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VOLUME 3/ISSUE 8 - JULY 2016

REFILLED TRIPLE LIPID RESTORE 2:4:2

A N T I - A G E I N G S K I N C A R E TO R E F I L L S K I N L I P I D S MAXIMISED CONCENTRATION 2% CERAMIDES 4% N ATURALLY OCCURRIN G C HOLES TEROL 2% FATT Y ACIDS

2:4:2

FULLNESS FEELS RESTORED

NATURALLY OCCURRING RESTORATIVE LIPIDS

TEXTURE FEELS RESURFACED RADIANCE REDISCOVERED

Managing Acne and Diet CPD Dr Anjali Mahto examines the literature on the association between acne and diet

Staying Safe in the Sun

Treating Melasma

Celebrity Endorsement

Practitioners discuss the best advice to offer patients to protect their skin from UV rays

Dr Maryam Zamani outlines treatment options for different types of melasma

Julia Kendrick takes a look at tried and tested tactics of celebrity endorsement


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UPPER FACIAL LINES The first and only aesthetic neurotoxin approved for combination treatment of Upper Facial Lines including: • Horizontal Forehead Lines • Crow’s Feet Lines • Glabellar Frown Lines

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Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-004 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, 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: Intramuscular injection (50 units/1.25 ml). 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: Intramuscular injection (50 units/1.25mL). 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. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton 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 aging or photodamage). In this

case, patients may 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). Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). 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 post-injection. Bocouture® may only be used by healthcare professionals with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz

Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: May 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® 50U Summary of Product Characteristics (SPC). April 2016. Available from: https:/www.medicines.org.uk/emc/medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, Double-Blind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. 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 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/69/MAY/2016/LD

Date of preparation June 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins


Contents • July 2016 06 News

The latest product and industry news

16 Conference Report

Aesthetics reports on the Facial Aesthetic Conference and Exhibition in London

18 News Special: JCCP

Aesthetics speaks to the founders of the Joint Council of Cosmetic Practitioners and investigates some of the concerns that surround it

CLINICAL PRACTICE

Special Feature Sun Protection Page 20

20 Special Feature: Staying Safe in the Sun

Practitioners discuss the best advice to offer patients for protecting their skin and detail which sunscreens they believe to be most effective

26 CPD: Acne and Diet

Dr Anjali Mahto explores the relationship between acne and diet

31 Spotlight On: earFold

Aesthetics investigates the efficacy of the earFold implant

34 Treating Melasma

Dr Maryam Zamani highlights the different forms of melasma and the variety of treatment options currently available

37 Advertorial: SkinCeuticals

Partnering in aesthetic practice

38 Breast Surgery Mr Adrian Richards examines different types of breast surgery procedures 43 Combining HA with Sodium Succinate

Dr Reza Mia outlines the results of combining HA with sodium succinate

46 Medical Tattooing

Karen Betts details how medical tattooing can build the confidence of people affected by facial deformity

50 Case Study: Treating Female Patterned Hair Loss

Dr Lisa Godfrey shares her experience of using PRP to successfully stimulate hair growth in a female patient

54 Advertorial: Radara

A micro-revolution in non-invasive antiageing skincare

55 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 56 How to Use Celebrity Endorsement to Boost Business

Julia Kendrick demonstrates how a celebrity partnership could be beneficial

58 Audio Branding

Dan Lafferty explains how to use sound to boost marketing efforts

60 The Importance of Understanding your Patients

Adrian Wales details how understanding different personality types can help to achieve a harmonious workplace

62 Aesthetics Awards 2016

Booking now open for this year’s Aesthetics Awards

63 In Profile: Dr Stefanie Williams Dr Stefanie Williams shares her professional journey and provides insight

on the differences between aesthetics in the UK and Germany

65 The Last Word

Business Develoment Celebrity Endorsement Page 56

Independent nurse prescriber Kelly Saynor discusses the importance of a cooling-off period and debates the related ethical and legal dilemmas

NEXT MONTH

Clinical Contributors Dr Anjali Mahto is an NHS and private consultant dermatologist. Her NHS base is in North West London and she works privately at Highgate Hospital and the Cadogan Clinic. She has an avid interest in the treatment of acne and its effects on the psyche. Dr Maryam Zamani is a board-certified ophthalmologist with experience in oculoplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine and has worked at Cardiff University in facial aesthetics. Mr Adrian Richards is a plastic and cosmetic surgeon and clinical director of both Aurora Clinics and Cosmetic Courses. In 2015 Mr Richards was named in world’s Top 500 Most Influential Cosmetic Doctors by international cosmetic surgery website RealSelf. Dr Reza Mia is an aesthetic practitioner and gained his medical degree from the University of Witwatersrand and MBA from the University of Liverpool. Dr Mia is a Key Opinion Leader for Institute Hyalual in South Africa. Karen Betts is a permanent makeup and medical tattooist with more than 20 years’ experience. Throughout her career, Betts has worked alongside numerous charities and performed a number of medical treatments, which aim to help transform lives. Dr Lisa Godfrey is a medical aesthetic practitioner and dental surgeon. She is a key opinion leader on PRGF-Endoret for BTI-Biotechnology and is their clinical trainer for the UK. She is currently two years in to studying for the MSc in non-surgical facial aesthetics at UCLAN.

