian Multicenter Study Group on Cyclosporin in Psoriasis. Cyclosporin versus etretinate: Italian multicenter comparative trial in severe plaque-form psoriasis. Dermatology. 1993; 187(1): 8-18. 4. Griffiths CEM; Clark CM; Chalmers RJG et al. A systematic review of treatments for severe psoriasis. Health Technology Assessment. 2000; 4:1-125. 5. Spuls PI; Witkamp L; Bossuyt PMM et al. A systematic review of five systemic treatments for severe psoriasis. British Journal of Dermatology. 1997;137: 943-949. 6. Naldi L; Griffiths CEM. Traditional Therapies in the Management of Moderate to Severe Chronic Plaque Psoriasis: An Assessment of the Benefits and Risks. British Journal of Dermatology. 2005; 152(4): 597-615. 7. Gawkrodger DJ, on behalf of the Therapy Guidelines and Audit Subcommittee of the British Association of Dermatologists. Current management of psoriasis. Journal of Dermatological Treatment. 1997; 8: 27-55 8. Mueller W; Herrmann B. Cyclosporin A for psoriasis. New England Journal of Medicine. 1979; 301: 555 9. Novartis. Neoral® soft gelatin capsules (ciclosporin capsules, USP) modified; Neoral ® oral solution (ciclosporin oral solution, USP) modified. Prescribing information, August 2002. 10. Griffiths CEM; Dubertret L; Ellis CN et al. Ciclosporin in psoriasis clinical practice: an international consensus statement. British Journal of Dermatology 2004; 150 (67): 11-23 11. Guenther L; Wexler DM. Inducing remission of severe psoriasis with low dose cyclosporin A. Canadian Journal of Dermatology. 1991; 3: 163-7. 12. De Rie MA; Bos JD. Cyclosporine immunotherapy. Clinical Dermatology. 1997; 15: 811-21 13. McClure SL; Valentine J; Gordon KB. Comparative tolerability of systemic treatments for plaque-type psoriasis. Drug Safety. 2002; 25: 913-27. 14. Paul CF; Ho VC; McGeown C et al. Risk of malignancies in psoriasis patients treated with cyclosporine: a 5 y cohort study. Journal of Investigative Dermatology. 2003; 120: 211-6 15. Heydendael VM,;Spuls PI; Opmeer BC et al. Methotrexate versus cyclosporine in moderate-tosevere chronic plaque psoriasis. New England Journal of Medicne. 2003; 349: 658-65 16. Sandhu K; Kaur I; Kumar B et al. Efficacy and safety of cyclosporine versus methotrexate in severe psoriasis: a study from north India. Journal of Dermatology. 2003; 30: 458-63 17. McClure SL; Valentine J; Gordon KB. Comparative tolerability of systemic treatments for plaque-type psoriasis. Drug Safety. 2002; 25: 913-27. 18. Lederle. Methotrexate sodium tablets, methotrexate sodium for injection, methotrexate LPF® sodium (methotrexate sodium injection) and methotrexate sodium injection. Prescribing information, August 2001. 19. Roenigk HH Jr; Auerbach R; Maibach HI et al. Methotrexate in psoriasis: consensus conference. Journal of American Academy of Dermatology. 1998; 38: 478-85 20. Said S; Jeffes EW; Weinstein GD. Methotrexate. Clinical Dermatology. 1997; 15: 781-97 21. Roenigk HH Jr; Auerbach R; Maibach HI; Weinstein GD. Methotrexate in psoriasis: revised guidelines. Journal of American Academy of Dermatology.1988; 19: 145-56 22. Tristani-Firouzi P; Krueger GG. Efficacy and safety of treatment modalities for psoriasis. Cutis. 1998; 61: 11-21. 23. Boffa MJ; Chalmers RJ; Haboubi NY et al. Sequential liver biopsies during long-term methotrexate treatment for psoriasis: a reappraisal. British Journal of Dermatology.1995; 133: 774-8 24. Boffa MJ; Smith A; Chalmers RJ et al. Serum type III procollagen aminopeptide for assessing liver damage in methotrexate-treated psoriatic patients. British journal of Dermatology. 1996; 135: 538-44 25. Zachariae H; Heickendorff L; Sogaard H. The value of amino-terminal propeptide of type III procollagen in routine screening for methotrexate-induced liver fibrosis: a 10-year follow-up. British journal of Dermatology. 2001; 144: 100-3 26. Haustein UF; Rytter M. Methotrexate in psoriasis: 26 years’ experience with low-dose long-term treatment. J European Academy of Dermatology and Venereology. 2000; 14: 382-8 27. Wollina U; Stander K; Barta U. Toxicity of methotrexate treatment in psoriasis and psoriatic arthritis— short- and long-term toxicity in 104 patients. Clinical Rheumatology. 2001; 20: 406-10 28. Kuijpers ALA; van de Kerkhof PCM. Risk-benefit assessment of methotrexate in the treatment of severe psoriasis. AmericanJjournal of Clinical Dermatology. 2000; 1: 27-39 29. Connetics Corporation. Soriatane® (acitretin) capsules. Complete product information, 2004. 30. Gollnick HP; Dummler U. Retinoids. Clinical Dermatology. 1997; 15: 799-810 31. Gollnick HP. Oral retinoids—efficacy and toxicity in psoriasis. British Journal of Dermatology. 1996; 135 (49): 6-17 32. Naldi L; Rzany B. Chronic plaque psoriasis. Clinical Evidence. 2002; 8: 1688-1708 33. Koo J. Systemic sequential therapy of psoriasis: a new paradigm for improved therapeutic results. Journal of American Academy of Dermatology. 1999; 41: 25-28. 34. Lebwohl M; Drake L; Menter A et al. Consensus conference: acitretin in combination with UVB or PUVA in the treatment of psoriasis. Journal of American Academy of Dermatology. 2001; 45: 544-53 35. Nijsten TE; Stern RS. Oral retinoid use reduces cutaneous squamous cell carcinoma risk in patients with psoriasis treated with psoralen-UVA: a nested cohort study. Journal of American Academy of Dermatology. 2003; 49: 644-50 36. Spuls PI; Rozenblit M; Lebwohl M. Retrospective study of the efficacy of narrowband UVB and acitretin. Journal of Dermatology Treatment. 2003; 14 (2): 17-20 37. Mrowietz U; Christophers E; Altmeyer P. Treatment of severe psoriasis with fumaric acid esters: scientific background and guidelines for therapeutic use. The German Fumaric Acid Ester Consensus

