Aesthetics January 2015

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VOLUME 2/ISSUE 2 - JANUARY 2015

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Facial Danger Zones CPD Article Dr Julian De Silva on avoiding adverse events in facial filler treatments

Prescribing

Weight Loss

Marketing

Pharmacist Brendan Semple discusses the use of prescriptions by medical aesthetic practitioners

Dr Amanda Wong Powell investigates the facts and figures of obesity in the UK and internationally

Michelle Boxall explores the most cost-effective and impactful marketing strategies for clinics

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Contents • January 2015 06 News The latest product and industry news 14 News Special Health Education England Stakeholder Summit report 16 On the Scene Out and about in the industry this month

Special Feature Professional Bodies and Associations Page 21

19 Aesthetics Conference and Exhibition 2015 A look at the speakers and sessions featured on the ACE 2015 Main Agenda

CLINICAL PRACTICE 21 Special Feature: Professional Bodies and Associations We take a look at some of the leading organisations within aesthetics 26 CPD Clinical Article Dr Julian De Silva discusses the facial danger zones associated with fillers and shares advice on how to prevent adverse events 31 Weight and Obesity Dr Amanda Wong-Powell discusses the current statistics for obesity 36 Prescribing in Medical Aesthetics Brendan Semple outlines the role of prescriptions for aesthetic professionals 38 Incorporating a Dietician Dr Anita Sturnham explains how to successfully incorporate dietary advice into your practice 42 Vitamin C and the Skin Dr Firas Al-Niaimi investigates the properties of this key anti-oxidant 45 Glycation Specialist skin nurse Lorna Bowes explores the concept of glycation 48 Mole Removal Dr JJ Masani shares his technique for safe and effective mole removal 50 Advertorial: SkinCeuticals Discover the new Day/Night Antioxidant kit from SkinCeuticals 51 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 53 Maximising Your Marketing Budget Michelle Boxall on the most effective strategies to ensure best value from your marketing budget 56 Building a Better Business Hugo Kitchen shares his vision for business success in aesthetics 59 Buying a Laser Don Berryhill outlines the factors to consider when buying a laser for your clinic 62 In Profile: Dr Tina Alster Wendy Lewis talks to US-based practitioner Dr Tina Alster about her successful career in aesthetics 64 The Last Word: Record Keeping Dr Askari Townshend recommends the best approach for handling and avoiding legal complaints

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IN PRACTICE Buying a Laser Page 59

Clinical Contributors Dr Julian De Silva is a facial cosmetic surgeon, specialising in the eyes, nose, face and neck areas.

He has experience in cosmetic/reconstructive facial surgery from fellowships in London, LA and New York.

Dr Amanda Wong-Powell is founder and medical director of Dr. W on Harley Street. Having completed basic surgical training, she is a member of the Royal College of Surgeons (Edinburgh), as well as a VASER liposuction surgeon.

Brendan Semple is a community pharmacist and director of the TLC Pharmacy Group. He is a member of the NHS National Appeal Panel and a board member of the Numark Pharmacy advisory board.

Dr Anita Sturnham is an experienced GP and specialist dermatologist. She is an ambassador for Unilever SkinCare and a medical expert for the consumer store, Superdrug, also regularly advising viewers on skincare via TV. Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon. He trained in Manchester and subsequently did a prestigious advanced surgical and laser fellowship. He now works at sk:n clinics in London.

Lorna Bowes is an aesthetic nurse and trainer.

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

Dr Jamshed (JJ) Masani is a general and aesthetic practitioner, specialising in mole removal. He trained as a doctor in Southern India, before moving to the UK and establishing his London-based clinic, the Mayfair Practice.

NEXT MONTH • IN FOCUS: Training and Education • CPD: Consultation and skin analysis • Cultural expectations in aesthetics • Differing mediums of training

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Editor’s letter “Oh what a night!” The Aesthetics Awards 2014 ceremony was quite an evening. Many congratulations to all the finalists, commended and highly commended, not to mention all the winners. A huge thank you to everyone involved - it was lovely to see all of you who attended Amanda Cameron Editor what was a fabulous celebration of our industry.

I felt extremely proud to play a part in the event itself and to have the opportunity to address the audience and welcome guests. Social media activity was in abundance, with #aestheticsawards even trending on Twitter. In the company of such high-calibre professionals and many marketeers, we were not surprised, but certainly delighted, to see all PR opportunities being maximised during, and soon after, the event. Inside the January issue of the journal, we have included a special Aesthetics Awards supplement so that you can read all about the evening and the wonderful entertainment, as well as enjoy photographs of the nights guests and winners. Now that the 2014 awards ceremony is over, we are already planning an even better event for next year, but in the meantime, we look forward to the Aesthetics Conference and Exhibition (ACE) 2015. We have been inundated with registrations for the free exhibition and clinical and business workshops, and tickets are

selling fast for what will be a very different conference programme this year. The new format for ACE 2015 will focus on the patient journey, so rather than simply a series of isolated lectures on the stage, you will be able to participate in the virtual clinic we are creating, and learn about areas of practice that you may not have had the chance to see before. An in-depth preview of the conference agenda can be found on page 19 of this issue. As we begin anew and look forward to the unfolding of 2015, we thought it important to speak to some of our industry associations, professional bodies and organisations that together form the aesthetic landscape. Our special feature this month covers the important work that they do, and what their plans are for the coming year. A traditionally post-festive-season patient concern is weight, so in this issue we have also included articles on body and fat, obesity statistics, and incorporating nutritional advice into your clinical practice. Following the Health Education England (HEE) Stakeholder Summit, held in early December, you will find a report of the event that highlights delegate’s thoughts and concerns. The article, to be found on page 14, will hopefully encourage you all to have your say on HEE’s recommendations before the consultation period closes on 9 January. I hope that you all were able to relax and enjoy Christmas, and from all of us at Aesthetics, we wish you a happy and prosperous 2015.

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Tapan Patel is the founder and medical director of VIVA

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

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

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

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

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

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Insider News

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Talk Aesthetics #BAPRAS Nigel Mercer / @NigelMercer Enormous privilege to take over @BAPRASvoice Presidency ceremonially from Graeme Perks at our AGM this evening. He is one of the nicest men #PatientCommunication Pam Underdown / @AestheticGrowth Patients want to know what COULD go wrong and what HAS gone wrong in similar situations, and what steps you’re taking to minimise that risk #Keogh Ashton Collins / @AH_SaveFace Injectables and treatments using lasers or intense pulsed light (IPL) are not classified as a regulated activity by the CQC. #keoghreport #Revalidation PIAPA / @PIAPA_UK Looking forward to working alongside the NMC and providing our members with the chance to contribute to the finalised Revalidation model #BodySculpting Dr Ravi Jain / @DrRaviJain Up early to catch the flight to London for the British Association of Body Sculpting annual meeting. #CPD #vaser #liposuction #MoleScanning P & D SURGERY / @pdsurgery Presenting the Mole Scanning Service to staff at Ramsay Winfield Hospital @ramsayhealthUK @ramsaycosmetic To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com

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Training

Aesthetic Connections launches CPD-approved consultation course A CPD-approved course, Advanced Consultation Training (ACT), has received support from key industry opinion leaders for creating a standard within the practitioner/patient consultation. Aesthetic course provider, Aesthetic Connections, created ACT with the hope of helping practitioners better manage patient expectations. Mr Matt James, consultant plastic and reconstructive surgeon at Guy’s and St Thomas’ Hospital, said, “Advanced Consultation Training is an excellent method that allows patients access to a standardised non-biased consultation. Patients are guaranteed high quality information for their consultation decision-making. The practitioner also has peace of mind knowing they have delivered all the appropriate information required to fully advise their patients and have protection against possible litigation. It also assists in delivering a safe and satisfactory treatment by realistically managing patient expectations.”

The course hopes to meet demand for a more rigorous consultation framework, particularly in the post-Keogh and revalidation environment. ACT developers, micropigmentation specialist, Anouska Cassano and Glenn Callaghan, professor of psychology and director of clinical training at the department of psychology at San Jose State University, believe that comprehensive patient evaluation is key to ensuring successful outcomes from aesthetic treatments. Callaghan said, “My experience provides a background in clinical psychology and evidencebased approach to assessment, which is the fundamental principle behind ACT: helping practitioners develop accountability and thoughtful methods to assess, treat, and refer clients for the best services in the area of aesthetic procedures.”

Cassano added, “Part of becoming an ACT-certified practitioner is recognising that not all clients may be right for what we do and the treatments we provide.

Although undergoing the training makes ethical and moral sense, it also makes good business sense. A more efficient consultation process will result in happier patients which leads to positive word of mouth recommendations, unarguably still the best and cheapest form of advertising.” When delegates have completed their training, their knowledge will be tested to ascertain if they can become certified ACT practitioners. Once certified, they may then be entitled to discounted insurance.

The course will be available in the UK in early 2015.

Tattoo removal

Syneron announce laser device has been cleared by FDA for tattoo removal Syneron Medical has announced that the Food and Drug Administration (FDA) has cleared their laser device, PicoWay, to remove all tattoo colours. The PicoWay Picosecond is a dual wavelength device, using 1064nm and 532 wavelengths. Red, yellow and orange can be removed with the 532nm wavelength, whilst black, brown, green, blue and purple are removed using the 1064nm wavelength. The laser incorporates picosecond (one trillionth of a second) pulse duration to generate an ultra-short and high peak of laser energy on the skin. Syneron claims this then creates a strong photo-mechanical impact that optimises the fracturing of tattoo ink.

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In support of the FDA 510 (k) clearance, the Picoway system was evaluated in a study by practitioners, including Dr Eric Bernstein, president of Main Line Center for Laser Surgery. Independent reviews found that 86% experienced a 50% tattoo clearance after three treatments. Dr Bernstein said, “As a dual wavelength Nd:YAG laser, it delivers extremely high peak-power, picosecond pulses enabling the treatment of all skin types.”

The company hope the laser will present a new era in aesthetics and dermatology applications. Amit Meridor, chief executive officer of Syneron Candela said, “Tattoo removal represents a significant market opportunity, with estimates that of the 45 million Americans with at least one tattoo, 20% want to have their tattoo removed. PicoWay provides a powerful new option, which clinical trials have shown to offer high rates of tattoo removal in very few treatments.”

Aesthetics | January 2015

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Conference

Award winners to speak at ACE 2015 Winners from the Aesthetics Awards 2014 are to present at the Aesthetics Conference and Exhibition (ACE) in March. Dr Tapan Patel, whose clinic received two awards, and Mr Dalvi Humzah, recognised at the ceremony for his training academy Facial Anatomy Teaching, will lecture delegates on non-surgical options for facial rejuvenation. Dr Raj Acquilla, who works with Dr Tapan Patel at his award-winning PHI clinic, will complete the injectables expert team to deliver two separate sessions over the ACE weekend. The sessions, only open to healthcare professionals, will provide invaluable guidance for mastering non-surgical treatment of the upper and lower face and neck using injectables. This will be the first time the celebrated international speakers will present together onstage, giving attendees the opportunity to watch live demonstrations of detailed techniques for the use of dermal fillers and botulinum toxin. Delegates can expect to learn how to avoid high-risk areas, whilst acquiring key skills to increase patient satisfaction and improve retention rates. Using the latest conference technology, the trio will teach attendees how to achieve the best results with dermal fillers, with the aim of enhancing aesthetic business and services. Visit www.aestheticsconference.com to book your place.

Research

Galderma releases draft results of Angel study Galderma has announced that the results from its recent Angel study look promising. The multicentre, prospective, non-interventional observational study, carried out in France, Germany, Spain and the UK, assessed patient satisfaction at three weeks and four months post treatment of glabellar lines with BoNT-A (s.U). According to Galderma, the results demonstrated a high level of satisfaction after the treatment, with 94.7% and 89.6% of subjects being “satisfied” or “very satisfied” with the aesthetic outcome at week three and month four, respectively.

Major reasons for satisfaction included the positive aesthetic outcome, a natural appearance, a rested look and the comfort of injection. Final publication date for the study is expected to be late 2014.

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Skincare

New non-prescription products from Obagi Healthxchange has introduced two new Obagi skincare products to complement its existing range. Obagi Retinol 1.0 is a new, stronger retinol product to follow on from Retinol 0.5 in the Obagi 360 series. The manufacturer recommends that this high strength, slow release product should be used in conjunction with either the 360 range or the NuDerm Fx range for a more effective non-prescription offering.

The second new offering, Hydrate Luxe, is a rich night hydration cream, designed for use in conjunction with Hydrate, which launched last year. Hydrate Luxe contains all the same ingredients as Hydrate – including hydromanil, derived from the Tara seed – but with added “biomimetic peptides”. These are said to purportedly act in harmony with the skin to encourage overnight renewal and support metabolic functions. Obagi claims this delivers a two-in-one moisturising action to create an instantly moisturised feel, as well as retaining water to provide longer-term hydration.

Anti-ageing

United Cosmeceuticals launches EVENSWISS Swiss cosmetics firm United Cosmeceuticals has announced the launch of its new product line, EVENSWISS. The products included contain the patented active ingredient Dermatopoietin – a full equivalent of the human epidermal cytokine interleukin-1 alpha, the natural polypeptide that controls the homeostasis of skin.

United Cosmeceuticals claims that dermatopoietin affects deep skin structures without penetration. There are ten products in the range which aim to treat ageing of the face, décolleté, body and hair, with a serum and shampoo designed to reduce hair shedding and repair hair damage.

Nine of the products are for home use, with one advanced formula – the Regenerative Plasma – for professional use. According to the company, this product helps skin to recover after cosmetic treatments and supports regeneration.

Accreditation

Save Face announces new benefits for members and consumers Accreditation body Save Face has partnered with workplace service provider PHS to offer revised benefits to its members. The organisation has also released an app that allows consumers to research the aesthetic market. According to Save Face, members can expect reduced costs on services such as waste management, which includes the disposal and recycling of healthcare, clinical, dental and chemical waste.

Members will also receive a discount on web-based organisation system, iConsult Aesthetic. The system provides diary management, invoicing, and business report tools, which aim to collect information that is then used to tailor individual treatments to each patient’s needs. The Save Face app aims to allow consumers to search for accredited practitioners, find information on treatments and talk to others considering aesthetic procedures. Co-director of Save Face Brett Collins said, “We want to support the industry to help raise standards across the board, so we provide as many tools as we can to make that happen.”

Aesthetics | January 2015

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Dermal filler

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Botox

Merz to launch Belotero+ Volume at ACE with Dr Arthur Swift Belotero+ Volume is set to have its official launch at the Aesthetics Conference and Exhibition (ACE) 2015. Belotero+ Volume, a volumising HA dermal filler, is the latest introduction to the Belotero range, which was recently awarded the Aesthetics Award for Injectable Product of the Year 2014. According to Merz, the new product has the unique advantage of CPM technology and, together with other products within the range, will provide a complete solution for treating superficial lines and wrinkles and restoring facial loss.

World-renowned surgeon Dr Arthur Swift will attend the conference to deliver a presentation and demonstrations on the new product, exclusively at the Merz Aesthetics Education & Demonstration Zone. Canadian surgeon Dr Swift completed his board certification in plastic surgery in 1986, and is currently in private practice in Montreal, having trained in both England and the United States. Dr Swift is one of the most sought after mentors in aesthetics, and is known globally as an expert in both invasive and non-invasive aesthetic treatment. A champion of continuing medical education, Dr Swift has held over 150 master classes for aesthetic practitioners in 32 countries, spanning over six continents.

Lasers

New hair removal laser claims to treat the whole back in under four minutes Asclepion Lasers has released a new triple wavelength laser, which claims to have the world’s largest spot size. The NeXT PRO has increased power from 800 Watts to 2400 Watts and two new handpieces; the XL handpiece and a new 755nm Alexandrite diode, which adds an extra wavelength to the existing 810nm and 940nm.

With a spot size of 34mm x 23mm (9.1cm²), Asclepion claim the laser is able to treat a full back of hair in under four minutes. As well as a decreased hair removal time, the laser caters for all skin types, suitable for vascular, acne, and skin rejuvenation treatments. The SMOOTHPULSE mode claims to offer a pain-free experience, offering a 12-shot-per-second repetition rate.

Nick Fitrzyk from Carleton Medical Ltd, the UK distributor for Asclepion, said, “The new NeXT PRO offers an unrivalled specification compared to other hair removal systems with 810nm, 755nm and 940nm in one upgradeable platform. Asclepion continue to develop the highest spec lasers on the market with the lowest running costs, the longest warranties and German-build quality.”

Research reveals what women want to know about Botox Research commissioned by Allergan has found that women feel they have limited information about Botox.

Allergan joined with SheSpeaks, an online women’s community, to conduct a survey around what questions women want answered in regards to Botox Cosmetic. It found that 54% of the 2,200 women surveyed wanted to learn about how much Botox actually costs, while almost half felt that cost was holding them back. “Many of my patients believe that Botox Cosmetic is more expensive than it is,” said Dr Youn, a board certified plastic surgeon specialising in cosmetic surgery. “Patients don’t realise that the cost of treatment not only includes the price of the product but, more importantly, the skill and expertise of the healthcare professional who is administering the treatment.” Another major point revealed in the study was that 40% of women were concerned about safety and side effects. A smaller portion (18%) were worried their face would not look natural after treatment.

In response to the study, Allergan has launched the new Allergan iVisualizer app, which enables consumers to upload images of their face in order to see what lines and wrinkles would look like postBotox, as well as providing access to further information on the treatment.

Lipolysis

New body contouring device launched Cryosthetics has launched a new device, the CryoContura+, which combines cryolipolysis and laser lipolysis for body contouring. The aim of the new machine is to soften the target fat with laser lipolysis prior to freezing it with cryolipolysis, in order to achieve better and faster results. The company claims that one CryoContura+ treatment will remove approximately 25% of fat in the treatment area. The treatment can be repeated every eight weeks until the desired result is achieved.

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The CryoContura+ machine has two heads, meaning that two areas can be treated at once, which Cryosthetics claims provides maximum return on investment.

Cryosthetics managing director Tracey Loughrey said, “CryoContura+ technology is safe, efficient, non invasive, easily repeatable and unlike other machines, quick and good value for money. Following the purchase of a CryoContura+ machine we provide full training, combining theory and practical sessions. Only once this is completed will the clinician receive a certificate of competence and a marketing support package.”

Aesthetics | January 2015

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Vital Statistics

Lasers

ABC Lasers to distribute Alma Impact Expert

Rhinoplasty was the most popular cosmetic surgery procedure for men in 2013

ABC Lasers will host an event to celebrate the launch of the Alma Impact Expert on 16 January. The Impact Expert laser, introduced by global laser manufacturer Alma Lasers, aims to help advance active skincare ingredients into the skin’s layers for enhanced aesthetic results. ABC Lasers claim that the device can treat all skin types and improve the appearance of redness, fine lines and wrinkles, sun damage, dehydrated, oily or congested skin. At the launch, set to take place at the Mayfair Hotel, London, skin-health expert Mimi Luzon will give a lecture on the Impact Expert and use the device for a live treatment demonstration.

Research

Study reveals large majority dislike having their picture taken A recent study has revealed that 76% of people felt that dissatisfaction with their appearance had prevented them from having their picture taken. The study by Sinclair IS Pharma, commissioned by Silhouette Soft, was conducted in order to find out what participants feel ages a person most. Of those surveyed, 69% felt that facial sagging and wrinkles aged a person more than anything else, but despite this, 80% would not consider invasive surgery due to cost and safety concerns. Almost half stated that signs of ageing affected their confidence. The research also addressed social media issues, where it was revealed that 32% of women did not post images on social media due to dissatisfaction with their appearance. It was found that the majority of people who were unhappy with their looks were aged between 30 and 39, at a rate of 66% in this age group. Over 25% of all surveyed admitted that they judged people based on the way they were ageing, with most people wanting to look young while appearing to age naturally.

BAAPS

Between 2010-2015 the skincare market is expected to have grown by more than 21%

21% growth

MarketLine

Even on cloudy days, up to 80% of the sun’s harmful UV rays can penetrate skin American Academy of Dermatology

Each year, more than 3.5 million cases of basal and squamous cell skin cancers are diagnosed in the US Medical News Today

If one parent has psoriasis, their child is around 10% more likely to also suffer from the skin condition National Psoriasis Foundation

Psoriasis

LEO Pharma announces results for topical psoriasis treatment

6 million

Americans suffer from the signs and symptoms of rosacea

Danish pharmaceuticals firm LEO Pharma has released the preliminary findings from its study into the efficacy of its Daivobet gel for the topical treatment of psoriasis. The company stated that use of the product resulted in significant improvement in disease severity and patient preference.

1,795 European patients who had mild to severe psoriasis took part in the study. In all cases the psoriasis had not responded sufficiently to previous topical treatment. After eight weeks of treatment with the calcipotriol/ betamethason dipropionate, 36.5% of patients were described as “clear” or “nearly clear” of psoriasis symptoms. Preliminary results were published in the Journal of the European Academy of Dermatology and Venereology.

Aesthetics | January 2015

National Rosacea Foundation

37%

In the past 12 months WhatClinic.com have seen a 37% increase in the volume of enquiries for medical aesthetic treatments in the UK WhatClinic.com

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Insider News

Events diary 29th January - 1st February 2015 International Master Course on Ageing Skin – IMCAS Annual Meeting 2015, Paris www.imcas.com/en/imcas2015/ congress 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com 26th - 28th March 2015 13th Anti-Aging Medicine World Congress, Monte Carlo www.euromedicom.com/amwc-2015/ index.html 7th - 9th July 2015 British Association of Dermatologists Annual Meeting 2015, Manchester www.bad.org.uk

Skin analysis

Skin analysis system launched

by Observ UK Observ UK has launched a new skin diagnostic machine, the Observ 520 Skin Analysis System. The Observ 520 system uses six different skin analysis modes – Daylight, True UV, Woods Light, Cross Polarised, Parallel Polarised and Complexion Analysis – to diagnose skin conditions and assess the severity of various age-related skin concerns, such as wrinkles, hyperpigmentation, porphyrins, enlarged pores, sun damage and excess keratinsation.

The machine then produces a detailed analysis report, which the practitioner can then use to create a personalised facial rejuvenation programme, as well as providing the option of sending a copy of the report directly to the patient.

The Observ 520 app is also available for use in conjunction with the skin analysis system, allowing practitioners to monitor their patients’ progress using an iPad. 10

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Research

Long-term Botox patients perceive themselves as younger than their age According to a study presented at the 2014 American Society for Dermatologic Study Annual Meeting, patients receiving continuous Botox treatment over the course of several years perceived themselves to look younger than their actual age.

Alistair Carruthers, Fellow of the Royal College of Physicians of Canada (FRCPC) presented the results of the study, which assessed 194 patients, aged 18 and above, with at least five years history of continuous treatment. Carruthers and his team reviewed patient records of Botox treatments from 1999 to 2012, evaluating facial areas treated, dosage per area, number of treatments performed, any accompanying aesthetic treatments and any adverse events associated with the Botox treatment. The mean age at first injection was 46.3 years, and data was collected from 5,112 treatment sessions with an average of two or more treatments annually, over a mean of 9.1 years. The researchers found that the longer patients were injected, the younger they perceived themselves to be. They also found that although dosing for glabellar lines and crows’ feet remained stable over the period covered, dosing for forehead lines had decreased since 1999.

ACE

Med-fx to be registration and consumables partner at ACE 2015 Med-fx has been announced as the registration and consumables partner of the Aesthetics Conference and Exhibition (ACE) 2015. The logistics company holds 25,000 medical products at its base in Essex, from dermal fillers to laser and surgery consumables, and supplies more than 7,000 practices in the UK. “Med-fx is a highly sophisticated logistics company, offering what you want, when you want it, allowing for maximum stock turn. Whilst price is something we instinctively think of, it is not necessarily the most important component in operating an efficient and profitable clinic. Stock turnover and zero wastage means far more than a few pounds off, to the successful day-to-day running of your business,” said David Gower. He added, “Med-Fx are delighted to once again work with ACE as the registration and consumables partner. We are ideally placed to support the huge clinical agenda for 2015, which features live technique demonstrations and masterclasses from the UK’s top practitioners.” In addition, Med-fx’s sister company, Medical Aesthetics Group will sponsor an ACE Masterclass on PDO threads, presented by Dr Elisabeth Dancey and Dr Sarah Tonks.