Booking now open for Aesthetics Awards 2016 www.aestheticsawards.com

• IN FOCUS: Tattoo Removal • Using PDT • Avoiding Burnout

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Editor’s letter So here we are in July already, with the holiday season fast approaching. Some of you will be taking a break with children on school holidays and others will be using the time to develop and grow your businesses by attracting new Amanda Cameron patients and retaining existing ones through the Editor warm months. As such, our Special Feature this issue is on choosing appropriate sunscreen for your patients. Turn to p.20 to learn how to encourage patients to protect their skin from harmful UVA and UVB rays, and discover practitioners’ preferred sunscreen products for staying safe in the sun. Cancer Research UK has published guidance on using sunscreen and I think it is worth repeating some of the points to your patients, who may not be familiar with all of the advice: use sunscreen together with shade and clothing to avoid getting caught out by sunburn; don’t be tempted to spend longer in the sun than you would without sunscreen; apply sunscreen to clean, dry skin; don’t store sunscreens in very hot places as extreme heat can ruin their protective chemicals; don’t forget to check the expiry date on your sunscreen. Most sunscreens have a shelf life of two to three years, but ensure your sunscreen has

not expired before you use it. Prominent ears can be a significant aesthetic concern for many people, whose only treatment option was once restricted to surgery. Now, however, Allergan has introduced the earFold – a non-surgical solution with minimal downtime. This month we were lucky enough to speak to earFold creator Mr Norbert Kang and key opinion leader Mr Nilesh Sojitra to discover how the treatment is utilised in practice – read more on p.31. Are you looking to further your professional development? Read our latest CPD article on p.26, which this month focuses on the association between diet and acne. Dr Anjali Mahto has presented an excellent review of the literature, while also providing helpful advice to practitioners on dietary guidance to give to patients suffering from acne. Don’t forget that if you read the CPD article online, you can add your CPD certificate to your online Training Record – a useful way to keep track of all your professional development this year. Visit www.aestheticsjournal.com to become a member of the website and join community discussions, advertise jobs, list training courses and classifieds, search the industry directory and catch up on all the latest news and features from Aesthetics!

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.

FOLLOW US

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0203 096 1228 | M: 07867 974 121 chris@aestheticsjournal.com Suzy Allinson • Associate Publisher T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com Amanda Cameron • Editor T: 0207 148 1292 | M: 07810 758 401 mandy@aestheticsjournal.com Chloé Gronow • Deputy Editor T: 0207 148 1292 | M: 07788 712 615 chloe@aestheticsjournal.com Kat Wales • Journalist T: 0207 148 1292 | M: 07741 312 463 kat@aestheticsjournal.com Shannon Kilgariff • Journalist T: 0207 148 1292 | M: 07584 428 630 shannon@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com Sammy Carlin • Customer Support Executive T: 0203 096 1228 | support@aestheticsjournal.com MARKETING Ameera Qureshi • Brand Manager T: 0207 148 1292 | ameera@aestheticsjournal.com EVENTS Helen Batten • Head of Events T: 0203 096 1228 | helen@synaptiqgroup.com Kirsty Shanks • Events Manager T: 0203 096 1228 | kirsty@synaptiqgroup.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

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ARTICLE PDFs AND REPRO

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 2016 Aesthetics. All rights reserved. Aesthetics Journal is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Qualification

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #TV Dr Sam Bunting @drsambunting Last-minute prep @itvthismorning #sunscreen #safesunbehaviour

#Training BCAM @BCAM01 BCAM Appraisers gaining yet more knowledge from BCAM’s training day #revalidation #designatedbody #BCAM #appraisal #Peers Sarah Tonks @DrSarahTonks Great to spend some time with these guys @drdavidjack @DrKishanR

#Conference Karen Betts @Karen_Betts Waiting for my plane to Italy. Really looking forward to speaking about lips at a conference in Bologna. Ciao UK #Patients Sabrina Shah-Desai @perfecteyesltd Such a pleasant surprise to receive thanks from a happy patient

#Meeting Dr Jonquille Chantrey @MissChantrey Chilled vibes after a busy day of scientific meetings about future beauty treatments. Just love #Malibu #LosAngeles #Recognition Gary Ross @ukaesthetic Great to see Mr Ross on Times Square. @realself Top 100. Only UK #plasticsurgeon for two years running. #Manchester.

