Aesthetics January 2016

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VOLUME 3/ISSUE 2 - JANUARY 2016

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Treating Scarring in Asian Skin CPD Dr Ardeshir Bayat and Sara Ud-Din discuss the treatments of scars in Asian skin

Radiofrequency Dr David Jack details the benefits of using a radiofrequency device for successful aesthetic treatment

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3D-lipo

The Ageing of the Temple

Fake & Counterfeit Products

Dr Sam Robson and Qura Shah explain how to rejuvenate the temple region

Professor Andy Pickett shares advice on recognising illicit aesthetic products

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Contents • January 2016 06 News

The latest product and industry news

14 On the Scene

Out and about in the industry this month

18 News Special: Stretch Mark Creams

Aesthetics investigates the efficacy of topical stretch mark treatments

20 Aesthetics Conference and Exhibition 2016

A look at the free business and clinical education available at ACE 2016

CLINICAL PRACTICE 22 Special Feature: Treating the Stomach

Practitioners share their approaches to targeting fat in the stomach area

27 CPD: Treating Scarring in Asian Skin

Dr Ardeshir Bayat and Sara Ud-Din explore scar treatment for Asian skin

34 Using Cryolipolysis to Treat Fat

Dr Galyna Selezneva describes how she uses cryolipolysis for fat reduction

36 Advertorial: 3D-lipo

3D-lipo presents the 3D-lipomed V2, used for fat removal, skin tightening and cellulite treatment

39 Treating Masseter Hypertrophy

Dr Souphiyeh Samizadeh discusses treating masseter hypertrophy and bruxism with botulinum toxin

43 The Ageing of the Temple

Dr Sam Robson and Qura Shah explain how the temple ages and outline how to use fillers to rejuvenate the temple

46 Case Study: Managing a Tattoo Complication

Dr Simran Deo details her experience of using microneedling to treat a hyperpigmented hypertrophic scar

49 Using Radiofrequency

Dr David Jack explores the benefits of having a radiofrequency device

52 Non-surgical Combination Technique for Treating the Perioral Area

Dr Richard Marques shares his approach to rejuvenating the perioral area using a four-stage process

54 Breast Reduction using Liposuction

Dr Harryono Judodihardjo outlines his technique for breast reduction

57 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 59 Distinguishing Fake and Counterfeit Aesthetic Products

Professor Andy Pickett details the types of illicit aesthetic products on the market and advises how their global circulation can be stopped

62 The Benefits of Medical Aestheticians

Amanda Elbourn discusses the advantages of employing a medical aesthetician in your clinic

64 Choosing Insurance

Simon McMillan explains how insurance works in medical aesthetics

67 In Profile: Rozina Ali

Miss Rozina Ali reflects on her career influences in medical aesthetics

69 The Last Word

Dr Martin Godfrey argues why the European aesthetics industry is falling behind and advises on what we should be learning from the US

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Special Feature Treating the Stomach Page 22

Clinical Contributors Dr Ardeshir Bayat has 20 years experience as a clinician scientist and has focused on skin health, scarring and regeneration. He is currently based at the University of Manchester., where he researches and lectures on the formation of scars.

Sara Ud-Din obtained her nursing honours degree from the University of Manchester, completed an MSc in Advanced Nursing Studies, pursued a career in research and is now part of the Plastic and Reconstructive Surgery Research (Bayat Research Group).

Dr Galyna Selezneva is an aesthetic medical doctor at the Dr Rita Rakus clinic in London. She specialises in non-invasive procedures for the face and body, using the latest technology including the fat-freezing CoolSculpting treatment.

Dr Souphiyeh Samizadeh is a dental surgeon who is actively involved with research into aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic.

Dr Sam Robson trained as a GP and began her aesthetics career in 2004. She is the medical director of Temple Medical in Aberdeen, an appraiser for the British College of Aesthetic Medicine and a medical advisor for the Royal National Lifeboat Institution.

Qura Shah completed her master’s at the School of Medical Sciences at the University of Aberdeen.

She currently works as a clinical therapist at Temple Medical with patients on medically-monitored weight reduction programmes.

Dr Simran Deo is a GP with further qualifications in dermatology and aesthetics, holding a diploma in dermatology from Cardiff University. She is currently the owner and director of True Tone Aesthetics in Windsor.

Dr David Jack graduated from the University of Glasgow, is a member of the Royal College of Surgeons of Edinburgh and is currently an aesthetic practitioner based between his clinics in Harley Street in London and Scotland.

Dr Richard Marques is a dentist and aesthetic practitioner, specialising in the mouth area. He operates from his Wimpole Street Dental Clinic off Harley Street and has worked to perfect many celebrities’ smiles.

Dr Harryono Judodihardjo is the medical director of the Cellite Clinic in Cardiff and specialises in liposuction hair transplant, lasers and injectable treatments. He obtained his master’s and PhD in dermatology from the University of Wales College of Medicine.

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

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

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Editor’s letter So, apart from me, who is still recovering from the Aesthetics Awards? I am not used to late nights and high heels! I hope you agree that the event was spectacular; I was so impressed when I arrived and saw the set, even bigger Amanda Cameron and better than last year, with nearly 600 of you Editor in attendance. Social media activity was also in abundance and it was great to see you all sharing photographs and maximising the PR opportunities! Many congratulations to all the Finalists, Commended and Highly Commended, not forgetting the well-deserving Winners! A huge thank you to everyone who attended and made the evening so special – truly a night to remember! You can read more about the fantastic ceremony, the fabulous entertainment and enjoy all of the photographs in our special Aesthetics Awards supplement, which will have arrived with this issue of the journal.

Can you believe that it is 2016 already? The years in which I have worked in aesthetics have gone so quickly, with new technology being introduced all the time. In particular, new treatments for weight loss and skin tightening on the stomach area are being introduced regularly, meaning patients no longer have to resort to surgery to remove unwanted fat. There is now a plethora of non-surgical

treatment options available, which we have examined in our January Special Feature on p.22. From flat, pale scars to prominent keloid scars, our patients are often concerned with the appearance these marks leave on their body. As such, we have three articles in this issue, which each address various scarring concerns, including the British Journal of Dermatology’s research into the formation of stretch marks on p.18, our comprehensive CPD article on treating scars in Asian skin by Dr Ardeshir Bayat and Sara Ud-Din on p.27, and a detailed case study on the treatment of a hypertrophic scar caused by a ‘blow-out’ of tattoo ink by Dr Simran Deo on p.46.

I must also implore you all to read Professor Andy Pickett’s article on fake and counterfeit botulinum toxin and filler products on p.59.

Having thoroughly researched, written and presented on the risks associated with using fake or counterfeit products, Professor Pickett is extremely knowledgeable on the subject. He provides vital advice on how to recognise fake or counterfeit botulinum toxin and fillers, whilst recommending how practitioners can help put a stop to such an unethical practice. Let us know what you think of the articles in this month’s journal by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com Finally, from all the Aesthetics team, we hope you have a wonderful 2016, filled with happiness and prosperity!

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

Dr Raj Acquilla is a cosmetic dermatologist with over 13 years

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. 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).

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

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

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Industry

Talk #Aesthetics

Pfizer to merge with Allergan in $160 billion deal

Follow us on Twitter @aestheticsgroup #Conference Sarah Tonks @DrSarahTonks Just landed into #Barcelona for the #SkinTech #ChemicalPeel conference – looking forward to seeing these new peels! #Awards Dr Anjali Mahto @DrAnjaliMahto Fun evening @aestheticsgroup awards last night and great to be part of the highly commended @cadoganclinic team!

#AestheticsJournal Lisajane @missljdavies Great to see @drathreya in this month’s @aestheticsgroup #greatread #Lasers Dr Suzanne Clements @SuzClements Thanks for great 2 days of expert clinical teaching on skin #lasers @Manchesterderm @lyntonlasers @DrNickLoweSkin

#Presentation Dr Ravi Jain @DrRaqviJain Thoroughly enjoyed presenting a lecture on #Vaser Liposuction to the head & neck last Friday @IAAFA #NewYear Facial Anatomy @facialanatomy @facialanatomy @pdsurgery @Anna32Baker What a year it’s been & what an exciting year to come #facialanatomy2016 #Awards Adrian Baker @Nurse_A_Baker Fabulous night at the @aestheticsgroup awards! Great catching up with people. Congrats to all nominated and winners

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US global biopharmaceutical company Pfizer will merge with Allergan in a stock transaction valued at US $363.63 per Allergan share; a total enterprise value of US $160 billion.

According to Pfizer, the merged company will adopt its name and create a leading global drugmaker. “The combination of Allergan and Pfizer is a highly strategic, value-enhancing transaction that brings together two biopharma powerhouses to change lives for the better,” said Allergan CEO Brent Saunders. “This bold action is the next chapter in the successful transformation of Allergan allowing us to operate with greater resources at a much bigger scale.”

Pfizer CEO Ian Read said the merger will help strengthen the pharmaceutical world and will, “Create a leading global pharmaceutical company with the strength to research, discover and deliver more medicines and therapies to more people around the world,” continuing, “Allergan’s businesses align with and enhance Pfizer’s businesses, creating best-in-class, sustainable, innovative and established businesses that are poised for growth.”

According to Pfizer, the merger is scheduled to close in the second half of 2016 and will result in more than $2 billion in savings over the first three years.

Launch

3D-lipo launches the 3D-lipomed V2 Aesthetic device manufacturer 3D-lipo has launched its latest multi-technology device, the 3D-lipomed V2.

According to 3D-lipo, the 3D-lipomed V2 incorporates the newest combination of advanced technologies to target specific body indications through the treatment of fat removal, skin tightening and cellulite. The company explains that the device will incorporate new cavitation cyclone technology that it has developed with a 200W output and a head size of 60cm2. Also featured is a high intensity focused ultrasound (HIFU) treatment, which aims to deliver a 24-line matrix of focused energy at a depth of 1.3cm to target stubborn pockets of fat and body sculpting. Another addition to the 3D-lipomed V2 is shockwave therapy, which aims to combat cellulite by stimulating the breakdown of fat cells, collagen synthesis and lymphatic drainage to improve skin elasticity and reduce cellulite. 3D-lipo’s existing Tripolar 3rd generation radiofrequency for face and body skin tightening will also be included in the new device. 3D-lipo will be showcasing the new 3D-lipomed V2 at the Aesthetics Conference and Exhibition (ACE) 2016 on April 15 and 16, with exclusive demonstrations and offers. To find out more about ACE 2016, visit www.aestheticsconference.com

Aesthetics | January 2016

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Dermal filler

Breit Aesthetics to distribute DERMAFILL in the UK Medical supply company Breit Aesthetics has partnered with SBS-Med to distribute its hyaluronic acid (HA) product, DERMAFILL, in the UK. Breit Aesthetics claims DERMAFILL is the first of a new fourth generation of safer, more effective, pure monophasic injectable dermal fillers.

The range is made up of four products, each specific to the indications being treated: DERMAFILL Global Xtra aims to treat fine lines and wrinkles; DERMAFILL Volume Ultra is aimed at correcting deep wrinkles and restoring facial volume; DERMAFILL Lips aims to redraw the lip contour and enhance volume and DERMAFILL Regen aims to optimise hydration of cutaneous skin tissue.

Countdown to ACE 2016 Latest programme updates Mr Adrian Richards’ Expert Clinic session will include a presentation on surgical and non-surgical procedures for facial beautification as well as a live injection demonstration performed by aesthetic nurse Melanie Recchia.

Wendy Lewis will speak at two Business Track sessions; one dedicated to the best practices for marketing your aesthetic clinic online and another which will provide advice on social media mastery.

Insight

Acne

mesoestetic Pharma Group launches new acne line in the UK Pharmaceutical manufacturer mesoestetic Pharma Group has launched a new acne line, acnelan. The acnelan acne solution is an intensive professional treatment combined with a home-maintenance line that aims to provide practitioners with an alternative to treat acne-prone patients. The professional treatment consists of three individual sessions that will be performed at 15-21 day intervals. Dr Asín, whose Spanish clinic, Aesthetic Dermatology Centre, participated in clinical trials of acnelan, said, “This new method provides good to excellent progressive and long-lasting results in most of the different types of acne treated.” The homecare line aims to maintain the effects of the professional treatment and includes a cleansing foam, a daily cream and descaling face mask. The active ingredients include salicylic acid, mandelic acid, shikimic acid and sodium lepargylate, which the company claims that, in combination with the exclusive bexaretinyl complex, will cleanse and renew acneprone and seborrhoeic skins.

Moisturiser

iS Clinical releases new Reparative Moisture Emulsion Cosmeceutical skincare brand iS Clinical has introduced its new moisturiser, the Reparative Moisture Emulsion. The product is formulated using pharmaceutical grade botanicals, peptides and powerful antioxidants aimed at hydrating the skin, helping to reduce the appearance of fine lines and wrinkles and improving skin health. iS Clinical claims that the moisturiser is one of the first generation of products to contain a uniquely designed, potent natural enzyme (SOD), which safely neutralises harmful free radicals while remaining active to combat photoageing and cell damage. The formulation also includes extremozyme, which aims to help prevent DNA damage. iS Clinical recommends this new product is used for dry skin, hyperpigmentation, ageing skin, sunburn and post-procedure skin.

Aesthetics | January 2016

Cosmetic doctor and international speaker Dr Raj Acquilla says: “I am delighted to present again next year at ACE with my friends and colleagues Dr Tapan Patel and Mr Dalvi Humzah. We will be running two Conference sessions; the first will discuss upper face beautification including the perioral area, brow and temple, and the second will be an indepth injection workshop focused on the chin and the submental area. Delegates will get to see relevant anatomy examples on a screen, whilst also watching live injection treatments to maximise the learning experience, providing them with a comprehensive understanding of the procedures. I’m really looking forward to another successful experience at ACE 2016 and I am excited to meet colleagues who are eager to enhance their practice by attending the highly educational clinical and business sessions.”

What delegates say “ACE talks are always very informative and entertaining and I found the exhibition really interesting.”

Cosmetic doctor, Londonderry

“ACE is always well structured and it’s good to find out about some new products. An absolutely amazing conference on both days.”

Aesthetic nurse, Essex

www.aestheticsconference.com HEADLINE SPONSOR

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Training

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Clinic

Highly Commended RA Academy Masterclasses announced for 2016 Dr Raj Acquilla will hold four exclusive masterclasses at the Healthxchange Academy in Manchester throughout 2016. The RA Academy, which was Highly Commended in the Training Initiative of the Year category at the Aesthetics Awards 2015, will take place in February, May, July and October next year. The masterclasses, run by Dr Raj Acquilla who was named Aesthetic Medical Practitioner of the Year at the Awards, will cover detailed aspects of facial anatomy as well as assessment, planning and injection techniques for botulinum toxin and fillers. “We are advancing fast in a rapidly growing industry with innovative developments in products and techniques, which ultimately enables more effective delivery of exquisite results,” said Dr Acquilla, adding, “those wishing to have hands-on experience will be able to do so according to their own bespoke learning needs and goals, and attendees will be given formal certification suitable for indemnity, and of course CPD accreditation.”

Distribution

Cynosure announced as distributor of MonaLisa Touch Developer and manufacturer of light-based aesthetic and medical treatment systems Cynosure has become the worldwide distributor of the MonaLisa Touch.

The MonaLisa Touch by DEKA is a treatment for patients suffering from vulvovaginal atrophy or genitourinary syndrome of menopause. The treatment aims to relieve patients of vaginal dryness and vulvar dryness, vaginal itching, painful intercourse and painful urination. The procedure consists of three five-minute treatments at six-week intervals and requires no anaesthesia. Cynosure claims the treatment has minimal side effects and patients can expect results and symptom relief after one treatment.

Thread lifting

Vida Aesthetics gains new PDO training consultant Aesthetic practitioner and dental surgeon Dr Irfan Mian will run advanced courses on his new PDO thread lift technique as the company’s new PDO thread training consultant. Dr Mian pioneered the Alternative Snooker Hold (MASH) technique in 2014 and Vida Aesthetics claims that it produces even better results than previous protocols. “Vida is delighted to have engaged the services of Dr Irfan Mian to teach PDO thread treatment techniques to our clients,” said Eddy Emilio director of Vida Aesthetics, adding, “we are particularly excited by the prospect of him sharing his expertise using PDO threads and describing the MASH technique that he developed, which delivers amazing results.” Dr Mian will cover both the theory and the practical aspects of the treatment in his first of many advanced training sessions on his MASH technique at Vida Aesthetics.

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Aesthetics

Aesthetics | January 2016

La Belle Forme merges with The Skin Clinic Glasgow-based cosmetic surgery clinic La Belle Forme has partnered with The Skin Clinic in Kent and Essex. The Skin Clinic will retain its name and staff, and the company’s founder, Dr Johanna Ward, will remain as medical director and lead cosmetic doctor at the two clinics. “We are delighted to have joined forces with La Belle Forme,” said Dr Ward, “it means that as well as retaining all our original staff and treatments, we will now be able to offer our clients an even wider range of services than ever before.”

The Skin Clinic will introduce full cosmetic surgery services, expand its laser treatments on offer and will also introduce a broader range of face and body contouring procedures.

The merger will allow La Belle Forme to gain access to The Skin Clinic’s technology and staff, as well as the benefit of having Dr Ward’s expertise on board.

The Skin Clinics at Kent and Essex will also have heavy involvement from the founder of La Belle Forme, consultant plastic surgeon Mr Taimur Shoaib, as well as aesthetic practitioner Dr Nestor Demosthenous.

IPL

Venus Concept UK introduces Venus Versa Venus Concept UK has launched the Venus Versa aesthetic tool kit and multi-platform intense pulsed light (IPL) device. The Versa provides a range of aesthetic treatment options such as acne, vascular and pigmented lesions, skin rejuvenation and hair removal. Venus Concept UK managing director Michael Dodd said, “We are excited to launch one of the first multi-platform IPLs to the UK market by a trusted and FDA-approved company to deliver results-oriented treatments for our clients.” According to Venus Concept UK, the Versa provides one of the largest spot sizes in the industry, creating faster and more efficient treatments with a repetition rate of up to three hertz.

Venus Concept UK also claims that the Versa delivers 1.5 times more energy than its competitor in the 515nm600nm and 650nm-820nm spectrum. The device supports four accumulative pulsed light (APL) adaptors and features a real-time cooling system, which monitors the applicator temperature at 1,000 times a second for safety and comfort. The all-in-one device is also compact to make it easy for practitioners to transport to different rooms around their clinic.

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Conference

New speakers announced for ACE 2016 Business Track A host of new speakers for the Business Track agenda at this year’s Aesthetic Conference and Exhibition have been announced.

The popular Business Track agenda will provide expert guidance from a number of leading consultants and successful entrepreneurs on building, sustaining and growing a practice in medical aesthetics on April 15 and 16. The programme will see presentations from international consultant, Wendy Lewis, who will share her vital advice on how to market your aesthetic clinic online, including a presentation on advanced social media mastery.

Also presenting will be aesthetic nurse and accredited civil expert witness Liz Bardolph, who will explain new consent law for use in practice and Mark Lainchbury, who will advise how to build your business through target marketing. Tax and VAT consultant, Veronica Donnelly, will provide insightful and practical information on the latest updates in her industry and aesthetic practitioner Dr Paul Charlson will also present an update on regulation, giving delegates useful tools to apply in their everyday clinic management.

Also presenting unmissable business topics will be Professor Mark Whiteley, Eddie Hooker, Dr Cheralyn Lumley, Julia Kendrick, Gary Conroy and Dr Chris Blatchley. The Business Track has a particular focus on supporting small businesses; providing sales, marketing and regulation advice and ideas on how to enhance a practice. To find out more and to register FREE for ACE 2016 visit www.aestheticsconference.com Skincare

Murad expands Anti-Aging Blemish Control range Skincare manufacturer Murad has introduced two new multi-functional products to its Anti-Aging Blemish collection.

Advanced Blemish & Wrinkle Reducer and Anti-Aging Moisturiser SPF 30 are aimed specifically at targeting blemishes in adult skin whilst also addressing signs of ageing.

Both new products contain fermented black tea, which aims to prevent the breakdown of collagen, and phytoestrogen black cohosh, which aims to help combat hormonal breakouts. Dr Howard Murad, founder of the skincare company, said, “Targeted anti-ageing blemish treatments can only be effective in alleviating both problems if they are balanced, gentle formulations that don’t dry out skin and exacerbate the signs of ageing.”

Insider News

39% of adults

were overweight in 2014

(World Health Organisation)

More than 20 million cosmetic surgical and non-surgical procedures were performed worldwide in 2014 (International Society of Aesthetic Plastic Surgery)

$81 million worth of fake and illicit medicines were seized by INTERPOL in June this year (INTERPOL)

There were 26,000 male breast reductions in the US in 2014, a 29% increase since 2000 (American Society of Plastic Surgeons)

70% of people click on links from page one of Google search results, while only 6% click on results on page two or three (Advanced Web Ranking) The global cosmetic surgery and services market is currently worth over US $20 billion, and is set to rise to over $27 billion by 2019 (Global Cosmetic Surgery and Service Market report 2015-2019)

Aesthetics | January 2016

The countries that performed the most cosmetic surgical and non-surgical procedures in 2014 were the United States at 20%, Brazil at 10% and Japan at 6% (International Society of Aesthetic Plastic Surgery)

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Events diary 22nd January 2016 RSM Aesthetics 8, London https://www.rsm.ac.uk/aesthetics8

28th – 31st January 2016 IMCAS World Congress 2016, Paris www.imcas.com/en/attend/imcas-worldcongress-2016

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

30th March – 2nd April 2016 AMWC World Congress 2016, Monte Carlo www.euromedicom.com

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Laser

Verju to be distributed in the UK Bodylase Medical is to distribute laser device Verju in the UK. Verju uses six green 532nm laser diodes and aims to reduce circumference of the waist, hips and thighs whilst also reducing the appearance of cellulite. The FDA-approved laser device, manufactured by Erchonia, sweeps the area of concern for a treatment period of 30 to 40 minutes. The green wavelength then aims to release more lipid material and contour the body while stimulating the removal of cellulite.

Managing director Katrina Waller said, “We are delighted to be given this great opportunity to launch the Verju, which we believe will transform the whole concept of body contouring to deliver far reaching health outcomes other than just concentrating on small localised areas of stubborn fat or cellulite.”

Training

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

Skincare

Exuviance launches Bionic Oxygen Facial Exuviance has introduced the Bionic Oxygen Facial to its skincare range, which aims to revitalise and detox the skin. The new ‘five-minute facial in a bottle’ is a dermatologist-developed facemask that infuses the skin with a triple oxygenated blend combined with Exuviance’s signature Bionic Complex. According to AestheticSource, the UK distributor of Exuviance, the mask is formed on contact with damp skin resulting in a relief for dull, tired complexions.

“We all know oxygen is vital for our bodies,” said advanced skin expert Debbie Thomas, continuing, “but it is also needed for healthy skin. The Bionic Oxygen Facial by Exuviance is innovative and targeted, giving skin a boost of detoxifying, brightening oxygen, instantly.”

The key ingredients include molecular oxygen, which is delivered to the skin by a triple oxygenated blend of perfluorohexane, perfluorodecalin and perfluoromethylcyclopetane to revitalise and energise the skin.

The mask also has Bionic Complex, a blend of polyhydroxy acids, gluconolactone and NeoStratapatented lactobionic acid that aims to maintain the skin’s elasticity and improve fine lines, wrinkles and pigmentation. The mixture also includes cucumber fruit extract, vitamin C, amino acids, proteins and lipids.

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Award-winning anatomy training courses to take place in 2016 Consultant plastic surgeon Mr Dalvi Humzah will present The Management of Non-surgical Complications Through Anatomy on March 7 and the award-winning Facial Anatomy Teaching class on May 23. Taking place at the Royal College of Surgeons in London, the two courses will teach delegates how to successfully administer nonsurgical procedures with a current and in-depth discussion of anatomy. The Management of Nonsurgical Complications Through Anatomy course will incorporate information on the diagnosis and current management strategies of toxin and dermal fillers. The class will include a practical dissection and hyaluronidase workshop, with discussions of the management of non-surgical complications. The Facial Anatomy Teaching class, which won the award for Training Initiative of the Year at the Aesthetics Awards in 2015 and 2014, will focus on the management of non-surgical complications for the face. Aesthetic nurse prescriber Anna Baker, who was Highly Commended in the Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year category at the Aesthetics Awards 2015, will accompany Mr Humzah in teaching delegates how to visualise the face in a three-dimensional manner. The morning session will include lectures and discussions on the current anatomical literature and developments that relate to all aspects of facial anatomy, while the afternoon session will detail anatomical aspects of the upper face including the tear trough and periocular anatomy, as well as the lower face and neck. This will be followed by a practical dissection session where delegates can recieve hands-on experience in exploring the anatomy of the face. “There have been major recent advances in anatomical knowledge that have implications for how we plan and deliver optimal aesthetic treatments,” said Mr Humzah, adding, “It is important that those professionals providing treatments to their patients are up-to-date with this constantly evolving anatomical knowledge.” Attendees will also be eligible to receive five CPD accreditation points from the Royal College of Physicians and Surgeons of Glasgow for each of the courses.

Aesthetics | January 2016

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Brand ambassador

Swisscode UK brand ambassador announced Cosmeceutical skincare manufacturer Swisscode UK has confirmed that naturopathic physician Dr Nigma Talib is its new brand ambassador.

Dr Talib will now offer the complete Swisscode range in her Notting Hill clinic based in the Body Work West health club. Swisscode, which has developed the Pure and Bionic ranges, aims to deliver products that boost the skin’s rejuvenation process, replenish moisture, improve skin texture, smooth lines and provide UV protection.

Teresa Da Graca, CEO of Pure Swiss Aesthetics, the distributors of Swisscode in the UK, said, “We are thrilled to have Dr Talib on board and for her to share our brand with her clientele,” Da Graca continued, “people come to Dr Talib for her 360 approach, she does not focus on just one part of your skin, body or health but your whole overall appearance and wellbeing, both inside and out. Swisscode are delighted to be part of this consultative wellbeing approach.”

At-home treatment

Fire & Ice facial now available in a ‘at-home kit’ iS Clinical has launched a Fire & Ice clinic treatment take-home kit, designed to give patients a home treatment that aims to optimise cell turnover and resurface the skin. As with the professional treatment, the at-home kit features a two-step resurfacing and rejuvenating process combined with pharma grade serums and complexes. The Tri-Active Exfoliate uses botanical enzymes, salicylic acid and eco-friendly micro-beads, which the company believes provide optimum physical and biochemical exfoliation. The Hydra-intensive formula features natural botanical antioxidants resveratrol, centella asiatica, green tea, aloe vera and rosemary extracts with botanically sourced hyaluronic acid, which aim to make the skin appear fresh and hydrated. The company claims that the intensive Fire & Ice clinic treatments leave the skin looking instantly more radiant and youthful, and that the new at-home kit is perfect for patients looking for a cost-effective treatment.

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Murad to launch Rapid Collagen Infusion for Lips Skincare manufacturer Murad will launch its new Rapid Collagen Infusion for Lips in February.

The product uses collagen technology that aims to enhance and restore lip volume and target the signs of ageing on and around the lips. The key ingredients include collagen support complex, an anti-ageing peptide blend that delivers micronised collagen amino acids to plump vertical lines and wrinkles; apple extract, to deliver hydration; hyaluronic acid and shea butter, for lip moisture and smoothness, and mustard sprout, which aims to help microcirculation to give a plumper lip appearance. According to Murad, the Rapid Collagen Infusion for Lips can be applied over the lips and on the surrounding area in a thin layer and can go under lipstick, gloss or balm. Dr Howard Murad, CEO and founder of Murad said, “Rapid Collagen Infusion for Lips will help give my patients and customers the freedom to express their happiness without worrying about the wrinkles it may leave.”

Aesthetics | January 2016

Insider News

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Sandra Fishlock & Sue Wales, founders of TEOXANE UK You have recently transitioned from Lifestyle Aesthetics to TEOXANE UK, what does 2016 bring?

We’re extremely pleased about the new transition, now that we are closer than ever to our partner TEOXANE, we are confident 2016 will see a spike in brand growth, business development, industry communication and innovation.

How does TEOXANE UK remain at the forefront of the dermal filler market?

Product innovation and R&D have always been at the heart of the TEOXANE philosophy. TEOXANE has launched some ground-breaking technology and product advances in particular with Redensity (I), Redensity (II) and of course the RHA range which is the first dynamic filler with both strength and stretch capabilities. In 2015 alone TEOXANE launched the dynamic RHA range and TeoPen both with the potential of changing the entire aesthetic market. Alongside a strong focus on R&D innovations, technology origination and a top market strategy, TEOXANE now supplies into 80 countries – all with strong influences, medical professionals and international KOLs. What’s the primary focus for TEOXANE UK? Continuing to offer practitioners support, training, innovation and solutions. We are extremely excited for the 2016 pipeline with more training, education and marketing activity than ever before.