Skincare

Handheld device launched for skin treatments Schick Medical has released a handheld device used to treat various skin conditions.

The device, Sqoom clinical, is used in conjunction with a range of gels which Schick claim aid skin issues such as psoriasis, rosacea, neurodermatitis and acne.

Sqoom clinical is said to work by using a magnetic field and ultrasound combination alongside restorative gels that are gently massaged into the skin via one million vibrations per second. The company claim that through the vibrations, gel penetrates the upper skin layers and through to the dermis.

With three different programme levels, the device has been developed to treat various skin types, such as gentle treatment of sensitive skin. Schick also claim the device can treat the pain of fractures to the tibia, distal radius and long tubular bones.

Aesthetics | January 2015

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Sunscreen

AADA welcomes passing of Sunscreen Innovation Act The American Academy of Dermatology Association (AADA) has released a statement applauding US Congress for passing the Sunscreen Innovation Act. The new act will give the Food and Drug Administration (FDA) the authority to prioritise the review and approval of more effective sunscreen ingredients, many of which have long been available outside of the US. The FDA has not approved a new sunscreen ingredient since the 1990s, and the AADA believe that consumers will now be able to reap the benefits with less exposure to harmful UV rays.

In the statement, AADA President Brett M Coldiron said, “The American Academy of Dermatology Association praises Congress for its widespread, bipartisan support of skin health with its passage of the Sunscreen Innovation Act. The move by Congress signals the urgent public health need to make more effective products available to consumers, as skin cancer rates continue to rise at an alarming pace.” He added, “The AADA looks forward to working closely with the FDA to implement the new law, and will be providing comments on its implementation.”

Dermatology

Survey shows US public misunderstands the work of dermatologists The results of a study published in the November issue of the Journal of the American Academy of Dermatology show that the US public has a low understanding of what dermatologists do, believing they spend far more time on cosmetic procedures than is actually the case.

800 adults were surveyed by telephone for the study, which was carried out by researchers at the University of Colorado. 92% of respondents believed that primary care physicians (GPs) put in longer hours than dermatologists, with 54% thinking the former have a more difficult job and 63% believing that primary care physicians have a more critical profession. 46% thought that dermatologists spent the majority of their time treating skin cancer, and 27% cosmetic treatments.

“The study shows that the public may not be fully aware of all the various areas of expertise and services that dermatologists provide, especially in the realm of medical dermatology,” said study co-author April Armstrong, of the University of Colorado. “Changing the public’s perception to reflect the reality of our range of expertise is an important and worthwhile long-term goal for our field.”

Equipment

Laser Physics introduce loyalty scheme Aesthetics equipment supplier Laser Physics has introduced a rewards scheme for customers to earn three points on every pound spent on products. Each point is then worth one penny on future Laser Physics purchases. The launch of the loyalty scheme coincides with the introduction of several new products to the Laser Physics medical and cosmetic range, including white skin marker pens, disposable towels, non-woven swabs, cotton buds and facial tissues. Practitioners can sign up by completing the form on the Laser Physics website.

Aesthetics | January 2015

Insider News

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Stuart Rose, Managing Director at Merz Pharmaceuticals Tell us about the new Merz Vision.

Over the last 12 months Merz has undergone a full strategic review, and aesthetic medicine is now at the very heart of our global business. Our Vision is to become the most trusted, admired and innovative aesthetics and neurotoxins company in the world.

What tangible steps are you taking on that journey?

Our biggest impact in the short term will be in our product offerings. In the first half of 2015 Merz will integrate the recently acquired Ultherapy platform (ultrasound energy device) to our business. Like the rest of our portfolio, Ulthera is FDA approved (four indications), and is unique in the energy device market in the precision it can deliver for skin lifting. The Belotero+ range will have one of the most exciting advances to that range, with the launch of our volumising HA (Belotero+ Volume). Soon after this we will launch Radiesse+ (containing lidocaine). These new product launches, coupled with the recent crow’s feet licence for Bocouture, will give us one of the most impactful FDA-approved portfolios for aesthetic practitioners worldwide.

You have some tough competition. How achievable is your Vision?

Aesthetic practitioners do benefit from some excellent competitors in the market. What makes Merz unique is our ability to focus on the long game and make investment decisions that may have longer-term payback than most public company shareholders would accept. Merz remains fully family owned which means that we are not subject to stock market or institutional shareholder pressures. All of our management time is dedicated to business growth. Our focus is always on what is right for customers, patients and employees. We want to build a business that has genuinely robust, sustainable value in it and, as we grow, invest our improving returns in product innovation, not shareholder dividends. The Merz family are very clear – we are not for sale. We want to invest and grow our business to deliver our Vision. And we will.

This column is written and supported by

11

Insider News

News in Brief Juvea Aesthetics launches training academy Juvea Aesthetics clinic, run by plastic surgeon Dr Faizeen Zavahir, will launch a new training course, Medical Aesthetic Training Academy (MATA), in March 2015. The Royal College of Surgeons has granted MATA permission to use cadavers for practical training. The training courses will cover all abilities, from basic to MSc level.

Karen Betts hosts Britain’s first certified permanent cosmetics exam All 29 participants passed the UK’s first certified permanent makeup cosmetics exam. Permanent makeup artist Karen Betts hosted the exam at her Yorkshire Training Academy in October where 29 candidates sat the exam. The international exam was launched by the Society of Permanent Cosmetic Professionals (SPCP) in 2004, following concerns that there was no official credentialing system in place for the profession.

MedivaPharma appointed distributor for Merz Aesthetics Pharmaceutical supplier MedivaPharma has been appointed distributor for Merz Aesthetics.

The company, which has more than ten years’ experience working in medical aesthetics in Europe, will also work with the Private Independent Practices Association (PIAPA) to provide support and mentoring services to aesthetic medical professionals.

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Psoriasis

Global survey highlights psoriasis sufferers’ wish to better understand disease and treatments An online survey has found that patients feel they need better education on treatments available to aid psoriasis. The International Federation of Psoriasis Associations (IFPA) brought attention to the results on World Psoriasis Day. They found that the top tool voted for was ‘Educating the patients about treatment options’. The survey was launched in June 2014 and features 17 suggested tools within advocacy, awareness and education. It is open to psoriasis patients and practitioners treating the disease, as well as family member and friends, until May 2015. Lars Ettarp, president of IFPA, said, “Today, patients wish to be well-informed about treatment options, especially when they have a chronic condition such as psoriasis, so that they can make important decisions regarding their disease management and care together with their doctors.” The results further highlighted that professionals and patients felt there was a lack of awareness about a number of serious conditions associated with psoriasis, such as psoriatic arthritis and metabolic syndrome, and a need for more information.

Rosacea

Survey reveals other skin conditions often present in rosacea patients A survey conducted by the National Rosacea Society has revealed that rosacea patients frequently suffer from other skin conditions, although they don’t tend to aggravate the symptoms of rosacea.

Of the 1,141 respondents, 55% reported to have suffered from another skin complaint at some point in their lives. Of those, 32% cited atopic dermatitis (eczema), 31% seborrheic dermatitis, 29% acne and 28% said they had been diagnosed with skin cancer. Psoriasis and actinic keratosis affected 16% and 14% respectively.

Of those who display symptoms of another condition, 42% said that their rosacea flares up when the other disorder is present, however only 23% reported an aggravation in rosacea symptoms during treatment for another condition.

Milestone

British doctor appointed lecturer at Norwegian university Glasgow-based aesthetic practitioner Dr Kieren Bong has secured a position as clinical lecturer at Buskerud University College, Norway’s leading centre for cosmetic dermatology. Dr Bong will lecture at the university, as well as sit on the examination board for the Masters degree, and head the dermal fillers’ faculty of Senzie Academy. Dr Bong currently runs the Essence Medical Cosmetic Clinic in Glasgow.

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Lifestyle Aesthetics celebrates 10year anniversary Lifestyle Aesthetics, the UK distributor for TeoSyal dermal fillers and cosmeceuticals, LA Science hair products and Jessners Peels, are celebrating their tenth anniversary working within the aesthetics industry.

Founded in 2004 by Sandra Fishlock and Sue Wales, both health industry professionals, the company was launched with the intention of providing safe and effective anti-ageing solutions for customers with busy lifestyles. The pair said, “The pursuit of this fundamental goal has been, and continues to be, the main focus of Lifestyle Aesthetics’ drive, as we strive to earn the trust of our partners and customers. Ten years on and Lifestyle Aesthetics has had more success than forecasted, winning many awards for our innovative, high quality product portfolio. Sourcing products that truly make a difference in people’s lives, Lifestyle Aesthetics continues to impress, influence and innovate the world of beauty.”

Aesthetics | January 2015

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Insider News Special

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Health Education England (HEE) held a consultation meeting for its report on ‘Non-surgical Cosmetic Interventions and Hair Restoration Surgery’, on 9 December.

HEE Stakeholder Summit The Stakeholder Summit, which took place at the Kia Oval, London, brought together again representatives from professional associations, royal colleges, regulatory bodies, education providers and insurers.

Lead members of the Expert Reference Group (ERG) presented HEE’s Qualification Requirements and latest developments, before answering delegate questions.

Most recommendations were well-received by stakeholders, particularly the Recognition of Prior Learning (RPL) and Accreditation of Prior Learning (APL). It was debated, however, how all of the recommendations would be regulated in practice.

Dental surgeon and aesthetic practitioner Dr Souphiyeh Samizadeh asked, “What measures are going to be put in place to make sure non-health professionals are not providing level seven [advanced] treatments, especially prior the implementation of these recommendations?” Many agreed with this question, further supporting her query on public protection. Professor David Sines, chair of the ERG, acknowledged, although possibly difficult to regulate, this issue would be addressed post-consultation.

Noel Griffin, team leader of the Department of Health (DoH) Public Health Policy and Strategy Unit, replied, “It’s good that work has already started and all we can try to do is ensure that work continues.” Dr Samizadeh argued this was insufficient. She said, “I am very glad that work towards regulating this industry has started, however it is not enough to leave patients and the public unprotected for another few years until training requirements and accreditation become mandatory.”

Many stakeholders felt implementation of the recommendations would take too long. Whilst HEE’s final report will be sent to the DoH in April, a delay in publication is likely due to May’s General Election. Carol Jollie, HEE performance and delivery manager, explained, “The date of publication depends on whether there is a change in government and what their priorities are.

She continued, “It would be beneficial if education providers supporting the proposals start adapting their courses, or create new ones that meet the requirements. Membership associations could also recommend that their members work towards HEE’s recommendations.”

Mike Mulcahy, dentist and ERG member representing the Faculty of General Dental Practice UK (FGDP), noted that he was impressed with the the suggestion made by another ERG member that prescribers of Prescription Only Medicines should be within the building when they are used, and be available after the event to deal with any postoperative side effects. Other stakeholders, however, questioned the location of the supervising prescriber.

Elizabeth Allen, trustee and principal tutor at the British Association of Skin Camouflage, felt that supervisors should be present in the same room, not just building.

HEE recommend that practitioners should perform 150 procedures over the preceding three-year period to be classed as a supervisor for training or providing oversight of more complex 14

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cosmetic procedures. Where clinical oversight was recommended, the regulated health professional would remain accountable for complications. Stakeholders doubted whether this number was sufficient to be regarded as an ‘expert’. Mrs Sarah Pape, consultant plastic surgeon and ERG modality lead representing the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), said the ERG had difficulty choosing the number, explaining, “There’s some evidence to suggest that if you have acquired 50 repetitions of any practical skill you’ve climbed the steepest part of the learning curve.” She highlighted that despite performing numerous procedures, not all practitioners are flexible enough to adapt to unexpected situations.

Providing supervisors can adapt their skills, consultant plastic surgeon Mr Dalvi Humzah agrees with the recommendation. He said, “The number may sound low but it does have some evidence base. Also, not everyone will want the responsibility of being accountable for other practitioners, and would not want to have to put themselves forward to be critical of practise when required.”

Andrew Rankin, nurse and ERG modality lead representing the British Association of Cosmetic Nurses, presented the possibility of creating an industry standards body, the Joint Council of Cosmetic Medicine, which would encompass the current associations and statutory regulators, and aim to improve cross-communication.

This suggestion received mixed reactions, with some stakeholders, such as independent nurse prescriber Emma Davies, supporting the idea: “We must rally support for a Joint Council”, whereas others like aesthetic practitioner, Dr Askari Townshend highlighted potential pitfalls: “The proposal was well intentioned but not something that I think is necessary or one that will contribute more than its cost in money and bureaucracy.”

Moving forward, Mr Humzah said, “I think we’re starting to see a basic framework but it needs to have some proper teeth to enforce it.” He added, “We need to look very carefully at who’s providing training and who’s labelling themselves as an expert.”

Although question time was limited, Carol Jollie emphasised that the consultation period, ending January 9, provides the opportunity for stakeholders to highlight concerns and share ideas. “It’s absolutely key that we get a good response from across the industry,” she said. “We want to fill our final report to the DoH with endorsements from practitioners, membership associations, insurance companies and training providers to ensure the recommendations have the support of everyone involved.”

To conclude, Emma Davies said, “HEE has to be commended for achieving so much, working with so many stakeholders, to deliver on its remit in such a timeframe. I think the one positive that has come out of this is that we’ve all gained professional experience working together.”

Email cosmetics@nwl.hee.nhs.uk to get a copy of HEE’s report and submit your views on the consultation.

Aesthetics | January 2015

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Ellansé Training Day, London Sinclair IS Pharma ran an Ellansé training day with boardcertified plastic surgeon Dr Pierre Nicolau, who travelled from Europe to share his expert knowledge on the Ellansé products and techniques.

The international pharmaceutical company held the event at Harley Street on November 21, offering practitioners the opportunity to utilise Dr Nicolau’s understanding and techniques. Aesthetic trainers and doctors, including Dr Askari Townshend, Dr Linda Eve, and Facial Anatomy Teaching founder Mr Dalvi Humzah, were amongst those who attended the event. Katrina Ellison, Sinclair Pharma brand manager, said, “It was very inspiring to bring together some of Sinclair Pharma’s finest doctors and trainers to meet with Dr Pierre Nicolau and gain further understanding of the Ellansé brand.”

Guests first attended a theory session with Dr Nicolau to learn the science behind the Ellansé product, and were later treated to a practical session. Lunch was followed by an afternoon consisting of practical demonstrations. Dr Eve said, “I was very impressed with the training from distinguished French plastic surgeon Mr Pierre Nicolau. He shared his extensive knowledge about Ellansé and discussed the differences between fillers that are bio-stimulators and those which are simple volumisers, whilst showing us the comparative benefits of each group. Ellansé is an effective treatment for both deep supra-periosteal and also sub-dermal injections, and provides long lasting results for 1-2 years.”

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Allergan #THISISME Campaign, London and Manchester Allergan recently hosted two consumer events in London and Manchester in order to mark the launch of its new campaign, #THISISME. The events were organised with the aim of educating women on the various filler treatments available, as well as encouraging them to embrace the signs of ageing.

Allergan ran the events in conjunction with Hello! Magazine, and speakers included beauty journalist Alice HartDavis, psychologist Honey Langcaster-James and, finally, aesthetics practitioners Dr Tracy Mountford and Dr Jonquille Chantrey. The rise of celebrity influence was discussed, along with the social trends that affect perceptions of ageing and can impact on women’s self esteem. Guests were also educated on dermal fillers, with speakers highlighting that those seeking treatment should not be concerned with media expectations of how older women should look.

They noted that people should age in the way they want to.

Attendees were invited to participate in mini consultations with Allergan’s aesthetic practitioners, Alison Telfer, Dr Sherina Balarathnam, Annie Grant and Rachel Goodard, as well as meet ambassadors of the campaign – who gave their first-hand experience of using fillers. Guests were also able to enjoy high-tech facial analyses, which used VISIA and VECTRA technology.

“The talks were very informative, but to me the ambassadors were the most inspiring part. Pictures on a screen can clearly be airbrushed but real life models clearly can’t. Having the practitioners, with whom we could discuss options available, and the ambassadors where we could see the finished result, in the same room was very effective,” said Julie Pitcher, 54, a consumer who attended one of the events.

Allergan also commissioned celebrity make-up artist Louise Constad to provide make-up tips for ageing skin. Guests were then treated to complImentary eyebrow shaping treatments from HD Brows.

Wigmore Medical Group Open Day, London The Wigmore Medical Open Day, held on November 29 at the Royal Society of Medicine (RSM) in London, aimed to strengthen and develop industry knowledge regarding skincare, body contouring, and injectables.

The open day, which included training and information on ZO Systems, consisted of three seminars by a group of aesthetic practitioners that included Dr Aamer Khan, Dr Rachael Eckel and Dr Sam van Eden.

“It was uplifting as a presenter to see the ZO Systems Day so well received. The ardour of the delegates was unwavering, yet especially palpable upon discourse of the new ZO products,” said Dr Rachael Eckel, cosmetic dermatologist and Z0 trainer.

The injectables agenda was run by Dr Aamer Khan, alongside other 16

international speakers such as Dr Kieren Bong, who demonstrated a comprehensive range of fillers and advised delegates on what to use, where to use it and why. The event was free of charge to all Wigmore Medical account holders, and attendees were able to watch live demonstrations and learn about product updates throughout the day.

Live demonstrations also allowed delegates from the audience to participate in an engaging debate on how best patients should be assessed and marked-up in preparation of treatment. With three separate agendas, Wigmore Medical aimed to provide something for everyone. The day mainly consisted of clinical sessions and ended with the Ivasix agenda, which detailed the benefits of using InMode applications. Dr Stephen Mullholland closed the event with a lecture on ‘How to run a successful aesthetic clinic’ and all delegates received a free copy of his book of the same title.

Aesthetics | January 2015

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Insider On the Scene

The Aesthetics Awards, London

The Aesthetics Awards, held in London at the Park Plaza Westminster Bridge Hotel, was a night of celebrations for the top practitioners, clinics, products, distributors and manufacturers within the aesthetic specialty in 2014. The event, on December 6, began with a pre-dinner drinks reception before guests were moved into the grand ballroom for a sit-down dinner, where Aesthetics journal editor Amanda Cameron gave a welcoming speech to officially open the ceremony. After dinner, guests were treated to a performance by comedian Dominic Holland, which was soon followed by the award presentations. Winners were recognised in 21 categories, with 145 entrants being successful in reaching the final stages. The awards included Training Initiative of the Year, won by Mr Dalvi Humzah for his training course Facial Anatomy Teaching, and The Save Face Aesthetics Award for Aesthetic Medical Practitioner of the Year, which was awarded to practitioner Dr Linda Eve. Finally, the prestigious Aesthetics Source Award for Lifetime Achievement was

presented to Dr Roy Saleh, who received a standing ovation from many of his fellow practitioners in honour of his hard work and dedication to medical aesthetics. Dr Saleh said, “Wining this award means that there is a belief, an acceptance and a feeling that you’ve reached a certain level in your career, but it’s important for me to say that my career isn’t over. The evening has been lovely – it’s been a delight.

Receiving this honour is the best part of it as it’s such an achievement for me. I don’t think that many people have won this award, and that makes me even more proud of the fact that I have.” In addition to celebrating aesthetic achievements, a generous £1,663.13 was raised for the Awards’ chosen charity, Changing Faces. See this month’s special Aesthetics Awards supplement for a full list of winners and to see a gallery of images from the evening or visit www. aestheticsawards.com.

Botulinum toxin and its applications a day course Thursday 29 January 2015 Royal Society of Medicine, London RSM member rates: £599 Non member rates: £669 Dermal fillers course Friday 30 January 2015 Royal Society of Medicine, London RSM member rates: £699 Non member rates: £799 Botulinum toxin and dermal fillers course intermediate Thursday 22 to Friday 23 January 2015 Manchester Conference Centre RSM member rates from £599 - £1,199 Non member rates from £649 - £1,399 Other dates are available for these courses, for more information and to register online visit www.rsm.ac.uk/courses

Botulinum toxin and its applications - a day course.indd 2

Aesthetics | January 2015

12/8/2014 12:17:59 PM

17

Syneron Candela Launches Breakthrough Technology. Again.

Introducing PicoWay. PicoWay is a remarkably innovative dual wavelength picosecond laser from Syneron Candela, the most trusted brand in lasers. With both 532nm and 1064nm wavelengths, PicoWay can treat a very broad range of pigmented lesions and tattoo types and colors on any skin type.

PicoWay has the highest peak power and the shortest pulse duration of any picosecond laser for superior efficacy, safety and comfort. Proprietary PicoWay technology creates the purest photo-mechanical interaction available to most effectively impact tattoo ink and pigmented lesions, without the negative thermal effects of other lasers.

And, PicoWay has the reliability physicians want.

www.syneron-candela.co.uk | info@syneron-candela.co.uk | Tel. 0845 5210698

Š2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB85961EN

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Amanda Cameron, Aesthetics journal editor and Aesthetics Conference and Exhibition programme organiser, highlights why ACE is set to revolutionise the conference line-up of 2015

The unique ACE 2015 learning experience The main agenda at the Aesthetics Conference and Exhibition 2015 is a programme with a difference. At Aesthetics, we know from our experience and knowledge of the specialism that there is a need for in-depth, CPD accredited and practical hands-on training in every aspect of the profession. At ACE 2015, we will give you this kind of training. ACE will recreate clinic environments and give you options for solutions to patient issues, including how to consult, carry out differential diagnosis and post-treatment follow up. Those attending will be able to customise their own learning agendas by choosing to attend one or more of the four main sessions, rather than only being able to select either a one or two-day conference pass, as is traditional at past UK aesthetic conferences. The ACE main agenda will begin on Saturday March 7 and will look at the treatment of fat on the body and face – with regards to both removing and replacing. With the demand for non-invasive procedures to improve the body increasing year-on-year, it is vital for practitioners to stay up-to-date with the latest developments in this field. This key session will be led by consultant plastic surgeon Mr Taimur Shoaib and Dr Mike Comins, who will together chair a panel of specialists in weight management and body sculpting. Mr Shoaib says, “The session will be a unique opportunity for clinicians of all training backgrounds to discuss fat reduction and enlargement. I’m excited by the conference session because of its uniqueness and the innovative way the session will be delivered.”

The session will run for three hours and will feature audience participation and debate on the merits of non-surgical fat reduction with surgery. Different types of surgical fat reduction methods will be discussed including laser, ultrasound and radiofrequency assisted liposuction. Dr T Vetpillai will present an alternative view of fat management with her unique approach to coaching and weight loss. During this session attendees will be invited to discover a range of different energy-based fat reduction methods that

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could be used in their clinic. Interaction will be at the forefront of all sessions, with delegates able to discuss treatment planning with the expert panel and debate on key issues including: which is better – vaser or laser? Who should be performing liposuction?

Where is fat grafting appropriate and where should you use fillers? Saturday afternoon at ACE is host to ‘Face Off’, the first instalment in the highly anticipated two-part advanced anatomy and injection session, led by awardwinning surgeons and physicians Mr Dalvi Humzah, Dr Tapan Patel and Dr Raj Acquilla.