Harley Academy launches Ofqual regulated course Aesthetic training provider Harley Academy claims it has become the first in the industry to offer Level 7 Ofqual regulated postgraduate qualification in cosmetic injectables. The launch of the Harley Academy Level 7 Qualification in Injectables course follows the recommendations released by Health Education England (HEE) in November 2015 on the qualification requirements for the delivery of cosmetic procedures. In regards to botulinum toxin and dermal filler treatments, the HEE report stated, ‘No treatments are able to be delivered until practitioners have successfully completed a qualification at level 7 (postgraduate level), at which point they would only be able to practise with clinical oversight.’ According to the founding director of Harley Academy, Dr Tristan Mehta, until now, there has been no professional training courses available that provide more than a weekend or day of training, whereas the new course will contain more then 50 hours of university-standard material. He said, “We have been working towards achieving the first Level 7 Ofqual-regulated qualification in aesthetics for more than 18 months. This is a very important moment for our specialty and we hope that this higher standard of education will propagate throughout practitioners and ultimately lead to improved patient safety.” To attend the course, practitioners must have a Level 6 (undergraduate) degree in medicine, nursing, midwifery, dentistry or pharmacy and have a valid GMC, NMC, GDC or GPhC number. The programme also provides an online learning platform at a postgraduate degree level, allowing practitioners to train from anywhere in the world. Harley Street cosmetic practitioner Dr Tapan Patel is the clinical lead for injectables at the Harley Academy and the academic moderation panel includes aesthetic practitioner Dr Simon Ravichandran and consultant plastic surgeon Mr Taimur Shoaib. Dr Mehta explains that upon completing the course graduates will have received extensive training and knowledge in both the theoretical and practical sides of botulinum toxin and dermal filler treatments. Training

Mr Dalvi Humzah announces new course for aesthetic trainers Consultant plastic surgeon and founder of Facial Anatomy Teaching Mr Dalvi Humzah is to launch a new course aimed at training established and aspiring key opinion leaders. The two-day practical programme aims to ‘train the trainer’ and teach skills to enhance the delivery of participants’ teaching. At the end of the two days, participants will be able to prepare effective visual aids, engage quickly and effectively, integrate tips and tricks into delivery, and more. A fully qualified faculty will facilitate the programme and assess trainers, as well as offering them feedback and support. The course will run on 17-18 October 2016.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Awards

Aesthetics Journal

Aesthetics

Skincare

Bookings for the Aesthetics Awards 2016 now open

With entry for the Aesthetics Awards now closed and entries currently being assessed for the shortlist, booking is now open for the most esteemed celebration in the industry. The ceremony will honour Winners, Highly Commended and Commended finalists in categories that include practitioners, clinics, treatments, products, suppliers and distributors at the Park Plaza Westminster Bridge Hotel on Saturday December 3. Dr Maria Gonzalez, whose clinic won the Best Clinic Wales Award in 2015, said of the event, “The evening was brilliant and winning was even more exciting!” The Awards will deliver an exciting night of entertainment and celebration, and professionals are encouraged to make the most of the perfect opportunity to network with industry leaders, key clients and contacts, whilst commending the achievements of the past year. Dr Tapan Patel, founder and medical director of PHI Clinic, who won the Oxygenetix Award for Best Clinic London at the Aesthetics Awards 2015 said, “The evening gets better and better, I have to say that the awards ceremony improves every year and I cannot wait to come back next year!” Two new sponsors have also been announced; AestheticSource will be sponsoring the award for Best Clinic Group UK & Ireland (3 or more) and Healthxchange Academy will sponsor the award for Sales Representative of the Year. To find out more and book your tickets visit www.aestheticsawards.com

DMK launches new line Skincare manufacturer Danné Montague-King (DMK) Skin Co has released a new skincare range called DMK Limited. The range comprises eight products that aim to reflect DMK’s business concept of rebuilding, protecting and maintaining the skin. The Mediterranean Pearls foaming cleanser is a gel that includes vitamin B-enriched microspheres that aim to gently buff the skin and loosen dead skin cells. According to the company, the Wetter than Water hydrating emulsion is immune-boosting, anti-inflammatory and antiageing, while the Firmatrix skin recovery serum contains botanics that rebuild the epidermal matix. The A2Z revitalising tinted day cream is formulated with nutrients to provide protection against UVA and UVB radiation, the Elevate cream targets the neck and décolleté, while the TransGenesis age management cream aims to renew cells, as well as increase the skin’s elasticity and moisture retention. Sun

Research indicates many people are using sunscreen incorrectly A survey by the American Academy of Dermatology (AAD) has indicated that only 32% of respondents knew that an SPF 30 sunscreen does not provide twice as much protection as an SPF 15. A total of 1,020 respondents completed the online survey, with less than half (45%) of respondents knowing that a higher SPF does not protect you from the sun longer than a lower SPF sunscreen. “It’s important that everyone understands what they are seeing on a sunscreen label,” said board-certified dermatologist Dr Abel Torres, president of the AAD. “A sunscreen with an SPF of 30 blocks up to 97% of the sun’s rays. Higher SPFs block slightly more rays, but a higher-number SPF does not allow you to spend more time outdoors without reapplication; all sunscreens should be reapplied every two hours, or after swimming or sweating.” The AAD recommends that everyone protects themselves from the sun by seeking shade; wearing protective clothing, such as a long-sleeved shirt, trousers, a widebrimmed hat and sunglasses; and using a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher, applying enough to cover all exposed skin.