Communication is a primary focus for us following the successful launch of the RHA Range, a product that the dermal filler market has never seen before and communicating the unique, science behind this dynamic HA is key to allow practitioners to move with the technology available and therefore deliver the best in class treatments to their patients.

What products would you suggest to deliver ‘best in class treatments’?

Key products in your clinic should consist of the RHA and Redensity ranges as well as the Teopen to deliver a more comfortable treatment. For traditional dermal filler injections, RHA offers the best results in both ease of injecting and patient satisfaction due to the dynamic properties of the gel, under both skin stretching and compression the gel adapts and keeps its performance. It’s important for the patient to care for their skin in between injections and with the same technology of cross-linked HA used in our dermal fillers integrated into a full skincare regime, TEOXANE Cosmeceuticals helps skin remain smoother, plumped and firm.

This column is written and supported by

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ACE 2016

Aesthetics Awards Winners to speak at ACE 2016

The Aesthetics Conference and Exhibition 2016 will host a number of leading experts who received recognition at the Aesthetics Awards 2015, held in London on December 5. Delegates will have the opportunity to meet and learn from the most talented professionals in the aesthetics industry, including Dr Raj Acquilla, Dr Tapan Patel and Mr Dalvi Humzah who respectively won the award for Aesthetic Medical Practitioner of the Year. The Oxygenetix Award for Best Clinic London and the award for Training Initiative of the Year. They will present together at two Conference sessions dedicated to the periorbital and submental areas. Mr Humzah will speak additionally in two more ACE conference sessions; one on treating the mid-face and another on enhancing the eye, with detailed analysis of relevant anatomy. Joining him in the session dedicated to the mid-face will be winner of Best Clinic Wales Dr Maria Gonzalez, who will discuss how to appropriately treat pigmentation, and Mr Taimur Shoaib, whose team won the Church Pharmacy Award for Clinic Reception Team of the Year, will provide advice on surgical and non-surgical methods of fat reduction and enlargement in the Conference session on treating the buttock and thigh area. In addition, Sharon Bennett, winner of The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year, will perform a live demonstration on how to treat the lips with injectables in a Conference session on the perioral area. Delegates can also experience a valuable talk from Dr Victoria Dobbie, founder and medical director of the winning practice for Best Clinic Scotland, who will run an Expert Clinic session on the use of botulinum toxin treatments. In addition, Liz Bardolph, whose prestigious career and contribution to raise standards in medical aesthetics was honoured with the Schuco International Award for Special Achievement, will present at the ACE Business Track session on the latest developments in patient consent. The Aesthetics Conference and Exhibition will take place in London on 15 and 16 April. To register free for ACE 2016 and to find out more about the speakers visit www.aestheticsconference.com Perioral

Transformulas Skincare releases Marine Miracle EyeZone Transformulas skincare has released the Marine Miracle EyeZone that aims to reduce the signs of ageing and eliminate dark circles around the eye.

The active ingredients include aldavine 5, which works to improve the rate of blood flow in the capillaries to prevent swelling; hesperidin methyl chalcone, which aims to make capillaries less visible and chamomilla recutita, which aims to reduce the appearance of broken capillaries.

The company claims the ingredients work together to brighten the under eye area, smooth the skin and improve resilience and elasticity, with noticeable results after 28 days of treatment.

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Aesthetics | January 2016

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News in Brief Medico Beauty launches new website and branding Medical aesthetic distributing company Medico Beauty has launched a new website, with fresh branding and a complete redesign.

The new ecommerce website aims to provide aesthetic professionals with a more comprehensive view of Medico Beauty’s education programmes and insight into the team’s dermal remodelling approach. Medico Beauty is the official distributor of advanced skin treatment lines CosMedix and Results Rx for the UK and Ireland.

Naturastudios to launch new additions to Dermapen 3 for microneedling treatments Naturastudios are to launch two new devices to be used with the Dermapen 3 hand piece: the Dermapen TattOff and Dermapen Infuse.

The Dermapen TattOff features a non-laser and non-thermolytic technology and aims to deliver precise tattoo removal and targeted skin rejuvenation for anywhere on the body.

The Dermapen Infuse is a drug delivery system that is designed to allow for a fast, pain-free infusion treatment that can deliver 200 injections per minute. The new devices will be available for purchase in the first quarter of 2016.

Dr Esho opens new clinic in Newcastle Aesthetic practitioner Dr Tijion Esho has opened a new clinic in Newcastle. Dr Esho celebrated the opening of Le Beau Ideal with a masquerade ball. Dr Esho said, “Le Beau Ideal is different from the norm. I created this clinic so patients could have not just a treatment, but an experience, and I believe I have captured that.”

Cellcosmet partners with Zen Pharmacy Swiss cellular skincare brand Cellcosmet has partnered with Zen Pharmacy, making its products available at the recently opened ZEN Healthcare in London’s Knightsbridge.

Chief operating officer at SwissCell UK, Dhinil Patel, said he is delighted to be working alongside Zen Healthcare, explaining, “Swiss Skincare is a perfect match for Zen’s clientele and emphasis on innovative and groundbreaking skincare solutions. We are very much confident that our brand will grow in this new environment.”

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Dr Preema Vig clinic launch, London Friends, family, colleagues and patients attended the opening of the Dr Preema London Clinic at Devonshire Place on November 25. Guests were greeted with a welcome drinks and canapé reception, and presented with complimentary treatments, followed by an acknowledgement speech and a raffle. Later in the evening, there was a demonstration of the CoolScuplting technology, an FDA-cleared non-surgical fat reduction treatment that uses controlled cooling to eliminate fat. Aesthetic practitioner, Dr Preema Vig, who is also the medical director at Beyond MediSpa at Harvey Nichols, said she is thrilled to be able to divide her time between the two practices.

“I have been quite taken aback by the overwhelming interest and support by both new and existing customers at the launch event,” Dr Vig said, continuing, “we had a very positive RSVP response and it is so nice to hear the positive feedback regarding our new premises and expanded treatment portfolio that now encompasses advanced medical facial peels, specialist treatments such as CoolSculpting and Thermavein and an increased number of clinic sessions offering more appointments with both myself and my medical aesthetician Amii Barry.”

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BAPRAS annual Winter Scientific Meeting, Birmingham Practitioners attended the British Association of Plastic Reconstructive and Aesthetic Surgeons’ (BAPRAS) annual Winter Scientific Meeting in Birmingham on November 25-27.

Approximately 400 delegates attended the three-day event, which showcased the latest developments and research in plastic surgery innovation. BAPRAS president and consultant plastic surgeon Mr Nigel Mercer said, “BAPRAS is proud to have hosted pioneering plastic surgeons from across the world that shared their expertise to help advance our wide ranging specialty for the benefit of patients everywhere.” He continued, “These discussions are crucial to helping drive best practice and patient outcomes.”

Key sessions of the meeting included member talks on efficiency improvement for free flap breast reconstructive surgery, presentations on microsurgery in hands, lower limbs and breasts, the Reconstructive Surgery Trials Network meeting and discussions on the role of plastic surgeons in trauma teams.

The annual event also featured the first meeting of the Innovation Group. Mr Ryan Kerstein, BAPRAS member and Innovation Group lead member, said, “The annual event saw the first meeting of the new BAPRAS Innovation Group, which showcased the best innovation in plastic surgery with the ultimate goal of developing new, safer and more efficient practices and products.” He added, “A wide range of exciting and original thinking was displayed, from a robot for craniofacial surgery to a mobile app to streamline referrals.”

‘Speed Date’ the Beauty Experts, London Aesthetic practitioners were on-hand to discuss their latest treatments and products at the Soho Hotel on December 4. The all-day event offered one-to-one meetings with aesthetic practitioners including dermatologist Dr Ariel Haus, cosmetologist Tammy Hollis and facialist Nathalie Eleni. Dr Haus introduced the new high-tech triple treatment, TrioTech from Triniti Plus, which aims to rejuvenate the face using three stages in one treatment. The first stage uses Intense Pulse Light, which aims to reduce the appearance of age spots and skin damage; the second stage uses light energy and radiofrequency (RF) to try to stimulate new collagen, and the third stage aims to treat fine lines and wrinkles by using RF to deliver controlled ablative and non-ablative fractional treatment. Dr Haus said, “The results are instant and skin looks tighter and more refreshed. Patients that have had the treatment are very happy with the results, and say it’s given them so much more confidence.” Also showcasing at the event was bioactive facelift Liquilift, created by cosmetologist Tammy Hollis. The product, that aims to give an instant facelift, contains liftonin, an active ingredient complex, which aims to treat skin ageing, as well as botanical silicon and tannins from oak.

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Aesthetics Journal

IBSA’s Marketing Meeting, Barcelona IBSA Farmaceutici Italia held its Annual Marketing Meeting at the Hilton Hotel in Barcelona on November 30. The event took place over two days and attracted more than 35 distributors from all over the world, including UK distributor HA-Derma. “It was our first meeting and we found it incredible useful,” said sales and marketing manager Iveta Vinklerova of HA-Derma, adding, “We couldn’t wait to pass all the news, tips and advice onto practitioners using the products.” The meeting included presentations on the latest developments on the new injectable hyaluronic acid product, Profhilo, and reports on the company’s annual achievements and future marketing plans by company manager Tania Pirazzini. Key sessions included presentations on Profhilo, as well as discussions on hyaluronic acid hybrid complexes. Plastic and aesthetic surgeon Professor Daniel Cassuto also discussed his previous experiences with Aliaxin dermal fillers and invited all distributors and their Key Opinion Leaders to his Profhilo Masterclass at the IMCAS World Congress 2016 in Paris later this month.

Aesthetics | January 2016

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InnoAesthetics Masterclass, Barcelona Medical Aesthetic Group, the UK distributor of InnoAesthetics, invited practitioners to a two-day masterclass led by founder of InnoAesthetics and pharmacist Dr Fernando Bouffard in Barcelona on November 24-25. A number of doctors, nurses and aestheticians were invited to attend the event, which saw Dr Bouffard sharing his knowledge on mesotherapy and skin peels.

The course provided delegates with detailed theoretical information and explained all mesotherapy pathologies and treatment areas, specifically focusing on existing InnoAesthetic

products. Medical Aesthetic Group also introduced delegates to the new Bio C skin peel and Eye Corrector peel, which are available in the UK now.

“The Barcelona Masterclass was beyond expectations,” said Dr Thomas Basler who attended the event, continuing, “from new insights into basic science applied to aesthetics to inspiring combinations of peels and mesotherapy – the training was brilliant.

I learnt so many new things to introduce to my clinic straight away, especially the new Eye Corrector Peel.”

The Aesthetics Awards 2015, London Practitioners, clinics, products, distributors and manufacturers were celebrated at the eagerly anticipated Aesthetics Awards ceremony at the Park Plaza Westminster Bridge Hotel in central London on December 5.

Guests enjoyed networking with friends and colleagues at the pre-dinner drinks reception, before moving into the ballroom for a three-course dinner, comedy set and the main Awards ceremony. The evening, hosted by comedian Simon Evans and compered by voiceover artist Peter Dickson, celebrated the very best achievements in medical aesthetics this year, recognising Commended and Highly Commended finalists, as well as the Winners, in 24 prestigious categories.

Editor of the Aesthetics journal Amanda Cameron said, “This year’s Aesthetics Awards was a huge success and truly a night to remember. It was wonderful to see so many medical aesthetic professionals in one room, celebrating the hard work and commitment each person has put in to our industry.”

Taking home the award for Medical Practitioner of the Year was Dr Raj Acquilla, who said, “It’s a great honour to be medical practitioner of the year because I really feel it’s the pinnacle of years of work, dedication, commitment and a quest for excellence in the UK.” Also recognised was chair of the British Association of Cosmetic Nurses (BACN) Sharon Bennett, who won the Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year. Bennett said, “I love working, I love doing what I do, and getting an accolade is just fantastic. It means more to me that this category is judged, rather than being a public vote, as it’s based on what I do.”

To end the ceremony, the prestigious Schuco International Award for Special Achievement was presented to aesthetic nurse prescriber Liz Bardolph. She said, “I was delighted and overwhelmed to receive such a prestigious award. To be recognised for my contribution to the field of aesthetics was both unexpected and fantastic.” Cameron concluded, “I would like to say a special thank you to our judges for taking time out of their busy schedules to carefully consider each of the entries and choose our winners. A big thank you must also go to all of our category sponsors, without whom this evening would not be possible. Finally, I would like to say thank you so much to everyone who entered, voted and attended the Aesthetics Awards 2015 – without you we wouldn’t have such a fantastic evening of celebration to look forward to each year!”

To view the full list of winners visit www.aestheticsawards.com 16

Aesthetics | January 2016

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Aesthetic Journal January 2016

News Special Stretch Mark Creams

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Stretch mark creams: misleading claims or understated benefits?

Aesthetics investigates the recent consumer headlines that claim stretch mark creams don’t work and asks professionals how patients seeking solutions to their scarring concerns can be appropriately advised A new study published in the British Journal of Dermatology (BJD), which researched the cause of stretch marks at a molecular level, suggests that current topical treatments aimed at treating and preventing stretch marks don’t work.1 The study, led by Dr Frank Wang et al,2 researched striae gravidarum, (a form of scarring of the skin on the abdomen, due to sudden weight gain during pregnancy) in 27 pregnant women. The researchers found that during pregnancy, and up to eight weeks after, elastic fibres in the dermis become disrupted. These fibres normally allow for the recoil of the skin, but, once disrupted, the study suggests that the fibres struggle to repair themselves. Following this new research, Dr Wang has suggested that topical creams couldn’t plausibly repair this damage.

Until now, there hasn’t been much investigation into the formation and treatment of stretch marks as they are not seen as medically dangerous.1 However, consultant dermatologist Dr Justine Kluk believes this study provides important 18

information on the pathogenesis of stretch marks and is a significant step forward for treatments. She says, “Until now, there wasn’t a very good understanding of what was happening at a molecular level in stretch mark formation. Now that the basic understanding is there, the foundations have been laid for developing better treatments.”

Consultant clinical and cosmetic dermatologist Dr Vishal Madan explains, “When treating stretch marks, we’re effectively dealing with a scar which also has tearing of the top layers of the skin. Its a very difficult thing to reverse.” This is something that patients can find very difficult to live with, and something that Dr Kluk believes is important to recognise, “Stretch marks

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are clearly not dangerous, however they are common and can be quite prominent.

Many women feel that they are unsightly or disfiguring. I think it is valid to conduct more research in this area so that new treatment options can be explored. We should also be sensitive to patients who come to us with these concerns because some will find it psychologically distressing and difficult to deal with.” Consultant dermatologist Dr Anjali Mahto agrees, “I think the problem we have had in the past is that scientists are focused on treating disease, and stretch marks falls into the cosmetic category, so there is not as much concern with treating it. But I think more and more we are now realising that psychodermatology is a real field of medicine and so I think more money will now be put into looking for effective treatments.”

At present, there is an abundance of topical treatments marketed at reducing and preventing stretch marks available to consumers over the counter. In light of Dr Wang’s research, however, we are led to question if all current products are insufficient, or can some make a visible difference? In addition, how should aesthetic practitioners advise patients looking to treat stretch marks topically?

The affect of stretch mark creams “Personally, I have never believed that these creams work,” says Dr Mahto, adding, “in my opinion, I haven’t found a cream that can totally protect against stretch marks.

Once you’ve got stretch marks, I don’t think there’s anything you can put on the skin that’s going to get rid of them. But what the Dr Wang et al study does suggest, is that we might be better off trying to find creams that can protect the elastic strands from breaking-down in the first place.”

Dr Madan adds, “Although there are yet to be studies that prove creams aimed at treating and averting stretch marks work, there are still benefits in women using them. Stretch marks are variable lesions and vary from person to person. So one person’s stretch marks may respond to one topical treatment, but it doesn’t mean others

“What you can safely say is that cocoa butter is a great moisturiser, but it doesn’t do anything for stretch marks” Dr Anjali Mahto

Aesthetics | January 2016

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“Until now, there wasn’t a very good understanding of what was happening at a molecular level with stretch mark formation. Now that basic understanding is there, it should be much easier to identify and target the treatments” Dr Justine Kluk will as well,” however, he continues, “I’ve not personally seen good results from topical therapies alone, and it depends a lot on what stage of development the stretch mark is at. If someone has got very established, white/silvery stretch marks, then it is unlikely that any topical treatment will make any improvement. However, if someone is in the very initial phase of the slightly red stretch marks, then it may be possible to improve them with certain treatments.”

Ingredients A wide range of ingredients is used in topical stretch mark products, but their role in avoiding and improving stretch marks is unclear. “Some products have hyaluronic acid (HA) in them as some practitioners believe by putting HA on the skin, it will help plump and moisturise the affected area which will improve the appearance. But HA is a big molecule, and for it to actually penetrate the skin, is probably pretty unlikely,” says Dr Mahto.

“Some products contain vitamin A or retinoids, and apparently there is some evidence to suggest these can help with the appearance of stretch marks. The only problem with retinoids is, they are class C drugs, so they’re not licensed for use in pregnancy.”

One particular ingredient that appears to be often promoted in topical stretch mark products is theobroma oil, more commonly known as cocoa butter. Touted for its ability to prevent and improve the appearance of stretch marks,3 often alongside other ingredients, many dermatologists believe it is nothing more than a good moisturiser, yet research by Statista indicates that one of the most well-known consumer brands of cocoa butter, which promotes it’s benefits

in improving the appearance of stretch marks, was used by 1.2 million people in the UK in 2014.4 “What you can safely say is that cocoa butter is a great moisturiser,” says Dr Mahto, “but it doesn’t do anything for stretch marks. Many of these ‘old wives tales’ are totally propagated and picked-up by the media. Some pregnancy magazines will say ‘cocoa butter is great for stretch marks!’ And that cycle never seems to break; nobody questions it and says, ‘hang on a minute – the science is all wrong!’”

These products continue to sell, despite scientific evidence that indicates that they do not produce significant benefit in the treatment of stretch marks. “There is a study which compared cocoa butter with a placebo, to see if it prevented stretch marks from forming,”5 says Dr Madan. He explains, “The products were used daily, between 12-18 weeks of pregnancy, until delivery, and they studied 175 women. The results showed no significant difference between the cocoa butter group and the placebo group.”

Marketing stretch marks and advising patients on their use Dr Kluk believes the message these products promote needs to be clearer to consumers, “There needs to be more honesty about what can realistically be achieved. Creams can potentially make the skin feel smoother and plumper in the short term, but if we don’t think that they’re actively going to reduce or eliminate stretch marks in the long run, and science seems to say that they won’t, then consumers should be made aware of this.”

Dr Madan believes it’s important to assess patients looking for treatment for stretch marks carefully, “Its not as simple as Aesthetics | January 2016

News Special Stretch Mark Creams

seeing a patient and then giving them a treatment option. You have to take their history, and this will include symptoms.

Some may be keen to get rid of the redness and others will have problems with the itchiness associated, and that is something that is understated. Recognising and understanding how to treat a patient’s symptoms is important.”

Dr Kluk adds, “I’d advise my patients considering a pregnancy to try and keep their skin in the best condition they can, through regular application of moisturiser in the absence of any proven preventative treatments. One cannot easily predict how much stretch each patient will experience during a pregnancy and there are a number of other unmodifiable risk factors for the development of stretch marks, so it is hard to give any other specific advice at this time.”

The future of topical treatments Following the recent study, Dr Wang et al are said to be continuing their research with the end goal of helping pregnant women prevent or effectively improve the appearance of stretch marks.1 Looking towards the future, however, could it ever be possible to create a topical treatment to treat stretch marks?

“I think there is a possibility of improving stretch marks by re-stimulating collagen, but anything that boosts natural collagen, in a permanent way, is not yet available,” says Dr Madan, adding, “I believe the key is prevention.” Dr Mahto concludes, “Do I think you can put something onto the skin that will penetrate once stretch marks are there? Probably not. The problem is, we don’t really know who is going to get stretch marks and who isn’t. So if your mum got them, then it’s likely that you will.

If you had stretch marks previously, you’ll probably get them again. But until we can figure out which patients are at risk, it’s going to be really tricky to find a better treatment.”

REFERENCES 1. Haley Otman, University of Michigan Health, Stretch mark science: What happens to your skin when pregnancy gives you a stretch mark? (2015) <https://www.uofmhealth.org/news/ archive/201511/stretch-mark-science-what-happens-your-skinwhen-pregnancy> 2. Wang et al, British Journal of Dermatology, Marked disruption and aberrant regulation of elastic fibres in early striae gravidarum, (2015) <http://onlinelibrary.wiley.com/doi/10.1111/ bjd.14027/abstract> 3. Palmers, Cocoa Butter Formula, (2015) <https://www.palmers. com/en/content/21-cocoa-butter-formula> 4. Statista, 2014, Brands of body creams and moisturisers for women ranked by number of users in the United Kingdom (UK) in 2014 (in 1,000) <http://www.statista.com/statistics/304364/ leading-body-cream-and-moisturiser-brands-in-the-uk/> 5. H. Osman et al, PubMed, Cocoa butter lotion for prevention of striae gravidarum: a double-blind, randomised and placebo-controlled trial, (2008) <http://www.ncbi.nlm.nih.gov/ pubmed/18715434>

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ACE 2016 Educational Programme

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Free CPD points at ACE 2016 The ACE agenda promises to suit all educational needs with its free business and clinical sessions The Aesthetics Conference and Exhibition (ACE) 2016 will host a variety of exciting, free, practical content spread across the twoday event on 15 and 16 April. Alongside the premium Conference programme with focused sessions on key anatomical areas, the free sessions will allow professionals to enhance their clinical and business skills within the CPD accredited Masterclass, Expert Clinic, Treatments on Trial and Business Track. ACE programme organiser and Aesthetics editor, Amanda Cameron, says the comprehensive free agenda is not to be missed. “Hundreds have already registered to attend the event,” she adds, explaining, “the free sessions are a great opportunity for practitioners to bring their entire clinic team to ACE because, not only are they all CPD accredited, for a total of 50 points available, but they allow the team to learn about different aspects of running a successful practice. We worked very hard to ensure the free clinical and business programme maintains its standards in delivering top content to delegates.” Cameron adds, “I think delegates will find the free sessions, which include guidance on both clinical and business skills extremely worthwhile.”

The Masterclass agenda, which will be supported by Galderma and HA-DERMA among other top medical aesthetic companies, will feature leading professionals demonstrating how to use the most popular products and treatments, while discussing the best ways to incorporate them in to a daily practice. Each 90 minute Masterclass will allow practitioners to build on their skills and understanding through informative and focused guidance.

At the Expert Clinics delegates can enhance their knowledge on the latest injectables, lasers, radiofrequency, and much more. Top practitioners including Dr Daron Seukeran, Dr Sarah Tonks, Mr Adrian Richards, Dr Jullian De Silva and Dr Victoria Dobbie will discuss and perform live demonstrations of the best treatment options and techniques in the industry. There will

also be sponsored sessions over the two days supported by AestheticSource, AesthetiCare, Rosmetics, Naturastudios, Fusion GT, Healthxchange Pharmacy, BTL Aesthetics, SkinCeuticals and Lynton Lasers. Engaging debates and insightful discussions are to be expected at the Treatments on Trial programme on Saturday 16 April. Delegates will have the opportunity to discuss the benefits of the latest products and learn how and when to use each treatment. BTL Aesthetics and Lumenis will be supporting Treatments on Trial, where professionals can listen to presentations and demonstrations on treatments and devices with similar indications and directly compare these to discover the best option for their practice.

With the huge success of the Business Track in 2015, non-clinical sessions will run throughout the Conference. There will be a dedicated area for the Business Track on the exhibition floor with focused sessions on marketing, social media, patient loyalty, clinic management, taxation, regulation and patient consent. ACE will welcome US based author and business consultant Wendy Lewis, PR expert Julia Kendrick and experienced VAT partner Veronica Donnelly, as well as Liz Bardolph, Gary Conroy, Mark Lainchbury, Professor Mark Whiteley and Dr Paul Charlson, among others, presenting on topics to support healthcare professionals in enhancing their practice and attracting more patients.

ACE 2016 features 2,500m2 of exhibition space, allowing delegates to freely explore the top medical aesthetic suppliers and manufacturers and discover the latest innovations. Visitors will be able to try new products, watch live demonstrations and talk to knowledgeable representatives about the best way to incorporate popular products and treatments in their clinics.

To access the Masterclass, Expert Clinics, Treatments on Trial, Business Track sessions and the Exhibition floor, practitioners can register online for free. Once registered, they can choose to purchase the premium Conference Pass for a full and comprehensive learning experience. The new website also allows delegates to create their own personalised programme with the ‘My Agenda’ function. The Aesthetics Conference and Exhibition will once again attract thousands of practitioners from across the industry, so be sure not to miss out on this key event in the professional calendar. To find out more and to book your place at ACE 2016 visit www.aestheticsconference.com HEADLINE SPONSOR

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Ultrasound-assisted liposuction Liposuction has been the go-to treatment for many patients seeking the removal of unwanted fat in stubborn areas for a number of years. However, although effective as a body contouring solution, often following weight loss, it is associated with a number of side effects and complications (Figure 1), and is an invasive procedure that often requires considerable downtime.5 Notwithstanding, it remains fairly common, with 7% more procedures carried out in 2014 than in the previous year, making it the fifth most popular surgical procedure in the UK.6

Treating the Stomach

Complications of liposuction Systemic

Odema

Significant blood loss

Ecchymosis

Allie Anderson speaks to practitioners about the numerous products and protocols that target fat and loose skin in the stomach region Whether it’s photos of the latest celebrity to have shrunk down instantly after giving birth, or research claiming that one must lose a specific amount of weight to appear more attractive to the opposite sex,1 it seems there is always a reason for people to be dissatisfied with their bodies. Much of the focus of these imperfections – perceived or actual – is on a person’s size and weight, so it’s no surprise that a new year tends to encourage people’s resolve to shed the pounds. Research has suggested that up to 20% of people will make New Year’s resolutions to lose weight,2 yet as many as three-quarters will fall by the wayside within just a few weeks.3 However, there are a number of aesthetic interventions available to help people in their quest to get rid of excess fat and create their ideal silhouette. Moreover, the treatments on offer are becoming progressively more effective at achieving their desired outcomes, with reports of fewer complications and adverse events. While the options for people who are very overweight remain somewhat limited to heavily invasive surgical procedures, aesthetic practitioners have a plethora of tools at their disposal in treating people who have smaller amounts of excess fat and a degree of loose skin, particularly around the stomach area.

Dr Martyn King, owner and director of Cosmedic Skin Clinic, offers a number of non-surgical treatments for reducing fat, combatting skin laxity and contouring the abdominal region. “It’s for all kinds of people; but for people who are really overweight the non-surgical treatments alone aren’t going to get rid of their fat,” he explains.

“So ideally people will have lost some weight, but they’ll have been left with little pockets of fat or little areas that are quite resistant.”

According to Dr King, the optimum patient profile is someone with a body mass index (BMI) of between 25 and 30, which is classed as ‘overweight’ according to NHS guidelines.4 However, he adds, this is not to say that there aren’t benefits for patients with a BMI less or more than this amount. In terms of targeting the stomach area, non-surgical treatments are typically aimed at either reducing fat, tightening the skin, or both. This article will discuss a range of different methods and detail how they work in practice.

22

Local

Seromas

Hypothermia

Haematomas

Visceral perforation

Wound infection

Fulminant infection

Under correction

Fat embolism syndrome

Overcorrection

DVT. thromboembolism

lrregularities

Pulmonary oedema

Neurological

Dissatisfied patient

Umbilical deviation Asymmetry Skin laxity Hyperpigmentation Scar related Skin necrosis Figure 1: complications of liposuction5

There have been several series of modifications to liposuction techniques, each looking to produce a more favourable treatment option with fewer adverse events. One such development is ultrasound-assisted liposuction (UAL), whereby high-frequency ultrasound energy is used to vibrate the tissue and break down the fat, which can then be removed by aspiration.

