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VOLUME 4/ISSUE 2 - JANUARY 2017

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Treating Under the Eye CPD

Mrs Sabrina Shah-Desai discusses the treatment of festoons and malar mounds

1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. RadiesseÂŽ - http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/PMAApprovals/ucm439066.htm. Last accessed 19/12/16

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Jawline Contouring

Topical Retinoids

Managing Cash Flow

Practitioners discuss how they each rejuvenate the lower face and jawline

Dr Sandeep Cliff examines the different types of topical retinoids

Reece Tomlinson details how to manage cash flow in your clinic


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Contents • January 2017 06 News

The latest product and industry news

14 On the Scene

Out and about in the industry this month

18 News Special: Labiplasty & FGM

Aesthetics investigates reports of cosmetic doctors facing prosecution for female genital mutilation following labiaplasty treatment

20 ACE Preview: Discover New Business Insights at ACE 2017

Special Feature Contouring the Jawline Page 24

A look at the FREE Business Track agenda at this year’s Aesthetics Conference and Exhibition

CLINICAL PRACTICE 24 Special Feature: Contouring the Jawline

Practitioners discuss techniques for lower face and jawline rejuvenation

31 CPD: Anatomical Basis of Festoons and Malar Mounds

Mrs Sabrina Shah-Desai examines the differences between festoons and malar mounds under the eye and the most appropriate course of treatment

34 An Overview of Non-surgical Body Contouring Treatments

Dr David Jack outlines different non-surgical body contouring treatments available and their outcomes

38 Case Study: Treating Vaginal Laxity and Sexual Dysfunction

Dr Natasha Ranga details her successful management of a patient’s vulvovaginal concerns with CO2 fractional laser

43 Non-surgical Rhinoplasty

In the second of their two-part article, Mr Geoffrey Mullan and Mr Ben Hunter expound on how to successfully perform a non-surgical rhinoplasty treatment

47 Topical Retinoids

Dr Sandeep Cliff outlines the different types of topical retinoids and their mechanisms of action

53 Abstracts

A round-up and summary of useful clinical papers

54 The Red Flag Patient

Dr Sangita Singh explains how to manage body dysmorphic disorder

57 Increasing Product Sales

Sales representative Jane Lewis outlines practical advice on ways to boost skincare product sales and retain patient custom

60 Managing Cash Flow

Clinical Contributors Mrs Sabrina Shah-Desai is an oculoplastic surgeon and specialises in cosmetic eyelid lifts, scar-less droopy eyelid correction and revision eyelid surgery. She is highly experienced in non-surgical aesthetic periorbital rejuvenation with botulinum toxin and dermal fillers. 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 Natasha Ranga is the clinical lead and director of Ranga Medical Ltd. After qualifying as a doctor she completed an array of courses in advanced non-surgical aesthetics and has an interest in medical applications of botulinum toxin. Mr Geoffrey Mullan is a cosmetic surgeon and medical director at Medicetics Clinics and training academy. He has taught anatomy at Guy’s Hospital and worked at the Royal Marsden Head and Neck Unit.

IN PRACTICE

In Practice Managing Cash Flow Page 60

Global business executive Reece Tomlinson explains the significance of cash flow management in clinic

Mr Ben Hunter is a consultant facial plastic surgeon and works at St George’s Hospital Medical School, and privately at the Lister Hospital and King Edward VII Hospital. Mr Hunter qualified with the Royal College of Surgeons of England. Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation.

64 Product Liability Insurance

Insurance and risk management consultant Holly Markham details the importance of due diligence when purchasing medical devices

67 In Profile: Alice Danker

Aesthetic nurse prescriber Alice Danker describes her journey through medical aesthetics and the importance of not working in isolation

69 The Last Word

Dr Martin Godfrey encourages the importance of regularly attending aesthetic conferences in order to remain up-to-date with the specialty

NEXT MONTH

Register FREE today for the Aesthetics Conference and Exhibition taking place March 31 and April 1, London www.aestheticsconference.com

• IN FOCUS: Dermatology • Using Peels • Treating Palmoplantar Hyperhidrosis • 5 Tips for Developing Patient Trust

Subscribe Free to Aesthetics

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Editor’s letter So the Aesthetics Awards 2016 have passed and may seem like a distant memory, but what a great memory, with more than 625 of you in attendance. It really was the biggest and best Awards ceremony yet! Thank you to Amanda Cameron all who entered, voted, judged, attended and Editor sponsored for making the night such a success and supporting this fantastic celebration of our industry. I know I said it on the night, but the entries were all of an amazing standard and each year the bar is raised, which can only be good for the specialty as a whole. We hope everyone has recovered from the celebrations. Many congratulations to all the Winners, Commended and Highly Commended, not to mention all those who were finalists – you can read all about their achievements in our Aesthetics Awards supplement, which subscribers will have received with this issue. A huge thank you to our brand director Suzy Allinson and our events manager Kirsty Shanks who made the evening run perfectly, I felt extremely proud to play a part in the ceremony itself and look forward to seeing what we can do to make the event bigger and better next year! The evening was a great success, and I adored

Hal Cruttenden and thought his topical humour was just right for the night. I am not surprised that social media is now awash with tweets and pictures of all the winners – I know you will use all the PR opportunities you can to grow your businesses. Also, many thanks for supporting our chosen charity, Operation Smile, which made £4,000 on the night – you can continue to donate by visiting their website. Now the work begins for the Aesthetics Awards 2017, which will take place on December 2 at the Park Plaza Westminster Bridge Hotel. Before that though, we have the Aesthetics Conference and Exhibition to look forward to! I hope you’ve all registered for the leading educational event set to take place on March 31 and April 1 this year. This issue focuses on contouring, something many patients may be seeking in the New Year. Our Special Feature explores contouring the jawline, with advice on using injectable and deviceled techniques from leading aesthetic practitioners on p.24, while Dr David Jack outlines the various body contouring methods in an extremely useful article on p.34. Let us know what you thought of this issue and your plans for 2017 by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com.

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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. Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. 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. 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.

years experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. 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. 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. 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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Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Sammy Carlin; support@aestheticsjournal.com © Copyright 2017 Aesthetics. All rights reserved. Aesthetics Journal is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

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Dermal fillers

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Training Benji Dhillon @drbenjidhillon What a day of learning @phiclinic from the man who knows it all when it comes to lasers. Dr Matteo Clementoni #rejuvenation #scars #sundamage @drtapanp #SocialMedia Dr Uliana Gout @UlianaGout Great session discussing social media impact in aesthetic medicine - thanks @WENDYLEWISCO for key tips #Dubai @DIAD_DIAL @fmsalali @abadawii

#AestheticsAwards2016 sk:n @sknclinics Having a great time at @aestheticsgroup Aesthetics Awards! Really proud to have been nominated for Best Clinic. #Awards #fingerscrossed

#Skin Dr Anjali Mahto @DrAnjaliMahto Updating core of knowledge laser safety at The Cranley Clinic today #meded #skin #dermatology

#Training Dr Askari Townshend @Dr_AskariT Just finished delivering another 2 day @zoskinhealth training at @WigmoreTraining. Great enthusiasm from the group…good luck guys

#Rhinoplasty Mr Ash Labib @ashlabib1 End of world tour 2016. Feel blessed! #aesthetics #nonsurgicalrhinoplasty #allergan

#AestheticsAwards2016 WestMidlandsHospital @WestMidsHosp Cosmetic Surgeon Dalvi Humzah is Crowned Aesthetic Medical Practitioner of the Year @ramsayhealthUK

FDA approves Restylane fillers for treatment of nasolabial folds The Food and Drug Administration (FDA) has approved Restylane Refyne and Restylane Defyne dermal fillers from Galderma for the treatment of nasolabial folds. Patients over the age of 21 have been approved for the treatment of moderate to severe facial wrinkles and folds, which was based on two studies to evaluate the products’ effectiveness and safety. In both studies, involving 171 and 162 participants, Restylane Refyne and Restylane Defyne met the studies’ endpoints, with both products showing an improvement in wrinkle severity for up to 12 months in the majority of patients. Study investigators used the Wrinkle Severity Rating Scale, reporting that 79% of Restylane Refyne subjects and 77% of Restylane Defyne subjects had at least a 1-grade improvement after six weeks. Vice president and general manager at Galderma’s Aesthetic and Corrective Business Unit, Kelly Huang, said, “Restylane Refyne and Restylane Defyne are the latest FDA-approved advancements in HA dermal fillers and align with Galderma’s mission to help individuals achieve natural-looking results through treatments with a long-standing history of proven safety and efficacy.” Aesthetics market

Global aesthetics market estimated to grow by 10.8% New data released by market research firm Markets and Markets has estimated the global aesthetics market to grow at a compound annual growth rate (CAGR) of 10.8% from now until 2021. Markets and Markets claims the key factors fuelling the growth of the medical aesthetics market are the growing adoption of minimally invasive and non-invasive aesthetic procedures, technological advancements in energy-based medical aesthetic devices, the increasing demand for aesthetic treatments among the male population and the availability of user-friendly aesthetic devices. However, it also claims that stringent safety regulations for aesthetic procedures and social stigma associated with these treatments are some of the key restraints hampering the growth of the market. A combination of ‘top-down and bottom-up approaches’ were used in this paper. A top-down approach starts with the big picture and breaks down from there into smaller segments. A bottom-up approach is the piecing together of systems to give rise to more complex ones, thus making the original systems sub-systems of the emergent one. This approach was used to calculate the market sizes and growth rates of the medical aesthetics market and its sub-segments. All percentage shares, splits, and breakdowns were determined using secondary sources and verified through primary sources. Primary interviews with key opinion leaders were also used to determine the percentage shares of each product across the globe. The report named Syneron Medical, Cynosure and Solta Medical the top three companies in the global energy-based devices market in 2015, while Allergan, Galderma and Merz Aesthetics were named the leading players in the global facial aesthetics market for the same year.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Training

Mr Dalvi Humzah presented with earFold training certificate Consultant plastic surgeon Mr Dalvi Humzah has become the first plastic surgeon in the West Midlands to offer the earFold treatment. Pioneered by plastic surgeon Mr Norbert Kang of the Royal Free Hospital in London, the earFold is a minimally invasive treatment for the correction of prominent ears. Mr Humzah, who has been trained in the treatment, was presented with a training certificate for earFold by Nicky Stephens, the aesthetic product specialist for Allergan. Mr Humzah said, “I am very pleased to be able to offer this treatment. Up to 2% of people suffer from prominent ears, and the earFold technique is a minimally invasive procedure that is quick and easy. It’ll be a huge benefit to my patients.” Contouring

3D-lipo launches 3D-Ultimate machine Aesthetic device manufacturer 3D-lipo has launched a new multi-technology machine that contains five technologies aimed at lifting and tightening the face and body. The five technologies in the 3D-Ultimate machine include: radiofrequency, duo cryolipolysis, shockwave, high intensity focused ultrasound (HIFU) and cavitation ultrasound. For the body, the radiofrequency technology is aimed at skin tightening, the duo cryolipolysis aims to target superficial fat, the shockwave technology helps to reduce the appearance of cellulite, the HIFU aims to remove fat and the cavitation is targeted at overall circumference reduction. According to the company, the HIFU can also be used for non-surgical face lifting. 3D-lipo claims that by using the device, practitioners will be able to add technologies that are not contained on their exisiting machines. Labiaplasty

Study suggests negative experiences motivate women to undergo labiaplasty Negative experiences and media influence were highlighted as major motivations for women undergoing surgery to their labia, according to a recent study. The study, published in the Aesthetic Surgery Journal, was based on 14 women who had undergone labiaplasty between January 2014 and April 2015, who were aged between 23 and 59 years old. The patients were interviewed five to 16 months post operation. From these interviews, the major themes for motivation included: media influence, negative commentary and experiences, body image dissatisfaction, sexual wellbeing and acceptability. 10 participants recalled at least one negative experience related to their labial appearance. These were predominantly comments from former sexual partners, though seven also reported comments of reassurance. All 14 participants reported general satisfaction postoperatively.

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

TRIUMPH AT THE AESTHETICS AWARDS The BACN was delighted to win the prestigious Hamilton Fraser Award for Industry Body/Association of the Year at the Aesthetics Awards 2016. We are thrilled that a number of BACN nurses also won other major awards at this industry-leading event: Frances Turner Traill – The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year Sharon Bennett and Anthea Whiteley – The Wigmore Medical Award for Best Clinic North for their clinic, Harrogate Aesthetics Anna Baker – The Enhance Insurance Award for Training Initiative of the Year, for her work alongside Mr Dalvi Humzah on the Dalvi Humzah Aesthetic Clinical Training Courses Anna Gunning (BACN DANAI affiliate) – The AestheticSource Award for Best Clinic Group, UK and Ireland (3 clinics or more) for her clinic group, The Laser and Skin Clinic Winning the Award for Association of the Year recognises the hugely successful transformation of the BACN over the last year with a rapidly growing membership base, increased member services and an increasingly important voice for regulation in the industry.

BACN STRATEGIC PARTNERS 2017 The BACN is delighted to announce that Allergan, Galderma, Church Pharmacy, AestheticSource and Hamilton Fraser will continue to support the association through its ‘Strategic Partnering Programme’ in 2017. In addition, Teoxane, Alumier Labs UK and Cynosure will support the BACN as new sponsors. These partnerships are now central to the operations of the BACN and allow it to deliver a huge, CPD-accredited training programme, from some of the most prestigious names in the industry. These arrangements reflect the BACN’s commitment to delivering education, training and continuing professional development for all of its members. Dates for the educational programme can be viewed on the BACN website. Remember, as a BACN member all of these events come free as part of the membership.

MEET A MEMBER Sharon King has worked in aesthetics for more than ten years. Originally a theatre sister in plastic and reconstructive surgery both in the NHS and the private sector, she now works independently with her husband Dr Martyn King at Cosmedic Skin Clinic, where they both train and offer mentorship to new injectors and nurses undertaking the V300 prescribing course. As a member of the BACN, King is keen to promote best practice through thorough training and comprehensive education.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Events diary 26th – 29th January 2017 IMCAS Annual World Congress 2017, Paris www.imcas.com

3rd – 7th March 2017 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

31st March – 1st April 2017 Aesthetics Conference and Exhibition, London www.aestheticsconference.com

6th – 8th April 2017 15th Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2017.org

15th – 18th June 2017 Facial Aesthetic Conference Exhibition (FACE) http://www.faceconference.com

15th – 17th June 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting http://www.bapras.org.uk

Training

AlumierMD UK becomes CPD accredited Alumier Labs has announced that delegates attending the Alumier Pro Comprehensive Training will now receive up to 14 continuing professional development points (CPD) for two days of education. Head of education at AlumierMD UK, Victoria Hiscock leads the course, which aims to build a greater knowledge of AlumierMD skincare products and chemical peels to achieve optimum results. It also provides delegates with an advanced understanding of anatomy and physiology of common skin conditions such as acne, pigmentation and rosacea, and the science behind different skincare ingredients. Hiscock said, “We are thrilled that our Alumier Pro Comprehensive Training has been recognised for its outstanding content and curriculum. Being able to offer our partnering medical professionals 14 points towards their CPD requirements is a testament to the efforts that have gone into making our training amongst the most progressive in the aesthetic industry.”

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Skincare

SkinMed launches Tebiskin OSK Lotion and OSK Clean Dermatological distribution company SkinMed has launched two new products designed for treating oily and problematic skin. Tebiskin OSK Lotion, which focuses on the management of acute acne and oily skin, aims to prevent the accumulation of sebum on the skin surface, clean the ducts of the sebaceous glands and reduce the severity of inflammatory cells. A case study conducted on the Tebiskin OSK Lotion by professor A.C. Chu et al, evaluated the efficacy and tolerability of the lotion containing triethyl citrate and ethyl linoleate in the treatment of mild to moderate acne vulgaris in 33 patients. The study indicated that patients treated with the lotion showed a reduction in lesion counts, acne grading by four weeks and a reduction in sebum production. Tebiskin OSK Clean is a pyruvic acid-based exfoliator that aims to slow down oil production while helping to unclog blocked hair follicle ducts. According to the company, Tebiskin OSK Clean aims to improve the condition of oily and problematic skin and contains triethyl citrate, pyruvic acid and triclosan that aim to eliminate and prevent the occurrence of manifestations of acne. The company further claims the wash also has antibacterial properties. SkinMed managing director and clinical trials supervisor, Peter Roberts said it is a, “Non-antibiotic, non-benzoyl peroxide, non-retinoid solution for acne and oily skin that works faster than routine prescription products and does not create resistant bacteria.” Tebiskin products are distributed in the UK by SkinMed Ltd. Patient safety

Expert Aesthetics introduces in-clinic psychologist Cosmetic surgeon Miss Jonquille Chantrey has introduced a psychologist to her Cheshire clinic to help more vulnerable patients that seek aesthetic treatment. Kerry Daynes, a consultant chartered forensic psychologist and chartered scientist, has worked in psychology for more than twenty years. Working alongside Miss Chantrey in her clinic, Daynes will assist each patient with their treatments and queries, whilst making sure the reasons behind each patient persuing a cosmetic treatment is not under any influence or peerpressure. Daynes said, “The aesthetic industry has boomed, yet has been slow to acknowledge the mind-body connection. There are numerous ways in which psychology can contribute to better outcomes for patients – from treating the stress underlying many skin conditions, to preparing people for cosmetic surgery.” She continued, “I have chosen to work with Miss Chantrey as I am a patient of hers and I love both her impeccable clinical standards and her ethics. We share the philosophy that there is a specific beauty that comes from looking in the mirror and being at peace with both what you see and who you see. We aim to help our patients achieve that.”

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Lips

New lip treatment launches in the UK An antiageing lip enhancement treatment from US cosmetic brand Infracyte has launched in the UK. LUSCIOUS LIPS is a lip gloss treatment that aims to naturally stimulate new collagen formation in the lips to increase lip volume, smooth lip wrinkles and provide moisture. The formula contains hyaluronic acid, organic moisturising oils, vitamins and organic plant extracts and comes in 12 shades that add colour and gloss to the area. Italian practitioner, Dr Loredana Desiato, said he recommends this treatment to complement lip filler treatments, “LUSCIOUS LIPS helps me to achieve the best results in lip fillers. My patients love using this treatment to extend the effect of lip filler and obtain natural beautiful fuller lips; it has unique antiageing properties, which heal, hydrate and plump the lips throughout the day.” According to UK distributor LA Beautiful, patented peptides and dehydrated marine collagen-filling spheres in LUSCIOUS LIPS ensure optimal absorption and plumping to increase lip volume. Kizzy Galvin, director of LA Beautiful, said, “Once the hyaluronic acid has been absorbed into the lip tissue, it searches for the body’s natural water stores to instantly re-plump lips as an effective topical alternative to doctor administered injections without stinging, burning or causing lip redness. This makes LUSCIOUS LIPS perfect for people who don’t want cosmetic surgery but still want the immediate volumising effects of these treatments, or for those who have had lip augmentation and want to maintain this look for longer.”

Vital Statistics According to World Atlas, the UK was ranked at No.27 among the most obese countries in the world in 2016 (World Atlas, 2016)

Last year the American Society of Plastic Surgeons reported that Americans spent more than $13.5 billion on surgical and non-surgical procedures in a single year (ASAPS, 2016)

A survey of more than 5,000 marketers revealed 63% plan on increasing their use of social networks in 2017 (Social Media Examiner, 2016)

Breast surgery

Survey suggests new trends for breast surgery A survey by The Plastic Surgery Group has indicated breasts with smaller nipples/areola rate higher in attractiveness than those with larger. According to surgeons within the clinic, the survey was conducted due to a noticeable shift in patient requests relating to nipple aesthetics. Consultant plastic surgeon Mr Dan Marsh said, “We have always asked our patients to choose the size of their nipple during surgery rather than using a standard template. Recently we have noticed a trend towards patients choosing a smaller diameter nipple when they are offered a choice of nipple sizes.” The survey involved 130 women, who were given a selection of photographs of breasts and nipples and asked to rate them from one to five in order of attractiveness and to say whether they felt the diameter of the nipple areola complexes shown were too big, too small or just right. The results indicated that the respondents found the smaller sized nipples more attractive than those with larger nipples. Those rated ‘just right’ in size had a nipple that occupied 25-30% of the breast when the breast is viewed from straight on. If a nipple was more than 50%, then 92% or respondents thought it was ‘too big’. 78% of respondents felt that if the nipple areola complex was less than 15% of the breast width the nipple was ‘too small’. Consultant plastic surgeon Mr Mo Akhavani said, “The traditional surgical teaching and marking for breast surgery uses standard nipple markers which are fixed in size – typically at 46mm in diameter. Clearly the results of our survey demonstrate that a single nipple size is not appropriate for all women and the nipple diameter should be adjusted so that it is 2530% of the breast width. There is also a modern trend towards smaller nipples.”

There was a 43% increase in men undergoing surgical and non-surgical cosmetic procedures in 2015 (ASAPS, 2015)

A global psoriasis survey of more than 8,300 people indicated that 84% of people with psoriasis have suffered discrimination and humiliation (Norvatis, 2016)

Small and medium-sized enterprises (SMEs) accounted for 99.3% of all private sector businesses at the start of 2015 in the UK (www.gov.uk)

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Conference

New sponsors announced for ACE 2017 Aesthetic insurance provider Enhance Insurance and aesthetic device manufacturer 3D-lipo have been announced as sponsors for the Aesthetics Conference and Exhibition (ACE) 2017. Enhance Insurance has chosen to support the free Business Track agenda, which will feature vital insights to help grow an aesthetic practice. A variety of topics will be covered over the two-day agenda, including marketing, sales, handling complaints, regulation updates and training advice. “Enhance are proud to be the sponsors for the Business Track at ACE 2017. The additional knowledge gained from these sessions is essential for medical professionals who wish to commit to excellence in aesthetics, assisting them to enhance patient outcomes and ultimately the profitability of their businesses,” said Holly Markham, business development executive at Enhance Insurance. Markham added, “We are really looking forward to attending this year’s conference. ACE is one of the leading medical aesthetics conferences in the UK, with a wide range of exhibitors, live demonstrations and masterclasses, as well as being a great opportunity to meet with existing and potential clients.” After a busy day of learning, conference delegates can enjoy a drink and opportunity to socialise with their peers and colleagues at the Networking Event on the evening of Friday March 31 thanks to Skincare

sponsor 3D-lipo. It will be the second year in a row that 3D-lipo has sponsored the Networking event, which they say is an integral part of the conference. “We are proud to be supporting the Networking Event for a second year because it is the ideal way to interact with colleagues in the aesthetics speciality, which is what ACE is all about,” said Roy Cowley, managing director of 3D-lipo Ltd. He added, “It also really brings a nice end to the first day of busy learning and allows people to get together and discuss the event so we are encouraging all delegates to take part and join us.”

Laser conference

Lamiderm Apex serum launches in UK The Lamiderm Apex serum for skin texture and elasticity restoration has been launched in the UK. According to the company, the product is the first in the UK to contain a naturally occurring LOX enzyme activator that aims to stimulate collagen, elastin and fibronectin fibres in skin cells. Also included in the formula is fertilised avian egg extract, which aims to provide growth factors ODGF and TGF-b to stimulate collagen that increases skin firmness, elastin that increases skin’s elasticity, and fibronectin that supports and repairs the skin as well as wounds. The company claims that the active ingredients in the product boost the production of elastin and collagen by up to 250%. The company also claims Lamiderm Apex has no harmful sulphates, such as sodium laureth sulphates or synthetic fragrance and is not tested on animals. Katie Cookson, owner of Discover Laminine, which distributes the product, said, “Having had chronic damage to my skin I can really see the difference and it has helped to build my confidence in the way I look.”