Both ‘Face Off’ and the continuing Sunday morning zonal treatment session will combine unique dynamic anatomical explorations with demonstrations on how to analyse the face to get the best results. This is a neverseen-before opportunity to experience these three world-class injectors demonstrating and presenting together onstage in practical and interactive sessions, open only to healthcare professionals. The top injectors will explore non-invasive treatments for upper and lower-face beautification, and attendees will be able to watch live technique demonstrations detailing the use of dermal fillers and botulinum toxin in the peri-orbital, peri-oral and neck regions. Delegates will also learn how to avoid high-risk areas in the upper and lower face, and how to deal with potential complications. The engaging format will allow attendees to question the experts and achieve tangible learning objectives through use of the latest conference technology. Of the session, Mr Humzah says, “I am looking forward to working with some of the leading experts in aesthetics and leading an interactive session with the presenters and delegates who attend ACE 2015. These sessions will be extremely informative, inspirational and enjoyable for all.” The final session of the weekend will be run by dermatology leaders Dr Stefanie Williams and Dr Christopher Rowland Payne, and is an unmissable opportunity for all those treating patients for skin issues and conditions, or for those looking to expand their treatment menu in this area. Follow the Aesthetics | January 2015

ACE 2015 Programme Overview

patient journey from live consultation, through to detailed discussion on the treatment of common dermatological conditions, looking at aesthetic treatments and combination treatment options, concluding with postprocedure maintenance. Delegates will learn how to manage common conditions such as acne, rosacea, seborrheic dermatitis and eczema, and will be invited to question the panel on the best cosmeceutical ingredients for anti-ageing and prevention. As part of the session, Dr Daron Seukeran will also provide key guidance on how to treat skin conditions using lasers. “Laser technology is advancing rapidly and continues to increase our range of treatment which can be safe and effective when used appropriately,” says Dr Seukeran. “I will describe the main use of lasers in treatment of the skin and aesthetics, and explore why different lasers are required to provide the full range of treatment.” The dermatology team will be joined by aesthetic nurses and skin experts Lorna Bowes and Anna Baker who will demonstrate expert techniques and treatments for anti-ageing, and other key issues such as the diagnosis of suspicious lesions. Anna Baker says, “Patients will frequently present in aesthetic practice with a variety of skin lesions, some of which may be non-melanoma skin cancer, which is increasing in prevalence. Topical photodynamic therapy is an effective treatment modality for specific superficial lesions; an interactive overview of the treatment pathway as well as the licensed indications for treatment will be discussed to provide an insightful perspective on this efficacious treatment.” Dr Acquilla concludes, “ACE 2015 is shaping up to to be the most exciting live injection symposium I’ve been involved within the UK. We will be delivering the latest anatomical knowledge and injection techniques in facial aesthetic medicine using cutting edge multimedia technology, giving the audience a unique interactive educational experience they won’t forget.”

The flexibility of the premium conference programme allows delegates to focus on their individual learning needs. Those choosing to attend more than one session are entitled to a discount which increases with the number of sessions booked.

Spaces are limited so visit the website to secure your place today. ACE will also once again feature Expert Clinic live demonstrations, supplier Masterclasses and Business Track workshops as part of the free Exhibition registration. Go to www.aestheticsconference.com to see the full programme and to register.

19

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Special Feature Aesthetic Organisations

The benefits of belonging This month’s special feature takes a closer look at the professional bodies and organisations that together make up the UK aesthetic landscape, and asks, what do they have to offer practitioners in 2015?

BCAM (British College of Aesthetic Medicine) What is BCAM? Founded in 2001, BCAM is a professional body that aims to encourage regulation within the industry and make aesthetic medicine safer for the public. It is a doctor-only organisation encompassing any medical specialty.

What does it do? BCAM has increasing input into standard setting across a range of institutions, such as Health Education England (HEE) and the General Medical Council (GMC), various diplomas and the Department of Health. This allows the organisation to influence the aesthetic agenda and provide education to the public and the medical profession.

Member benefits: Any aesthetic doctor can apply for associate membership and after two years, following Board approval, full membership. It offers peer support through a website forum, advice on matters concerning practice, and appraisal with a Responsible Officer, leading to revalidation. It also hosts an annual conference and is involved in standard setting, on which members have a chance to present their views.

The future: Dr Paul Charlson, president of BCAM, says, “In the future we aim to become more involved in diploma development.

We aim to create a new website with social media linkage to allow members to be easily identified by the public, and increase our media presence and membership in order to be seen as the ‘go to’ organisation for high quality advice and practitioners.”

BCAM has a network of over 300 doctors. www.bcam.ac.uk

BAAPS (British Association of Aesthetic Plastic Surgeons) What is BAAPS? BAAPS is a professional body specifically for surgeons practicing aesthetic surgery. It is a registered charity dedicated to advancing education and the practice of aesthetic plastic surgery for public benefit.

What does it do? BAAPS offers training and support to members. All members need to be on the specialist register, sponsored by two other full members, and be able to demonstrate competence in aesthetic surgery. They must submit an annual audit of their figures and abide by a code of practice, reinforcing the BAAPS brand to the public. BAAPS has recently launched regional training meetings and hopes to assist the industry by promoting training, research, ethics, public education and safety.

BAAPS has an average annual meeting attendance of 200 surgeons. baaps.org.uk

Member benefits: Practitioners can attend a free annual meeting, receive a free subscription to the Aesthetic Surgery Journal, contribute to an annual national surgical audit, and support research into aesthetic surgery. BAAPS claims that patients can look for membership to the association as reassurance that their surgeon will act in an ethical and safe manner according to a specific code of practice.

The future: Paul Harris, BAAPS council member, says, “As a result [of the Keogh report], we should be able to establish a clear set of standards in training, audit and patient communication that will significantly reduce the chances of rogue practitioners causing damage to or profiteering from patients.”

BACN (British Association of Cosmetic Nurses) What is BACN? The BACN is a professional membership organisation for fully qualified nurses or trainees, in cosmetic nursing. It aims to ensure cosmetic nurses are recognised and can access current legislation, education and peer support to ensure consumers receive safe, professional treatment.

What does it do? The BACN agreed a three-year strategic plan in 2014 meeting their member needs. It also saw publication of the RCN/BACN Accredited Competency Framework for Aesthetic Nurses. It aims to be an integral part of shaping the standards of non-surgical practice in both Europe and the UK, actively encouraging member participation.

Member benefits: In 2015, BACN hopes to offer a strong, revitalised regional network for nurses to meet, exchange best practise, attend workshops and obtain CPD points. Members can expect news, events and resources on practise, research, products and suppliers. They may also receive discounted insurance, events, and magazine subscriptions.

Aesthetics | January 2015

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Special Feature Aesthetic Organisations

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The future: “There are some exciting new benefits for BACN members for 2015 including strategic sponsored Super meetings, in addition to regional meetings, and a new BACN App for easier website access to news, classifieds, guidelines and protocols,” says Sharon Bennett, chairperson of BACN. “We are also hoping to agree an associate membership for other professionals, giving access to meetings and education to GMC, GDC and overseas nurses, though retaining NMC registrants at board level. The BACN is working on the NMC pilot for revalidation, along with other healthcare organisations, to enable a smooth transition when the service is initiated in September 2015.”

Since 2010 the BACN have grown to over 600+ members. www.cosmeticnurses.org

UKAAPS (UK Association of Aesthetic Plastic Surgeons) What is UKAAPS? UKAAPS was formed as a professional body by a group of like-minded plastic surgeons, with membership only available to those who are fully accredited and practice non-surgical aesthetics and aesthetic/cosmetic surgery.

What does it do? It provides support for aesthetic plastic surgeons and aims to show the public that there is training available for aesthetic plastic surgeons.

The training provided by UKAAPS is in the form of the MCh Plastic and Aesthetic Surgery Practice course, which allows practitioners to develop their knowledge and expertise as aesthetic plastic surgeons, and also works to assure the public of full specialist training.

Member benefits: UKAAPS offers members training and event days, which vary from live surgery events to industry meetings. They have regular council meetings to discuss developments and showcase live surgeries in the UK and abroad.

Plastic surgeons on the MCh degree course must complete 14 competencies and are provided with VLE learning platforms, live surgery demonstrations and supervised practical surgery. All UKAAPS members are members of BAPRAS. The future: Professor James Frame, president of UKAAPS, says, “UKAAPS has already set its house in order before the Keogh report and the GMC recommendations. It provides the world-first university validated training course in aesthetic www.ukaaps.org surgery for plastic surgeons.”

Over 185 surgeons internationally logged in to watch UKAAP’s July Surgery Masterclass online.

BCDG (British Cosmetic Dermatology Group)

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BAPRAS (British Association of Plastic Reconstructive and Aesthetic Surgeons) What is BAPRAS? BAPRAS is a registered charity and the only statutory association for plastic, reconstructive and aesthetic surgeons and trainees in the UK. What does it do? The goal of the association is to drive professional standards, education and innovation across plastic surgery. BAPRAS works with its members to create best practice in the UK and internationally, and aims to deliver improved outcomes for patients. It also aims to differentiate itself by developing policy in a patient-focused manner from the perspective of plastic surgeons as a community,.

Member benefits: BAPRAS offers a range of membership options to suit all levels of surgical expertise. The association facilitates the development of plastic surgery both by subspecialty and as a whole. Members are expected to contribute to the speciality and take part in an on-going exchange of information, knowledge and expertise. They receive reduced rates of registration for BAPRAS meetings and courses, as well as support from colleagues and special interest groups in dealing with challenging clinical cases and ethical issues.

The Future: “BAPRAS is collaborating with major independent providers and other mainstream surgical associations to represent surgery as a whole and to develop novel methods for the training of surgeons in procedures no longer available on the NHS,” says Mark Henley, chairman of the BAPRAS Independent Practice Committee.

“This includes the use of surgical simulation and ‘Hands On’ training in the independent sector.”

BAPRAS has 800+ members to date www.bapras.org.uk

The BCDG has 56 full members, all on the GMC Specialist Register.

What is the BCDG? A section of the British Association of Dermatologists (BAD), the BCDG is a national body for dermatology trainees, consultant dermatologists who are GMC specialist registered and physicians with approved post-graduate dermatology training.

What does it do? The BCDG provides academic and clinical knowledge in cosmetic www.bcdg.info dermatology. It shares advice on cosmetic training, as well as advising post-graduate medical education students and the Government. The BCDG aims to facilitate communication between the BAD in a professional, evidencebased and unbiased manner for the benefit of the public and media.

Member benefits: Members will receive educational training to further their understanding and expertise in cosmetic dermatology and cosmetic procedures. The BCDG communicates with consultant and trainee dermatologists, providing them with information on ethical and clinical standards of practice within the cosmetic area. The BCDG also provides educational programmes, which are all CME/CPD approved.

These include an annual clinical and scientific meeting, focused practical workshops and teaching sessions at the annual BAD meeting.

The future: “The BCDG is committed to continued education. This year, members can look forward to workshops on neurotoxins and fillers in April, discussions on dyspigmentation at the BAD meeting in July, and the annual BCDG Clinical Meeting in November”, says Nick Lowe, BCDG president.

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Aesthetics | January 2015

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IHAS (Independent Healthcare Advisory Services)

PIAPA (Private Independent Practices Association)

What is IHAS? IHAS is a division of the Association of Independent Healthcare Organisations (AIHO), the trade association for independent hospitals.

What does it do? Within the last decade IHAS has had a significant role in the operational policy and regulation in the independent healthcare sector. AIHO/IHAS works in tandem with ISCAS, the Independent Sector Complaints Adjudication Service, which provides an independent review stage for third stage complaints from aiho.org.uk independent hospitals and clinics. Private patients treated in the UK do not have access to the Public Services Ombudsman for resolving complaints.

Member benefits: IHAS offers networking opportunities through its medical revalidation workstream for all the Responsible Officers in the sector, who meet on a regular basis with the GMC. It also assists with the development of the National Workforce minimum dataset, so workforce data can be captured from the independent sector in conjunction with the NHS. The future: “IHAS has maintained its relationships with the system regulators in all four countries and with the professional regulators,” says director Sally Taber.

“IHAS was asked by the previous government to set up a self- regulation scheme for cosmetic injectables. Treatments You Can Trust (TYCT) has been established since 2010 to ensure the quality assurance of those who undertake cosmetic injectables.”

What is PIAPA? PIAPA was founded by a group of aesthetic nurses in 2004 with the aim of offering support to independent practitioners.

What does it do? PIAPA aims to promote safety, integrity and clinical excellence within the industry.

Board members regularly meet with Health Education England and the Nursing and Midwifery Council to discuss the implementation of new regulations and practise guidelines.

Member benefits: Members can expect to receive training opportunities, access to business coaching, certificate of membership, NMC and revalidation information, discretionary discounts and portfolio and APEL advice.

The future: Co-founder of PIAPA Yvonne Senior, said “PIAPA was created to support, reassure and improve practitioners, and as we face a pivotal time of change in medical aesthetics, we plan to do exactly the same in the future.”

IHAS links with AIHO, representing over 200 hospitals nationally.

PIAPA has more than 200 members. www.piapa.co.uk

SOMUK (Society of Mesotherapy UK)

Save Face

What is SOMUK? SOMUK is the only society specialising in Mesotherapy in the UK, with membership available to all interested medical professionals.

What does it do? SOMUK aims to establish and maintain standards of clinical excellence in the science of mesotherapy. It also acts as a resource for safe ethical practice and strives for the development of evidence-based medicine in support of the use of mesotherapy. It further aims to elevate mesotherapy as a recognised established therapy in aesthetics and pain management, and aims to work closely with authorities and insurance companies in order to ensure the safe practice of mesotherapy.

Member benefits: Members are updated with information on mesotherapy, are able to attend congresses at a reduced fee, and potentially receive free of charge training courses. Members are actively encouraged to engage in networking both nationally and internationally to share experiences, ideas and innovation in order to improve and maintain standards of safe ethical practice.

The future: “Within one year we are proud to have become official partners of well-known national and international congresses, which is a great benefit for members and the development of mesotherapy in the UK,” said Dr Philippe Hamida-Pisal, president of SOMUK. “One of our main goals for the future is to set up a post-graduate university diploma in Pain Management using mesotherapy.”

What is Save Face? Save Face is the largest voluntary register of accredited practitioners in the UK. The organisation provides consumers with information on non-surgical treatments so that they can be fully informed when deciding on aesthetic procedures. Save Face is not a substitute for membership with a professional body.

What does it do? Save Face aims to educate and protect the consumer. Its support packages aim to add value to practitioners, whilst the organisation hopes to establish an objective set of standards, which both practitioners and clinics can be measured against in order to achieve accreditation.

Member benefits: Practitioners must pay to register with Save Face and will receive an independent inspection and verification of their standards in practise, and a means to gather and present their evidence when required for appraisal, revalidation, insurance, and job applications. Save Face offers a verification process, providing policies and forms of support to ensure safe running of clinics.

Members can also receive discounted services.

The future: “We need to build consumer confidence in the safety of these treatments when delivered by safe hands in a safe environment using safe products,” said Emma Davies, clinical director of Save Face.

“The consumer needs a credible register that provides more than just a register, whilst professionals need to recognise the place for – and value of – this model of self-regulation, and support it.”

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SOMUK has a current membership of 47 interested parties.

Since August Save Face has accredited 110 practitioners across 200 UK locations.

www.somuk.co.uk

www.saveface.co.uk

Aesthetics | January 2015

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CPD Facial Danger Zones

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Facial Danger Zones: avoiding serious complications in non-surgical filler injections Dr Julian De Silva discusses facial danger zones and how to treat and prevent serious adverse events Abstract Over the past decade non-surgical filler injections have become an increasingly popular treatment for soft tissue augmentation and facial rejuvenation. For the most part, these filler injections are considered relatively safe. Yet from my knowledge of case reports and conference discussions, there seems to be an increasing number of serious adverse events occurring, including loss of visual function, blindness, skin necrosis and facial scarring associated with the use of filler injections. In this article, I discuss the underlying facial anatomy and mechanism of these serious adverse events, the concept of facial danger zones, and present a discussion of both treatment and prevention of these serious adverse events.

Introduction Soft tissue fillers are an increasingly popular treatment for soft tissue augmentation and facial rejuvenation. The American Society for Aesthetic Plastic Surgery reported approximately 13% growth in non-surgical treatments between 2012 and 2013; with non-surgical treatments making up over 80% of all treatments performed.1 The consequences of serious adverse events can be devastating.

They can include visual blindness,2,3,4,5,6,7,8,9,10,11 skin necrosis11,12,13 and permanent facial scarring.11,12,13 In this article I examine the concept of facial danger zones specific to facial anatomy. I discuss the facial anatomy that underlies the danger zones, and the treatment and avoidance of these complications with modified techniques.

The most serious complications with non-surgical and surgical filler treatments include: • Unilateral or bilateral visual impairment or blindness • Skin necrosis • Cerebrovascular event Soft tissue filler products that have been associated with these serious adverse events include; hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid and polymethyl methacrylate, silicone and fat transfer.7 Facial Anatomy Key to our understanding of how these serious adverse events occur is knowledge of the facial vascular anatomy. Anatomy of the face can be broadly defined into these five layers: 1. Skin (Epidermis and Dermis) 2. Subcutaneous fat in compartments (Figure 1) 3. Underlying facial muscles and SMAS (Superficial muscular aponeurotic system) (Figure 2) 4. Profuse anastomosis of facial vessels (Figure 3) 5. Skull The arteries that branch from internal and external carotid arteries provide the vascular supply to the skin and subcutaneous tissue 26

of the face. The eye is vascularised by the ophthalmic artery via a branch from the internal carotid artery – called the central retinal artery (Figure 4). The central retinal artery is essential for normal visual function and any damage or blockage of this artery has the potential to reduce visual function within minutes. The ophthalmic artery continues in the orbit to the supraorbital and supratrochlear arteries. The supratrochlear artery lies in the areas of the corrugators and inferior anastomoses with the dorsal nasal artery.

The supraorbital nerve exits the orbit in the superior orbital notch and anastomoses temporally with the superficial temporal artery.

The external carotid artery lies in the lateral aspect of the neck.

At the antero-inferior tragus it divides into the superficial temporal artery and the middle temporal artery. Although the larger vessels are anatomically described, there is a rich vascular anastomosis that increases the risk of an intra-arterial injection of filler with nonsurgical treatments (Figure 3).

A further consideration is that patients who have undergone previous non-surgical or surgical treatments may have an underlying change in their anatomy and be at higher risk of a serious adverse event. This is evident for the nose where previous rhinoplasty may have injured vascular anastomosis, making nonsurgical filler injections post-rhinoplasty a higher risk procedure.15 Mechanism of Serious Adverse Events Loss of visual function occurs as a consequence of occlusion of the central retinal artery. The central retinal artery provides the principle blood supply to the key part of the eye (retina) that provides vision. If these cells are deprived of oxygen, even for a short period, they become permanently damaged leading to a irreversible loss of visual function. For this to occur there is a mechanical blockage of arterial blood flow along the central retinal artery. In this case, filler injected into the soft tissues around the periorbital areas is inadvertently injected intraarterially (Figure 5) into one or more of the five facial danger zones. With sufficient pressure and volume, there is a retrograde flow of the filler along the artery via vascular anastomosis to the central retinal artery. Some of the filler product flows anterograde into the central retinal artery, resulting in occlusion of the central retinal artery and compromised visual function. The extent of the visual function deterioration will be dependent on the volume of filler that has flowed along the artery and the resulting homogeneity of the central retinal artery blockage.

If sufficient volume and pressure of the filler is injected, the entire ophthalmic artery may become occluded. Occlusion of the ophthalmic artery will result in ischaemia to the anatomical structures of the orbit including ocular rectus muscles for eye movement. This is characterised by visual loss coupled with pain

Aesthetics | January 2015

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Although serious adverse events from the use of non-surgical treatments are rare, the consequences can be devastating and loss of normal ocular movements.3 Necrosis of the skin occurs as a consequence of compromised arterial blood supply to the skin. The injection of filler into an endartery may result in antero-grade flow and occlusion of the blood vessel. In addition, injection of a sufficient volume of filler near an end-artery may result in compression of the vessel; this may be more likely with a filler that expands after use such as a hydrophilic hyaluronic acid. Compromised arterial supply to the skin results in rapid hypoxia, characterised by blanching of the skin and ischaemic pain.12,16 A very rare complication is a cerebrovascular accident (CVA or stroke) as a consequence of non-surgical hyaluronic acid fillers.18 This occurs as a consequence of the rich vascular anastomosis between the vascular supply of the face and orbit, retrograde flow of the advertent injection of hyaluronic acid material to be forced into the ophthalmic artery and internal carotid artery. Subsequent anterograde flow of the material in the internal carotid artery is then able to result in blockage of the end arteries to the brain resulting in a CVA. Facial Danger Zones On evaluation of both the medical literature for complications related to filler injections and our knowledge of the facial anatomy, we can derive specific areas of the face that are at a higher risk of these potentially devastating adverse events (Figure 6 & 7).

Facial danger zones and associated facial arteries: 1. Glabellar area: Supraorbital & Supratrochlear arteries 2. Nasal augmentation: Angular artery 3. Nasolabial groove: Facial artery 4. Tear trough (Nasojugal groove): Infraorbital artery 5. Temporal volume loss: Superficial temporal artery Treatment of Complications The treatment of visual loss as a consequence of intra-arterial filler injection and central retinal artery occlusion is challenging.

The use of a hyaluronic acid filler warrants the injection of hyaluronidase with the intention of dissolving the filler. Urgent blue light referral to an ophthalmic emergency unit is warranted as failure to take action could result in permanent visual loss.

Treatment includes the use of medications to reduce intraocular pressure, carbogen treatment to cause vasodilation and hyperbaric oxygen. Cadaver studies have suggested treatment with urgent retro-orbital injection of hyaluronidase into the retro-bulbar orbital space may be effective in the treatment of blindness.19 The treatment of impending skin necrosis is characterised by an attempt to reverse the end-arterial occlusion and to reduce the resulting inflammatory process that results in soft tissue damage.

Treatment with an emergency kit should include hyaluronidase

CPD Facial Danger Zones

(only applicable for hyaluronic acid fillers), a nitrate patch or paste, anti-inflammatory medication (oral or intravenous prednisolone: reduce inflammatory damage to the ischaemic soft tissues), vasodilators and hyperbaric oxygen (increase blood supply to the soft tissues reducing ischaemic tissue damage).16 There is currently limited scientific evidence that supports the use of the different treatment modalities, and the treatment methodology listed is mostly derived from relatively low level scientific evidence including anecdotal evidence and case reports.

Based on the limited information we do have, here are suggestions for an emergency filler kit for treatment of vascular necrosis: • Hyaluronidase: If hyaluronic acid injected 6-8x 0.05cc of hyalurondiase (150units/ 0.1cc) into the skin (although up to 1,000 units has been advocated) or alternatively into Retro Bulbar Orbital Space (400-800 units injected with 25-gauge needle or cannula into infero-temporal orbital quadrant )19 • Warm compression and massage • Nitrate patch or Nitroglycerine paste (for 12 hours) • Aspirin (Acetylsalicylic acid) 300mg • Intravenous hydrocortisone 100mg • Oral dexamethasone 60mg for five days • Sildenafil (Vascular dilation) • Hyperbaric oxygen • Antibiotics (prevent secondary bacterial infection) • Antivirals (around mouth to prevent secondary viral infection) Discussion and Prevention of Complications Although serious adverse events from the use of non-surgical treatments are rare, the consequences can be devastating. They can include blindness, skin necrosis and facial scarring. The treatment of these serious adverse events is both challenging and limited, and prevention of these complications is preferred.

There are a number of measures that can be taken to mitigate the risk of a serious complication after non-surgical filler injections.

In the first instance this is an understanding of the underlying anatomy and the concept of facial danger zones. On injection of the filler, aspiration of the filler before injection may result in a flash back of blood if the needle is injected into a facial artery – although this method may not be conclusive if there is no flash back, as there may be a collapse of the artery on the pressure of aspiration. A flash back of blood would enable the injector to re-position the needle to an alternative location. From my experience, I have noted that the use of cannulas with bluntKey points: prevention of complications • Knowledge of vascular facial anatomy • Concept of facial danger zones associated with higher risk of treatment • Hyaluronic acid product has the advantage of hyaluronidase antidote • Aspiration needle technique before injection • Cannula technique over needle technique • Low pressure injection • Low volume fractionated technique of injection • Recognise immediate blanching of skin • Use of local anaesthesia with adrenaline to cause local vasoconstriction of facial blood vessels • Emergency filler kit

Aesthetics | January 2015

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CPD Facial Danger Zones

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ended tips is less likely to result in traumatic injury to an arterial wall and can result in the injection of the filler intra-arterially. In my opinion, a low-pressure injection makes an intra-arterial injection less likely, and a low volume of filler injection makes the bolus less likely to result in central retinal artery occlusion. An injection that results in immediate blanching of skin should be treated as vascular compromise and requires urgent treatment (vascular occlusion results in skin hypoxia, the reduced oxygen carriage in the skin results in a change in skin colour). The pre-filler use of local anaesthesia with adrenaline results in local vasoconstriction (reduced diameter of the arteries), reducing the risk of intraarterial injection. Some injectors prefer filler treatments without the use of adrenaline in the local anaesthesia as this may mask //Figures// the discolouration caused by intra-arterial injection,17 making the Figure 1: Subcutaneous fat compartments of the face (Rohrich, 2007) ishcaemia caused by intra-arterial more difficult to see.