How it works “Ultrasound technology has been used in medicine for many years, and now precise, controlled power can be used to target fat,” explains cosmetic surgeon Dr Max Marcellino. The procedure is, in application, very similar to traditional liposuction: after the treatment area is injected with tumescent fluid, probes are inserted through the skin to the target area. These probes deliver high-frequency ultrasound, which shakes loose the fat cells while ensuring surrounding tissue is unaffected. These loosened fat cells are then free to mix with the fluid, which is removed from the body through a cannula.7 “I use this method as, in the majority of cases, I have better skin retraction, smoother, faster and more controllable results,” explains Dr Marcellino. “It is ideal for treating the ‘beer belly’ for men, and the flanks and tummy of women of any age with a degree of skin excess. All patients can be suitable. The limit is when there is too much skin excess or skin elasticity, and in these cases I would perform a mini-abdominoplasty associated with UAL, or

Aesthetics | January 2016

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full abdominoplasty.” Studies have reported the efficacy of latergeneration UAL machines and technology, suggesting that they deliver greater fragmentation of fat cells at a lower energy setting and using pulses of energy, rather than a continuous flow.8 It has been reported that patients generally experience less pain, with the shorter operative time resulting in preservation of vessels and nerves.9 However, the treatment could arguably be superseded by newer technologies,8 some of which are discussed herein.

Cryolipolysis Cryolipolysis is a process by which small areas of fat are literally frozen, while the skin is left intact and undamaged. Its therapeutic applications evolved from the scientific understanding of the physiological process involved in frostbite, and it has been widely used in medical aesthetics for around five years.10 How it works Application of cryolipolysis entails a moulded cup-type device being placed on the area of the stomach to be treated. The device is held onto the area for around 45 minutes to an hour, during which time it uses suction to draw the fat up into cooling panels. The fat is cooled to a temperature of around -5°C, at which point it is broken down and can be disposed of via the body’s lymphatic system.

According to Dr King, up to 40% of fat cells can be removed, after which you can achieve visible and impressive results. An added advantage is that because the procedure does not involve surgery and is minimally invasive, there is no downtime and no requirement for anaesthetic. “I have seen a few cases where people have got frost burns from cryolipolysis,” he comments. However, reliable technology in expert hands should preclude such damage to the skin. A 2015 review of clinical evidence concluded that cryolipolysis is a safe, effective non-surgical option for fat removal and body contouring, with few side effects (mild redness and bruising and some localised pain in the days following the procedure),10 thereby, according to Ingargiola et al, presents, “A compelling alternative to liposuction and other, more invasive methods.”11 According to Dr Beatriz Molina, founder and medical director of Medikas, fat freezing tends to be more popular with male patients than with female patients, because it’s arguably ‘manlier’ than other fat reduction treatments. “Also, the majority of males have a much thicker skin and thicker adipose tissue accumulating,” she explains, adding, “and generally more fat with less skin laxity, which women tend to have, so the cryolipolysis is more suitable for men anyway.”

As well as cryolipolysis for slightly overweight patients, Dr Molina says it’s also effective for smoothing and flattening skin without removing any fat in very slim women.

Fat cavitation As well as applications in liposuction, ultrasound technology can be used in other ways to reduce fat and sculpt the region being treated, namely ultrasound fat cavitation. This technique delivers ultrasound to transform fat cells into liquid, through a hand-held applicator that is passed over the skin.

How it works Unlike UAL, ultrasound cavitation is non-invasive, enabling the broken down fat to be removed naturally by the body, rather than being sucked out. Dr King explains, “This works by vibrating the fat cells together and generating heat, and that causes destruction of the membranes in the fat cells. The content of the fat cells

Special Feature Stomach Treatment

effectively spills out and can be removed during normal lymphatic drainage.”12 Each treatment takes 30 to 45 minutes, and a course typically involves around six sessions, although some results are visible straight away. “Post treatment, you can quite often see an inch loss around the abdomen,” he adds. “But after that it’s common to redistribute and put some fat back on. You tend to find when you measure the patient a week or two later, it’s half an inch less (in total).” As such, fat loss happens gradually over the treatment course.

Anecdotal evidence suggests fat cavitation is painless, with side effects limited to some mild redness in the area, and because it’s a non-invasive procedure, there is no need for anaesthesia and it results in no scarring or long-lasting skin marking.13 Published evidence supports the notion that ultrasound cavitation is ‘a promising and safe technology’ in tackling localised adipocyte fat.12 Radiofrequency A fourth option is to deliver radiofrequency (RF) energy non-invasively to the tissue to target fat and tighten the skin, giving a smoother and more toned look. The RF waves are turned into heat, which, when applied in a controlled way to the fatty layers under the skin, causes destruction of subcutaneous fat cells and collagen synthesis, leading the skin to contract and tighten. As with other methods, the surrounding tissue and skin are undamaged in the process. 14 How it works The application of RF energy causes charged molecules and ions in the cells to collide together, transforming them into heat. This, in turn, results in a micro-inflammatory process that stimulates the production of collagen. Manipulating skin cooling at the same time also results in the heating and reduction of fat, making RF devices an effective treatment for the non-invasive management of skin laxity and cellulite.14 Dr Tracy Mountford, founder and medical director of Cosmetic Skin Clinic, says the device she uses, “Focuses radiofrequency energy to kick start the body’s own natural collagen stimulation – a combination of heat energy to deep tissue with cooling effects to protect the skin’s surface.” The device’s hand piece is passed over the area several times, the session lasting between 45 and 90 minutes, depending on the size of the area being treated, the severity of the problem and the desired outcome. “It is suitable for people who have lost weight and are physically fit, between the breast and lower abdomen where skin becomes crepe-like and lax,” Dr Mountford explains, adding, “we can Before

After

Figure 1: Before and after treatment with the ALMA ACCENT 88mm spot size hand piece. Images courtesy of Dr Jorge F. Ottini, Argentina.

Before

After

Figure 2: Before and after treatment with the ALMA ACCENT 88m spot size hand piece. Images courtesy of Dr Nariaki Miyata Plastic Surgery & Skin Clinic Tokyo, Japan.

Aesthetics | January 2016

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Special Feature Stomach Treatment

Indeed, published evidence confirms that such technology produces improvements in the appearance of skin laxity, while also successfully reducing fat and sculpting the body.10,18 Dr Molina also offers a combined technique to treat cellulite and stretch marks and contour the stomach area. The method purportedly has a 100% response rate, with patients achieving an average 68% improvement in cellulite and 3.58cm reduction in circumference.19 Patient profile is a contributing factor in the treatment’s success, however. “For stretch marks, patients of any age are suitable, but newer stretch marks are much easier to treat than old ones,” she comments. “If someone had a child 20 years ago, it’s going to be harder to treat than someone who had a child three or four months earlier.”

Figure 3: Before and after six sessions of radiofrequency treatment. Images courtesy of Dr Beatriz Molina.

treat love handles, muffin tops, mummy tummies and post-pregnancy skin laxity, as well as pre-menopausal and menopausal women requiring re-contouring and firming.”

RF energy is not without its limitations, however. “It’s a superficial treatment so it’s not so good for reducing fat,” comments Dr King adding, “but it can be used to correct fat loss in other areas, like around the face and jowls, and for skin tightening.” It is reported that current protocols for RF treatment generally result in at least a mild improvement in skin tone, with a temporary reduction in the appearance of cellulite and possible inch loss, with minimal risks and downtime.16 RF and ultrasound combination A number of practitioners employ technology that combines radiofrequency energy with ultrasound to maximise effects of both reducing fat and tightening skin. Dr Nestor Demosthenous explains that the depth-controlled heating with RF waves is able to specifically target the epidermis, dermis and hypodermis, thereby addressing skin laxity (as described above), while ultrasound technology works on adipocyte membrane, causing its breakdown and the natural expulsion of fat droplets.

How it works “During treatment, RF is delivered via rapid ‘in-motion’ technology directly to the tissue causing the rapid rotation of water molecules – 40.68 million transmissions to the tissue per second,” Dr Demosthenous says, adding, “this rotation generates friction, which produces powerful and effective heat that causes volumetric contraction, stimulating the formation of new collagen to tighten and firm the skin on the face and body. The device also utilises exclusive ultrasound selective resonance that uses cold and hot ultrasonic waves that selectively resonate with and destroy fat cells, while leaving surrounding tissue unharmed. The selective sound waves disrupt fat cell membranes leading to the gradual breakdown and release of stored fat through the lymphatic system.”

Dr Anita Sturnham also uses a combined RF and ultrasound device, which, she says, is used to reduce fat and smooth skin in problem areas including the abdomen, saddle bags and love handles. “It heats the fat cells to a therapeutic temperature of 45-46°C, which stimulates fat cell death,” she comments. “The treatment is suitable for both male and female patients, with areas of stubborn fatty tissue that can’t be shifted by diet and exercise. The ideal patient needs to be motivated to lose weight and willing to engage in a diet and lifestyle care plan, to improve the efficacy of treatment.”

Conclusion As technology and treatment protocols become more advanced, the options available for treating the stomach become more expansive, demonstrating improved outcomes and, importantly, are more tolerable. “People are quite relaxed when they are having these treatments done; some have a massaging effect as well,” remarks Dr Molina. “Patients can be chatting to you, or checking emails during the procedure, so it’s a nice experience.” Managing the expectations of carefully selected patients is key, says Dr Mountford. She adds that, “trained, experienced specialists who are skilled in body treatments, following strict protocols for maximising the effect of the technology” is also important. “There is also an element of artistry, where best results can be achieved.”

REFERENCES 1. Ryan L, Revealed...how much weight YOU need to lose to look healthier - AND appear more attractive to the opposite sex. (Daily Mail, 2015) <http://www.dailymail.co.uk/health/article-3344631/ Revealed-weight-need-lose-look-healthier-attractive-opposite-sex.html> 2. thinkmoney, 14.5m Brits set to make a New Year’s Resolution to lose weight (2012) <https://www. thinkmoney.co.uk/pdf/new-years-resolutions.pdf> 3. Daily Express, How most New Year resolutions end today, (2012) <http://www.express.co.uk/news/ uk/294421/How-most-New-Year-resolutions-end-today> 4. NHS Choices, What is the body mass index (BMI)? (2014) <http://www.nhs.uk/chq/Pages/3215. aspx?CategoryID=51> 5. Dixit VV & Wagh MS, ‘Unfavourable outcomes of liposuction and their management’, Indian J Plast Surg, 46(2) (2013), pp.377-392 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3901919/> 6. British Association of Aesthetic Plastic Surgeons, Tweak not tuck. New statistics show extreme surgery’s gone bust – surgeons welcome more educated public, (2015) <http://baaps.org.uk/aboutus/press-releases/2039-auto-generate-from-title> 7. Vaser.com, VASERlipo Science, (2015) <http://www.vaser.com/the-vaser-difference/vaserlipo-science> 8. Sachin M Shridharani, Justin M Broyles & Alan Matarasso, ‘Liposuction devices: technology update’, Med Devices (Auckl), 7 (2014), pp.241-251 <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4114741/#b9mder-7-241> 9. de Souza Pinto EB, Abdala PC, Maciel CM, et al., ‘Liposuction and VASER’, Clin Plast Surg, 33(1) (2006) pp.107-15, vii. <http://www.ncbi.nlm.nih.gov/pubmed/16427979> 10. The American Society for Aesthetic Plastic Surgery, Does fat freezing yield results similar to liposuction? (2013) <http://www.surgery.org/consumers/plastic-surgery-news-briefs/fat-freezing-yieldresults-similar-liposuction-1051795> 11. Ingargiola MJ, Motakef S, Chung MT, et al., ‘Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms’, Plast Reconstr Surg, 135(6) (2015) pp.1581-90 <http:// www.ncbi.nlm.nih.gov/pubmed/26017594> 12. Daniele Bani, Alessandro Quattrini Li, Giancarlo Freschi, and Giulia Lo Russo, Histological and Ultrastructural Effects of Ultrasound-induced Cavitation on Human Skin Adipose Tissue. Plast Reconstr Surg Glob Open. 2013 Sep; 1(6): e41. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4174158/, 13. Pure Medspa, Fat cavitation (2014) <http://www.medsparaleigh.com/fat-cavitation/> 14. Gold MH, ‘Update on Tissue Tightening’, J Clin Aesthet Dermatol, 3(5) (2010), pp.36-41. <http://www. ncbi.nlm.nih.gov/pmc/articles/PMC2922712/> 15. Bani D, Li AQ, Freschi G & Lo Russo G, ‘Histological and Ultrastructural Effects of Ultrasound-induced Cavitation on Human Skin Adipose Tissue’, Plast Reconstr Surg Glob Open, 2013 1(6): e41. <http:// www.ncbi.nlm.nih.gov/pmc/articles PMC4174158/> 16. Consulting Room, Treatments – Radiofrequency For Cellulite & Fat Information (UK: Consulting Room, 2015) <http://www.consultingroom.com/treatments/radiofrequency-cellulite-fat> 17. McDaniel D, Weiss R, Weiss M, et al., ‘Two-treatment protocol for skin laxity using 90-Watt dynamic monopolar radiofrequency device with real-time impedance intelligence monitoring’, J Drugs Dermatol, 13(9) (2014) pp.1112-7 <http://www.ncbi.nlm.nih.gov/pubmed/25226013> 18. McDaniel D, Fritz K, Machovcova A, Bernardy J, ‘A focused monopolar radiofrequency causes apoptosis: a porcine model’, J Drugs Dermatol,13 (11) (2014) pp.1336-40 <http://www.ncbi.nlm.nih.gov/ pubmed/25607699> 19. Plastic Surgery Practice, Cellulite Meets Its Match with InMode Aesthetic Solutions (BodyFX, 2013) <http://www.plasticsurgerypractice.com/2013/11/cellulite-meets-its-match-with-inmode-aestheticsolutions-bodyfx/>

Aesthetics | January 2016

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one point

CPD Treating Scars

Treating Scarring in Asian Skin Dr Ardeshir Bayat and Sara Ud-Din discuss the different invasive and non-invasive treatments of scars in Asian skin Scar formation after the most minor skin injury is often inevitable.

Following cutaneous injury, there are important implications for patients with Asian skin types due to the genetic propensity for abnormal scar formation and hyperpigmentation in the pigmented skin.1 Therefore, prevention of abnormal skin scarring is considered paramount in these patients. In addition, these patients have a greater genetic susceptibility for hypertrophic and keloid scar formation in pigmented skin.2 Interestingly, there are some significant structural and physiological differences noted between Asian and Caucasian skin (Figure 1) with regard to structure and process of wound healing and scar formation.1,2 Asian skin has a thicker dermis than Caucasian skin of the same anatomical site, and a higher collagen density, which can lead to an increased fibroproliferative response during healing.1 Furthermore, scars can become abnormal and develop into hypertrophic scarring with a prolonged period of inflammation, leading to increased erythema during wound healing.1,2 Asian skin also exhibits increased melanin, sebum secretion, fibroblast proliferation, collagen formation and fibroplasia compared to Caucasian skin.2,3 It has been shown that scar maturation can take place over a longer period of time in this skin type.2 Both excessive inflammation and increasing mechanical tension have shown adverse effects in abnormal scar development;4,5 thus, it is important to tailor treatment options to

the individual bearing in mind their skin type.

Multiple treatment modalities are utilised in the management of skin scarring in Asian patients (Figure 2). The treatments currently used have limited and variable efficacy, and at times have an unknown mechanism and mode of action, with potentially undesirable side effects.4-7 Additionally, many of the treatments tend to be long-term, can make the lesions worse, or are unable to prevent recurrence of the lesion.8 The management of scars can be categorised by scar type (atrophic/acne scarring, hypertrophic scarring, keloid scarring) and the currently available treatment options (whether it is invasive or non-invasive) used in Asian skin.

Asian skin characteristics compared to Caucasian skin Structure of Dermis (In comparable anatomical sites)

During Scar Formation

Thicker dermis1

Longer period of erythema1,2

Higher collagen density1

Increased sebum secretion1-3

Increased melanin1-3

Increased fibroblast proliferation1-3 Increased collagen formation and fibroplasia1-3

Figure 1: Table demonstrating the differences between Asian and Caucasian skin types

Treatment Type

Indication

Dosage

Duration

Possible Side Effects

Corticosteroid injections

Keloid

1-40mg/mL

Max. dosage of three injections every 3-4 weeks

Telangiectasia, atrophy, hypopigmentation, pain

Laser therapy

Atrophic/Hypertrophic

1-24 treatments

Intervals of 4-8 weeks

Hypopigmentation, pain, pruritus, purpuric spots

Chemical peel

Atrophic

Glycolic acid: 10%-35%

1-2 min repeated monthly for up to six months

Stronger concentrations may lead to irreversible scar formation

Pressure therapy

Hypertrophic

20-25mmHg

Five months

Can cause discomfort, blistering, ulceration, scar breakdown

Silicone gel

Hypertrophic/Keloid

Gel/Sheet dressing

12-24hrs a day

Pruritus, rash, skin breakdown

Onion extract gel

Hypertrophic

Apply three times daily 12% gel

12 weeks

May lead to irritation

Electrical stimulation

Hypertrophic/Keloid

DW waveform given in 30 minute sessions

Minimum two treatments per week, can be given daily until symptoms subside

May lead to transitory inflammation in early stages of treatment

Photodynamic therapy

Keloid

3-5 treatments

Weekly sessions

Short term pain and inflammation, long term hyper/hypopigmentation

Radiotherapy

Keloid

One treatment per day at 400 cGy per treatment

Four days

Varying effect on pigmentation, may lead to acute perichondritis when cartilage present

Surgery

Hypertrophic/Keloid

May need adjuvant therapy

As required

Permanent scarring, risk of recurrence

Figure 2: Suggested treatment options for Asian patients based on published literature

Aesthetics | January 2016

27

CPD Treating Scars

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Treatment of atrophic/acne scarring Invasive: lasers Previous studies have shown beneficial effects of using various lasers in the treatment of acne scars in Asian patients. One such study used punch excision and erbium:YAG fractional laser which is used for skin resurfacing.9 Punch biopsies were created in the scar and laser treatment was initiated two weeks later. The researchers noted a quick recovery time, and that the treatment was safe and effective, but the study was limited by a very small sample size. Ablative carbon dioxide (CO2) fractional resurfacing for facial acne scars in Asian patients can be effective.10 All CO2 lasers have a wavelength of 10,600 nm, a fluence of 5 J/cm2 and a pulse duration of < 1 ms.10 Fractional photothermolysis has been used for treating acne scars in Asian females.11 Fractional photothermolysis uses small laser beams to create multiple microscopic areas of thermal necrosis within the skin. This therapy destroys the epidermis and dermis however, the 3-dimensional pattern of damage heals quickly.11 It has been noted that erbium:YAG laser has less residual thermal dermal damage and less erythema compared to fractional CO2 lasers.10 Fractional erbium:YAG laser has been suggested to be more suitable for treating superficial skin lesions, although fractional CO2 lasers may be superior for certain scars.9 Use of

fractional radiofrequency micro-needle system on affected scars has shown a 26-50% improvement of acne scars and found no significant adverse effects.12 Non-invasive: chemical peels Chemical peeling is a widely used procedure in treating acne scars, but there are few studies on Asians, who are more prone to develop hyperpigmentation.5 Chemical peels can have an antiinflammatory and lightening effect on acne.13,14 There is, however, a risk of hypopigmentation and hyperpigmentation.13 A pilot study evaluated the safety of using 100% trichloroacetic acid in 10 patients with darker skin types with acne ice pick scars.14 There was one case each of hypopigmentation and hyperpigmentation.

More than 70% improvement was seen in eight out of ten patients and a 50-70% improvement was observed in the remaining two patients. The authors reported that this treatment was safe and efficacious based on the 10 patients treated and they noted no significant side effects.14 The use of a glycolic peel as an adjuvant to micro-needling has also been investigated, which can improve acne scars and pigmentation.15 This therapy was shown to be safe in Indian skin types III–IV.

Treatment of hypertrophic scarring Invasive: surgery Surgery can be used selectively but effectively in the management of hypertrophic scarring in Asians.16 One study reported the use of surgery in the management of hypertrophic scarring in Asians.16 Forty Japanese patients who had undergone a caesarean delivery, abdominal or gynaecological surgery were evaluated in a randomised study using surgery for hypertrophic scar management. The patients were randomly assigned to the linear incision group (n = 20) or the small-wave incision group (n = 20). The results showed a postoperative recurrence rate of 40% and 15%, respectively, in the treated groups.16 Invasive: lasers Pulsed-dye lasers can be effective in treating hypertrophic scar and keloid redness, size, texture and pliability.17 Flashlamp-pumped pulseddye laser (585nm) is used for the treatment of hypertrophic scars and can improve scar pliability, texture, reduce erythema and symptoms.17,18 Multiple treatment sessions are advocated to obtain the optimal response, however, lower fluences are recommended for preventing side effects in Asian skin.18 Side effects can include mild swelling, erythema and purpura.18 Potassium titanyl phosphate (KTP) laser (532 nm),19 non-ablative 1550nm erbium-glass and ablative 106000nm CO2 fractional lasers have all been demonstrated to reduce scar formation.20 Laser therapy has been shown to be of some benefit for treating atrophic or acne scars in Asian skin. It is important to consider that patients with higher Fitzpatrick skin types tend to require lower energy densities. Additionally, for patients who have acne scars with less fibrotic tissue, lower fluences should be used.

Non-invasive: pressure therapy The effect of pressure is poorly understood, however, it has been suggested that it works by a reduction of oxygen tension in the scar 28

Fractional erbium:YAG laser has been suggested to be more suitable for treating superficial skin lesions, although fractional CO2 lasers may be superior for certain scars

through occlusion of small blood vessels, resulting in a decrease of myofibroblast proliferation and collagen synthesis.21,22 High pressure has been shown to be superior to low pressure for scar management by helping to prevent the thickening and hardening of the scars and reduce blood flow.23 This was demonstrated in a study by Candy et al22 who looked at different pressures in 17 Chinese patients with hypertrophic scars. The results showed that both low and high pressure produced reduction in scar thickness and redness, but the improvement in the high pressure group was statistically better than that of the counterpart (both p<0.05). Another study combined pressure therapy and silicone to prevent hypertrophic scarring; however, they noted no further benefit.24

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Non-invasive: silicone gel Topical silicone gel is used as a potential option for the management of hypertrophic scars and keloid scars due to the ease of application, cost and lack of side effects.25 Even though there is no active ingredient present in silicone-only preparations, silicone gel sheeting is thought to minimise mobility and reduce the tension placed on the scar.26,27 The exact mechanism of action of silicone gel is unclear, but it is thought to act as an impermeable/occlusive membrane to maintain skin hydration.28,29 It is also unclear how this works in the Asian population. Silicone elastomer sheeting has been advocated to be worn over the scar (as soon as a scar is formed) for 12 to 24 hours per day for at least two to three months.30 Silicone gel needs to be in place for at least 12 hours a day for three to six months in order to reduce scar thickness, pain, pruritus and pliability.31 However, there have been mixed reports regarding the effectiveness of silicone gel application and its efficacy has been

CPD Treating Scars

challenged in all skin and scar types.32,33 The use of silicone gel containing vitamin C has also been evaluated in facial surgery.34 This was compared to a control group of scar patients who did not have any adjunctive treatment. They noted a decrease in scar elevation, the hypo- or hyperpigmentation of the scars was more normalised in the treatment group, and there was a significant decrease in melanin and erythema. Therefore, silicone gel containing vitamin C may be an appropriate treatment to regulate pigmentation in scars found in Asian skin.34 Non-invasive: onion extract gel Onion extracts have been shown to accelerate wound healing in vitro.35 When applied three times daily for 12 weeks to Pfannenstiel caesarean section scars in Asian skin, it demonstrated a significant difference in scar height and symptoms but no significance in pliability, redness or overall cosmetic outcome.36

Treatment of keloid scarring Invasive: surgery Surgery is chosen for selected cases of keloid scars in the hands of an experienced specialist and performed carefully for keloids resistant to other non-invasive management modalities.37,38 There is a high recurrence rate if used alone but the overall recurrence rate of combined surgical excision and radiation therapy for keloid treatment is 21%.38 Keloid total excision and postoperative radiation therapy should be customised according to keloid scar site.39 Side effects may include a high risk of hyperpigmentation and subcutaneous atrophy as well as a potential risk of secondary radiation carcinogenesis.39 Invasive: corticosteroid injections Combination therapy, using surgical excision followed by intradermal steroid or other adjuvant therapy, can be effective in keloid management.40 Corticosteroids reduce excessive scarring by decreasing collagen synthesis,41 and can inhibit fibroblast proliferation and encourage scar regression.42 The effectiveness of single or multiple intralesional steroid injections is variable, with recurrence rates ranging from 9% to 50%.43 Furthermore, this therapy can be associated with significant adverse effects such as lipo-dermal atrophy, telangiectasia and pigment changes.44,45 Invasive: radiotherapy It has been suggested that irradiation may restore a balance between collagen synthesis and degradation in keloid scars.46 Radiation therapy administered to older patients or patients with severe multiple acne keloids has been shown to be beneficial in some studies.46-48 It is necessary to apply radiation carefully to prevent secondary radiation carcinogenesis.47 Other possible adverse side effects include redness, rash, tingling, numbness or burning sensations.47 Both hyperpigmentation and hypopigmentation can occur, and may sometimes be permanent.48 Recurrence rates are higher in sites with increased tension such as the sternum.48 Non-invasive: photodynamic therapy Photodynamic therapy (PDT) using methyl aminolevulinate and

aminolevulinic acid was demonstrated in keloid fibroblasts from various lesion sites.49,50 A positive effect of PDT was reported in a case study of a patient with a persistent keloid that had not responded to a number of routine therapies and this showed the treatment was effective.51 More recently, a case series also evaluated the effect of PDT on 20 patients with keloid disease and demonstrated that this reduced blood flow (p = 0.032) and increased pliability (p = 0.001).52 Only one patient with a keloid in a stress-prone anatomical location experienced recurrence of KD. All other patients had no recurrence at nine-month followup.52 Minimal side effects were noted including inflammation and pigmentation changes in three patients. All three patients had a Fitzpatrick score of 3 or above.

Non-invasive: electrical stimulation Electrical stimulation in the treatment of keloid scars has been investigated both in vitro and in vivo. The role of electrical stimulation on patients with symptomatic hypertrophic and keloid scars (including Asian patients) has been investigated in two case studies.53,54 Both case series used the same electrical stimulation device. One study included 18 patients (three Asian) with raised dermal scarring showed reduced pain scores (from day 0 to month 1, P = 0.007) and pruritus scores (from day 0 to week 1, P = 0.007; and day 0 to month 1, P = 0.002). No adverse side effects were noted. The other case series investigated the effect of electrical stimulation in 30 patients with more than 140 scars and demonstrated a statistically significant (p < 0.05) reduction of symptoms and Manchester scar scores. These case series have demonstrated positive results, however, further rigorous randomised controlled trials are necessary.

Non-invasive: cryotherapy Evidence on cryotherapy is generally anecdotal and based on a small series of patients with a lack of a control arm.55,56 In addition, it has been used successfully for the management of smaller keloid lesions although it is limited by considerable pain and prolonged healing times.57 However, there are no studies predominantly in Asian patients to date.

Aesthetics | January 2016

29

CPD Treating Scars

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Conclusion Given the complex nature of scar management in Asian patients and the scarcity of effective treatment options, preventive measures should take precedence with caution regarding use of treatment modalities with potential side effects. The ideal solution for scar management in Asian skin would involve early intervention in controlling inflammation and tension as these measures are likely to improve symptoms and may prevent risk of abnormal scar development.4-6 In addition, choice of therapy should start non-invasively using topicals with effective active ingredients with minimal side effects before moving onto more invasive and complex modalities of management.

There is a lack of well-designed randomised controlled trials evaluating treatment modalities for scar management, particularly in Asian patients and available studies tend to be limited by small patient numbers. Furthermore, there are a substantial number of studies using different treatments for scar management; however, many do not report the details of the demographic data, thus it is difficult to know if Asian patients were included. Therefore, these studies were not included in this paper.

Silicone gel therapy is recommended as a treatment option with minimal side effects for the initial management of both hypertrophic scars and keloids by Kim et al who provided a paper on guidelines for scar management in Asian skin.58 However, the research has been shown to be inconclusive and in the absence of an active ingredient, in cases failing to respond to silicone gel topical/sheeting, alternative treatment options should be considered. Emerging solutions for scars as a topical with active ingredients can also be used alone or in combination with silicone sheeting. Corticosteroid therapy effectively treats symptoms in Asian patients with keloids. Surgical excision with adjuvant therapies has been shown to be an effective and safe treatment for keloids. Multiple treatments with lower fluences of pulsed-dye lasers are recommended for prevention of

hyperpigmentation in Asian patients with hypertrophic scars.