BMLA conference introduces aesthetics session to agenda The Annual Conference of the British Medical Laser Association (BMLA) has introduced aesthetic-orientated sessions to its agenda for the first time. The 35th annual conference, which will take place in Manchester between May 17-19, will include three sessions focused on using lasers for aesthetic treatments. Consultant dermatologist Dr Firas Al-Niaimi will be chairing two sessions, Non-laser Aesthetics and Lasers and Light Sources in Aesthetics, while a session entitled Lasers and Light Sources in Aesthetics will be chaired by Dr Claudia van de Lugt. “BLMA is a scientific meeting that combines scientists, physicists, doctors, nurses, and allied healthcare professionals who use lasers,” said Dr Al-Niaimi, who is also on the BMLA executive committee. He added, “Delegates can look forward to new parallel sessions on aesthetics. There are also courses for beginners in lasers for those who are newer to using these devices. I am really looking forward to the conference this year.” Training

Dalvi Humzah Aesthetic Training announces new training dates Course dates for 2017 have been announced for Dalvi Humzah Aesthetic Training. The Facial Anatomy Teaching course will be held on February 24 and the Management of Non-Surgical Complications Through Anatomy Teaching will take place on May 18 at The Royal College of Surgeons. As well as these training events, a new dermatology course, Skin Lesions in Medical Aesthetic Practice, has also been introduced, which will take place on April 21 at The Birmingham NEC Crowne Plaza. Among those leading these training sessions will be consultant plastic, reconstructive and aesthetic surgeon, Mr Dalvi Humzah, consultant dermatologist, Dr Stephanie Munn, dermatology nurse specialist Isabel Lavers and cosmetic and dermatology nurse practitioner Anna Baker.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Aesthetics

Vaginal rejuvenation

Alma Surgical launches FemiLift Smart A new robotic probe for the Alma FemiLift C02 laser which aims to treat feminine health concerns has been released. The Alma FemiLift Smart incorporates technology that aims to allow practitioners to provide fast and homogeneous treatments when using the Alma Femilift to treat patients for vaginal tightening, stress urinary incontinence, vaginal dryness, recurrent vaginal infection, Genito-Urinary Syndrome of Menopause (GSM), and post-delivery rehabilitation. The probe studies the depth of the vagina and conducts the treatment automatically, which allows practitioners to provide more precise and faster treatments for feminine health concerns. The upgraded platform and probe aim to enable practitioners to quickly adjust treatment settings based on the patient’s specific needs. Professor Paolo Scollo, president of the Italian Society of Gynecology and Obstetrics, said, “FemiLift Smart, the next generation device, represents a novel approach for outpatient medical treatments. The FemiLift procedure provides excellent and precise results that are free from side effects and completely asymptomatic.” Collagen supplement

BOLEY Nutraceuticals launches collagen drink New aesthetic manufacturer BOLEY Nutraceuticals Ltd has launched the re-branded collagen supplement drink Totally Derma. The supplement, previously known as Aneva Derma, contains bio-absorbable collagen and hyaluronic acid and the company claims the combined levels of both ingredients are higher than other collagen-boosting beverages on the market. Totally Derma contains more than 10,000mg of hydrolysed powdered collagen (bovine source) per daily serving, as well as vitamin C, green tea extract, grapeseed extract, copper, zinc, manganese and alpha lipoic acid. Training

Save Face announces Recognition of Prior Learning programme Independent accreditation body Save Face is now offering a Recognition of Prior Learning (RPL) programme in conjunction with an Ofqual-regulated awarding body. According to Save Face, the RPL programme, in combination with remote e-learning, will enable aesthetic practitioners to match their experience and competency in providing cosmetic injectables with an Ofqual regulated Level 7 qualification in Aesthetic Medicine. RPL assesses a learner’s previous achievements and whether they can demonstrate that they can meet the assessment requirements for a unit through knowledge or skills they already possess and will not need to develop through a course of learning. Save Face claims the RPL programme is a time and cost effective method of gaining a recognised qualification that allows practitioners to demonstrate that they have the practical and theoretical skills required to be awarded an Ofqual regulated qualification.

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Mr Jazz Dhariwal, managing director of Breit Aesthetics Why did you first become interested in the aesthetics industry? I enjoyed continued success in several niche medical sectors before I was invited into the medical aesthetics world some 13 years ago. I quickly realised that this exciting and dynamic industry moved rapidly and responsively to the growing demands of medical professionals, who all shared the common goal of bringing the very best products and procedures to their individual clinical practice. How has Breit Aesthetics continued to outpace the industry norm? Breit Aesthetics is a specialist supplier of leading innovative solutions to the medical aesthetics community. Having a real passion for innovation and working hard for our clinics to bring leading solutions to their continually developing needs, the move to establish Breit Aesthetics in 2011 created much interest in the technologies of DERMAFILL, PRP, and skin remodelling with EnerJet. Our success has come from supporting antiageing treatment providers to become leaders through medical innovation within their field. Which product will lead your continued growth through 2017? A proven champion in the broader European marketplace, DERMAFILL is the first of a new fourth generation of safer and more effective pure monophasic injectable dermal fillers that exceed the strict standards of the FDA’s very low level BDDE controls. This new advancement of cleaner manufactured homogenised viscoelastic hyaluronic gels comes pre-purified to a new unseen standard. DERMAFILL is made of very strong chains of HA that utilise the innovation of the unique Time-X technology, which results in a product that is easier to use. It allows for improved tissue control whilst creating immediate visible results that are more consistent and long-lasting without the drawbacks of conventional HA technologies. Delivering a remarkable augmentation in each application, this competitively priced, clinically supported advancement has gained a loyal following from long-term industry experts. This column is written and supported by

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Digital

Aesthetica Solutions launches online platform Aesthetic distributor Aesthetica Solutions Ltd has launched a new website to provide ease of access for practitioners wishing to order products online. The new website features a simple platform for searching and purchasing dermal fillers, toxins, chemical peels and skincare brands from a variety of manufacturers. “Aesthetica Solutions launched in the UK in March 2016 and we believe this new platform will take our new business to the next level,” said managing director of Aesthetica Solutions, Trish Patel, adding, “It is our ethos that we supply a service that facilitates all purchasers of injectable products, enabling practitioners, no matter how big or small, to be able to order top quality products at prices that did not discriminate against low volume orders. At present there is no other company in the UK that is able to offer this and that is what excites us so much about launching the Aesthetica Solutions Ltd website – it’s an added service to our clients.” Skincare

The Murad Method Facial System launches in the UK Skincare company Murad has launched a new set of personalised facial treatments. The Murad Method Facial System aims to promote whole-person wellness, targeting multiple skin concerns while delivering relaxation with touch-point massage and nutritional advice. Each treatment begins with an in-depth, segmented, five-zone analysis of skin that aims to reveal its true health. This allows practitioners to treat multiple skin concerns at different levels of severity in one prescriptive treatment, using professional-strength products. Massage techniques used in the treatment focus on lymphatic massage and acupressure that aim to enhance overall wellness and induce relaxation to relieve stress. Upon completion of the treatment, patients are gifted with a personalised recipe card and an inspiration card, which features a motivating quote from founder of the company, Dr Howard Murad. Dr Murad said, “The Murad Method Facial System is designed to treat individual needs but to also give patients the tools and insight they need to live and feel younger.” Technology

Karidis Clinic launches cosmetic surgery mobile app Cosmetic surgeon Mr Alex Karidis has announced the launch of the Karidis Clinic application to help patients throughout their surgical experiences at the clinic. The app, which can be downloaded on a mobile device, acts as a timeline informing patients on the next step in their treatment, surgery or examination as they undergo cosmetic procedures. According to Mr Karidis, the app offers a step by step guide from a patient’s pre-surgical treatment through to recovery and provides tips on preparation, alerts on how to remain at optimum health, recovery support and further patient care and appointments. The app has five procedure options available, including facelift, breast augmentation and eye surgery. “We want to take the fear out of the unknown and make each individual feel they are never alone in this process as we understand having a life changing procedure can be an isolating period, certainly through the recovery stage,” said operations director of Karidis Clinic, Deborah Vine. She added, “The Karidis Clinic app will give patients necessary information at the touch of a button.”

THE BUSINESS DESIGN CENTRE / LONDON / 31 MAR & 1 APR 2017

COUNTDOWN TO ACE 2017 AGENDA INSIGHT: EXPERT CLINIC This year, 17 innovative sessions will take place at the free Expert Clinic. Held on the Exhibition Floor, the Expert Clinic is the perfect place to drop by and pick up key clinical skills in all aspects of aesthetics; from injectables to lasers and skincare to chemical peels. So far, AestheticSource, Mesoestetic, Cynosure UK Ltd, HA Derma, Merz Aesthetics, Lynton Lasers, Naturastudios, AesthetiCare, Neocosmedix, Rosmetics, Church Pharmacy, Fusion GT, Teoxane UK and AlumierMD have all been confirmed as sponsors, with more to be announced soon. SPEAKER INSIGHT Aesthetic nurse prescriber Lorna Bowes will be speaking in The Basics of Facial Assessment session on the Premium Clinical Agenda. She says, “From being a part of ACE since its inception, I can truly say it is a must-attend event for all medical aesthetic professionals. The wide variety of both clinical and business content on offer means delegates can learn how to enhance all aspects of their aesthetic practice. I shall be speaking in The Basics of Facial Assessment session, along with Dr Souphiyeh Samizadeh and Dr Uliana Gout, where we will advise delegates who may be new to the specialty on how to assess and treat an ageing female face, a young female face and a male face. There will be live demonstrations, useful treatment techniques and fascinating discussions – I look forward to meeting you there!” WHAT DELEGATES SAY “A huge vibrant buzzy event to attend; really enjoyable!” AESTHETIC BUSINESSPERSON, LONDON

“As an advanced practitioner, I attend conferences to continually progress my learning, and I would advise any injector, no matter how experienced, to do the same.” AESTHETIC DOCTOR, LONDON

HEADLINE SPONSOR

www.aestheticsconference.com

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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News in Brief Healthxchange Pharmacy donates £20,000 to the Tumaini Charity Pharmaceutical supplier Healthxchange Pharmacy has donated £20,000 to a charity to fund the education of orphaned students, in order to train them to become pharmaceutical dispensers. So far, 20 dispensers have been trained as a direct result of Healthxchange’s donations and they are now working in Tanzania. Healthxchange hopes that by training orphaned students to become pharmaceutical dispensers this will effectively enable local people to increase their own economic means rather than purely receiving aid. Sally Durant Training Consultancy announces new team member Heather Maurice-Brook has become the new marketing manager and Level 4 course tutor for Sally Durant Training Consultancy. As an aesthetician, Maurice-Brook has trained in aesthetic devices and cosmeceutical products and has a lot of experience in laser and skin treatments. Founder of the consultancy, Sally Durant, said she is thrilled to have MauriceBrook on board, “She has extensive clinical experience coupled with a solid background in education and training, both of which will be a great asset in the continuing progression of our course provision and the qualification standards we represent.” Clarification In the article Lifting the Breast with PDO Threads in the October issue of Aesthetics, Dr Victoria Manning and Dr Charlotte Woodward stated that they use the technique that was originally developed by Dr Jacques Otto. This was incorrect, Dr Otto does not use PDO threads in the breast and the technique they use was developed by Dr Jani Van Loghem at Doctors Inc Amsterdam. Dr Manning and Dr Woodward would like to apologise for any confusion caused. Clarification In the Special Feature Hyaluronic Acid in Practice, published in the December issue of Aesthetics, Dr Kathryn Taylor-Barnes stated that she uses Neauvia fillers and that they contain polycaprolactone. This was an error, Neauvia does not contain polycaprolactone, its cross-linking agent is polyethylene glycol. Dr Taylor-Barnes would like to apologise for any confusion caused.

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Threads

Intraline launches PDO threads Medical aesthetics company Intraline has launched the Intraline PDO (polydioxanone) Threads. The new thread range, which launched this month, aims to rejuvenate ageing skin by stimulating the production of the patient’s own collagen, elastin and hyaluronic acid. They also aim to stimulate the development of new blood vessels and improve lymphatic drainage, resulting in a better skin quality with a smoother, brighter appearance. The company claims that results can be seen immediately after treatment and continue to improve for six to eight months and can last for up to 18 months. Intraline is currently working with aesthetic practitioner Dr Huw Jones on six UK white clinical papers studying 40 patients over a 12-month period. The aim of the study is to monitor the physical and biological activity and changes of the Intraline PDO Threads once the thread has been inserted in the tissue. Siobhan Cunney, director of threads at Intraline, said, “Intraline PDO Threads have been long anticipated by the industry; however, Intraline didn’t want to compromise – getting our PDO threads right was essential.” She continued, “We are are proud to introduce the latest specifically designed threads which, coupled with our clinical white papers, offers quality, and a safe and effective treatment.”

On the Scene

2017 and Beyond: Future Trends of Aesthetics, London

Esthetique Distribution and Cosmedic Pharmacy celebrated their recent union by hosting an event on November 30 to showcase upcoming non-surgical and aesthetic trends for 2017 at the Royal Society of Medicine, London. Guests were greeted with champagne on arrival before a presentation by Dr Martyn King on aesthetic treatments set to become trends in 2017. Dr King also discussed how non-invasive alternatives to surgery have advanced to result in quicker, safer and more natural-looking results. Following this, Dr Dan Dhunna performed a live demonstration of a thread lift on a male model, before Miss Emeline Hartley provided guests with several before and after case studies of thread lifts. Magda K Krol, business development director of Esthetique Distribution, said, “The event was a great success, with the guests enjoying the talks and hands-on demonstrations immensely. We’re delighted to be working alongside Cosmedic Pharmacy and we look forward to 2017.”

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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The Aesthetics Awards 2016, London Practitioners, clinics, products, training, distributors and manufacturers were celebrated at the Park Plaza Westminster Bridge Hotel in central London on December 3 for the spectacular and eagerly anticipated Aesthetics Awards ceremony. The annual event recognises the very best in medical aesthetics and was even bigger and better than before, with more than 625 guests and 24 winners. The evening began with a glamorous drinks reception, which was followed by a three-course dinner and comedy set from host, Hal Cruttenden, who is best known for appearing on shows such as Mock the Week, Michael McIntyre’s Comedy Roadshow and The Royal Variety Performance. Editor of Aesthetics, Amanda Cameron, then opened the ceremony with a welcome speech, before the Winners, Highly Commended and Commended finalists were recognised. After winning The Med-fx Award for Best Clinic London, Dr Tapan Patel, founder and medical

Aesthetics Journal

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director of PHI Clinic, said, “I am thrilled. Winning it once was amazing, winning it the second year was really unexpected, but to win it three times, I really have to dedicate it to the team. This was not possible without the fantastic bunch of people that we have managed to bring together and I have to say it is a privilege as a clinic owner to have such a marvelous team to work with.” This year, The Dermalux Award for Medical Aesthetic Practitioner of the Year went to Mr Dalvi Humzah and The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year was awarded to Frances Turner Traill. Speaking of her win Turner Traill said, “I'm over the moon to win this award. It was totally unexpected. It's the highest accolade so it doesn't get much better than this!” Dr John Curran was 2016’s worthy winner of The Schuco International Award for Special Achievement, which recognises the outstanding work of an individual working within medical aesthetics. He said, “Winning the award for special achievement makes me feel humbled, I’ve had so much help over the years – from people at the beginning who mentored me and taught me, colleagues who’ve supported me, nurse, doctors, everyone within the industry – it’s been a fabulous ride, it’s so amazing to be given recognition for something I didn’t expect.” Speaking of the evening, Dr Sam Robson, the founder and medical director of Temple Medical in Scotland, said, “I came to the Awards because I love catching up with my colleagues, I love having fun with my team, and I really look forward to us celebrating and being part of the aesthetics world. I think the Aesthetics Awards is an important event for the industry because of the opportunity to recognise people who have done well and promote excellence.” Read the Aesthetics Awards supplement that arrived with this issue or visit www.aestheticsawards.com to view the full list of Winners, Highly Commended and Commended finalists.

On the Scene

On the Scene

Biofibre Hair Implantation launch evening, London Aesthetic practitioners from across the country gathered at the Crowne Plaza London City hotel on November 23 for the launch of the Biofibre Hair Implantation device. Guests at the launch event, which was hosted by the product’s distributor Fusion GT, enjoyed champagne and canapés, as well as music from a live jazz band. Sales manager at Fusion GT, Kelly Morrell, opened the presentation by introducing Fusion GT director Tiziana Giovanelli and explaining more about the company and the aesthetic devices it produces. Morell then introduced hair surgeon Dr Luca De Fazio, who went on to speak about the new device and the results that can be achieved. Dr De Fazio claimed that the ‘Biofibre Hair Implant is a simple and effective procedure suitable to solve alopecia at any age, to give an immediate aesthetic result’. He explained that the device can be used in combination with follicular unit extraction (FUE) procedures, is suitable for both men and women, and comes with 13 different coloured artificial hairs that can be blended to create a colour match for the patient. The material of the hair is a medical grade polyamide and results are said to last five to seven years on average. He then showcased before and after images of patients he had treated with the device. Morrell concluded the presentation by thanking guests for attending and taking questions from the audience.

Dr Joney De Souza PCA SKIN launch, London On December 2, aesthetic practitioners gathered at Dr Joney De Souza Skin & Laser Clinic on Wigmore Street for the launch of the PCA SKIN chemical peel products. Guests were treated to champagne and canapés on arrival and were able to pose questions to Dr De Souza about PCA SKIN products, which were on display. He explained that the peels can be used on all skin types, including sensitive skin, and aim to deliver an excellent result with minimal downtime. PCA SKIN products contain naturallyoccuring alpha and beta hydroxy acids, peptides, antioxidants, MMP inhibitors and active botanicals, which aim to reduce the depth of surface lines, smooth rough skin texture, fade discolouration and assist in clearing acne and blemishes. Aesthetician Elizabeth Shaw from Church Pharmacy, which distributes PCA SKIN, then performed a live demonstration of the chemical peel and PCA daily care products before taking questions from guests about their use. Shaw said of the event, "We are extremely honoured to be in partnership with Dr De Souza and team. PCA SKIN is a very reputable brand, so to partner with such a prestigious clinic is a fantastic opportunity for us. We are delighted with the positive response from the guests on the evening and the results Dr De Souza and his team are seeing in clinic. We are looking forward to working with the team on the journey ahead, which will include many more exclusive events.”

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Why is Labiaplasty being Compared to Female Genital Mutilation? With recent news reports that three cosmetic doctors could be facing prosecution under female genital mutilation (FGM) laws for carrying out labiaplasty for cosmetic reasons, Aesthetics asks, ‘Is labiaplasty comparable to FGM?’ On November 22, the Telegraph reported that the British courts were currently deciding whether to employ FGM laws in three cases where practitioners had carried out cosmetic genital surgery on women.1 But with the first FGM prosecution to reach the courts resulting in an acquittal last year,2 there hasn’t yet been a single conviction for carrying out the illegal practice in the UK. Could it be possible that the cosmetic doctors in question may be the first to be indicted? The three cases currently going through the British courts – one in Cheshire and two in London – stem from private practices. According to news reports, the doctors carried out ‘illegal cosmetic surgery’ for patients wanting a ‘designer vagina’ procedure but the full details are yet to be disclosed. It is reported that the adult women paid for the surgery ‘in the belief that it would make them more attractive.’3

What is FGM? According to the World Health Organisation (WHO), FGM ‘comprises all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons’.4 WHO estimates that 200 million girls and women alive today have been subject to the practice in 30 countries in Africa, the Middle East and Asia, where FGM is pervasive.5 WHO states it is a violation of the human rights of girls and women, has no health benefits and can cause harm in a number of ways.3 The practice of FGM4 There are many reasons why FGM happens, but, most commonly, the following apply: To ensure premarital virginity and marital fidelity as it is believed in some communities that a woman’s libido should be reduced. When a vaginal opening is covered or narrowed during the procedure, the fear of the pain of opening it, and the fear that this will be found out, is expected to discourage extramarital sexual intercourse among women. FGM is associated with cultural ideas of femininity and modesty, which include the notion that girls are clean and beautiful after removal of body parts that are considered unclean, unfeminine or male. It is often considered a cultural tradition, which is sometimes used as an argument for its continuation. It is considered a necessary part of raising a girl and preparing her for adulthood and marriage.

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Why do patients seek labiaplasty? Mr Navid Jallali, consultant cosmetic and reconstructive surgeon, who performs labiaplaty procedures, says that although we don’t know the full details of the case, he believes the majority of patients in the UK are having the procedure due to severe functional issues, “A lot of my patients say the labia gives-way during intercourse, they can’t exercise because the labia is so large, they can’t wear tight clothing, and some don’t have intimate relationships because they are embarrassed of the appearance. I wouldn’t operate purely for cosmetic reasons, there has to be a functional component.” Consultant plastic surgeon Mr Christopher Inglefield, who has carried out many labiaplasty procedures, agrees, “Very few of our patients have surgery for cosmetic reasons. The majority, over 95%, have surgery for physical symptoms or because of psychosexual symptoms.” He adds, “It is very insulting for these patients to be compared to victims of FGM who are taken at a young age to an often unknown individual and have their genitalia completely mutilated. I see many of these victims for reconstructive surgery and to even compare those to an individual who has consented to have a procedure is just degrading.” Are they comparable? Despite FGM being illegal in the UK for the past 31 years,6 a study in 2014 by City University London and Equality Now – an international human rights organisation dedicated to action for the civil, political, economic and social rights of girls and women – estimates that 137,000 women in the UK are affected by FGM and a further 20,000 are thought to be at risk each year.7 The Home Office made a statement two years ago that labiaplasty operations may be illegal unless there was a medical or psychological reason for them,1 and now a home affairs select committee wants to outlaw female genital cosmetic surgery because they believe it is similar to FGM. “We cannot tell communities in Sierra Leone and Somalia to stop a practise that is freely permitted on Harley Street,” said the chairman

FGM classifications Procedures Female genital mutilation is classified into four major types: Type 1: Often referred to as clitoridectomy, this is the partial or total removal of the clitoris, and in very rare cases, only the prepuce (the fold of skin surrounding the clitoris). Type 2: Often referred to as excision, this is the partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora. Type 3: Often referred to as infibulation, this is the narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the labia minora, or labia majora, sometimes through stitching, with or without removal of the clitoris. Type 4: This includes all other harmful procedures to the female genitalia for non-medical purposes, e.g. pricking, piercing, incising, scraping and cauterising the genital area. Complications following FGM are more likely with increasing severity of the procedure and include: severe pain, haemorrhage, fever, infections, shock and death. Long-term complications can also follow, such as urinary and vaginal issues, scarring, sexual problems, increased risk of childbirth complications and psychological issues.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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of the select committee, MP Keith Vaz, in a report published in 2015.8 The committee is calling for the FGM law to be changed so that it specifically outlaws the surgery as ‘a criminal offence’.8 “Where do you draw line?” says Mr Inglefield. “Should we outlaw rhinoplasty because patients should accept their noses? Should we outlaw circumcision because it is an assault on male genitalia? I think the issue is ignorant; people are trying to impose their opinion on individuals who have free will,” he adds. Mr Inglefield explains how the process of a patient coming in for a labiaplasty is so significantly different to FGM, “A woman comes in to have a conversation because she has concerns about her labia. This happens in front of a nurse who acts as the patient’s chaperone; the patient is never seen on her own. On average, these patients have been thinking about having the procedure from anywhere between two to six years – I even had one case where a woman had been thinking about surgery for about twenty years.” He describes the treatment as incomparable to victims of FGM, “I saw a patient two weeks ago, who, at the age of seven, was taken by her grandmother in Sierra Leone to an individual in the village and she was severally assaulted, with most of her genital tissue removed; no anaesthetic and no sterile tools were used. You can’t compare the two.” Mr Jallali believes there is a big misunderstanding about what FGM is and what a labiaplasty is. “I think most of the general public think that the procedure for labiaplasty is done on a ‘whim’ and that patients are unsatisfied, but actually we’re finding the exact opposite; patients have very few complications, it often enhances their function, including their sexual activity with their partner, and is a positive, life-changing procedure.”