Figure 2: Muscles of facial expression

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Conclusion The use of non-surgical filler injections for soft tissue augmentation and facial rejuvenation continues to grow and is generally regarded as safe and effective. The adverse events such as the loss of visual function, blindness and skin necrosis, which have been reported, highlight the importance of adequate knowledge in the management and prevention of further serious complications. Knowledge of the underlying anatomy, mechanism, preparation for emergency treatment and steps taken towards prevention are important to ensure that the risk of these events is minimised and appropriate.

Dr Julian De Silva is a facial cosmetic surgeon, specialising in the eyes, nose, face and neck areas. He has experience in cosmetic/reconstructive facial surgery from fellowships in London, LA and New York.

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Figure 1: Subcutaneous fat compartments of the face (Rohrich, 2007)12

Figure 5: Intra-­‐arterial injection of filler results in retro-­‐grade flow of the filler into Figure 2: Muscles ofthe facial expression the ophthalmic artery and central retinal artery. Occlusion of the central

retinal in painless loss of vvessels ision. courtesy of Prof. Von Hagens Figure 3: aPrtery rofuse raesults nastomosis of facial blood

Figure Anastomosis oanastomosis f facial vessels around the facial eyes Figure 3:4: Profuse of blood vessels courtesy of Prof. Von Hagens 2014.

2014.

Figure 5: Intra-­‐arterial injection filler results in raround etro-­‐grade flow of the filler into Figure 4: Anastomosis ofof facial vessels the eyes the ophthalmic artery and the central retinal artery. Occlusion of the central retinal artery results in painless loss of vision.

Figure 6: 5: The concept of facial injection danger zones. njections of filler these areas Figure Intra-arterial of Ifiller results ininto retrohave an flow increased risk ofiller f intra-­‐arterial and can artery result in serious grade of the into theinjection ophthalmic and theadverse events. central retinal artery. Occlusion of the central retinal artery

results in painless loss of vision.

REFERENCES

1. ‘Cosmetic Surgery National Data Bank Statistics’, (American Society for Aesthetic Plastic

Surgery: US, 2103) http://www.surgery.org/sites/default/files/Stats2013_4.pdf Last accessed: 17

December 2014 2. Carle MV, Roe R, Novack R, Boyer DS. ‘Cosmetic facial fillers and severe vision loss’, JAMA Ophthalmol, 5 (2014) p.637-9.

3. Chen Y, Wang W, Li J, Yu Y, Li L, Lu N, ‘Fundus artery occlusion caused by cosmetic facial injections’, Chin Med J (Engl), 127 (2014) p.1434-7.

4. Yanyun C, Wenying W, Jipeng L, Yajie Y, Lin L and Ning L, ‘Fundus artery occlusion caused by

cosmetic facial injections’, Chinese Medical Journal, 127 (2014) p.1434-1437.

5. Kim YJ, Choi KS, ‘Bilateral Blindness after Filler Injection’, Plast Reconstr Surg, 131(2013) p. 298- 299.

6. Kim SN, Byun DS, Park JH, Han SW, Baik JS, Kim JY, Park JH, ‘Panophthalmoplegia and vision

loss after cosmetic nasal dorsum Clininto Neurosci, 21 (2014) p.678-80.

Figure 6: The concept of facial danger zones. Iinjection’, njections of Jfiller these areas 7. aLazzeri D, Agostini T, Figus M, Nardi aM, Lazzeri S, ‘Blindness following cosmetic have n increased risk of intra-­‐arterial injection nd Pantaloni can result iM, n serious adverse events.

injections into the face’, Plast Reconstr Surg, 129(2012) p.995-1012.

8. Woo SJ, Park SW, Park KH, Huh W, Jung C, Kwon OK, ‘Iatrogenic retinal artery occlusion

caused by cosmetic facial filler injections’, American Journal of Ophthalmology, 154(2012) p.653-662.

9. Lee DH, Yang HN, Kim JC, Shyn KH, ‘Sudden unilateral visual loss and brain infarction after

28

Figure 6: The concept of facial danger zones.

Injections of filler into these areas have an increased risk of intra-arterial injection and can result in serious adverse events.

autologous fat injection into nasolabial groove’, Br J Ophthalmol, 80 (1996) p.1026-1027.

10. Egido JA et al., ‘Middle cerebral artery embolism and unilateral visual loss after autologous fat

injection into the glabellar area’, Stroke, 24 (1993) p.615-616.

11. Ozturk CN, Li Y, Tung R, Parker L, Piliang MP, Zins JE, ‘Complications following injection of soft-

tissue fillers’, Aesthet Surg J, 1 (2013) p.862-77.

12. Funt D, Pavicic T, ‘Dermal fillers in aesthetics: an overview of adverse events and treatment approaches’, Clin Cosm Inv Derm 129(2013) p.295-316.

13. Dayan SH, Arkins JP, Mathison CC, ‘Management of impending necrosis associated with soft

tissue filler injections’, J Drugs Dermatol JDD, 10 (2011) p.1007-12.

14. Rohrich RJ, Pessa JE, ‘The Fat Compartments of the Face: Anatomy and Clinical Implications

for Cosmetic Surgery’, Plast Reconstr Surg, 119 (2007) p.2219-2227.

15. Kurkjian TJ, Agnad J, Rohrich RJ, ‘Soft-Tissue Fillers in Rhinoplasty’, Plast. Reconstr. Surg, 133 (2014).

16. Tsai M, Hsia T, Han Y, Wu H, Lin Y, ‘Successful Hyperbaric Oxygen Therapy In Complications Of

Fillers Rhinoplasty Cases Report’, The Internet Journal of Alternative Medicine, 9 (2014).

17. Emer J, & Waldorf H, ‘Injectable neurotoxins and fillers: There is no free lunch’, Clinics in Dermatology, 29 p.678-690.

18. He MS, Sheu MM, Huang ZL, Tsai CH, Tsai RK, ‘Sudden bilateral vision loss and brain infarction

following cosmetic hyaluronic acid injection’, JAMA Ophthalmol, 131 (2013) p.1234-5.

19. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A, ‘Blindness caused by cosmetic

filler injection: a review of cause and therapy’, Plast Reconstr Surg, 134 (2014) p.1197-201.

Aesthetics | January 2015

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Spotlight On Obesity Statistics

Figure 2: Obesity prevalence rates quoted by QOF, by Region in England – 2012/13 Region

Obesity Prevalence (%)

North of England

12

Midlands and East of England

11.2

London

9.2

South of England

9.7

Obesity Pandemics: The Fat Figures

problems. Adults with a BMI of more than 35 have a very high risk rate with any waist circumference (Figure 1).4 The Quality and Outcomes Framework (QOF) prevalence data tables for 2012/13 show a breakdown of obesity at a regional level in England (Figure 2). It shows that there is a clear north-south divide, with Northern England having higher obesity prevalence rates than Southern England.4 In 2012, in Scotland 27.1% of adults were classified as obese, and 64.3% of adults were classified as being overweight or obese . In Wales, 23.0% of adults were classified as obese, and Dr Amanda Wong Powell presents 58.5% of adults were classified as being overweight or obese. the statistics around obesity in the This compares with 24.7% of adults being obese in England and 61.9% of adults being overweight or obese.4 These results put the UK and internationally Scottish on top of the overweight and obese list followed by the Obesity and being overweight are the number five cause of English and then the Welsh. death globally, causing 2.8 million adult deaths annually.1,2 One In 2013, more than half (52.6%) of the adult population in the in four adults are now classed as obese, and worldwide obesity European Union reported that they were overweight or obese. has nearly doubled since 1980.1,2 The World Health Organisation This compares to just two years ago when 50.3% of the European (WHO) classifies a person as overweight if they have a body mass adult population in The Organisation for Economic Co-operation index (BMI: kg/m2) of more than 25, and a person as obese if their and Development (OECD) reported that they were overweight BMI is more than 30. The obese group is further classified into or obese. The least obese countries were India (2.1%), Indonesia Class I: moderately obese with a BMI of 30-35, Class II: severely (2.4%) and China (2.9%). The most obese countries were the US obese with a BMI of 35-40 and Class III: very severely obese with (36.5%), Mexico (32.4%) and New Zealand (28.4%).7 a BMI of more than 40.

An endocrinology study8 suggested that India has the lowest Although BMI is a very acceptable method of measuring obesity, it obesity rates due to its traditional strengths in maternal nutrition, does not differentiate between mass due to fat or muscle. Hence, walking, yoga, meditation and traditional folk dance. Perhaps the waist circumference is also another method used to measure lifestyle difference, diet, pattern of snacking, eating frequency, obesity. A waistline of more than 102cm in men and 88cm in portion sizes, and high proportion of food prepared outside the women is considered to be overweight. The National Institute home is a more likely cause of the increased obesity rates in for Clinical Excellence (NICE) guidance on overweight and western countries.9 obesity statistics highlights the impact of increased BMI and waist The obesity pandemics lead to increased risk factors for other circumference on risk factors for developing long-term health medical conditions, including cardiovascular (heart disease and stroke predominantly), Figure 1: NICE Risk Categories diabetes, and musculoskeletal disorders (osteoarthritis Waist Circumference particularly). Childhood obesity is Low High Very High BMI associated with a higher chance (<94cm in men) (94-102cm in men) (>102cm in men) of adult obesity, disability, and (<80cm in women) (80-88cm in women) (>88cm in women) premature death. But in addition Normal: 18.5-25 No increased risk No increased risk Increased risk to increased future risks, obese children experience breathing Overweight: 25-30 No increased risk Increased risk High risk difficulties, greater risk of fractures, hypertension, early markers of Obesity I: 30-35 Increased risk High risk Very high risk cardiovascular disease, insulin Obesity II: 35-40 Very high risk Very high risk Very high risk resistance, and psychological effects.5,12 The rising numbers of Obesity III: 40 + Very high risk Very high risk Very high risk overweight patients will place Aesthetics | January 2015

31

Spotlight On Obesity Statistics

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Figure 3: Obesity Risks 6

will be even better. As healthcare professionals, supporting our patients in their weight loss programme can play a significant role. The National Classification BMI (kg/m2) Risk of co-morbidities Obesity Forum has a very useful Obesity Care Underweight < 18.5 Low* Pathway Toolkit on weight management service.10 Identifying patients who are ready to change, and Healthy weight 18.5– 24.9 Average are prepared to commit to the change, will determine the success of the programme.

Overweight (or pre-obese) 25–29.9 Increased The food industry can help promote healthy lifestyles Obesity, class I 30–34.9 Moderate by reducing fats, sugars and salt content, as well as ensuring healthy and nutritious foods are available Obesity, class II 35–39.9 Severe and affordable to all consumers. One problem, which has always been difficult to address, is that it Obesity, class III ≥ 40Very severe is generally cheaper for a family to eat unhealthily. *Other health risks may be associated with low body mass index (BMI).

Despite changes made to food labelling to inform consumers, it is still hard for a non-expert, even an increasing demands on health services as a consequence. educated one, to make sense of the figures on packaging in These cut-offs are based on epidemiological evidence of the link order to make appropriate purchasing decisions. between mortality and BMI in adults.

Monitoring of health, exercise and fitness are growing industries, The causes of obesity lie with mismanaged and disproportionate but it is probably the case that the people regularly running, calories intake – people are eating more than they need and working out and monitoring themselves with active wristbands not shifting those excess calories. It is our lifestyle; particularly and mobile apps, are not the people with the obesity problem. the higher consumption of processed food, high calories, It is estimated that by 2025, 47% of men and 36% of women high fat, non-active jobs, and a ‘couch potato’ attitude. The (aged between 21 and 60) will be obese. By 2050, it is estimated supermarket ‘Buy One Get One Free’ deals do not help either. that 60% of males and 50% of females could potentially be We as consumers need to be more savvy and as individuals more obese.11 There is no quick fix to this epidemic. This is a global conscious of our body. It is not difficult to understand that if you issue, which needs to be tackled by everyone on every level. eat too much and do not exercise enough, the excess energy will Having insight into the issue is a start. then be saved as fat, but it is our mentality and habit that results in Dr. Amanda Wong-Powell is the founder and Medical weight gain. Obesity is preventable and it is our duty as aesthetic Director of Dr. W on Harley Street. She has completed practitioners and medical professionals to educate our patients her basic surgical training, and is a Member of the Royal as to not only what we can do for them, but also what they can do College of Surgeons (Edinburgh). She was a registrar in for themselves.2 Trauma and Orthopaedics before deciding to venture into aesthetic medicine, which she has been practising for the last 6 Choosing to have a healthy diet that incorporates fruit and years. Dr Wong-Powell is a VASER liposuction surgeon, and also has vegetables, as well as cutting out food high in fats and sugars, an interest in weight loss management. She is also Medical Director of can help immensely. Exercising at least twice weekly for at least Meducatus, the medical training platform for doctors and surgeons. half an hour will help, although half an hour a day every day

As healthcare professionals, supporting our patients in their weight loss programme can play a significant role.

32

REFERENCES: 1. Obesity Facts and Figures, (Europe: European Association for the Study of Obesity, 2013) <

http://easo.org/obesity-facts-figures> [accessed 24 November 2014].

2. Obesity and Overweight Fact sheet No311,(World Health Organisation, 2014) http://www.who. int/mediacentre/factsheets/fs311/en/ [accessed 24 November 2014].

3. BMI Classification (World Health Organisation, 2014) http://apps.who.int/bmi/index. jsp?introPage=intro_3.html [accessed 24 November 2014].

4. Paul Eastwood ‘Statistics on Obesity, Physical Activity and Diet: England 2014’, Health & Social

Care Information Centre (2014) http://www.hscic.gov.uk/catalogue/PUB13648/Obes-phys-acti- diet-eng-2014-rep.pdf [accessed 24 November 2014].

5. David CW Lau et al, ‘2006 Canadian clinical practice guidelines on the management and

prevention of obesity in adults and children’ Canadian Medical Association Journal (CMAJ),

176 (2007) http://www.cmaj.ca/content/suppl/2007/09/04/176.8.S1.DC1/obesity-lau-onlineNEW. pdf [accessed 24 November 2014].

6. ‘Obesity: preventing and managing the global epidemic. Report of a WHO Consultation’,

World Health Organisation (WHO) Technical Report Series 894 (2000) http://www. who.int/nutrition/publications/obesity/WHO_TRS_894/en/ [accessed 24 November 2014].

7. ‘Health at a Glance 2013, OECD Indicators’, Organisation for Economic Co-operation and Development (2013) http://dx.doi.org/10.1787/health_glance-2013-en [accessed 24 November 2014].

8. Unnikrishnan AG et al, ‘Preventing obesity in India: Weighing the options’, Indian J Endocrinol Metab, 16 (2012) p.4-6 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263196/ [accessed 24

November 2014].

9. BA Swinburn et al, ‘Diet, nutrition and the prevention of excess weight gain and obesity’, Public

Health Nutrition, 7(1A), p.123-146. http://www.who.int/nutrition/publications/public_health_nut3. pdf [accessed 24 November 2014].

10. David Haslam et al,‘Obesity Care Pathway Toolkit’ National Obesity Forum (2006) http://www. nationalobesityforum.org.uk/images/stories/care-pathway-toolkit/Toolkit_supporting_

obesity_care_pathway_annexes_1_to_9__Feb_07_2006.pdf [accessed 24 November 2014].

11. ‘Healthy lives, healthy people: A call to action on obesity in England’ Department of Health, (2011) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213720/ dh_130487.pdf [accessed 24 November 2014].

12. ‘Complications of Childhood Obesity’, Childhood Obesity Foundation, http://www. childhoodobesityfoundation.ca/complicationsOfChildhoodObesity [accessed 24 November 2014].

Aesthetics | January 2015

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35

Clinical Practice Prescribing

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and Customs (HMRC) outline crucial points that explain when goods provided on prescription can be zero-rated for VAT purposes:3

Prescribing in medical aesthetics Pharmacist Brendan Semple discusses the role of prescriptions in medical aesthetics Often, the first thing many practitioners wonder when they complete their aesthetic training is how to access the drugs and devices that they are going to require in order to start their aesthetic practice. It can sometimes be their first venture outside of the NHS, and having to manage the legal, ethical and VAT implications can be quite daunting. This article seeks to clarify some of these matters and help you navigate the current legislation.

All practitioners are able to purchase certain commonly-used products over the counter in a pharmacy. Needles, syringes, swabs, gloves, cannulas and, most surprisingly, dermal fillers are classified as medical devices and there are no legal barriers to their supply. In our pharmacy we always check a practitioner’s professional qualification and ensure that they have completed a course in the use of fillers before making a sale, but there is no legislation in place that prevents the supply of dermal fillers to anyone. These goods are subject to 20% VAT.1 Prescription only medicines (POMs) such as botulinum toxin, adrenaline, hyaluronidase and IV sodium chloride can be purchased directly from the manufacturer, a wholesaler or a pharmacy via stock order by a doctor or dentist. Supplies obtained in this way are also subject to 20% VAT.1 Nurse Independent Prescribers (NIPs) have similar prescribing privileges to doctors 36

and dentists, however their handling of stock is significantly different. NIPs cannot order stock in the same way as doctors and dentists as they always require a prescription to be written and dispensed prior to administering a POM to a patient.

Consequently, they are unable to treat new patients at their first consultation. This is unless they work in the same clinic as a doctor or dentist, who is required to be present when the nurse administers the POM. In my experience, practitioners tell me the most convenient way to obtain the products they need is to send a prescription to a pharmacy. When writing a private prescription for a patient, there are some key points to bear in mind:2 • Once written, the prescription is the property of the patient • You must receive consent from the patient to send and receive their prescription • The transaction is between the patient and the pharmacy • Once dispensed, the medication is the property of the patient • The original copy of the prescription must be sent to the pharmacy within 72 hours One key advantage of prescriptions over stock-orders from a manufacturer or wholesaler is that, in certain circumstances, they are zero-rated for VAT. HM Revenue Aesthetics | January 2015

• The supply must be of ‘qualifying goods’ • The goods must be dispensed to an individual for that individual’s personal use • The goods must not be supplied for use for patients while in hospital or in a similar institution or administered, injected or applied by health professionals to their patients in the course of medical treatment • The goods must be dispensed by a registered pharmacist or under a requirement or authorisation under a ‘relevant provision’ • The goods must be prescribed by an appropriate ‘relevant practitioner’ The key point in the above legislation is that if the supply is for a medical treatment (exempt from VAT) then the prescription should attract 20% VAT. If the supply is for a cosmetic treatment (subject to 20% if VAT registered) then the prescription is zerorated. This means that whether the treatment is considered medical or cosmetic, HMRC are expecting to receive VAT at some point in the transaction.

The only exception to this is if the practitioner is not registered for VAT and the patient is receiving a cosmetic treatment.

The threshold for VAT registration is currently £81,000, therefore the patients of practitioners whose turnover falls below this amount may not have to pay any VAT in the course of their treatment.4 It is worth remembering that when a prescription is dispensed, the transaction is between the pharmacy and the patient. This sum is not part of the practitioner’s income and should not be part of the equation when considering whether you have reached the threshold to register for VAT. What records do pharmacists keep?

When we receive a prescription for a new patient, we create a Patient Medication Record (PMR) on our pharmacy computer system. This will record the full details of any prescription including who wrote the prescription, the date it was written and what was prescribed. We make an entry in our private prescription register and we scan the Rx and attach a copy to the patient’s file.

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This means that there is a full audit trail detailing everything from the date of consultation through to the time of dispensing. Hamilton Fraser Insurance, a UK-based specialist insurance company and provider of cosmetic liability insurance, warns that prescriptions written for a patient subsequent to them having had their treatment using stock from another source, could leave the practitioner legally exposed as their policy may not respond to any claims.5 Medication for use in emergencies Current good practice suggests that practitioners should have immediate access to a selection of medication for use in the event of any complications during a treatment. These include:6 • • • • • • •

iv antihistamine iv steroid adrenaline hyaluronidase asprin glyceryl trinitrate paste medical oxygen

This again can be problematic for nurse practitioners, as the rules on named patient treatment would apply again. For example, each patient would need these drugs to be prescribed prior to any treatment programme. This is obviously economically unviable and an incredible waste of medication as, hopefully, you will never need to use any of it! There is, however, another way to access most of these items without breaking any laws.

Regulation 238 of the Human Medicines Regulations 2012 allows for certain prescription-only medicines to be administered by anyone for the purpose of saving a life in an emergency. The medicines this concerns are covered in Schedule 19 of the regulation and are listed below.7 Medicinal products for administration by injection by anybody for the purpose of saving a life in an emergency: • A drenaline 1:1000 up to 1mg for intramuscular use in anaphylaxis • Atropine sulphate and obidoxime chloride injection • Atropine sulphate and pralidoxime chloride injection • Atropine sulphate injection • Atropine sulphate, pralidoxime mesilate and avizafone injection

Aesthetics

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hlorphenamine injection C Dicobalt edetate injection Glucagon injection Glucose injection Hydrocortisone injection Naloxone hydrochloride Pralidoxime chloride injection Pralidoxime mesilate injection Promethazine hydrochloride injection Snake venom antiserum Sodium nitrate injection Sodium thiosulphate injection Sterile pralidoxime

As long as you have access to a supply, you can legally administer adrenaline, chlorphenamine, or hydrocortisone to any patient in an emergency. GTN paste and aspirin are available to purchase over the counter in a pharmacy, so you can also keep that in your clinic stock supply.

BOC Industrial Gases, one of the largest suppliers of industrial gases in the UK, will open a medical gas account and supply you with medical O2. Hyaluronidase is currently the only drug that cannot be legally used by a nurse in an emergency situation without issuing a prescription first.

Finally, this is a quick reminder about the legislation regarding unlicensed and offlabel use of medicines. There are clinical situations when the use of unlicensed medicines or use of medicines outside the terms of the license (ie, ‘off-label’) may be judged by the prescriber to be in the best interest of the patient, on the basis of available evidence.

It is advised by the MHRA8 that before prescribing an unlicensed medication, practitioners must be fully satisfied that there is not any other medicine that could meet the patient’s needs. There should also be effective evidence to show the safety and efficacy of the off-label medication, and the practitioner must take responsibility for prescribing it and overseeing the patient’s care – this includes follow-up. It’s important that all off-label medication is recorded when prescribed, and, where this is not the usual practice, also the reasons for the prescription of this medicine.

It’s best to give patients, or those authorising treatment on their behalf, the ability to make an informed decision by outlining enough information about the proposed treatment – particularly regarding serious or common adverse reactions.

Although it may not always be necessary to draw attention to the license when seeking Aesthetics | January 2015

Clinical Practice Prescribing

consent for a medicine, it’s good practice to give as much information as the patient requires or sees relevant, even when current practice allows the use of medicine outside the terms of its contract. Be sure to explain the reasons for prescribing a medicine off-label where there is little evidence to support its use.

The MHRA also reiterates that it is crucial to report suspected adverse drug reactions via the Yellow Card Scheme, which collects this information in order to monitor the safety of all healthcare products in the UK and those medicines in clinical use.8 It would further be prudent to check with your insurers before using an unlicensed product on your patients.

Hopefully you’ve discovered something beneficial for your practice in this article.

I would heartily recommend that you establish a good working relationship with your chosen pharmacy. We share a duty of care with your patients and are always more than happy to research any pharmaceutical query you may have.

Brendan Semple is a community pharmacist and director of the TLC Pharmacy Group, which has seven branches, including TLC Aesthetic Pharmacy which is based in Moss Park, Glasgow. He is a member of the NHS National Appeal Panel and a board member of the Numark Pharmacy advisory board.