There is increasing evidence that laser therapy has a role in the management of problem hypertrophic and keloid scars. However, the variety of lasers and the lack of level 1 evidence suggest that their role is still unclear. Despite a number of published studies, more randomised studies are needed to better clarify their role in the treatment of Asian skin. The available evidence suggests that the 585nm pulsed-dye laser is a commonly used option for laser treatment of hypertrophic scars and keloids. However, atrophic scars may be best treated with ablative CO2 and erbium:YAG lasers. Multiple sessions of lower fluences of pulsed-dye lasers have been used for prevention of hyperpigmentation in Asian patients with hypertrophic scars. Silicone-based products can be used as an initial treatment option with/without topical with active ingredients, whilst surgery, radiation therapy and corticosteroid injections have been shown to be effective in treating keloid scars in Asian patients. However, there is a lack of conclusive data. Further larger sampled high quality research is required in order to gain a greater understanding of scar therapies, specifically in Asian skin types.

REFERENCES 1. Jonathan M. Sykes, ‘Management of the aging face in the Asian patient’, Facial Plastic Surgery Clinics of North America, 15 (2007), pp.353-360.

2. John A. McCurdy, ‘Considerations in Asian cosmetic surgery’, Facial Plastic Surgery Clinics of North America, 15 (2007), pp.387-397.

3. Yukio Shirakabe, Yoshiro Suzuki and Samuel M. Lam, ‘A new paradigm for the aging Asian face’, Aesthetic Plastic Surgery, 27 (2003), pp.397-402.

4. Brian Berman and Harlan C. Bieley, ‘Keloids’, Journal of the American Academy of Dermatology, 33 (1995), pp.117-123.

5. Alison E. Siemp and Richard E. Kirschner, ‘Keloids and scars: a review of keloids and scars, their pathogenesis, risk factors, and management’, Current Opinions in Pediatrics, 18 (2006), pp.396-402.

6. Shahram Aarabi, Kirit A. Bhatt, Yubin Shi, Josemaria Paterno, Edward I. Chang, Shang A. Loh, Jeffrey W. Holmes, Michael T. Longaker, Herman Yee and Geoffrey C. Gurtner, ‘Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis’, The Journal of the Federation of American Societies for Experimental Biology, 21 (2007), pp.3250-3261.

7. Lisa O’Brien, Abhay Pandit, ‘Silicone gel sheeting for preventing and treating hypertrophic and keloid scars’, Cochrane Database Systematic Review (2006) (CD003826).

8. Nick L. Occleston, Anthony D. Metcalfe, Adam Boanas, Nicholas J. Burgoyne, Ketty Nield, Sharon O’Kane and Mark W. J. Ferguson, ‘Therapeutic improvement of scarring: mechanism of scarless and scar-forming healing and approaches to discovery of new treatments’, Dermatology Research and Practice, (2010) (405262).

9. Hei Sung Kim, Eu Jin Cho, Young Min Park, Hyung Ok Kim and Jun Young Lee, ‘Punch excision combined with erbium:YAG fractional laser: Its application on different types of scars in Asian patients (a pilot study)’, Journal of Cosmetic and Laser Therapy, 13 (2011), pp.196-199.

10. Hyun Woo Kim, Sung Eun Chang, Jeong Eun Kim, Joo Yeon Ko and Young Suck Ro, ‘The safe delivery of fractional ablative carbon dioxide laser treatment for acne scars in Asian patients receiving oral isotretinoin’, Dermatologic Surgery, 40 (2014), pp.1361-1366.

11. Kyung Eun Jung, Kum Hee Jung, Young Min Park, Jun Young Lee, Tae Yoon Kim, Hyung Ok Kim and Hei Sung Kim, ‘A split-face comparison of ablative fractional lasers (CO(2) and Er:YAG) in Asian patients; postprocedure erythema, pain and patients satisfaction’, Journal of Cosmetic and Laser Therapy, 15 (2013), pp.70-73.

12. Veraphol Vejjabhinanta, Rungsima Wanitphakdeedecha, P. Limtanyakul and Woraphong Manuskiatti, ‘The efficacy in treatment of facial atrophic acne scars in Asians with a fractional radiofrequency microneedle system’, Journal of the European Academy of Dermatology and Venereology 28 (2014), pp. 1219-1225.

13. Yuko Taenaka, Nobukazu Hayashi, Mikiko Takeda, Sayaka Ashikaga and Makoto Kawashima, ‘Glycolic acid chemical peeling improves inflammatory acne eruptions through its inhibitory and bactericidal effect of Proprionibacterium acnes’, Journal of Dermatology, 39 (2012), pp.350-354.

14. Deepali Bhardwaj and Niti Khunger, ‘An assessment of the efficacy and safety of CROSS Technique

with 100% TCA in the management of ice pick acne scars’, Journal of Cutaneous and Aesthetic Surgery, 3 (2010), p.93-96.

15. Jaishree Sharad, ‘Combination of micro needling and glycolic acid peels for the treatment of acne scars in dark skin’, Journal of Cosmetic Dermatology, 10 (2011), pp.317-323.

16. Chenyu Huang, Shimpei Ono, Hiko Hyakusoku and Rei Ogawa, ‘Small-wave incision method for linear hypertrophic scar reconstruction: A parallel-group randomized controlled study’, Aesthetic Plastic Surgery, 36 (2012), pp.387-395).

17. Navid Bouzari, Stephen C. Davis and Keyvan Nouri, ‘Laser treatment of keloids and hypertrophic scars’, International Journal of Dermatology, 46 (2007), p.80-88.

18. Taro Kono, Ali Riza Ercocen, Hiroaki Nakazawa, Takashi Honda, Nobukazu Hayashi and Motohiro Nozaki, ‘The flashlamp-pumped pulsed dye laser (585 nm) treatment of hypertrophic scars in Asians’, Annals of Plastic Surgery, 51 (2003), pp.366-371.

19. Ji Sup Yun, Young Jun Choi, Won Serk Kim and Ga Young Lee, ‘Prevention of thyroidectomy scars in Asian adults using a 532-nm potassium titanyl phosphate laser’, Dermatologic Surgery, 37 (2011), p.1747-1753.

20. Cho Suhyun, Jung Jin Young, Shin Jung U and Lee Ju Hee, ‘Non-ablative 1550nm erbium-glass and ablative 10,600nm carbon dioxide fractional lasers for various types of scars in Asian people: Evaluation of 100 patients’, Photomedicine and Laser Surgery, 43 (2014), pp.42-46.

21. Lisa Macintyre and Margot Baird, ‘Pressure garments for use in the treatment of hypertrophic scars a review of the problems associated with their use’, Burns, 32 (2006), pp.10-15.

22. Lai Hoi Yan Candy, Li-Tsang Wai Ping Cecilia and Zheng Yong Ping, ‘Effect of different pressure magnitudes on hypertrophic scar in a Chinese population’, Burns, 36 (2010), pp.1234-1241.

23. Phyllis Chang, KN Laubenthal, RW Lewis 2nd, MD Rosenquist, P Lindley-Smith and Gerald P. Kealey, ‘Prospective, randomized study of the efficacy of pressure garment therapy in patients with burns’, Journal of Burn Care and Rehabilitation, 16 (1995), pp.473-475.

24. Lars Steinstraesser, Ewa Flak, Bernd Witte, Andrej Ring, Daniel Tilkorn, Jorg Hauser, Stefan Langer, Hans-Ulrich Steinau and Sammy Al-Benna, ‘Pressure garment therapy alone and in combination with silicone for the prevention of hypertrophic scarring: Randomized controlled trial with intraindividual comparison’, Plastic and Reconstructive Surgery, 128 (2011), pp.306e-313e.

25. Demetris Stavrou, Oren Weissman, Eyal Winkler, Lior Yankelson, Eran Millet, Oren Paul Mushin, Alon Liran and Joseph Haik, ‘Silicone-based scar therapy: A review of the literature’, Aesthetic Plastic Surgery, 34 (2010), pp.646-651.

26. Rei Ogawa, ‘The most current algorithms for the treatment and prevention of hypertrophic scars and keloids’, Plastic and Reconstructive Surgery, 125 (2010), pp. 557-568.

27. Michael H. Gold, Teresa D. Foster and Melissa A. Adair, ‘Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following surgical procedure in an office setting’, Dermatologic Surgery, 27 (2001), pp. 641-644.

28. Yukimasa Sawada and Ken Sone, ‘Hydration and occlusion treatment for hyper- trophic scars and keloids’, British Journal of Plastic Surgery, 45 (1992), pp.599-603.

30

Dr Ardeshir Bayat has worked as clinician scientist for the past 20 years. He is currently based at the University of Manchester, where his research is focussed on human skin health through identifying better outcomes for patients suffering from abnormal cutaneous healing and fibrosis.

Sara Ud-Din obtained her nursing honours degree in 2007 from the University of Manchester and completed an MSc in Advanced Nursing Studies in 2011. Following this, she pursued a career in research and has been part of the Plastic and Reconstructive Surgery Research (Bayat Research Group) since 2010.

Disclosure: Dr Ardeshir Bayat is the co-founder of Solution for Scars

Aesthetics | January 2016

29. Chih-Cheng Chang, Yea-Fhey Kuo Hsien-Ching Chiu, Jia-Luen Lee and Tak-Wah Wong, ‘Hydration, not silicone, modulates the effects of keratinocytes on fibroblasts’, Journal of Surgical Research, 59 (1995), pp.705-711.

30. Brian Berman, Oliver A. Perez, Sailesh Konda, Brice E. Kohut, Martha H. Viera, Suzetter Delgado, Deborah Zell and Qing Li, ‘A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management’, Dermatologic Surgery, 33 (2007), pp.1291-1302; discussion 1302.

31. Sharad Mutalik, ‘Treatment of keloids and hypertrophic scars.’ Indian Journal of Dermatology, Venereology and Leprology, 71 (2005), pp.3-8.

32. Cecilia WP Li-Tsang, Joy CM Lau, Jenny Choi, Chetwyn CC Chan and Li Jianan, ‘A prospective randomized clinical trial to investigate the effect of silicone gel sheeting (Cica-Care) on posttraumatic hypertrophic scar among the Chinese population,’ Burns, 32 (2006), pp.678-683.

33. Kin Yoong Chan, Cheen Lan Lau, Syed Mohd Adeeb, Sathappan Somasundaram and Mohd Nasir-Zahari, ‘A randomized, placebo-controlled, double-blind, prospective clinical trial of silicone gel in prevention of hyper-trophic scar development in median sternotomy wound’, Plastic and Reconstructive Surgery, 116 (2005), pp. 1013-1020; discussion 1021.

34. In Sik Yun, Han-Su Yoo, Yong Oock Kim, Dong Kyun Rah, ‘Improved scar appearance with combined use of silicone gel and vitamin C for Asian patients: a comparative case series’, Aesthetic Plastic Surgery, 37 (2013), pp. 1176-1181.

35. Wai Sun Ho, Shun Yuen Ying, Pik Chu Chan and Henry H. Chan, ‘Use of onion extract, heparin, allantoin gel in prevention of scarring in Chinese patients having laser removal of tattoos: A prospective randomized controlled trial’, Dermatologic Surgery, 32 (2006), pp. 891-896.

36. Kumutnart Chanprapaph, Somsak Tanrattanakorn, Penpun Wattanakrai, Pranee Wongkitisophon and Vasanop Vachiramon, ‘Effectiveness of onion extract gel on surgical scars in Asians’, Dermatological Research Practice, (2012) (212945).

37. Thomas A. Mustoe, Rodney D. Cooter, Michael H. Gold, Richard Hobbs, Albert-Adrien Ramelet, Peter G. Shakespeare, Maurizio Stella, Luc Teot, Fiona Wood and Ulrich Ziegler, ‘International clinical recommendations on scar management. International Advisory Panel on Scar Management’, Plastic and Reconstructive Surgery, 110 (2002), pp. 560–571.

38. Sukwha Kim, Tae Hyun Choi, Wei Liu, Rei Ogawa, Jeong Seok Suh and Thomas A. Mustoe, ‘Update on scar management: Guidelines for treating Asian patients’, Plastic and Reconstructive Surgery, 132 (2013), pp.1580-1589.

39. Rei Ogawa, Tsuguhiro Miyashita, Hiko Hyakusoku, Satoshi Akaishi, Shigehiko Kuribayashi and Atsushi Tateno, ‘Postoperative radiation protocol for keloids and hypertrophic scars: Statistical analysis of 370 sites followed for over 18 months’, Annals of Plastic Surgery, 59 (2007), pp.688-691.

40. Ali Al-Attar, Sarah Mess, John Michael Thomassen, C Lisa Kauffman and Steven Davison, ‘Keloid pathogenesis and treatment’, Plastic and Reconstructive Surgery, 117 (2006), pp.286-300.

41. BJ McCoy, Robert F. Diegelmann and Irwin K. Cohen, ‘In vitro inhibition of cell growth, collagen synthesis, and prolyl hydroxylase activity by triamcinolone acetonide’, Proceedings of the Society for Experimental Biology and Medicine, 163 (1980), pp.216-222.

42. Wen-Sheng Wu, Feng-Sheng Wang, Kuender D. Yang, Chao-Cheng Huang and Yur-Ren Kuo, ‘Dexamethasone induction of keloid regression through effective suppression of VEGF expression and keloid fibroblast proliferation’, Journal of Investigative Dermatology, 126 (2006), pp.1264-1271.

43. Gerd G. Gauglitz, Hans C. Korting, Tatiana Pavicic, Thomas Ruzicka and Marc G. Jeschke, ‘Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies’, Molecular Medicine, 17(2011), pp. 113–125.

44. Ali Sadeghinia and Saeed Sadeghinia, ‘Comparison of the efficacy of intralesional triamcinolone acetonide and 5-fluorouracil tattooing for the treatment of keloids’, Dermatologic Surgery, 38 (2012), pp.104-109.

45. Gan Muneuchi, Shigehiko Suzuki, Masayuki Onodera, Osamu Ito, Yuiro Hata and Hiroharu H. Igawa, ‘Long-term outcome of intralesional injection of triamcinolone acetonide for the treatment of keloid scars in Asian patients’, Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery, 40 (2006), pp.111-116.

46. P. Durani and Ardeshir Bayat, ‘Levels of evidence for the treatment of keloid disease’, Journal of Plastic, Reconstructive and Aesthetic Surgery, 61 (2008), pp.4-17.

47. Sharma S, Bhanot A, Kaur A and Dewan SP, ‘Role of liquid nitrogen alone compared with combination of liquid nitrogen and intralesional triamcinolone acetonide in treatment of small keloids’, Journal of Cosmetic Dermatology, 6 (2007), pp.258-261.

48. Kamal Malaker, Mustafa Zaidi and Mohamed Rida Franka, ‘Treatment of earlobe keloids using the cobalt 60 teletherapy unit’, Annals of Plastic Surgery, 52 (2004), pp.602-604.

49. Christensen E, Warloe T, Kroon S et al, ‘Guidelines for practical use of MAL-PDT in non-melanoma skin cancer’, Journal of the European Academy of Dermatology and Venereology, 24 (2010), pp.505-512.

50. Jenifer Mendoza, Anil Sebastian, Ernest Allan, Donald Allan, Parthasarathi Mandal, Teresa Alonso-Rasgado and Ardeshir Bayat, ‘Differential cytotoxic response in keloid fibroblasts exposed to photodynamic therapy is dependent on photosensitiser precursor, fluence and location of fibroblasts within the lesion’, Archives of Dermatological Research, 304 (2012), pp.549-562.

51. Zhuxiang Nie, Ardeshir Bayat, Farhad Behzad and Lesley E. Rhodes, ‘Positive response of a recurrent keloid scar to topical methyl aminolevulinate-photodynamic therapy’. Photodermatology, Photoimmunology and Photomedicine, 26 (2010), pp.330–332.

52. Sara Ud-Din, Grace Thomas, Julie Morris and Ardeshir Bayat, ‘Photodynamic therapy: an innovative approach to the treatment of keloid disease evaluated using subjective and objective non-invasive tools’, Archives of Dermatological Research, 305 (2013), pp.205-214.

53. Donna Perry, James Colthurst, Pam Giddings, Duncan A. McGrouther, Julie Morris and Ardeshir Bayat, ‘Treatment of symptomatic abnormal skin scars with electrical stimulation’, Journal of Wound Care, 19 (2010), pp. 447-453.

54. Sara Ud-Din, Pam Giddings, James Colthurst, Sigrid Whiteside, Julie Morris and Ardeshir Bayat, ‘Significant reduction of symptoms of scarring with electrical stimulation: evaluated with subjective and objective assessment tools’, Wounds, 25 (2013), pp.212-224.

55. Rusciani L, Paradisi A, Alfano C, Chiummariello S, Rusciani A, ‘Cryotherapy in the treatment of keloids’, Journal of Drugs and Dermatology, 5 (2006), pp. 591–595.

56. Yaron Har-Shai, Edmond Sabo, Ewa Rohde, Michael Hyams, Chalid Assaf and Christos C. Zouboulis, ‘Intralesional cryosurgery enhances the involution of recalcitrant auricular keloids: A new clinical approach supported by experimental studies’, Wound Repair and Regeneration, 14 (2006), pp.18-27.

57. Paul A. Kelly, ‘Medical and surgical therapies for keloids’, Dermatological Therapy, 17 (2004), pp.212-218. See comment in PubMed Commons below 58. Sukwha Kim, Tae Hyun Choi, Wei Liu, Rei Ogawa, Jeong Seok Suh and Thomas A. Mustoe, ‘Update on scar management: guidelines for treating Asian patients’, Plast Reconstr Surg, 132 (2013) pp.1580-1589.

Carboxytherapy medical device for the treatment of skin pathologies (psoriasis, eczema, sores, arthritis, arthrosis and periarthritis), stretch marks, anti-aging and localized weight loss procedures.

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Using Cryolipolysis to Treat Fat Dr Galyna Selezneva details how she uses cryolipolysis to break down fat cells and reduce body fat in patients

Non-invasive procedures to reduce fat through targeted apoptosis or necrosis of adipocytes have grown in popularity, challenging liposuction as the dominant body contouring procedure.1 These procedures include the use of focused ultrasound, radiofrequency, laser techniques, and cryolipolysis (fat freezing). They are quick, affordable, mostly involve no anaesthesia, and avoid the risk and side effects of surgery. Body contouring procedures vary in terms of response rates, side effects, discomfort or pain they may cause, as well as the number of treatments required. However, I have seen impressive results and high levels of patient satisfaction when using cryolipolysis on my patients. Cryolipolysis exploits the premise that fat cells freeze before skin.2 Targeted cooling triggers apoptosis, followed by an inflammatory response in which lipid cells are destroyed by macrophages, while leaving overlying skin intact. Within two to three months following treatment, the volume of fat in the treated area should have decreased.3 In this article, I will detail how cryolipolysis is applied, the results that patients can expect to see and its safety.

Treatment process Before any treatment starts, I engage in a full consultation with the patient, examining their medical history, eligibility for treatment and result expectations. As with any treatment, there will be those deemed unsuitable for cryolipolysis, such as patients with visceral fat, rather than subcutaneous fat or abdominal hernias. In such cases, we may be able to recommend an alternative treatment, such as radiofrequency, that uses heat to target fat cells, or a consultation with our in-house dietitian and personal trainer to achieve weight-loss in a more traditional way. I agree a treatment plan with the patient, which will be structured according to the personâ&#x20AC;&#x2122;s shape, areas of concern and desired outcome. We tend to agree on a one-off treatment of one area, but with some patients, we may agree on two to three treatments, aimed first at volume loss, and thereafter at body contouring. The most commonly treated areas are the abdomen, arms, flanks and thighs. Treatment begins by measuring their dimensions, such as waist, thigh or arm circumference, depending on the area of concern. This is followed by baseline 360-degree photographs or, as Before

our clinic has recently introduced, 3D images. Photographs are taken prior to the first treatment and give the patient a much better idea of their initial body shape, as well as helping us to keep a record of how treatment is developing. 3D imaging is of particular benefit to the patient because, as the results of cryolipolysis are gradual, they can sometimes forget how they looked before. So far, feedback about this protocol has been very positive. I mark the targeted area and apply the cryolipolysis applicators â&#x20AC;&#x201C; moulded cups with cooling panels that adhere through suction, drawing tissue in and chilling it. When treatment begins, patients feel some pulling and, inevitably, feel cold.

The optimum temperature is 4 degrees Celsius; to freeze fat cells and

Images are taken prior to the first treatment and give the patient a much better idea of their initial body shape, as well as helping us to keep a record of how treatment is developing leave non-fat cells unharmed.11 Although no anaesthesia is needed, suction can initially be uncomfortable as the targeted area goes numb.

However, patients soon settle down and can fall asleep, read, answer emails or undergo complementary treatments. Each area requires an hour under the machine; this length of time appears to be standard.

After treatment, I vigorously massage the affected area for at least two minutes. This improves the outcome by helping to break down the crystallised layer of fat beneath the skin. We prefer not to treat more than four to six areas of the body during one session, so the patient does not become uncomfortable.

After

Side effects The patient will feel sore afterwards, and there is some swelling and discomfort. Oil, moisturiser or body lotion can be used to soothe a sore area but this is not always necessary. Typically there is minimal downtime and I always give my patients my private number so they can contact me any time after treatment. Although there is no reason to stop patients resuming normal activities immediately, a prudent practitioner will recommend that they listen to their bodies first.

Figure 1: Female menopausal woman in her early 50s treated with a large cryolipolysis applicator on the lower and upper abdomen, and with a smaller applicator on the flanks.

34

Results As the inflammatory response on which cryolipolysis depends is slow, the results are gradual, starting to show at four weeks, with best results

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I see a clear and visible reduction of fat in patients that I treat, but they all react individually and in some cases, subsequent treatments may be necessary developing by four to six months.6 I see a clear and visible reduction of fat in patients that I treat, but they all react individually and in some cases, subsequent treatments may be necessary. In my clinical experience, the majority of patients also enjoy psychological benefits from treatment once they see unwanted fat gone. I have noted that most are subsequently motivated to eat healthier, exercise more, lose weight and even change their wardrobe.

Research In a clinical study on CoolSculpting, Pietrzak et al reported that only six of 528 patients who were treated with the cryolipolysis device were dissatisfied with the outcome, and four of those were then satisfied when treated a second time. It was observed that well managed treatments using the cryolipolysis device could yield results comparable to those of liposuction.5 Research

by Coleman et al on 10 human subjects treated with a prototype device, indicated that cryolipolysis resulted in a normalised fat layer reduction of 20.4% at two months and 25.5% six months after treatment.2 Literature reviews from this period also underlined the method’s efficacy.

Recent studies concentrating on the effectiveness of this technique when applied to specific body areas, reported mean normalised fat reduction of between 2.6mm and 2.8mm to the thighs. Munavalli and Panchaprateep also recently demonstrated the feasibility of cryolipolysis for treating pseudogynecomastia.8 Moreover, the benefits of cryolipolysis can be long-term, with results visible up to five years later.9

Safety and side effects Recent research has indicated that cryolipolysis does not produce any significant adverse side effects such as scarring, ulceration, or disfigurement, and where effects have been noted, they have been minor, temporary and well tolerated.3,6 Research on porcine models demonstrated that prolonged, controlled local skin cooling reduced subcutaneous fat without damaging skin.10 Other studies discount the potential for changes in lipid levels or liver function after cryolipolysis.11

Treatment Focus Cryolipolysis

Known side effects of this procedure are: • Redness and bruising: erythema of the skin, bruising and temporary numbness at the targeted site are commonly observed following treatment, but resolve quickly.7 • Late-onset pain: late-onset pain may occur several weeks after treatment, but is rare and usually resolves without intervention.3,6 Keaney, Gudas and Alster suggest that late-onset pain is not uncommon, and recommend suitable counselling and intervention.

• Sensory alteration: short-term changes in the function of peripheral sensory nerves may occur, but these return to normal within several weeks with no long-term damage to nerve fibres or skin.2 • Paradoxical adipocyte hyperplasia (PAH): in rare cases additional fat can grow at a treatment site, the incidence of which has been indicated as 1 in 20,000 patients.13 Conclusion I have noticed an increase in popularity for cryolipolysis treatment and believe this is a result of its efficacy. In my opinion, cryolipolysis can offer practitioners significant business growth opportunities, as well as providing patients with noticeable results. I have attended reputable workshops in Miami, US, with the leaders in the field to learn about the procedure, so that I can endeavour to give my patients a much better, natural-looking shape using cryolipolysis. I would recommend fellow practitioners do the same. One of the best pieces of advice I can offer colleagues wishing to adopt or perfect this treatment is to accrue as much hands-on experience as possible and, above all, to choose your patients well. With the right patient, this treatment can achieve excellent results.

Dr Galyna Selezneva is an aesthetic medical doctor at the Dr Rita Rakus clinic in London. She specialises in non-invasive procedures for the face and body, using the latest technology including the fat-freezing CoolSculpting treatment.

REFERENCES 1. Krueger, Nils, Mai, Sophia V., Luebberding, Stefanie, and Sadick, Neil S., ‘Cryolipolysis for non-invasive body contouring: clinical efficacy and patient satisfaction’, Clinical, Cosmetic and Investigational Dermatology, 7 (2014), pp. 201–05.

2. Coleman S.R., Sachdeva K., Egbert B.M., Preciado J., Allison J., ‘Clinical efficacy of non-invasive cryolipolysis and its effects on peripheral nerves’, Aesthetic Plastic Surgery, 33 (4) (2009), pp.

482–88.

3. Dierickx C.C., Mazer J.M., Sand M., Koenig S., Arigon V., ‘Safety, tolerance, and patient satisfaction with non-invasive cryolipolysis’, Dermatologic Surgery, 39 (8) (2013), pp. 1209-16 4. Zelickson B., Egbert B.M., Preciado J., Allison J., Springer K., Rhoades R.W., and Manstein D., ‘Cryolipolysis for non-invasive fat cell destruction: initial results from a pig model’, Dermatologic Surgery, (10) (2009), pp. 1462–70.

5. Stevens, W. Grant, Pietrzak, Laura K., and Spring, Michelle A., ‘Broad overview of a clinical and commercial experience with CoolSculpting’, Aesthetic Surgery Journal, 33 (6) (2013), pp. 835–46.

6. Avram M.M., and Harry R.S., ‘Cryolipolysis for subcutaneous fat layer reduction’, Lasers in Surgery and Medicine, 41 (10) (2009), pp. 703–08; Nelson A.A., Wasserman D., Avram M.M., ‘Cryolipolysis for reduction of excess adipose tissue’, Seminars in Cutaneous Medicine and Surgery, 28 (4) (2009), pp. 244–49.

7. Stevens, W. Grant; and Bachelor, Eric P., ‘Cryolipolysis conformable-surface applicator for nonsurgical fat reduction in lateral thighs’, Aesthetic Surgery Journal, 35 (1) (2015), pp. 66–71; Zelickson, Brian D., Burns, A. Jay, and Kilmer, Suzanne L., ‘Cryolipolysis for safe and effective inner thigh fat reduction’, Lasers in Surgery and Medicine 47 (2015), pp. 120–27.

8. Munavalli, Girish S., and Panchaprateep, Ratchathorn, ‘Cryolipolysis for targeted fat reduction and improved appearance of the enlarged male breast’, Dermatologic Surgery, 41 (9) (2015), pp. 1043–51.

9. Bernstein E.F., ‘Longitudinal evaluation of cryolipolysis efficacy: two case studies’, Journal of Cosmetic Dermatology, 12 (2) (2013), pp. 149–52.

10. Manstein D., Laubach H., Watanabe K., Farinelli W., Zurakowski D., and Anderson R.R., ‘Selective cryolysis: a novel method of non-invasive fat removal’, Lasers in Surgery and Medicine, 40 (9) (2008), pp. 595–604; Zelickson et al (2009).

11. Derrick, Chase D., Shridharani, Sachin M., and Broyles, Justin M., ‘The safety and efficacy of cryolipolysis: a systematic review of available literature’, review article, Aesthetic Surgery Journal, 35 (7) (2015), pp. 830–36; Ingargiola, Michael J., Motakef, Saba, Chung, Michael T., Vasconez, Henry C., and Sasaki, Gordon H., ‘Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms’, Plastic and Reconstructive Surgery, 135 (6) (2015), pp. 1581–90; Manstein et al (2008); Zelickson et al (2009); Klein K.B., Zelickson B., Riopelle J.G., Okamoto E., Bachelor E.P., Harry R.S., Preciado J.A., ‘Non-invasive cryolipolysis for subcutaneous fat reduction does not affect serum lipid levels or liver function tests’, Lasers in Surgery and Medicine, 41(10) (2009), pp.785–90.

12. Keaney, Terrence C., Gudas, Amber Tario, and Alster, Tina S., ‘Delayed onset pain associated with cryolipolysis treatment: a retrospective study with treatment recommendations, Dermatologic Surgery, 41 (11) (2015), pp. 1296–99.