Aesthetics

Summary Whilst it is still unknown whether the cosmetic doctors in question will be prosecuted, going forward, Mr Inglefield says there needs to be better education for the general public and better training for surgeons, “I see women who’ve had bad labia surgery, so bad that it almost could be classed as borderline FGM – but that is a minority. You don’t pass a law to stop the minority.” He explains, “Surgical training in this country is a real challenge. Some surgeons believe they can do what they like without accountability but hopefully this will change.” At the time of publishing, prosecutors are still assessing whether or not bringing charges to the practice of labiaplasty is within the public interest. REFERENCES 1. Telegraph reporters, Doctors who perform genital cosmetic surgery could be criminalised under FGM laws, (2016) <http://www.telegraph.co.uk/women/health/doctors-perform-genital-cosmeticsurgery-could-criminalised/> 2. Telegraph, NHS doctor cleared in less than 30 minutes in first FGM case, (2015) <http://www. telegraph.co.uk/news/uknews/law-and-order/11390629/NHS-doctor-cleared-of-performing-FGMamid-claims-he-was-used-as-a-scapegoat.html> 3. Martin Bentham, Doctors face prosecution over genital cosmetic surgery in London clinics, Evening Standard, (2015) <http://www.standard.co.uk/news/crime/doctors-face-prosecution-over-genitalcosmetic-surgery-in-london-clinics-a3400726.html> 4. WHO, Female genital mutilation, (2016) <http://www.who.int/mediacentre/factsheets/fs241/en/> 5. UNICEF, Female Genital Mutilation/Cutting: A Global Concern New York, (2016) <https://www.unicef. org/media/files/FGMC_2016_brochure_final_UNICEF_SPREAD.pdf> 6. Radhika Sanghani, Outlawing ‘designer vaginas’: Have MPs gone mad? Telegrpah (2015) http:// www.telegraph.co.uk/women/womens-health/11475276/Designer-vaginas-to-be-made-illegal-HaveMPs-gone-mad.html 7. Radhika Sanghani, FGM affects 137,000 women in England and Wales, reveals shocking new study, (2014) <http://www.telegraph.co.uk/women/womens-politics/10980268/FGM-affects-137000-womenin-England-and-Wales-reveals-shocking-new-study.html> 8. Parliament, Conclusions and recommendations, (2015), <http://www.publications.parliament.uk/pa/ cm201415/cmselect/cmhaff/961/96109.htm>

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Discover New Business Insights at ACE 2017

patient databases, marketing and clinic finances. Keeping updated with aesthetic training is always considered to be an extremely important factor in this industry; Dr Tristan Mehta of the Harley Academy will delve into this further and discuss what practitioners should be prioritising when to training. Dr Mehta said, “2017 is going to be Aesthetics details how to make the most of the ita comes very important year for training in aesthetic medicine FREE Business Track agenda at the Aesthetics because of the new frameworks that are being developed by the JCCP – I will be talking about what these new Conference and Exhibition (ACE) 2017 standards look like and ways in which practitioners can go In aesthetics, business insight is just as important as clinical about getting the right training.” knowledge if you want to be successful in today’s market. On March 31 and April 1, you can attend sessions on the Free Business Business Track Day 2 Track agenda at this year’s Aesthetics Conference and Exhibition On April 1, you will have the opportunity to make the most out of even to hear the latest tips and advice to grow your aesthetic practice. more business content, including how to understand your clinic's data This year, the Business Track, which will be held in the Exhibition Hall and figures to maximise on patient retention by business development at the Business Design Centre in London, will showcase even more of director Gilly Dickons. As well as this, Mr Adrian Richards will discuss the industry’s most renowned business experts and knowledgeable business building, while cosmetic practitioner Dr Rita Rakus will draw speakers than ever before. upon her 25 years of aesthetic medical experience to discuss how to choose the right clinical equipment that best suits your practice. Showcasing the Business Track Do you know when to say ‘no’ to your patients? Dr Sangita Singh will At ACE 2016, the Business Track sessions proved extremely popular speak at the Business Track on patient selection and communication, yet again among individuals looking to increase their skills in and how to consult patients to determine treatment suitability. With marketing, digital strategy, regulation, training and product selection. a large number of possible treatments available, nurse prescriber This year, the sessions will build upon these topics and more to Lorna Bowes will discuss her preferred combination treatments from provide extensive skills and understanding to raise your clinic to the a business perspective, and will advise how they can be successfully next level. From handling patient complaints, to building a brand integrated into a clinic’s portfolio. If you are interested in expanding with PR, to adding treatment combinations to your clinic offering, the your portfolio to train and educate others, a valuable session by Business Track will provide you with all the necessary information consultant educators Lisa Hadfield-Law and Hayley Allan will teach you need to ensure you run a successful business in 2017. you how to engage with students successfully. This year, Enhance Insurance will sponsor the comprehensive Finally, knowledge of the legal implications of not complying with the agenda. Holly Markham, business development executive at General Medical Council is vital, so consultant plastic surgeon and Enhance Insurance, said, “There are a number of disciplines outside trainer Mr Dalvi Humzah will provide doctors with an update on the of clinical technical training that are required in order to adhere to latest rules, regulations and legalities that must be adhered to for best practice and ensure the highest standards of patient safety. This successful practise in this specialty. Mr Humzah said of the Business additional knowledge gained from the Business Track sessions is Track, “Many clinicians are comfortable with the clinical areas of their essential for medical professionals who wish to commit to excellence practice, however areas of safety and quality may let their whole in aesthetics, assisting them to enhance patient outcomes and practice down and result in loss of staff and patients. Attention to good ultimately the profitability of their businesses.” clinical notes and providing appropriate information to patients will   help improve practice and patient retention.” Business Track Day 1 On March 31, director of EF Medispa Rudi Fieldgrass will open Make the most of ACE 2017 the Business Track with a talk on ‘Growing an Aesthetic Business’, With more sessions to be announced, you are encouraged to make encompassing practical advice on how to become more reputable the most out of the free Business Track sessions on March 31 and and profitable. Sales and marketing professional, Gary Conroy will April 1. As an added benefit, you will receive 0.5 CPD points for each then discuss how to choose a suitable skincare range for your clinic, session, which will last 30 minutes each. Free ACE 2017 registration followed by Dr Simon Zokaie, who will share advice on how to will also provide you with access to the Expert Clinic, Masterclasses adapt your clinic website to provide an online purchasing platform. and Exhibition. Delegates can also book to attend the Premium What should you do if someone lodges a complaint against you? Clinical Agenda, which has four separate sessions to choose from, all To help you with this common practitioner concern, Naomi Di-Scala, focused on treating different types of ageing faces. the cosmetic manager at Hamilton Fraser Cosmetic Insurance, will present on how to handle complaints and update delegates on your If you attended ACE last year, simply update your details on our obligations as practitioners. Plastic surgeon, trainer and clinic owner website – aestheticsconference.com – or register now to make Mr Adrian Richards will discuss the latest developments from the the most of the vast range of free content on offer. Joint Council for Cosmetic Practitioners (JCCP), while public relations consultant Julia Kendrick will use her experiences over the past 12 HEADLINE SPONSOR BUSINESS TRACK SPONSOR years to deliver advice on how to build your reputation and stand out from the crowd. For those who are thinking of opening a new clinic, or who have recently launched one, Annalouise Kenny, director of Skin Philosophy clinic, will provide insights on hiring staff, setting up

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Contouring the Jawline Practitioners discuss techniques for rejuvenating the lower face and jawline Perioral lines, loss of volume to the lips, nasolabial folds and marionette lines are all common lower facial concerns that patients present with when seeking aesthetic treatment. In addition, a sagging jawline is a key indicator of facial ageing and often has a significant impact on a patient’s appearance. The combined effects of gravity, progressive bone resorption, decreased tissue elasticity, and redistribution of subcutaneous fullness all contribute to the manifestations of facial ageing;1 however, there are a number of non-surgical options available to help lift and contour the lower face.

Aesthetics Journal

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still keep results looking natural. “We use specific measurements tailored to each patient to know where to treat to ensure that the patient looks natural, but also better,” she explains. Dr Goldie notes that she’s started to treat the jawline in relatively younger patients, in particular those in their early 40s. “Instead of leaving treatment until patients come in specifically asking for jawline treatment, we’re looking at jawlines as part of the overall beautification process. Some patients may not have noticed that their lower face is starting to sag – they mainly see lines around the mouth – but if you point it out to them then suddenly they notice it,” she explains. Cosmetic surgeon and aesthetic practitioner Miss Jonquille Chantrey explains that the lower face is a very common area of concern amongst patients. “In particular, patients are concerned with loss of continuation of the jawline, jowl formation, development of submental fat and generally feeling as though their lower face may be getting more gaunt or sagging,” she says. Similarly to Dr Goldie, Miss Chantrey will offer the patient a full facial assessment in which she will discuss how facial fat pads change over time and how ageing of the mid-face may be influencing patients’ lower facial concerns. “Once we’ve talked about the fat composition and volumetric changes, the bone changes that have occurred in the mandible over a period of time and the muscle influencers, we talk about the skin,” she says. Taking note of the skin’s integrity, its elasticity, and whether there’s any ptosis is essential in order to understand how to safely and successfully approach treatment, Miss Chantrey explains, adding that it is also vital that practitioners discuss patients’ skin health habits – in particular whether they smoke or have smoked and how much time they spend in the sun. Aesthetic nurse prescriber Jacqueline Naeini adds that other lifestyle factors should be taken into consideration too – including the patient’s diet, general health and stress levels. “As much as they may not want to change these habits, I will always provide advice if I think it may help,” she explains. Dermal fillers Administering dermal filler treatment can offer significant improvement to the contour of the jawline. While hyaluronic acid (HA) can be used successfully, Dr Goldie’s treatment of choice is RADIESSE (+), a dermal filler composed of small calcium hydroxylapatite (CaHA) microspheres that is suspended in a soft gel matrix.2 Once injected, it aims to provide immediate volume and

Consultation “Every patient benefits from a full face consultation where we look at the structure, the soft tissues and the proportions of their face,” says aesthetic practitioner Dr Kate Goldie. Before After “It’s interesting for patients to learn how each part of the face relates to the bit beside it, and never is this more true than for the lower face, which shows the effects of everything that happens above it,” she explains. In her consultations, Dr Goldie will talk through each part of the patient’s face and point out the cause and effect of each aesthetic concern. Doing so, she notes, allows patients to understand that lower face ageing is generally a result of ageing of the mid-face and helps patients to recognise that only addressing one concern is not necessarily going to have an overall positive effect. She adds that performing a full face clinical analysis helps the practitioner to understand where they can get an uptake of extra skin and Figure 1: Before and immediately after treatment with ULTRAcel. Images courtesy of Dr Jonquille Chantrey.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Botulinum toxin type A free from complexing proteins Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: M-BOC-UK-0046. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients may

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not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with Botulinum neurotoxin products. Upper Facial Lines: very common: Headache. Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent postinjection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: December 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50 units Summary of Product Characteristics (SmPC). March 2016. Available from: https://www.medicines.org.uk/emc/ medicine/23251. 2. Bocouture® 100 units Summary of Product Characteristics (SmPC). September 2016. Available from: https://www.medicines. org.uk/emc/medicine/32426. 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157. Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0040 Date of Preparation November 2016

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Before

After

Before

After

Aesthetics Journal

Figure 2: Before and after treatment with botulinum toxin. Images courtesy of Dr Souphiyeh Samizadeh.

correction, as well as stimulate the skin to produce its own natural collagen.2 “Patients get dynamic results as it can really sharpen the jawline,” says Dr Goldie, adding, “As it contains CaHA, resorption of the gel occurs over three to six months so you will get increased dermal depth, more collagen and more/better quality elastin.” Regardless of the type of filler used, Dr Goldie recommends the use of a cannula when treating the jawline to avoid the risk of injecting an artery. “The facial artery in that region is protected by the superficial muscular aponeurotic system (SMAS),3 so it’s not easy to accidently go underneath that fascia with a cannula. However, I can go underneath that fascia with a long needle without actually knowing it,” she explains, noting, “By using a cannula I can stay in the plain where there are no major arteries and I would feel it if I moved out of this area.” According to Dr Goldie, successful results are achieved by injecting subdermally with lots of little passes. She adds, “We examine the jawline in three dimensions, aiming to straighten it – particularly with the formation of jowls – sharpen and then contour it.” In Dr Goldie’s experience, treatment results usually last for a year, however, in some cases it can last up to 18 months. “I tell my patients a year but we quite often get longer,” she says. Botulinum toxin Dental surgeon and aesthetic practitioner Dr Souphiyeh Samizadeh also offers injectable treatment to contour the jawline. She says it is important to take note of the patient’s cultural differences, emphasising that not everyone desires the same jawline aesthetic. In her experience, she has found that, “Although most women desire a straight or feminine jawline, eastern patients desire a soft jaw angle, whereas western patients desire a more well-defined jaw angle.” A square face shape, she says, is an indicator of a masculine facial feature, which might prompt patients to seek aesthetic treatment. She explains that injecting botulinum toxin into the masseter muscles to induce disuse atrophy (muscle weakening) is a non-surgical approach of de-bulking masseter muscles and reducing lower face width, which, she says, is very common in Asian countries.4 Dr Samizadeh notes that numerous studies have highlighted the benefits of this non-invasive approach since consultant neurologist Dr Peter Moore and consultant and oral maxillofacial surgeon Mr Geoffrey Wood introduced the botulinum toxin injection of the hypertrophic masseter to treat functional problems in 1994.5 For example, she says, Kim et al treated 1,021 patients with botulinum toxin for aesthetic purposes

Aesthetics

to reduce the volume of masseter muscle in 2005. They concluded that it is a simple technique, with few side effects and reduced recovery time, and can also replace surgical masseter resection.6 Another benefit of injecting the masseter muscles with botulinum toxin is that it can treat a bruxism. Dr Samizadeh says, “Although scientific evidence is not abundant, a number of studies and literature reviews have indicated reduced frequency of bruxism events, decreased bruxism-induced pain levels and high anecdotal patient satisfaction.”7,8,9 Threads While there are a number of different types of threads available to contour the jawline, Dr Jacques Otto uses polydioxanone (PDO) threads. “The threads aid the soft tissue, as well as the skin and are good for redistribution of subcutaneous fat and skin laxity,” he says. PDO is a biodegradable synthetic polymer, traditionally used as sutures in surgery.10 Dr Otto explains that as well as lifting and tightening the jawline, threads aim to stimulate new collagen and elastin production, producing an overall rejuvenated effect. He notes that it is important to take a thorough history before treating the patient to ensure that they are a suitable candidate for treatment. “If someone has very lax skin then they may need surgical treatment,” says Dr Otto, explaining, “In some patients where the skin is really wrinkled, the threads don’t always work well as the skin puckers when you tighten it – those patients are better off having surgery.” Dr Otto explains that he uses an 18 gauge needle to create an entry point in the skin, before inserting the threads with a blunt cannula. He does not recommend using a needle for thread insertion due to the risk of damaging nerves or blood vessels. Combining thread treatment with botulinum toxin can also be beneficial to the lower face, says Dr Otto. “I inject botulinum toxin two weeks before a thread lift to relax the platysma muscle and get a better result,” he says. Side effects of thread lift treatment can include, asymmetry and threads being visible under the skin, however thorough training should of course lower this risk, as well as bruising and swelling. Dr Otto notes that attempting to minimise swelling too soon may affect collagen formation so advises patients not to take medication that aims to do this. Prior to treatment, Dr Otto says he informs patients that a thread lift treatment shouldn’t necessarily be a one-off treatment. “If you have good results you need to maintain them,” he says, adding, “There is less risk involved than surgery and if you start early enough then patients can avoid having surgery at all.”

Regardless of the type of filler used, Dr Goldie recommends the use of a cannula when treating the jawline to avoid the risk of injecting an artery

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Ultrasound and radiofrequency For patients who may be needle phobic or unsure about undergoing injectable treatment, Miss Chantrey offers ULTRAcel treatment. “The ULTRAcel device is a great starting point for those patients who are presenting with a lower face concern and don’t want any form of filler or threadlift,” she says. Similarly to other ultrasound devices, ULTRAcel uses high intensity focused ultrasound (HIFU) technology to reach a depth of 3-4.5mm to target the SMAS, fascia, fibrous tissue of the fat layer, dermal layer and the dermis.11 ULTRAcel also incorporates grid radiofrequency and radiofrequency with microneedling that aims to promote the production and remodelling of collagen.11 Miss Chantrey explains, “It essentially uses the principles of microneedling, but adds radiofrequency that goes through the needles and is delivered to the level of the dermis that we need it to in order to stimulate fibroblasts and the production of collagen.” Miss Chantrey says that most patients are satisfied with results after one HIFU treatment, but some may need to undergo two procedures. “We try to get the outcome that they’re looking for in one session and then review in a 12-week period to see how they’re improving,” she says. For the radiofrequency/microneedling part of the treatment, she has found that patients generally require three treatments, spaced six weeks apart. Safety is of course paramount when using any technological device and Miss Chantrey highlights the importance of thorough training and understanding of facial anatomy before offering treatment. She says, “When it comes to the microneedling with radiofrequency it is a very powerful device that can cause burns and pigmentation changes, so it needs to be used in the hands of people who really know what they’re doing with it.” Dr Goldie also uses an ultrasound device to contour the jawline, this time Ultherapy. The FDA-approved device uses ultrasound imaging, to allow the practitioner to see down to 8mm below the skin on a screen.12 The Ultherapy transducers offer three different treatment depths: 4.55mm to the SMAS/platysma, 3mm to the deep dermis and 1.5mm to the superficial dermis.12 Dr Goldie says, “Over time, we have found that Ultherapy is particularly effective at prevention and contraction.” She notes that there is no real downtime to Ultherapy – patients can bruise and there may be a little bit of redness or swelling, but nothing significant. To avoid any potential complications she says it’s important that practitioners understand the depth to which they’re penetrating, the anatomy of the area being treated and, of course, how the technology works. In addition, Dr Goldie says that she often uses Ultherapy in combination with dermal filler treatment. “They work really well together,” she says, adding, “I use Ultherapy first and then dermal filler treatment two weeks after. I’ve just worked on a consensus paper with [clinical researchers] Dr Alastair and Dr Jean Carruthers and it was agreed that they shouldn’t be done at the same time, it’s better to leave a two-week interval.” Skincare For Naeini, as well as the other practitioners, taking care of patients’ skin is an imperative part of any successful treatment. “Good skin health is important to help with many antiageing concerns and also acts as a good preventative measure,” says Naeini. Ensuring patients are using a sunscreen to protect from UVA and UVB damage is Naeni’s first priority, before she goes on to recommend the use of vitamin A. She says, “Vitamin A also has antioxidants, and stimulates and increases the production of collagen, elastic fibres and glycosaminoglycans.”13 In addition, she

Aesthetics Before

After

notes that the use of alpha hydroxy acids is also beneficial for antiageing as they work to decrease the stratum corneum’s thickness and increase cell turnover.13 “This can also help soften the appearance of Figure 3: Before and after the lower face was treated pore size, lines and with 1ml of Volift to each side. Skincare included the wrinkles, and help to use of the NeoStrata Skin Active range, a retinol and SPF. Images courtesy of Jacqueline Naeini. even the distribution of pigmentation,” she adds. Naeini advises that vitamin A can cause some irritation to the skin so use should be built up slowly to ensure patients’ toleration. “The patient can also experience slight redness, as well as flaking and dryness of the skin,” she says, explaining that this is caused by the retinol increasing cell turnover. Naeini recommends using a good humectant to help reduce redness and keep the skin hydrated. The practitioners interviewed agree that ensuring patients are given reliable aftercare advice, relating to the treatment they’ve undergone and their ongoing skin health, is key to enhanced results and patient retention. Naeini adds, “Giving the patient a good, effective and simple regime is important so that they comply more with their home skincare routine, therefore enhancing results.” Conclusion Lower face treatments will continue to be ever popular with aesthetic patients. While improving the appearance of lines and wrinkles is of course necessary, it is apparent that contouring the jawline can have a significant impact on a patient’s whole facial aesthetic. Having awareness of the wide range of treatments that are available, as well as how to utilise the best techniques and administer procedures safely, can have a hugely positive influence on your clinical practice. REFERENCES 1. Coleman SR, Grover R, ‘The anatomy of the aging face: volume loss and changes in 3-dimensional topography’, Aesthetic Surgery Journal (2006) <https://www.ncbi.nlm.nih.gov/pubmed/19338976> 2. How does Radiesse work? (UK: Merz Pharmaceuticals, 2016) <https://global.radiesse.com/radiesse/ how-it-works#how-it-works> 3. Peter M. Prendergast, ‘Anatomy of the Face and Neck’, Springer, p.33. 4. Ahn J, Horn C, Blitzer A, ‘Botulinum toxin for masseter reduction in asian patients’, Archives of Facial Plastic Surgery, 6 (2004) pp.188-191. 5. 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. 6. Kim SK, Han JJ, Kim JT, ‘Classification and treatment of prominent mandibular angle’, Aesthetic plastic surgery, 25 (2001) pp.382-387. 7. 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. 8. 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. 9. de Mello Sposito MM, Teixeira SAF, ‘Botulinum Toxin A for bruxism: a systematic review’, CEP.5716:150. 10. Kucharczyk P, ‘Preparations and modifications of biodegradable polyesters for medical applications’, Tomas Bata University in Zlin, (2013) <http://digilib.k.utb.cz/bitstream/handle/10563/27267/ kucharczyk_2013_dp.pdf?sequence=1> 11. Ultracel, FAQs, (UK: Ultracel UK, 2016) <http://ultraceluk.com/faq/#1453065890713-25e4a607-4b6e>  12. Ultherapy, Harness the power of sound to non-invasively list skin, (US: Ultherapy, 2016) http://www. ultherapy.com/Physicians/Science-Of-How-Ultrasound-Skin-Lift-Works 13. Ganceviciene R et al, ‘Skin anti-aging strategies’, Dermato Endocrinology, (2012), pp.308-309. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3583892/>

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Anatomical Basis of Festoons and Malar Mounds Mrs Sabrina Shah-Desai explains how to differentiate between festoons and malar mounds under the eye and discusses the most appropriate course of treatment Puffy, swollen eyelids are one of the common manifestations of under-eye ageing. Most patients with ‘eye bags’ present with skin laxity, a herniation of intraorbital eyelid fat, periorbital weakening of the soft tissues, bony resorption and a tear trough deformity.1 Although ‘baggy eyelids’ can be hereditary and are mainly a cosmetic concern, swollen eyelids can often be caused by seasonal allergies, blepharitis2 and, rarely, can be a cause of serious underlying conditions such as thyroid eye disease (over or under-active) or fluid retention due to compromised renal and liver function.1,3 Malar mounds and festoons Some people develop ‘saddle bags’; a mound with laxity of the skin and orbicularis muscle around the lower eyelid that starts accumulating fluid at the lid cheek junction. These ‘saddle bags’ can be split into two categories: a malar mound, which is a soft tissue elevation protruding from the lateral part of the malar eminence near the lower eyelid cheek junction (Figure 1), and a festoon, which is hanging tissues between two points (Figure 2). These two distinct entities are likely to fall within a complex continuum of anatomic findings, as when the skin loses elasticity the malar mound can become a festoon.1 Children can demonstrate the precursors of malar soft tissue convexities, which become defined with age, as creases delineate the upper and lower borders. Malar mounds can exhibit a familial inheritance pattern and occur at any age.4 Based on anatomic location, Furnas4 further distinguished between palpebral festoons (eye bags), which occur above the boundary of the inferior orbital rim, and malar festoons and mounds (saddle bags), which in terms of anatomic location, are found inferior to the bone. He divided these into pretarsal, preseptal, orbital, orbitomalar, and malar, although combinations of multiple sites may be concurrently present. He found that anatomically, festoons can affect any part of the upper or lower eyelid, but the hallmark is the sagging of the orbital segment of the orbicularis oculi muscle of the lower eyelid.1 Upper eyelid festoons can cause a droopy eyelid (ptosis) by a mechanical effect and can also sag beyond the eyelashes, thus obstructing the superior visual fields.5 The anatomic basis of these structures were poorly described until Pessa6 identified a specific connective tissue band in the orbitomalar