REFERENCES 1. UK Government, VAT for Consumers (UK: gov.co.uk, 2014)

<https://www.gov.uk/vat-consumers> [Accessed 9th

December] (p. 1) 2. Pharmaceutical Society Northern Ireland, Professional

Standards and Guidance for Pharmacist Subscribers

(Northern Ireland: PSNI.org.uk, 2009) <http://www.psni.org.

uk/documents/319/Standards+on+Pharmacy+Prescribing.pdf

> [Accessed 9th December] (Section 3.3.1) 3. HM Revenue and Customs, Health Professionals

and Pharmaceutical Products:

HMRC Reference:Notice 701/57 (July 2014) (UK: HM

Revenue and Customs, 2014) <http://customs.hmrc. gov.uk/ channelsPortalWebApp/channelsPortalWebApp. portal?_nfpb=true&_pageLabel=pageVAT_ ShowContent&propertyType=document&id=HMCE_

CL_000121#P88_9161> [Accessed 27 November] (Section 3.2) 4. UK Government, VAT Registration Thresholds (UK:

gov.co.uk, 2014) <https://www.gov.uk/vat-registration-

thresholds> [Accessed 9th December] 5. Owen Wood, Aesthetics Journal Article, 14 November 2014 6. Christopher Inglefield, Fiona Collins, Marie Duckett, Kate

Goldie, Gertrude Huss, Santdeep Paun, and Stephanie Williams, Expert Consensus on complications of botilinum

toxin and dermal filler treatment (UK: Aesthetic Medicine

Expert Group, 2014) 7. The Human Medicines Regulation (2012), Regulation 238,

Schedule 19 http://www.legislation.gov.uk/uksi/2012/1916/

pdfs/uksi_20121916_en.pdf [Accessed 27 November] 8. Medicines and Healthcare products Regulatory Agency,

Drug Safety Update (UK: mhra.gov.uk, 2009) <http:// www.mhra.gov.uk/home/groups/pl-p/documents/ publication/con043810.pdf>

37

Clinical Focus Diet and Nutrition

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Incorporating a dietician into your practice General practitioner and skin specialist Dr Anita Sturnham shares her experience of incorporating a dietician’s expertise to improve patient results Nutrition is essential as part of an antiageing skincare regimen. There are two main processes that are thought to induce skin ageing: intrinsic and extrinsic factors.8 Extrinsic ageing is caused by environmental factors such as sun exposure, air pollution, smoking and poor nutrition.

Intrinsic ageing generally reflects our genetic background. Various expressions of intrinsic ageing include thinning of the skin with exaggerated expression lines. Extrinsically aged skin is characterised by photo damage, such as lines, wrinkles, pigmented lesions, hypopigmentation and actinic keratoses.7 A network of antioxidants such as vitamins E and C, coenzyme Q10, alpha-lipoic acid, glutathione, and others can reduce signs of ageing. Antioxidants are the body’s defense against free-radical damage and oxidative stress. They fight free radicals by supplying them with the electron that they lack, therefore neutralising their harmful effects. Mitochondrial mutations of DNA accumulate during ageing and can be detected at elevated levels in prematurely aged skin following chronic exposure to UV light. In vitro data provides evidence that dietary micronutrients such as β-carotene interact with UVA in the cell and prevent the induction of photoageing-associated 38

mitochondrial DNA mutations.9 An antioxidantrich diet packed full of fruits and vegetables is therefore a crucial component of any patient’s anti-ageing plan.

My practice offers patients skincare, healthcare and nutritional advice all under one roof. It is a medical centre that offers a comprehensive range of facial and body treatments, skin treatments, GP health reviews, nutritional support, skin cancer checks and total body mole mapping, as well as Health MOTs. My clinical background allows me to provide patients with a specialist medical and skin assessment, looking not just at skincare but also at their overall health. It is well known that the appearance of your skin can often reflect your inner health and wellbeing. To have great skin, you need to have good health – total wellness is the aim for all of our patients at my practice.

As a general practitioner (GP) with a specialist interest in skin, I understand the importance of having a multidisciplinary approach when managing most health conditions. Over the years I have noticed a strong connection between an individual’s nutrition and their health. For example, those who consume large quantities of sugary foods and drinks have an increased risk of obesity and Type 2 Aesthetics | January 2015

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diabetes. In my own practice, I have noticed a connection between diet and skin diseases such as acne and eczema. For example, those who consume diets high in sugar seem to be more prone to outbreaks of these inflammatory skin conditions. It makes sense that if we feed our bodies with the right nutrition, we can reduce our risks of many diseases, including heart disease, strokes, diabetes and even skin disease.

Following this philosophy, I created Nuriss Skincare and Wellness Clinic. Nuriss comes from the French verb ‘nourrir’ (to nourish), meaning ‘to give a person or other living thing the food and other substances necessary for life, growth and good health’. Throughout my career I have been left frustrated when seeing patients in great need of nutritional support, but who are unable to access it easily. In my experience, access to a dietician has been limited due to a lack of available funding and resources. Even within hospital settings, a small team of dieticians are usually spread very thinly, allowing only a select number of patients access to this service. Patients often visit my clinic suffering from health issues such as irritable bowel syndrome, polycystic ovarian syndrome and acne vulgaris. I believe that a well-balanced diet can improve such issues so, as well as including nutritional advice in patients’ treatment plans, I have also incorporated a dietician into my clinic.

This service has always been available there and I am fortunate enough to have worked professionally with an excellent registered dietician during my years of practice. Our close working relationship has meant that introducing the role of ‘the dietician’ into our team of experts at Nuriss has been an easy one.

Dietitians are the only nutrition professionals to be regulated by law, and are governed by an ethical code to ensure that they always work to the highest standard.10 It is very much my personal choice to work with a dietitian rather than a nutritionist. Some may say that a nutritionist is just as good as a dietician however, although they have good knowledge about nutrition, as they are not regulated, my preference is to work with a dietitian.

At Nuriss we have allocated two days of every week for appointments designated to general medicine and nutrition. Our dietician, Lucy Jones, is employed by Nuriss on these days. If required, she is also able to offer consultancy-based work on other days of the week. Every Monday our Nuriss medical team also runs their health MOT clinic. The aim of our MOTs is to identify current health issues

Clinical Focus Diet and Nutrition

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Aesthetics Journal

By looking at inner wellness, health nutrition and skincare together, we can provide the ultimate skincare programme and screen for potential disease risk factors.

During the GP assessment, we talk through all aspects of a patient’s current health, screen for diseases, and perform blood and urine tests. We offer an advanced body composition analysis (called ‘Seca’ Testing), which assesses a number of parameters, including muscle and body fat percentage, body mass index, hydration and cellular activity levels.

This is followed by an in-depth consultation with our dietician, who will advise on all aspects of nutrition, review patients current diet and lifestyle and recommend diseasespecific dietary plans. For example, patients with irritable bowel syndrome may be started on the FODMAP diet, while patients with acne may be started on a low glycaemic index diet and one favouring foods known to be beneficial for the skin. According to dietician Lucy Jones, “Your food intake represents the foundations of good skincare.

The right nutrition can support healthy skin, reduce acne and even skin ageing. For those wanting to look and feel good, we can address health from the inside out in our comprehensive MOTs and health checks.”

Let’s use acne vulgaris as a case study; a common issue seen both in general practice and dermatology clinics. The literature examining the link between diet and acne has been very mixed over the years. However, there is now a growing body of epidemiologic and experimental evidence that suggests there could be a strong relationship between diet and acne.3 The evidence is more convincing for high glycemic diets, compared with other dietary factors such as the dairy-acne connection.1 Dairy ingestion appears to be weakly associated with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fibre remain inconclusive.1 Dermatologists and dietitians continue to debate and research the potential relationship between diet and acne. Most experts would agree, however, that diet does have an impact for most patients and the best dietary approach is to address each acne patient individually, carefully considering the possible benefit of dietary counselling.2 Personally, I have seen fantastic results in 40

the management of acne vulgaris. As an example, I have been seeing a 25-year-old female (Patient A) from London, with a history of acne vulgaris since the age of 17. She has been treated with topicals, oral antibiotics and Roaccutane in the past, unfortunately with poor results. At the time of presentation to me, she was taking oral Lymecycline and using topical Benzylperoxide. A low glycaemic index diet, rich in antioxidants and omega-3 fatty acids has totally transformed her skin.

Patient A said, “I have battled with my acne for years. For me, medicine was just one part of the puzzle. Good skin care was another part of the puzzle. Nutrition was the missing piece of the puzzle and now I have great skin.”

Nutrition and protection against environmental exposure Other examples of the benefits of using nutrition in skincare can be found by looking at the way in which nutrition can protect our skin from environmental damage. A diet rich in carotenoids is known to prevent cell damage, premature skin ageing, and even skin cancer. Cutaneous carotenoids can be enriched in the skin by nutrition, and a diet rich in antioxidants has been shown to increase free-radical protection after UVA/UVB irradiation.9 Antioxidants naturally occurring in the skin are superoxide dismutase, catalase, alpha-tocopherol, ascorbic acid, ubiquinone, and glutathione, and many of them are inhibited by UV and visible light.4 The antioxidant diet should contain large amounts of vitamins A, E, and C, grape-seed extracts, coenzyme Q10, and alpha-lipoic acid.4 The most highly recommended foods include: avocados, berries, dark green leafy vegetables, orange-coloured fruits and vegetables, pineapples, salmon, and tomatoes.

During the early planning stages of the ‘Nuriss’ brand and my clinic, I believed that having input from a dietician was an essential part of our patient journey. This belief was based on my own working experience, rather than in-depth research on the matter. I wanted to give my patients something that had always been missing from practices where I have worked Aesthetics | January 2015

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previously. I was also aiming to create the ‘ultimate’ clinic where patients could access healthcare, skin care and nutrition support under one roof.

In recent years, our patients seem so much more interested in the idea of using nutrition as a medicine and are happy that we endorse that ethos at Nuriss too.

The feedback from patients so far has been fantastic and, whilst not every patient needs to see a dietician, those that don’t need it seem reassured that we are able to offer them access to this service, if required. For those that do need and want nutritional support, the seamless transition from doctor to dietician, works well here.

The only difficulty was working out how to integrate this service into our practice. It was unlikely that we would require a dietician every day, so from a business perspective I also had to assess the costs of time and resources when setting up the clinic. The solution seemed to be to allocate set times/ days of the week for this service, So far, this seems to work well within our clinic.

In summary, I believe that the future of skin care lies in a holistic approach. By looking at inner wellness, health, nutrition and skincare together, we can provide the ultimate skin care programme.

Dr Anita Sturnham Dr Anita Sturnham is an experienced GP and a skin specialist. She is an ambassador for Unilever SkinCare and a medical expert for Superdrug, previously appearing on television to share her expertise. She currently works as a General Practitioner, combining NHS duties with private practice, recently opening her own clinic, Nuriss, in London.

REFERENCES 1. Thiboutot DM, Strauss JS, ‘Diet and acne revisited’, Arch Dermatol, 138 (2002), p.1591-1592.

2. Anderson PC, ‘Foods as the cause of acne’, Am Fam Physician, 3 (1971) p,102-103.

3. Katta R, Desai SP, ‘Diet and Dermatology: The role of dietary

intervention in skin disease’, J Clin Aesthet Dermatol, 7

(2014) p.46-51.

4. Fuchs J, Huflejt ME, Rothfuss LM, Wilson DS, Carcamo G,

Packer L, ‘Acute effects of near ultraviolet and visible light

on the cutaneous antioxidant defense system’, Photochem Photobiol 50 (1989) p.739-744.

5. Solauri E, ‘Probiotic in human skin disease’, Am J Clin Nutr

73 (2001), p.1142-1146.

6. Pillai S, Oresajo C, Hayward J, ‘Ultraviolet radiation and

skin aging: Role of reactive oxygen species, inflammation

and protease activation, and strategies. Review’. Int J

Cosmet Sci 27 (2005), p.17-34.

7. H. Sies, W. Stahl, ‘Carotenoids and UV protection’,

Photochem. Photobiol. Sci, 3 (2004) p.749-752.

8. Yaar M, Gilchrest BA. Aging of skin. In: Freedberg IM,

Eisen AZ, Wolf K, Austen KF, Goldsmith LA, Katz SI, editors.

Fitzpatrick’s dermatology in general medicine, vol 2. New

York: McGraw-Hill; 2003. p. 1386– 98.

9. Eicker J, Kurten V, Wild S, Riss G, Goral- czyk R, et al. 2003.

Beta-carotene sup- plementation protects from photoaging-

associated mitochondrial DNA mutation.Photochem.

Photobiol. Sci. 2:655–59 10. Health and Care Professionals Council. http://www.hpc-uk. org

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Spotlight On Vitamin C

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Vitamin C and the skin Dr Firas Al-Niaimi investigates the physiologic properties and mode of actions of this key anti-oxidant Abstract: Anti-oxidants have become increasingly popular as cosmeceuticals due to the beneficial effects that they exert on oxidative stress and free radicals generated by exogenous factors such as pollution and solar radiation. Vitamin C is the main anti-oxidant in the skin and has been used extensively for this purpose. This article details some of the physiologic properties of vitamin C, as well as its main mode of actions.

Introduction: Vitamin C is arguably the most well-known anti-oxidant in human skin. Its importance in health was signified in 1937 by Dr Albert Goyrgi who won the Nobel prize for identifying vitamin C as the main cause of scurvy. Unlike plants and some animals, humans are unable to synthesise vitamin C due to an absent enzyme called L-gluconogamma lactone oxidase and therefore rely entirely on external supplementation either in the form of diet (citrus fruit and green vegetables) or topical application in the case of cosmeceuticals.1 The absorption of vitamin C in the gut is limited by an active transport mechanism and therefore despite high-intake doses of oral vitamin C, only a small fraction of it will eventually be biologically available and active in the skin, hence for any discernible role of its actions in the skin, it needs to be supplied topically.2 Bioavailability and kinetics of vitamin C: Vitamin C is available in a number of active forms which include L-ascorbic acid, ascorbyl-6-palmitate, and magnesium ascorbyl phosphate of which L-ascorbic acid is the most biologically active and well-studied.1 Although all three types exert biological activity and an anti-oxidant effect, this is believed to be achieved, in part, by the conversion to the active form of L-ascorbic acid once penetrated through the stratum corneum. Unlike ascorbyl-6-palmitate and magnesium ascorbyl phosphate, which are lipophilic and stable but probably less biologically active; L-ascorbic acid in contrary is hydrophilic and unstable. The rate-limiting effect in magnesium ascorbyl phosphate is often its release from the vehicle and its conversion to biologically-active L-ascorbic acid.3 The hydrophilic nature means that L-ascorbic acid is poorly penetrated in the skin due to the impermeable hydrophobic stratum corneum. Furthermore, L-ascorbic acid is a charged molecule which 42

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will further limit the penetration.4 The instability of the molecule (i.e its degradation upon exposure to air and light) means that for L-ascorbic acid to be able to remain stable and penetrate through the stratum corneum it needs to be formulated in a way that provides both stability and permeability. An effective method of achieving this is by reducing the acidity (pH) of L-ascorbic acid below 3.5 which has shown to greatly aid in its penetration, largely due to the transformation to the uncharged form of the molecule.5 In one example of a currently available L-ascorbic acid product (from SkinCeuticals), the addition of ferulic acid aids in both stabilisation of the molecule as well as achieving an acidity of a pH below 3.5.4 The optimal concentration of vitamin C depends on its formulation, however in most cases for it to be of biological significance it needs to be higher than 8%.5 Studies have shown that a concentration above 20% does not increase its biological significance and in contrary may cause some irritation.4 The most available reputable products of vitamin C today are therefore in the range of 10 to 20% to exert an anti-oxidant effect and with lower concentrations for its role in anti-inflammatory conditions.

Continuous efforts are being made to be able to enhance efficient transepidermal delivery of the stable form of vitamin C. This includes the use of nanoparticles, microspheres (for graded delivery), and laser delivery.6 Vitamin C as an anti-oxidant: It is now well known and accepted that environmental factors such as solar radiation, pollution, smoking, etc. can cause damage to the skin through the generation of so-called “oxidative stress”.7 This oxidative stress can cause damage to the skin in the form of dyspigmentation, the formation of “sunburn” cells, thymine dimers, solar elastosis, and up-regulation of a number of markers that lead to impaired cell cycle division.8 Trans-urocanic acid is a by-product of fillagrin present in the skin which acts as a chromophore for photons of radiation (mainly ultraviolet and to a degree infrared) leading to the formation of singlet oxygen. This will lead to a cascade of events leading to the formation of so-called “reactive oxygen species” or “free radicals”.9 These are highly toxic unstable molecules that can cause damage to the nucleic acids (main component of DNA), proteins, and cell membranes.

Clinical manifestations of these effects include photodamage/photoageing and predisposition to skin cancer.2 Anti-oxidants act by neutralising the singlet oxygen cascade and therefore limiting the formation of reactive oxygen species.

This occurs predominantly by a process of electron transfer/ donation.1,2 Anti-oxidants include a range of natural and synthetic products such as viamin E (alpha tocopherol), ferulic acid, phloretin, idebenone, green tea (polyphenols), resveratrol, lycopene, grape seed, niacinamide, ubiquinone, geinstein, silymarin, coffee berry, polyhydroxy acids, carotenoids, kinetin, and glutathione. Vitamin C is the most powerful anti-oxidant available for skin protection.10 In clinical and laboratory studies vitamin C has been shown to improve all parameters of photodamage and predisposition to skin cancer and these include, in particular, a reduction in solar radiationinduced erythema, “sunburn” cells and “thymine dimers”.1,5 A number of important products that are produced as a result of reactive oxygen species formation and cascade include: p53, activation of AP-1 (activator protein-1), Langerhans cells CD1a, thymine dimers, activation of Caspase-3 and Caspase-7.4 p53 is a cellular protein induced by solar radiation in response to structural DNA damage. Upon radiation, its levels will rise to try and

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Key points: • • •

• •

• •

Vitamin C is the most powerful anti-oxidant in the skin and L-ascorbic acid is its most active biological form Stability and permeability are two important factors in the delivery of vitamin C into the skin Solar radiation in the form of ultraviolet and some infrared rays cause “oxidative stress” and this is neutralised by vitamin C “Oxidative stress” can cause a cascade of events in the skin leading to what is clinically evident as “photoageing” Vitamin C exerts beneficial effects on the formation of collagen in addition to prevention of collagen breakdown caused by solar radiation Vitamin C has also shown to exert anti-inflammatory effects through inhibition of the transcription factor NFĸB Interference with the enzyme tyrosine kinase means that vitamin C exerts anti-pigmentation effects, albeit a bit weaker than some of the other available products in the market

slow down the cell cycle allowing for repair of the damaged DNA and the induction of a process of programmed cell death called apoptosis.11 Therefore raised levels of p53 indicate solar radiationinduced cellular damage and topical application of vitamin C has shown to decrease the levels of p53 upon radiation, a testimony of the photoprotective effects of vitamin C.4 AP-1 is a protein that is activated as a result of reactive oxygen species formation and leads to up-regulation of a number of proteases called matrix metalloproteases (MMPs).1 These proteases act to degrade and damage collagen in the dermis leading to some of the photoageing effects observed. Vitamin C has shown to inhibit the activation of AP-1 which would lead to a reduction in MMPs and a reduction in collagen damage. Langerhans cells CD1a are antigenpresenting cells present in the epidermis, which act by initiating a protective immune response. Their numbers are decreased upon reactive oxygen species formation and hence solar radiation can lead to a decrease in a particular cellular immune response. Products containing vitamin C have shown to prevent the reduction of these cells upon solar radiation, further demonstrating the anti-oxidant effect of vitamin C.12 Other effects of vitamin C on skin: In addition to the anti-oxidant effect achieved through neutralisation of the oxidative stress, vitamin C has also demonstrated a number of additional beneficial effects on the skin. Vitamin C is essential for collagen biosynthesis and serves as a co-factor for prolyl and lysyl hydroxylase, important enzymes responsible for cross-linking and stabilisation of collagen fibres.13 Vitamin C has also shown to activate transcription factors such as pro-collagen mRNA that lead to collagen synthesis. Impairment of collagen has been observed clinically in the presence of vitamin C, and Scurvy is a great example of this.14 In summary, vitamin C exerts its beneficial effects on collagen both through collagen biosynthesis as well as inhibition of collagen breakdown through down-regulation of the activity of MMPs. Beneficial effects of vitamin C on elastin were also observed. Elastin is an enzyme that degrades elastic fibres leading to the characteristic appearance of photoageing known as solar elastosis. In vitro studies have shown that vitamin C inhibits the biosynthesis of elastin.15 An anti-inflammatory effect of vitamin C has also been observed both clinically and in cultured human cells. Laboratory studies have

Spotlight On Vitamin C

shown that vitamin C inhibits activation of transcription factor NFĸB, a transcription factor responsible for the production of a number of pro-inflammatory cytokines such as TNF-alpha, IL-6 and IL-8. These cytokines are responsible for a number of inflammatory pathways implicated in certain dermatoses.16 Despite these anti-inflammatory effects, vitamin C is not primarily used in practice for inflammatory dermatoses. Vitamin C also plays a role as an anti-pigmentation agent. It interacts with copper ions at tyrosinase-active sites and inhibits the action of the enzyme tyrosinase – the main enzyme responsible for the conversion of tyrosine into melanin - and therefore can be used in anti-pigmentation treatment.17 Conclusion: Environmental triggers such as pollution, smoking, and in particular harmful solar radiation cause damage to the cells through the formation of reactive oxygen species. Vitamin C is the most powerful anti-oxidant in the skin and is able to provide photoprotection through neutralisation of the oxidative stress cascade. This photoprotective effect is complimentary to the “sunscreen effect” provided by the application of sunblocks, the latter absorbing or reflecting ultraviolet light but not primarily neutralising free radicals. Objective parameters studied in laboratory setting have shown a reduction in a number of parameters that correlate to photoaging, all of which are reduced by the use of vitamin C. Furthermore, vitamin C has shown to have beneficial effects in collagen synthesis as well as anti-inflammatory and anti-pigmentation effects. A number of different formulations exist with L-ascorbic acid proving the most biologically active when formulated appropriately.

Dr. Firas Al-Niaimi is a consultant dermatologist and laser surgeon and works at sk:n clinics in London.

He trained in Manchester and subsequently did a prestigious advanced surgical and laser fellowship at the world-renowned St. John’s Institute of dermatology at St. Thomas’ Hospital in London. He has authored more than 80 publications including chapters of books and is on the advisory board for a number of respected journals. Dr Al-Niaimi is also a speaker and advisor for L’Oréal.

REFERENCES: 1. Farris PK. Cosmetical Vitamins: Vitamin C. In: Draelos ZD, Dover JS, Alam M. editors.

Cosmeceuticals. Procedures in Cosmetic Dermatology. 2 nd ed. New York: Saunders

Elsevier; 2009. p. 51-6.

2. Traikovich SS. Use of Topical Ascorbic acid and its effects on Photo damaged skin topography.

Arch Otorhinol Head Neck Surg 1999;125:1091-8.

3. Austria R, Semenzato A, Bettero A. Stability of vitamin C derivatives in solution and topical formulations. J Pharm Biomed Anal. 1997;15(6):795-801.

4. Lin FH, Lin JY, Gupta RD, Tournas JA, et al. Ferulic acid stabilizes a solution of vitamins C and E

and doubles its photoprotection of skin. J Invest Dermatol. 2005;125(4):826-32.

5. Pinnell SR, Yang H, Omar M, et al. Topical L-ascorbic acid: percutaneous absorption studies.

Dermatol Surg. 2001;27(2):137-42.

6. Lee S, Lee J, Choi YW. Skin permeation enhancement of Ascorbyl palmitate by lipohydro gel

formulation and electrical assistance. Bio Pharma Bull 2007;30:393-6.

7. Tyrrell RM. Solar ultraviolet A radiation: an oxidizing skin carcinogen that activates heme oxygenase-1. Antioxid Redox Signal. 2004;6(5):835-40.

8. Fisher GJ, Wang ZQ, Datta SC, et al. Pathophysiology of premature skin aging induced by

ultraviolet light. N Engl J Med. 1997;337(20):1419-28.

9. Hanson KM, Simon JD. Epidermal trans-urocanic acid and the UV-A-induced photoaging of the skin. Proc Natl Acad Sci 1998;95:10576–10578.

10. Shindo Y, Witt E, Han D, et al. Enzymic and non-enzymic antioxidants in epidermis and dermis

of human skin. J Invest Dermatol. 1994;102(1):122-4.

11. Meplan C, Richard MJ, Hainaut P. Redox signaling and transition metals in the control of the

p53 pathway. Biochem Pharmacol 2000;59:25-33.

12. Oresajo C, Stephens T, Hino PD, et al. Protective effects of a topical antioxidant mixture

containing vitamin C, ferulic acid, and phloretin against ultraviolet-induced photodamage in

human skin. J Cosmet Dermatol. 2008;7(4):290-7.

13. De Tullio MC. Beyond the antioxidant: the double life of vitamin C. Subcell Biochem.

2012;56:49-65.