13. Jalian, H. Ray, Avram, Mathew M., Garibyan, Lilit, Mihm, Martin C., and Anderson, R. Rox, ‘Paradoxical adipose hyperplasia after cryolipolysis’, JAMA Dermatology, 150 (3) (2014),pp.317–19.

Aesthetics | January 2016

35

NEW FOR 2016

Introducing the 3D-lipomed V2 - the next generation multi technology approach to treating fat removal, skin tightening and cellulite reduction.

Fat Removal

“3D-lipo has always had a clear strategy and has become synonymous with the multiple technology device platforms that we manufacture. Our simple philosophy is that one technology will not treat all body indications, so we strive to ensure that we incorporate the best technology to successfully treat the 3-Dimensions being fat removal, skin tightening and cellulite.

Skin Tightening

Even with fat removal alone, some technologies are better for sculpting and targeted fat removal whilst others specialise in deeper fat removal and overall circumference reduction more effectively. This approach has been the making of 3D-lipo, and the results achieved by this methodology have been the foundations of the company’s success.

Cellulite

As the old saying goes ‘If it isn’t broken, don’t fix it’ however it is our mission to periodically update our platform as and when the technology comes along that could potentially offer advantages in treatment for a specific indication.

The 3D-lipomed has always been our premium product, and I am now pleased to announce the launch of our new 3D-lipomed V2. Our powerful 200 watt cavitation will remain the choice of treatment for deeper fat removal and overall circumference reduction. In addition, our popular tri-polar radio frequency for the face and body will also be incorporated in the new platform. HIFU technology is set to replace cryolipolysis as the new direction in targeted fat removal, due to its precise nature of delivery and speed. Also, the clinically proven shockwave therapy will be introduced to combat cellulite and will replace our acclaimed 3D-dermology vacuum skin rolling / RF. The new 3D-lipomed V2 truly represents the latest combination of advanced technologies to target the specific body indications, and thus deliver the best possible patient outcomes in one affordable machine. We look forward to sharing the benefits of our brand new creation at the forthcoming trade show events this year.”

Roy Cowley, Managing Director, 3D-lipo Ltd

“Results achieved by this methodology have been the foundations of the company’s success...”

Before

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Before

After

FOCUSED FAT REDUCTION

Before

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SHOCKWAVE THERAPY (ESWT) Treatment of Cellulite

Shockwave Therapy works by stimulating fat breakdown, collagen synthesis and lymphatic drainage via the delivery of radial shockwaves.

This is the latest technology clinically proven to reduce the appearance of cellulite and increase skin elasticity.

FOCUSED FRACTIONAL R/F

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

NEW FOR 2016

HIFU BODY

Targeted Fat Removal / Sculpting The latest technology delivering a 24 line matrix of focused energy at a depth of 1.3cm. This latest technology has benefits over cryolipolysis as it can be even more specifically targeted and treatment time is reduced.

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LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients.

In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis.

Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection.

Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions.

Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

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 Galderma (UK) Ltd.

AZZ/018/0313

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Technique Masseter Hypertrophy

discuss masseter hypertrophy and its nonsurgical treatment using BTXA, as well as its role as an adjunct treatment for bruxism.

Treating Masseter Hypertrophy Dr Souphiyeh Samizadeh details the occurrence and efficacy of treating masseter hypertrophy and bruxism with botulinum toxin Introduction: The use of botulinum toxin Botulinum toxin (BTX) has been successfully used for the treatment of many conditions including excessive muscle tone, movement disorders, strabismus, dystonias, blepharospasm, hemifacial spasm, cervical dystonia, juvenile cerebral palsy, and adult spasticity.1,2 Use of BTX for cosmetic purposes has gained popularity in the past two decades and, recently, other therapeutic uses of BTX have been studied.3 A number of potential new cosmetic and therapeutic indications including conditions associated with pain, excessive or dyssynergic muscle contraction and hypersecretion of glands have emerged, which have attracted a significant amount of interest from the scientific community.2 Botulinum toxin A (BTXA) inhibits acetylcholine release from nerve terminals at the neuromuscular junction, resulting in inhibition of muscle contraction.4 In addition, BTXA also produces localised chemical denervation of parasympathetic postganglionic cholinergic fibres, making it effective for the treatment of hyperhidrosis and hypersalivation.1 Studies of conditions such as myokymia, bruxism, and anal fissure have also reported promising results.5-7 A secondary outcome of the BTX injection is pain-relief, suggesting BTX has a direct effect on pain mechanisms, which may be independent of its neuromuscular actions.8 This finding has resulted in new emerging

indications, including treatment for conditions associated with pain, such as migraine, headaches, myofascial pain, neuropathic pain and chronic lower-back pain.2 Current evidence suggests that BTX can selectively weaken painful muscles and interrupt the spasm-pain cycle. The analgesic effects of BTXA were first reported after observation of substantial pain relief in cervical dystonia.8 Initially the pain reduction was attributed to reduced muscle hyperactivity,8,9 however, a direct analgesic effect has been shown in animal studies.9,10 Various studies have reported positive results for management of conditions associated with pain using BTX,8,11 however further research is necessary.

BTXA is very commonly used in Asia for lower facial contouring and to treat masseter hypertrophy, as Asian women tend to dislike the square face shape and favour a delicate ovoid shape instead.12-14 In this article I will

Figure 1: Masseter muscles are located laterally to the mandibular ramus, and therefore play a significant role in facial aesthetics

Aesthetics | January 2016

Masseter muscle hypertrophy The masseter muscle is one of the four principal muscles of mastication (chewing) and is essential for adequate mastication.15 Masseter muscles are located laterally to the mandibular ramus,16 and therefore play a significant role in facial aesthetics (Figure 1). Enlarged and hypertrophied masseter muscles will alter facial lines and can have a negative aesthetic impact â&#x20AC;&#x201C;potentially causing facial asymmetry and a square face shape, which is often considered a masculine trait.17 Masseter hypertrophy was first described by Legg in 1880.18 It is a relatively uncommon condition and is characterised by benign unilateral or bilateral enlargement of the masseter muscles (Figure 2).17,18 Masseter hypertrophy is asymptomatic and the reason patients seek help is predominantly related to aesthetics, in particular if there is noticeable asymmetry due to unilateral presentation.17 Masseter muscle hypertrophy can also be a result of dietary habits, chewing gum habits and bruxism (teeth grinding).18-20

Figure 2: Masseter hypertrophy, which appears worse on the patientâ&#x20AC;&#x2122;s left-hand side

A well-defined jawline is often considered a sign of youth and beauty.21 However, a square jaw shape, which may be out of proportion with other facial features and, in cases of severe masseter hypertrophy and unilateral hypertrophy, can be seen as a disfigurement to a patient. There are also ethnic variations in perception of beauty; Baek et al reported that oriental women greatly desire an oval, delicate and feminine facial shape.22 This is particularly true for Korean women, who tend to have a wide jaw bone15. In addition, as part of their diet, they chew rough and hard food regularly, resulting in well-developed masseter muscles.15 Furthermore, in Korea, the belief that certain facial features bring good or back luck, in addition to the social preferences of slim and smaller faces, has resulted in popular lower face remodelling treatments.14 39

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Diagnosis Prior to treating masseter hypertrophy, it is important to ensure you have the correct diagnosis. Other reasons for swellings at the angle of the mandible could be due to:17,18 • Compensatory hypertrophy (due to hypotrophy or hypoplasia in the contralateral side) • Masseter muscle intrinsic myopathy • Masseter tumour • Salivary gland disease • Parotid tumour • Parotid inflammatory disease • Odontogenic problems • Neoplasms of soft tissues Masseteric hypertrophy, accompanied by bruxism and frequently clenching the jaw can result in tooth wear, fracture of the teeth and restorations, toothache, masticatory muscle pain, temporomandibular joint pain, and tension-type headache.23 Treating masseter hypertrophy Treatment of masseter enlargement is usually unnecessary and is carried out for aesthetic purposes.18 Aesthetic contouring of the angles of the jaw can be carried out both surgically and non-surgically. Surgical aesthetic contouring of the prominent mandibular angle through partial excision of the masseter muscle and/or osteotomy (reduction of the thickened bone in the region of the mandibular angle) is well reported in literature.22,24 However, surgical approaches are invasive, have a relatively long recovery time and complications such as hematoma, nerve injury, facial nerve paralysis, infection, trismus, asymmetric resection, uneven contour lines and sequelae from general anaesthesia, can occur.14 Injecting BTX into the masseter muscles to induce ‘disuse atrophy’ is a nonsurgical approach of de-bulking masseter muscles and reducing lower face width, which, as discussed, is very common in Asian countries.25 Numerous studies have highlighted the benefits of this non-invasive approach since Moore and Wood introduced the BTXA injection of the hypertrophic masseter to treat functional problems in 1994.26 Following this, Rijsdijk and colleagues, in 1998, reported the use of BTXA for aesthetic volume reduction of the hypertrophic masseter.27 In 2001, Von Lindern et al published an on article the use of BTX for masseter and temporal muscles.28 Kim et al treated 1021 patients

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with BTXA for aesthetic purposes to reduce the volume of masseter muscle in 2005. They concluded that BTXA is a simple technique, with few side effects and reduced recovery time, and can also replace surgical masseter resection. They reported five steps for the progression of BTXA in masseter muscles after injection:14 • • • • •

Week 1: Muscle softening Week 2-4: Muscles noticeably thinner Week 10-12: Maximum effect Week 12+: Action recurs Week 16+: Muscle volume recurs

Treating bruxism In addition to reducing the volume of the masseter muscles, injection of BTXA into this area has been shown to reduce pain and grinding episodes. Although scientific evidence to support treatment of bruxism with BTXA is not abundant, current studies and literature reviews have shown reduced frequency of bruxism events, decreased bruxism-induced pain levels and high anecdotal patient satisfaction.5,29,30 Various hypotheses have been described for the mechanism by which BTXA relieves pain. These include direct effects at the neuromuscular junction, direct antiproprioceptive effects on nerves, inhibition of the release of various neuropeptides and neuromodulators, and blockage of the transmission of afferent neuronal signals.31 Conclusion BTXA injection is a non-invasive, effective and safe treatment for masseter muscle hypertrophy and lower face contouring. It can also be used as an effective adjunct for the treatment of bruxism. Important issues such as immune-resistance from repeated injections and long-term cost effectiveness of treatment should be considered when offering this treatment option to patients.

Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine.

Aesthetics | January 2016

Technique Masseter Hypertrophy

REFERENCES 1. Aoki KR, Guyer B, ‘Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions’, European Journal of Neurology, 8 (2001) pp.21-29.

2. Thant Z-S, Tan E-K, ‘Emerging therapeutic applications of botulinum toxin’, Medical Science Monitor, 9 (2003) RA40-RA48.

3. Shilpa PS, Kaul R, Sultana N, et al, ‘Botulinum toxin: The Midas touch’, Journal of Natural Science, Biology, and Medicine, 5 (2014) pp.8-14.

4. Lang A, ‘History and uses of BOTOX (botulinum toxin type A)’, Lippincotts Case Manag, 9 (2004) pp.109-112.

5. Persaud R, Garas G, Silva S, et al, ‘An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions’, JRSM Short Rep, 4 (2013) p.10.

6. Shim YJ, Lee MK, Kato T, et al, ‘Effects of botulinum toxin on jaw motor events during sleep in sleep bruxism patients: a polysomnographic evaluation’, J Clin Sleep Med, 10 (2014), pp.291-298.

7. Dat A, Chin M, Skinner S, et al, ‘Botulinum toxin therapy for chronic anal fissures: where are we at currently?’, ANZ J Surg, (2015).

8. Colhado OC, Boeing M, Ortega LB, ‘Botulinum toxin in pain treatment’, Rev Bras Anestesiol, 59 (2009) pp.366-381.

9. Sim WS, ‘Application of Botulinum Toxin in Pain Management’, The Korean Journal of Pain, 24 (2011) pp.1-6.

10. Dressler D, Adib Saberi F, ‘Botulinum toxin: mechanisms of action’, European neurology, 53 (2005) pp.3-9.

11. De Andres J, Cerda-Olmedo G, Valia JC, et al, ‘Use of botulinum toxin in the treatment of chronic myofascial pain’, Clin J Pain, 19 (2003) pp.269-275.

12. Ahn J, Horn C, Blitzer A, ‘Botulinum toxin for masseter reduction in Asian patients’, Arch Facial Plast Surg, 3 (2004) pp.188-191.

13. Park MY, Ahn KY, Jung DS, ‘Botulinum toxin type A treatment for contouring of the lower face’, Dermatologic surgery, 29 (2003) pp.477-483.

14. Kim N-H, Chung J-H, Park R-H, et al, ‘The use of botulinum toxin type A in aesthetic mandibular contouring’, Plastic and reconstructive surgery, 115 (2005) pp.919-930.

15. Kaya B, Apaydin N, Loukas M, et al, ‘The topographic anatomy of the masseteric nerve: A cadaveric study with an emphasis on the effective zone of botulinum toxin A injections in masseter.

Journal of plastic, reconstructive & aesthetic surgery’, JPRAS, 67 (2014), pp.1663-1668.

16. Netter FH, ‘Atlas of human anatomy’, Elsevier Health Sciences, (2014).

17. Rispoli DZ, Camargo PM, Pires Jr JL, et al, ‘Benign masseter muscle hypertrophy’, Revista Brasileira de Otorrinolaringologia, 74 (2008) pp.790-793.

18. Kebede B, Megersa S, ‘Idiopathic Masseter Muscle Hypertrophy’, Ethiopian Journal of Health Sciences, 21 (2011) pp.209-212.

19. Rispoli DZ, Camargo PM, Pires JL, Jr., et al, ‘Benign masseter muscle hypertrophy’, Braz J Otorhinolaryngol, 74 (2008) pp.790-793.

20. Klasser G, Rei N, Lavigne G, ‘Sleep Bruxism’, In Pagel JF, PandiPerumal SR, (Eds). ‘Primary Care Sleep Medicine’, Springer New York, (2014) pp.327-338.

21. Sadick NS, Karcher C, Palmisano L, ‘Cosmetic dermatology of the aging face’, Clinics in dermatology, 27 (2009) S3-S12.

22. Baek S-M, Baek R-M, Shin M-S, ‘Refinement in aesthetic contouring of the prominent mandibular angle’, Aesthetic plastic surgery, 18 (1994), pp.283-289.

23. Ham JW, ‘Masseter muscle reduction procedure with radiofrequency coagulation’, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons, 67 (2009) pp.457-463.

24. Kim SK, Han JJ, Kim JT, ‘Classification and treatment of prominent mandibular angle’, Aesthetic plastic surgery, 25 (2001) pp.382-387.

25. Ahn J, Horn C, Blitzer A, ‘Botulinum toxin for masseter reduction in asian patients’, Archives of Facial Plastic Surgery, 6 (2004) pp.188-191.

26. Moore AP, Wood GD, ‘The medical management of masseteric hypertrophy with botulinum toxin type A’, Br J Oral Maxillofac Surg, 32 (1994) pp.26-28.

27. Rijsdijk BA, van ER, Zonneveld FW, et al, ‘Botulinum toxin type A treatment of cosmetically disturbing masseteric hypertrophy,’ Ned Tijdschr Geneeskd, 142 (1998), pp.529-532.

28. von Lindern JJ, Niederhagen B, Appel T, et al, ‘Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscles: an alternative treatment’, Plast Reconstr Surg, 107 (2001) pp.327-332.

29. Long H, Liao Z, Wang Y, et al, ‘Efficacy of botulinum toxins on bruxism: an evidence-based review’, International Dental Journal, 62 (2012) pp.1-5.

30. de Mello Sposito MM, Teixeira SAF, ‘Botulinum Toxin A for bruxism: a systematic review’, CEP.5716:150.

31. Song P, Schwartz J, Blitzer A, ‘The emerging role of botulinum toxin in the treatment of temporomandibular disorders’, Oral diseases, 13 (2007) pp.253-260.

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The Ageing of the Temple Dr Sam Robson and Qura Shah explain how the temple ages and share advice on successfully rejuvenating the area using filler The temple forms the lateral boundary of the periorbital region of the upper third of the face. The cumulative effects of age are particularly apparent in this area, making it a common target for aesthetic rejuvenation.

The youthful face is full, convex and usually round or oval in shape with uniform distribution of subcutaneous and deep fatty tissue.1 There is a morphological loss of fullness with age, relating to both skeletal changes and soft-tissue atrophy, particularly in the temporal and buccal regions.2 There is a tendency for the shape of the face to become gradually more ‘monkey-nutshaped’ rather than the round or oval shape commonly seen during youth, giving rise to a more skeletal appearance.2 Anatomy and ageing The neonatal skull is characterised by a significantly large cranium in relation to the facial skeleton. With age, remodelling of the craniofacial skeleton occurs, during which selective deposition and resorption of bone allow the infant skull to widen and elongate in order to take on the adult form.3 Facial skeletal remodelling is a dynamic process continuing throughout the adult lifespan and becoming most notable after the third decade. After about 50 years of age, the human adult skull begins to take on similar features to the infant skull, with a gradual decrease in its size.2 The change in the rate of bone deposition and resorption leads to a decrease in the maxilla and enlargement

of the bony orbits.3 The overall effects on the dimensions of an elderly human skull are a reduction in height and slight increase in width and depth.1 These skeletal changes cause gradual loss of support to the craniofacial soft tissue and changes in the distribution of subcutaneous adipose tissue leading to visible signs of ageing, such as a deepening of the nasolabial folds, sinking of the eyelids and hollowing of the temples.4 In terms of facial soft tissue, there is significant prolapse in various regions with age, with a loss of volume due to the depletion of fat and decreased subcutaneous support from collagen and elastin. In the forehead and brow region, the orbital rim and zygomatic arch become more apparent, resulting in an excess of orbital and temporal skin.4 In youth, deep

Clinical Focus Temple Ageing

and superficial pads of temporal fat, as well as the overlying temporalis muscle provide support to the periorbital area and lateral brow. There is a loss of temporal fascia and significant reduction in volume to the area, with the temporal fossa becoming increasingly more apparent and concave.4 A secondary effect is the loss of support to the eyebrows and a descent of any remaining soft tissue, leading to brow ptosis.4 The lateral brow lowers and flattens, and this is augmented by the drooping of the eyelids and the formation of forehead rhytides.1 Many patients overlook the loss of volume at the temples and change in the shape of the face, initially seeking treatment for major frown lines such as the nasolabial fold and forehead rhytides. However, the distribution of facial fatty tissue is one of the main indicators of age so, in order to regain a youthful appearance, it is essential to restore the fullness.1 Whilst changes to the bony framework of the face can’t be reversed by the aesthetic practitioner, loss of soft tissue volume to the face can be replaced. Treating the hollowing of the temples by revolumising the area with dermal fillers gives a more youthful look and has the secondary effect of lifting the lateral brow.

Treatment using fillers Dermal fillers provide an instant, minimally invasive and effective reversal of temporal volume loss. Whilst traditional human and bovine collagen fillers are used to fill fine lines, treatment of temporal volume loss is best carried out using hyaluronic acid (HA) fillers, such as Juvéderm, Belotero and Emervel. Collagen fillers are light and nonviscous fluids at room temperature and, if they come from bovine sources, can cause immunogenic reactions.5 HA fillers on the other hand possess ‘dynamic viscosity’, with

Whilst changes to the bony framework of the face can’t be reversed by the aesthetic practitioner, loss of soft tissue volume to the face can be replaced

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Clinical Focus Temple Ageing

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Before

After

Before

After

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Figure 1: Before and after initial treatment of temple hollowing using JuvĂŠderm Voluma.

Images courtesy of Temple Medical

viscosity altering under different levels of pressure. During injection, HA fillers maintain a steady fluidity but once inserted they lose viscosity, making them stable and unlikely to migrate.5 This type of filler is ideal for treating the temples, with little or no migration, and immediate rejuvenation. It is better to under-correct the region with HA filler and assess the results before deciding if further treatment is required, rather than risking over-correction.

An alternative to HA fillers is the use of active fillers, which act as stimulators of collagen production by increasing inherent fibroblast activity. Microspheres of poly-Llactic-acid (PLLA) found in fillers such as Sculptra, which is the only FDA-approved filler of this kind,6 can be implanted at the temples to gradually fill the space created

Middle temporal

Superficial temporal

Transverse facial

Internal maxillary

by the loss of temporal fat and fascia. Using PLLA to treat the temples usually involves two to four treatments; with patients revisiting six to eight weeks post treatment.

When using collagen stimulators, patients must be advised to massage the area of treatment daily to smooth the collagen and prevent the formation of nodules.

From our experience, by the eighth week, the patient should see at least 20% of the total correction required. Whilst HA fillers provide instant rejuvenation and last about 12 to 18 months, use of PLLA microspheres takes eight to 10 months to reach the final desired effect, however this treatment has the benefit of lasting several years.5 Another option is calcium hydroxyapatite fillers, which act as conventional fillers after injection, causing instant smoothing of lines in the area. After several months, however, the Internal carotid micro-particles begin to Opthalmic stimulate production of Lacrimal collagen to restore volume in the area, amplifying and Suprorbital prolonging the rejuvenated Supratrochlear effect for up to two years.5 Whilst HA fillers act as Infraorbital temporary solutions, Angular collagen-stimulators are seen as a more permanent treatment as the effects are apparent for at least two Superior years.5 labial

External carotid Inferior labial Facial

Figure 2: Branches of the ophthalmic artery, which pass through the temple.9

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Achieving optimum results In terms of patient satisfaction, it is essential to manage and agree on the reality of expectations.

Each individual ages

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uniquely, so it is important to assess the facial anatomy and extent of volume loss, and to discuss the benefits, as well as limitations of using different fillers. The practitioner should educate the patient in what can realistically be achieved, with photographs taken before and after treatment. Many patients first recognise a prolapse of facial soft tissue with the deepening of laughter lines and periorbital wrinkles. Treating the nasolabial folds without addressing temple hollowing can create the appearance of puffy cheeks and distort the shape of the face. The patient should be informed that restoring the correct distribution of volume to the face provides the visual perception of youth. Although the volume can be restored in significantly sunken temples with filler, there may be an excess of redundant skin, which requires secondary measures or surgical intervention in order to fully rejuvenate the region. The patient should be made aware of this during consultation. The aesthetic practitioner also has a responsibility to provide the most cost-efficient treatment. Whilst soft tissue fillers could be applied to fully occupy temple depressions, this would not be an economic use of filler. With this region in particular, filler can be applied as pillars to act as â&#x20AC;&#x2DC;tent-polesâ&#x20AC;&#x2122; in order to strategically lift the area (Figure 1) with the same effect as filling the entire cavity but at a fraction of the cost. With use of collagen-stimulators, the practitioner must bear in mind that there will be a gradual expansion to fill the space; overfilling the area can add to the risk of nodule formation.7 When treating the temples with HA or calcium hydroxyapatite fillers, it is also important to inject the filler deep enough to avoid the development of small subcutaneous nodules.7 The anatomic difference in the thickness of the dermis at different regions of the face must be considered. In the temporal and periorbital region in general, there is a reduction in dermal thickness, and in this region a light filler of small particle size is appropriate. The lower viscosity of small particle fillers yields a better result in areas of reduced dermal thickness.5 Possible complications Whilst dermal fillers are minimally invasive and adverse reactions are rare, the patient must be fully informed of these risks nonetheless and the practitioner should be able to carry out appropriate action in these events.

The patient should be advised to carry out gentle and regular massage post treatment, especially if they have been treated with PLLA-filler, to avoid nodules and encourage

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Aesthetics Journal

uniform distribution. Whilst certain nodules can be punctured and drained, such as the small white nodules formed from superficially injected calcium hydroxyapatite fillers, deeper nodules formed from lack of massage of PLLA fillers are difficult to reverse.7 In cases of overcorrection using HA filler or development of nodules, hyaluronidase can be used to dissolve the filler.3 A small amount of bruising or swelling can be expected with injecting the thin dermis of the temples, particularly in older patients, and persistent swelling can usually be managed with antihistamines.8 With treatment of the temples the most severe risk is injection of filler into the optic circulatory system, which can cause retinal occlusion and potentially blindness.8 The close proximity of distal branches of the ophthalmic artery to the site of injection can lead to perforation of one of these arteries (Figure 2). The systolic pressure within these arteries can cause any displaced filler to travel to the retinal artery causing blockage, blurred vision and complete loss of sight.8 To reduce the risk of arterial blockage, the practitioner should use small volumes of filler in order to avoid the arterial network of the temple, filler should be injected at the level of the temporal periosteum.8

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Clinical Focus Temple Ageing

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Conclusion Correct injection technique is key to a successful outcome, with permanent filler generally injected deeply into the temple depression, allowing room for innate collagen production and temporary filler injected at a more superficial level in strategic pillars to lift the area. Since the eyes and brows are key aesthetic features, and both are affected by temporal hollowing, revolumising the temples has a dramatic rejuvenating effect on the face.

Dr Sam Robson trained as a GP before beginning her career in aesthetics in 2004.

She is the medical director of Temple Medical in Aberdeen, an appraiser for the British College of Aesthetic Medicine and a voluntary medical advisor for the Royal National Lifeboat Institution.

Qura Shah is a Master’s graduate from the School of Medical Sciences at the University of Aberdeen. She currently works as a clinical therapist at Temple Medical with patients on a medically monitored weight reduction programme. Shah is trained in the use of low-frequency ultrasound to treat subcutaneous adipose tissue.

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

REFERENCES 1. Coleman, Sydney R. and Grover, Rajiv ‘The anatomy of the aging face: Volume loss and changes in 3-dimensional topography’, Aesthetic Surgery Journal 26 (2006), pp.4-9.

2. Albert, A. Midori et al. ‘A review of the literature on the aging adult skull and face: implications for forensic science research and applications’, Forensic science international 172 (2007) pp.1-9.

3. Mendelson, Bryan and Wong, Chin-Ho ‘Changes in the facial skeleton with aging: implications and clinical applications for facial rejuvenation’, Aesthetic Plastic Surgery 36 (2012) pp.753-760.

4. Kaur, Manavpreet et al. ‘Analysis of facial soft tissue changes with aging and their effects on facial morphology: A forensic perspective’, Egyptian Journal of Forensic Sciences 5 (2015) pp.45-56.

5. Sherman, Richard N. ‘Avoiding dermal filler complications’, Clinics in Dermatology, 27 (2009), pp.23-32.

6. Soft Tissue Fillers Approved by the Center for Devices and Radiological Health, (US: FDA, 2015) <http://www.fda. gov/MedicalDevices/ProductsandMedicalProcedures/ CosmeticDevices/WrinkleFillers/ucm227749.htm> 7. Lafaille, Philippe and Benedetto, Anthony ‘Fillers – Contraindications, side effects and precautions’, The Journal of Cutaneous Aesthetic Surgery, 3 (2010), pp.16-19.

8. Funt, David and Pavicic, Tatjana ‘Dermal fillers in aesthetics: an overview of adverse effects and treatment approaches’, Clinical, cosmetic and investigative dermatology, 6 (2013) pp.295-316.

9. Erian A, Shiffman M, ‘Advanced surgical facial rejuvenation: Art and clinical practice’, Facial Anatomy, (2012) p.13.

FURTHER READING Coleman, S. et al. ‘A comparison of lipoatrophy and aging: volume deficits in the face’ Aesthetic Plastic Surgery 33 pp.14-21.

Emre, Ismet Emrah and Cakmak, Ozcan ‘Ageing face, an overview – Aetiology, assessment and management’ The otorhinolaryngologist, 6 (2013), pp.160-166.

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Aesthetic Journal January 2016

Case Study Microneedling

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Case Study: Managing a Tattoo Complication Dr Simran Deo shares a case study detailing her experience of using microneedling to treat a hyperpigmented hypertrophic scar following ‘blow-out’ of tattoo ink With an increasing number of patients undergoing tattoo application, there has been a rise in complications and desire for removal in recent years.1 Tattoo leakage, or ‘blow-out’ occurs if the artist, or applicator, presses too hard, leading to tattoo pigment in the dermis and hypodermis.2 The resultant hyper-inflammatory response can be difficult to treat; however, microneedling provides a promising new modality for treatment.3 Case Study Introduction A 37-year-old lady of Asian descent (Patient A) was treated for a disfiguring, extensive, inflammatory linear lesion, which descended from the lateral canthus of the right eye to just inferior to the zygomatic arch (Figure 1). In this case, related articles and case studies were reviewed to determine the best treatment modality for Patient A. The patient’s primary concern was overall cosmetic improvement. In treating the patient, we were able to obtain a reasonably successful cosmetic result. The patient said that she had undertaken a semi-permanent makeup tattoo application of her eyebrows 18 months previously. In the week subsequent to this, she had noted a slow descension of pigmentation from her right upper eyelid to the hollow of her right cheek. This scar formation was felt

More than 60% clinical improvement of scarring was achieved at four weeks

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declined on the NHS, costing the patient thousands of pounds.