Aesthetics

region, which originates from the periosteum of the superior aspect of the infraorbital rim and inserts into cheek skin 2.5-3cm inferior to the lateral canthus (Figure 3). This fascial band of impermeable tissue delineates the inferomedial aspect of the malar mound and divides the suborbicularis oculi fat (SOOF) into a superior and inferior compartment. The lymphatics of the inferior compartment are continuous with the cheek drainage, whilst the superior compartment is compromised, and can be prone to collecting fluid in predisposed individuals.6 The SOOF has variable thickness, being most prominent in the central and lateral malar region. Medially, the SOOF engulfs the mimetic muscles and lies superficial to the periosteum.6 Pessa theorises that loss and/or ptosis of the SOOF and its adjacent deep fat compartments, in combination with the attenuation and relaxation of connective tissue, contributes to ‘malar bags’ associated with ageing.6 Aetiological factors 1. Genetically predisposed individuals with a familial history of festoons and malar mounds have compromised permeability characteristics of the malar septum. This predisposition to malar mounds may worsen by chronic lower eyelid oedema, which may progressively lead to the development of malar mounds and, over time, develop laxity of the attachments between the orbicularis and the deep fascia and cause festoons.1 2. Age is associated with a reducing orbicularis oculi muscle thickness and increasing orbital fat prolapse. Progressive sagging of the orbicularis oculi muscle can occur as it attenuates, until the orbital portion of the orbicularis oculi folds are suspended across the lid, akin to a curtain swag.4 Commonly, protruding intraorbital fat accompanies festoons and malar mounds; as the orbicularis oculi muscle becomes thinner, the orbital fat prolapse becomes more prominent. Occasionally, festoons are composed solely of muscle and skin. 3. Festoons and malar oedema can also occur as a complication from dermal filler injections in the infraorbital hollow and tear trough. This is related to various factors, including predisposed individuals, large

Figure 1: Patient presenting with mild malar mound and skin laxity at lid cheek junction

Figure 2: Patient with familial upper and lower lid festoons

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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volumes of injected filler, superficial placement of filler within the malar septum and high G prime (elasticity) fillers that may compromise the lymphatics further by direct pressure.7 4. Other Iatrogenic causes include post-surgical trauma e.g. after nose/ sinus or eyelid/face lift surgery,8 as the lymphatic drainage from the periorbital area is limited to the superficial channels on the conjunctiva and eyelid skin, and the bony orbit and its contents lack lymphatic channels.9

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Assessing the patient A detailed history, including family history, is invaluable. Ensure the patient does not suffer with chronic allergies, thyroid eye disease or renal dysfunction, for which blood tests may be required. All patients need to be asked of relevant history of filler injection(s), type of filler material used and duration of lid swelling. History of onset, fluctuation and progression are vital. Chronicity of lid swelling can prove to be a challenge, requiring prolonged interventions. As lower eyelid ‘bags’ are caused by fat that has protruded forward,1 they appear more obvious when the patient

Figure 3: Schematic representation of the malar septum from Pessa JE and Garza JR

5. The eyelid seems to preferentially accumulate fluid in conditions causing localised edema such as blepharitis2 or allergic conditions such as seasonal allergies.1 Blepharitis is a common eyelid inflammation that is often associated with symptoms of dry eyes. Underlying causes can be a bacterial eyelid infection or a common inflammatory skin condition such as acne or rosacea, which is characterised by facial redness and pimple-like bumps around the cheeks, nose, forehead and chin.10 The eyelid can behave like a fluid sponge in conditions causing systemic edema9 like underactive thyroid, chronic kidney disease and liver insufficiency.2 Esmaeli et al described a case of lower lid festoons, which occurred during treatment of chronic myelogenous leukemia with Imatinib. It was felt that inhibition of platelet-derived growth factor receptor on dermal dendrocytes in the eyelid skin might be responsible for the localised oedema that is seen in patients on chronic therapy with Imatinib (STI571) 9 6. Chronic skin elastosis due to solar damage and smoking.1 Before

Figure 4: No change in appearance of malar mound when the patient smiles

looks upwards. To differentiate between fat and fluid, I ask the patient to ‘squeeze’ their eyes shut. When the patient forcibly smiles, they contract the orbicularis oculi muscle, intraorbital fat gets pushed back into the eye socket by a tautened muscle and only the redundant skin laxity of the festoon is visible. Festoons will often be associated with a history of variability of the ‘eye-bag’, for example, an increase in swelling or fluctuation in size after a salty meal. The patient will often mention that they have ‘good and bad days’ with the fluctuation of the festoon. Also, the swelling will not conform to the contours of the demarcated fat compartments After

Figure 5: Malar oedema secondary to dermal fillers

Before

Figure 6: Resolution of malar edema following dissolution with hyaluronidase After

Figure 7: Patient demonstrating malar mounds and festoons with eye bags

Figure 8: Patient three months after surgical upper and lower lid blepharoplasty with midface lift

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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of the lower lid (the fat appearing on the upper cheek/lower eyelid). A purplish colour will suggest that the swelling is due to fluid. Festoons do not look more prominent when the patient looks up, whilst malar mounds do not change much with a smile (Figure 4). Determining best treatment method for the patient Treatment options include non-surgical and surgical methods. The underlying principle is to treat the primary cause, for example, if there is an acute history of malar mounds related to allergies, treat the patient with systemic antihistamines. A pink or reddish eyelid margin should alert the clinician to a blepharitis, which can be treated by warming, mechanical massage, and topical or systemic immune modulating measures.10 Note the quality of facial skin, as acne and rosacea patients are predisposed to blepharitis and may be predisposed to developing festoons. Alternatively, if the malar mound is secondary to acute oedema following surgery, then oral steroids with or without diuretics have been indicated to be beneficial.11 Rule out systemic causes (like underactive thyroid or renal dysfunction) by blood investigations.1,3 Medical treatment of festoons with oral diuretics or steroid injections may produce minimal improvement, which is usually transient.11 In predisposed patients, with involutional ageing changes as the primary cause of malar mounds, proper patient and filler selection can reduce the incidence of malar oedema with non-surgical hyaluronic acid filler treatment. The aim is to limit lymphatic compromise by choosing a hyaluronic acid filler with low G prime, as with a lower lifting force, there is a reduced theoretical possibility of compressing the lymphatics. A small volume of filler is placed at the pre-periosteal level deep to the malar septum.7 For malar oedema secondary to hyaluronic acid fillers, hyaluronidase should be used to dissolve it.7 (Figures 5 & 6) For chronic malar bags and festoons, where there is no medical condition or it has been treated adequately, surgical correction can be beneficial.11 Surgical treatment of festoons is directed at improving the tone of the orbicularis oculi muscle by taking up the redundant muscle in a way that avoids compromise of muscle function. Malar mounds are improved or completely effaced by surgical lower lid blepharoplasty and mid-face-lift procedures that elevate and tighten the soft tissues of the malar area, or by direct excision of the festoon (Figure 6 & 7).11 Newer therapies, including intralesional tetracycline 2% injection, which acts as a sclerosant to seal the cavity of the festoon 12 or carbon dioxide (CO2) and Erbium-YAG (Er:Yag) laser which create a wound in the area of the festoon, allowing the new healing skin to

For chronic malar bags and festoons, where there is no medical condition or it has been treated adequately, surgical correction can be beneficial

Figure 9: Patient after upper lid surgical blepharoplasty and lower lid Agnes radiofrequency

be of better quality10 may offer less invasive options to treat lower eyelid festoons. I have has had early encouraging results with a radiofrequency needling device in treating lower lid festoons, (Figure 9) but further long-term studies are required. Summary Individuals with a predisposition to malar mounds pose a unique challenge to aesthetic practitioners using hyaluronic acid fillers. In this group of patients, festoons and malar mounds remain a poorly recognised and challenging condition to treat non-surgically. Aesthetic practitioners need to maximise patient outcomes by using low G prime hyaluronic acid fillers injected deep in the pre-periosteal plane in small volumes, with a low threshold to dissolve any malar edema that may develop and persist. Mrs Sabrina Shah-Desai is an oculoplastic surgeon and specialises in cosmetic eyelid lifts, scar-less droopy eyelid correction and revision eyelid surgery. She is highly experienced in non-surgical aesthetic periorbital rejuvenation with botulinum toxin and dermal fillers. Mrs Shah-Desai is a keen educator and runs surgical training wet labs. REFERENCES 1. Goldberg RA, McCann JD, Fiaschetti D, Simon GJB. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg. (2005);115:1395–1402. 2. Hussein N, Schwab IR. Blepharitis and Inflammation of the eyelids. In: Tasman W, Jaeger EA, eds. Duane’s Ophthalmology. 2013 ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:vol 4, chap 22. 3. McKeag D, Lane C, Lazarus JH, Baldeschi L, Boboridis K, Dickinson AJ et al., European Group on Graves’ Orbitopathy (EUGOGO), Clinical features of dysthyroid optic neuropathy: a European Group on Graves’ Orbitopathy (EUGOGO) survey, Br J Ophthalmol. 2007 Apr;91(4):455-8. Epub 2006 Oct 11. 4. Furnas DW. Festoons of orbicularis muscle as a cause of baggy eyelids. Plast Reconstr Surg. 1978;61:540–546. 5. Savar A, Blaydon SM, Nakra T, Shore JW. Ptosis surgery. In: Tasman W, Jaeger EA, eds. Duane’s Ophthalmology. 2013 ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:vol 5, chap 78. 6. Pessa JE, Garza JR. The malar septum: The anatomic basis of malar mounds and malar edema. Aesthetic Surg J. 1997. 17:11-7. 7. David Funt, Tatjana Pavicic. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clinical, Cosmetic and Investigational Dermatology (2013) Dec 12;6:295316. 8. Kpodzo DS, Nahai F, McCord CD, Malar mounds and festoons: review of current management, Aesthet Surg J. 2014 Feb;34(2):235-48. 9. Kikkawa DO, Lemke BN. Applied anatomy of the eyelids, lacrimal system, and orbit. Curr Opin Ophthalmol. 1991;2:568–572. 10. Kılıç Müftüoğlu İ, Aydın Akova Y. Clinical Findings, Follow-up and Treatment Results in Patients with Ocular Rosacea. Turkish Journal of Ophthalmology. 2016;46(1):1-6 11. Esmaeli B, Prieto VG, Butler CE, Kim SK, Ahmadi MA, Kantarjian HM, Talpaz M, Severe periorbital edema secondary to STI571 (Gleevec), Cancer. 2002 Aug 15;95(4):881-7. 12. Adam J. Scheiner, Sterling S. Baker Chapter Master Techniques in Blepharoplasty and Periorbital Rejuvenation, Laser Management of Festoons pp 211-221 13. Kpodzo DS, Nahai F, McCord CD, Malar mounds and festoons: review of current management, Aesthet Surg J. 2014 Feb;34(2):235-48. 14. Perry JD, Mehta VJ, Costin BR, Intralesional tetracycline injection for treatment of lower eyelid festoons: a preliminary report, Ophthal Plst Reconstr Surg, (2015)

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An Overview of Non-Surgical Body Contouring Treatments Dr David Jack outlines the different non-surgical body contouring treatments available and the results that they aim to achieve The quest for the ideal body has been a long held mission of many people of all ages across the world. Frustrated with exercise and diet, which often require strict and almost obsessive rigidity, people frequently end up looking into other options to reduce areas of stubborn fat and cellulite. Over the past few decades, multiple treatment modalities have been developed in an attempt to cater to those looking to shift these stubborn inches, which won’t disappear with even the strictest of diets or the most intense training schedules. In the past, this would almost invariably mean a visit to a plastic surgeon for either excisional body contouring surgery (such as abdominoplasty, brachioplasty and other similar procedures) or traditional liposuction. Nowadays, there is a plethora of new devices and techniques, which offer a favourable alternative to surgery for these patients, both in terms of morbidity and financially. In this article, I will outline some of the newer treatment options available in the world of body contouring, the approach to patients seeking these treatments, expected outcomes and potential adverse effects that may be experienced.

Patients seeking body contouring In my experience, patients attending clinics with body contour concerns fall under two broad categories, with several common characteristics. Firstly there will be those patients who are well informed about the various different treatment modalities and techniques, who may even have tried some treatments previously, and who have a clear idea of what they would like to achieve. Generally, I find this group is slightly more realistic about the outcome they are hoping to achieve with treatments. The second group I tend to see are less well-informed and, therefore, have a less realistic idea of what can be achieved with non-invasive/minimallyinvasive body contouring treatments. These patients generally are noncommittal about exercise and diet and are less likely to complete treatment courses. Managing the latter group is often the most challenging. Generally patients will present with an area of concern, whether it is the abdomen, thighs or lower back, for example. The typical concerns patients seek treatments for are excess fat, cellulite or pockets of stubborn fat that don’t resolve with diet and exercise. As with any other aesthetic treatments, body dysmorphic disorder (BDD) in potential patients can be an issue, and must be taken into consideration, which I shall explain in the patient’s assessment section below. Indeed, body-contouring treatments are thought to be the most commonly sought cosmetic treatments by patients with BDD.1

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Patient assessment/selection When selecting and assessing patients for non-surgical and minimally invasive body contouring, it is important to take a thorough history, including dietary and exercise history to identify any lifestyle factors that may need to be addressed, and also an in-depth assessment of the individual’s expectations and reasons for seeking these treatments. As mentioned above, patients with unrealistic expectations of the potential outcome of non-surgical treatments can become disappointed in the longer term, should the results not be as expected. Therefore, it is extremely important that any pre-treatment information given to patients is thorough, clear and realistic (if even underestimated). It is also important that for most non-invasive treatments, the practitioner emphasises the requirement for repeated treatments and the delayed nature of the final result, as, in my experience, this tends to be forgotten. Pre-treatment photography and volume measurement is an essential part of this process, as results can be more easily seen when comparing before and after photographs. At this stage, it is also important to rule out, as far as possible, any patients with symptoms of BDD. It is useful to have a validated screening questionnaire, such as the Body Dysmorphia Disorder Questionnaire (BDDQ), which has an accuracy of 94% for detection of this disorder.2 Avoiding treating patients with unrealistic expectations or psychopathology will prevent the almost inevitable post-treatment complaints, secondary to unsatisfactory outcomes.

Methods of body contouring A plethora of body contouring treatments have been developed over the last 20 years or so. In this section, I will briefly outline some of the major treatment modalities available to non-surgical aesthetic clinics. Many of these treatments are based on thermal injury at temperatures which selectively induce apoptosis in adipocytes, however, there has been much interest lately in treatments that can selectively target these cells without the potential side effects that heating or cooling tissues for sustained periods can cause. Radiofrequency Radiofrequency (RF) has been a key modality of power delivery to tissues for a variety of purposes over the last 75 years.3 RF treatments are based on the principal of skin and deep tissue heating through conversion of radiofrequency waves to heat energy, resulting in vasodilatation and inflammatory

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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changes, with subsequent stimulation of dermal thickening and deeper connective tissue thickening and reorganisation.4 This heating of the adipocyte layer to 43-45°C has been indicated to induce selective apoptosis in fat cells, with sparing of surrounding cells, with volume reduction three to eight weeks post RF treatments.5 Most non-ablative RF treatments require multiple treatments sessions for optimal results. Although RF treatments are considered on the whole to be safe, with modern devices often having in-built temperature sensors to prevent overheating of the surface of the skin, these devices are, to a large extent, operator dependent so complications such as burns do still occur. In addition, older monopolar RF devices have been associated with uneven depths of RF penetration and later unevenness of fat breakdown and associated surface contour abnormalities.3 Bipolar or multipolar RF handpieces tend to be much more predictable in the depth of penetration of RF waves, so the risk of unevenness and contour abnormalities is less with these when compared to monopolar RF.3 Transient post-treatment effects such as erythema are common and expected. Cryolipolysis Cryolipolysis or ‘fat freezing’ is based on the principle that adipocytes are more susceptible to cooling than other cells. When exposed to low temperatures, fat cells are triggered to undergo apoptosis, resulting in an inflammatory response and removal by phagocytes. Subsequently there is a volume reduction and restructuring of the whole subcutaneous layer when the inflammatory response has reduced.6 Several devices are available on the market today, often combining freezing with a vacuum mechanism and skin surface protection. Although these treatments may result in some posttreatment erythema, paraesthesia and bruising, side effects are rare and treatments are generally suitable for all skin types. Postprocedural pain is fairly common but resolves with time and analgesia. Often more than one treatment is required for optimal results and the best results are often seen after four six months.7,8 High intensity focused ultrasound The use of high intensity focused ultrasound (HIFU) for fat loss is a relatively recent development. HIFU has traditionally been used in medical aesthetics for several years, primarily to tighten and lift the SMAS layer of the face. It has been indicated that this technique, which uses focused ultrasound to create deep areas of coagulative necrosis in the subcutaneous layer, results in volume reduction and tightening, being apparent around 12 weeks post treatment.9 Again, more than one treatment is usually required to provide optimal results. These treatments are again suitable for all skin types and generally have a minimal side-effect profile. Low level laser therapy A recent review by Dr Sarah Tonks in the August issue of this journal elegantly highlighted the use of low level laser therapy (LLLT) in body contouring and other areas of medicine.11 This exciting technology, which is based on the exposure of infrared or near infrared light, has been indicated to effect body composition in multiple ways, both directly, by inducing changes in adipocyte metabolism, and also by changing the expression of the hormone involved in appetite, leptin. Several devices utilising wavelengths of light between 532 nm and 635 nm have been approved by the Food and Drug Administration for body contouring. These devices, similar to RF, require multiple treatment sessions for full effectiveness with minimal, if any, side effects.11

Aesthetics

Deoxycholic acid The use of unregulated injectable treatments for submental fat has been of interest for some time, with the CE-approval of a preparation of deoxycholic acid being granted in 2012.10 These injections work on the basis that deoxycholic acid acts as a lytic agent when injected into areas of fat, causing disruption of adipocyte membrane integrity and subsequent adipocytolysis. Following this, a mild inflammatory response with phagocytosis and removal of cellular debris results in long term volume reduction in areas treated.12 Deoxycholic acid has been indicated to clear rapidly following injection, and its action appears to be limited to lipid-rich tissues, alleviating concerns that surrounding tissues could be damaged from treatments. In addition, there does not appear to be a measurable increase in plasma lipid levels following these treatments.12 Treatment of submental fat with a deoxycholic acid preparation (ATX-101) has been subject to a phase III randomised control trial in Europe, which demonstrated a favourable outcome in the submental area (volume reduction with no increase in skin laxity) with minimal side effects; these being transient and local to the injection sites, including pain, erythema and oedema.13 Multiple treatments spaced over several weeks are usually required for deoxycholic acid injections for optimal results.

Conclusion Body contouring is an area of medical aesthetics that is developing rapidly, with many new devices coming to market every year, using multiple different technologies. For these treatments, patient selection is probably the most challenging, as many non-invasive treatments require multiple sessions (and are, therefore, time intense for both patient and provider) so patient expectations must be managed carefully. The choice of equipment for an individual practice will depend on a variety of factors, including cost, patient demographics, space available and staffing levels. 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. de Brito MJA, Prevalence of body dysmorphic disorder symptoms and body weight concerns in patients seeking abdominoplasty, J Aesthet Surg, (2016) Mar 4;36(3):324-32. 2. Brohede S, Wingren G, Wijma B Wijma K Validation of the Body Dysmorphic Disorder Questionnaire in a community sample of Swedish women, Psychiatry Res, (2013) Dec 15;210(2):647-52. 3. Jack DR, Radiofrequency: an important tool in the aesthetic practitioner’s repertoire, Aesthetics journal January (2016). 4. Royo de la torre J, Moreno-Moraga J, Muñoz E, Cornejo Navarro P Multisource, Phase-controlled Radiofrequency for Treatment of Skin Laxity: Correlation Between Clinical and In-vivo Confocal Microscopy Results and Real-Time Thermal Changes, J Clin Aesthet Dermatol, (2011) Jan; 4(1): 28–35. 5. Franco W, Kothare A, Goldberg DJ. Controlled volumetric heating of subcutaneous adipose tissue using a novel radiofrequency technology, Lasers Surg Med, (2009);41(10):745–750. 6. Krueger N, Mai SV, Luebberding S, Sadick NS, Cryolipolysis for noninvasive body contouring: clinical efficacy and patient satisfaction Clin Cosmet Investig Dermatol. (2014); 7: 201–205. 7. Ortiz AE, Avram MM, Noninvasive Body Contouring: Cryolipolysis and Ultrasound Semin Cutan Med Surg (2015) 34(3) 129-33 8. Avram M.M., and Harry R.S, ‘Cryolipolysis for subcutaneous fat layer reduction’, Lasers in Surgery and Medicine, 41 (10) (2009), p.p. 703-08 9. Shalom A, Wiser I, Brawer S, Azhari H. Safety and tolerability of a focused ultrasound device for treatment of adipose tissue in subjects undergoing abdominoplasty: a placebo-control pilot study. Dermatol Surg, (2013);39(5):744–751. 10. Rauso R, Salti G, A CE-Marked Drug Used for Localized Adiposity Reduction: A 4-year Experience Aesthet Surg J (2015) 35(7) 850-7 11. Tonks S, ‘Body Contouring and LLLT.’ Aesthetics journal, August (2016). 12. Thuangtong R, Bentow JJ, Knopp K. Tissue-selective effects of injected deoxycholate. Dermatol Surg. (2010);36:899–908. 13. B Rzany, T Griffiths, P Walker, S Lippert, J McDiarmid, and B Havlickova Reduction of unwanted submental fat with ATX-101 (deoxycholic acid), an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study Br J Dermatol, (2014) Feb; 170(2): 445–453.

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has a 360-degree probe that is inserted into the vaginal canal directing and concentrating the laser all around the canal to manage these concerns. The fractional CO2 laser directly remodels the vaginal mucosa via new collagen formation and elastic fibers on the skin.4 I used the Venus CO2 laser, which is what the protocol, the Venus-VT, is based on, however there are others available that may be considered for this treatment. One study has suggested that fractional C02 lasers can improve the vaginal canal tightness beyond the introitus without causing damage to the surrounding tissue.3 The protocol also includes treating the labia minora and majora as a non-surgical labiaplasty.

Case Study: Treating Vaginal Laxity and Sexual Dysfunction Dr Natasha Ranga details how she successfully managed a patient’s intimate vulvovaginal concerns with CO2 fractional laser Globally, approximately 15% of the pre-menopausal population have vulvovaginal concerns,1 however the true figure may be underestimated as it is often being perceived as an embarrassing problem, so many patients may not seek help or treatment. Myself and Dr Jorge Zafra, who assisted me with this article, have personally noted an increase in popularity for vaginal treatments, however there is no one clear definition on what the procedure involves or its intended benefits.2 Managing concerns The concerns that many patients present with include vaginal laxity, dryness, urinary stress incontinence, sexual discomfort, dyspareunia and psychosexual problems.2 Vaginal rejuvenation addresses all of the above concerns, and refers to restoring a woman’s intimate health to a pre-menopausal state and a prepartum restoration. Sexuality plays an important part in a woman’s health, quality of life and general wellbeing. In my experience in general practice, these vaginal concerns are difficult to treat, and often women just put up with the concerns. Many women who have given birth vaginally, experience stretching of their vaginal tissue, while many post-menopausal women have vaginal atrophy changes. Both of these types of patients may have longterm physical and psychological consequences including loss of sensation, stress incontinence, vaginal laxity, and pain including dyspareunia or general intimate discomfort at anytime. Vaginal rejuvenation is the treatment of these concerns and lasers are at the forefront in the management.3 We have developed a protocol with a fractional CO2 laser that

Case study introduction In July 2016, 34-year-old Caucasian Patient A was treated for vaginal laxity and dryness. She had given birth to two children, the most recent being four years prior. In her consultation she said that she had had no previous non-surgical vaginal rejuvenation treatments. She also had no past medical history that would be significant to this procedure such as recent surgical labiaplasty, which is a clear contraindication. It should be noted that she had a Mirena coil in situ, previous surgical labiaplasty more than 10 years ago, no known drug allergies, no sexual health history, and cervical smears up to date with no abnormalities.