14. Grosso G, Bei R, Mistretta A, et al. Effects of vitamin C on health: a review of evidence. Front

Biosci (Landmark Ed). 2013;18:1017-29.

15. Farris PK. Topical vitamin C: a useful agent for treating photoaging and other dermatologic conditions. Dermatol Surg. 2005;31(7 Pt 2):814-7.

16. Murray JC, Burch JA, Streilein RD, et al. A topical antioxidant solution containing vitamins C

and E stabilized by ferulic acid provides protection for human skin against damage caused by

ultraviolet irradiation. J Am Acad Dermatol. 2008;59(3):418-25.

17. Matsuda S, Shibayama H, Hisama M, et al. Inhibitory effects of novel ascorbic derivative VCP-

IS-2Na on melanogenesis. Chem Pharm Bull 2008;56:292-7.

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RSM ICG-7 Interventional cosmetics: New and controversial treatments Date: Friday 27 - Saturday 28 February 2015 Venue: Royal Society of Medicine, London CPD: 12 credits (6 per day - applied for) Interventional cosmetics is the most rapidly growing branch of medicine and surgery today – attend this two day symposium for an update on trends and techniques and advance your skills and knowledge.

Programme includes: • • • • • •

Fillers - advanced uses & complications Botulinum - advanced uses & complications Cosmoceuticals New and controversial therapies A range of hands on workshops Live demonstrations of several treatments

Early bird rates expire on Tuesday 27 January 2015: RSM members: £100 - £315 Non members: £150 - £400 Contact details: www.rsm.ac.uk/rsmicg7 Email: rsmprofessionals@rsm.ac.uk Tel: +44 (0) 20 7290 3928

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Glycation Lorna Bowes examines the concept of glycation and reviews the evidence behind various topical ingredients shown to inhibit accumulation of Advanced Glycation Endpoints (AGEs) As we, aesthetic practitioners, cosmetic dermatologists and cosmetic scientists, learn more about the ageing process, we uncover new and improved ways to target the many signs and symptoms of ageing skin. Sometimes, these new understandings pave the way for new ingredients, and at other times we discover that existing proven technologies have actions previously not described or fully understood.

Glycation and AGEs There are many processes implicated in ageing, however one generating increased interest in both general and aesthetic medicine is glycation.

AGEs, or Advanced Glycation End products, is the name given to the irreversible damage caused to proteins by sugar molecules, i.e. glycation. This is a negative process that is not exclusive to the skin, but is found throughout the body where proteins are present. Glycation differs from glycosylation, as glycosylation is a normal process in which sugars are combined with protein in a site-specific, enzyme-mediated process that is essential for molecular function. Glycation, however, is an abnormal process; a non-enzymatic joining of a sugar with a protein that impairs molecular function and causes irreversible damage to proteins in the skin, as well as other organs. The more we understand AGEs, the more interest there is in finding the perfect AGE inhibitor. AGEs are not only relevant in aesthetics; exogenous AGEs are formed when sugars are cooked in combination with proteins and fats.

This is seen by the food industry as a very positive reaction as they are able to use this to create a cooked effect. For example, by adding sugar to food before cooking, the glycation process creates the non-enzymatic browning reaction, which improves the appearance of the food and is important for flavour.1 The food industry terminology for this is ‘caramelisation’, first described by Louis-Camille Maillard, a French chemist in 1912, and hence known as the Maillard reaction, a non-enzymatic browning process.3

Glycation before using maltobionic acid

Treatment Focus Glycation

Glycation has been widely studied in relation to diabetes, with results from multiple medical studies1 showing that not only is there a link between obesity and the onset of diabetes, but that there is a correlation between the quantity of food cooked at high temperature and the development of type 2 diabetes and related cardiovascular disease. Researchers have looked for possible links between increased AGEs and a reduction in the body’s natural defense against insulin resistance. It is this research which led to new research being undertaken focusing on the skin ageing effects of glycation.

How are AGEs formed in the skin?

The Maillard reaction occurs irreversibly in the skin, causing protein crosslinking, which leads to yellow colouring and a sallow appearance.2 The production of AGEs in skin is a slow three-step chemical process; the longer the biological half-life of a protein, the stronger the effect of glycation on the protein. Collagen is a triple helical structure of protein, mostly glycine, proline and hydroxyproline, which is essential for the structure of the Extra Cellular Matrix (ECM) in the skin. Collagen has a significant halflife in the dermis and is thus highly susceptible to the damage potential of AGEs. In the presence of heat, the primary amino acid component of the collagen triple helix is ‘grabbed’ by a sugar (glucose) yielding glycation intermediates known as Schiff bases (step 1), which in turn are oxidised and either disseminate or form a further intermediate known as an Amadori product (step 2). Finally in step 3, lasting several weeks, irreversible oxidative crosslinks are formed by the Amadori products and AGEs are ultimately formed causing slow deterioration of structural tissue.3,4,5 The damaged collagen is less susceptible to normal catabolism and therefore AGEs accumulate in the skin, as described above in the Maillard reaction. Additionally, with around 30% of the sugars and AGEs that we eat ending up in the skin, accumulation of AGEs is compounded. In addition, UV exposure, pollution and smoking add to the production of AGEs. Likewise, increased accumulations of AGEs are seen in certain diseases such as diabetes.6,7 Cosmetic Appearance of AGEs AGEs accumulate in the upper dermis and this causes the yellowing of skin known as sallowness. Due to the effect of the crosslinking of the collagen and damage to the elastin in the skin, the skin becomes brittle and inflexible, wrinkles develop and the loss of elasticity leads to stiffness of the skin. The dermal processes involve the mid dermis as well as the upper dermis, creating an immediate challenge to formulators as the processes that active ingredients are required to affect are protected by the skin barrier function.

Anti-glycation results after using maltobionic acid

Aesthetics | January 2015

Anti-glycating Ingredients To create an anti-glycating effect, scientists have studied a selection of inhibitors.

For example, aspirin blocks glycation by acetylating lysine residues; there are protein competitors that work by inhibiting sugars, such as aldose and ketose, which prevent a Maillard reaction in the presence of proteins.

This is in fact one of the 45

Treatment Focus Glycation

@aestheticsgroup Aesthetics Journal An#-­‐Glyca#on E ffect o f P HA/Bionics An#-­‐Glyca#on Effect of PHA/Bionics

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Percent Non-Enzymatic Glycation Relative to Water Control Percent Non-Enzymatic Glycation Relative to Water Control

Conclusion Glycation is a significant part of the process that causes the visual signs of photodamage such as sallowness and the 80 80 typical criss-cross pattern of fine lines seen Positive * 0.01% in severe photodamage. These are ageing control 60 Positive * 0.01% control concerns that the vast majority of patients 60 0.05% * 0.05% coming in to our clinics demonstrate to * * 0.10% 40 some degree. We have a wide array of * * 0.10% 40 0.50% cosmetic ingredients available to us, in an * * 0.50% 20 * even greater number of formulations. The * 20 * choices of both single active ingredients * * Complete 0 with single or multiple potential actions, inhibition Complete Aminoguanidine Gluconolactone Lactobionic Acid Maltobionic Acid 0 inhibition and the selection of specific combined Aminoguanidine Gluconolactone Lactobionic Acid Maltobionic Acid active ingredients made by the formulators, *Significant inhibition of non-enzymatic glycation expressed as a % of water control, p<0.05. can make a vast difference to the effect *Significant inhibition of non-enzymatic glycation expressed as a % of water control, p<0.05.

Green B, Edison B et al Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic Protein Glycation and of topical products. Polyhydroxyacids and Sallowness. Poster presentation 72nd Annual Meeting of the American Academy of Dermatology, March 2014. bionic polyhydroxyacids come from the key pharmaceutical approaches in diabetes, along with the use of dermatologist/dermatopharmacologist team who discovered aminoguanidine and pyridoxamine.8 the first alpha hydroxyacid, glycolic acid, to be used in either Aminoguanidine was one of the first substances shown to have pharmaceutical preparations or cosmetic formulations.16 Alongside an effect on AGE formation. This is not routinely used in topical the other proven anti-ageing actions of increased exfoliation anti-ageing formulations, but as well as being used in diabetes, it and keratinization (improved clarity and reduced acne lesion is frequently cited as the positive control in studies of other AGE count, improved skin depth and density, reduced skin surface inhibiting ingredients. The effect of aminoguanidine is attributed roughness, improved laxity, reduced pore size and improved skin to its trapping of early glycation products, although effects on barrier function), polyhydroxyacids and bionic polyhydroxyacids later stages of glycation have not been shown and it has been have been shown to effectively inhibit non-enzymatic glycation. associated with adverse effects when trialled in patients with Long-term use of these advanced hydroxyacid ingredients will diabetes. therefore maintain healthy skin and reduce exposure to the The challenge for topical anti-glyactors is to discover their efficacy. damaging and cosmetically distressing effects of AGEs.1 In particular, whether they provide adequate dermal penetration Lorna Bowes is an aesthetic nurse and trainer with an and tolerability. Metal chelation and anti-oxidative effects could, interest in dermatology, formerly a committee member theoretically, affect the oxidative steps in AGE formation. Zinc, of the Royal College of Nursing Aesthetic Nurse Forum manganese, ascorbic acid, alpha lipoic acid, green tea and and a founding member of the British Association of Cosmetic Nurses. With extensive experience of Vitamins C & E have all been shown to have antioxidant and/or delivering aesthetic procedures, Lorna trains and lectures regularly on metal chelation benefits. These ingredients are increasingly being procedures and business management in aesthetics. Lorna is director used in nutraceutical skin beverages and as topical antioxidants in of Aesthetic Source. cosmeceutical formulations.9,10 REFERENCES 1. Green B, Edison B et al, Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic Hydroxyacids have attracted much interest as antiglycation

Protein Glycation and Sallowness. Poster presentation 72 Annual Meeting of the American ingredients. Second generation hydroxyacid, gluconolactone,

Academy of Dermatology, March 2014.

2. Ohshima H, Oyobikawa M et al. ‘Melanin and facial skin fluorescence as markers of yellowish a so-called polyhydroxyacid, and third generation ‘bionic

discolouration with aging’. Skin Res and Tech 15 (2009) 496-502.

3. Schmid D, Muggli R et al. ‘Collagen glycation and skin aging’. Cosmetics and Toiletries polyhydroxyacids’ lactobionic and maltobionic acid were studied

Manufacture Worldwide (2002) 1-6 and shown to reduce the visual measure sallowness. The key study 4. Bucalla R, Cerami A. ‘Advanced glycosylation; chemistry, biology and implications for diabetes

and aging’. Adv Pharmacol 23 (1992) 1-4. to assess antiglycation effects used aminoguanidine 0.01% as the 5. Briden B, Sugar and The Skin, (London: Body Language, 2014) www.bodylanguage.net/sugar- skin/ [Accessed 28 November] positive control, and compared gluconolactone at 0.05%, 0.10% and 6. Briden B, Sugar and The Skin, (London: Body Language, 2014) www.bodylanguage.net/sugar- 0.50%, lactobionic acid at 0.05%, 0.10% and 0.50%, and maltobionic skin/ [Accessed 28 November] 7. Green B, Edison B et al. Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic acid at 0.05%, 0.10% and 0.50% over a 24-day incubation period.

Protein Glycation and Sallowness. Poster presentation 72 Annual Meeting of the American

Academy of Dermatology, March 2014.

A significant inhibitory effect was demonstrated, with results similar 8. Schmid D, Muggli R et al. ‘Collagen glycation and skin aging’. Cosmetics and Toiletries in all cases to the positive control – aminoguanidine. These

Manufacture Worldwide (2002) 1-6.

9. Verbek P, Siboska G et al. ‘Kinetin inhibits protein oxidation and glyoxidation in vitro’. Biochem hydroxyacids are known as antioxidants with powerful metal

Biophys. Res. Commun. 276 (2000) 1265-1270.

10. Paraskevi Gkogkolou & Markus Böhm (2012) ‘Advanced glycation end products’. Dermato- chelation and lipid peroxidation effects. In addition maltobionic acid Endocrinology 4:3 (2012) 259-270 <http://www.tandfonline.com/doi/pdf/10.4161/derm.22028> has also been shown to inhibit UV induced hyperpigmentation.15

[Accessed 28th November] 11. Berardesca E, Distante F, Vignoli GP, Oresajo J, Green B. ‘Alpha hydroxyacids modulate Of course, these ingredients are well known and highly respected

stratum corneum barrier function’. British Journal of Dermatology 137 (1997) 934-938 12. Bernstein, EF, Brown, DB, Schwartz, MD, Kaidbey, K, Ksenzenko, SM. ‘The Polyhydroxy due to their other already well-documented effects of increasing

Acid Gluconolactone Protects Against Ultraviolet Radiation in an In Vitro Model of Cutaneous exfoliation, keratinization gently increasing cell turnover, improving

Photoaging’. Dermatologic Surgery, Inc 30 (2004) 1-8.

13. Grimes PE, Green BA, Wildnauer RH, Edison BL. ‘The use of polyhydroxy acids (PHAs) in clarity and reducing spots, plumping and firming the skin, reducing

photoaged skin’. Cutis 73(suppl 2) (2004) 3-13.

14. Green BA, Edison BL, Sigler ML. ‘Antiaging effects of topical lactobionic acid: results of a skin surface roughness, improving laxity, reducing pore size and

controlled usage study’. Cosmet Dermatol 21(2) (2008) 76-82. building the skin barrier by both improving dermal components 15. Green BA, Edison BL, Wildnauer RH. ‘Maltobionic acid, a plant-derived bionic acid for topical anti-aging’. Am Acad of Dermatol 54(3) (2006) AB37. such as collagen and glycosaminglycans, thus increasing the skin’s 16. Van Scott EJ, Yu RJ: Control of Keratinization with a-Hydroxy Acids and Related Compounds.

11, 12, 13, 14, 15

Archives of Dermatology 110: 586-590, 1974. ability to retain water.

No 100 effect No effect 100

(100% inhibition) (100% inhibition)

nd

th

th

nd

46

Aesthetics | January 2015

Before

After

16 weeks use of NeoStrata Skin Active 4 product regimen; an advanced, comprehensive antiaging regimen, to target all the visible signs of aging with state-of-the-art technologies 1 1.

Farris PA, Edison BL, Brouda I et al.: A High-Potency Multimechanism Skincare Regimen Provides Significant Antiaging Effects: Results From a Double-Blind, Vehicle-Controlled Clinical Trial.

Journal of Drugs in Dermatology 11(12) 1447-1454, 2013

Cellular Restoration Reduces the effects of glycation

Ingredients 5% Maltobionic Acid a bionic polyhydroxyacid 5% Gluconolactone a polyhydroxyacid

2

5% Glycolic Acid an alpha hydroxy acid

Formulated to synergistically restore skin’s essential cells

Peptides

Designed to rebuild the deep matrix for skin that is firmer and more lifted

SuperFruit Antioxidants including Chardonnay Grape Seed Extract

Reduces oxidative damage

Apple Stem Cell Extract A poster presented to the American academy of dermatology in 2014 showed that polyhydroxyacids and bionic polyhydroxyacids effectively inhibit non-enzymatic glycation. 2 Therefore long-term use of these advanced hydroxyacid ingredients will maintain healthy skin as well as reducing exposure to the damaging and cosmetically distressing effects of AGEs. 2 2.

NeoStrata Skin Active Best Cosmeceutical Range WINNER in both 2013 & 2014

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Green B, Edison B et al, Antiaging Bionic and Polyhydroxyacids Reduce Non-Enzymatic Protein Glycation and Sallowness. Poster presentation 72nd Annual Meeting of the American Academy of Dermatology, March 2014.

Meeting the needs of your business, delivering high satisfaction to your patients Call us on 01234 313130 info@aestheticsource.com www.aestheticsource.com

Techniques Mole Removal

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CONTRAINDICATION

Using radio-wave surgery for mole removal

Patients with cardiac pacemakers are an absolute contraindication as radiowaves interfere

Dr JJ Masani explores the science and technique behind removing moles using radiosurgery WHAT IS RADIO-WAVE SURGERY? Radiosurgery (synonymous terms: radio-wave surgery, micro-wave surgery, high- frequency surgery, electro-surgery, Bovie’s Current) has a high frequency current of 2 to 4 MHz (million times/sec), and is cold to touch at the cutting electrode, thus produces less tissue damage.1 Domestic mains electric current of 50Hz (1 Hz = 1 wave form per second) creates copulation with high temperature, as well as tissue damage.1 The cutting electrode has less lateral heat than most lasers, creating excellent cutting ability, less tissue damage, less post-operative pain and above all, less scarring when removing moles. As there is no necrosis or carbonisation, the specimen can be sent for histopathology. There is also no pressure applied to skin, as with a scalpel. Radiowave surgery should not be confused with electric cautery, where the equipment uses heat (50 to 400 Hz) – the cutting electrode of radiosurgery is stone cold.1 Besides excision of moles, radio-wave surgery can be used (with no scarring to minimal scarring) in senile angiomas, xanthomas, keloids, rhinophymas, spider veins, epilation of hair and skin tightening). In my opinion we are, as aesthetic physicians, dermatologists and surgeons, underusing this innovative technology. There seems to be a lack of knowledge on radiosurgery as it is not yet taught in medical schools.

Compared to scalpel technology, the equipment is expensive and the technique is quite different.

HISTORY The application of heated stones to obtain haemostasis has been used since ancient times.2 Later, during the nineteenth century, surgeons used cautery and electricity within medicine. Although radiosurgery was introduced before the 1920s, credit is given to physicist William Bovie, who developed the first prototype of the modern radiosurgery generator for diathermy. This allowed Dr Harvey Cushing, a neurosurgeon, to successfully remove a vascular myeloma from the head of a 64-year-old patient on 1st October 1926 in Boston. Liebel-Flarsheim Co then purchased the patent for the Bovie Unit for $1, and proceeded to make millions.2

The first principle of all electromagnet wave form is that electrons move in an 2 See Figure 2 where the lead wire electromagnetic medium, always a circuit.

Figure 1: Image demonstrates the completeing electromagnet circuit from the generator producing radiowaves (2 MHz to 4 MHz high frequency) passes to the active electrode with a loop, which is used in a feathering manner to cut the mole. The

SCIENCE BEHIND RADIOSURGERY 2 The first principle of all electromagnet wave form is that electrons move in an electromagnetic medium, always completeing a circuit.2 See Figure 1 where the lead wire from the generator producing radiowaves (2 MHz to 4 MHz high frequency) passes to the active electrode with a loop, which is used in a feathering manner to cut the mole. The loop is at room temperature. The radiowave then travels through the body on to the antenna (like the aerial of a radio loop is at room temperature. The radiowave then travels through the body on to the orantenna mobile back to thephone) generator. (likephone) the aerialand of a radio or mobile and backThe to thesecond generator.principle toThe understand is that there is a frequency and a wavelength to second principle to understand is that there is a frequency and a wavelength to consider in in anyany electromagnetic radiation, with domestic power having a longpower wavelength, consider electromagnetic radiation, with domestic low frequency and is hot to touch. Radio-frequency, on the other hand, is a shorter having a long wavelength, frequency is hot wavelength with high frequency andlow is cold to touch. Upand to visible lightto thetouch. infrared spectrum is non-ionising to our DNA, and beyond UV light it is ionising to our DNA and Radiofrequency, on the other hand, is a shorter wavelength with harmful.2 high frequency and is cold to touch. Up to visible light the infrared Figure 3: The electromagnetic radiation spectrum

COMPARISON OF LATERAL HEAT AND TISSUE DAMAGE BY ENERGY SOURCES2 1. Radio-Wave Surgery 2. CO2 Laser 3. Holmium Laser 4. ND:YAG

0.02 mm damage 0.5 mm damage 0.5 mm damage 2.3 mm damage

CONTRAINDICATION Patients with cardiac pacemakers are an absolute contraindication as radiowaves interfere with cardiac pacemakers – they too work on the principles of electromagnetic radiation.3 Some newer pacemakers are not altered by radiosurgery wave forms, and this should be checked with the cardiologist prior to treatment.

48

with cardiac pacemakers – theyjewellery too work on the of electromagnetic radiation.3 A patient must not wear orprinciples be in contact with metal Some newer pacemakers are not altered by radio surgery wave forms, and this should be the of cardiologist to treatment. duechecked to thewith risk burnsprior caused by an alternate current path or “capacitive coupling”.

Radiowaves arewithnon-ionizing, thus cause A patient must not wear jewellery or be in contact metal due to the risk of burns caused by an alternate current path or "capacitive coupling". Radiowaves are non-ionizing, 4 no damage todamage animal DNADNA or orsurrounding tissue, like mobile thus cause no to animal surrounding tissue, just likejust mobile phones.

However, 4 all general rules of safety with electro-magnetic equipment must be followed. phones.

However, all general rules of safety with electro-magnetic This includes making sure no alcohol is used for cleaning and there is no presence of ignitable gases in the operating room. This includes making sure no alcohol equipment must be followed.

SCIENCE BEHIND RADIOSURGERY is used for cleaning and there is no presence of ignitable gases in 2 the Figure operating room.

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Figure 2: The Electromagnetic Radiation Spectrum To understand the principle of an electric circuit, one could compare it with our WC where the cistern, which is full of water, has potential energy (voltage), and when we pull the flush, water runs down the pipe (current-measured in amperes) and the force with which it runs is classed January 2015as watts or power, or if timed in one second, a joule. Thus voltage X amperes = watts. Remembered by the pneumonic: VAW. Ohms is the resistance offered by what we clear in the WC, or in case of radiowave surgery, is our body offering the

DERMOSCOPY DE

resistance. The soiled water then goes to the cesspit, gets purified and returns to the cistern, thus completing the circuit.

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Techniques Similarly senile angiomas, xanthomas,Mole keloids, rhinophymas, spider veins and warts ca aestheticsjournal.com Removal 1 be excised without scarring.

//Box out// spectrum is non-ionising to our DNA, and beyond UV light it is Case Study Figure 4: Case study 2 ionising to our DNA and harmful. To understand the principle a. of an electric circuit, one could compare it with our WC where the cistern, which is full of water, has potential energy (voltage), and whenRECOGNITION we pull the flush,OF water runs down theUSING pipe (current//SUBHEAD// MOLES (NAEVI) DERMASCOPE measured in amperes) and the force with which it runs is classed as watts or power, or if timed in one second, a joule. Thus Voltage Afterxtaking a detailed history and carrying out an VAW) examination Amperes = Watts.medical (Remembered by the pneumonic: Ohms of the patient, I c. proceed to use the Dermascope to distinguish between benign and malignant moles is the resistance offered by what we clear in the WC, or in case of (BCC, SCC, melanomas). Appropriate training and experience in the use of the radiowave surgery, is our bodydiagnosis offering the resistance.

Theitssoiled Dermascope brings about a better of the naevi and nature, prior to excision. then goes can to the cesspit, getsusing purified and returns to thethe iPhone 4, 5 or 6, and Goodwater quality images now be taken a Dermascope with othercistern, smart phones with an adaptor costing less than £30.00. thus completing the circuit.

(As demonstrated in Figure 2)

b.

POST SURGERY DERMOSCOPY P a. DERMOSCOPY b. POST SURGERY c. SIX WEEK LATER

SIX WEEK LATER POST SURGERY SI

EXCISION OF BENIGN NAEVI (MOLES)

Once the naevi is diagnosed as benign, one can use the //Subheading// Patientradiowave Histology generator Report and tungsten loop to feather and shave the

naevi until the pigment is removed without hitting the dermis to //Subheading// Patientcan Histology avoid scarring. The tissue scooped be sentReport for histopathology Possible Seborrhoeic keratosis.

Excised by radio surgery. for one month. as there is no carbonisation of tissue. Similarly senilePresent angiomas, Clinical Data: xanthomas, keloids, rhinophymas, spider veins and warts can be Macroscopic: excised without scarring.1 Possible Seborrhoeic keratosis. Excised by radio

Clinical Data:

SIX WEEK LATER

Lesion from scalp: A rough pale hairy slightly friable skin lesion 5 x 4 x 3 mm. Bisecte Patient Histology Report Macroscopic: Microscopic: Clinical Data: //Subheading// Lesion from scalp: A rough pale hairy slightly fria Patient Histology Reportseborrhoeic Possible keratosis.