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Conference. British Journal of Dermatology. 1999; 141: 424-429 38. Fumedica Pharmaceuticals. Fumaderm® Initial/Fumaderm ®. Summary of product characteristics, 2003. 39. Sharma VK; Dutta B; Ramam M Hydroxyurea as an alternative therapy for psoriasis. Indian journal of dermatology, venereology and leprology. 2004; 70(1): 13-17. 40. Layton AM; Sheehan-Dare RA; Goodfield MJ; Cotterill JA. Hydroxyurea in the management of therapy resistant psoriasis. The British journal of dermatology. 1989;121(5): 647-653. 41. Treumer F; Zhu K; Glaser R et al. Dimethylfumarate is a potent inducer of apoptosis in human T cells. Journal of Investigative Dermatology. 2003; 121: 1383-1388. 42. Skaria AM; Schmid U. Antipsoriatic effect of fumaric acid derivates. Journal of American Academy of Dermatology. 1996; 34: 323-324 43. Altmeyer PJ; Matthes U; Pawlak F et al. Antipsoriatic effect of fumaric acid derivatives. Results of a multicenter double-blind study in 100 patients. Journa of American Academy Dermatology. 1994; 30: 977-81 44. Dalhoff K; Faerber P; Arnholdt H et al. [Acute kidney failure during psoriasis therapy with fumaric acid derivatives]. Dtsch Med Wochenschr 1990; 115:1014-1017 45. Roodnat JI; Christiaans MH; Nugteren-Huying WM et al. [Acute kidney insufficiency in patients treated with fumaric acid esters for psoriasis]. Ned Tijdschr Geneeskd. 1989; 133: 2623-2626 46. Raschka C; Koch HJ. Longterm treatment of psoriasis using fumaric acid preparations can be associated with severe proximal tubular damage. Human and Experimental Toxicology. 1999; 18: 738-739 47. Hoefnagel JJ; Thio HB; Willemze R; Bouwes Bavinck JN. Long-term safety aspects of systemic therapy with fumaric acid esters in severe psoriasis. British Journal of Dermatology. 2003; 149: 363-369 48. Nugteren-Huying WM; van der Schroeff JG; Hermans J et al. Fumaric acid therapy for psoriasis: a randomized, double-blind, placebo-controlled study. Journal of American Academy of Dermatology. 1990; 22: 311-12 49. Gollnick H; Altmeyer P; Kaufmann R et al. Topical calcipotriol plus oral fumaric acid is more effective and faster acting than oral fumaric acid monotherapy in the treatment of severe chronic plaque psoriasis vulgaris. Dermatology 2002; 205: 46-53 50. Young M; Aldredge L; Parker P. Psoriasis for the primary care practitioner. Journal of the American Association of Nurse Practitioners; 2017; 29(3): 157-178. 51. National psoriasis foundation: Moderate to Severe Psoriasis and Psoriatic Arthritis: Biologic Drugs. Accessed at: https://www.psoriasis.org/about-psoriasis/treatments/biologics 52. Feldman SR. Evolution in psoriasis management. The Journal of dermatological treatment; 2017; 28(3): 187. 53. Finlay AY; Salek MS, Haney J. Intramuscular alefacept improves health-related quality of life in patients with chronic plaque psoriasis. Dermatology 2003; 206: 307-15 54. Gordon KB; Papp KA; Hamilton TK et al. Efalizumab for patients with moderate to severe plaque psoriasis: a randomized controlled trial. Journal of American Medical Association. 2003; 290: 3073-3080. 55. Krueger GG; Papp KA; Stough DB et al. A randomized, double-blind, placebo-controlled phase III study evaluating efficacy and tolerability of 2 courses of alefacept in patients with chronic plaque psoriasis. Journal of American Academy of Dermatology. 2002; 47: 821-33 56. Krueger GG. Clinical response to alefacept: results of a phase 3 study of intravenous administration of alefacept in patients with chronic plaque psoriasis. Journal of European Academy of Dermatology Venereology. 2003; 17 (2): 17-24 57. Lebwohl M; Christophers E; Langley R et al. An international, randomized, double-blind, placebo-controlled phase 3 trial of intramuscular alefacept in patients with chronic plaque psoriasis. Archives of Dermatology. 2003; 139: 719-27 58. Lebwohl M; Tyring SK; Hamilton TK et al. A novel targeted T-cell modulator, efalizumab, for plaque psoriasis. New England Journal of Medicine. 2003; 349: 2004-2013. 59. Ortonne JP. Clinical response to alefacept: results of a phase 3 study of intramuscular administration of alefacept in patients with chronic plaque psoriasis. Journal of European Academy of Dermatology and Venereology. 2003; 17 (2): 12-16. 60. Umezawa Y. Mini-review:TNFα inhibitors treatments for Psoriasis. Inflammation and regeneration. 2008;28(1):27-30. 61. Wu NL; Hsu CJ; Sun FJ; Tsai TF. Efficacy and safety of secukinumab in Taiwanese patients with moderate to severe plaque psoriasis: Subanalysis from ERASURE phase III study. The Journal of dermatology; 2017. 62. Singh V. Clinical Outcome of a Novel Anti-CD6 Biologic Itolizumab in Patients of Psoriasis with Comorbid Conditions. Dermatology research and practice. 2016. 1-4 (article ID1316326) 63. Vangipuram R; Alikhan A. Apremilast for the management of moderate to severe plaque psoriasis. Expert review of clinical pharmacology. 201710(4): 349-360. 64. Del Rosso JQ; Kircik L. Oral Apremilast for the Treatment of Plaque Psoriasis. The Journal of clinical and aesthetic dermatology. 2016; 9(9); 43-48. 65. Haber SL; Hamilton S; Bank M; Leong SY; Pierce E. Apremilast: A Novel Drug for Treatment of Psoriasis and Psoriatic Arthritis. The Annals of pharmacotherapy.2016; 50(4): 282-290.

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A summary of the latest clinical studies Title: Cheek Volumization and Nasolabial Folds Authors: Lambros, V, Mowlds DS Published: Plastic and Reconstructive Surgery, January 2018 Keywords: Cheeks, hyaluronic acid, nasolabial folds, volumisation Abstract: The impression that cheek filling results in longitudinal shortening (‘lift’) of the skin and elevation of the nasolabial crease (NLC) or nasolabial fold (NLF) has become common within the facial injection community, but remains unsubstantiated. In this study, 77 patients were evaluated preand post-injection injection of the cheeks with a hyaluronic acid filler using a 3-dimensional camera system. A constant pattern of skin expansion away from the center of the injection and perpendicular to the surface of the skin was observed. A subgroup of 37 patients without differences in their preand post-injection facial expression were analyzed by direct comparison and failed to demonstrate lateral traction (or ‘pull’) on the intervening skin from the cheek injection site to the nasolabial crease. Further, there was no photographic difference in the nasolabial fold or nasolabial crease. The only patients who demonstrated photographic improvement of the medial face were those who had filler placed directly in the transition between the lateral nasolabial fold and cheek (nasojugal crease). It is likely that expanding the nasojugal crease is the direct visual cue that leads to perceived improvement in the nasolabial fold. Title: Safety and Efficacy of a Non-Invasive 1060 nm Diode Laser for Fat Reduction of the Abdomen Authors: Bass LS, Doherty ST Published: Journal of Drugs in Dermatology, January 2018 Keywords: Abodomen, fat reduction, laser Abstract: Changes in temperature are known to produce apoptosis in adipocytes. This study examines the use of a non-invasive treatment that applies 1060 nm laser energy transcutaneously to hyperthermically induce disruption of fat cells in the abdomen. 35 subjects received application of 1060 nm laser on the abdomen for fat reduction. Ultrasound images and high-resolution two-dimensional photography were recorded at baseline, six weeks, and 12 weeks post treatment. Subjects maintained a stable diet and exercise routine throughout the course of the study. Weight was recorded at baseline and each follow-up visit. Three board certified dermatologists were trained as blinded evaluators and tasked with identifying before and after photographs from randomized, paired baseline, and 12-week photographs. Ultrasound images were used to measure the fat thickness change from baseline at six and 12 weeks. Level of patient satisfaction was graded at 12 weeks using a six point Likert scale. 23% of subjects were Fitzpatrick IV-VI. Blinded evaluators correctly identified the post-treatment photograph 95% of the time (88%, 97%, and 100%). Mean reduction in fat layer thickness from baseline was statistically significant (P less than 0.001) at both six weeks (1.5 +/-1.23 mm) and 12 weeks (2.65 +/-1.41 mm). Mean weight change was +0.1 lb. Side effects were mild to moderate including edema, tenderness, and induration mostly resolving