On inspection, Patient A had an obvious well demarcated, hyperpigmented linear scar running from the lateral canthus of the right eye, over the zygomatic arch and into the hollow of the right cheek (Figure 1). This was most likely a response to residual tattoo pigment. The scar appeared fragmented at the superior aspect, with two well-circumscribed discoid blue/black lesions at the lateral canthus. Dispersing as it travelled inferiorly, it became more red/brown in appearance. The scar appeared raised and shiny, implicating a chronic inflammatory process. The two wellcircumscribed discoid lesions appeared to contain tattoo pigment.

Having maintained a superior skincare regime following the insult, Patient A’s overall skin tone and texture were well maintained for her age, with no evidence of any other hyperpigmentation or scarring.

Consultation A joint discussion was undertaken with Patient A, exploring her requirements and expectations. Her concerns were purely cosmetic; however, the scar had a significant impact on her quality of life, leading to the commencement of anti-depressants. Patient A was very distressed and tearful, with a Manchester Scar Scale score of 16 out of a maximum of 21.4 Due to the likely presence of tattoo pigment at the lateral canthus, laser treatment could possibly be required at a later stage. It was advised that in order to adequately determine the diagnosis, a biopsy of the lesion should be undertaken; however, the patient declined due to an impending family wedding. Instead, a course of microneedling was advised due to results achieved in previous patients, suggesting sessions be undertaken on a case-by-case basis only, in order to assess improvement and re-assess the management plan at each individual stage.

Method Once informed consent was given by Patient A, EMLA cream was applied. The patient was advised to wait until adequate anaesthesia was achieved, and the skin was cleansed and dried.

Using a sterile technique to minimise the risk of infection, the 1.5mm needles were applied at a rate of 100-120 insertions per minute, depending on the location of the scar, with 100 insertions per minute being applied at the lateral canthus, and 120 more inferiorly. The needles were applied to the scar only, with three passes being undertaken on each occasion. The surrounding skin remained untouched. Whilst continuing a sterile procedure, any Figure 1: Patient A before microneedling

to have occurred due to leakage or ‘blow-out’ of the tattoo pigment.

She denied any trauma to the area at the time, and had not recently been pregnant or taken any oral contraceptives, which can worsen hyperpigmentation, or cause melasma.20 There had not been any subsequent pigmentation on the contralateral side of the face, forehead or chin.

After having previously been advised a diagnosis of melasma, Patient A underwent multiple chemical peels, and used various lightening creams, with little improvement. Treatment had been 46

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Figure 2: Patient A, review four weeks after microneedling treatment

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haematogenous fluid produced during treatment, was massaged back into the scar to promote an inflammatory cascade. The area was then cleansed and 1% hydrocortisone was applied, followed by a factor 50 sun protectant in order to avoid any exposure to UVA and UVB rays.

Aftercare and maintenance Following the treatment, the patient was advised to avoid sun exposure, soaps and scrubs and to always wear SPF 50, regardless of the weather. Reviews were arranged four to six weeks after each treatment.

Results The results on each review were noted and dramatic, with the patient reporting an improvement in her mood and in her ability to apply makeup and camouflage the scar. The treatment response was assessed by comparing pre-treament and four week post-treatment clinical photography. More than 60% clinical improvement of scarring was achieved at four weeks after a single treatment based on independent practitioner assessment. No significant adverse effects were noted. The improvement was persistent at the one month follow-up after each treatment. During the four-week review following the fifth treatment, the resultant Manchester Scar Scale demonstrated significant results, improving from 16 to seven.4 Discussion Tattooing has become increasingly popular, not only amongst the younger generations, but the older too, leading to a parallel increase in the occurrence of adverse reactions.21 With the ever-increasing incidence of complications due to tattooing, practitioners should be well informed of the possible complications. It is vital that they are able to recognise the signs and symptoms, as well as appropriately counsel their patients on the risks of tattoo application.5 According to literature, the most frequent tattoo-related concerns are allergic contact dermatitis due to a delayed hypersensitivity reaction to tattoo pigments.6,7 The main pigment thought to cause an allergic reaction is red pigment, due to the presence of new organic pigments (pigment red 181 and 170).8 The blue, green, and black pigment are less frequently the cause of allergic contact dermatitis.9-12 Treatment of scars still remains a challenge for most doctors, with scarring being a distressing condition for most patients in the ever-increasing aesthetically aware population. Post-acne scarring, for example, besides causing cosmetic disfigurement, can lead to significant psychological issues if facial scarring is present at a young age.13 Microneedling is safe for use on all skin phototypes14 and for the treatment of scars it is advised that the needle length should be selected considering the depth of the scar present, with a needle length of 1.5mm-2mm being described in many clinical studies.14,15,16 The process relies on an inflammatory cascade and the release of growth factors occurring due to needle insertion into the stratum corneum. It is this formation of micro-channels or micro-wounds in the papillary dermis of the skin that are thought to create a confluent zone of superficial bleeding which acts to stimulate various growth factors, thus stimulating subsequent neocollagenesis and neovascularisation via the process of wound healing. It is these growth factors that are believed to be responsible for the beneficial effects of microneedling in the treatment of scars and photoageing.16,17 Besides acne and post-surgical scars, microneedling has also been used in the treatment of varicella scars and post-herpetic facial scars with good success.3,15 There has,

Case Study Microneedling

however, been little reported on the impact of microneedling on either chronic inflammatory lesions or on the breakdown of tattoo pigment within the hypodermis or dermal layer, except in the method of salabrasion.18 Based on the above information, theories suggest that by inducing the release of growth factors such as; Plateletderived Growth Factor (PGF), Transforming Growth Factor alpha and beta (TGF-α and TGF-β), and Fibroblast Growth Factor (FGF), the normal process of wound healing is re-initiated, enabling any scars present to heal to an aesthetically acceptable point.16,17 Based on this theory of the acute inflammatory process, which leads to both initial phagocytosis (breaking down) of any foreign body present, as well as engulfing by macrophages, it is felt that microneedling could contribute to the breakdown of tattoo pigment within the hypodermal layer.19 Conclusion As no biopsy was undertaken, there was a lack of histological evidence to confirm the presence of tattoo pigment within the lesion.

There was, however, both historical and observational evidence determining its presence. The results of the treatment showed a significant improvement of the residual pigment and surrounding hypertrophic and hyper-pigmented scar with just five sessions of microneedling. This suggests that microneedling offers a new, effective and safe means for the treatment of leakage of tattoo ink into the dermal and hypodermal layers.3 Dr Simran Deo is a GP with further qualifications in dermatology and aesthetics, holding a diploma in dermatology from Cardiff University. She is currently the owner and director of True Tone Aesthetics in Windsor.

REFERENCES 1. George Chapman and Catherine Anne Thoroton Hildyard, ‘Two decades later: a delayed red ink tattoo reactions,’ BMJ Case Reports (2014).

2. F.Z. Lamchahab, B. Guerrouj, S. Benomar et al., ‘Henna symbolic tattoo and real dermatitis,’ Archives de Pediatrie, 18 (2011), 653-656.

3. I.M. Costa, M.C. Costa, ‘Microneedling for varicella scars in a dark-skinned teenager,’ Dermatologic Surgery, 40 (2014), 333-4.

4. Regina Fearmonti, Jennifer Bond, Detlev Erdmann, Howard Levinson, ‘A Review of Scar Scales and Scar Measuring Devices,’ Eplasty, 43 (2010).

5. Elizabeth Juhas & Joseph C. English, ‘Tattoo-Associated Complications,’ Journal of Pediatric and Adolescent Gynecology, 26 (2013), 125-129.

6. M. Tang, H. Beltranimelli, D. Perruchoud et al., ‘A tattoo complicated by allergic contact dermatitis and pannicultis,’ Journal of the European Academy of Dermatology and Venereology, 28 (2014), 127-128.

7. J. Vilaplana, J.M. Chimenos, A.I. Ferńndez, N.Pereira-Veigab & C. Romaguera, ‘Problems in the diagnosis of contact dermatitis by tattooing,’ Exogenous Dermatology, 1 (2002), 307-312.

8. C. Piérard-Franchimont, J.F. Hermanns & G.E. Piérard, ‘Skin reactions to tattoo ink,’ Revue Médicale de Liège, 66 (2011) 430-433.

9. J. Kazandjieva & N. Tsankov, ‘Tattoos: dermatological complications,’ Clinics in Dermatology, 25 (2007), 375–382.

10. A. Rostenberg, R.A. Brown & M.R. Caro, ‘Discussion of tattoo reactions with report of a case showing a reaction to a green color,’ AMA Archives of Dermatology and Syphilology, 6 (1950), 540-547.

11. D.J. Tazelaar, ‘Hypersensitivity to chromium in a light-blue tattoo,’ Dermatologica, 141 (1970), 282–287.

12. W.D. Tope, J.L. Arbiser & L.M. Duncan, ‘Black tattoo reaction: the peacock’s tale,’ Journal of the American Academy of Dermatology, 35 (196), 477-479.

13. J.Y. Koo & L.L Smith, Psychologic aspects of acne. Pediatr Dermatol 1991; 8(3): 185-8 14. G Fabbrocini, V De Vita, A Monfrecola, et al., ‘Percutaneous collagen induction: an effective and safe treatment for post-acne scarring in different skin phototypes.’ Journal of Dermatology Treatment, 25 (2014), 147-52.

15. Imran Majid, ‘Microneedling therapy in atrophic facial scars: an objective assessment,’ Journal of Cutaneous and Aesthetic Surgery, 2 (2009), 26-30.

16. G Fabbrocini, N Fardella, A Monfrecola, et al., ‘Acne scarring treatment using skin needling,’ Journal of Clinical and Experimental Dermatology, 34 (2009), 874-9.

17. A.F Falabella & V Falanga, ‘Wound healing’ The Biology of the Skin, (New York: Parethenon, 2001), 281-99.

18. Alexandra M.M. Strong & Ian T. Jackson, ‘The removal of amateur tattoos by s8labrasion,’ British Journal of Dermatology, 101 (2006), 693–696.

19. S.L Kilmer & J.M Garden ‘Laser treatment of pigmented lesions and tattoos,’ Seminar in Cutaneous Medicine and Surery Journal, 19 (2000), 239.

20. Grimes, Pearl E MD; Yamada, Nanaka MD; Bhawan, Jag MD “Light Microscopic, Immunohistochemical, and Ultrastructural Alterations in Patients with Melasma,” American Journal of Dermatopathology: 27 (2005), 96-101.

21. C.I Jacob, ‘Tattoo-Associated Dermatoses: A Case Report and Review of the Literature,’ Dermatol Surg, 28 (2002), 962-965.

Aesthetics | January 2016

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Clinical Practice Radiofrequency

RF energy can be delivered to the skin in a variety of ways, the most common being monopolar, where RF is delivered via a single probe placed on the skin with a grounding pad distant to this site; or bipolar, where the RF is delivered from a probe with two electrodes placed over the treatment area.1 Multipolar devices are also available on some platforms and are similar to bipolar but consist of three or more electrodes. The depth of penetration when using monopolar RF is dependent on the tissue impedance (which varies minimally from person to person) and the cross-sectional area of the monopolar probe, whereas the depth of penetration of bipolar RF depends on the distance between the two electrodes on the probe, with increasing distance resulting in increased depth of penetration.2

Using Radiofrequency Dr David Jack outlines the benefits of having a radiofrequency device in an aesthetic clinic In the last 15 years, the use of radiofrequency (RF) devices in medical aesthetics has significantly augmented the spectrum of treatments available to practitioners in this field. The principles of RF have been utilised in many diverse branches of medicine and research, such as radiology and cardiology, for more than 75 years, highlighting the versatility and efficacy of this treatment modality. In this article I will summarise the basics of RF, the history of its uses in modern medicine and the applications and pitfalls of its use in medical aesthetics.

What is radiofrequency?

Radiofrequency is the term given to any alternating electrical current that, if applied to an antenna, creates an electromagnetic field that propagates through space in the surrounding area. The frequencies of radio waves in this group can be anything from 3 kilohertz (kHz) – a unit of alternating current or electromagnetic wave frequency equal to one thousand hertz – to 300 gigahertz (GHz) – unit of alternating current or electromagnetic wave frequency equal to one thousand million hertz. The radiofrequency spectrum can be divided into bands, sometimes referred to as the microwave spectrum, ranging from very low frequency (3-30 kHz) to extremely high frequency (30-300 GHz). This spectrum is inversely proportional to the free space that these wavelengths can transmit, for example, very low frequencies can transmit between 10-33km distance whereas extremely high frequencies can only transmit 1-10mm. The advantage of this principle in medicine is that the energy generated in this way can be transmitted from such an antenna and applied directly to tissues, so that this energy can be directed and absorbed and even retransmitted for a variety of purposes. The major reason for using RF over other devices on the skin for rejuvenation is that it can be used to deliver heat energy to tissues non-specifically, unlike lasers, which depend on chromophores.1

Applications and use of RF in medicine The application of RF energy in medicine is well established. As such, RF is the basis of magnetic resonance imaging (MRI) and surgical diathermy, both commonplace applications being used millions of times per year in hospital practice. In cardiology, RF is used for ablative interventions, for example, ablation of accessory conduction pathways, and in oncology/oncological surgery for tumour/metastasis ablation.

Since 2000, RF treatments have been increasingly used in medical aesthetics, owing to their their versatility, efficacy and safety.3 Numerous RF devices have been developed and modified over this time, delivering RF energy by a variety of different means. In addition

Appropriate patient selection and realistic management of expectations, as with all non-surgical aesthetic treatments is key in the use of radiofrequency to the monopolar and bipolar classification of RF delivery, there are several other variations of delivery systems such as fractional or sublative RF (where RF is delivered via a microneedle handpiece to physically ablate the skin and deliver deeper bipolar RF); phasecontrolled RF (where a two-dimensional or three dimensional probe is used to deliver RF to a fixed volume area); and combination RF therapies that apply light, massage, vacuum or pulsed electromagnetic fields. Older machines tended to use monopolar, but there were higher risk of burns/fat atrophy, so most modern machines are bipolar.13 It has been shown in a randomised trial that the use of RF in combination with dermal filler treatments is safe.2 The most common indication for RF in this field is non-ablative skin tightening,2 with numerous devices designed to fulfil this aim.

The lower face is a very commonly treated area. Devices such as Thermage and Pellevé, use RF energy to selectively heat the deep dermis and subcutaneous fibrous septae, causing cleavage of hydrogen bonds in the collagen fibres and subsequent collagen denaturation. The following inflammatory and proliferatory stages of healing are believed to then stimulate new deposition and

Aesthetics | January 2016

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restructuring of collagen fibres, resulting in tightening of the skin over the ensuing months. It has been shown that non-ablative RF treatments require repeated low energy RF treatments rather than a single high energy insult to produce the most noticeable improvements in skin laxity, as lower energies result in less heating and therefore less risk of burns.4,5 In addition, the use of lower energies results in a reduction of discomfort and reduced risk of burn injuries.4,5 As well as skin tightening, there is evidence that nonablative RF treatments are also effective as a treatment for active acne vulgaris.6 Deep skin tightening, reduction of acne scarring, improvement of keloid/hypertrophic scars, stretch marks and ablation of rosacea/ thread veins can be achieved using fractional RF methods.7 As mentioned above, fractional radiofrequency devices (such as Intracel, Fractora and Inifini) generally consist of bipolar microneedle handpieces of various lengths and needle arrangements, which are used to penetrate the skin physically. These ablate the skin surface to deliver the RF energy deeper into the tissues, causing subdermal electrothermal coagulation without excessive heating of the skin surface (compared to fractional laser, for example). This has the benefit of reduced superficial thermal discomfort and protracted erythema when compared to fractional laser treatments but the same surface ablation.8 Deeper tissue stimulation results in the familiar inflammatory changes and post-inflammatory neocollagenesis associated with non-ablative RF treatments but with the additional benefit of ablative resurfacing. This renders it an ideal treatment for problems such as acne scarring, where the skin surface texture is improved, in addition to improving the quality and structure of the deep scar tissue.

Fractional RF has also been shown to be an effective treatment for active acne.9 In addition to skin RF treatments, I’ve noticed that deeper targeted treatments have become a popular way to reduce cellulite and volume of subcutaneous fat. A variety of different devices are available, both non-ablative and ablative. Non-ablative devices include bipolar probes, such as Forma Plus and suction coupled devices such as BodyFx, which uses vacuum suction to create a volume of deep subcutaneous tissue between a pair of RF electrodes. This then delivers pulses of RF energy across a fixed volume of the deep tissue.

Several recent studies have shown RF to be an effective means of volumetric fat reduction,10,11 however, the number and duration of treatments, and the optimum settings on the myriad of different devices have yet to be evaluated. RF-assisted liposuction techniques such as BodyTite and NeckTite, which use a combined RF and suction probe, have been shown to provide excellent aesthetic results with the added benefit of overlying skin tightening12 when compared to traditional liposuction methods.

Complications and challenges of RF treatments RF treatments on the whole tend to be considered safe in trained hands. The very nature of these treatments, whereby tissues are heated to temperatures in excess of 43°C can potentially result in thermal injury and burns if either excessive energy is used or if there is prolonged contact in a given area to such an extent the tissue integrity is compromised.16 Most modern RF handpieces have built-in temperature sensors to prevent such excessive heating.

With some older monopolar devices, unintentional and excessive treatment of subcutaneous fat of the face has led to fat atrophy and depressions.13 I believe this is rare with modern equipment.

As with any aesthetic treatment, RF treatments are not effective in every patient, for reasons unknown, and unrealistic expectations of the scope and possibilities of RF treatments can sometimes be

Clinical Practice Radiofrequency

an issue for both patients and practitioners unfamiliar with these treatments. The effectiveness of these treatments are also very operator dependent, with wide variation based on experience and aggressiveness of treatments. Appropriate patient selection and realistic management of expectations, as with all non-surgical aesthetic treatments is key in the use of RF. Conclusion Radiofrequency in aesthetic practice is an effective and relatively safe treatment, which has applications in multiple aesthetic clinical concerns, from skin laxity to cellulite. A huge number of RF devices are available on the market so it can be difficult to decide which would suit your patient group most. The new multi-modality devices, such as those combining RF with ultrasound or lightbased technologies offer exciting and diverse options for clinics and practitioners looking to purchase new equipment that fulfils a broad range of patient demands. The most advanced RF devices are constantly being improved and developed so it is important to keep up-to-date with the latest technological advances in this field and as with all practices in medical aesthetics, there is a requirement for further research to fully evaluate the optimum parameters for usage of these treatments.

Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his nonsurgical aesthetic practice, having worked in this sector part-time for almost seven years.

REFERENCES 1. Mutalik, S. Radiofrequency in dermatosurgery. J Cut Aesth Surg. 2008; 1:pp94 2. Goldman MP, Alster TS, Weiss R., A randomized trial to determine the influence of laser therapy, monopolar radiofrequency treatment, and intense pulsed light therapy administered immediately after hyaluronic acid gel implantation Dermatol Surg. 2007; 33(5):pp.535-542 3. Elsaie ML, Choudhary S, Leiva A, Nouri K. Nonablative radiofrequency for skin rejuvenation, Dermatol. Surg. 36, pp.577, g.l. Surg.

4. Kist D, Burns AJ, Sanner R, et al. Ultrastructural evaluation of multiple pass low energy versus single pass high energy radiofrequency treatment, Lasers Surg Med. 2006; 38:pp.150-15 5. Dover JS, Zelickson B. Results of a Survey of 5,700 Patient Monopolar Radiofrequency Facial Skin Tightening Treatments: Assessment of a Low-Energy Multiple-Pass Technique Leading to a Clinical End Point Algorithm, Dermatol Surg. 2007; 33:pp.900-907 6. Ruiz-Esparza, J. and Gomez, J. B. Nonablative Radiofrequency for Active Acne Vulgaris: The use of Deep Dermal Heat in the Treatment of Moderate to Severe Active Acne Vulgaris (Thermotherapy): A Report of 22 Patients, Dermatol Surg. 2003; 29: pp.333-339 7. Krueger N, Sadick NS, New-generation radiofrequency technology, Cutis. 2013; 91(1):pp39-46 8. Chandrashekar BS, Sriram R, Mysore R, Bhaskar S, Shetty A. Evaluation of Microneedling Fractional Radiofrequency Device for Treatment of Acne Scars, J Cutan Aesthet Surg. 2014; 7(2): pp.93.14 9. Kim ST, Lee KH, Sim HJ, Suh KS, Jang MS. Treatment of acne vulgaris with fractional radiofrequency microneedling, J Dermatol. 2014;41(7):pp.586-91 10. Wanitphakdeedecha R, Iamphonrat T, Thanomkitti K, Lektrakul N, Manuskiatti W. Treatment of abdominal cellulite and circumference reduction with radiofrequency and dynamic muscle activation J Cosmet Laser Ther. 2015; 17(5):pp.246-51 11. Luebberding S1, Krueger N, Sadick NS. Cellulite: an evidence-based review Am J Clin Dermatol.

2015; 16(4):pp.243-56 12. Hurwitz D1, Smith D. Treatment of overweight patients by radiofrequency-assisted liposuction (RFAL) for aesthetic reshaping and skin tightening Aesthetic Plast Surg. 2012; 36(1):pp.62-71 13. de Felipe I, Del Cueto SR, Pérez E, Redondo P, Adverse reactions after nonablative radiofrequency: follow-up of 290 patients J Cosmet Dermatol. 2007; 6(3):pp163-6 14. I Bogdan Allemann & D J Goldberg, Radiofrequency Devices, Basics in Dermatological Laser Applications Karger; New York, (2011) p.150 15. J. Kaufman, Radiofrequency successful for aesthetic indications as technology evolves, Dermatology Times, (2011) <http://dermatologytimes.modernmedicine.com/dermatology-times/news/ modernmedicine/modern-medicine-feature-articles/radiofrequency-successful-aes?page=full> 16. MSI, Radio Frequency Technology, (N.D) <http://www.msimedspa.com/en/subservicesdetails. aspx?SubSrvceId=16&SrvceId=10>

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Technique Perioral Treatment

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Non-surgical combination technique for treating the perioral area Dr Richard Marques explains his approach to rejuvenating the perioral area using a four-stage process There are many different types of treatments that can be used on the perioral area to reduce fine lines and achieve a rejuvenated look. This article describes a multi-step process using four stages consisting of: a TCA chemical peel, microneedling, botulinum toxin and dermal filler, which aims to give a refreshed and youthful appearance to the lips and perioral area. There are of course many other methods that can be used, however this article will concentrate on the treatments listed above and detail how they can be used in succession as one overall treatment for the area, with which I have personally had much success.

It is important that the practitioner wears latex gloves during this time to protect the hands.1 The TCA peel removes the top-layer of dry (or dead) skin cells. This is done as the first step to allow the microneedling to work more effectively, helping the serums to penetrate to the dermis. No further treatment should then be given to the patient for one to two weeks before proceeding to the next step in the treatment process. This will give the skin a chance to recover. During this time, bright sunlight should be avoided and sun protection and moisturiser used, as the skin can be affected by UV rays. This is due to a part of the protective layer of the skin having been removed during the treatment process.

The Four-step Process

Step Two The second step of treatment involves microneedling around the patientâ&#x20AC;&#x2122;s mouth to stimulate new skin production and introduce vertical channels for serums to penetrate. A 1.5mm-2mm microneedle with 35 needles should be used, I believe this is the optimum microneedle due to its depth being able to penetrate to the dermis, but not being too aggressive. Microneedling is carried out by applying even pressure around the perioral area to produce the characteristic insertion points. Co-enzyme Q and EGF serums (containing vitamins A, C and E) are recommended for use after the treatment.

This should then be left for another one to two weeks before proceeding to the next stage.

Step One It is important that the perioral area is thoroughly cleaned and prepped before starting any treatment, ideally with sterile wipes to prevent any antimicrobial infection.

The first step in this treatment course is to use a 30% trichloroacetic acid (TCA) solution peel. The 30% solution is my preference as it is gentler in this delicate area, but still effective. A spot test should be performed first to assess the skinâ&#x20AC;&#x2122;s reaction to the solution. A thin layer of the TCA solution is then applied around the perioral area with a facial brush and the solution is left in place for one to two minutes. Following this, I use a neutraliser to halt the progression of the peel.

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Step Three The third step is the use of botulinum toxin in two areas; the mentalis muscle and the corners of the mouth. Firstly, I inject around 5-10 units of toxin in the mentalis muscle in the chin, to lessen the strength of the chin muscles and help prevent the potential appearance of a masculine mouth, as the strong chin muscle is associated with a male appearance. I use just one point of injection in the central part of the lower chin.

Secondly, I inject in the corners of the mouth to prevent a downward pull, which can lead to a relaxed upward smile. Typically, around four units should be injected into the depressor anguli oris (DAO), either side, to relax the muscles and prevent the downward pull in this area. This is the area where care must be taken not to over-inject or dissipate, in order to avoid affecting mouth function.

The correct technique is to place your finger just below the corner of the mouth and inject at this point. This gives you the correct insertion point and prevents the botulinum toxin from travelling up too high.2 Treatment should then be left for a further two weeks before finishing with hyaluronic acid dermal fillers.

The 30% solution is my preference as it is gentler in this delicate area, but still effective Step Four For the best filler results overall, you need to select the correct filler, the correct depth of injection and the correct depth of filler placement. I have found that Teosyal Deep Line or JuvĂŠderm Ultra are good fillers to use in this area. One syringe (1ml) is recommended for the lip area and one syringe (1ml) for the area around the mouth.

This amount avoids over-bloating of the lips. By using a cannula and an automated dispenser it will aid the treatment around the lips and help administer the filler in a controlled, gradual manner. When injecting the lip, I typically recommend giving the

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patients a dental block; this helps to reduce any discomfort, although many dermal fillers now come with local anaesthetic in them.

In the lip area, I use a ‘linear threading’ technique, where the needle is inserted into the skin and the filler is deposited in a linear fashion along the track as the needle is slowly withdrawn.3 This is first used in retrograde to plump the lips and can be corrected with extra product if necessary. The vermillion border and vertical rhytides are important, and a gradual 0.5ml of filler can be used here.

This amount fills the creases without causing puffiness in the area. By injecting in the corners of the lips, you can produce a cupid’s bow appearance. Providing support here and in the philtrum of the lip aims to produce a natural-looking appearance.

Points to consider To achieve accurate and natural results it is important to think about the anatomical features of the area you are treating. The distance between the base of the nose and upper lip should be 18-20mm and between the base of the nose and lower lip it should be 36-40mm – I believe these are the ideal

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dimensions. The melomental folds can also be filled out after assessment following botulinum toxin. To assess, get the patient to move their mouth and check for appearance of the folds. You must place the filler gently in this area and the injection should be sub-dermal and not too superficial to reduce these lines. For the melomental folds it is best to use a cross-hatching and/or fanning technique.

Aftercare instructions are important at each stage of the process to ensure the best outcomes for the patient, especially in a multi-stage process such as this. Examples of aftercare instructions include not using saunas or steam rooms during the process.

Managing complications Complications can occur with any procedure. The botulinum toxin may cause unwanted loss of mouth movement; in this instance, the patient should be reassured, as it will return to normal in one to three months. Dermal fillers can cause lumpiness but hyaluronidase can be used to dissolve these. Massaging afterwards helps to avoid the formation of lumps.

Technique Perioral Treatment

If you have any doubts, always seek advice from a mentor or refer to a more experienced practitioner.

Conclusion Overall, this four-step treatment can give fantastic results for lip and perioral rejuvenation but must be performed in a careful and considered manner. The practitioner should review the patient’s progress between each stage of treatment, and time adjustments should be made as appropriate.

Dr Richard Marques is a dentist and aesthetic practitioner, specialising in the mouth area. He operates from his Wimpole Street Dental clinic off Harley Street and has worked to perfect many celebrities’ smiles.

REFERENCES 1. Marta Rendon, Diane Berson et al, Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing, J Clin Aesthet Dermatol.

2010 Jul; 3(7): pp.32–43.

2. PK Nigham and Ajana Nigham, Botulinum Toxin, Indian Journal of Dermatology 2010 Jan-Mar; Ed 55 pp.8-14 3. S, R. Cohen, Techniques in Aesthetic Plastic Surgery Series, Facial Rejuvenation with Fillers with DVD, Volumetric use of injectable fillers in the face, Saunders; China, 2009: p4 <http://www.elsevierhealth.co.uk/media/us/ samplechapters/9780702030895/Chapter%2007.pdf>

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Treatment Focus Breast Reduction

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Breast reduction by open-surgery vs. liposuction I believe the main advantage of performing breast reduction (reduction mammaplasty) by open-surgery over liposuction, is that the final shape and size of the breasts can be better predetermined.