ExcisedThere by radio Present Skin shows an Seborrhoeic irritated keratosis. aresurgery. no atypical features, and the lesion for hasone been excised. month.

Microscopic: Clinical Data:

Macroscopic: //End box out//

//End box out// Diagnosis: Skin shows ansurgery. irritated seborrhoeic Possible Seborrhoeic keratosis.

Excised by radio for 5 one month. Th Lesion from scalp: A rough pale hairy slightly friable Present skin lesion xkeratosis.

Skin from scalp – Seborrhoeic keratosis. lesion has been excised.

4 x 3 mm. Bisected.

Macroscopic:

Microscopic: //End boxbox out// //End out//

Diagnosis:

Skin from scalp – Seborrhoeic Skin shows an irritated seborrhoeic keratosis.

There are no Lesion from scalp: A rough pale hairy slightly friable skin lesion 5 x 4keratosis. x 3 mm. Bisected //Before and after imagery// //Before and after //End //End box box out// out// imagery//

Figure 3: Mole examination using a Dermascope and an iPhone

atypical features, and the lesion has been excised.

Microscopic: RECOGNITION OF MOLES (NAEVI) USING DERMASCOPE Diagnosis: //Before andand after imagery// //Before after imagery// After taking a detailedOF medical history and (MOLES) carrying out an Skin from scalp –seborrhoeic Seborrhoeickeratosis. keratosis.There are no atypical features, and the //SUBHEAD// EXCISION BENIGN NAEVI Skin shows an irritated //Before //Before and after after imagery// imagery// lesion has and been excised. examination of the patient, I proceed to use the Dermascope to Oncedistinguish the naevi between is diagnosed as benign, one canmoles use the radiowave benign and malignant (BCC, SCC, generator and Diagnosis: tungsten loop to feather and shave the naevi until the pigment is removed without hitting melanomas).

Appropriate training and experience in the the Skin fromas scalp – Seborrhoeic keratosis. the dermis to avoid scarring. The tissue scooped can be sentuse for of histopathology there is Dermascopeofbrings about a better diagnosis of the naevi and its no carbonisation tissue. nature, prior to excision. Good quality images can now be taken 4 using a Dermascope with the iPhone 4, 5 or 6, and other smart phones with an adaptor costing less than £30.00. See Figure 3.

If the lesion is recognised as malignant, or after histopathology Before Before Before is diagnosed as malignant, then the general rules of surgical Before Before principals apply and excision has to be wider than the margins, as Before Before well as deeper, to reach subcutaneous tissue. This too could be carried out by radiosurgery using a tungsten wire instead of a loop, but the patient must then be told that a scar will result owing to a wider and deeper excision, and sutures or a skin graft may apply.

Dr Jamshed (JJ) Masani runs the Mayfair Practice, a combined GP and aesthetics clinic in London. He trained Before Before Before as a doctor in Southern India, before moving to the UK in Before Before 1978. Dr Masani is well known across the industry as one of Before Before the leading aesthetic doctors to specialise in mole removal.

REFERENCES: 1. Dzingel, R, ‘Radio Surgery in Dermatology’, Cosmetic Medicine, 25 (2004), p.1430-4031.

2. Masarweh, N et al, ‘Electro-Surgery: History, Principles and Current and Future Uses’, American College of Surgeons Publications, (2006), p. 520.

3. ‘Electromagnetic interference’, MHRA, (2014) http://www.mhra.gov.uk/Safetyinformation/

Generalsafetyinformationandadvice/Technicalinformation/Electromagneticinterference/

Last accessed: 12/12/14.

4. ‘Cell Phones and Cancer Risk’, National Cancer Institute, (2013) http://www.cancer.gov/cancertopics/

factsheet/Risk/cellphones Last accessed: 12/12/14.

Before

Aesthetics | January 2015

Straight after Procedure Straight after Procedure

8 weeks after Procedure 8 weeks after Procedure

Straight after Procedure after Procedure Straight after Procedure weeks after Procedure Straight after Procedure 88weeks 8 weeks after Procedure Straight Straight after after Procedure Procedure 8 weeks 8 weeks after after Procedure Procedure

Dermoscopy Dermoscopy Dermoscopy Dermoscopy Dermoscopy Dermoscopy Dermoscopy

Straight after treatment Straight after treatment Straight after treatment Straight after treatment Straight after treatment Straight Straight after after treatment treatment

After

6 6

6 6

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Advertorial SkinCeuticals

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SkinCeuticals Antioxidant Essentials Renowned for creating a fresh, radiant and healthy complexion, the SkinCeuticals skincare range comprises of an essential toolkit to help your patients achieve perfectly clear skin. In time for the New Year, SkinCeuticals has released a unique product set to address both the internal and external factors that contribute to skin damage and, consequently, premature ageing. The Day/Night Antioxidant kit contains 15ml of Resveratrol B E and either 15ml of CE Ferulic or 15ml of Phloretin CF. The latter two are vitamin C-based serums that are proven to prevent free radical damage sustained throughout the day. Resveratrol B E is SkinCeuticals’ hotly anticipated night-time antioxidant, which has been flying off the shelves since its launch in June. This new antioxidant formulation protects the skin from both internal and external sources of premature ageing. The effective combination of day and night specific antioxidants provides supreme 24-hour protection from skin damage, whilst simultaneously visibly improving the appearance of the skin over a matter of weeks. These superior results make the Day/Night AOX Kit an essential purchase for your clinic.

CE Ferulic The daytime serum, CE Ferulic, is a combination of L-Ascorbic acid, Ferulic Acid, and Vitamin E. The triple antioxidant formulation has been proven to give skin incredibly effective protection from environmental damage and boost the skin’s natural antioxidant defenses.

It has also been proven to protect skin from infrared radiation (IR), which accounts for 54% of the total solar energy reaching the skin. Considering that only 7% of total solar energy comes from UVA and UVB rays, protecting the skin from IR is extremely important.

A particular type of IR, called IRA, reaches the skin’s dermal layers daily, and is responsible for creating harmful free radicals which diminish the skin’s antioxidant capacity and ultimately result in wrinkles, loss of elasticity and reduced firmness. C E Ferulic neutralises free radical damage, stimulates collagen synthesis and helps correct premature signs of ageing, such as fine lines and wrinkles. It leaves skin visibly firmer and more nourished.

Phloretin CF Phloretin CF is another daytime antioxidant that contains 2% Phloretin, derived from the bark of apple trees. It is particularly effective at reducing pigmentation. The formulation is a preventative and corrective topical antioxidant that combines the power of Phloretin with 10% Vitamin C and 0.5% Ferulic Acid to diminish hyperpigmentation, improve elasticity, and accelerate cell renewal to retexturise skin. In addition, the antioxidant products all comply with the Duke Antioxidant Patent, which states that effective topical vitamin C formulations must: Contain pure L-Ascorbic acid (derivatives cannot be used by the skin) Contain a high concentration of L-Absorbic acid (between 10% and 20%) Be formulated at an acidic pH of between 2.0 and 3.5

Resveratrol B E Resveratrol B E is SkinCeuticals’ first antioxidant that is specifically designed to work through the night. Over time, skin loses its ability to repair itself due to the onslaught of free radical damage it sustains during the day. This brand new antioxidant formulation will help maintain healthy cell longevity by neutralising this damage and repairing the visible effects of skin ageing whilst you sleep.

Resveratrol is a potent antioxidant, building a reputation as the ‘longevity molecule’ over the last decade due to the theory that it works as an intracellular effector to modulate the signalling pathways responsible for age-related deterioration and functional decline. However, it is notoriously difficult to stabilise. For the first time, SkinCeuticals’ advanced research labs have been able to formulate an optimised concentration of pure, stabilised, resveratrol – proven to penetrate skin through a delivery system of hydrotropes.

Combined with 0.5% Baicalin and 1% Alpha Tocopherol, Resveratrol B E reduces intracellular inflammation, stabilises cell survival conditions and protects cellular membrane from free radical damage. The winning formula provides 41% more antioxidant protection than any one of the aforementioned antioxidants alone.

In a 12-week clinical trial of 55 females, aged between 45-60, Resveratrol BE significantly improved skin radiance, firmness, elasticity and density.

The SkinCeuticals Day/Night AOX kit provides the perfect tools to ensure skin is cared for 24/7. Safe in the knowledge that the SkinCeuticals founder, Dr Sheldon Pinnell, has amassed over 200 scientific publications in peer-reviewed journals on topical vitamin C, antioxidants, collagen synthesis and photo-damage, makes the SkinCeuticals’ range one that you can trust. “Our mission at SkinCeuticals is to improve skin health and fight against the major causes of skin ageing. Dedicated to this purpose, we make one simple promise: provide quality products, backed by sciences.”

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Aesthetics | January 2015

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Clinical Practice Clinical papers

A summary of the latest clinical studies Title: Comparison of the effect of diode laser versus intense pulsed light in axillary hair removal.

Authors: P Ormiga, CE Ishida, A Boechat, M Ramos-E-Silva.

Published: Dermatologic Surgery, October 2014 Keywords: IPL, diode laser, hair removal Abstract: Devices such as diode laser and intense pulsed light (IPL) are in constant development aiming at permanent hair removal, but there are few comparative studies between these technologies. The objective was to comparatively assess axillary hair removal performed by diode laser and IPL and to obtain parameters of referred pain and evolution response for each method.

A comparative prospective, double-blind, and randomized study of axillary hair removal performed by the diode laser and IPL was conducted in 21 females. Six sessions were held with application of the diode laser in one axilla and the IPL in the other, with intervals of 30 days and follow-up of 6 months after the last session. Clinical photographs and digital dermoscopy for hair counts in predefined and fixed fields of the treated areas were performed before, 2 weeks after the sixth session, and 6 months after the end of treatment. A questionnaire to assess the pain was applied. The number of hair shafts was significantly reduced with the diode laser and IPL. The diode laser was more effective, although more painful than the IPL. No serious, adverse, or permanent effects were observed with both technologies. Both diode laser and the IPL are effective, safe, and able to produce lasting results in axillary hair removal.

Title: Facial rejuvenation: combining cosmeceuticals with cosmetic procedures Authors: JD Wisniewski, DL Ellis, MP Lupo.

Published: Cutis, September 2013 Keywords: facial rejuvenation, cosmeceuticals, injectables, anti-ageing Abstract: Cosmetic patients are looking for a more youthful appearance without spending a lot of money, feeling any pain, or experiencing any post-procedure downtime. New cosmeceutical therapies can be used adjuvant to chemical peels, lasers, and injectables, making anti-aging regimens less painful and requiring less post-procedural healing time. Adjunctive agents can be used to enhance chemical peels and decrease post-inflammatory hyperpigmentation (PIH). Topical retinoids used prior to ablative laser treatments can aid in faster post-procedure healing and reepithelialization. Cosmeceuticals that contain both antioxidants and anti-inflammatories can help reduce post-procedure inflammation.

Acetyl hexapeptide-3 is an effective topical agent for decreasing wrinkles and can be used as an adjunct to intramuscular botulinum neurotoxin, which may reduce the number of injections needed.

Topical hyaluronic acid also would help patients who are averse to needles or are just starting to get wrinkles and are looking for noninvasive therapy. This article reviews combinations of cosmeceuticals with cosmetic procedures that dermatologists may want to consider discussing with their cosmetic patients.

Title: Anti-aging and filling efficacy of six types hyaluronic acid based dermo-cosmetic treatment: double blind, randomized clinical

trial of efficacy and safety.

Authors: V Nobile, D Buonocore, A Michelotti, F Marzatico.

Published: Journal of Cosmetic Dermatology, December 2014 Keywords: facial rejuvenation, dermal fillers, anti-ageing, volume Abstract: Human skin aging is a multifactorial and complex biological process affecting the different skin constituents. Even if the skin aging mechanism is not yet fully unravelled it is evident that epidermis loses the principal molecule responsible for binding and retaining water molecules, resulting in loss of skin moisture and accounting for some of the most striking alterations of the aged skin.

This Study investigated the cosmetic filling efficacy of Fillerina(®) in decreasing the skin aging signs and in improving facial volume deficiencies. A placebo-controlled, double-blind, randomized clinical trial was carried out on 40 healthy female subjects showing mild to moderate clinical signs of skin aging. The effect of the treatment on skin surface and on face volumes was assessed both in the short-term (3 h after a single product application) and in the long-term (7, 14, and 30 days after continuative daily use). Three hours after a single application and after 7, 14, and 30 days of treatment the lips volume increased by 8.5%, 11.3%, 12.8%, and 14.2%. After 7, 14, and 30 days: (1) skin sagging of the face contours was decreased by -0.443 ± 0.286, -1.124 ± 0.511, and -1.326 ± 0.649 mm, respectively; (2) skin sagging of the cheekbones contours was decreased by -0.989 ± 0.585, -2.500 ± 0.929, and -2.517 ± 0.927 mm, respectively; (3) cheekbones volume was increased by 0.875 ± 0.519, 2.186 ± 0.781, and 2.275 ± 0.725 mm, respectively; (4) wrinkle volume was decreased by -11.3%, -18.4%, and -26.3%, respectively; and (5) wrinkle depth was decreased by -8.4%, -14.5%, and -21.8% respectively. This study demonstrated the positive filling effect of Fillerina(®) in decreasing the clinical signs of skin aging and in improving the face volumes.

Title: Safety and efficacy of combining microfocused ultrasound with fractional CO2 laser resurfacing for lifting and tightening the face and neck Authors: JA Woodward, SG Fabi, T Alster, B Colón-Acevedo.

Published: Dermatologic Surgery, December 2014 Keywords: ultrasound, skin tightening, laser Abstract: Microfocused ultrasound (MFU) and ablative fractionated laser (AFL) resurfacing techniques have been used separately to noninvasively improve skin laxity and rhytides on the face and neck. Simultaneous combination treatment would be anticipated to provide further improvement but has not previously studied. A retrospective analysis of 100 combination face and neck treatments from 3 centers was performed, including collective treatment protocols, postoperative recovery, side effect profile, and clinical results. Skin laxity and photodamage (rhytides and texture) showed significant improvement with combination MFU + AFL treatment. Except for increased facial swelling in a small percentage of patients, postoperative recovery and side effects were comparable with those obtained after application of individual treatments. Combination MFU-AFL on the face and neck is a safe and effective method for targeting multiple facets of facial and neck skin aging and can be safely performed in a single treatment session.

Aesthetics | January 2015

51

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How To Maximise Your Marketing Budget Michelle Boxall looks at strategies to ensure you get the most value when marketing your clinic For most businesses, the New Year brings renewed efforts and inspiration to make improvements and grow sales. Planning for the year ahead can be an exciting activity; but new ideas, unfortunately, often have to be tempered by the constraints of a small budget. Many clinics have modest marketing budgets, and even the larger chains and services within the aesthetics industry have to look for good return on investment (ROI) in the current economic climate.

Marketing budgets are often the first cost to be cut in times of austerity.

The short-term gain, however, can often deliver long term pain when it impacts on sales further down the road. When businesses finally come back round to the idea that ‘something’ has to be done in order to grow or maintain revenue, the question over what that ‘something’ should be can be challenging.

Clinic owners may find themselves trapped in a cycle of indecision, running in circles looking for that something that will transform their business, but never making any long-term commitment. Decision makers can be frozen by the fear of investing in a strategy that doesn’t work, trying to avoid wasting money that they simply cannot afford to lose. This vicious cycle may actually precipitate poor decision-making; where clinic owners will only trial a marketing activity for a short period, with minimum financial investment alongside little or no personal investment of time. It is not surprising then, that these marketing quick-fixes don’t usually work and only add fuel to the fire of marketing uncertainty. You should recognise that while it is easier to swallow small budget losses, these can quickly add up to significant financial losses when considered over a number of years.

Fail to Plan and You Will Plan to Fail The first place to start when considering any marketing activity is in understanding and/or establishing your business goals and objectives. It is not enough to say that you just want to grow sales. If you don’t take

Marketing Strategic Advice

the time to look closely at your business and devise a clear business strategy, then the scattergun approach to marketing will likely lead to failures within any outcomes.

Your business plan should provide the structure for your marketing plan. The more detailed your business objectives, the more accurate you can be in your promotional planning. For example, when looking at sales objectives, you should clarify the value of any increase in sales; what treatments or product lines will provide this increase and which type of customer.

If you have decided that your increase in sales is going to come from a new body-contouring treatment, when most of your clientele only buy in to facial anti-ageing, then an exercise in targeting your current customers could be worthwhile. However, if you have already sold body-contouring treatments to your customer base and are looking for a 100% increase in sales, then it is obvious that you need to find brand new customers. If you then look to explore where these customers can be found and who they are, you are more likely to predetermine improved marketing accuracy.

The importance of business planning is paramount. It is still surprising to me, how many aesthetic companies look to promote their treatments with no fixed decisions on which treatments, market segments and points of differentiation to target.

Marketing Plan Once you have your business objectives, you can start to plan your marketing programme. It is usually impossible to promote every aspect of your product portfolio and, therefore, deciding on which products should take priority is key. If your business objectives lie in differentiating your business from your key competitors, then choosing products that do this could be important. If, however, your sales targets are paramount, choosing to push your best-selling hero products could be a good strategy.

Take some time to analyse your sales data from the previous year.

Which treatments made you the most money; if you want improved profitability? Which treatments and products sold the most and when; if you want increased revenue? Where are you losing clients to your competitors? Any activity that can help you to avoid the scattergun approach to marketing will improve your chances of success. Here we will explore various marketing tools and look at different ways to approach maximising your budget and ROI.

Marketing Audit Take a look at everything you are already doing.

Consider marketing materials such as leaflets, your website and social media, and see how you can improve. Do an assessment to find out what is actually working and what is not. Ask your clientele how and why they buy from you, and assess whether there are any inconsistencies in their perceptions and your communication aims.

Look at what you are doing in-house and what activities you are outsourcing. If there are tasks you can do internally, leave the expensive consultants to activities that really require their expertise.

Get the most out of your content and printed collateral: This can include anything from posters, leaflets, business cards and invites to events. Be sure that all your collateral is brand coherent and keep to the same style, use of logos, tone of voice and key messages. Your marketing materials can work harder for you when they present a brand, and not just information. Furthermore, clients can be confused by too much information, and therefore excellence in copywriting is

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equally as important as design and style.

Content should include case studies, alongside before and after photos, and up-to- date prices. Technical and medical information should be short and concise, with a focus on service and customer care. Maximise any creation of content and images by using them across all relevant activities. Content for a press release can also be used in a blog and newsletter.

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When you find a marketing activity that works, then stick with it Outsourcing PR

Social media Social media is increasingly offering cost effective tools that can raise consumer awareness and even drive customer enquiries. Building a Facebook and Twitter group can be a powerful tool to interact with your customer base. A business can engage with people online, with whom ordinarily they could not have access to.

Bear in mind that social media can be time consuming; especially if you are creating original and informative content. To maximise cost benefits, you should try to use this content across all your marketing platforms, and vice versa. In particular, your PR campaigns should provide engaging material for your social conversations.

Ensuring that your content reflects the message you want to promote, correlates with your brand, and is current and engaging, is important.

Outsourcing the social media activity alongside PR or advertising is therefore becoming commonplace. A more cost effective exercise, however, might be to send an administrative member of staff on a short social media course, and then ask any outsourced agencies to contribute extra content from activities they are already undertaking, preferably without extra charge. Free treatments and competition prizes or half price offers are a few atypical ideas, but can work to engage potential customers, increasing their motivation to interact with your clinic. Furthermore, extracting client data can be likened to finding pots of gold, and if your audience feel they are getting something they want for free this can often provide the motivation for them to positively engage with your promotion.

Database management: newsletters, texts and email campaigns Once you have built a client database, you can communicate with them through newsletters and texts etc. Information can include promotions and offers, and this activity can be relatively inexpensive. Weekly or monthly newsletters are a great way to showcase new treatments, products and services, as well as being another way to engage with your customers on trends and case studies. Events to promote new treatments will also utilise your database. Quarterly or seasonal invites to clients for clinic events can be a very cost-effective way of marketing and interacting with new and loyal customers. Wherever possible include a call to action that links to your website.

Networking Networking with health and beauty professionals outside of your business can be effective to gain mutual clients. If you have colleagues that offer complementary services such as holistic practices, dentistry etc., sharing client promotions can offer greater scope for growth and reach of audience. Smaller towns can especially benefit through not competing but joining forces.

In addition, local businesses can provide a low-cost route for new business. Local offices and shops near your premises can be targeted through flyers, leaflets, email campaigns and social media.

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PR is a marketing activity that can cost a lot of money, without delivering any return, and can have a bad reputation in terms of ROI. When it is done correctly, however, the results can be fantastic – delivering huge uplifts in sales and new enquiries. In my experience, the relationship, co-ordination and actions of the aesthetics business has as much to do with any successful outcome as the skills of the agency. Clients on small retainers can produce high-value and high-impact press coverage when they work well with their agency. Similarly, clients on huge retainers can drive poor outcomes. So, how do you get the most value from your PR agency? A good working relationship goes a long way. In my experience, team members work hard for clients that apply pressure, but not so much that the work is no longer enjoyable.

Providing case studies, exclusive angles on products and treatments, alongside charismatic and credible spokespeople with expertise, will help your PR campaign deliver a return. Undertaking some of the work will also benefit a small PR budget; particularly when it comes to ideas generation.

Advertising can work for the tough negotiator Advertising is not always a viable long-term option for the small marketing budget. However, local magazines can be inexpensive and can work for some clinics, dependent on location and the quality of readership. Negotiating editorial alongside any paid - for promotions can be a worthwhile effort – as is a test campaign. Again, a call to action should always be included in the copy.

If it’s not broken don’t fix it When you find a marketing activity that works, then stick with it. A common mistake can come from changing working practises for the sake of trying to find improvements or just for a change. Realistic expectations and targets are important to ensure a programme is not thrown out in pursuit of the impossible.

New Year’s resolution The year ahead is exciting. According to the review of the regulation of cosmetic interventions in 2013 by the Department of Health1, the value of UK cosmetic procedures was set to rise to £3.6 billion in 2015, with non-surgical procedures accounting for 75% of the market value. Take the time to plan now. Any investment of time will pay dividends later.

Michelle Boxall is the managing director of Image Box PR, one of the UK’s leading marketing communications agencies, specialising in aesthetic PR. Michelle holds a bachelor degree in public relations and has more than 19 years communications experience working across health, beauty and aesthetics.

REFERENCES: 1. Gov.uk, Independent Report: Review of the Regulation of Cosmetic Interventions (www.gov.uk, 2013)

< https://www.gov.uk/government/publications/review-of-the-regulation-of-cosmetic-interventions>

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Business Building Commercial Knowledge

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Building a better aesthetic business Dr Hugo Kitchen shares his vision for business success in the field of aesthetics today The value of the UK cosmetic procedures market is growing. It was worth £2.3bn in 2010 and is estimated that it will grow to £3.6 billion by 2015.1 If the effects of the economic downturn are still being felt in some industries, the cosmetic and aesthetic sector has never looked healthier. As we climb out of recession, the percentage of disposable income which is being freed up for self-enhancement is making the outlook rosier than we could have predicted even a year ago. This, coupled with the launch of some new and innovative treatments over the last couple of years which have given practitioners a plethora of new ways to treat their patients, means that practice owners such as myself have many good reasons to feel positive about the future.

Of course, running a dermatherapy practice does not come without its challenges – as my brother and colleague James Kitchen, my wife Carron and I have experienced over the years. No successful venture in the sector is alike but I am convinced that the most successful practice owners share a similar business mindset, and that the key business drivers are invariably the same.

First of all, the business model that you are adopting today – however sound it may be – may not be applicable in a few years’ time, and it is therefore essential that anyone entering this sector remains open-minded about embracing changes. Whilst your clinical skills may make you feel very confident, and your patients’ praises may stroke your ego and reassure you that you are doing

Take time to listen to what patients have to say, as this is a fantastic way of keeping abreast of new procedures 56

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everything right, this unfortunately does not mean you have what it takes to build a successful business.

Competition is fierce and there is an abundance of procedures on offer from a multitude of providers. Patients are increasingly knowledgeable about the latest in cosmetic surgery and aesthetic treatments , and they will make a point of researching them from any available source and comparing procedures. You can’t outspend the big players, but you can out-think them by knowing your local market and harnessing local knowledge to gain the edge.