Training

Marion Gluck Training Academy announces new course Bio-identical hormone specialist Dr Marion Gluck has launched a new course at the Marion Gluck Training Academy, ‘Introduction to Bio-Identical Hormone Replacement Therapy (BHRT)’. The one-day course was developed by Dr Gluck to educate aesthetic medical professionals on how to treat patients with BHRT and how they can offer their patients a personalised approach to balancing hormones. The one day course will help delegates understand the role of hormones and will discuss the treatment and management of common, female hormone-related conditions, such as premenstrual

syndrome (PMS), perimenopause and menopause, using bio-identical hormones. Dr Gluck said, “It’s my personal mission to develop awareness of BHRT into the mainstream, to ensure that medical professionals and patients know what options are available to them. I’ve developed this introductory course to enable practitioners to be confident in prescribing BHRT, and key to this is the ongoing support they will receive after the course.” Registrations for the Introduction to BHRT course are now open and the first session will be held on July 16, with more dates to follow.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Conference

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Botulinum toxin

Save the date for ACE 2017

MHRA approves Bocouture for upper facial line treatment

The annual Aesthetics Conference and Exhibition (ACE) will take place at the Business Design Centre in Islington, London, on March 31-April 1 next year. ACE offers a premium Conference agenda, which aims to deliver talks on cutting-edge topics from leading UK and international speakers. It also brings together the highest quality exhibitors from across the aesthetics industry, enabling visitors to see all the key manufacturers and suppliers under one roof. Plus, the free Masterclasses, Experts Clinics and Business Track workshops will offer the latest innovations in techniques, treatments and business development strategies to educate and motivate delegates to enhance their practice in 2017. Feedback from ACE 2016 indicated that 92% of respondents rated the conference as either ‘good’ or ‘excellent’ for the overall experience. One delegate said, “I love the workshops, they’re so informative, I love the way they go into the anatomy and teach you the positives and negatives on what to look out for – they show you lots of case studies and injection techniques which are fantastic.” Another delegate said, “ACE gets better and better each year; it has the best aesthetic clinicians doing live demonstrations, and has provided a lot of relevant information on new and upcoming products. I look forward to attending in 2017.” The survey also found that 94% of attendees would recommend the event to a friend or colleague, and 98% would consider returning in 2017. Julia Kendrick, ACE 2016 speaker, said, “ACE 2016 was fantastic! I think everybody has been extremely impressed by the quality and the quantity of suppliers and information – it’s where everybody comes for networking and building up business. It’s a huge, vibrant, buzzy event to attend, and really enjoyable!” Entry to the Exhibition, Masterclasses, Expert Clinics and Business Track workshops will once again be free-of-charge, making ACE 2017 a must-attend event for all discerning aesthetic practitioners. For the latest ACE 2017 news and updates visit www.aestheticsconference.com

The Medicines and Healthcare Products Regulatory Agency (MHRA) has approved Bocouture, a botulinum neurotoxin type A treatment, in the UK for treatment of upper facial lines. Bocouture is distributed by Merz, who claim the product is the only neurotoxin approved in the UK by the MHRA for combined upper facial line treatments, including horizontal frown lines, lateral periorbital lines and glabellar frown lines. “Merz is a global leader in the aesthetics space and is proud to be able to provide patients and physicians in the UK with the first and only aesthetic neurotoxin approved for combination treatment of upper facial lines,” said managing director of Merz Pharma UK, Stuart Rose. He continued, “This expanded indication for Bocouture is a result of our on-going investment in research and development and supports our vision to become the most admired, trusted and innovative aesthetics and neurotoxins company worldwide.” According to Merz, the approval of the treatment is based on the results of a pivotal randomised double-blind, placebo-controlled study consisting of 156 patients from the UK, France and Germany. The patients received upper facial line treatment with Bocouture, and researchers found that the product was safe and effective in treating upper facial lines, both combined and separately, with effects lasting for up to four months.

Dentists

Industry

Dr Demosthenous launches training course for dentists Cosmetic practitioner Dr Nestor Demosthenous will run a two-day aesthetic training course for dentists at his new clinic in Edinburgh on July 30 and 31. According to Dr Demosthenous, the course is the first of its kind in Scotland and aims to help dentists develop and expand their knowledge and skills in medical aesthetics. The agenda will include theoretical anatomy training, followed by advanced botulinum toxin and dermal filler injection techniques to the lower face with the aim of producing natural-looking results. Dr Demosthenous will also discuss business techniques and teach delegates about patient safety including industry laws and regulations, insurance, stock ordering/control and good ethical practice. Dr Demosthenous said, “I have taught many dentists advanced aesthetic procedures and they are fantastic at performing these. I find that a lot of ‘basic toxin and filler courses’ miss out a vital step of diagnosing the ageing face, at least this was the case when I started. There are many dentists in Scotland wanting to branch into aesthetics and we therefore decided to run a curriculum where these fundamentals were addressed from the start, rather than down the line, and include business development and complications modules.”