within 1-3 weeks post treatment. No serious adverse events were reported. 1060 nm based laser treatment can consistently reduce the fat contour in the abdomen with an excellent safety profile in all skin types. The study met all three of its prospectively defined endpoints of success.  Title: Cutaneous Mycobacterium Massiliense Infection from Tattooing: A Common Yet Under-Reported and Persistent Epidemic Hazard for Dermatologists Authors: Anuszweski S, Harb J, et al. Published: BMJ Case Reports, January 2018 Keywords: Dermatology, infection, tattoos Abstract: Tattoo popularity continues to rise, with three in 10 Americans bearing at least one. Among tattoo complications, nontuberculous mycobacteria (NTM) has emerged as a global public health concern. NTM infections associated with tattooing of immunocompetent individuals have occurred as sporadic cases and community outbreaks. Water sources are considered the major pathogenic reservoirs. Tattoo-related inoculation has been linked to contamination of ink, either during the manufacturing process or during dilution of black ink using non-sterile water. NTM infections have also been documented in a number of cosmetic and surgical procedures, including cutaneous surgery, Mohs micrographic surgery, mesotherapy, liposuction and laser resurfacing. NTM inoculation through exposure to contaminated water or non-sterile instruments remains a challenge for dermatologists and risk to patients. We reported a case of cutaneous Mycobacterium massiliense infection following tattoo placement. This report underscores the importance of clinicians to consider NTM infections in the differential diagnosis of procedure-related reactions. Title: Clinical Evaluation of a Novel Fractional Radiofrequency Device for Hair Growth: Fractional Radiofrequency, for Hair Growth Stimulation Authors: Lotti T, Verner I Published: Dermatologic Therapy, January 2018 Keywords: Alopecia, hair, laser, radiofrequency, Abstract: AGA is a common disorder. Different treatments are available to prevent hair loss and achieve hair growth with variable results. The purpose of the present study was to evaluate the efficacy and safety of a novel fractional radiofrequency (RF) device (HairLux, Innogen Technologies Ltd., Yokneam, Israel), to prevent hair loss and induce hair growth. Twenty-five patients received 10 fractional RF treatments every 2 weeks, and were followed up 2 months after the last treatment. All patients were evaluated by global photography. In 10 patients, blinded manual hair counts were performed. Patients demonstrated less hair shedding, fuller hair, and faster hair growth. There was an average increase of 31.6% in hair density (based on hair counts) and 18% increase in hair shaft thickness. All subjects tolerated the treatments well. The HairLux device is effective and safe for hair growth stimulation in AGA. Ten treatment sessions are recommended to maximize results.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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and publications to their name, as companies often use KOLs to consult for them, conduct trials, give lectures and presentations, as well as publish clinical data. Marcia Angell, former editor-in-chief of the New England Journal of Medicine once said, “To buy a distinguished, senior academic researcher, the kind of person who speaks at meetings, who writes textbooks, who writes journal articles — that’s worth 100,000 salespeople.”3

What makes a good KOL? In our opinion, a good KOL will always be striving for development and growth. They will be educated to the highest level and have access to the most current information and trends, sometimes way ahead of their peers. A KOL should be naturally inquisitive in their own field of practice and will want to, or already will, make contributions to scientific and medical publications. Naturally, with the opportunity to work with the newest of treatments and devices, comes the real possibility of improving patient care and satisfaction. The Royal College of Physicians’ ‘The Seven Principles of Public Life applied to doctors' (Figure 1), provides an excellent basis for governing the relationship between doctors and the pharmaceutical industry.4 These seven principles relate to personal attributes every health professional should portray to maintain a healthy, transparent relationship when engaging with a pharmaceutical company.

Training

The Role of a KOL Dr Martyn King and nurse prescriber Sharon King explain the role of a KOL What is a KOL? Key opinion leaders (KOLs) are physicians or other healthcare professionals who influence their peers' medical practice, including, but not limited to, prescribing behaviour, meaning to prescribe one product/drug over another.1 However, an online survey of 185 pharmaceutical professionals and 199 KOLs in Berlin revealed that 62% believe the term KOL should be replaced due to its negative connotations. These include the fact that peers may feel KOLs judgement and promotion of a product may be dependent on what they are being paid by a company.2 Often KOLs are chosen due to their prescribing behaviour and spend, although other practitioners are often more interested in thought leaders with academic standing

KOLs are often expected to demonstrate or train on behalf of a company. In these circumstances, the KOL must take responsibility to ensure standards are met, treatments are conducted in an appropriate facility, models are fully consented and appropriate aftercare and follow-up is arranged. When training other practitioners, the KOL must ensure this is done safely and training protocols are adhered to (most companies will have a training manual stipulating appropriate product, injection technique and volumes), and be prepared to stop a delegate from treating when patient safety is compromised. Training is not a time for KOLs to disregard the training manual and show off their own skills or techniques, as this may be replicated by delegates and lead to an adverse event which the company must deal with. The KOL should only allow the company to issue certificates of successful completion of training when they feel the practitioner is competent to undertake the procedure in their own practice. There have been numerous circumstances over the years, in our experience, where we have had to intervene and either refused to issue a certificate, or recommended attending a further training course. Prior to training, the KOL should ensure that the company has verified the professional status and current registration for all

Selflessness

Doctors should act solely in the public interest. Their responsibility to patients must override all other interests.

Integrity

Doctors should not place themselves under any financial or other obligation to the industry, which may influence the performance of their duties as a doctor.

Objectivity

Doctors should make decisions based on the best available independent scientific evidence.

Accountability

Doctors are accountable for their decisions and actions. They must submit themselves to whatever scrutiny is appropriate to assure the integrity, objectivity, and honesty of their work.

Openness

Doctors must be as open as possible about the decisions and actions they take. They must be prepared to give reasons for their decisions.

Honesty

Doctors have a duty to declare any private interests relating to their public duties. They should take steps to disclose or resolve any conflicts arising in a way that protects the public interest.

Leadership

Doctors should promote and support these principles through leadership and example.

Figure 1: ‘The Seven Principles of Public Life applied to doctors’ from The Royal College of Physicians4

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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but a disclosure may simply state the practitioner’s name and involvement with the company.

Other considerations

The KOL should only allow the company to issue certificates of successful completion of training when they feel the practitioner is competent to undertake the procedure in their own practice

Often, companies may insist that their KOLs only use products in their portfolio as a pre-requisite to becoming a KOL. As practitioners, our duty of care is to the patient and, if there is a more appropriate procedure or a safer product to use for an indication, we are professionally obliged to inform our patients of this and give them the option to choose a different product or procedure. We have found that there are many ‘self-professed’ experts in the aesthetics specialty who are very active on social media forums, as well as other platforms, and approach companies with their own demands to become KOLs. This can be awkward for both the company and the practitioner and, in our opinion, if you must ask to become a KOL, you don’t deserve to be one. Similarly, buying a lot of products from a company might make you a key account for them but does not necessarily make you an expert and does not automatically entitle you to become a KOL. From our experience, there will already be a good working relationship between the company and practitioner and the company will approach the practitioner themselves.

Conclusion delegates as, in our opinion, the number of aesthetic practitioners who have been removed from their professional register and continue to practice regardless is rather alarming. It is of equal concern the number of aesthetic doctors who claim to be aesthetic surgeons without ever completing their surgical training.