Take time to listen to what patients have to say, as this is a fantastic way of keeping abreast of new procedures which are no doubt being heavily promoted to them. Make sure you do your research too as patients will expect you to be fully conversant with these to help them make the best choices. This means you need to remain abreast of all the latest treatment developments, so when asked you can talk about them knowledgeably, even if you don’t offer them. It’s then possible to talk convincingly about why the procedures you do offer are the most applicable to their needs.

What’s more, patients are not just looking for the best results anymore. They want the whole journey to be flawless, with minimal pain and effort. Patients expect an outstanding level of care from the moment they come through the door and throughout the treatment. They are entrusting you with what matters to them the most and are prepared to pay big money, which warrants a golden service every single time.

What I have observed over the years is that the skills of one clinician alone is not sufficient to keep the business buoyant. It is about the clinical and interpersonal skills of every member of the team. It is about how unique the whole patient experience has been. Empowering your staff, working as a team and promoting regular feedback and an open dialogue will go a long way.

Relationship building – with patients and with your team – is another key factor to your success.

Cosmetic surgery and aesthetic treatments are no longer seen as the preserve of rich celebrities; patients from all walks of life want to feel as special as the stars. The ‘popularisation’ of cosmetic procedures is actually giving practice owners an ever increasing number of consultation opportunities, so the main challenge is to maintain very high safety and quality standards whilst striving to be innovative and forward thinking, keeping your finger on the pulse whilst not falling for all the fashions.

One important pitfall to avoid is to become complacent with how your clinic is set up; assuming that it cannot be improved and that your patients are 100% satisfied. With endless technological and clinical advances, practice owners cannot afford to settle into a happy equilibrium. At the Stratford Dermatherapy Clinic, we have embraced new treatments when these made sense for the business – for the short and long term. Beware of taking on any new treatments merely because they are proving popular, trendy or rumoured to be lucrative.

We recently introduced four contemporary innovations – Pellevé, PelleFirm, Vaser Lipo and Bodyjet – into our business model. We invested in these treatments because the companies behind them demonstrated a strong commitment to support us and our patients, because their strong clinical evidence is irrefutable, their safety and quality standards are very high and our patients have reported tangible visible results within a short timescale. These have proved brilliant adjuncts to the business, ensuring we stay ahead of the curve. It is crucial to assess all these factors before choosing to invest in any new technology or treatment.

Aesthetics | January 2015

Advertorial Vida Health and Beauty

Tips for product or treatment selection The aesthetics sector is evolving at a fast pace and patients always want you to anticipate their needs and excite them with the latest new treatments and products. To identify new and clinically-sound treatments or products to complement those you currently offer, here are fourteen key criteria to look for when making your final decision: 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Unique selling points with benefits which are easy for the patient to understand (this frees up expensive chair time explaining the treatment, and costs less to promote).

The non-invasive nature of a procedure can be preferable as it taps into the current zeitgeist for minimal intervention.

Favourable reviews with no bad press reports – nationally and internationally.

Take into the account the views of reputable clinicians who have already performed the procedure and who have given their views on potential obstacles and risks.

Training must be efficient and carried out within a reasonable time frame, or if a longer training period is required then it must considerably enhance a clinican or staff’s skill set.

Assessment of profitability (length of procedure, chair time required, price of equipment, seniority of staff required during treatment).

Expenditure for consumables needs to be limited or easy to factor into the treatment cost.

Patient compliance should ideally be easy (pain-free, no or minimal side effects, no or minimal preparation, minimal downtime with fast return to normal life).

Initial results need to show immediately or in a relatively short space of time to help with word of mouth recommendation – a fast and impressive outcome also motivates patients to trust you with other issues they may have, resulting in more treatments being carried out.

A win-win outcome, working with a reputable brand which delivers the promised results and has been backed by clinical research and/or successful number of cases.

Marketing support from product and treatment companies A quick return on investment is always a benefit and is important to factor in.

I feel privileged to be awarded complete trust by my patients and it is my duty of care to provide them with the best advice and best treatment options. The rapport I have built over the years has helped elevate my reputation and turn my practice into a healthy profitable business. 90% of my patients have had two or more treatments and 95% of my entire client base has confirmed their full satisfaction. This is what makes good business sense.

Dr Hugo J Kitchen is a cosmetic physician with 26 years’ experience. He is a member of several organisations including the British College of Aesthetic Medicine and the American Institute of Aesthetic Medicine. Dr Kitchen is the clinical director of Stratford Dermatherapy Clinic and specialises in facial aesthetics and body sculpting.

REFERENCES 1. Parliamentary Office of Science and Technology, Cosmetic Procedures (UK: Houses of Parliament,

2013) <www.parliament.uk/briefing-papers/POST-PN-444.pdf> [Accessed 5th December 2014] p. 1

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“I have found the Pistor Eliance to be an asset to the practice. It has enabled me to provide a more consistent treatment and improved results, Patients love the results and the delivery of the treatment is virtually pain free. I have also managed to reduce the time it takes to carry out the treatment allowing me to increase the number of sessions I can provide throughout the working day. It’s also light on consumables and the programmable modes take the guesswork out of providing the correct treatment method.

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Buying a Laser

Aesthetic lasers: should you buy new or used?

Laser sales consultant Don Berryhill shares his advice on purchasing a reliable laser for your clinic Many practitioners looking to purchase medical lasers are often confronted with the issue of deciding whether or not to buy directly from the manufacturer or possibly consider purchasing a used system from a broker.

This can be a daunting task for some, and I’ve spoken to many laser consumers over the years who have struggled with this decision. It is a little like trying to decide whether to buy a new or used car, however, most people are a bit more familiar with cars than they are lasers. Some buyers are obviously more comfortable purchasing a new laser for the peace of mind and perks that come with buying new and don’t mind paying a premium. Others are hoping to spend the least amount of money possible and just want to find a great deal. Each option has several issues to consider.

My aim is to make you a better-educated consumer and help you feel more comfortable when choosing a laser, whilst limiting the sometime unpleasant surprises that can arise. This is by no means a comprehensive guide, but should give you a good idea of some important things to consider.

Advantages of buying a new laser When buying new, you will get the latest and greatest version of whatever’s on the market. That can be very important, especially in an industry as dynamic as aesthetic laser treatments. Patients and consumers are often looking for breakthrough treatments so it can make a big difference if, in your clinic, you have the newest technology and most innovative treatments on the market. The other big advantage of buying from the manufacturer or the official distributor is getting up-to-date training, marketing support, and general ongoing support from the company and sales representative.

In regards to training, some lasers are more operator-dependent than others and the trainer supplied by the manufacturer or distributor should be more knowledgeable than anyone else.

Certain cosmetic laser treatments are very much about the art of the treatment, as well as the science, so the practitioner needs to be trained well enough to be confident and somewhat artistic in their approach to getting the best results for patients. Each patient is different, so the practitioner needs to adapt their laser treatment accordingly.

If you like to be an early adopter of new technology, the laser company should be willing to give you extra support in order to make sure you’re successful. For them, it’s important you give good recommendations of their laser to other potential buyers.

I would advise having a number of face-to-face meetings with the sales representative to establish exactly what the company is willing to do to support you. Many options are negotiable before you make a purchase and you should remember; you’re the one in the driver’s seat. The price of a laser is likely to drop in a relatively short period of time so you should insist on getting the most for your money if you’re investing in a company’s newest technology.

Disadvantages of buying new Cost: Buying a new laser is similar to buying a new car; as soon as you drive it out of the showroom, its value depreciates significantly.

Even though high quality lasers are usually in the £30,000 range and up, they’re still not as expensive overall as they were 10-15 years ago and the quality is much better now. Having worked directly for a laser manufacturer and distributor for several years, I’ve come to understand and appreciate the costs that go into making a laser available for sale and the support needed after the sale. It’s a pricey operation to take a laser from the drawing board to the consumer. If the laser being bought is one that’s been around for a while, the pricing should be lower or more negotiable.

If you’re considering purchasing a brand new model, sometimes it’s better to wait for the second version. There is then usually enough feedback for the manufacturers to see what needs to be changed and there’s also a good chance it will be less expensive. If you buy a company’s first laser model, you may want to try and negotiate some upgrade options over the first year. The company may not be willing to give it to you at no charge but you might be able to lock in a better price whenever a better version becomes available.

Obsolescence: Laser technology has consistently marched forward, with improvements made on a fairly regular basis. It’s somewhat like buying a computer. Within a couple of years many companies will come out with a modified or improved version of whatever it is you bought. Occasionally, it doesn’t even take that long because sometimes companies will push to clear out their initial inventory as there may already be another version in the works that they are

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Product Selection Buying a Laser

preparing to launch. Even if a laser is considered obsolete, it doesn’t mean it has to be immediately carted off to the dustbin (unless you can no longer get parts for it). If the laser is still performing well and both the practitioners and patients are still happy, keep on zapping. The differences between many of the older lasers and the newer ones are usually speed, software, system size, hand piece options, or additional wavelengths. Hence the old lasers can still be effective for years to come, maybe just not as fast or as comfortable to use as newer versions.

Advantages of buying a used laser Saving money: New lasers are expensive so if you can find the right deal, you could end up saving a bundle. If you already have a laser that you are comfortable with using and are just looking to add another one to your clinic, the used market may be the place to go. You will need, however, to make sure it can be serviced by a third party if you don’t want to pay the extra fees most manufacturers now charge.

Sometimes an older model may be better to consider because it’s likely to be a more basic system, making it easier to work on and get parts for.

Also, there are typically more of them on the market and you can usually get a more reasonable price.

Disadvantages of buying used Buying a used laser can either be a really good, or a really bad thing. I’ve seen it go both ways. Two big issues to consider when buying used are: Can you get the laser completely serviced? Is what you assume you’re buying, exactly what’s going to be delivered? Ask a lot of questions, get references, records of service, a checklist of any work that’s been done, and verify what you’re being told is true. There can be hidden pitfalls and unanticipated costs when buying used compared to buying new. Potentially the worst surprise someone buying a used laser may encounter is having to go back to the manufacturer for repairs and being hit with recertification fees that could cost anywhere from £1,000-£16,000.

Unfortunately there are a few bad apples wherever you go. Some 60

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Compliance with laser safety standards Laser protection advisor, and director of Bioptica Laser Aesthetics, Mike Regan explains that there are particular standards that lasers must adhere to in order to be classed as safe.

He says, “Recent years have seen a significant amount of work being done by the various international and European bodies responsible for the definition of laser product safety standards. The main International Electrotechnical Commission (IEC) standard for medical and aesthetic laser products is IEC 60601-2-22.” Regan also explains that, with regard to laser safety eyewear in Europe, the standardisation body is CEN (European Committee for Standardisation) and the relevant standard required is EN 207.

Laser consultant and technical officer at Lasermet, Peter Fishwick, details what these standards mean for practitioners looking to buy a laser.

All laser products that are introduced for sale in the UK must comply with various standards. The current laser standard is BS/EN 60825-1:2014 ‘Part 1: Equipment classification and requirements’. Medical laser products must comply with the additional requirements in BS/EN 60601-2-22:2013 ‘Medical electrical equipment: Particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment.’

These standards are functionally identical to the international standards produced by the International Electrotechnical Commission (IEC) of the same number. This means that products that comply with the international standard will also comply with standards in the UK. As the United States is not a signatory of the IEC, devices made in the US do not necessarily comply with BS/EN 60825-1 and 60601-22. In theory, the standards are enforced by various enforcement bodies such as Trading Standards to detect non-conformances and intervene where necessary. However, as manufacturers are able to self-certify it is very difficult for Trading Standards to find non-compliance in products that are coming in from overseas unless a product is reported to them by a consumer. When buying a laser these are the type of things you should be looking out for: What class is it? All laser products are classified from Class 1 to Class 4, where Class 1 is safe under normal operating conditions and Class 4 is potentially hazardous to both direct viewing and diffuse (scattered reflection). Class 4 is the most hazardous class and a large number of medical lasers fall into this category. Lasers in Class 1C, 3B and 4 will require additional training and safety infrastructure (LPS, LPA etc.)

Is it correctly labelled? All lasers should have labelling or user information that details the output of the laser. This should include the wavelength and power as well as any pulse information (if required). Along with the class of the laser this information should be available to you before you buy the laser.

Does it have the required safety features? For example, for a class 3B or 4 medical laser these include: interlock connectors, emission indicators, and requirements for any footoperated switch. There are also requirements for a remote interlock connector and key control.

Viewing optics must have an emission below the Class 1 Limits, and there must be a Laser Ready indicator to tell you when the device is powered up, as well as an emission indicator to tell you when the device is emitting.

The laser must have a target-indicating device and, if this is another laser, it must be less than Class 3R (Class 2 for Eyes). Also required are “Stand by/ready” controls, an emergency-stop facility, and a means of identifying emission levels. Approved laser safety enclosures are required to prevent unintentional exposure.

Eyewear for laser protection should meet EN 207 and the wavelength and power density of the laser will determine the type of eyewear required. Consequently, different lasers require different eyewear and advice should be sought from a laser safety specialist.

Certain products will require more training and an increased safety structure. Advice from an LPA, LPS or LSO should be sought when buying a Class 1C, 3B or 4 Laser. This will ensure you are compliant with the Control of Artificial Optical Radiation at Work regulations.

If you need to know if a product you own, or are looking to buy, meets these standards you should contact Trading Standards or a UKAS approved test house that specialises in IEC 60825-1 and 60601-2-22. Many products are certified through test houses such as UL, ITS, SGS and BV, and these test houses will make sure that any product that bears their ‘mark’ will meet the required standards. Independent test houses such as Lasermet will provide information to both consumers and manufacturers alike.

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Ask a lot of questions, get references, records of service, a checklist of any work that’s been done, and verify what you’re being told is true brokers selling used lasers have virtual inventories and work by getting a deposit from you and then searching for a laser that is similar to what was originally advertised. Sometimes what shows up is substantially different from what you thought you ordered; be cautious and ask the right questions. I’ve known of a few instances where no product is delivered and the broker has avoided all phone calls and kept the consumer’s deposit. As a consumer, you should know exactly who you are dealing with and make sure you have more than one way to contact the seller if need be.

Some brokers stock their inventory and have their own service specialists inspect and repair the lasers before selling them. You

Buying a Laser

may pay a bit more for this service but it could be worth it. Their inventory may be limited but it is possible that they can still find you a suitable product, which can be serviced prior to sale – something you should insist upon. Some may claim they have the resources to fix any problem you might have with a laser, when in reality they can’t. Ask detailed questions about how any service issues will be addressed. Will service just be a phone call from a technician trying to walk you through a fix? If you’re not comfortable working on equipment, it would be wise to figure this out up front.

Financing Obtaining finance can be difficult so it’s a good idea to get approved for a loan before you begin your laser search. I’ve seen many practitioners who decide what they want, then get the unpleasant surprise of not being able to get funding when they are ready to buy. Another good reason to get your financing approved upfront is that it will put you in a better negotiating position if you’re buying new. If you’re buying used, that killer deal on a laser you just found could go quickly, so you’ll want to be able to make the purchase straight away.

Don Berryhill is the founder of Lasercoach, a consultancy agency specifically aimed at cosmetic and medical practitioners. He aims to be an unbiased information source, to help practitioners and business owners become better educated consumers, and choose lasers and related equipment that best fit their practice needs.

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“There is no elevator to success, you have to take the stairs” Washington DC’s Dr Tina Alster is a true Renaissance woman in the field of laser dermatology. After two decades in private practice, she continues to break new ground. Wendy Lewis speaks to her about her journey into aesthetics A pioneer in laser dermatology, Dr Tina Alster broke through the glass ceiling early on to claim her place in a field largely dominated by male engineers and scientists. Her leadership and innovation in cosmetic laser surgery has afforded her a global reputation. Dr Alster founded the Washington Institute of Dermatologic Laser Surgery in 1990, as the first private practice in the world exclusively dedicated to the development and delivery of advanced laser skin treatments. Dr Elizabeth Tanzi became co-director in 2001, and the Institute has since grown to include Drs Terrence Keaney, Tania Peters, and Rebecca Kazin. A large part of the practice is also devoted to clinical research. Dr Alster’s career spans two decades of honours.

She has been listed in America’s Best Doctors, Town & Country’s Best Cosmetic Surgeons, America’s Elite 1000, Washingtonian’s Best Doctors, Marquis Who’s Who in Medicine and Healthcare, Who’s Who of American Women, amongst others. She was selected as Allure’s Influencer of the Year and received the Women’s Dermatologic Society Legacy Award. She has served as a consultant to Lancôme, Clarisonic, La Mer, and continues to influence new product development and industry direction.

Alongside her professional accomplishments, Dr Alster has managed to live a life of balance. She and her husband, Paul Frazer, a Canadian political-affairs consultant and former Canadian ambassador to the Czech and Slovak Republics, have one son who recently started university. Dr Alster’s modern facility on K Street is frequented by many, and in 2013 she created W for Men, along with Dr. Keaney, as the world’s first clinical practice dedicated exclusively to laser and skin treatments for men. W for Men features a private entrance and services catering specifically to male clients. According to Dr Alster, coming next is a new location in the suburban area of Chevy Chase, Maryland, opening in early 2015. But what first sparked Dr Alster’s interest in lasers and light? “I was always a bit of a science nerd,” she says.

“Physics and chemistry were two of my favorite subjects, so it was natural that I was attracted to lasers and light.” However, while she was a dermatology resident, Dr Alster had a memorable patient interaction which propelled her into the field.

“She was a 44-year-old who had a dark facial port-wine stain. She had never displayed her birthmark to her husband or teenage son and would only remove a small portion of her camouflage makeup for me to assess her condition. Upon her urging, I investigated further an article I had recalled reading about a new laser 62

Aesthetics | January 2015

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procedure that targeted blood vessels (which are in numerous supply in port-wine stain birthmarks). The more I researched the subject, the more interested I became. I got so interested that I applied for a specialised laser surgery fellowship in Boston in lieu of my final year of dermatology training at Yale University. I was so fortunate that I was introduced to this burgeoning field of medicine at such an early time in my career. The patient’s persistence paid off for both of us – I found my calling and she ended up having her vascular birthmark removed.”

A close-knit team is crucial to the success of the Washington Institute of Dermatologic Laser Surgery.

Dr Alster’s current key employees have been at the clinic for at least ten years, some of them for as long as 22 years. “Each of them is smart, hard working, considerate, and trustworthy,” says Dr Alster. “After an initial screening by my chief medical administrator, Georgina Eva, who has been my longest-standing employee, each applicant is interviewed personally by me. In addition to confirming his or her proper education and training for the job at hand, I make sure the applicant is a good “fit” for the team. While there are a number of objective measures that can be used, I often go with my ‘gut’. A pleasant personality and a degree of humility are just as important as an extensive knowledge base. I have chosen great team players who make the work atmosphere pleasant for me and for my patients.” Dr Alster founded and created her own SKIN IS IN skincare range in 2011.

“SKIN IS IN was conceived with the realisation that most people are confused with the wide array of skin care products on the market,” she explains. “After decades of cherry-picking skincare products for me and my patients, I wanted to take the confusion out of skincare. Knowing that good basic skincare is the foundation for healthy looking skin, I developed separate daily skincare kits for children, teens, men and women that each contain a cleanser, a daytime antioxidant moisturiser with SPF, and a night time peptide rejuvenating cream.” Having assembled her strong team, Dr Alster is proud of creating a practice that is regarded as world-class, delivering technically advanced treatments and technologies to patients. Dr Alster also combines clinical practice with research, teaching and mentoring, receiving many professional accolades, including the Women’s Dermatologic Society mentorship and legacy awards.

“I believe in paying it forward’,” she says, “and have established undergraduate and graduate scholarship endowments for women pursuing careers in medicine at my alma mater, Duke University.”

Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on anti-ageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications.

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The Last Word Record Keeping

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Aesthetics Journal

The last word Dr Askari Townshend argues the importance of a skilful and thorough approach to handling inevitable legal complaints In the last decade of performing aesthetic treatments, I have had two patients take legal action against me. As I believe I have treated over 15,000 in this time, I don’t think I’m doing too badly. If you treat enough patients, regardless of how good you are, the nature of the aesthetics industry means that you will probably receive a letter from a solicitor at some point in your career. If you don’t, either you haven’t done enough treatments, or you’ve been extremely lucky.

The fear of receiving one of these letters affects our practice, whether we admit it or not. A clear example of this is the detailed paperwork we often use when delivering a simple, safe and relatively comfortable procedure such as botulinum toxin. This kind of procedure often has a consent form far longer and more detailed than those I used to use in the NHS for painful operations that resulted in permanent scarring, risked serious complication or even death.

Although many of us call them patients (I now do this less and less), most of our aesthetic clients (implying a more intimate relationship than a ‘customer’ making a quick and simple transaction) are in good health. They are not seeking treatment for a medical complaint, but are making a decision as a consumer to access a paid-for service. In the NHS (which many of us trained and worked in, and still do) patients often do not have that choice – they are seeking medical assistance, which is free at the point of delivery. If they endure pain and suffering during this time, it is often accepted as a price worth paying in exchange for cure or improvement of their medical health. When seeking private, paidfor treatment that is often to simply improve appearance, the pain and suffering they are prepared to accept decreases dramatically.

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Most complaints are received by the practitioner or clinic in the first instance where, once again, the fear of the solicitor’s letter affects behaviour. In most cases, detailed and informed consent has been gained and a careful treatment performed.

If a problem occurs, clients may decide that although they accepted the risk, they have changed their mind and want a refund.

The potential damage to our reputations, headache of possible legal action and the loss of a client lead many to issue this refund.

If you do, I would recommend being wary of setting a precedent and indemnifying the client, in addition to paying for medical liability insurance. The refund could also be interpreted as an admission of fault when we know that complications will always occur, regardless of care and skill. In reality, the refund is unlikely to protect reputation in any way – I suspect that these clients will share their experience regardless.

In my own practice, I rarely give refunds in these situations. I do all in my power to prevent and treat the complication, and to provide the client with all the support (and more) that should be expected of a diligent and caring medical professional – this is part of the service we should all offer and feel a professional and moral obligation to provide. In addition, dealing with and resolving a complaint in a compassionate and empathetic manner is something we should all do for our clients. This is crucial in bringing the matter to an amicable conclusion. Do this poorly and do not be surprised to receive that letter containing a legal complaint, which may well come months (or even years) after you have forgotten about it. Indeed, it is possible to receive this letter even when you thought an amicable conclusion had been achieved.

Aesthetics | January 2015

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When complications or complaints arise, it is vital to carefully document the entire process, including all communications (such as calling and leaving a message if there is no answer) both in writing and by taking photographic evidence of the problem. If the client then wishes to pursue a legal path, you should have all that you need to defend yourself. In my experience, patients rarely keep good records of their experience, though with the popularity of camera phones they will often have graphic evidence of any injury.

When receiving a complaint or legal letter, our human response is to feel hurt, attacked and then defensive. This is to be expected when you have done your very best to help someone who then pursues you for recompense. However, it is important to keep things in perspective: do not confuse the law and legal system with justice and truth – these things can often be quite different! In any event, it is extremely unlikely that the case is going to be thrashed out in front of a judge in a courtroom – out of court settlements avoid even bigger legal fees that can sometimes overshadow the payment to the claimant.

If a client has suffered unduly or unexpectedly after a treatment (regardless of how carefully or skilfully it was performed) they may well be entitled to compensation, and for this we shouldn’t begrudge them. Stating complications clearly on a signed consent form doesn’t mean that you are able to avoid all future legal recourse. These situations are why you pay for medical liability insurance – just ensure that you have all of the information needed to enable your team to represent you to the best of their ability.

You may be the best, most thoughtful practitioner, and yet still receive that solicitor’s letter. This in no way reflects on your skill or practice. It is vital to bear this in mind if you do find yourself in the position that I was in, reading the dreaded letter. Thorough documentation and providing your client with the careful care and support required will mean that this kind of incident is dealt with correctly and efficiently, ensuring the best outcome for both parties.

Dr Askari Townshend With over 10 years injectable experience, Dr Askari Townshend’s interests also include lasers and peels. Until 2013, as Director of Medical Services at sk:n, Dr Townshend was responsible for overseeing medical complaints. He is now lead trainer and medical consultant for Sculptra UK and is currently teaching on an MSc Facial Aesthetics Course.

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

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

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

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

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

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

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

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

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

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

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

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

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