EF MEDISPA launches first franchise outside of London Medical spa group EF MEDISPA has launched its first franchise in Bristol. The new medispa, which specialises in advanced aesthetic treatments, will also offer wellness services, fitness classes, a juice bar and Bristol’s first ‘Drip and Chill Lounge’ – for IV vitamin infusion therapy. Bristol franchise owner Elena Hunt, said, “To be part of the prestigious EF MEDISPA brand is amazing. It means we have access to the best technology and knowledge in the medispa industry as well as an unrivalled treatment menu. We are offering state-of-the-art treatments and procedures, not seen before on the Bristol market.” EF MEDISPA founder, Esther Fieldgrass, said, “We are delighted to have launched the first franchised EF MEDISPA flagship clinic in Bristol.”

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Aesthetics Journal

Nutraceuticals

Esthechoc released in the UK Cambridge Chocolate Technologies has released a new nutraceutical product in the UK that comes in the form of chocolate. According to the company, Esthechoc has an antiageing effect that works by increasing the skin’s antioxidant protection, reducing inflammation, boosting microcirculation to the skin and maintaining healthy oxygen levels. The product aims to do this through the inclusion of the antioxidant astaxanthin, an anti-inflammatory substance, and cocoa polyphenolic epicatechins, that aim to increase oxygen transport in plasma and microcirculation. Cambridge Chocolate Technologies also claims that the combination of epicatechins and astaxanthin, as well as a unique patented micellar technology used in the chocolate, increases the bioavailability of the components. The creator of Esthechoc, Dr Ivan Mikhailovich Petyaev, said, “Chocolate, when combined with our patented technology, has a range of benefits throughout the body. When combined with astaxanthin, the active in Esthechoc, there is a superadditive effect from the polyphenols in the cocoa and the antioxidant so that they become 10 times more powerful than when ingested alone.” Esthechoc is exclusively distributed in the UK by Medical Aesthetic Group.

Aesthetics

Vital Statistics People who use sunscreen daily show 24% less skin ageing than those who do not (Annals of Internal Medicine, 2013)

60% of social media users are most likely to trust social media posts by doctors over any other group (Master of Health Administration, 2016)

Since 2000, buttock lift procedures have risen by 252% (4,767 in 2015, up from 1,356 in 2000) (American Society of Plastic Surgeons, 2016)

Radiofrequency

Triangle Surgical introduces ThermiRF to UK A multi-platform technology aimed at providing long-lasting skin tightening has been launched in the UK. Thermi, which is approved by the Food and Drug Administration (FDA), uses heat to deliver aesthetic treatments such as wrinkle reduction, skin tightening, face and neck lifting, excessive sweating and vaginal rejuvenation. The LINIA Skin Clinic on Harley Street will act as the centre of excellence for practitioner training and development of the technology across the multiple clinical indications. The device offers simultaneous dual monitoring of internal and external tissue temperature using a temperature-sensitive probe, alongside infrared imaging. The probe is inserted under the skin to heat subdermal tissues to a specified temperature – the internal temperature is monitored and regulated by the computer system, while infrared imaging provides realtime guidance for practitioners, aiming to ensure safety and precision of the heating effect and delivery of optimal results in a single treatment. “Thermi really represents a revolution in precision dermal and subdermal skin tightening,” said aesthetic practitioner Dr Amanda Wong-Powell. “The beauty is in the treatment flexibility; whether you’re looking at vaginal rejuvenation, tightening sagging jawlines, or superficial skin resurfacing – it’s all possible in the one platform with the different applicators and will give patients fantastic, long-lasting results, which is what it’s all about!”   There is a variety of handpieces available for Thermi, including the ThermiTight, to help with subdermal tissue remodelling and ThermiDry, to help with the disabling of the axillary sweat glands. “We’re very proud to be at the forefront of launching Thermi in the UK here at LINIA,” said Dr Simon Zokaie, medical director at the LINIA Skin Clinic, adding, “we will be the UK Centre of Excellence for this new technology, responsible for delivering the highest quality training for doctors wishing to use Thermi in their clinics.”

Women who use makeup on a daily basis are absorbing almost 5lb of chemicals a year into their bodies (Richard Bence, 2007)

85% of mums who were

overweight one to two years after giving birth blame pregnancy for their weight problem (Baby Center, 2016)

The facial aesthetic market lost more than $500 million in revenue due to counterfeit products and parallel imports (Decision Resources Group, 2015)

69% of web user’s time

is spent looking at the left half of the webpage (Nielson Norman Group, 2010)

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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

17th September 2016 British Association of Cosmetic Nurses Annual Conference and Exhibition, Birmingham www.bacn.org.uk

22nd September 2016 Royal Society of Medicine, Safety and Risk in Healthcare www.rsm.ac.uk

24th September 2016 British College of Aesthetic Medicine Conference 2016, London www.bcam.ac.uk

3rd December 2016 Aesthetics Awards, London www.aestheticsawards.com

31st March - 1st April 2017 Aesthetics Conference and Exhibition www.aestheticsconference.com Microneedling

mesoestetic launches m.pen Pharmaceutical manufacturer mesoestetic Pharma Group has launched the m.pen for microneedling. The m.pen is a rechargeable cordless microneedling device that aims to optimise the effectiveness of the active ingredients by generating micro-channels in the skin. The device has 11 sterilised single-use microneedles that can be adapted and customised depending on the area of the treatment. It also has two speed options that allow for 13,200 microchannels per minute. According to mesoestetic, the microchannels enhance the absorption of the substances, allowing it to go deeper into the layers of the dermis, increasing its efficacy and results. The company also claims the micropunctures activate the release of growth factors, stimulating the fibroblasts and production of elastin, collagen and glycosaminoglycans. The m.pen has been specially designed to maximise the results of mesoestetic’s meso.prof products. The product is distributed in the UK by Wellness Trading.