Payments Payments made by, and received from, pharmaceutical and device companies can often be a double-edged sword. Practitioners partnering with companies should always be mindful of their own professional codes of conduct about payments, coercion and bribery and should make themselves familiar with the Association of the British Pharmaceutical Industry (ABPI)5 and Medicines and Healthcare Products Regulatory Agency’s (MHRA)6 Blue Guide regulations on financial payments and endorsements. In January 2015, the ABPI, an executive agency sponsored by the Department of Health that regulates medicines, medical devices and blood products, started to collect data recording the amounts paid to individual doctors and to other healthcare professionals by pharmaceutical companies, and recorded the type of work for which the payment was made.5 They did this to highlight openness and transparency within the industry. Up until this point, pharmaceutical companies only needed to disclose the amounts they had paid for services on an aggregate basis. The data was made available for the public from 1st July 2016 and is freely available online.5 Being a KOL often attracts payment; this may be a retainer, a training/speaker fee, out-of-pocket expenses or a combination of these. Any fees should be justifiable and relative, and not prejudice best practice or patient safety, as this will be taken into consideration in the event of a complaint to the regulatory or professional bodies.7 Finally, if a KOL is acting on behalf of a company, there must be full disclosure at the outset, so all participants are aware of any conflicts of interest. Often, and ideally, a contract is signed

Over the years, we have acted as KOLs and speakers for more than 15 different pharmaceutical companies and distributors, but we have also declined a few when we felt their stipulations compromised our own clinical practice and morals. As a KOL, it’s important to be well educated, inquisitive, and have a strive for growth and development in the specialty. We would certainly advise any practitioner who is approached to be a KOL to be fully aware of any demands imposed by the company and to make a decision based on their own professional standings and not on financial inducements. Dr Martyn King is the director of Cosmedic Skin Clinic, medical director of Cosmedic Pharmacy, chair of the Aesthetic Complications Expert Group, member of the British College of Aesthetic Medicine and board member for the British Association of Sclerotherapists. He is a national and international accredited trainer and speaker and has written articles for leading journals. Sharon King is an NMC registered nurse, an independent prescriber and a board member of the British Association of Cosmetic Nurses (BACN). King is also a member of the Aesthetic Complications Expert Group and is the nursing director of Cosmedic Pharmacy. In addition, she is a clinical trainer and regularly trains on behalf of many leading aesthetic companies. REFERENCES 1. Nugent, T. Director of Marketing, Medical Marketing Services Inc. [http://www.pharma-mkting. com/glossary/keyopinionleader.htm] 2. Mack, J. A KOL By Any Other Name. Pharma Marketing News, April 2015. 14(3) 3. Seife, C. How Drug Company Money Is Undermining Science. Scientific American, December 2012. 307(6) 4. Committee on Standards in Public Life, Guidance The 7 principles of public life (1995) [https:// www.gov.uk/government/publications/the-7-principles-of-public-life/the-7-principles-of-publiclife--2] 5. ABPI, Disclosure UK [http://www.abpi.org.uk/ethics/ethical-responsibility/disclosure-uk/] 6. MHRI, The Blue Guide – Advertising and Promotion of Medicines in the UK (2014) [https://www. gov.uk/government/uploads/system/uploads/attachment_data/file/376398/Blue_Guide.pdf] 7. GMC, Good Medical Practice - Financial Arrangements (2013) [https://www.gmc-uk.org/guidance/ ethical_guidance/30188.asp]

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Using Paperless Medical Records Aesthetic practitioner Dr Brian Franks details how to transition from paper medical records to digital Around 2,500 years ago, ancient Greek physician Hippocrates used pen and papyrus to record medical records.1 Whilst medicine and technology has advanced considerably since then, it is remarkable that for many of us, the practice of recording, filing and retrieving patient information has not. Although there are excellent alternatives to the mighty pen, it is understandable why some practitioners are hesitant to embrace new technology. However, to meet the needs of an increasingly demanding world, with time becoming ever-more precious and, regulations requiring more transparency and increasing competition – it is necessary to change our behaviour and adapt to more efficient, effective and economic ways of running clinics. This move towards the paperless office started half a century ago with the advent of the first commercial computers, built by manufacturing company IBM in the 1950s, with hospitals as key customers.2 Yet, more than 50 years later, most clinics are still yet to wean themselves off paper completely. In order to leave our comfort zone, there has to be very compelling reasons to change. Fortunately, the speed of technological development means that there are now some remarkable digital systems available for the aesthetic medical practitioner. These digital systems have functions that include the ability to run a clinic’s entire operation and management, covering all areas from patient scheduling, medical questionnaires, consultations, consent forms, before and after treatment plans, patient aftercare notes, stock management, invoicing and reporting.

Digital systems Using a digital system has the potential to completely change how your clinic runs. It removes the hours filing and retrieving paper records, the stressful hunting for misplaced records, and printing out consent forms when you have run out. It also reduces the considerable time in clinic, long after the last patient has left, writing up notes and filing

before and after photographs on a potentially unsecure office computer. A comprehensive digital system will reduce the administrative burden enormously, freeing up practitioners’ time to see more patients. The front-ofhouse staff and other support staff will also have more time to answer calls and focus on patients. There are digital systems that will group questionnaires, consent forms, photos and medical notes in one location that can be filed securely and easily retrieved. Some systems even provide prepopulated medical notes for frequently occurring consultations, which are more comprehensive than quickly scribbled notes jotted down in a busy clinic. All of this assists in increasing patients’ satisfaction with the clinic’s services. Thus, when the practitioner’s consultation is over, the administration is also over and spare resources can be set free to work on operations that increase patients’ experience and building long-term patient relationships. In turn, this could lead to increased patient retention and spend, all helping to improve the financial performance of the business. One major advantage of cloud-based digital systems – where data and programmes are stored and accessed over the internet instead of a computer hard drive – as opposed to systems with local data storage, is the remote accessibility of clinic notes. This means that practitioners are able to view and add to the clinic note away from the office, if necessary. Finally, coming in May next year there is requirement under General Data Protection Regulations (GDPR), which among other things, will mean practitioners must know where all their patient records are at all times.3 This is possible with a tightly managed paper system, but it is considerably easier to comply when using a high-quality medical digital platform.

From paper to digital So, how do you move to the digital space? Firstly, you need to decide which system to use, as there is a plethora of choice for clinics and practitioners.

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Stage 1: Suitability of software The practitioner and the front of house staff must both be involved in the purchase process so the best system is acquired, to suit both practitioner and clinic staff. The most important criteria are: • Software that meets both the needs of the administrator and the practitioner. • Software that is highly secure.I suggest finding out if the provider is International Organisation for Standardisation (ISO) accredited; has robust data monitoring; undergoes regular third party penetration testing by a recognised security company (also known as ethical hacking); has hourly back-up; 256 bit AES encryption (a specification for the encryption of electronic data approved by the US National Security Agency for top secret information); an Incident Response Plan (IRP) if there is a data breach, such as the recent attack from a leading London plastic surgery clinic; and does the provider have cyber insurance? • Can medical data be easily retrieved when migrating from one computer system to a new computer system? Stage 2: Time vs. cost You should consider the amount of time you are currently spending on paperwork and what the cost of your time and the time of your support team adds up to. Even your ‘free time’ such as your evenings, if spent working, equates to a cost. With more available time, how much better would your customer service and revenue be? How much space is required for filing and what is the cost of printing? Most importantly, what is the cost of a lost medical record? When it comes to choosing a digital system, pricing varies from a free solution, such as Google Docs, to more expensive products. Stage 3: Support Support is critical and should be an important consideration. This could be to learn how to use a new feature or to fix a bug that you’ve come across. You need to find out what Service Level Obligations (SLO) the vendor offers and how critical issues are dealt with out of hours. In addition to technical support, does the vendor provide any support to help improve business performance? For example, in what ways can the software help you save time or grow your sales? Stage 4: Contractual terms What are the contractual terms for support, such as working hours of the support team,

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


contract duration, i.e. can you cancel at any time or is there a minimum period or a cancellation period? What support is there for set up, training/coaching, product development and costs of data migration from an existing database?