This is because a skilled surgeon using open-surgery can shape the breasts by removing the right amount of both skin and fat, whereas liposuction can only remove the fat, not the skin. However, this does not mean that after liposuction the breasts will be left looking like an empty sac as, after the procedure, the skin is likely to contract and cause the breasts to be uplifted.

Breast Reduction using Liposuction Dr Harryono Judodihardjo details his technique for breast reduction using liposuction and explains how this procedure compares to opensurgical intervention Small breasts may cause many women to be psychologically unhappy with their appearance, however breasts that are too large (macromastia) can cause not only negative psychological effects, but also physical discomfort. The weight of large breasts can often cause backache, as well as embarrassment to the sufferers, due to their appearance. Successfully treated, these patients are often amongst the most grateful patients I treat within medical aesthetics.

There are two ways by which breasts can be reduced in size: the open-surgical method and the liposuction method. Even though breast reduction by liposuction is a procedure that was first introduced more than 20 years ago,1 many surgeons are still skeptical and prefer to perform breast reduction through open surgery. This article will discuss the advantages and disadvantages to both procedures, while also describing the techniques used for breast reduction by liposuction in more detail. There are many different methods of performing liposuction. I prefer to use the ‘Pure Tumescent Liposuction with microcannula technique’ as first described by Dr Jeffrey Klein. The term ‘liposuction’ used in this article refers to this particular method, which may or may not be similar to other methods of performing liposuction.

Before

Figure 1: Before breast reduction using liposuction

After

In my opinion, breast reduction by liposuction has many advantages over open-surgery. Here are some of them: • Less complication: infection and skin necrosis after liposuction is very rare.

• Less scarring: the scars left by liposuction are very small and almost undetectable, compared to the large anchor-shaped scars caused by open-surgery breast reduction.

• Faster recovery: after liposuction, patients can usually go back to work after just a few days of recovery.

• Less discomfort: painkillers are rarely needed after liposuction.

• Maintaining nipple sensation: liposuction causes much less trauma to the nerves compared to open-surgery, therefore most patients do maintain their nipple sensation after the procedure.

• Maintaining the ability to breastfeed:2 liposuction tends to only remove the adipose tissue and not the glandular tissue, and, thus, the ability to breastfeed after the procedure is usually maintained.

• Lower cost: liposuction is a day procedure, mainly performed under local anaesthetic only. No hospital stay is needed after the procedure. The cost should therefore be lower than the more invasive surgical reduction mammoplasty.

Patient selection for breast reduction liposuction The ideal patients for breast reduction liposuction are healthy females who are aged 40 or above, who have realistic expectations of the outcome. Older female’s breasts have more fat than glandular tissues and this makes it much easier to perform the liposuction. Glandular tissues are fibrous and make it difficult for the liposuction cannula to penetrate. The result will also be better in the fatty breasts, as a larger volume of fat can be removed. It is important that before the procedure, the practitioner estimates how much fat is to be taken out, or otherwise too much fat might be removed.

Surgical reduction mammoplasty, on the other hand, is less suitable for older females. Compared to liposuction, the more invasive surgical procedure has an increased risk of poor wound healing and infection after the surgery.3 Breast reduction liposuction can reduce the appearance of ptotic breasts, but the main function of this procedure is for reducing breast volume. Patients who need a breast uplift are not suitable for liposuction and should be referred for breast uplift surgery.

Figure 2: After breast reduction using liposuction

Images courtesy of Dr Harryono Judodihardjo

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Concerns of reduction mammoplasty There are differing opinions as to whether a mammogram is needed prior to a reduction mammaplasty treatment. The result of a recent survey showed that UK breast surgeons tend to be pro-mammogram prior to the treatment, but plastic surgeons seemed to be less inclined to do so.4 Breast cancer is the most common cancer in

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women and occult cancer cells have been found in the histological specimens obtained from surgical reduction mammoplasty.5 The risk of finding occult malignant cells is believed to increase with advancing age, so it is therefore prudent to encourage patients to have a mammogram done prior to either method of reduction mammoplasty procedures, especially those in the 50 and above age group.6 One common question asked by patients is: does reduction mammoplasty cause breast cancer? To my knowledge, there has been no evidence of this so far. In fact, the opposite seems to be true. There is evidence that indicates that the risk of developing breast cancer is correlated to the size of the breast.7 Larger breasts have more breast tissues and, therefore, there are more cells that are potentially capable of becoming malignant. Surgical reduction mammaplasty has been shown to reduce the incidence of breasts cancer and has even been suggested as a prophylactic procedure.8 So far, I have found no evidence that breast reduction by liposuction causes breast cancer.

Some practitioners are concerned that either method of reduction mammoplasty will make it difficult to detect breast cancer in the future.

The worry is that the scar tissue and fibrosis after the procedure will somehow make it more difficult for a radiologist to spot the breast changes. I have more than 15 years experience in performing breast reduction by liposuction and have so far not received a single complaint from any radiologists that the procedure has made it difficult for them to do their job competently. Other practitioners who have studied this question more systematically also share this opinion.9 Breast reduction liposuction procedure Practitioners who are already proficient in performing liposuction should be able to perform breast reduction liposuction, once they have been sufficiently trained. The procedure is largely similar to performing liposuction to other areas of the body.

Like any other medical procedure, the patient will need a full medical consultation and examination prior to the procedure. It is important to find out what is really troubling the patient – is it breast ptosis or large volume? Examine the patient to see if they need a breast lifting procedure or breast reduction procedure and advice the patient accordingly. The breasts will also need to be examined for signs of breast cancer. I would then advise that you send the patient home to think about what has been said and also to encourage them to have a mammogram done if they are going to have the procedure.

On the day of the procedure, perform a general medical examination to make sure that the patient is fit for the treatment. Take photographs prior to the treatment as some patients do forget how they looked before and you can compare these with the patient after the procedure. This is not a common problem for breast reduction, as most patients will be relieved by the reduction in the breast weight and be less concerned with the aesthetic outcome of the procedure.

Estimate the volume of the breasts using the water displacement technique as discovered by Archimedes.10 Put simply, just dip a breast, one at a time, in a bucket of water filled to the brim and measure the volume of the water displaced. This will give a guide as to how much fat can be removed. As a general rule, do not remove more than half of the breast volume.

The liposuction procedure itself is quite straightforward. Remove the fat from the entire breast as necessary, while avoiding the tough glandular tissues. The liposuction cannula will need to be maneuvered to go round the glandular tissues that are normally placed just under the areolar. Avoid performing liposuction on an area of about 10cm wide under the clavicles, as this area is more vascular. Also avoid

Treatment Focus Breast Reduction

The ideal patients for breast reduction liposuction are healthy females who are aged 40 or above putting the incision site in the keloid-prone area around the sternum.

After the procedure, compress and bind the area tightly to avoid bruising. Personally, I do not stich the small incision sites needed for the microcannula access, as this will allow the tumescent fluid and blood to leak out, and, thus, reducing haematoma. I advise my patients to remove all compression after 24 hours and to wear a brassiere that they are used to wearing, and not to change them for smaller brassieres until at least four weeks post treatment. I found that excessive pressure only delays the healing and does not lead to better results.

Potential complications Breast reduction by liposuction, if done properly, is generally very safe.

The complications are no different to liposuction used in other areas of the body. These include: haematoma, pseudo-cysts formation, infection, bruising, swelling, mild pain and tenderness.11 Patients need to be advised that, as with all liposuction, the best results can only be seen six to 12 months after the surgery.

Conclusion Reduction mammaplasty by liposuction can offer a lot of advantages over the open-surgical method. This is a procedure that has been tried and tested for more than 20 years, while also being indicated as safe and effective.1 For the sake of our patients, this simple procedure should be recommended more often, especially to those who are older and are at a higher risk of complications from open surgery.

Dr Harryono Judodihardjo is the medical director of the Cellite Clinic in Cardiff that he founded in 1998.

He obtained his master’s degree and PhD in dermatology from the University of Wales College of Medicine.

He specialises in aesthetic dermatology procedures such as liposuction, hair transplant, lasers and injectable treatments.

REFERENCES 1. Matarasso A, Courtiss EH. Suction mammoplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg 1991;87:709–716.

2. Habbema L, Alons JJ. Liposuction of the female breast: a histologic study of the aspirate. Dermatol Surg. 2010 Sep;36(9):1406-11.

3. Shermak MA, Chang D, Buretta K, Mithani S, Mallalieu J, Manahan M. Increasing age impairs outcomes in breast reduction surgery. Plast Reconstr Surg. 2011 Dec;128(6):1182-7.

4. Hennedige AA, Kong TY, Gandhi A. Oncological screening for Bilateral Breast Reduction: a survey of practice variations in UK Breast and Plastics surgeons 2009. J Plast Reconstr Aesthet Surg. 2011 Jul;64(7):878-83.

5. Freedman BC, Smith SM, Estabrook A, Balderacchi J, Tartter PI. Incidence of occult carcinoma and high-risk lesions in mammaplasty specimens. Int J Breast Cancer. 2012;2012:145630.

6. Van der Torre PM, Butzelaar RM. Breast cancer and reduction mammoplasty: the role of routine preoperative mammography. Eur J Surg Oncol. 1997 Aug;23(4):341-2.

7. Jansen LA, Backstein RM, Brown MH. Breast size and breast cancer: a systematic review. J Plast Reconstr Aesthet Surg. 2014 Dec;67(12):1615-23.

8. Palmieri B, Benuzzi G, Costa A, Grappolini S. Breast reduction and subsequent cancer: a prophylactic perspective. Breast. 2006 Aug;15(4):476-81.

9. Muir TM, Tresham J, Fritschi L, Wylie E. Screening for breast cancer post reduction mammoplasty.

Clin Radiol. 2010 Mar;65(3):198-205.

10. Archimedes’ principles (US: Encyclopedia Britannica, 2014) http://www.britannica.com/science/ Archimedes-principle 11. Liposuction – Risks (UK: NHS Choices, 2015) <http://www.nhs.uk/Conditions/Liposuction/Pages/Risksand-complications.aspx>

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The Power of Skin Resurfacing Q&A with qualified medical aesthetician and registered nurse Sarah Dale of Sarah Dale Aesthetics What attracted you to purchase a NanoFractional RF™ device?

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Our Clinic was seeing a lot of skin irregularities that our IPL alone could not handle. The clinic needed equipment that would complement our existing services without competing as well as give clients a results oriented treatment. I wanted something with as little discomfort and downtime as possible but packed with benefits.

How Does the Venus Viva Work?

melasma, scars and skin texture but I have the confidence and education to know that skincare alone would not get the results we were aiming for. I was first introduced to Venus Concept with the purchase of my first medical device: The Venus Freeze, which I still use to this day. It is in my opinion the safest radio frequency device on the market. I was attracted to this device as it was compact, portable and did not require the downtime and pain associated with fractional treatments and I was so impressed with the results as well as the support from the company that when they announced the launch of the Venus Viva I purchased the machine immediately.

complete versatility with customized treatment settings for multiple levels of ablation or coagulation. Viva™ also utilizes a unique energy delivery mechanism called SmartScan™ that consists of two distinct features:

The Venus Viva™ operates with the revolutionary NanoFractional Radio Frequency™ (RF) and SmartScan™ technology that delivers results through selectional dermal heating.

The use of NanoFractional RF™ delivers energy through the epidermis, to the dermis, rebuilding collagen and fibroblast stimulation, all resulting in tissue remodelling. The Venus Viva

payment options as well as business support.

We have been very happy not only with the results of the Venus Viva but with Venus Concept the company itself.

After

What results are gained from a NanoFractional RF™ resurfacing treatment?

At SDA we have seen a wide range of positive results from a decrease in visible pores, evening skin texture, reduction in fine lines and wrinkles, reduced pigment in melasma,

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Safe on all skin types, regardless of age or colour Patients with Acne scars, fine wrinkles and surface irregularities of the skin

Patients with loose skin Patients who desire a smother appearance and tightening of their skin Patients looking to improve the tone and texture of their skin 1. RF energy is deployed via an array of small pins into the skin in a “scanner” like manner creating up to 160 micro wounds with every pulse. This results in significantly reduced patient discomfort compared to other technologies, with more consistent endpoints and reduced downtime.

2. SmartScan™ also consists of a pattern selection tool that allows the clinician to customize the treatment size and density for each pulse. This results in safer, more optimized treatments with better clinical outcomes.

What is to be expected of the Treatment? Who is a candidate for this treatment?

Before

Safe for both men and women

Patients with pigment irregularities such as sun damage and freckles

What should you look for when purchasing a NanoFractional RF™ device?

Make sure it is safe technology. At SDA we only partner with quality companies that have proven trusted technology as well as a FDA stamp of approval. It’s very important to see case studies,

outcomes of the skin as well as many other complimentary treatments. Immediately after the treatment the skin is red and warm which will resolve in a few hours. The treatment is well tolerated and there is little to no discomfort after the treatment. Depending on the level of ablation you and your medical provider have chosen the degree of redness and mild irritation will vary. We recommend camouflage makeup and you may return to work the same day. The 15 minute fraction procedure is performed comfortably and may involve using a topical anaesthetic cream and cryogen skin cooler if patient desires. Candidates for this treatment:

Typical treatment protocol consists of 2 to 3 treatments spaced 3 to 4 weeks apart. The Venus Viva treatment may be bundled in a complete program with tightening treatments, IPL treatments for advanced colour correction, EMS for strengthening the muscles for a facial elevation, chemical peels and microdermabrasion for clearing acne lesions, neurotoxin and soft tissue fillers to enhance the aesthetic

Aesthetics | January 2016

Cost of treatment starts at £250 per session.

Before

After

www.venusconcept.com 0208 748 2221 www.sarahdaleaesthetics.com Sarah Dale is a qualified Registered General Nurse who, after having received electrolysis for hair removal for many years decided to start her Light treatments for permanent hair removal and skin rejuvenation.

Now an advanced practitioner with over 10 years experience in IPL/Laser Treatments and Equipment and more recently Venus Viva treatments. She regularly updates her training to ensure use of the most advanced professional standards.

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Abstracts Clinical Papers

A summary of the latest clinical studies Title: Mechanism of Action, Efficacy, and Adverse Events of Calcium Antagonists in Hypertrophic Scars and Keloids: A Systematic Review Authors: Verhiel S, Piatkowski de Grzymala A, van der Hulst R Published: Dermatologic Surgery, December 2015 Keywords: Scars, calcium antagonist verapamil, hypertrophic scar, keloids Abstract: Pathological scars often cause major cosmetic and functional consequences, which make effective treatment important. An emerging and promising treatment option is the calcium antagonist verapamil. The aim of this study was to provide a comprehensive evidence-based review of current evidence on mechanism of action, efficacy, and adverse events of calcium antagonists in treatment of hypertrophic scars and keloids. A Cochrane Library and PubMed search was performed for the literature pertaining to treatment with calcium antagonists in pathological scars. Articles were categorized into two groups: mechanism of action or efficacy and adverse events. Six in vitro studies were included in the first subgroup. Calcium antagonists have been found to reduce extra cellular matrix production, induce procollagenase synthesis, and inhibit interleukin-6, vascular endothelial growth factor, and proliferation of fibroblasts. Eight studies with a median level of evidence of 3.5 (range: 2-4) were included in the second category.

Important methodological shortcomings of the available literature were identified. Interesting results have been reported, but further large scale, high-quality studies are needed to optimally evaluate efficacy of treatment with calcium antagonists.

outpaced inflation, national health expenditure growth, and increases in reimbursements for physician services.

Title: Changes in Retail Prices of Prescription Dermatologic Drugs From 2009 to 2015 Authors: Rosenberg ME, Rosenberg SP Published: The Journal of the America Medical Association Dermatology, November 2015 Keywords: Dermatology, prescription drugs, medication, survey Abstract: To determine the changes in the prices of commonly prescribed dermatologic medications since 2009 and to identify trends in price increases for different classes of drugs. Four national chain pharmacies received surveys requesting price data on commonly prescribed dermatologic drugs in 2009, 2011, 2014, and 2015.

Subsequent surveys increased to eventually include 120 additional brand-name drugs and their generic alternatives when available.

Owing to the frequency of prescription, diseases treated, or unusual price increases, 19 brand-name drugs surveyed in all 4 years were selected for final price trend analysis, which was conducted from August 1 to 15, 2015. Retail prices of topical and systemic drugs for the treatment of various dermatologic conditions. Prices of surveyed brand-name drugs increased rapidly between 2009 and 2015. Of the 19 brand-name drugs analyzed, the retail prices of 7 drugs more than quadrupled during the study period. Among these 19 drugs, the mean price increase was 401% during the 6-year survey period, with the majority of the price increases occurring after 2011. The price of prescription dermatologic drugs rose considerably from 2009 to 2015, with the vast majority of price increases occurring after 2011. Percent increases for multiple, frequently prescribed medications greatly

Title: Update on the Management of Rosacea Authors: Weinkle AP, Doktor V, Emer J Published: Plastic Surgical Nursing, October-December 2015 Keywords: Rosacea, laser, topical systemic, light therapy, skin disorder Abstract: Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea.

Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future.

Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Title: Differential diagnosis of heavily pigmented melanocytic lesions: challenges and diagnostic approach Authors: Aung PP, Mutyambizi KK, Danialan R, Ivan D, Prieto VG Published: Journal of Clinical Pathology, December 2015 Keywords: Melanoma, hyperpigmentation, scar, pigmented lesion Abstract: The differential diagnosis of heavily pigmented melanocytic neoplasms includes melanoma (especially animal type), melanosis of partially or completely regressed melanoma, blue naevus (BN), pigmented Spitzoid lesions, recurrent naevus, combined naevus, pigmented spindle cell naevus, epithelioid blue naevus of the Carney complex/pigmented epithelioid melanocytoma, deep penetrating naevus, hyperpigmented scar after surgery of melanoma in which there are also melanophages and hyperpigmentation due to the minocycline, a tattoo or a hyperpigmented scar. Pathologists face challenges when evaluating a pigmented lesion, especially in a small superficial biopsy, because it is difficult to access important histopathological features to differentiate benign versus malignant melanocytic lesions. The histological features that favour a diagnosis of melanoma include dimension (>6â&#x20AC;&#x2026;mm), asymmetry, poor circumscription, irregular confluent nests, confluent lentiginous junctional melanocytic proliferation, lack of maturation with descent in the dermis, suprabasal pagetoid melanocytes, asymmetrical distribution of melanin pigment, cytological atypia, dermal mitotic figures, asymmetrical dermal lymphocytic infiltrate and necrosis.

Aesthetics | January 2016

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Distinguishing Fake and Counterfeit Aesthetic Products Professor Andy Pickett details the types of fake and counterfeit aesthetic products on the market and shares advice on how the industry can help to stop their global circulation The global pharmaceutical market is currently valued at approximately US $1,000 billion a year, and has doubled within the last ten years.1,2,3 The industry is continuously growing, with, for example, around 7,000 biopharmaceutical products alone still in development.4 Unfortunately, however, the manufacture and distribution of fake and counterfeit pharma products is prevalent throughout the world. The urge to make quick money from the misfortune of patients, many of whom are in dire need of those products, seems irresistible to many. Figures from the Pharmaceutical Security Institute (PSI), established in 2002 as a joint industry activity to combat counterfeit products, show the extent of the issue.

The PSI reports more than 2,000 incidents each year over the past five years on record; almost half the arrests in relation to the incidents have been in Asia.5 Large-scale police operations from international organisations such as INTERPOL have also reported significant illicit trade. In November 2008, INTERPOL began Operation Pangea I to target the sale of illegal medicines online. The organisation has since continued this operation every year, with Pangea VIII in 2015 resulting in a record 20.7 million illegal medicines seized, worth USD $81 million.6 Counterfeit vs. Fake Types of illegal products fall into two categories, counterfeit products and fake products.7 Counterfeit products are designed to deceive the purchaser by branding the copy with the same name as the original. They are often difficult Aesthetics | January 2016

Product Knowledge Illicit Products

to tell apart from the original, as the packaging is carefully copied and almost indistinguishable from the branded product.8 Fake products, on the other hand, are given different names and branding but still make false claims to efficacy, purity and potency by pretending to be the same as the original – but cheaper.9 Enticing names are often used which could, through the direct-to-consumer sales on the internet, deceive clinicians, as well as the public, into buying them. These simple definitions make identifying illegal products, and what type they are, easier. Other definitions can be much more complex, such as those adopted by the World Health Organisation (spurious/falsely-labelled/ falsified/ counterfeit medicines),10 however these terms are not necessary within the medical aesthetic industry.

In this article, two categories of illegal products that are regrettably now commonplace in the aesthetic industry are examined: botulinum toxin (BoNT) products and dermal fillers. Highly reputable distributors are a key element of the business chain integrity. Yet still, some practitioners buy directly from unnamed, illicit sources and deceive their patients into thinking that ‘it’s the same as the original’.

Hopefully, by drawing attention to the dangers of administering fake and counterfeit products, we will eventually see the prevalence of this issue decrease.

Botulinum toxin Since the subject was first highlighted in 2008,7 much has been written about illicit BoNT products that exist on the market. Even so, they still persist despite the warnings, alerts and information shared frequently with both practitioners and patients.

Together with Dr Martin Mewies, I analysed nine unlicensed BoNT products in 2007-2008 and published our data as an alert to all.7 There were three counterfeit products found in Brazil, Iran and Russia, and a series of fake products that we found easily within Iran. We found no toxin activity in three of the products, which was as expected; why would

Enticing names are often used which could, through the direct-to-consumer sales on the internet, deceive clinicians, as well as the public, into buying them 59

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you put real toxin into a fake product anyway? But, more alarmingly, we found up to five times the labelled potency in other product vials – three of the products contained more toxin than the labelled amount. This would result in an overdose to any patient given the material. We found no assurance of quality, safety or sterility for any of the products we examined, except for some nicely designed certification, apparently from regulatory authorities, which never existed anyway.7 Colleagues in other companies, coincidentally, published similar findings for a fake BoNT product of Chinese origin.11 In general, the illegal BoNT products seemed to mostly originate from Asia, in particular, China. We investigated further and discovered that even legal Chinese products, available in China, were also being illegally distributed in some countries under several product names.11 With no assurances of safety, these fake and counterfeit products can provide a serious risk to patients. We found that most of the ‘data’ supporting them on their websites was false, invented or even stolen from other genuine product literature.7 The products are mainly targeted at the patient, using direct selling to cut out the doctor and give a ‘cheaper alternative’.

There has been one famous incident in the past where four patients were given ‘research grade’ BoNT at too high a dose.

Subsequently, they suffered the terrible effects of full-blown botulism as a result (overdosing with BoNT leads to the same effects as food-poisoning botulism).12 Details of this ‘Florida Incident’ in 2004 have been published several times, including a patient’s own terrible account of what she experienced.13 The incident has led the Food and Drug Administration (FDA) and the US Department of Justice (DoJ) to carry out a major investigation that has lasted many years due to the complexity and scale of the crimes being committed.14 Prosecutions are still being carried out today and are occasionally reported by the DoJ. The

With no assurances of safety, these fake and counterfeit products can provide a serious risk to patients. We found that most of the ‘data’ supporting them on their websites was false, invented or even stolen from other genuine product literature

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extent of illegal use of this product from a research supplier was extraordinary; hundreds of doctors were involved as well as entire clinics, leading to receptionists, nurses and doctors being jailed.14 The FDA has recently issued another warning to the profession about counterfeit Botox being detected in the US.14 The counterfeits have very similar packaging to the original so the FDA has included details in its alert about the differences found.

Botox, like all the BoNT products available in the US, is also used for therapeutic treatments of muscular conditions in doses far higher than used aesthetically. These higher doses of such illegal products pose great risk to the patient.

Dermal fillers Given the very large numbers of dermal filler products available throughout the world, it is no surprise that counterfeit and fake versions are readily available. Like BoNT products, they are generally destined for the public, sold and distributed through the internet. Although dermal fillers based on modern, hyaluronic acid (HA) formulations are recognised as ‘inert’ materials, achieving temporary results by physically filling wrinkles and creases in the face, there are many so-called ‘permanent’ filler products available illegally.15 The original ideas, which led to the birth of the permanent versions, were to minimise the number of treatments a patient would need over the years. Unfortunately, they are also the cause of side effects and issues from reactions in facial tissues.16 Legal, licensed, permanent fillers do exist and, when used safely, can produce successful aesthetic results. However, some comprise complex mixtures including, for example, bovine collagen and plastic microspheres.17 The use of these is far smaller than the HA-based products and often, skill and special techniques are required from clinicians to achieve satisfactory results without side effects. Training of even highly experienced practitioners is vital with these products. Placing permanent fillers into the hands of patients for self-injection is, therefore, a high-risk activity. Even worse, as we are all aware, providing poor quality, potentially unsterile products can lead to serious complications.

There are many clinicians who have had to physically remove these types of products from patients to eliminate the side effects of lumps, granulomas and other immune reactions.16

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In 2011, together with colleagues Colin Stone and Sherry Knight from the BBC, I investigated the availability of permanent fillers on the internet. I easily purchased one, which was sent in a US Postal Service envelope from Chicago, Illinois, as a syringe in a package and disguised in a catalogue of garden products. I ordered a second syringe later, because the first one had leaked into the packet. The rather extraordinary findings were published the same year, together with photos of what the product looked like.

The labelling of the syringes referred to a manufacturer that had gone out of business some years before – even the spelling of the labelling was incorrect.15 Working towards a solution Given the extent of the issues concerning fake and counterfeit products within the aesthetic industry, it is essential to keep informing clinicians of all the issues involved, both frequently and in detail.

How can this be achieved when there are so many publications now available? One solution is through international congresses, where many attendees from both the industry and professions can hear, first-hand, what the situation really is. The providers are then also equipped to inform their patients and reinforce the issues surrounding the use of unsafe illegal products.

For some time now, the major International Master Course on Aging Skin (IMCAS) congresses, in both Paris and Asia, have regularly held sessions to update clinicians on fake and counterfeit products. These sessions have been dedicated to providing the latest information on these fake products that is available from different regions of the world, especially Asia. This has led to IMCAS sponsoring the formation of the Global Coalition Against Fake Medical Aesthetic Products, a group of manufacturers and clinicians who focus on informing colleagues, patients and the industry throughout the world about all the issues associated with counterfeit and fake products. The Coalition was presented at IMCAS 2014 in Paris following successful sessions in Singapore, Shanghai and later sessions in Hong Kong and Paris, which kept the information flow at a concentrated level.

Stop the purchase There is really only one final solution to combat fake and counterfeit aesthetic products – stop their purchase. If there is no market and no demand for cheap copies, then there would be no such products. Constant education and information to highlight the issues, especially relating to safety, must be the way forward.

Product Knowledge Illicit Products

Informing both clinicians and patients about the risks being taken, and when and where these products are used, is of vital importance. The Coalition is a good example of how the industry can band together to achieve these aims.

Disclosure: Professor Andy Pickett is the director and founder of Toxin Science Limited, UK, adjunct professor at the Botulinum Research Center, IAS, USA and senior program leader & scientific expert, Neurotoxins, at Galderma Aesthetic and Corrective Global Business Unit. The opinions and views expressed in this article are those of the author and Toxin Science Limited only.

Professor Andy Pickett has provided scientific and technical expertise on the function, physiology, quality and production of botulinum toxin for more than 26 years. He has presented and written extensively on his research into fake and counterfeit products, aiming to raise international awareness of the potential risks to patients.

REFERENCES 1. IMS Health, IMS Health Forecasts Global Drug Spending to Increase 30 Percent by 2020, to 1.4 Trillion, As Medicine Use Gab Narrows, (Danbury, US: IMS Health, 2015) <http://www.imshealth. com:90/en/about-us/news/ims-health-forecasts-global-drug-spending-to-increase-30-percentby-2020> 2. World Health Organisation, Trade, foreign policy diplomacy and health: Pharmaceutical Industry, (2015) <http://www.who.int/trade/glossary/story073/en/> 3. Statista, Revenue of the worldwide pharmaceutical market from 2001 to 2014(in billion U.S. dollars), (2014) <http://www.statista.com/statistics/263102/pharmaceutical-market-worldwide-revenue-since-2001/> 4. PhRMA Chart Packs, Pharmaceuticals in perspective 2015, (Washington DC, 2015) <http:// chartpack.phrma.org/biophrma-chartpack/research-and-development/more-than-7-000-medicines-in-development-globally> 5. Pharmaceutical Security Institute, Counterfeit Situation: Indecent Trends, (Washington DC, 2014) < http://psi-inc.org/incidentTrends.cfm> 6. INTERPOL, Operations: Pangea, (2015) <http://www.interpol.int/Crime-areas/Pharmaceutical-crime/Operations/Operation-Pangea> 7. Pickett, A & Mewies M, Serious issues relating to the clinical use of unlicensed botulinum toxin products, J Am Acad Dermatol, 61 (2009), p.149-50.