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Acquisition

Pfizer acquires Anacor Pharmaceuticals Global US biopharmaceutical company Pfizer has announced it will purchase Anacor in a US $5.2 billion deal. The transaction will allow Pfizer to access the company’s main asset, Crisaborole, a non-steroidal topical PDE4 inhibitor that is currently under review by the FDA for the treatment of eczema. Albert Bourla, group president of Pfizer’s Global Innovative Pharma and Global Vaccines, Oncology and Consumer Healthcare Businesses, said, “We believe the acquisition of Anacor represents an attractive opportunity to address a significant unmet medical need for a large patient population with mild-tomoderate atopic dermatitis, which currently has few safe topical treatments available.” Crisaborole is a topical ointment that aims to inhibit PDE-4 in target cells, which reduces the production of pro-inflammatory cytokines, which is believed to cause the signs and symptoms of atopic dermatitis. Pfizer expects to complete the acquisition later this year. Rosacea

Allergan announces FDA acceptance for potential treatment of facial erythema An investigational topical prescription product for the treatment of persistent facial erythema associated with rosacea in adults has been accepted by the FDA for standard review. Oxymetazoline HCl cream 1.0% is a sympathomimetic agonist that is selective for the a1A-adrenoceptor over other a1-adrenoceptors and nonselective for the a2-adrenoceptors. The New Drug Application (NDA) submission for oxymetazoline HCL cream 1.0% was based on data collected from two phase three pivotal clinical trials of a 29-day treatment duration and a one-year open label clinical trial. These studies enrolled male and female patients who were 18 years of age or over with moderate to severe persistent facial erythema associated with rosacea. “While rosacea is a common chronic skin condition that affects more than 16 million people in the US alone, there is a significant unmet need in effective, FDA-approved treatments for the condition,” said David Nicholson, chief research and development officer at Allergan. He continued, “The NDA filing of oxymetazoline speaks to our strong commitment to ongoing innovation of our medical dermatology portfolio, and we look forward to bringing a new treatment option to patients with rosacea.” Industry

Novus Medical to distribute Asclepion in the UK Aesthetic laser supplier Novus Medical has announced it will distribute devices from German company Asclepion in the UK. Asclepion manufactures MedioStar for hair removal, as well as a number of Q-Switched Ruby lasers and Q-Switched Nd:YAG lasers for tattoo removal. Director of Novus Medical, Jim Westwood, said, “We are totally focused on supplying the highest quality products that can deliver all businesses’ requirements, and we’re delighted to be exclusively showcasing Asclepion.” He continued, “Innovation, quality and a unique understanding of the needs of medispas and clinics who operate in an ever increasingly competitive market are what make Novus Medical the ideal supplier for Asclepion.”

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Chemical peels

4T Medical launches new CLINICCARE peels Medical aesthetic distributor 4T Medical has launched new superficial alpha/beta hydroxy chemical peels by CLINICCARE. The peels come in three target ranges for specific skin indications: the CLINICCARE GLOW Peel aims to provide an intensive anti-pigmentation effect and improve the appearance of uneven skin tone and dullness; the CLINICCARE PURE Peel is targeted towards treating acne and improving the skin’s texture and the CLINICCARE REFRESH Peel is designed to provide an antiageing, tightening and skin rejuvenating effect. Managing director of 4T Medical, Julien Tordjmann, said, “The peels from CLINICCARE fit perfectly into our professional range and have been specifically formulated to target three particular skin concerns – photoageing, fine lines and wrinkles, and acne.” Industry

Radiesse Lidocaine receives CE mark Merz has announced that its dermal filler Radiesse Lidocaine with integral 0.3% lidocaine has received the CE mark. Merz claims the product provides an immediate lifting effect and stimulates the natural production of collagen, which aims to produce lasting results. “For many years, Radiesse has been a cornerstone of Merz’s global aesthetics portfolio,” said Can Gumus, vice president of global marketing aesthetics for Merz Pharmaceuticals. He continued, “We are excited to introduce Radiesse Lidocaine, a technology that delivers the trusted properties of Radiesse along with enhanced patient comfort. Merz’s research and development programmes are strongly committed to meeting key unmet needs of physicians and patients around the world. The addition of Radiesse Lidocaine is an important step as we continue to build on the unique technology platform underlying Radiesse.” The opaque dermal filler contains a small amount of local anaesthetic and is indicated for deep dermal and subdermal soft tissue augmentation of the facial area, and for restoration and correction of volume loss. Makeup

5 Squirrels launches Your Signature Mineral Makeup Private label cosmeceutical supplier 5 Squirrels has launched Your Signature Mineral Makeup. The new makeup range comprises a wide palette of colours of mineral foundation and blushers suitable for all skin types. The range is said to be especially beneficial for sensitive skin, skin that is prone to acne, and skin that typically reacts allergically to cosmetics, because it doesn’t contain the oils, artificial colours, chemicals or preservatives that typically dry out or irritate skin. “Your Signature Mineral Makeup allows clinics the opportunity to offer their patients high quality makeup at affordable prices safe in the knowledge that they are in control of their own brands,” said Gary Conroy, co founder of 5 Squirrels Ltd. “This helps to re-establish trust and loyalty with patients who are grateful for the advice they have received whilst appreciating good value for money.”