What is Normal?

The choice of supplier is a critical business decision and is a longterm commitment so needs careful consideration. The software is a core element of your business and will help greatly to market your business for sale at some point in the future. It will be an essential component of your future wealth and needs to be treated accordingly.

The transition When the system and supplier is selected, the most important task is installation. I found that this is best achieved with small steps. Many systems provide a range of features that the user needs to become familiar with over a period of months, as opposed to a few days. But in a few hours of training, the user should have a very good grasp of the essentials of the system. Most clinics already use computers for diary management or invoicing and it is essential to keep both systems running in parallel for at least a month to ensure a smooth transition. Some ways of working will inevitably be different and will take some adjustment. But the big change is in the management of paper. A useful check is to take the patient challenge. Simply take the first few patients on any given day (I find 10 is useful) and carry out the full patient pathway using the digital system and see how this compares to your tried and tested paper system. The benefits should become immediately apparent. My personal advice is to keep existing paper records. It is too time consuming to digitise these records. When seeing one of your existing patients, you will need to have their paper records to hand, but ask them to complete the medical forms on the new system and gradually, the paper record should, for most cases, only be needed one more time. Over the course of a year, the clinic will be able to transition fully to a digital system. 2,500 years further on; the four humours of Hippocratic medicine are no longer considered the best theory of the human body and, for an increasing number of aesthetic clinicians, pen and paper is also no longer the best technology. Disclosure: Dr Brian Franks is the key opinion leader for the Consentz digital record keeping system. Dr Brian Franks is the programme clinical director and senior lecturer for the MSc in Clinical Aesthetic Non-surgical Interventions at the European Dental and Medical Institute. He is a facial aesthetics practitioner and joint principal of the Level 7-accredited Dr Brian Franks Facial Aesthetics Training Courses. Dr Franks is a key opinion leader for the Consentz digital record keeping system. REFERENCES 1. Richard F. Gillum, From Papyrus to the Electronic Tablet: A Brief History of the Clinical Medical Record with Lessons for the Digital Age, The American Journal of Medicine, <http://www.amjmed. com/article/S0002-9343(13)00398-7/fulltext> 2. IBM 100, The IBM 700 Series, Icons of Progress <http://www-03.ibm.com/ibm/history/ibm100/us/ en/icons/ibm700series/> 3. Martin Swann, ‘Getting Ready for GDPR’, Aesthetics journal, July 2017. <https://aestheticsjournal. com/feature/getting-ready-for-gdpr>

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Selling Skincare Online Marketing consultant Adam Hampson discusses how aesthetic clinics and practitioners can use e-commerce to improve profit Many clinics are beginning to, or already, sell skincare on their websites as an additional revenue stream. Selling products online is known as e-commerce and, in my experience, allows the opportunity for a clinic to boost its bottom line and attract new customers. For patients, it can help to reduce confusion and uncertainty over which skincare to buy, as your clinic will effectively be a ‘one-stop-shop’, where they can purchase treatments, procedures and skincare, all from the same place. This article will outline how best to choose skincare to stock and how to start selling it online.

Choosing skincare to sell Choosing skincare that you really believe in, and understanding its benefits, is essential when choosing what to sell. Marketing a new arm of your business can be time consuming, often taking months, and costly, ranging from hundreds to thousands of pounds. It’s important to be certain that you’re ready to back your products completely, making them integral to the heart of your clinic and its services. There are numerous types of skincare that you could choose to sell, as discussed below.

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worth considering selling skincare that complements the treatments your clinic carries out, for example, selling a soothing moisturiser a patient could use following a chemical peel. This enables your clinic to build additional sales and boosts the relationship between you and your patient, as they are fulfilling both their treatment and skincare needs in one place. You’ll need to think about the prices your patients would be willing to pay and consider what other clinics are selling. Invest some time in finding out which ranges appear to be most popular on competitors’ websites and perhaps consider adjusting the price and the way you market your products so that you have an edge over your competitors. Signature skincare developed by a third party One option is to develop your own skincare range through a third party, which can be designed specifically for aesthetic clinics’ patient profiles and needs. Clinics can handpick the products with ingredients which they feel would appeal be most relevant to them. The products are branded for your clinic, helping you to establish your presence and credibility within a crowded market, and preventing being undercut by online sales. This solution presents a relatively simple and straightforward way of selling your own skincare range. With this option, you can set your own prices to maximise potential sales and profit. Unlike other cosmeceutical skincare ranges, customers will not be able to find other retailers that sell your branded skincare range, whether online or in store. This option is exclusive and helps to set your clinic apart from others.

Designing your own skincare range Investing in your clinic’s own skincare range can be extremely rewarding. At the same time, it’s both challenging and time consuming. It works in a similar way to launching a signature skincare range developed by a third party (see above) except that, instead of doing this through a consultancy, you develop the Skincare from renowned cosmeceutical brands products yourself. Although you will already have a strong idea Today’s skincare customer can be extremely discerning and of what your customers (and potential customers) want, carrying sceptical. You may choose to sell cosmeceutical products on your out market research and extensive competitor analysis is a critical website as, generally, they are formulated with more potent and starting point. You can do this by attending presentations and active ingredients for clinically-proven results than high-street events from competitors, contacting and arranging site visits skincare ranges.1 with manufacturers, and understanding the legal requirements Choosing a cosmeceutical range to sell should be based on the you need to comply with, including EU regulations.2 Joining patients you already have and those you’d like to attract. Talk to your an organisation such as the Cosmetic, Toiletry & Perfumery patients and listen to what they’re looking for in skincare – what are Association (CTPA) could be a good starting point for accessing their common concerns and conditions? Although most clinics have information on regulations and contacting other companies, their own recommendations for post-procedure treatment, it’s also such as manufacturers within the cosmetics industry, to discuss how best to begin.2 It’s also important to consider, and action, how you want Stock control and managing cash flow the packaging designed, as well as One of first the practicalities to consider is having the budget to buy stock, which will developing a marketing strategy, either depend on the approach you choose. It’s beneficial to speak to skincare manufacturers with an agency or on your own. The benefits and resellers directly to ensure you get the most competitive prices. You’ll also need of designing your own skincare range to check minimum order quantities to work out how much budget you will need to include complete ownership and creative set aside. Whenever possible, keep the number of products small until sales become control, enabling you to meet the needs of established, to cut potential risks. your customers whilst also appealing to new Until you begin to sell skincare, it can be difficult to forecast future sales. If possible, it’s potential customers. This ambitious option a good idea to have a financial buffer (keeping money aside in case of unexpected, involves more investment upfront, as it is emergency expenses) or cut other costs (such as investing in new technology or hiring more expensive (likely to cost thousands of new staff) during the roll out of e-commerce skincare. This can help to maintain a healthy pounds) and time-consuming (likely to take cash flow and establish profit and loss. about two years), than other alternatives previously mentioned.