8. World Health Organisation, ‘Fact sheet N°275 ’, Substandard and counterfeit medicines, (2003) <http://www.who.int/mediacentre/factsheets/2003/fs275/en/> 9. Pickett A, ‘Researcher Examines the World of Fake Injectable Products,’ The Aesthetic Guide, Medical Insights Inc, (2011) p.48-56.

10. World Health Organisation, ‘Fact sheet N°275 ’, Medicines: spurious/falsely-labelled/falsified/ counterfeit (SFFC) medicines, (2012) <http://www.who.int/mediacentre/factsheets/fs275/en/> 11. Hunt, T & Clarke, K, Potency of the botulinum toxin product CNBTX-A significantly exceeds labeled units in standard potency test, J Am Acad Dermatol, 58 (2008) p.517-8.

12. Chertow, D.S., et al., Botulism in 4 adults following cosmetic injections with an unlicensed, highly concentrated botulinum preparation, JAMA, 2006. 296 (20), p.2476-9.

13. Marcus, S.M., Reflections on the care of a patient severely poisoned by ‘rogue’ botulinum toxin and rendered paralysed for a protracted hospital stay. The Botulinum Journal, (2009) p.318-339.

14. FDA Law Enforces Crack Down on Illegal Botox Scammers, 2015 http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm048377.htm Pickett, A., Serious issues relating to counterfeit dermal fillers available from Internet sources. J Am Acad Dermatol, 65 (2011) p.642-3.

15. Funt D & Pavicic T, ‘Dermal fillers in aesthetics: an overview of adverse events and treatment approaches,’ Clinical, cosmetic and investigational dermatology, CCID 6 (2013) p.295-316.

16. Attenello NH & Maas CS, ‘Injectable fillers: review of material and properties,’ Facial Plast Surg 31(2015), p.29-34.

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product ingredients and the benefits they can have. As such, they should be able to provide valuable advice to patients while ensuring their skin is in the optimum condition to enhance the effects of medical treatments. In our clinic, our cosmeceutical suppliers provide extensive training on the different ranges of products they offer to ensure medical aestheticians offer the correct combination of products to patients, which suit a range of different skin types and conditions.

Doing so can bring substantial additional revenue and profits to the clinic, as well as increase the repeat number of visits patients make to purchase professional skincare products.

Reducing costs One of the most valuable contributions that medical aestheticians can bring to a business is to lower costs per treatment. The average aesthetic doctor is paid in excess of £100 an hour, meaning each minute of their schedule is precious as they offer high-end clinical aesthetic treatments whilst maintaining the success of their business.

Medical aestheticians, on the other hand, usually cost less than £20 an hour. They are able to perform the treatments that do not have to be carried out by highly-skilled medical practitioners, for instance laser hair removal and fat freezing that are often labour intensive.

The Benefits of Medical Aestheticians Clinic operations director Amanda Elbourn discusses the advantages of employing a medical aesthetician in your clinic Beauty is a major component of the science and technology industries. In the UK alone there are more than one million people employed in the field of cosmetics, which is worth an estimated £17 billion – a figure that is predicted to grow by a further 16% in 2016.1,2 Even through the tumultuous times of the recession, the UK beauty industry thrived, expanding by 15.5% from £6.1 billion in 2008 to £7.1 billion in 2013. 1,2 With such rapid growth there is strong justification for investing in aestheticians to work in medical clinics (medical aestheticians), a role that is proving invaluable for aesthetic businesses in order for them to expand and flourish. In Courthouse Clinics, for example, medical aestheticians performed more than 30,000 treatments in 2014 alone, and the clinic chain currently employs 33 medical aestheticians across 10 different sites.4 There are endless benefits to employing medical aestheticians, which in turn benefit both the patient and the medical practitioner.

Practitioner benefits The care and support provided by medical aestheticians does not only benefit the patients. When performing advanced medical treatments that require assistance, medical practitioners can use the medical aestheticians not only to aid them in carrying out the procedure, but also to provide valuable patient care and attention. Again, cementing a trusting relationship between patient and aesthetician as well as between the doctor/nurse and aesthetician is paramount for repeat business, overall satisfaction and business growth.

Skincare is a huge growth area in medical aesthetics. Last year the total value of skincare sales in the UK was £1 billion and the anti-ageing sector now accounts for 42% of total UK sales.3 Medical aestheticians should have in-depth knowledge regarding the anatomy of skin, 62

Expansion Another significant advantage to employing medical aestheticians is the facility to expand upon the clinic portfolio. There is a vast array of technologies and techniques that would prove detrimental to profit if they were to be offered by a doctor or a nurse. These ‘entry-level treatments’ include popular and well-known procedures such as microdermabrasion, skin health assessments, some skin peels and various laser treatments that can complement more advanced treatments. It is simply not cost-effective for medical practitioners to provide these. Medical aestheticians are not only able to carry these treatments out at a lower cost rate to the business, but are also able to act as consultants for patients, educating them and suggesting complementary medical practitioner-led treatments as well as introducing possible skincare ranges offered within the clinic. To put this into perspective, more than 30% of patients who initially booked to see a medical aesthetician at Courthouse Clinics later booked an appointment with a doctor.4 As previously mentioned, science and technology plays an important role within the beauty industry. Along with the progression in our understanding of the human body, there has been an emergence of innovative technologies that are able to tackle cosmetic concerns for the face, body and skin that require less medical skill to operate.

Sophisticated equipment within clinics is now commonplace; some expensive services that would previously have been provided by a highly-qualified doctor or nurse can now be made more affordable to the patient when performed by less qualified employees. From a business standpoint, this provides a significantly higher profit margin.

A medical aesthetician with the appropriate training and skill level has the potential to bring approximately £2,000 income4 to the business each week through offering these lower-skill treatments.

Other aesthetic treatments can be provided by a combination of both a medical practitioner and a medical aesthetician. Microneedling, for example, provides the opportunity for a two-tier pricing system that will suit different clients’ budgets. Some patients prefer to continue to use the same practitioner that they have built a rapport with, whilst other patients prefer a doctor to perform their treatment, which provides the patient with choice and confidence. Some treatments combine the requirement for both medical practitioner and medical aesthetician,

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for example a doctor may consult a patient with acne concerns but suggest a combination of skin peels and light rejuvenation treatments that can then be administered by the medical aesthetician. There is also a requirement for both a medical practitioner and medical aesthetician to be present for certain aesthetic procedures, i.e. during minor operations and advanced laser skin resurfacing treatments, the medical aesthetician can assist a doctor at a considerable lower cost than a nurse. This allows the medical aesthetician to assist in more complicated procedures and ensure maximum patient comfort.

Marketing Medical aestheticians are, relatively speaking, an ingenious and natural marketing tool for any aesthetic business. It could be argued that there is a more personable approach between the patient and the aesthetician as the rapport is often based on repeated treatments, from monthly to even weekly revisits, e.g. combination skin rejuvenation treatments. A level of trust is often developed that allows the patient to feel comfortable when seeking advice on advanced and more expensive procedures e.g. injectable treatments. Medical aestheticians should have a sound knowledge of all treatments offered within the clinic to answer any initial questions that would then encourage a new consultation with the doctor. Patient experience for more complex procedures can also be greatly improved as medical aestheticians can add a beauty element with an additional relaxing service. For example, they could offer a soothing hand massage while the patient is under a rejuvenation light. Using Courthouse Clinics as an example again, figures show slightly higher positive customer satisfaction for treatments conducted solely by a medical aesthetician, than those that include all treatments. The average customer satisfaction score for treatments conducted by only a medical aesthetician in 2015 was 96.5% from 972 surveys received.4 In comparison, the total data across the company for the same period which included all treatments, provided an average customer satisfaction score of 95.6%.4 Non-surgical aesthetics is entirely focused on patient loyalty and repeat business, so to have a reliable model for this in-clinic is essential.

Recruitment When recruiting medical aestheticians it is integral that they have a minimum skill level of NVQ Level III in beauty therapy or equivalent with preferably at least three to four years experience in beauty therapy to provide some of the more advanced treatments. Whilst hiring a newly qualified beauty therapist is possible, I would prefer to ensure past experience of delivering beauty treatments, client care and a strong evidence of sales ability. It is also important to provide a good commission structure to provide incentives for selling both treatments, treatment packages and retail products as aestheticians, unlike medical practitioners, usually have a strong background in sales. Targets are vital with any client-facing role. In addition, it is vital that the medical aestheticians you employ understand the need for excellent customer service skills and patient confidentially.

Skill development Medical aestheticians can develop their skills in order to offer a variety of treatments, providing opportunities for both the individual medical aesthetician and the business as a whole. A comprehensive training programme is essential when planning for any medical aesthetician to join your clinic. External training provided by suppliers must be supported with a detailed internal training schedule to ensure treatments are delivered with safety, compliance and competence.

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More than 95% of laser treatments at Courthouse Clinic are carried out by medical aestheticians and our data for 2014 provides the supporting evidence that medical aestheticians are able to safely carry out advanced laser treatments with only three incidents out of 14,000 laser treatments throughout the year.4 Medical staff should also provide support and training to ensure aestheticians appreciate the need for accuracy with medical records and reliability with before and after photographs. It is also important to form a cohesive team with the medical practitioners and the aestheticians so that the practitioners can freely offer their support and expertise whenever required. Teamwork is encouraged at all levels and should be led by clinic managers who hold regular team meetings and encourage all practitioners to experience any available treatments. At Courthouse Clinics we have successfully implemented a buddy system between practitioners and aestheticians in each clinic to further develop the trust between both parties. This also encourages cross-referrals of patients.

Conclusion Overall, when hiring a medical aesthetician you are seeking someone who can combine practical training with affability. The balance is needed for you to get the most out of your business and for your medical aesthetician to get the most out of their career.

The importance of medical aestheticians within the aesthetics industry is clear. The general day-to-day running of the clinic and the overall profit margin is not only greatly improved, but also encourages further business development. Medical aestheticians that deliver great customer service ensure patients are happy with both their treatment and care, which could encourage referrals to their friends and family. However, it is essential that in order for a business to prosper, one must ensure that the most suitable medical aestheticians are employed and trained appropriately in their roles.

Expert Commentary “Working alongside a doctor augments the advice and professional care I feel we are able to offer clients; with the support of the doctor’s knowledge I feel that we can confidently carry out accurate and excellent aesthetic treatments to ensure optimum care and results.”

Becky Crozier Medical aesthetician at Courthouse Clinics, Wilmslow

“Working closely with our aestheticians enhances our patients’ experience. We can compliment injectable and laser treatments with skin health assessments, peels, skin tightening and lifting procedures, so between us we can offer a full spectrum of antiageing and skin rejuvenation treatments.”

Dr Robin Stones Medical director at Courthouse Clinics

Amanda Elbourn is the RGN/RSCN operations director for Courthouse Clinics. She has worked in the aesthetics industry for 12 years, initially as a nurse practitioner before moving toward the management sector of the industry.

Presently she is responsible for the day-to-day running of all clinics within the Courthouse group.

REFERENCES 1. Raconteur, Health Beauty and Wellbeing Market Overview, (2015). <http://www.thewholesaler.co.uk/ suppliers/health_beauty_and_wellbeing/> 2. Beatrice Aidin, Future of Skincare, Changing face of skincare in the UK, 319 (2015) p. 3. <https:// raconteur.uberflip.com/i/524994-future-of-skincare> 3. Imogen Matthews Associates, Premium market report for beauty (2014).

4. Data provided by Courthouse Clinics.

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Insurance Policy Advice

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2) Will the market dynamic change?

Insurance operates in a cycle. As premiums rise, profitability returns and this encourages new entrants to the market, which increases competition and should hopefully reduce pricing. At the moment there are little or no signs of any meaningful changes in the market so it is very difficult to predict any imminent changes.

Choosing Insurance Simon McMillan shares advice on how insurance works in medical aesthetics I am often surprised at how naïve some practitioners can be when it comes to protecting themselves with insurance effectively. There is no doubt that the market dynamic is changing and aesthetic professionals are becoming embroiled in a broader range of complaints including technical challenges, frustrations around often routine complications and subjective criticisms of the results. No matter how spurious you believe a claim to be, it has to be addressed and, unfortunately, this can be difficult against a backdrop of rising premiums and increased excesses. The whole environment is perhaps fuelled as a consequence of recent high profile group actions such as the PIP implant claims and the growing litigation in the NHS. With regards to the NHS, the numbers are quite staggering; the NHS Litigation Authority (NHS LA) published its latest account figures for the past year that show the NHS paid out more than £1.1bn to patients and their legal representatives in 2015; a number that is expected to rise to £1.4bn over the coming year.1 In my role as a marketing and operations director of a cosmetic surgery group, I talk to a variety of practitioners and surgeons on a daily basis and the most discussed topic is always the evolving claims culture and the knock-on effect it has on insurance. Certainly, over the last couple of years, we have tried to better educate the industry and have forged close ties with insurers and brokers to try and find innovative solutions. I asked Andy Morley, group managing director of ProAktive Risk Group, who has acquired 20 years of insurance industry experience, seven key insurance questions to help practitioners make the right decisions to protect themselves and their clinic.

1) Why is my premium and excess so much higher this year?

At this time, more than any other, medical professionals are under the spotlight.

Patients, as consumers, are more aware of their rights and their expectations are often inflated. Add to this the ravenous personal injury industry and it is no surprise that the number of claims has increased in recent years. While the private sector is very fragmented with limited consolidated information, premiums are going up and the reasons are similar to those set out by the NHS LA.2 The Spectre of PIP continues to cast a shadow, the Medical Defence Organisations’ are becoming more selective and this has resulted in an increased nervousness in the insurance sector. A number of insurers have withdrawn altogether and those that remain have increased their rates and policy excesses and often reduced the scope of cover. In essence, this is an example of demand outstripping supply and this always results in higher prices.

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Aesthetics | January 2016

3) Why is an insurer’s financial strength rating important and why is the cheapest option not always the best solution?

When you buy insurance you are buying a promise that the organisation that stands behind you has the financial strength to deliver on its promise and pay compensation, costs and expenses associated with a claim. Not all insurers are created equal and there is often a misplaced belief that they are all regulated and have to meet stringent financial criteria.

Many insurers engage credit rating agencies to independently verify their financial strength and these are publicly available for scrutiny via Zurich Insurance Group.3 Some insurers do not have a credit rating and this means that their balance sheet strength is unknown. Often these insurers are based offshore in international tax havens with light regulation. If an insurer does become insolvent you will probably have to pay your premium again, and any claims that you have outstanding may not be paid.

4) How do I reduce my risk and get a better profile with insurers, and what is the role of a broker?

The role of your broker is very important. It is essential that they understand your past, your present and your future and this will be fundamental in deciding your cover needs. The broker needs to understand your operation and the risk management measures you have in place. They can advise on improving these and then ensure that you are presented in the best possible light to the insurance market, which means that it is essential that they have a full understanding of your sector.

5) Explain the difference between a ‘claims made’ and a ‘claims occurring’ policy?

An insurance policy on a ‘claims occurring’ basis means claims that occur during the policy period, irrespective of when the claim is made. This means that policy is in place at the time the issue occurs – even if this policy is subsequently lapsed.4 An insurance policy on a ‘claims made’ basis means claims that are made and reported during the policy period for work previously undertaken. The policy contains a ‘Retroactive Date’ and this essentially specifies the date from which cover will apply.5 A claims occurring policy negates the necessity for ‘run off’ cover should a surgeon or practitioner cease to continue working, however, a claims made policy will require a ‘run off’ extension as a policy needs to be in place should a claim arise.6 Great caution should be exercised when changing insurer to ensure all potential liabilities are covered.

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It’s important to engage insurers early in the claims process to keep them on board and to engage them in a defence 6) When is the right time to notify a claim? Too early and it looks like I have a bad claims record, too late and I might prejudice the claim?

The claims notification process is explicit and will be detailed within your policy document. Failure to comply with this could result in your insurer refusing to provide indemnity. Typically they will insist that any

Aesthetics

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claim, or indeed ‘circumstance’ that could give rise to a claim, should be presented within 30 days. It’s important to engage insurers early in the claims process to keep them on board and to engage them in a defence. This can also help with future renewal negotiations, as they want to work with transparent professionals who have an interest in mitigating potential losses.

7) Should I settle or fight claims?

Firstly, you should never admit liability.

Once again, insurers will argue that you have prejudiced their position and could refuse to provide indemnity. You should also engage your insurer rather than try and defend the claim yourself as they may again argue that you have prejudiced their position.

In every case, the strongest possible defence should be presented, however, the ability for the claim to be defended will depend on your records and documentation. Your insurer would certainly prefer not to pay a claim; however, if they feel they are unable to offer a defence, possibly due to a lack

Insurance Policy Advice

of evidence, they will seek the most economic settlement, which may be at odds with your own view.

Simon McMillan is a qualified solicitor and was part of the founding team of MYA Cosmetic Surgery, one of the largest cosmetic surgery providers in the UK. McMillan is an active member of the Independent Healthcare Advisory Services (IHAS) and regularly participates in activities to improve quality and transparency in cosmetic surgery.

REFERENCES 1. NHS Ligitation Authority, ‘NHS Litigation Authority Annual Report and Accounts 2014/15’, (NHS, 2015), < www.nhsla.com/CurrentActivity/Pages/News.aspx> 2. NHS Litigation Authority, ‘Litigation Authority and the Commercial Insurance Market: Briefing Paper’, (2013), < http://www.nhsla. com/CurrentActivity/Documents/NHS%20LA%20Report%20 -%20Marsh%20Report.pdf> 3. Zurich Insurance Group, ‘List of financial strength and issuer credit ratings’, (2015), <https://zurich.com/en/investor-relations/ ratings 4. Which?, ‘Choosing private medical insurance‘, (2015), http://www. which.co.uk/money/insurance/guides/choosing-private-medical-insurance/how-private-medical-insurance-works/ 5. Newman, S, ‘What is a retroactive date and what does it mean for your professional indemnity policy’, (Hiscox PLC, 2014), https://www.hiscox.co.uk/business-blog/retroactive-date-mean-professional-indemnity-policy/ 6. Newman, S, ‘“Claims made” vs. “claims occurring” – simplifying insurance jargon’, (Hiscox PLC, 2015), < https://www.hiscox. co.uk/business-blog/claims-made-vs-claims-occurring-simplifying-insurance-jargon/>

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In Profile Miss Rozina Ali

“You must be sure that you are 100% committed to your work in order to have a fulfilled and happy professional life” Miss Rozina Ali discusses her career influences and how an interest in slowing down the signs of ageing led her into medical aesthetics Raised in a working class family in inner-city Liverpool, becoming a reconstructive surgeon may have initially seemed like a challenge for Miss Ali. Now, based at the Norfolk and Norwich University Hospital and the Cadogan Clinic in Chelsea, she reminisces about the encouragement she received from a young age to pursue her career. “I was just a child when I told my family and school teachers that I wanted to become a surgeon,” she says, “no one ever said, ‘no you can’t’ or ‘that’s too difficult’ – the school was supportive, my family were encouraging and I was never faced with any obstacles I couldn’t overcome in making my dream come true.”

In 1989, Miss Ali graduated from the University of London with a first class degree in BSc Anatomy. She then went on to graduate from St Thomas’s Hospital Medical School in 1992, before gaining a Fellowship of the Royal College of Surgeons in 1996. One of Miss Ali’s first surgical jobs was working alongside a colorectal surgeon at the Queen Mary’s Hospital in Sidcup, who guided her first steps in carving a career in plastic surgery. “The surgeon I was working with said I had a ‘good pair of hands’, and advised I go into plastic surgery.” Subsequently, she moved on to a stand-alone plastic surgery unit in Billericay, where she worked for an initial six months as a senior house officer. “It was here I was told that if I was serious about becoming a plastic surgeon, I needed to demonstrate my commitment with specialist training and academic research.”

Miss Ali embarked on study and microsurgery training at the Centre for Cutaneous Research in London, before registrar training, including stints in Hull, Wakefield, Chelmsford and The Royal London Hospital. She also undertook craniofacial training at the Great Ormond Street Hospital. She proclaims her hallmark as being ‘dedication and focus’ and went on to win scholarships, including the Steven Kroll Scholarship in Belgium in 2004, which allowed Miss Ali to further train in perforator flaps and breast reconstruction work, and the International Microsurgery Fellowship in 2007, to study microvascular reconstructive surgery in Taiwan for a year. “I was very much living a student existence, even though I was grownup and a plastic surgeon trainee. My life was very much about clinical research, writing papers, editing books and living the life of a trainee in the Far East. It was wonderful; I loved the intensity, the innovation, and the sheer excitement. It was a truly fantastic time in my professional life!”

It wasn’t until 2008 that Miss Ali began her career in medical aesthetics. She explains, “I think on a professional level, my interest in aesthetics was about demand, as there was lots of it. The appeal of treatments was rising and I was able to offer the relevant procedures; on a personal level, it was about curiosity and a deep interest. Amongst many other questions I had, I wanted to learn whether it is actually possible to slow down the physical appearance of ageing. When I began to explore, I realised that the narrow path I

was following led to a massive and varied industry.”

As well as presenting at conferences, including the annual Aesthetics Conference and Exhibition (ACE), Miss Ali has also had the opportunity to explore other fields, which have stemmed from her career in aesthetics and reconstructive surgery.

She enjoyed television success in the 2012 BBC Horizon documentary ‘The Truth About Looking Young’ and Channel 4’s 2013 six-part series ‘How Not To Get Old’. “At first, I felt incredibly nervous and anxious. I was lucky that the first thing I did with the BBC was scripted!” she explains, “Doing ‘How Not To Get Old’ was unscripted, which I found more challenging since it was about my personal style and practice. However, I was relieved when I would get respected plastic surgeons approaching me after they had watched the programmes saying, ‘Yes, that’s how I do it’ or ‘I’m glad that you do it my way’. It was reassuring for me and it felt good to be complimented for my portrayal of the profession.” For practitioners looking to explore the world of medical aesthetics, Miss Ali advises, “Only get into aesthetics if you are truly interested. It’s not easy, it changes quickly and expectations often outstrip techniques or technology. You must be sure that you are 100% committed to your work in order to have a fulfilled and happy professional life.”

What technological tool do you think best compliments your work?

I particularly like mesotherapy injections and using a microneedling pen. Surgical skill is tactile, I like the way the pen is held and its precise function allows me creativity and control.

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

I think, on a personal level, it would have to be from my father.

He’s all about doing the right thing, for the right reasons and doing it well. He always says, ‘Follow your heart’, and it’s something that I’ve always stuck to.

What aspects of the industry do you enjoy the most?

I think what I like most is how fast it moves. It’s not an industry that rests on its laurels; it’s all about the next big thing and I really enjoy working at such a pace.

Do you have an ethos or a motto that you work by?

‘An eye for detail!’ I think that everything I do in plastic surgery and within the aesthetic industry is about attention to detail. To be measured, proportionate and precise is an excellent ideal.

Aesthetics | January 2016

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The Last Word Dr Martin Godfrey argues why the aesthetics industry in Europe is falling behind other continents and advises on what we should be learning from the US The global market I’m not usually much of a globetrotter, but over the last few months I’ve had the privilege to attend three of the most prominent medical aesthetics conferences in the world. The experience has not only opened my eyes to the truly global nature of our industry, but also to the very real differences that still exist between continents.

It’s clear that medical aesthetics, with or without surgery, is huge – estimates vary, but last year worldwide, its combined value was put at €5billion, with projections of more than €6.5billion by 2018. However, growth appears to be inconsistent across the globe. Not surprisingly, the US continues to dominate, with a market value of €2.5billion last year and projections of €3.5billion by 2018.1 And while most of the world, including Latin America and Asia-Pacific regions, are expected to maintain growth, for the first time there has been a contraction in Europe, especially in Southern Europe. In addition, Asia Pacific looks set to overtake Europe as the second most important region for aesthetics.1 But why is Europe falling behind?

Success in the US The under performance of the European market is debateable. Much can be attributed to the recession that continues to affect Europe, but less so in the US and Asia. However, not all can be due to a lack of money, since sales of luxury goods in Europe (a market populated by a very similar purchasing group) have performed much better.2 One can speculate, though, that the US could be thriving because it’s an industry that appears to be more widely understood and accepted by the public, and we have much to learn from them.

Public relations In my opinion, US-based aesthetic practitioners appear much more comfortable in their own skin, compared with their European counterparts. Clearly they are able to use a much wider gamut of media to promote themselves and their clinics and, as a result, many become local and even national ‘celebrities’. This allows them to project a much more personal, emotional image to their potential customers, enhancing their ability to hook into the patient-friendly appeal of non-surgical cosmetic procedures.

Practitioners in most of Europe cannot advertise, but by marketing their clinics in a more media-savvy way and understanding the social media preferences of their patients, they could improve their appeal.

In the US there is a plethora of local TV and radio stations that I believe makes it easier for practitioners to appear regularly as ‘experts’.

Health and beauty programmes, like the Dr Oz Show, for example, have dedicated anti-ageing sections with available slots for aesthetic practitioners. These programmes can then be downloaded and added on to the practitioners’ website.

Enhancing their service Faced with a polyglot mix of races, including Hispanic, black American, Caucasian and Asian, more US aesthetic practitioners seem

Last Word Global Marketing

committed and informed of the significant differences and challenges that these skin types can present. This has led to an increased offering in a greater variety of skin products, over and above the mainstream aesthetic techniques. I believe that European practitioners could also benefit from this approach, offering a wider range of moisturisers, serums, growth factors and cosmeceuticals, which are tailored to individual patients rather than the mass market, as add-ons and enhancers to their work.

Patient demographic Last, but certainly not least, is the rise of men as significant consumers of aesthetic medical treatments. A report, released by the American Society for Aesthetic Plastic Surgery, indicated an overall increase of 43% in men having surgical and non-surgical treatment within the past five years in the US.3 Although Europe has also noted an increase, the US approach appears to me to be more unique in driving male custom. I have noticed that the West Coast in particular is seeing a boom in male-only clinics, where the ambiance is designed to appeal and resonate directly with men. These new clinics are often staffed entirely by men, eschewing any touch of the feminine. As far as I’m aware, we don’t have any clinics like this in the UK and believe it could serve us well to tap in to this potentially profitable market. It is clear that the male market is becoming a significant new source of work for many clinics in the US, and we could do more to encourage such growth in Europe.

Follow the leader Ultimately, though, it’s marketing that makes the difference; and it’s not just regulation that is holding us Europeans back. Like our timidity to experiment with techniques, we still haven’t jumped onto the social media bandwagon and really sold ourselves as they do in the US. And until we do, much of what we do in Europe will remain a wellkept secret, known only to a few well known, well-defined population groups. At the moment it seems as though the US is pulling away from Europe and, in fact, our industry appears to be going in the wrong direction. Europe can try to narrow the gap and deliver US-level treatment outcomes, but we have to keep up with the latest global trends, ensure our equipment is state-of-the-art and that our marketing techniques are fine-tuned to the real needs of our patients.

With the multiplicity of sophisticated techniques, equipment and complementary products such as cosmeceuticals now pouring onto the market, it’s hardly credible that Europe cannot improve on what the rest of the world, particularly the US, seems so good at already.

Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd. A trained medical practitioner, Dr Godfrey has a wealth of expertise in health and nutritional product marketing. His main responsibilities are gaining scientific verification for Minerva’s products through overseeing clinical trials and obtaining the support of medical professionals.

REFERENCES 1. Statista, Value of global aesthetic medical and surgical market from 2012 to 2018, by region (in billion euros)(2014) <http://www.statista.com/statistics/319147/global-aesthetic-medical-and-surgerymarket-value-by-region/> 2. C. D’Arpizio, F. Levato & D. Zito et al, (2014) Bain & Company, Luxury goods Worldwide Market Study Fall-Winter 2014 <http://www.bain.com/bainweb/PDFs/Bain_Worldwide_Luxury_Goods_ Report_2014.pdf> 3. A. Sorrel, American Medical News, (2010) Medical liability: A world of difference <http://www. amednews.com/article/20100503/profession/305039938/4/> 4. ASAPS, Statistics, Surverys & Trends, The American Society for Plastic Surgery Reports Americans Spent more than 12 Billion in 2014; Procedures for Men Up 43% Over Five Year Period, (2015) <http://www.surgery.org/media/news-releases/the-american-society-for-aesthetic-plastic-surgeryreports-americans-spent-more-than-12-billion-in-2014--pro>

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UK/0721/2015

Date of Preparation: October 2015