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

CLINIC INSPECTIONS Clinic inspections are a complicated issue with regard to what non-surgical treatments are being administered in a clinic by nurses, and whether CQC inspection is required. The BACN is taking up this issue with the CQC and the Department of Health. There is a new system in place in Scotland and one being developed in Wales. The BACN will report back on developments. We are interested to know if any nurses have had issues in this area.

REVALIDATION The BACN support for nurses going through revalidation is growing with the new Revalidation Register, established to help BACN nurses through the process. We have had a great reaction and support for this. More information can be found on the BACN website.

JCCP New Joint Council for Cosmetic Practitioners (JCCP) stakeholder events will launch on the following dates in July: 7th Jul: Beauticians and the new JCCP, London 21st Jul: The JCCP Register – Development and Structure, London 29th Jul: The JCCP – Implications for Education and Training, London If you would like to attend please contact: paul.burgess@jccp.org.uk

DATES FOR YOUR DIARY 1st Jul: BACN Regional Meeting, Newcastle 4th Jul: BACN Regional Meeting, Belfast 8th Jul: BACN Regional Meeting, Cardiff 11th Jul: BACN Regional Meeting, Leeds 15th Jul: BACN Regional Meeting, Cambridge 18th Jul: BACN Regional Meeting, Southampton 22nd Jul: BACN Regional Meeting, Birmingham 17th Sep: BACN Annual Conference, Birmingham International Convention Centre Booking now open for members and non-members via the BACN website.

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

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Body contouring

Syneron Candela launches UltraShape Power Aesthetic device company Syneron Candela has launched a new non-invasive body contouring treatment. The UltraShape Power aims to target stubborn pockets of fat on areas of the body such as the stomach, thighs, flanks, bottom, back and upper arms that diet and exercise cannot often reach. The FDA-approved device delivers focused pulsed ultrasound energy that aims to destroy fats cells without destroying the surrounding tissue, blood vessels and muscles. The body then clears the fat cell content through its natural metabolic process. Results of a clinical study, which included 43 participants who had the recommended three treatments, indicted a circumference reduction of 2.62cm at a 12-week followup. It also indicated that 80% of participants reported an improvement two-weeks post treatment. Syneron Candela claims the device does not cause any discomfort and has no downtime. Insurance

Hamilton Fraser named in The Leap 100 Companies List Insurance company Hamilton Fraser has been named as one of the top most exciting, fast-growing companies in the UK in The Leap 100 Companies List. The Leap 100 Companies List was assembled by finance news provider, City A.M, and commercial law firm, Mishcon de Reya, and aims to support companies that excel in four areas of leadership, ambition, team and income. This year marks Hamilton Fraser’s 20th anniversary, and CEO of the company, Eddie Hooker said he is extremely proud to be included in The Leap 100 Companies List. “We have worked tremendously hard over the past 20 years to achieve this level of success and it is very rewarding that our efforts are being acknowledged, especially on our 20th anniversary. We hope to build on our success with a vision of doubling the size of Hamilton Fraser within the next five years,” he said. Hamilton Fraser was founded in 1996 and specialises in property and medical indemnity insurance. Skin

FDA approves Ameluz for actinic keratosis The FDA has approved an aminolevulinic acid hydrochloride gel for the treatment of mild-to-moderate actinic keratosis on the face and scalp. Ameluz is the first prescription medication produced by pharmaceutical company Biofrontera. It is used in combination with photodynamic therapy using Biofrontera’s BF-RhodoLED lamp, which together aim to provide a topical treatment for actinic keratosis. The most common adverse reactions include site erythema, pain/burning, and irritation.