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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E-commerce platforms The next thing you need to consider is the platform to sell your skincare. Selling and buying online has become the norm for many consumers nowadays. There is a strong focus on saving time and money by researching online, using mobile apps, developing more personal and relevant relationships with online retailers, and enjoying the convenience of faster delivery and lower prices.3 However, this means that selling advanced skincare with resultsbased benefits, is not enough in itself – it must be supported by a viable e-commerce platform. There are several options which can help a clinic achieve this. Rent an online store This option is relatively quick, simple and straightforward. There are several e-commerce solutions that enable you to set up an online store to sell products, including Shopify,4 BigCommerce5 and LemonStand.6 An online store is connected to your existing website and operates as the invisible ‘backend’ that runs the shop. Complete online store solutions provide themes which can be customised with colour, font and imagery, to create a platform that complements and reflects your clinic without the need for advanced design skills. Online stores also enable you to accept credit card payments and track and respond to orders quickly and easily. The core idea is that you will be able to focus on your clinic’s business instead of getting bogged down with e-commerce detail. Sales insight and information (included in some packages) from your online store is designed to help you understand sales, orders and trends, so you can tailor marketing and business activity accordingly. Find out before choosing a company whether they provide marketing features such as search engine optimisation (SEO), simplified pricing structures for major carriers, and the opportunity to grow your e-commerce solution with apps such as MailChimp for Shopify, enabling you to stay in touch with customers who have placed orders via email.7 Renting an online store can start at around £20 per month for a very basic site, or up to £200 a month for more advanced features designed especially for scaling a business,8 although there are several free trials and discount offers on the market. Shopify, for example, offers a free 14-day trial and BigCommerce a 15-day free trial. Going for this option should ensure a seamless and consistent experience for all customers, as the website templates are predesigned for smartphones and tablets as well as laptops and desktops. Add e-commerce to an existing website If your clinic already has its own functioning website, then it’s worthwhile considering adding to what you already have with an e-commerce plug-in or add-on (programmes that are easy to install and are used as part of a web browser). There are numerous solutions on the market including WordPress and Wix. WordPress provides an e-commerce plug-in known as WooCommerce (part of a package), which enables your clinic to gain immediate functionality for selling products upon installation.9 This type of solution is extremely popular with many online retailers. WooCommerce, for example, currently powers over 39% of all online stores,10 as it is easily accessible and relatively straightforward. Prices vary depending on package costs such as security and maintenance but, for extensions and web hosting, the average annual cost is around £380.11 Develop a dedicated e-commerce platform Larger clinics, or clinics with substantial e-commerce activity, may eventually look to create and build their own website from scratch, using a dedicated e-commerce platform tool such as Magento. This

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solution is more flexible than using hosted solutions such as Shopify or WordPress, as it is dedicated specifically to your clinic. Initial and ongoing investment is essential to develop scope, wireframes (designing a website at a structural level) and functional specifications that can be scaled, evolved and tailored over time.12 Magento is the world’s most popular e-commerce platform,13 and is different to an online store in that you use it to build a website from scratch, making it a good reference point for clinics considering a dedicated platform, with another alternative being OpenCart. You may also need to use the additional services of designers, developers or a web agency. You’ll be able to customise your platform for a unique and consistent brand experience and may have access to the expertise of implementation partners available through the platform’s website, to ensure your clinic gets the most from the investment. Ultimately, this is the most robust solution, making it the most expensive too.

Creating a marketing strategy You may already have a marketing strategy in place but if not, you’ll need to consider how you’re going to tell existing and potential customers that you are selling skincare online. A good starting point is sharing the news with the patients you already have. You could do this by notifying patients as they’re welcomed into the clinic for an appointment, or alternatively by email, telephone, posters and/or leaflets. Perhaps more challenging, is raising awareness for potential customers outside of your clinic. You could use your website and costeffective marketing methods such as social media and networking. Of course, you’ll need to budget for this type of marketing activity, accounting for costs such as designing leaflets, adding to your current website and attending events.

Conclusion Entering the world of e-commerce holds many benefits for clinics and practitioners. E-commerce is an additional revenue stream that works around the clock, making profit whether your clinic is open or closed. It also presents the opportunity to diversify your clinic’s business, making it more robust and resilient. Adam Hampson is the founder and director of Cosmetic Digital, a web design and digital marketing agency in Nottingham that works with clients in the cosmetic medical sector. He is also a public speaker on aesthetics marketing and branding. REFERENCES 1. LinkedIn, Key differences between drugstore, cosmeceutical and pharmaceutical skin care, <https:// www.linkedin.com/pulse/key-differences-between-drugstore-cosmeceutical-skin-care-skelly/ >, published 21st June 2016 2. Cosmetic, Toiletry & Perfumery Association (CTPA), About ctpa, <http://www.ctpa.org.uk/content. aspx?pageid=234 >, viewed November 2017 3. Entrepreneur, 5 ways technology is changing ecommerce, <https://www.entrepreneur.com/ article/288149>, published 26th January 2017 4. Shopify, What does Shopify do? < https://www.shopify.co.uk/faq/what-does-shopify-do>, viewed October 2017 5. BigCommerce, Home page <https://www.bigcommerce.com/?irgwc=1&utm_ term=Wl8SMBxvzRofV2rS6aTHxX2DUkmUCbSGtyuY0w0&utm_content=185949&utm_ campaign=237999&utm_medium=affiliates&utm_source=ImpactRadius >, viewed November 2017 6. LemonStand, Home page <https://lemonstand.com/# >, viewed November 2017 7. MailChimp, Use MailChimp for Shopify, < https://kb.mailchimp.com/integrations/e-commerce/usemailchimp-for-shopify>, updated 17th October 2017 8. Shopify, Pricing, <https://www.shopify.co.uk/pricing>, viewed December 2017 9. WordPress, About us, <https://wordpress.com/about/ >, viewed October 2017 10. E-commerce platforms, The best free WordPress ecommerce plugins, <https://ecommerce-platforms. com/articles/7-best-free-wordpress-ecommerce-plug-ins>, published May 2017 11. Biglione, K. How much does WooCommerce Cost? <https://wpapprentice.com/blog/how-much-doeswoocommerce-cost/> published Jan 2016 12. Power Retail, E-Commerce Technology Basics: Part Three – Dedicated E-Commerce Platforms, < http://www.powerretail.com.au/getting-started/e-commerce-technology-basics-part-three-dedicatede-commerce-platforms/>, published 19th June 2013 13. Magento, Why Magento, <https://magento.com/advantage>, viewed October 2017

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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In Profile: The Mayous Mr Bryan Mayou and Dr Susan Mayou reflect on their surgical and dermatological careers, as well as their achievements in aesthetics