Treatment protocol: Cleanse the area with a mild antiseptic and allow to dry, so no residue is left to interfere with the fractional CO2 laser. • Fully insert the 360-degree laser head/vaginal probe and slowly withdraw it at 0.5cm intervals after each laser blast is delivered. Do not use any lubrication as this interferes with the laser treatment. • The laser is set to deliver the energy equally at 360 degrees in the vaginal canal; point energy is set to 19.0mj, power 19w and the duration 1.0ms. • There can be up to three passes of the laser treatment.

Sexuality plays an important part in a woman’s health, quality of life and general wellbeing

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Questionnaires The International Consultation on Incontinence Questionnaire–Vaginal Symptom (ICIQ–VS)4 is a questionnaire developed to assess the impact of vaginal symptoms and associated sexual matters on quality of life and outcome of treatments. It focuses on 14 vaginal symptoms and 10 sexual matters; it takes up to five minutes to be completed, it scores a maximum of 53 in vaginal symptoms and 58 in sexual matters. The higher the scores, the more unsatisfied the patient. We suggest this is conducted prior to the initial consultation in the privacy of the patient’s home; some patients find it helpful to do in the company of their partner. The importance of the questionnaire is to measure both the severity and the perceived impact of symptoms, which enables the ability to monitor patients’ symptoms over time and to assess the effectiveness of treatment.8

It is vital that the patient is provided with all necessary information regarding treatment including expectations, outcomes, and potential side effects prior to the treatment

The Female Sexual Function Index (FSFI),5 is a questionnaire that has been developed specifically for assessing sexual functioning (e.g. sexual arousal, orgasm, satisfaction, pain). The index has 18 items and has a maximum score of 36, which takes less than five minutes to complete. It is not a measure of sexual experience, knowledge, attitudes, or interpersonal functioning in women and was not designed for use as a diagnostic instrument and should not be used as a substitute for a complete sexual history in clinical evaluation.9

and recommendation of subsequent sessions or, if needed, gynaecology referral for further studies. The questions are asked pre-treatment and then post-treatment at time intervals of seven days, one month, three months, six months and 12 months. The case study was at one month and seven days at the date of which this article was written.

• The laser setting and laser head is then altered for external treatment, targeting the labia minora and majora. • The external settings for the laser are; point energy 7.0mj, power 7w, duration 1.0ms. • Treatment delivery time is a short five minutes. Consultation A joint discussion was undertaken with Patient A, which included a thorough medical, sexual, and gynaecological history and examination. The examination is very important and the use of dilators can be used to determine canal diameter, in this case this was not done as we did not have access to a dilator and instead used the patient’s answers to the questionnaires before and after. It is vital that the patient is provided with all necessary information regarding treatment including expectations, outcomes, and potential side effects prior to the treatment, and that they are given as much time as they need to ask questions. Included in our consent was a cooling-off period where at anytime Patient A could withdraw. The consultation is especially important in this type of procedure as it is such a personal treatment and the patient must feel completely comfortable with all of the treatment protocols. As there were no contraindications to treatment, Patient A was deemed suitable for C02 fractional laser. Patient A was given two questionnaires prior to the treatment; the ICIQ–VS4 and the FSFI,5 which were also conducted after the treatment and used as a comparison to determine the treatment’s effectiveness. The combination of the ICIQ-VS and FSFI questionnaire in the protocol is ideal for patient selection, evaluation of treatment outcome over time

For the pre-treatment questionnaires, her FSFI score was 24.9 and her ICIQ–VS4 score was 22. There are no scores that would be unacceptable to treatment as all patients would have been screened out with the initial history and any contraindications to the treatment highlighted. The results were analysed and her expectations discussed. She reported that her main concerns included laxity and occasional dryness and we were confident that the protocol would successfully treat these. The exact details of the procedure were explained to Patient A and what she could expect to experience during the treatment was discussed. A consent form was signed and an information leaflet on post-procedure care was discussed with the patient and given to her for reference. Prior to treatment, patients are advised to avoid creams, lubricants and sexual intercourse for five to seven days. The key points discussed are outlined below: • When the laser head and surrounding vaginal probe is inserted for the internal treatment, there may be some discomfort, but it is generally described as smooth and comfortable. • For the external treatment, there may be some discomfort, but it is generally described as resembling a warm spoon against the skin. • The patient may experience some tingly sensations, especially during the outer treatment. • A ‘buzz’ or ‘sizzle’ sound may be heard the more external the treatment becomes. • There may be some soreness or irritation straight away and for 48 hours after. • It is not uncommon for there to be some spotting 24-48 hours after the procedure.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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This case study highlights the effectiveness and safety of CO2 fractional laser treatment for vaginal laxity and dryness in premenopausal women

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month intervals to improve the effects and to build upon the first treatment. Having a course of three treatments may help results last longer than 12 months, but there is no current evidence for this. She may not need second and third treatments, and the decision to go ahead will be based on her questionnaire scores and her reviews. Conclusion This case study highlights the effectiveness and safety of CO2 fractional laser treatment for vaginal laxity and dryness in premenopausal women. It is a simple and time efficient treatment. It is non-surgical with minimal downtime, is minimally invasive and no general anaesthesia is required. It is essentially an ambulatory treatment that can help the confidence and satisfaction of women. In this case, Patient A had a very good result with improved quality of life and sexual function. It must be noted that only adequately trained practitioners with laser safety training and expertise in this anatomical region, as well as in consulting and history taking, should be delivering this treatment to this sometimes-vulnerable group of patients. Note: Dr Natasha Ranga was assisted with this article by Dr Jorge Zafra, who has a Master’s Degree in aesthetic medicine and antiageing and has a private medical practice based in Bristol.

• There have been some patient reports of a ‘watery discharge’ occurring up to two to three days after the procedure, and they were advised to seek medical attention. In this one case, the patient was reviewed and examined for infection; swabs were sent and urine was checked and no infection was found. I advised her to allow time for it to resolve which it did within four weeks. This has occurred in one patient we have treated so it is now included in the aftercare advice. • Every patient is given a patient information leaflet on post treatment care and possible symptoms of concern. Post-treatment care Following treatment, Patient A was advised not to have intercourse for four days. She was also instructed to avoid creams, lubricants and feminine products for five days, avoid bathing or showering for four hours and to avoid swimming pools and hot tubs for 48 hours. This is important aftercare to increase collagen formation, allow the tissue to remodel and to prevent infection. Results The patient returned to clinic for a review at seven days, two weeks and at four weeks. At the four week review, Patient A was very pleased with the results, reporting an increase in vaginal tightness and sexual function and reduced vaginal laxity, which were reflected in her scores. Her FSFI score was 14.9 (previously 24.9) and her ICIQ Vaginal Symptoms Questionnaire 12 (previously 22).

Dr Natasha Ranga is the clinical lead and director of her cosmetic antiageing practice, Ranga Medical Ltd in Leicester City. After qualifying as a medical doctor in 2009 from the University of Leicester, she completed an array of courses in advanced non-surgical aesthetics. She also has a keen interest in women’s health and medical applications of botulinum toxin. REFERENCES 1. AH Kegel, ‘Progressive resistance exercise in the functional restoration of the perineal muscles’, American journal of obstetrics and gynecology, 56(1948), pp.238-48. 2. Nappi, R E., Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause’, Climacteric, 17(2014) pp.3-9.
 3. Fistonic I, Fistonić I, Sorta-Bilajac Turina I, Gustek Findri S, Laser treatment of early stages of stress urinary incontinence significantly improves sexual life, Annual Congress of the European Society of Sexual Medicine, Amsterdam, (2012) <https://www.researchgate.net/publication/279849203_Laser_ treatment_of_early_stages_of_stress_urinary_incontinence_significantly_improves_sexual_life > 4. Bramwell R, Morland C, Garden A, ‘Expectations and experience of labial reduction: a qualitative study’, Br J Obstet Gynaecol 114(2007) pp.1493–9. 5. Tierney EP, Hanke CW, ‘Ablative fractionated CO2, laser resurfacing for the neck: prospective study and review of the literature’, J Drugs Dermatol, 8(2009) pp.723-731.
 6. N Price, SR Jackson, K Avery, ST Brookes, P Abrams, ‘Development and psychometric evaluation of the ICIQ Vaginal Symptoms Questionnaire: the ICIQ-VS Department of Obstetrics & Gynaecology’, John Radcliffe Hospital, Oxford, UK b Department of Social Medicine, University of Bristol, (2006). 7. R Rosen, C Brown, J Heiman, S Leiblum, C Meston, R Shabsigh, D. Ferguson, R D’Agostino, ‘The Female Sexual Function Index (FSFI): A Multidimensional Self-Report Instrument for the Assessment of Female Sexual Function Journal of Sex & Marital Therapy’, 26(2000) pp.191–208. 8. Price N, Jackson S, Avery K, Brookes S & Abrams P, ‘Development and psychometric evaluation of the ICIQ Vaginal Symptoms Questionnaire: the ICIQ-VS’, BJOG: An International Journal of Obstetrics & Gynaecology, 113(2006), pp.700–712. 9. Meston CM, ‘Validation of the Female Sexual Function Index (FSFI) in Women with Female Orgasmic Disorder and in Women with Hypoactive Sexual Desire Disorder’, Journal of sex & marital therapy, 29(2003), pp.39-46.

Discussion The treatment for this patient was viewed as successful as she had a marked reduction in the two questionnaires used. She also reported reduced vaginal laxity and improvement with stress incontinence during exercising. She will be reviewed at three, six and 12 months. During each review, the questionnaires will be repeated and the patient will report any changes. The results are expected to last 12 months after one treatment5 and this patient is eligible to have a second and third treatment at three-

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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• Alar recess • Glabella • Micronose (requires larger volumes)

Nose treatment techniques The use of both cannula and needles in NSR are both commonplace. For the techniques below we advocate the use of a cannula where possible, as the outcome of a significant intravascular injection of HA is so dire. Athough, we acknowledge it can be a more uncomfortable and difficult procedure than with a needle, while some finessing is still sometimes required with a needle.

Non-surgical Rhinoplasty In the second of their two-part article, Mr Geoffrey Mullan and Mr Ben Hunter advise how to successfully perform a non-surgical rhinoplasty treatment Non-surgical rhinoplasty (NSR) is a procedure that is attractive to many patients who are not prepared for the downtime or risk of complications associated with surgical interventions, or who do not need a surgical reduction rhinoplasty.1,2 NSR involves the reshaping of a nose using soft tissue augmenters such as hyaluronic acid (HA) and can provide a very natural result.1 This article will draw upon the anatomical considerations discussed in our previous article, will explore the techniques for NSR and provide tips on how to perform a successful treatment. The possible complications and risks will also be explored, as well as how to best manage and avoid these.

1. Correcting the nasal dorsum- cantilever nose lift By creating an entry point (after a small bleb of 2% lignocaine) at the nasal tip, you can access past the sellion for dorsal augmentation and posteriorly to the nasal spine in the case of tip elevation with a 22G, 50mm blunt cannula. For the dorsum, depth should be at the deep subcutaneous layer in the supra-periosteal plane and the cannula should be inserted all the way up the dorsum past the sellion to the nasion. It is important to pinch the dorsum of the nose to check the positioning of the tip of the cannula and later to help mould the product and avoid lateral spread. A slow retrograde technique (injecting product as the cannula is withdrawn) will help the product stay in the correct plane. If the dorsum needs to be widened, do not try to add larger volumes in the single tunnel formed by the cannula. Instead, retract the cannula and form a new tunnel lateral and inferior to the first, repeat for the contralateral side. The sellion, the deepest point of the nasal root, is usually found to be a little bit higher in the Caucasian face than compared to other ethnicities.4 Injection of the dorsum can move this point by as much as 5mm to be closer in line with the medial brow. By assessing the rhinion, a decision should be made as to whether product should only be injected to this point. If required, in the case of a small dorsal hump appearance, it can be improved by injecting product both at the cephalic and caudal part of the hump. Augmenting the medial brow to the dorsum completes the treatment, using a 30G needle and carefully aspirating before injecting in a retrograde manner and contouring the glabella in balance with the upper nasal dorsum. By injecting from the medial brow to the radix it is possible to create a smooth arch whilst softening any pre-existing glabellar frown line.

Techniques for NSR Some nose deformities are relatively simple to treat in NSR, others should be left to more experienced practitioners, or may require a surgical solution.

Trichion Glabella Nasion

Low risk regions Low risk areas are relatively easy to treat and get good results, with a low chance of complications. Low risk areas include: 3 • Mild dorsal hump • Saddle deformity • Short nose and flat nose

Sellion (radix)

High risk regions High risk areas such as the nasal tip and glabella have the highest rate of skin necrosis, and should only be performed by experienced practitioners. High risk areas include: 3 • Nasal tip

Mention

Supratip break Tip defining point Pronasale Infratip lobule Subnasale Pogonion

Cervical point

Figure 1: Useful nasal anatomy

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Before

NSR key considerations • If you are injecting in high-risk regions like this it is essential to have hyaluronidase on hand and to know the correct dilution factors. • A hard, thick fibrous tip that does not move when the nasolabial junction is pinched will be difficult to elevate nonsurgically and a surgical solution should be sought. • Patients who have had any implants placed during surgery should not have anything more than tiny amounts of HA, 0.10.2ml in total to feather irregularities. • A compromised, altered blood supply coupled with arteries that may be fixed by scar tissue greatly increase the risks of causing skin and cartilage necrosis. Therefore extra caution should be taken and an understanding that the tissue may not be as pliable and more difficult to inject filler into.

Aesthetics aestheticsjournal.com After

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2. Correcting the nasal tip region A bifid tip can be corrected by injecting product into the interdomal area, which can also be injected and filled to widen a narrow nasal lobule. To raise the nasal tip, it is vital not to inject into the tip itself. There is no solid foundation to lay the filler on, so no lasting change is achieved and it can lead to potential vascular compromise of the skin envelope. Cadaveric studies have shown a midline longitudinal columellar artery in 31.1% of dissections that would be at risk by injection at this point.11,12 Instead, inject between the footplates of the lower lateral cartilages and the anterior nasal spine at the base of the columella (0.5-1.0ml Before

After

Figure 3: Patient unhappy with dorsal hump and masculine appearance of nose. Treated with 0.55ml of hyaluronic acid. Dorsal hump disguised with dorsal augmentation at the radix and in the supra-tip area to give more feminine profile and supra-tip break with slight ‘kick-up’ of nasal tip.

desirable nasolabial angle ideal is 110-120 degrees (as discussed in Part 1 of this article, there are different ranges and it varies for men and women), however in many patients, this is often less than 90 degrees. To correct this, using a 30G needle, enter the skin to the nasal spine. This is normally done in conjunction with correction of the columella using a slow bolus of product. When treating both areas up to a total of 1ml of product can be used. 4. Spreader grafts There have also been descriptions of NSR for functional problems as well as cosmetic. The most notable is the use of injectable fillers to try to widen the nasal valve, this in turn improves the passage of air. This is classically a surgical procedure carried out by harvesting cartilage grafts and inserting them to lift the upper lateral cartilages off the septum and therefore widen the nasal airway. This has been described with both HA and hydroxyapatite. While these injections will only be temporary, at the least, this allows a patient to assess the potential functional improvement that could be achieved with a surgical procedure.5

Complications of NSR

Figure 2: Patient requested NSR for low radix and under developed dorsum and requested more tip rotation and projection. Treated with 0.9ml of hyaluronic acid. Dorsal augmentation, small amount to refine tip, columella treated as well as tip lift at base of columella to lift tip and improve nasolabial angle.

may be needed). A hard thick fibrous tip that does not move when the nasolabial junction is pinched will be difficult to elevate. These patients will require a surgical procedure to reposition the nasal tip. Injecting up to 0.5ml into the columella can provide support for the tip of the nose, and if the tip droop is minor, it may be enough to provide the correction on its own.13

The greatest concern when treating the nose is intra-arterial injection of product. The literature has well documented cases of brain infarction, skin necrosis and blindness from injecting fat, fillers and volumisers.7 The mechanism for blindness is well considered and appears to be an embolic event. Injection into an artery causes retrograde flow proximal to the central retina’s branching point. The filler is then carried forward with the blood flow, causing an obstruction. Clinically, patients may present with a sudden blind spot or visual field deficit; this may match a filling defect in the retina, so avoidance is critical when injecting in this area. The ophthalmic artery terminates in two small branches, the superior trochlear artery and the dorsal nasal artery.8 It is very important to note that the proximal blood supply has short and direct connections to the internal carotid and retinal arteries. Product injected into these can cause blindness and brain infarction.8 The distal blood supply at the tip and alar can also be affected by embolisation, leading to ischaemic events from prolonged erythema to skin necrosis. Signs of inter-arterial injection

3. Correcting columella recession From the nasal tip, place the cannula posteriorly down the columella in the midline and inject slowly in a retrograde manner with multiple tunnels if required, up to a maximum of 0.5ml. The

Pain: escalating pain may be a sign of increasing ischaemia Blanching of the skin: avoid using adrenaline when injecting the nose so any sudden blanching can be easily recognised

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After

Figure 4: Patient unhappy with the flattened position at the radix (bridge of the nose). Treated using a cannula and tunneling technique – 0.75ml of hyaluronic acid used – entry point at tip region, radix built up and widened in this area.

The desirable nasolabial angle ideal is 110-120 degrees, however in many patients, this is often less than 90 degrees Livdeo phase: blotchy red or blue mottled skin patches may be a sign of tissue ischaemia Capillary refill: normal capilllary refill is one to two seconds after thumb depression and a slow refill is a sign of vascular compromise, which can lead to ischaemia and ultimately cell and tissue death. After the initial ischaemic event from the filler injection, the healing phase will occur firstly with demarcation of the healthy and necrotic tissue. After a period, this necrotic tissue sloughs off and healing occurs with new skin and scar tissue formation. Management9 Due to the nature of products used today most complications can be reversed with the use of hyaluronidase if HA is used. There are differing hyaluronidase units required that will depend on the type of product being used. Injecting product into the arterial supply can have devastating consequences. In the case of a vascular event, injecting hyaluronidase both into the surrounding tissue, but ideally the vessel, is the best hope for reperfusion. Examination of the pattern of ischaemic change will determine which branches have been affected. Nitropaste, hot compresses, hyperbaric oxygen and GTN, a nitrate dilator used for angina, have all been suggested to treat these events, but as often discussed in various round table events with many practitioners, the key factor is to inject hyaluronidase in significant volumes as soon as possible. Knowledge of the relevant anatomy and a good technique can help to avoid complications. Other complications • Lumps and nodules: can occur if too much product is injected, the product is injected too quickly or if the product is injected too superficially. Correct with excision and drainage of product or hyaluronidase.

Aesthetics

• Tyndall effect: blue discolouration of the skin caused by too much product placed too superficially. This can be removed by injection of hyaluronidase. • Infection: proper skin disinfectant agents should be used and a good technique with minimal incision sites. Broad-spectrum antibiotics such as ofloxacin10 can help to deal with more persistent infections such as those proposed by the biofilm theory. • Delayed hypersensitivity: all sites of injected HA become hard several months after treatment. Various treatments including longcourse antibiotics, steroids and removal of all traces of HA have been suggested.

Conclusion For practitioners wanting to achieve good NSR results, they must be suitably trained and have knowledge in the appropriate anatomy of the nose. They should also conduct a thorough consultation with the patient prior to treatment. Avoidance of complications is reduced by good technique (aspirating before injection and use of cannula where possible) and awareness of the blood supply to the nose. This article is the second of two on non-surgical rhinoplasty by Mr Geoffrey Mullan and Mr Ben Hunter. Their previous article was published in the December 2016 issue of Aesthetics, and detailed the relevant anatomy to consider for non-surgical rhinoplasty. To read this article, visit www.aestheticsjournal.com. Mr Geoffrey Mullan is a cosmetic surgeon and medical director at Medicetics Clinics and Training Academy. He has taught anatomy at Guy’s Hospital and worked at the Royal Marsden Head and Neck Unit, with an advanced understanding of the deep structures of the face. He has been a dermal filler trainer for Allergan and offers workshops in a number of treatments in central London. Mr Ben Hunter is a consultant facial plastic surgeon with extensive experience and expertise in nasal surgery. He works at St Georges Hospital Medical School, London and privately at the Lister Hospital, Chelsea and King Edward VIIth Hospital London. Mr Hunter qualified with the Royal College of Surgeons of England and holds European Board Certification in Facial Plastic and Reconstructive Surgery. He runs training workshops alongside Mr Mullan and a number of other faculty in central London. REFERENCES 1. Jasin ME, ‘Nonsurgical rhinoplasty using dermal fillers’, Facial Plast Surg Clin North Am, 21(2013), pp.241-52. 2. Pontius AT, Chaiet SR, Williams EF, ‘Midface injectable fillers: have they replaced midface surgery?’, Facial Plast Surg Clin North Am., 21(2013), pp.229-39. 3. Sykes JM, Tapias V, Kim JE, ‘Management of the nasal dorsum’, Facial Plast Surg, 27(2011), pp.192202. 4. Papel et al, Facial Plastic and Reconstructive Surgery, Thieme Medical Publishers, 3(2009). 5. Nyte, CP, ‘Spreader Graft Injection With Calcium Hydroxylapatite: A Nonsurgical Technique for Internal Nasal Valve Collapse’, The Laryngoscope, 116(2006), pp.1291–1292. 6. Inoue K SK, Matsumoto D, Gonda K, Yoshimura K, ‘Arterial embolization and skin necrosis of the nasal ala following injection of dermal fillers’, Plast Reconstr Surg, 121(2008) pp.0 127-128. 7. DeLorenzi C, ‘Complications of injectable fillers, part I’, Aesthet Surg J, 33(2013) pp.561-75. 8. Lin YC, Chen WC, Liao WC, Hsia TC, ‘Central retinal artery occlusion and brain infarctions after nasal filler injection’, QJM, 108(2015) pp.731-2. 9. Kim J, Ahn D, Jeong H, Suh IS, ‘Treatment algorithm of complications after filler injection: based on wound healing process’, Korean Med Sci, 2014 Nov;29 Suppl 3:S176-82. 10. Bakshi SS, ‘Comment on: Effect of topical ofloxacin on bacterial biofilms in refractory post-sinus surgery rhino-sinusitis’, Eur Arch Otorhinolaryngol, 273(2016) pp.2853-4. 11. Tansatit T, Moon HJ, Rungsawang C, Jitaree B, Uruwan S, Apinuntrum P, Phetudom T, ‘Safe Planes for Injection Rhinoplasty: A Histological Analysis of Midline Longitudinal Sections of the Asian Nose’, Aesthetic Plast Surg, 40(2016), pp.236-44. 12. CD Hymphrey, JP Arkins, S Dayan, ‘Soft tissue fillers in the nose’, Aesthetic Surgery Journal, 29(2009), pp.478-84. 13. Hee-Jin KIM, Kyle SEO, ‘Clinical Anatomy of the Face for Filler and Botulinum Toxin injection’, Publshed by Springer.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Aesthetics

Retinoid actions As mentioned previously, retinoids have multiple modes of action, which are outlined below.

Topical Retinoids Dr Sandeep Cliff outlines the different forms of topical retinoids and discusses their mechanisms of action ‘Retinoid’ is an umbrella term to describe all forms of vitamin A, including both naturally and synthetically produced derivatives, which have been in regular use in dermatology for more than 70 years.1 Retinoids have been used to treat a variety of cutaneous disorders such as plaque psoriasis, acne, oily skins, epithelial tumours and photoageing with more than 2,500 compounds now available.1 This article will explore the common forms of topical retinoids, how they work and their different functions, as well as how they can be combined with other ingredients.