“When people say thank you and write letters, that’s just the greatest pleasure” Mr Bryan Mayou grew up in Warwickshire and, like his father, always wanted to be a doctor. However, he never knew that he would succeed in bringing innovative treatments to the UK. “I went to Epsom College as a child, which at the time was basically a school for doctors’ children, so I was surrounded by medicine and everyone close to me knew I was really fascinated in surgery. Years later, after bringing liposuction to the UK, it’s now my favourite treatment,” he explains. After graduating from the University of Birmingham, Mr Mayou completed a Fellowship at the Royal College of Surgeons and then became a consultant plastic surgeon in the NHS. “Surgery was always enormous fun,” he says, “In the early days I worked very hard, for long hours, and I was on duty all of the time. I was very happy because I enjoyed what I did. I always found reconstructive plastic surgery fascinating because it was constantly developing, with so many new techniques and procedures, such as microvascular and endoscopic surgery and lasers.” Reflecting on the cosmetic surgery and aesthetic specialty’s developments, Mr Mayou says he is thrilled to have experienced such ‘dramatic changes’ in the treatment possibilities. He explains, “I have seen both the surgical and the non-surgical technologies develop really rapidly since my training. The rise of fillers to me was a surprise as the technology progressed so fast, but I have now used all sorts of fillers in my lifetime and I find that they are particularly good for damaged noses, where surgery is particularly difficult. I also find it interesting that certain surgical procedures are quite non-existent now, such as the surgical brow lift. I thought that would be a very prominent treatment but most practitioners use toxin, so I haven’t done one in many years!” As mentioned, Mr Mayou has played an important part in introducing

new techniques to the UK, with liposuction being his most cherished accomplishment. He elaborates, “I first heard about liposuction in 1982 through my next-door neighbour. At first, I thought it went against all the principles of plastic surgery and I didn’t think it would work – you’re just inserting a ‘sucker’ that blindly takes out fat, there is going to be bleeding and bruising, and it seemed unlikely you would get a nice smooth result. But one day, she told me she knew it worked because she had gone to France to have the treatment herself! So, I wanted to investigate.” Mr Mayou says that he later arranged for French and Swiss surgeons who were pioneering the techniques to visit the UK to teach him and other plastic surgeons. “We didn’t have the instruments in 1983, so I had to work with an instrument maker so we could do it. Liposuction became extremely useful in reconstruction and cosmetic surgery and I used it quite a lot. It was great because we could use it for really difficult-to-treat cases, such as gynaecomastia and ankles – which gives marvellous results.” Mr Mayou also took part in research, and set up a private laser and dermatological surgery unit called Laserway with dermatological surgeon Mr Neil Walker. He explains, “We were doing a lot of interesting research of vascular and pigmented birthmarks and tattoo removal. We did studies on children with big birth marks and big moles that might cover half the face or half the body. We would treat their skin surgically and with lasers – I always had a big fascination with lasers and we introduced the pulsed dye laser and ruby laser to the UK.” Working in private practice was something that Mr Mayou loved as he enjoyed the freedom of doing more of what he wanted. “Opening our own practice is something my wife, Dr Susan Mayou, and I really wanted to do. So, in 2007, we opened The Cadogan Clinic in Chelsea and, as Susan is a consultant dermatologist, it was perfect because we each have different experiences and knowledge,” he explains. In 2012 the clinic expanded and moved down the road. It now has three surgical theatres, six aesthetic treatment rooms, seven consulting rooms, and around 50 employees. Mr Mayou adds, “We have a comprehensive facility and provide a full service with experts in surgery, dermatology and other fields such as cosmetic podiatry, vascular surgery, gynaecology and non-surgical aesthetics. We have everything under one roof and when it comes to the aesthetics side, we get the doctors, nurses and aestheticians to all work together, so if the patient needs referring to a different specialist, they have access to that.” This clinic is among Mr Mayou’s biggest achievements, he says, “Winning The Dermalux Award for Best Clinic London was thrilling. Just having happy patients is a huge achievement for me. When people say thank you and write letters, that’s just the greatest pleasure.”

Mr Bryan Mayou

1969

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1977

1984

1985

1982

1988

Dr Susan Mayou

Graduated University of Birmingham medical school

Fellowship of the Royal College of Surgeons

Graduated University of London medical school

Training at St John’s Hospital for Diseases of the Skin

Senior registrar at St Thomas’ Hospital – dermatology

Consultant at Queen Victoria Hospital & St Thomas’ Hospital

Set up Laswerway

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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“There is nothing like teaching other people to make sure you get the facts right yourself” In her early days, Dr Susan Mayou, who grew up in Buckinghamshire, appeared to be headed towards a career in cardiology after completing her medical degree at the University of London. She explains, “I did my physician exams and worked at St Thomas’ Hospital specialising in cardiology when I met Bryan playing tennis. Bryan worked with an anaesthetist who was also my flatmate and I remember my flatmate and I actually had a list of the three most eligible men at St Thomas’, and Bryan was one of them! When we married, I decided to specialise in dermatology instead of cardiology as I thought that would work better with our lifestyle due to the hours.” Dermatology had always been of interest to Dr Mayou. She explains, “I always liked the feeling of doing something good for somebody; skin disease causes such distress to patients both because of the effect on appearance as well as symptoms and people are very happy after you have treated their skin problem, which really appealed to me.” She trained at St Thomas’ Hospital, St John’s Hospital for Diseases of the Skin and St Bartholomew’s Hospital and Queen Mary’s University Hospital, gaining experience in treating acne, eczema, birthmarks, moles, skin cancer and other skin conditions. She was also appointed as a consultant dermatologist at Westminster Childrens’ and Queen Mary’s University Hospital, Roehampton. Unlike many dermatologists in the UK at the time, Dr Susan Mayou developed a fascination for non-surgical aesthetic treatments, an area which was previously outside the remit of most dermatologists. She explains, “When the cosmetic industry started to develop, I believe it was viewed as rather down-market by the British Association of Dermatology (BAD), because dermatologists in the UK were few in numbers, therefore, it was felt that doing cosmetic work was a waste of a dermatologist’s training as there were many more serious conditions for us to focus on.” However, Dr Mayou believed that dermatologists were in a unique position to optimise their in-depth knowledge of skin for cosmetic purposes. “I started doing aesthetic work because I liked the fact that I could enhance someone’s appearance in a conservative way using botulinum toxin and fillers. It made patients feel better about themselves, which can lead to a better quality of life,” she explains. Dr Mayou soon realised that there needed to be more support for dermatologists who were wanting to delve into this field. “Myself

Aesthetics

and many of my colleagues started getting aesthetic complication cases referred to us as we were the most knowledgeable and most equipped to deal with skin issues. However, most of us weren’t doing the procedures in the first place and needed more knowledge in this area. On the back of this, myself and one of my senior colleagues, Dr Andrew Griffiths, created the British Cosmetic Dermatology Group (BCDG), which was then accepted as a subsidiary group of the BAD,” she explains. The purpose of this group is to ensure that dermatologists have access to training in aesthetics, Dr Mayou says, explaining, “We created theoretical and practical training modules so that dermatologists can understand the treatments to a very high standard. Not all are wanting to do the treatments themselves, but it’s important for them to know about them.” Dr Mayou says her job has led her to unexpected opportunities, “Through the aesthetic and cosmetic line, I have become a dermatological advisor to Neutrogena and also Johnson & Johnson; through that I have had exposure to marketing, branding and advertising, which I find absolutely fascinating as they are important business development strategies to know about.” When discussing her biggest achievements, Dr Mayou is proud of her involvement in the BCDG and the success of the Cadogan Clinic. At the clinic, she is proud that herself and Mr Mayou can pass on knowledge to their employees and their aesthetic ‘Fellows’, who are invited to join them to learn at the clinic, and create an environment to share information. “We have a multidisciplinary team and like to work together to determine how different individuals should be managed using different perspectives,” she explains, adding, “There is nothing like teaching other people to make sure you get the facts right yourself.” What do you like the most about your jobs? B: I think it is most fun when working with interesting patients. S: I agree, I love learning about the patients you get in dermatology and aesthetics. I also love that you can have the same patients for 10-20 years. How do you stay up to date? B: We have always been keen on education and are regularly teaching. Our aesthetic Fellows are very useful as they are always teaching us about their interesting research. S: I like to learn about new technologies and products by attending conferences, such as the American Academy of Dermatology and the Aesthetics Conference & Exhibition. How did you feel to win your recent Aesthetics Award? S: Winning The Dermalux Award for Best Clinic London was really exciting! We weren’t expecting it and it was so lovely to have our work recognised. B: We were thrilled – it’s a really fantastic honour. What do you think the future holds for our specialty? B: At our clinic, we are trying to ensure everything is backed up with scientific evidence, and I think that’s going to be the future. S: I agree, knowing whether products work is very important, so I think this will be a huge focus in the future.