What are retinoids? There are three generations of retinoids (Figure 1).2 They are compounds that have biological activity similar to naturally occurring vitamin A (retinol) and cover a huge spectrum of effects, from cosmetic to prescription-only medicine use. It is important to note that vitamin A cannot be synthesised by the body, but needs to be supplied to the body, for example as a topical product, in a ‘ready to use’ form.3 First generation

Second generation

Third generation

Retinol

Etretinate

Arotinoid

Tretinoin

Acitretin

Adapalene

Isotretinoin

 

Tazarotene

Figure 1: Chart showing the different generations of retinoids2

Retinoids are known to be irritating to the skin, which limits their use in many patients.3 Retinol and retinaldehyde are commonly used in aesthetic skincare products, as they are gentle yet effective alternatives to retinoic acid (RA). Topical retinoids have different effects on cell proliferation under different conditions. It has been demonstrated that retinoids can exert both immunomodulatory and antiinflammatory activity, and in psoriasis have been indicated to reduce proliferation, enhance differentiation, regulate corneocyte desquamation, modulate lymphocyte function and inhibit neutrophil migration.4

Photodamage Use of both RA and retinol has been indicated to increase epidermal thickness and has demonstrated increases in procollagen I and procollagen III protein expression.5 Topical retinoids can act as UV filters as retinoids absorb UV light; an in vitro study with mice skin exposed to topical retinyl palmitate demonstrated effects in prevention of UVB induced erythema and DNA photodamage, suggesting that epidermal retinyl esters have a biologically relevant filter activity.6 In an eight-week double-blind, split face, vehicle-controlled study with digital photography, researchers demonstrated that the retinol treated side had statistically significant reductions in: lines and wrinkles, mottled pigmentation, and improvements in firmness, elasticity and overall photodamage.7 Fine lines and wrinkles and HA production Topical vitamin A preparations are widely used as a treatment for fine lines and wrinkles.8 Studies have indicated that retinoids increase water content in the dermis by stimulating glycosaminoglycan (GAG) synthesis, particularly hyaluronic acid (HA) and by stimulating both transforming growth factor (TGF-beta) procollagen leading to an increase in dermal Type I collagen.9,10,11 Matrix metalloproteinase production and consequently collagen degradation are prevented when retinoids are applied topically prior to ultraviolet irradiation.8 Skin roughness Retinoids speed up epidermal cell turnover by modulating the expression of relevant genes, increasing cellular differentiation and proliferation.9,12 Hyperpigmentation RA has been used for hyperpigmentation as it increases cell turnover, which in turn decreases contact time between keratinocytes and melanocytes and reduces pigment through epidermopoiesis, with a reduction of clumping of melanin in basal cells.10 RA suppresses UVB-induced pigmentation by reducing tyrosinase activity. The acid acts at a posttranscriptional level on tyrosinase and tyrosinase-related protein.13,14 Antibacterial and sebum reducing properties In patients with acne, topical retinoids have

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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been suggested to increase follicular epithelium turnover, expelling mature comedones and inhibiting formation of microcomedones and creating a negative environment for Propionibacterium acnes.15 Sebum reduction has been demonstrated in various studies, as well as for the control of formation of comedones, reduced lesion count and increased epithelial desquamation.16,17 Retinoids as antioxidants Topical retinoids have been shown to have antioxidant, free-radical scavenging properties in vitro,10 and Draelos suggests their use alongside other topical antioxidants to ensure full antioxidant protection.18

Common types of topical retinoids Tretinoin Tretinoin in the treatment of photoageing was first demonstrated in 1984. Using an animal model, Kligman et al. observed that 10 weeks of tretinoin treatment on photoaged mice skin resulted in the repair of new collagen in the papillary dermis with a direct correlation to wrinkle effacement.1,19 There are many other studies that support the widespread use of tretinoin in both clinical and aesthetic scenarios.1,3,19,20 Isotretinoin Isotretinoin has been used both orally and topically. For topical use, it has been shown to result in a reduction of fine lines and wrinkles as well as pigmentation, sallowness and texture without causing significant irritation.21,22 In 2005 Griffiths et al. conducted a six-month, multicentre, double blind, randomised, parallel-group, vehicle controlled study of 346 subjects with photoaged skin using 0.05% isotretinoin combined with sunscreen. Out of the subjects, 172 received active ingredients and 174 received only the vehicle. Profilometry measurements of replicas of the periorbital region, taken at zero and six months, demonstrated significant reductions in wrinkle depth and improvement in fine lines.23

Treatment with vitamin A is known to be associated with ‘the retinoid response’, a phrase to describe the typical outcome of pruritus, burning sensation at treatment sites, peeling and erythema

Aesthetics

Retinol The mode of action of retinol involves conversion to all-trans-retinoic acid via retinaldehyde within keratinocytes to exert an effect on the epidermis.24 Retinol induces epidermal thickening, enhances the expression of retinol binding protein genes CRABP II and CRBP but produces less erythema and irritation when compared to tretinoin.9 Retinol is also associated with less trans epidermal water loss, erythema and scaling than RA whilst stimulating collagen synthesis and reducing matrix metalloproteinases (MMP) production.9,25 In 2015 Randhawa et al. studied prolonged use of retinol demonstrating that 0.1% retinol significantly improves the signs of photoageing and improvements in photodamage at all time points versus vehicle during the study. Histochemical reports indicated increased expression of procollagen Type I and hyaluronan at 52 weeks.26 Adapalene Adapalene was the first of the third generation retinoids to be approved by the Food and Drug Administration for acne treatment.27 In one study, Chandararatna demonstrated that adapalene has excellent follicular penetration28 anti-imflammatory29 and comedolytic activity.30 Adapalene is more stable and is associated with less irritation31 than its relative, tretinoin, not breaking down in the presence of light or air.30 Tazarotene Tazarotene gel 0.05% or 0.1% is used for photodamage and is also indicated for plaque psoriasis and acne.32 Tazarotene has the ability to regulate cell proliferation, cell differentiation and inflammation, as well as down regulating keratinocyte expression.33 Results in a comparative study suggested efficacy of adapalene and tazarotene were comparable.34 Lowe et al conducted a further double-blind randomised multi-centre 24 week study of 173 participants that compared tretinoin 0.05% and tazarotene 0.1% daily at night. Results suggested a benefit of tazarotene over tretinoin at 16 weeks for photodamage, coarse wrinkling, fine wrinkling and mottled hyperpigmentation. For tazarotene, patients reported a higher incidence of a burning sensation on the skin in the first week of treatment, but not thereafter.32

Adverse effects of retinoids Treatment with vitamin A is known to be associated with ‘the retinoid response’, a phrase to describe the typical outcome of pruritus, burning sensation at treatment sites, peeling and erythema.35 The type and dose of retinoid may affect the degree of the retinoid effect,36 conversely, the response to treatment of photoageing does not appear to be dose dependent. In a 99-patient, 48-week study, Griffiths concluded that mechanisms other than irritation dominate tretinoin-induced repair of photoageing in humans.37 To overcome the issue of the retinoid effect, to reduce patient compliance, Bauman advises patients to introduce topical retinoids at the lowest dose – which differs according to the type of retinoid and the delivery system – and acclimatise to the product by increasing frequency of application gradually from once weekly to once nightly, then increasing the dose gradually with a possible aim of moving to a prescription retinoid.2 In my experience, other ways to reduce the retinoid response would be to increase dermal and epidermal hydration, hence the search for ideal ingredients to combine with retinoids.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Combination with other topical ingredients Combining topical vitamin A with other ingredients offers two strong possible benefits – synergy for increased treatment effect and a reduction in the retinoid response. There are many combinations now in use, mostly using retinol as this is the cosmetic form that, as above, has indicated good results within studies discussed in terms of efficacy. Retinol 0.5% in combination with resveratrol, niacinamide and hexylresorcinol was studied in a 10-week, open label study of 25 patients. By week four, hyperpigmentation, skin clarity, skin tone and wrinkles were improved, with mild retinoid dermatitis occurring early in the study. However, by week 10, all tingling, stinging, itching and dryness had resolved.38 As early as 2006, Sayo had demonstrated a synergistic production of HA when combining retinol with NAG.39 In an vitro study looking at stimulation of keratinocyte HA production by N-acetylglucosamine (NAG) and retinol, Sayo demonstrated that retinoids induce expression of HA synthesis (HAS3) mRNA, but NAG does not work through this mechanism indicating that NAG has a complementary mode of action.39 Two forms are available, one at 0.2% retinol and the other at 0.5%. The proof of concept study on the 0.2% preparation demonstrated improvements in all measured ageing symptoms at week four, continuing through to week 12.40

Conclusion We now have a selection of cosmetic preparations with retinol and retinoids as well as pharmaceutical preparations of vitamin A to choose from. Cosmetic companies have spent years attempting to create products that get the best out of vitamin A, without creating the retinoid response. This can be achieved by either creating a delivery mechanism that allows gentle, slow release of retinol, or by combining retinol with ingredients that will reduce the potential of the retinoid effect. Disclosure: Dr Sandeep Cliff is a key opinion leader and consultant for antiageing skincare distributor AestheticSource. Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation.

Aesthetics REFERENCES 1. Kligman AM, ‘The growing importance of topical retinoids in cinical dermatology: a restrospective and prospective analysis’, J Am Acad Dematol, 39(1998). 2. Bauman L, Saghari S, ‘Cosmetic Dermatology: Principles and Practice’, 2(2009). 3. Mukherjee S, Date A, Patravale V et al, ‘Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety’, Clin Interv Aging 1(2006) pp.327–48. 4. Pappas A (ed) Elewa RM, Zoubolis CC, ‘Nutrition and Skin: Lessons for Anti-Aging, Beauty and Healthy Skin’, Springer Science+Business Media, (2011). 5. Kong R Cui Y, ‘A comparative study of the effects of retinol and retinoic acid on histological, molecular, and clinical properties of human skin’, J Cosmet Dermatol, 15(2016) pp.49-57. 6. Antille C, Tran C et al, ‘Vitamin A exerts a photoprotective action in skin by absorbing UVB radiations’, J Invest Dermatol, 121(2015) pp,1162-7. 7. Tucker-Samaras T, Zedayko T, ‘A stabilized 0.1% retinol facial moisturizer improves the appearance of photodamaged skin in an eight-week, double-blind, vehicle-controlled study’, Journal of Drugs in Dermatology. 8(2009) pp.932-936. 8. Buchanan PJ, Gilman RH, ‘Retinoids: literature review and suggested algorithm for use prior to facial resurfacing procedures’, J Cutan Aesthet Surg, 9(2016) pp.139-44 9. Kang S, Fisher GJ, Voorhees JJ, ‘Photoaging and topical tretinoin: therapy, pathogenesis, and prevention’, Arch Dermatol, 133(1997) pp.1280–1284. 10. Sorg O, Antille C, Kaya G, Saurat JH, ‘Retinoids in cosmeceuticals’, Dermatol Ther, 19(2006) pp.289–296. 11. Ligade VS, Sreedhar D, Manthan J, Udupa N, ‘Cosmeceuticals: Are they truly worth the cost? Indian J Dermatol Venereol Leprol’, 75(2009) pp.8–9. 12. Riahi R, Bush, ‘A Topical Retinoids: Therapeutic Mechanisms in the Treatment of Photodamaged Skin’, Am J Clin Dermatol, 17(2016) pp.265-76. 13. Hoal E, Wilson EL et al, ‘1982 Variable effects of retinoids on two pigmenting human melanoma cell lines’, Cancer Res 42,5191-5. 14. Picardo M, Carrera M, ‘New and experimental treatments of cloasma and other hypermelanoses’, Dermatol Clin, 25(2007) pp.353–62. 15. Thieltz A, Sidou F., ‘Control of microcomedone formation throughout a maintenance treatmetns with adaplene gel, 0.1%’, J Eur Acad Dermatol Venerol, 21(2007) pp.747-53. 16. Stinco G, Piccirillo F, ‘Efficacy, tolerability, impact on quality of life and sebostatic activity of three topical preparations for the treatment of mild to moderate facial acne vulgaris. G Ital Dermatol Venereol’, 151(2016) pp.230-8. 17. Fox L, Csongradi C, ‘’Treatment Modalities for Acne’, Molecules (2016). 18. Draelos ZD , ‘Cosmetic Dermatology: Products and Procedures’, Wiley Publishing. Kindle Edition (2011). 19. ‘FDA approves Differin Gel 0.1% for over-the-counter use to treat acne’, Food and Drug Administration, (2016), <http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ ucm510362.htm> 20. S Mukherjee, A Date, V Patravale, et al, ‘Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety’, Clin Interv Aging, 4(2006) pp.327–348. 21. Fisher GJ, Datta SC, Talwar HS, et al.’The molecular basis of sun induced premature ageing and retinoid antagonism. Nature, (1996) 379:335–8. 22. Armstrong RB, Lesiewicz J, Harvey G, et al, ‘Clinical panel assessment of photodamaged skin treated with isotretinoin using photographs’, Arch Dermatol, (1992) 128:352–6. 23. Maddin S, Lauharanta J, Agache P, et al, ‘Isotretinoin improves the appearance of photodamaged skin: results of a 36-week, multicenter, double-blind, placebo-controlled trial’, J Am Acad Dermatol, (2000) 42:56–63. 24. Griffi ths CE, Maddin S, Wiedow O, et al, ‘Treatment of photoaged skin with a cream containing 0.05% isotretinoin and sunscreens’, J Dermatol Treat, (2005) 16:79–86. 25. Kurlandsky SB, Xiao JH, Duell EA, et al., ‘Biological activity of all-trans-retinol requires metabolic conversion to all-trans-retinoic acid and is mediated through activation of nuclear retinoid receptors in human kertinocytes’, J Biol Chem, (1994) 269:32821–7. 26. Fluhr JW, Vienne MP, Lauze C, et al. ‘Tolerance profile of retinol, retinaldehyde and retinoic acid under maximized and long-term clinical conditions’, Dermatology, (1999) pp.57–60. 27. Giguere V Ong ES et al, ‘Identification of a receptor for the morphogenic retinoic acid’, Nature (1987) pp.330-624. 28. Millikan L, ‘Adapalene: an update on newer comparative studies between the various retinoids.’, Int J Dermatol,(2000) pp.39:784. 29. Chandraratna RA., ‘Tazarotene-first of a new generation of receptor-selective retinoid’, Br J Dermatol, 135(1996) pp.18-25. 30. Burke BM Cunliffe WJ, ‘The assessment of acne vulgaris – the Leeds technique’, Br J Dermatol, (1984) pp.113:83. 31. Randhawa M, Rossetti D, ‘One-year Topical Stabilized Retinol Treatment Improves Photodamaged Skin in a Double-blind, Vehicle-controlled Trial’, Journal of Drugs in Dermatology 14(2015) pp.271-276 32. Kakita L, ‘Tazarotene versus tretinoin or adapalene in the treatment of acne vulgaris’, J Am Acad Dermato (2000). 33. Verschoore M, Bouclier M et al, ‘Topical retinoids. Their uses in dermatology’, Dermatol CLin. (1993). 34. Nagpal S, Athanikar J, Chandraratna RA, ‘Separation of transactivation and AP1 antagonism functions of retinoic acid receptor alpha’, J Biol Chem, (1995) pp.270:923–7. 35. Lowe N, Gifford M, Tanghetti E, et al. ‘Tazarotene 0.1% cream versus tretinoin 0.05% emollient cream in the treatment of photodamaged facial skin: a multicentre, double-blind, randomized, parallel-group stud’, J Cosmet Laser Ther, (2004) pp,6:79–85. 36. Oda RM, Shimizu RW, Sabatine SC et al. ‘Effects of structural changes on retinoid cytotoxity in the CHO clonal assay’, In vitro Toxicol, (1996) 9:173–81. 37. Griffiths CE, Finkel LJ et al, ‘An in vivo experimental model for effects of topical retinoic acid in human skin’, Br J Dermatol, (1993) pp.129:389 38. Sayo T, Saki S, ‘Synergistic Effect of N-Acetyglucosamine and Retinoids on Hyaluronan Production in Humna Keratinocytes’, Skin Pharmacol Physiol (2004)17:77-83. 39. Griffths CE, Kang S et al, ‘Two concentrations of topical tretinoin (retinoic acid) cause similar improvement of photoaging but different degrees of irritation. A double-blind vehicle-controlled comparison of 0.1% and 0.025% tretinoin creams’, Arch Dermatol, (1995);131:1037. 40. Farris P, Zeichner J, ‘Efficacy and Tolerability of a Skin Brightening/Anti-Aging Cosmeceutical Containing Retinol 0.5%, Niacinamide, Hexylresorcinol, and Resveratrol’, J Drugs Dermatol, (2016) Jul 1;15(7):863-8.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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A summary of the latest clinical studies Title: Botulinum toxin A for palmar hyperhidrosis: assessment with sympathetic skin responses evoked by train of stimuli Authors: Al-Hashel JY, Youssry D, Rashaed HM, Shamov T, Rousseff RT Published: Autonomic and Autacoid Pharmacology, November 2016 Keywords: Botulinum toxin, primary palmar hyperhidrosis, sympathetic skin response Abstract: Objective assessment of the effect of botulinum toxin A (BT) treatment in primary palmar hyperhidrosis (PH) is attempted by different methods. We decided to use for this purpose sympathetic skin responses evoked by train of stimuli (TSSR). Twenty patients with severe PH (five female, median age 24, range 18-36) were examined regularly over 3 months after receiving 50 UI BT in each palm. TSSR were recorded from the palms after sensory stimulation by a train of three supramaximal electric pulses 3 millisecond apart. Results were compared to longitudinally studied TSSR of 20 healthy sex- and age-matched control subjects. All hyperhidrosis patients reported excellent improvement. TSSR amplitudes decreased at week 1 (mean 54% range 48%-67%) and over the following months in a clinically significant trend (slope R=-.82, P<.0001). This study suggests that TSSR may help in assessment of treatments in PH. It confirms objectively the efficacy of BT in PH.

the sun. The objective measures show improved pigmentation in both UV-exposed and UV-protected groups.

Title: Autologous skin cell transplantation and medical needling for repigmentation of depigmented burn scars on UV-protected and UV-exposed skin Authors: Busch KH, Bender R, Walezko N, Aziz H, Altintas MA, Aust MC Published: Journal: Handchirugie Mikrochirurgie Plastische Chirurgie, November 2016 Keywords: Burn scars, UV, medical needling, skin cell, scars, pigmentation Abstract: Burn scars remain a serious physical and psychological problem for the affected people. Both clinical studies and basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient related to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling does not influence repigmentation of large hypopigmented scars. The goal is to evaluate whether both established methods – needling (improvement of scar quality) and non-cultured autologous skin cell suspension (NCASCS) “ReNovaCell” (repigmentation) - can be combined. So far, 20 patients with mean age of 33 years (6-60 years) with deep second and third degree burn scars have been treated. The average treated tissue surface was 94 cm² (15-250 cm²) and was focused on areas like face, neck, chest and arm.  The patients have been followed up for 15 months postoperatively. The scars were subdivided into “UV-exposed” and “UV-protected” to discover whether the improved repigmentation is due to transfer of melanocytes or to reactivation of existing melanocytes after exposure to UV or

Title: Injectable shape-memorizing 3D hyaluronic acid cryogels (3D MA_HA) for skin sculpting and soft tissue reconstruction Authors: Cheng L, Ji K, Shih TY, Haddad A, Giatsidis G, Mooney DJ, Orgill DP, Nabzdyk CS Published: Tissue Engineering Part A, November 2016 Keywords: Hyaluronic acid, injectable, skin sculpting, tissue reconstruction Abstract: Introduction Hyaluronic acid based (HA) fillers are used for various cosmetic procedures. However, due to filler migration and degradation, reinjections of the fillers are often required. Methacrylated HA (MA-HA) can be made into injectable, shape-memorizing fillers (3D MA-HA) aimed to address this issue. In this study shape retention, firmness and biocompatibility of 3D MA-HA injected subcutaneously in mice were evaluated. Methods: Fifteen mice, each receiving two subcutaneous injections in their back, were divided into 4 groups receiving HA, MA-HA, 3D MA-HA or saline, respectively. Digital imaging, SEM and IVIS, durometry and histology were utilized to evaluate in vitro/vivo degradation and migration, material firmness and the angiogenic (CD31) and immunogenic (CD45) response of the host tissue towards the injected materials. Results: Digital imaging, SEM and IVIS revealed that 3D MAHA fillers maintained their pre-determined shape for at least 30 days in vitro and in vivo. Little volume effects were noted in the saline and other control groups. There were no differences in skin firmness between the groups or over time. 3D MAHA maintained its macroporous structure with significant angiogenesis at the 3D MA-HA/skin interfaces and throughout the 3D MA-HA.

Title: Pathogenesis and clinical presentation as a key for a symptom-oriented therapy Authors: Reinholz M, Ruzicka T, Steinhoff M, Schaller M, Gieler U, Schofer H, Homey B, Lehmann P, Luger TA Published: Journal der Deutschen Dermatologischen Gesellschaft, December 2016 Keywords: Rosaea, forehead, nose, chin, cheeks, pathegenesis Abstract: Rosacea is a common chronic inflammatory skin disorder that typically occurs in adults and affects the face. Synonyms of rosacea include “acne rosacea”, “couperose” and “facial erythrosis”, in German also “Kupferfinne” and “Rotfinne”. The disorder is characterised by a chronic and flaring course and is caused by a genetically predisposed, multifactorial process. A higher incidence is seen in people with fair skin and a positive family history. The characteristic rosacea symptoms manifest primarily, but not exclusively centrofacially, with forehead, nose, chin and cheeks significantly affected. Based on the various main symptoms a classification of the individual clinical pictures can be performed. The present review provides an introduction on pathogenesis and clinical manifestations of rosacea and prefers a symptom-oriented therapy approach.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Prevalence of BDD It is estimated that BDD affects between 1-3% of the general population. For patients presenting for medical aesthetic treatments, studies have consistently suggested that the rate increases to between 5-15%.6,9 There have also been some international studies that have used clinical interviews of patients reporting even higher rates of approximately 20% of patients. This suggests that a busy aesthetic practice is likely to encounter several patients with BDD every month.6

The Red Flag Patient Dr Sangita Singh explains body dysmorphic disorder and how to screen patients for the condition With the concomitant rise in social media, in particular the ‘selfie’ and the apparently more image conscious population in the UK, cosmetic interventions seem to have become increasingly socially acceptable among consumers who are influenced by the media and celebrity culture. Additionally, non-surgical treatments are set to become more popular as people lean towards less invasive procedures that are less expensive and viewed as having fewer risks and quicker results.1 Psycho-social research demonstrates that physical appearance influences many aspects of our life, including quality of life, self-esteem, body image, interpersonal relationships, employment opportunities and financial success.2 It is therefore not surprising that many people are interested in improving their appearance in order to gain these advantages. But as we see growing numbers attending for non-surgical procedures, we will also see a greater numbers of what we may call ‘Red Flag Patients’.

Who are the Red Flag Patients? There are several categories of Red Flag Patient; examples include the ‘perfectionist patient’, ‘litigious patient’, ‘unrealistic patient’ and the ‘indecisive patient’. However, in this article I shall be focusing on the patient with body dysmorphic disorder (BDD).4 Body dysmorphic disorder BDD is defined as a preoccupation with a slight or imagined defect in physical appearance. This preoccupation must cause significant distress or impairment in functioning and must be associated with disruption in daily functioning.1 For patients with BDD, the face, nose, skin, and hair are the most common focus of concern;8 however, any feature or area of the body can be the focus, so the diagnosis is very pertinent to those practising aesthetic medicine. It can be challenging applying this diagnosis to our patients as we are often treating ‘slight’ imperfections in essentially ‘normal’ features. Therefore, for our patients, it is more relevant to look at the second part of the definition regarding the disruption in daily functioning. The degree of distress, which is caused by a perceived deficit, can be very variable from one person to another. A patient with BDD will be overly concerned and spend an excessive amount of time on behaviours such as; mirror gazing, comparing their features to others, camouflaging tactics to hide the defect and seeking reassurance.3 For example, a woman interested in aesthetic treatments who reports that she spends hours trying to conceal her defects, has stopped going out in certain situations and lost contact with many friends due to her appearance, is likely to meet the BDD criteria. However, a woman who reports being somewhat self-conscious of her ageing facial features when compared to younger work colleagues would be unlikely to meet the criteria. I shall discuss how to screen for BDD later in the article.