1991

1992

1996

1997

2000

2007

2010

2017

Consultant at St John’s Centre for Dermatology

Consultant at Queen Mary’s University Hospital & Chelsea and Westminster Hospital

Entered Specialist Plastic Surgery Register

Entered Specialist Dermatology Register

Co-founded BCDG

Mr Bryan Mayou & Dr Susan Mayou opened the Cadogan Clinic

The Cadogan Clinic expanded and moved

The Cadogan Clinic won The Dermalux Award for Best Clinic London at the Aesthetics Awards 2017

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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The Last Word Medical director Lesley Spencer argues in support of selling gift vouchers in aesthetic clinics Gifting, of any sort, is most often done with love and consideration towards the person for whom the gift is intended. This applies as much to a gift of an aesthetic treatment as it would do to any other present. As we generally buy presents for those we know and love, it follows that we know and appreciate their likes and dislikes. I am a practitioner first and foremost because I enjoy my job; I appreciate the rapport built with my patients and it’s a great feeling to see, and celebrate, the final results with them. However, I am also in business and therefore must make a profit, and providing an extra point of sale through a gift voucher is a way to increase that, which is why I choose to use gift vouchers in my clinic. Others, however, have opposing views. The argument may be that, by making aesthetic treatments a gift, you are downplaying any risks that can occur. Clinical negligence solicitor Elise Bevan’s stance on the topic, as stated in an article on law firm Penningtons Manches’ website, is, “There is an assumption that a gift is always a good thing but people need to take medical intervention seriously and go through the whole of the education process before committing themselves.”1 In this article, I will explain why I believe using gift vouchers in an aesthetic clinic is acceptable. Using gift vouchers Although I support the use of gift vouchers, I will never issue them for specific treatments. Instead, they can be used against a treatment of the patient’s choice, which can be decided during a free consultation. For example, someone may gift a patient £50 to use in my clinic. Then, when the patient books in for a consultation, we will decide what treatment to perform, based on their concerns, and the voucher will be used against the overall cost. This ensures that the patient does not feel under pressure to book in for a ‘lip filler treatment’, just because they have money-off that specific treatment. We don’t advertise botulinum toxin as a treatment option for gift vouchers as it is a prescription only medicine (POM), however, following a patient consultation, it may be an option.

It may be that existing patients buy gift vouchers for friends or family who have never been to the clinic before, which, in my opinion, is fine. From the existing patient’s point of view, they are recommending a clinic they know and respect, which operates to the highest standards of clinical practice. However, the gift recipient should also put their mind at ease by firstly doing some research, checking the clinic’s testimonials and accolades for example, so they can be more assured that the clinic is safe with fully trained, competent, experienced and fully insured practitioners. I personally don’t include any specific content on the gift voucher regarding treatments, instead, the recipient is required to discuss options during pre-treatment consultation. Patient consultation The patient consultation is a prime opportunity to speak one-to-one with the recipient of the gift voucher, to ensure the procedure/treatment is something the patient definitely wants and isn’t something they have been pressured into having by the buyer of the gift voucher. As well as being in the right frame of mind for aesthetic treatments, a patient should also be an ideal physical candidate for treatment, which is why a consultation is so important for patients purchasing treatment with, or without, a gift voucher. For example, if the patient is pregnant, they would likely be unsuitable for laser treatments or, if they have recently used retinoids, they may not be suitable for a chemical peel. Following the consultation, it’s important to give the patient time to decide that they definitely want the treatment – the General Medical Council (GMC) states that, ‘You must give the patient enough time and information to reach a voluntary and informed decision about whether to go ahead with an intervention’.2

loyalty cards) in ways that could encourage people to make an untimely or ill-considered decision.’3 Register of cosmetic providers, Treatments You Can Trust (TYCT), which works for the benefit of patients who are considering aesthetic treatments, advises that gift vouchers that cover part, or all of, the cost of non-surgical cosmetic treatments, may be advertised in the published media and also on the provider’s own website, as well as point of sale literature in the clinics. However, it must be clearly stated in the terms and conditions that the voucher is redeemable against cash should the recipient prefer, or if the recipient is not suitable for treatment.3 Summary Personally, if gift vouchers for aesthetic treatments were ever made illegal, I would be loudly and firmly against it. Providing clinics offer thorough consultations to ensure all gift voucher recipients are suitable for the selected treatment and definitely want to go ahead, they can offer valuable business opportunities for clinics – increasing revenue and potentially gaining new patients. In aesthetics, people should, after professional consultation, be free to make a responsible and informed choice that will make them happy. By gifting vouchers for a range of treatments and procedures, patients are presented with that opportunity, which is why I believe they are a great tool for any aesthetic clinic. Lesley Spencer is the founder and clinical director of Chaelis Clinic, based in Northamptonshire. Having worked in the beauty/ aesthetics specialty for over thirty years, Spencer has a portfolio of industry standard, multi-level qualifications and a wide range of experience. She has trained many consultants, surgeons and nurses in aesthetic technologies in the UK and the Middle East. REFERENCES 1. Bevan, E. ‘The Gift of Cosmetic Surgery Should Not Dowplay The Risks of Surgery’ (December 2015) <https://www. penningtons.co.uk/about-us/> 2. GMC, ‘Consultation on cosmetics interventions guidance’ General Medical Council (June 2015) <https://www.gmc-uk. org/12___Consultation_on_cosmetic_interventions_guidance. pdf_61112289.pdf> 3. GMC, ‘TYCT Policy Statement – Advertising and Promotion’ General Medical Council (November 2015) https://www.gmc-uk. org/TYCT_policy_statement_advertising_non_surgical_ cosmetic_treatments_2015__2_.pdf_64613628.pdf

Guidelines Currently, selling gift vouchers for non-surgical cosmetic treatments is legal. However, guidance from the GMC states that, ‘You must not use promotional tactics (for example, but not limited to, discounts, time-limited deals, refer a friend offers, gift vouchers or

Reproduced from Aesthetics | Volume 5/Issue 3 - February 2018


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Just Eliza

Preserve the identity of your patients with natural-looking results.1 Azzalure® is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (vertical lines between the eyebrows) seen at frown and/or lateral canthal lines (crow’s feet lines) seen at smile lines, in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.2 References: 1. Molina B et al. J Eur Acad Dermatol Venereol 2015;29(7):1382-1388 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary. Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Glabellar lines: recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units (60 Speywood units for both sides, 0.30 ml of reconstituted solution) divided into 3 injection sites; 10 Speywood units (0.05 ml of reconstituted solution) administered intramuscularly into each injection point. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Nestlé Skin Health S.A. AZZ17-05-0026 Date of preparation: May 2017

alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines.. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: January 2017

Keep it natural. Keep it real.

Aesthetics February 2018  

DERMATOLOGY

Aesthetics February 2018  

DERMATOLOGY