The effect of aesthetic treatments on BDD One of the largest studies reported that less than 5% of those who had treatment had seen any improvement in their BDD symptoms, whilst 95% experienced no change, or a worsening in the condition.6 Some developed new concerns following treatment, which is seen in the normal course of the disorder. The focus of concern shifts from one feature to another. The biggest concern though is the correlation between BDD and suicide. BDD is one of the most lethal psychiatric disorders, with a mean annual suicide attempt rate of 2.6%.6 Treating a patient with BDD is not just potentially detrimental to the patient but also to the practitioner, as around a third of aesthetic surgeons have been threatened legally and 2% threatened physically by patients with BDD.6 Given that the suicide rate in those suffering from BDD is high, it is not surprising that the growing consensus is that appearanceenhancing treatments are contraindicated in patients with BDD. Assessing patients to screen for BDD The most crucial step prior to any treatments being carried out is the consultation. The first consultation will lay the groundwork for everything that follows, so it is important that it isn’t rushed. The consultation is an opportunity to assess the patient’s suitability for treatment, build rapport and trust, as well as displaying our expertise. The consultation should include a psychological assessment that focuses on motivations and aims, and appearance and body image concerns. Motivations and expectations Patients can be internally or externally motivated.1,2 Internal motivations include: aiming to improve a certain feature in order to improve body image and selfesteem; to build confidence; look more youthful; or to increase self confidence by

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Those who spend long periods of time, during the day, dwelling on their appearance, may be suffering from BDD improving physical appearance. External motivations include: a job promotion; a new relationship; to please friends and family; or relief from emotional distress such as bereavement or divorce. Patients who are externally motivated are looking for some secondary gain. Interestingly, there have been studies suggesting that being motivated for aesthetic surgery to please a romantic partner is associated with a poor postoperative outcome.6,10 It is also important to ensure that a patient’s expectations are realistic and achievable, such as a youthful, refreshed look or improvement in a body area that they feel self-conscious about; as opposed to looking ten years younger or indeed looking like a celebrity. Physical appearance and body image It is always important to ask the patient what it is that concerns them about their

appearance. They should be able to point to specific concerns and we should be able to visualise these readily. If the patient is overly concerned about a defect that we can’t readily identify, they may be suffering from BDD. We must also assess the degree of dissatisfaction a patient experiences. Some degree of dissatisfaction with body image is present amongst most patients. Those who spend long periods of time, during the day, dwelling on their appearance, may be suffering from BDD. Patients should also be asked how their feelings about their appearance affect their daily functioning. Those who have lost jobs or social contact, as they are not able to engage in normal daily activities could be suffering from BDD.3,6,7 There are also several scales that can be used to assess symptom severity such as: the Body Dysmorphic Disorder Questionnaire (BDDQ), BDDQ –

Case example A 53-year-old female patient attended for a first consultation. She had previous botulinum toxin treatment and dermal filler in her nasolabial lines from another practitioner. Her concern was with her nasolabial lines, which she wanted injected. I discussed with her how enhancing her cheeks would achieve a better aesthetic outcome and she seemed happy with this course of action. When I told her the treatment could not be done on the same day, she became very unhappy. She told me the treatment needed to be done prior to a male friend arriving in about two weeks’ time, otherwise she would be unable to meet him. She also mentioned she had been avoiding social situations where people may take photographs and may post them on social media. After trying to persuade me for some time and realising she wouldn’t be treated, she told me her issues weren’t psychological, which was not something I had mentioned to her at this point. When I suggested that perhaps some of her behaviours warranted exploring she became extremely angry. At this point I ended the consultation, and though I had said I would see her again in a week, I reflected on the consultation and decided I would not be treating her, as I was concerned about her having BDD. To my surprise she did book back in a week later. When I explained my reasoning for not treating her, she became very angry; threatening to sue the clinic and suggesting that I should be struck off. In cases such as this I usually take the clinic manager into the consultation. This can be a good tool if you have a particularly difficult patient who refuses to take no for an answer. In this case it meant the patient was told by us both that any treatment wouldn’t be going ahead and what her options were. Which in this case, was a refund of her consultation fee, as a gesture of goodwill, or a second opinion. This case study shows how important it is to fully consult and explore possible BDD symptoms and not to treat patients under pressure. If I had treated her, I believe that it is highly likely that she would be dissatisfied and I could now be dealing with legal action.

dermatology version and the Body Image Disturbance Questionnaire.1,2,5 Practitioners may want to use these to help with the assessment of BDD. If BDD is suspected it is important that these patients are referred for psychological assessment and not offered treatment. Conclusion The aesthetic market is growing, as is the knowledge and acceptance of the treatments we can provide. As the treatments increase in popularity and we see more patients seeking treatment, it is inevitable that we will see more unsuitable ‘Red Flag Patients’. The most important of these are the patients with BDD, as studies have consistently suggested these patients make up 5-15% of a clinic’s clinetele.6 The evidence indicates that treating these patients can lead to significant harm for both the patient and the practitioner. It is therefore extremely important that we consult thoroughly in order to screen all patients and ensure we don’t treat any we suspect may have BDD, but rather refer them for psychological evaluation. Dr Sangita Singh graduated from Barts and The London Medical School in 2003. For the past five years she has dedicated her time to specialising in medical aesthetics and is a cosmetic doctor at Courthouse Clinics. Dr Singh prides herself on putting the patient at the heart of the consultation, in order to ensure treatments are in line with patient expectations. She speaks regularly at aesthetic conferences on how to best manage ‘red flag patients’. REFERENCES 1. T. F. Cash, K. A. Phillips, M. T. Santos, and J. I. Hrabosky, ‘Measuring “Negative Body Image”: Validation of the Body Image Disturbance Questionnaire in a Nonclinical Population’, Body Image, 1 (2004), 363-72. 2. R. G. Dufresne, K. A. Phillips, C. C. Vittorio, and C. S. Wilkel, ‘A Screening Questionnaire for Body Dysmorphic Disorder in a Cosmetic Dermatologic Surgery Practice’, Dermatol Surg, 27 (2001), 457-62. 3. W. L. Ericksen, and S. B. Billick, ‘Psychiatric Issues in Cosmetic Plastic Surgery’, Psychiatric Quarterly, 83 (2012), 343-52. 4. T. C. Flynn, ‘Red Flag Patients’, in Cosmetic Bootcamp Primer: Comprehensive Aesthetic Management, ed. by Kenneth. Beer, Mary. P. Lupo and Vic. A. Narurkar (CRC Press, 2011), pp. 43-45. 5. K. A. Phillips, The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder (New York, NY: Oxford University Press, 1996). 6. D. B. Sarwer, and J. C. Spitzer, ‘Body Image Dysmorphic Disorder in Persons Who Undergo Aesthetic Medical Treatments’, Aesthet Surg J, 32 (2012), 999-1009. 7. V. Veer, L. Jackson, N. Kara, and M. Hawthorne, ‘Pre-Operative Considerations in Aesthetic Facial Surgery’, The Journal of Laryngology & Otology, 128 (2014), 22-28. 8. OCD UK, Body Dysmorphic Disorder, (2016) <http://www.ocduk. org/bdd> 9. David B Sarwer, Canice E Crerand, Body dysmorphic disorder and appearance enhancing medical treatments, ScienceDirect, (2007) <http://fulltext.study/download/903290.pdf> 10. David B Sarwer, Psychological Assessment of Cosmetic Surgery Patients, Plastic Surgery Key, (2016) <http://plasticsurgerykey. com/psychological-assessment-of-cosmetic-surgery-patients/>

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Increasing Product Sales Sales representative Jane Lewis provides practical advice on how to boost skincare product sales and retain patient custom Selling skincare products in your clinic can provide the patient with a more complete approach to their skin health. Certain products can help with preparing the skin for treatments, as well as complementing and maintaining the outcomes of the treatments you offer. Providing your patient with the appropriate skincare regime can help keep them loyal to you and your clinic, especially if the ongoing advice and care is given with the purchase. The majority of patients will benefit from a good skin regime, which includes the use of sunscreen, antioxidants and a retinoid.1 A standalone product routine may be ideal for the younger patient or for those that are not ready to have treatments, potentially reaching out to a new clientele. Opportunities According to the UK Office for National Statistics, 35% of the population will be 50 years of age during 2016-2030.2 Research conducted by beauty retailer Escentual indicated that women over 50 have become the biggest buyers of beauty products in Britain.6 Celebrity endorsement often sells products and there are ranges that are available that have appropriate celebrity endorsement; marketing campaigns that are using models such as Helen Mirren are very attractive to this particular age group.6 Find out which celebrities use the products, or ingredients, you retail to enhance your marketing efforts. Another opportunity is male facial skincare, which is estimated to

be worth £96 million in the UK.4 The male grooming market is valued at $6 billion in the US alone and £25 billion globally. In the US, 43% of men are using skincare products beyond shaving; eye creams, moisturisers, luxury facial cleansers and concealers have become routine.5 What products should you sell? With many excellent cosmeceutical ranges available, knowing where to start can be confusing. You may consider looking at the most popular brands being promoted in other clinics, you might wish to offer products for the most common conditions that you treat or there may be other criteria you use to start to select your range; whatever your rationale, you will need to have a plan. Consider: what gaps do you have in your product portfolio? What is new and exciting and would it enhance your business and would your patients be interested? Before taking on a product, it is also important to research the technology and where it may fit in with the other ranges you stock. Clinical studies that support the product are very important. Firstly, make your initial product selection simple, as you can always expand the range later. It is helpful to have a core basic range that resonates with most patients, looking to build key products to complement your most popular treatment. This core basic range could include a sunscreen, retinoid and antioxidant, as mentioned earlier. The look and the design of the packaging may be

something to consider, but more importantly, patients like to feel they have been given a bespoke skincare regime which is unique to the problem and has been put together on the day with their skin type and aesthetic concern in mind. Cost can be an objection for some patients in clinics; your location may play a role in this. Consider choosing products that have a high, medium and low price range, therefore stocking several different brands that will suit all pockets. This may help overcome any objection. Consider ‘tried and tested’ products that you would feel confident using and recommending. If a product is backed by clinical data and gives proven results, you and your staff will be confident in the results that can be achieved when advising patients. Encourage clinic staff to use the products themselves, so they can see firsthand what the benefits are and therefore be able to communicate these to patients more effectively. Is having your own brand an option? It’s a sure-fire way of keeping patients loyal to you, as they won’t be able to find your product elsewhere, but this comes with research, commitment and investment. There are a few companies that specialise in creating your own brand and can help guide you in the process. Where should products be displayed? It’s important to display the products you have invested in. You need to consider practicalities; your access and the patients access to the product, so don’t have them tucked away in a cupboard. Have them on display and at eye level so the customer can see them clearly; it will spark a conversation. This is especially true for products displayed at the reception area. Displays should be bright and open so patients can touch and read the details on the product packaging. There should be lighting inside the display or directed on to it, items and shelving must be dusted daily and the display units should have a storage area underneath the main shelves so stock can be replenished quickly. Having products available in the consulting room so you can show the patient how to apply and what they feel like will help break down objections. Samples are also helpful when allowing patients to feel and try a product, such as a sunscreen, but if the product is ‘active’, it may take longer than the sample lasts to see any changes on the skin, so this may add a negative to the patient’s view of the product, therefore, samples should be selected carefully.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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RUSAC process I follow the RUSAC consultation process – a method which was taught to me by Allergan during training, which stands for: rapport, uncover, support, acceptance and close. It follows the principles that you have to strike a rapport with your patient to allow you to understand what they need. You uncover their needs by the questions you ask, restating them and receiving confirmation from the patient that you have understood their needs correctly. The support that you give through this process is to find the best solution to fit the patient’s needs; this will involve dealing with and overcoming objections and misconceptions, giving knowledge and professional advice. The patient has come to the clinic for advice and a plan of action to address their concerns, therefore checking with them and obtaining their acceptance that their concerns have been addressed allows you to confirm the treatment and/or product plan and propose the next steps. This will lead to the close of the sale, where both parties are keen to proceed. How to sell Selling is considered by many to be an ‘art of persuasion’. The sales process refers to a systematic course of repetitive and measurable milestones. In this case the stages of selling and buying, involve: • Getting to know what the patient wants • Understanding the patient’s concerns in order to provide a solution to their problem • Seeing it from the patient’s point of view and asking: is the proposal or solution ‘worth the price’? For many of us who consult with patients on a daily basis in-clinic, the sales process can be a hurdle to overcome, as most medically-trained professionals are not always natural ‘sales people’. This does not mean we have to go in with a ‘hard sell’ but we do have to consider how we can follow a process, which allows us to overcome obstacles and doubts we face from our patients to enable us to promote and sell appropriately. We should not assume that our patients will ask for or know what they need, therefore it’s important to communicate openly with them to ensure that the patient’s requirements are assessed and properly met without the fear of ‘selling’. How you approach the conversation is key. Challenges to in-clinic sales Competing with internet sales can be challenging, especially as some suppliers have their own website, which means they could be in direct competition with us as clinic owners. In a similar vein, self-diagnostic sites, which allow you to input details about your skin type and a product regime will be designed for you, also usually have the advantage of being able to sell at a lower price. It’s important to note that counterfeit products are a problem, especially on the internet; some $15,000,000 is lost per year through counterfeit goods in the US.3 You may need to advise your patients that expired and counterfeit products are being sold, which

may be detrimental, or at best, ineffective. Additional challenges include other clinics reducing prices, and patients believing that OTC products are as effective as a clinic product and/or that clinic products cost many times more – educating the patient is key. This can be challenging at times without technology such as a skin imaging system. You’re also likely to meet patients that are anxious due to a bad experience from previous use and so will need to take time to overcome this. Monitor the measure of success Find out what percentage of your patients are buying products – I would personally expect 50% of patients to regularly purchase products. What is the percentage of repeat sales? What is the ratio of products to treatment sales? Once you can answer these questions you can implement strategies so the numbers can be improved. Patient skin reviews See the patient regularly to tweak or augment the regime; some patients will benefit from seasonal reviews. This can be as often as weekly, particularly if they are suffering from acne or rosacea. Once a regime is working, reviews could be three to four times per year. Have measures in place to be able to show the patient how much their skin has changed and is improving; it’s often difficult for patients to remember their starting point and it’s encouraging for them to see improvements. Offering imagery, such as those taken with a complexion analysis system, are invaluable. It also helps practitioners to see if a product is working as expected so they can react appropriately to get the best result for the patient. If you can show patients results they will trust you and continue to purchase your products. Be aware of life and product usage. Does your patient’s product need replenishing in one month or three months?

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Make sure you have a review session in place so that you don’t allow your patients to run out of their products. Product range reviews It is important to know what are you selling. What are your best selling products? What doesn’t sell and why? Be ruthless. If you can’t sell the product, then consider dropping it. Sales should be reviewed monthly with an overview of performance of the product at three months; this should give you an idea if it is working for the patients and the staff who are selling. Make time to review your range quite frequently so that you can consider condensing or expanding to give you the best offering, outcomes and to not waste your hard-earned cash on something that’s not working for you or your patients. Conclusion Product sales in-clinic give an opportunity to engage with new and existing patients; you’ll be able to increase patient spend per visit, and engage patients who do not want to or who are not ready for treatment, if products are seen as a fundamental part of the patient journey. The patients’ outcomes should be improved by your suggestions, enhancing their loyalty for longer. Selling appropriate products in the right manner can create a long-term gain for your business. Jane Lewis started her nursing career in 1981 and moved into the private sector in 1986, gaining extensive experience in plastic surgery and dermatology; most notably Lewis was the development director for a large chain of aesthetic clinics for fifteen years. Lewis runs an award-winning aesthetic clinic, The Skin to Love Clinic, in St. Albans Hertfordshire. REFERENCES 1. Ruta Ganceviciene, Aikaterini I. Liakou,  Athanasios Theodoridis,  Evgenia Makrantonaki, and Christos C. Zouboulis, Skin antiaging strategies, Dermatoendocrinol. (2012) Jul 1; 4(3): 308–319. doi:  10.4161/derm.22804 2. ONS, Mid-2014 Population Estimates UK Office for National Statistics, 2015. Data on file 3. RNCOS, Global Cosmeceuticals Market Outlook 2020, (2015), <http://www.researchandmarkets.com/research/mx7tb7/global> 4. Kathryn Hopkins, Beauty is big business for Britain, Raconteur, (2015), <raconteur.net/lifestyle/beauty-is-big-business-for-britain> 5. Elizabeth Sergan, The Secret Psychology Behind Selling Beauty Products to Men, Racked, (2014) <http://www.racked. com/2014/11/11/7569603/beauty-products-for-men-dove-labseries> 6. Fiona Mcintosh, The older woman refusing to be invisible: ignored by the beauty industry despite their vast spending power, now the over-50s are fighting back, Mail Online, (2016), <http://www.dailymail.co.uk/femail/article-3677859/The-olderwomen-refusing-invisible-Ignored-beauty-industry-despite-vastspending-power-50s-fighting-back.html>

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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we must also be cognisant of operational profitability, as it is a good indicator of whether or not the clinic is making money and capable of generating cash flow from its day-to-day operations. Consequently, when the operations of the clinic are not making money, it is a very clear sign of the cause of current or impending cash flow problems and should immediately be noted.

3. Negative working capital: working

Managing Cash Flow Global business executive Reece Tomlinson explains the importance of managing cash flow in clinic and how to effectively control it Cash flow management problems have led to the demise of many successful businesses. According to corporate credit reporting firm Dun and Bradstreet, poor cash flow management causes 90% of small business to fail.1 Additionally, a recent study by the Business Development Bank of Canada suggested that poor cash flow management is the largest cause of business failure.2 Another by the coveted US Bank suggests that 82% of all business bankruptcies are due to poor cash flow management.3 Effective cash flow management should be made a priority to ensure the success of any business. In order to further explore and understand this, we must understand what exactly does ‘cash flow’ mean? Simply stated, cash flow is the movement of funds in and out of the business. There are two possible cash flow outcomes that will result from this activity: positive cash flow occurs when cash inflows during a period are higher than the cash outflows during the same period. Conversely, negative cash flow occurs when more cash is spent than generated. The generation of positive cash flow is, arguably, the most critical measure of success in operating a financially sound and sustainable clinic or business.3 By trade, I am a chartered professional accountant and an advisor to many companies, with a focus on turning around businesses in potential danger. I have learnt that there are certain cash flow indicators

that all clinics should be regularly reviewing and paying close attention to. Aside from more obvious indicators such as law suits over non-payment, defaulting on payroll obligations and legal payment demands, there are five indicators that individually or in any combination, are direct warning signs of current or impending cash flow problems.

Negative cash flow indicators: 1. Late payment or non-payment of suppliers and bills: although this may be a clear sign of cash flow problems, it can be easy to overlook the risk that late bill payments have on your clinic. Not only do late payments increase the cost of paying bills, as you are typically subject to interest or late fees, but they also decrease your credit score and allow bill payments to build.

2. Lack of profitability from operations: profitability can be separated into two key categories; operational profitably – the profits that are generated from the operations of the business, and net profitability4 – the profits you generate after you consider things such as taxes and depreciation. In order to make things simple, it is best to place a higher degree of emphasis on operational profitability, as this generally depicts the money coming in from daily operations. Although generating positive cash flow is ultimately the objective in any business,

capital, which is defined as ‘current assets less current liabilities’,5 is an incredibly important measure for any clinic to pay attention to as it primarily signals the company’s short term financial health. The aim is to have working capital remain consistently positive, as this signals that the clinic has more current assets (cash and accounts receivables) than it does current liabilities (accounts payable and short term debt). This represents the capability of carrying on business without requiring that external cash be reinjected back into the business in the form of debt, or perhaps the owner’s money. Negative working capital is a red flag of more severe cash flow problems. Taking things like renovations, the purchase of new equipment and investment in long-term assets out of the equation; negative working capital can signal mismanagement of cash, major financial challenges and generally means that spending has exceeded the incoming cash flow and therefore is not sustainable. I would recommend reading Entrepreneurial Finance by Steven Rogers if you are eager to learn more about this very important principle in accounting and how it relates to your clinic.

4. Borrowing to keep the company going: having on-demand debt instruments such as lines of credit and credit cards can be both a blessing and a curse to the clinic. In many ways, on-demand debt instruments can be a great way of reducing expenses, increasing flexibility and actually preserving cash. However, they also present the potential for mismanagement, which can exacerbate the problems listed above and can create sizeable interest payments from lenders and suppliers, which only further squeezes cash flow.

5. Surviving from the cash coming in day to day: although there is no definition on

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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what this exactly means, it can generally be referred to as ‘the money goes out as quick as it comes in’. While one would assume that this type of issue impacts only small clinics, it often impacts small and big clinics alike. The reasons that clinics can get into this kind of situation vary, but typically, it is derived from a combination of poor operational profitability and spending cash ineffectively, such as on long-term assets. The purchase of the ‘newest’ cosmetic laser on the market is an example of this. While it may be a strategic long-term investment, it also has the ability to drain the company of its lifeblood; cash on hand. Now that some cash flow problem indicators have been identified, the next step is understanding how to strategically manage and correct these issues in order to ensure the longevity of the business or clinic. It is crucial to note that issues like these must be identified and mitigated as soon as possible, as they can quickly become the demise of any organisation. Fortunately, there are six common tactics that I have utilised to improve cash flow and correct the trajectory of a company heading down an otherwise ominous path. Unfortunately, there is rarely a single solution that will solve all cash flow problems and these solutions require hard work, commitment and sometimes very tough decisions to be made.

Correcting cash flow problems Some tactics that can be used to correct cash flow problems consist of:

1. Lower your costs: when a clinic is facing cash flow issues, which are derived from the lack of sufficient profitability from operations, lowering costs is a key element in turning the situation around. The lack of sufficient profitability from operations influences the clinic dramatically. Left unchecked, insufficient profitability can create a situation where all of the above mentioned indicators of cash flow problems appear. Consequently, in such a situation, action needs to be taken to correct the underlying problem. Regardless of the size of the clinic, discretionary and non-crucial costs can be decreased or cut out entirely. Depending on the severity of the cash flow problems the clinic is experiencing, the aim is to cut costs so the company is generating

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positive cash flow again without detracting from the core of the business and its ability to provide its goods or services or impact the primary business, generally referred to ask discretionary expenses, such as; travel, non-immediate ROI advertising, attending events, entertainment, technology, printing, employee perks and etc. For example, one should cut expenses that their customers would never see versus those that could impact the customers’ experience. In specific circumstances where cost cutting alone may not be enough to generate positive cash flow, the goal becomes to cut costs as significantly as possible without impacting the ability of the business to deliver its products or services to customers.

2. Delay or revise capital expenditures: a capital expenditure, such as the purchase of an aesthetic laser treatment device, is generally defined as an expense that benefits the company over a long period of time. Many clinics find themselves with cash flow problems due to capital expenditures in which they use cash flow from operations or their cash reserves to fund them. Whilst reinvestment back into the clinic is not a bad thing, the problem can stem from the fact that free cash flow is needed for operations and by using such cash flow to fund major purchases and investments, it reduces the clinic’s cash on hand. Utilising cash on hand for capital expenditures can create a situation where the clinic may become incapable of maintaining the operations of the business. This situation can become a slippery slope and can lead to issues such as the inability to pay bills on time, missing critical obligations, and going into debt to cover operations. The simple solution is to either cease such purchases, or rather

finance them through other methods such as long-term debt, capital leases or slowing down the rate of investment. Although it may seem counterintuitive, the cost of borrowing for a capital expenditure may be significantly less than the cost of having to deal with continued cash flow problems, as well as the costs associated with late payment, high interest-bearing forms of debt.

3. Decrease customer payment terms: if customers are provided credit by the clinic it can present a plethora of challenges from a cash flow perspective. In such an event, aim to reduce credit provided or reduce the time in which a customer is permitted to pay their invoice. For example, if the customer is provided with 30-day terms to pay an outstanding invoice, either reduce the terms, or offer an early payment incentive, such as 2% off the invoice, if it is paid within ten days in an effort to entice the customer to pay it early. Depending on circumstances, cutting credit to customers entirely or utilising a third party, such as an aesthetic treatmentfinancing firm, to provide the customer with credit can help reduce cash flow stress. Note that if the majority of sales are provided on customer credit, one should elect to find an alternative solution such as using a third party to provide credit rather than simply cutting credit entirely.

4. Focus on reducing ‘cash flow lag’: one of the biggest causes of cash flow challenges for businesses in any industry is simply due to cash flow timing. Cash flow lag is not an official term, but is something I use to describe the time difference between when cash comes in versus when it goes out. The larger the lag (difference) between when it goes out versus when it comes in, the greater the

Unfortunately, there is rarely a single solution that will solve all cash flow problems and these solutions require hard work, commitment and sometimes very tough decisions to be made

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Focus on purchasing the level of inventory you need and place more frequent orders

cash flow pressure. Unfortunately, for most clinics, cash is often required to be spent prior to it coming in. For example, if the clinic is performing dermal filler treatments, the clinic is therefore required to have these products on hand in the form of inventory, which they can then utilise for a patient’s procedure. Consequently, the clinic is required to purchase the dermal fillers prior to the treatment and only receives money from the patient after the treatment. The delay between when the money is spent versus when it is received creates pressure on cash flow at some incremental level. In order to decrease cash flow lag there are a few simple things the clinic can do:

a. Purchase on supplier credit: many suppliers will provide clinics with credit lines where payment is due in 30 days rather than immediately, which allows the clinic to collect money from its patients prior to spending it on products.

b. Ask patients to pay up front: this may or may not be possible but getting the patient to place a deposit for treatments, even at a slight discount, can help the clinic reduce cash flow lag dramatically.

c. Utilise common forms of credit: most clinics have credit available to them in the form of credit cards or lines of credit. Similar to purchasing on supplier credit, using common forms of credit can help reduce cash flow challenges due to cash flow lag. It should be noted, however, that some forms of credit, such as credit cards, are great tools if used properly. When not used properly, they can present large interest rates, which can present even further pressure on cash flow.

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going down the path of growth and that you have plans for how you will manage surprises. A mentor of mine, Warren Rustand, chairman of SC Capital Partners and previous CEO of more than 17 companies, uses the term ‘the rule of 24’, wherein you can expect things are going to cost two times as much and take four times as long to get to where you want to go in a growth scenario. It is crucial to limit growth so it is sustainable and, if it is not sustainable, look for long-term debt or equity investment solutions finance growth versus relying on cash flow.

d. Reduce inventory levels: buying large levels of inventory may give you a sense of security, but it can also become a burden on cash flow. Focus on purchasing the level of inventory you need and place more frequent orders.

5. Analyse the return on investment (ROI): many clinics find that they spend money on items and activities, for which they then have a difficult time analysing a direct ROI to the clinic. Return on investment can be defined as the benefit to the clinic from investing money or resources in an activity, piece of equipment or asset. Whether it is spending on various forms of marketing, a new position in the clinic or the newest equipment, it is recommended that you closely analyse return and potential return on all spending. I personally spend a lot of time with clinic owners around the world, and I am consistently amazed at how little analysis is performed to determine whether spending money on certain things is actually generating a return on investment for the clinic. Therefore, strategically analysing all spending is critical, and can be a great way of identifying activities that are not generating positive cash flow. This can then be a method for saving cash and allows the clinic to focus more on the activities that are actually generating a return, which in itself can benefit cash flow.

6. Realise that growth costs cash: many clinic owners focus on the growth of their business. It is important, however, to realise that growing actually costs money. Growing at a faster pace than the rate of which the company is generating cash will create negative cash flow and burn through available cash. The best way to manage this is to ensure that you have sufficient working capital prior to

Summary Many of the cash flow issues that a clinic faces can be easily identified, addressed and corrected. To do so requires initiating some challenging discussions and potentially making some humbling decisions. If you are experiencing these challenges know that you are not alone and they can indeed be corrected if acted upon in a timely and systematic approach. It is always recommended that cash flow problems, or potential problems be addressed as soon as possible. Reece Tomlinson is the global CEO of Intraline Medical Aesthetics Ltd. He holds an MBA, is a chartered professional accountant and has completed extensive executive education. Tomlinson’s areas of expertise include: executive leadership, strategy development and execution, international business management, negotiations, product commercialisation, business development, sales management, corporate finance and M&A. REFERENCES: 1. Dunn & Bradstreet, ‘Cash Flow’, D&B Small Business, (2015) <http://dnbsmallbusiness.com.au/Cash_Flow/> 2. Business Development Bank of Canada, ‘Cash Flow Management’, April (2014) https://www.bdc.ca/en/Documents/ analysis_research/CashFlowManagement_Apr2014.pdf 3. Inc., ‘How to Manage Cash Flow’, (2016) <http://www.inc.com/ encyclopedia/cashflow.html> 4. Steven Rogers, Roza Makonnen, Entrepreneurial Finance, the Third Addition, McGraw Hill, 2014, United States 5. MSG, What is Negative Working Capital?, (2016) <http://www. managementstudyguide.com/negative-working-capital.htm> FURTHER READING Tim Berry, ‘10 Critical Cash Flow Rules’ Entrepreneur Magazine, (2007) <https://www.entrepreneur.com/article/187366> My Say, ‘Seven Tips for Smoothing Out Your Small Business’ Cash Flow’, Forbes Magazine, (2014) http://www.forbes.com/sites/ groupthink/2014/05/06/seven-tips-for-smoothing-out-your-smallbusiness-cash-flow/#68b1f42d3ec3 Steven Rogers, Entrepreneurial Finance (2014) McGraw-Hill Education; US

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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Product Liability Insurance Insurance and risk management consultant Holly Markham discusses the importance of due diligence when purchasing medical devices In the UK, medicines and medical devices are subject to the general product liability directive rules of the European Union. Where an injury or death has been caused by a potentially defective product, it can be possible to pursue a claim against the manufacturer or supplier of that product pursuant to the Consumer Protection Act 1987.1 Under Section 3 of the EU Directive, strict liability will be imposed on the manufacturer/supplier if the court is satisfied that the safety of the product was ‘not such as persons generally were entitled to expect’.1 The strict liability regime imposed in the Directive sets out three core requirements for establishing liability on the part of the producer: • A product defect • Damage • A causal link between these two One example, which was at the heart of a public healthcare scandal and proved to be a widespread issue, was Poly Implant Prothese (PIP), which left more than 300,000 women in 65 countries with substandard industrial-grade silicone gel breast implants.2 It is alleged that Jean-Claude Mas, founder of Poly Implant Prothese (PIP), switched the externally purchased medical grade CE-marked silicone for an inhouse produced industrial grade product to recoup market share and drive profits. These implants were then sold at a cost nine times less than medical graded implants. However, with PIP going into liquidation and owner and founder Jean-Claude Mas bankrupt, there was very little remedy for those who had been affected.3 Even if PIP had product liability insurance in place, Mas had acted illegally and insurers do not cover the liability of perpetrators of crime, fraud or dishonesty against the acts they have committed.4 It is important to note that the Product Liability Directive and the Consumer Protection Act (CPA) make the producer strictly liable.5 A producer is not just the manufacturer of the finished product but any component or person putting their name to it. The definition of producer also includes any importer bringing products to the European Economic Area (EEA), which could deem distributors and suppliers equally liable.5

Due diligence In my professional opinion, the PIP scandal could have been avoided. Questions should have been asked, not only by the distributors and suppliers, but also by the medical professionals who purchased the implants. This is something known as due diligence. Aesthetic practitioners are often bombarded by distributors and sales representatives promoting the latest revolutionary medical equipment, next generation laser, breast implant, filler or cosmeceutical skincare range. You may already have a whole arsenal of equipment in your clinic, but have you ever asked your supplier or

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distributor if they hold products liability or product recall insurance? Have you carried out any of your own due diligence on the supplier and/or the manufacturer?

Carrying out due diligence Before purchasing any medical devices or products, it is vital that you carry out due diligence and consider the factors below. Financial status Check the financial status of your distributor, supplier and/or the manufacturer. This is important to ensure that you are purchasing from a financially sound, viable source and, should things go wrong, you and your patients will not be left without any remedy. Taking the PIP case as an example, the company started showing signs of financial difficulties in 2003, which can be traced through regulatory filings. Financial difficulties in this instance led to the company acting unscrupulously, the business going into liquidation, Mas bankrupt and imprisoned, and no redress for patients.7 Background check Research as much as possible about any product or device you are looking to purchase. Thorough research on a product or device before you purchase is an important practice of carrying out your own due diligence on a product and the supplier/manufacturer to identify any potential issues that may arise. Questions to consider Below are some questions to consider to ensure you are carrying out due diligence. Systematic controls, approvals and certification procedures by professional licencing authorities: • What systematic controls, approval and/or certification procedures by professional licencing authorities have been carried out? • Are they FDA approved? CE marked? • Has there been a revocation of FDA authorisation? If so, why? Were the products or device deemed unsafe in any way? • Where are the products manufactured, within the EU or outside of EU territories? • What safety rules and efficacy testing applies before the product or device reaches the market in the territory it was manufactured? • Who is responsible for translating any instructions, warnings and safety precautions of the device or product? (If they are purchased from outside the EU, sometimes it is the supplier/distributor responsible for this). • If instructions are in South Korean or Chinese, is the distributor able to translate adequately to ensure the safety of the patient and appropriately train users of the device or product? Clinical research and data • What clinical research and data on the product or device is available? • What do the results demonstrate?

Definition The definition of due diligence according to the Cambridge Dictionary is, “The detailed examination of a company and its financial records, done before becoming involved in a business arrangement with it.”6

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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• Are the products effective for their intended use? • Have there been any adverse reactions or issues? • What are the risks and complications to patients and staff using the device/products? Components in the product • What ingredients are used in the product? A full list should be obtained to understand any contraindications of the products in line with a patients’ medical history. • Who is responsible for devising the training programme of the device or product? Are they medically qualified? • Does the trainer hold medical indemnity and professional liability protection? Product liability and product recall insurance • Does the distributor, supplier or manufacturer have appropriate products’ liability and or product recall insurance? Any business that designs, manufactures or supplies a physical product that is sold or given away for free can be held legally responsible for injuries and damages resulting from a faulty product.8 If you are purchasing any medical device or product that is intended for use on your patients, it is vitally important that you check that the supplier, distributor or manufacturer (if purchasing direct) has the appropriate cover in place.

What is product liability? Product liability insurance covers the cost of compensating anyone who is injured by a faulty product that a business designs, manufactures or supplies. Most policies, whether it is an office, clinic or medical indemnity policy, will provide Public and Product Liability as standard. However the standard cover is not intended to protect you if you manufacture, distribute, supply medical devices or products. If you have not disclosed these activities as a material fact to your broker or insurer and it is not stipulated on the policy schedule, then it is likely that it is not covered.9 Who needs it? Any business can be held liable for faulty products even if you did not manufacture them. You may be liable if: • Your business’s name is on the product or you have rebranded them • Your business repairs, refurbishes or changes a product • If you re-label, provide instructions, training and guidance in conjunctions with a product • Goods are damaged and not fit for purpose due to how your business has stored the products • You imported the product from outside the European Union • You cannot identify the product’s manufacturer, or the manufacturer has gone out of business – as in the case of PIP where the business went into liquidation. Therefore the supplier/ distributors can be held liable What does it cover? Product liability insurance protects a business that designs, manufactures or supplies medical devices and products against the cost of compensation for: • Personal injuries caused by a faulty product • Loss of or damage to property caused by your faulty product • Unforeseeable circumstances such as product faults that your quality control system could not identify10

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Product liability insurance may not cover you for: • Faulty products resulting from bad workmanship – an efficacy extension can usually be provided on request to cover this • Financial losses to a business or person caused by your faulty product If you do not manufacture the product but you distribute it, you should be covered if you can show that: • The products were faulty when they were supplied to you • You gave customers adequate safety instructions and warnings about misuse • You included terms for the return of faulty goods to the manufacturer • Your supply contact with the manufacturer covers product safety, quality control and returns • You have good quality control and record-keeping systems

Buying product liability and recall insurance You can buy product liability insurance directly from an insurer or broker, however it is imperative that you choose a provider that fully understands your industry. The risks faced by your business, specifically in relation to the products you use and/or supply, are unique and specialist advice will be needed. If you purchase cover from an insurance broker who does not have an in-depth understanding of medical devices, life sciences and products liability in relation to your industry, how are they going to be able to provide suitable advice? Working with a specialist broker will provide you with the assistance you need to establish not only how best to insure against these risks posed but also how, via effective due diligence and risk management, you can reduce the exposure to your business. With an influx of products and devices available on the market, there is probable cause to take extra precaution to avoid another PIP scandal. A repeat of PIP could quite easily be avoided if a culture of effective due diligence on the distributors, manufacturers and suppliers of these medical and aesthetic devices is adopted within your business. This coupled with an ongoing commitment to risk management will provide some safeguards to the risk of a repeat of PIP and give a little more protection for your business, its reputation and more importantly your patients. Holly Markham is the business development executive at Enhance Insurance, which specifically covers medical professionals. She has more than 10 years’ experience working in providing risk management advice and implementing high-level insurance programmes to mitigate and protect businesses. In 2013, Allianz highlighted Markham as one of the UK’s top five young brokers. References 1. Product Liability under the Consumer Protection Act <http://www.out-law.com/topics/commercial/ supply-of-goods-and-services/product-liability-under-the-consumer-protection-act/> 2. BBC News, Health, ‘Q&A:PIP breast implants health scare’ (2013) <http://www.bbc.co.uk/news/ health-16391522> 3. BBC News, Europe, ‘Breast implants: PIP’s Jean-Claude Mas gets jail sentence’ (2013) <http://www. bbc.co.uk/news/world-europe-25315627> 4. Insurance Europe, ‘Key Messages on Compulsory Liability Insurance for Manufacturers of Medical Devices and In-Vitro Diagnostic Devices’ (2013) <http://www.insuranceeurope.eu/sites/default/ files/attachments/Key%20messages%20on%20compulsory%20liability%20insurance%20for%20 manufacturers%20of%20medical%20devices%20and%20in-vitro%20diagnostic%20devices.pdf> 5. Consumer Protection Act 1987<http://www.legislation.gov.uk/ukpga/1987/43> 6. Cambridge Dictionary ‘Due Diligence’ <http://dictionary.cambridge.org/dictionary/english/duediligence> 7. Choosing a Breast Implant, ‘Background and History of Poly Implant Prothèse (PIP)’ <http://www. choosingabreastimplant.co.uk/background-and-history-of-poly-implant-prothese-pip/> 8. Association of British Insurers, ‘Product liability insurance’ (2014) https://www.abi.org.uk/Insuranceand-savings/Products/Business-insurance/Liability-insurance/Product-liability-insurance 9. Financial Ombudsman Service, Issue 46 ‘Non-disclosure in insurance cases’ (2005) <http://www. financial-ombudsman.org.uk/publications/ombudsman-news/46/46_non_disclosure_insurance.htm> 10. Association of British Insurers, ‘Product liability insurance’ <https://www.abi.org.uk/Insurance-andsavings/Products/Business-insurance/Liability-insurance/Product-liability-insurance>

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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“I think aesthetics is about giving people time to open up before you even consider treatment” Aesthetic nurse prescriber Alice Danker describes her journey from midwifery to medical aesthetics and the importance of not working in isolation There are not many areas of nursing that aesthetic nurse prescriber Alice Danker has left untouched. From midwifery and working in a neonatal unit, to running a residential home for the elderly, Danker has worked in many specialties before finding her ideal career in aesthetics. “I came from Malaysia in 1976 aged 20 and studied nursing in King’s Lynn, East Anglia,” explains Danker. “I then worked in a few areas of nursing before setting up a residential home in Harrogate in 1987. I did that for 12 years, but one morning I felt so burnt out I thought ‘I can’t do this anymore’.” Danker always had a passion for beauty and in 1999 she decided to close her business and undertake a level 2 and 3 qualification in beauty therapy. She explains, “Nurses weren’t really doing aesthetics then, so the next best thing was beauty therapy.” In 2003, when Danker saw a medical practitioner injecting dermal fillers in an exhibition area of a convention, she was intrigued, saying, “At first I thought ‘I can’t do that to people!’ It took me two years to pluck up the courage to train.” In 2005, Danker trained with Q-Med (now Galderma) in dermal filler injections and it was the beginning of her career in aesthetics. “I really enjoyed it. I’m very artistic and for me, it wasn’t just about picking up a needle, it was being able to make someone feel whole again and refreshed.” Danker made it a priority to get the relevant training every time a new product came on to the market, saying, “I would get training every few months; once you’ve had your initial basic training, it’s really up to you to improve and get better.” Having already opened a beauty business after closing down her residential home, Danker started to include aesthetic treatments to Vanity Beauty and Aesthetics clinic in Harrogate and since then, she has ensured she remains educated in order to keep practising, “It is so important to remain educated. If you don’t want to learn anything anymore then I think it is time to stop, because there are always new developments,” she explains, adding, “It is also about being safe. It is not just about picking up a needle and sticking it into somebody, it is such an art.” Danker’s commitment to education and excellence led her to become a member of the British Association of Cosmetic Nurses (BACN) and in 2012 she became the regional lead for Yorkshire and Humberside. “I really enjoy it,” says Danker. “The BACN are the champions for nurses in aesthetics. Without the BACN I don’t think nurses would be as recognised as much as they are.” As well as organising regional meetings, Danker has set up a local group where she and others can support each other. “There is no need to be a lone practitioner anymore, it is not safe to work in isolation,” Danker explains. “There are about 15 to 18 of us in Leeds and Harrogate and we are very close and can phone one another at any time. Then there are a few of us that will actually meet up and do treatments to watch and learn. Whenever we learn something new, we will get together and practise until we are satisfied with the results we can achieve and are confident enough,” she adds. Learning in this manner is one way that Danker ensures that she is always practising safely, which she feels is the most important thing to be aware of as a practitioner today, “It is so important to be safe. If you’re not sure on a product or procedure then don’t do it! You need to make sure you are properly trained first.” Despite the hours of dedication to learning and training, Danker finds the specialty extremely enjoyable. “I enjoy it so much that it never feels challenging,” she explains, “I truly enjoy making people feel good. I recently asked a patient what she found most memorable about me and she replied, ‘you always make me feel good!’ and that was lovely.” Danker concludes, “Sometimes patients come to me in tears and need a chat; people go through all sorts of personal problems and it is so nice, within the four walls, to hug them and listen to them. I think aesthetics is about giving people time to open up before you even consider treatment.”

What treatment do you enjoy doing the most? I enjoy doing all the treatments that I offer and tailoring them to suit individual patients’ concerns. Do you have an ethos or motto you follow? If I feel I wouldn’t have that treatment myself then I am not going to sell and promote it to my patients. If I have gone through the experience, then I can explain to my patients what it is like afterwards and what side effects to look out for. Looking back, is there anything you would have done differently? I wish I could have started earlier! What is the best career advice you have ever been given? When you’re starting a business do it slowly, and don’t buy expensive equipment straight away. Which aspects of the industry do you enjoy the most? Making people feel so much better in themselves. When patients are smiling when they look in the mirror and say ’wow’, there is nothing better than that!

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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The Last Word Dr Martin Godfrey argues the importance of regularly attending aesthetic conferences in order to remain up-to-date with the specialty Medical aesthetic conferences are a fantastic way of keeping up-to-date with this ever-changing specialty and refreshing knowledge and skills. But to some, especially those who are new to aesthetics, these events may feel quite overwhelming. As an attendee, the abundance of information, albeit useful, may leave some feeling bewildered, as there is a lot to be taken in within a short space of time. So, why attend conferences when you could read journals and textbooks instead? And why attend not just once a year, but several times? Some practitioners may believe attending just one conference a year ‘will do’, but I believe it is essential to attend multiple conferences each year in order to remain competent, highly skilled and safe. Although I am unaware of any statistics to back this up, I strongly believe from my experience of regularly attending aesthetic conferences that there is an 80/20 rule in play: 80% of the aesthetic practitioners who attend these meetings are the same 20% of the total UK population of aesthetic practitioners. In other words, if my theory is correct, the majority aren’t regular attendees. It is possible that some practitioners assume that it is just as easy, but less hassle, to keep up-to-date through reading magazine articles, going on training courses and having a couple of visits from sales representatives. Others may worry conferences represent a lot of ‘in your face hard-sell’ and too many ‘over-slick and over-promising’ presentations, although this isn’t the case. On paper, the conference agenda might seem to have very similar presentations to the previous congress, but what might look

like a similar presentation is likely to be very different in person. The aesthetics specialty is forever changing and almost every session is likely to be updating delegates with the latest clinical research and findings. Therefore, those that do register to attend will certainly reap tangible rewards. But of course, it is not always a cheap day out – taking a small group to one of these conferences could match the cost of that new device or skincare brand you’ve been looking at, which most likely puts off many people. However, many events offer free entry to the exhibition and a number of presentations, which is certainly something that ought to be taken advantage of. Aside from this, there are many other good reasons to make the effort to attend the main conference itself. The importance of attending Going to conferences gives perspective; it’s all very well looking at adverts or watching videos promoting the latest product or treatment, but you do this in isolation. The great thing about conferences, particularly by attending regularly, is having the ability to judge far more objectively what our peers really rate as good or bad; discovering what the latest trends are and learning about other practitioner’s experiences with certain machines, procedures, side effects and companies. You can assess this on several levels – go to a presentation and a peer you respect, someone like you, facing the same issues and challenges, gives you new insights, helping you to make an informed decision about whether to make a purchase. Conferences and exhibitions also give us the opportunity to get our hands on the

equipment. Aesthetics is a very practical specialty and without seeing the goods in real life and being able to compare them to others on the market, it can be difficult to understand what we need or what we aspire to. There’s also an ever-expanding list of competitive devices and materials being developed. It can be near impossible to choose one without trying it out, even vicariously at an exhibition stand. The events provide a variety of learning opportunities all in one place; giving us the chance to see live demonstrations, develop business skills, which may be difficult to advance when you work alone, and the opportunity to meet and listen to speakers from all over the world in one place. Going forward The question then remains – how often should we be attending conferences? At the end of the day, it does come down to personal preference. My preference, and what I recommend, is to attend at least two to three big meetings a year. If you have the funds, then travelling to international events can be very insightful, however, there are a number of hugely educational conferences available in the UK that provide content that is equally as valuable and allow you to meet manufacturers, suppliers and distributors working within your local area. In addition, presentations are likely to be more relatable as the speakers will have a good understanding of UK trends and how to successfully communicate with your patients. A number of UK-based conferences also feature speakers from abroad – if you are looking for a little international flair. Conclusion While of course a thorough understanding and training in the treatment you are offering is essential to creating optimum results for your patient, it is my opinion that you should also be up to date with all the latest news, techniques, treatment options and business development opportunities within aesthetics. And to do this, conferences and exhibitions offer a valuable source of education for every practitioner. 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.

Reproduced from Aesthetics | Volume 4/Issue 2 - January 2017


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

The VYCROSS™ Collection includes:

JUVÉDERM® VOLBELLA® with Lidocaine

JUVÉDERM® VOLUMA® with Lidocaine

JUVÉDERM® VOLIFT® with Lidocaine

JUVÉDERM® VOLIFT® Retouch® with Lidocaine

1. Raspaldo H. J Cosmet Laser Ther. 2008;10:134-42. 2. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167–172. 3. Callan P et al. A 24 hour study: Clin, Cosme and Investig Derm, 2013. 4. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147-58. 5. Jones D et al. Dermatol Surg. 2013;1–11. UK/0721/2015

Date of Preparation: October 2015


Aesthetics January 2017