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News in Brief First ISAT international conference to be held in September The International Society of Aesthetic Trichology (ISAT) is to hold its first conference in Warsaw on September 23-24. The ISAT congress, Challenges in Aesthetic Trichology, aims to provide an opportunity for all attendees to network and explore new scientific advancements in the latest trichology studies. Around 300 delegates are expected to attend to listen to talks from 19 speakers including Dr Nilofer Farjo, Dr Benjamin Farjo and Dr David Perez-Meza. The Ruth Eaton Clinic wins outstanding clinic award A clinic in Bishop’s Stortford, Hertfordshire, has won the Outstanding Clinic Award from Teoxane. The Ruth Eaton Clinic was awarded for its ‘excellence in business practice, patient safety and commitment to developing the aesthetics market’. Independent nurse prescriber and founder of The Ruth Eaton Clinic, Ruth Eaton, said, “It’s a great accolade for myself and my clinic team as we all take part in a holistic approach to what suits our patients’ needs.” TYCT announces new chair Independent cosmetic advisory scheme Treatments You Can Trust (TYCT) has announced Baroness Morris of Bolton as its new chair. Baroness Morris is currently deputy speaker and deputy chairman of committees in the House of Lords. The director of TYCT, Sally Taber, said, “We are delighted that Baroness Morris shares our objective of a safer public in the nonsurgical market for cosmetic interventions.” Murad launches limited edition suncare for charity Skincare company Murad has released a limited edition version of its Invisiblur Perfecting Shield SPF 30 in support of The Prince’s Trust charity’s 40th year. Invisiblur Perfecting Shield SPF 30, now available in a limited edition size 50ml bottle, is a clear sunscreen that aims to protect all skin types and includes antioxidants that aim to hydrate and smooth the skin. As well as protecting the skin against UVB and UVA rays, the company claims the product protects against pollution.

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Dermal fillers

Allergan’s JUVÉDERM VOLBELLA XC approved by FDA The FDA has approved Allergan to market JUVÉDERM VOLBELLA XC for lip augmentation and to correct perioral rhytides in adults over the age of 21. In several clinical trials, including the US pivotal study where 168 patients were treated with the dermal filler, the product was found to effectively increase lip fullness and soften the appearance of lines around the mouth in approximately two-thirds of patients treated through one year. “JUVÉDERM VOLBELLA XC is formulated with VYCROSS, a proprietary filler technology from Allergan, which yields smooth products that have been engineered to address specific patient concerns such as lip fullness, age-related volume loss in the cheek area, or perioral rhytides,” said Allergan chief commercial officer Bill Meury. He continued, “The FDA approval of JUVÉDERM VOLBELLA XC further demonstrates Allergan’s commitment to developing advanced products and technologies that allow healthcare providers to better address evolving patient needs.” Industry

Schuco announced as new Neauvia distributor Aesthetic skincare distributor Schuco International has been named as the exclusive UK and Ireland distributor of Neauvia Organic. Neauvia Organic is a line of Swiss dermal fillers that are developed by Matex Lab SA. Instead of using 1 4-butanediol diglycidyl ether (BDDE) they use a new crosslinker polyethylene glycol (PEG) polymer, which the company claims is non-toxic and degradable in the tissue. According to Schuco, Neuvia fillers are the first and only biomimetic fillers in the world and the formula allows for longer lasting and safer results, which reduce the risk of the formation of granulomas and inflammation. “We believe Neauvia is truly unique and will revolutionise the market,” said commercial director at Schuco International, Chris Littlejohn. He continued, “It has a number of components that together differentiates it against everything else on the market; using IPN technology, degradable PEG, whilst being an organic biomimetic filler.” Neauvia is now exclusively available through Cosmedic Pharmacy. Digital

ClinicSoftware.com launches app in UK Clinic organising and management company ClinicSoftware.com has launched an app for iPhone and Android that aims to make it easier for businesses and patients to browse appointments in a calendar format. The new app allows business owners and clinic staff to view appointments and provides easy access to the appointment history of customers, including any notes with that appointment, facilitating easy re-booking and rescheduling. The software also allows clinics to manage their schedules, look up customer information, history, appointments, courses, account balances, vouchers and can track the sales from the day. Customers will be able to use the new software, to book and keep track of their appointments, manage their balances, read reviews and receive booking notifications.

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Dr Tiina Orasmae-Meder, founder of Meder Beauty Why did you create your own cosmetic line? I worked in laboratories in Switzerland and France, but when peptides first came about, the idea to apply them to wrinkle correction was too bold for them; it hadn’t been marketed yet, was too complicated, and required serious training. In the end I decided to try on my own. What was the biggest challenge? Finding a way to prepare the skin for the peptides to penetrate it and work their magic. It finally came together when I discovered the works of Japanese physiologists, proving that nicotine-induced vasodilation enhances the skin’s penetrability and allows the delivery of peptide molecules to the end fibres of mimic muscles at the papillary dermal level. What prompted the idea of non-invasive mimic wrinkle correction? When we offered the first programme in 2009, I was thinking of all the women who couldn’t have injections; those who were pregnant, nursing, or suffering from neurological conditions. But after launching it I realised the demand was wider than that. Many people were afraid of the jabs, or wanted something more natural. And since the effect was noticeable right away they kept coming back for more and recommending Meder to others. We ended up working in 24 countries. In 2013 we upgraded that first procedure and released the complete skincare line: four professional and 21 homecare products. In 2015 we added two more creams for the neck and bust area. Is this mimic wrinkle correction line your headliner? It’s hard to say which of our programmes is most sought after. The prebiotic treatment for acne and rosacea is just as popular as wrinkle correction or face lifting with growth factors. For me the crucial thing is Meder’s high safety standards. We never use aggressive ingredients (not even acids or retinol), all professional products are sterile and come in disposable packaging. Homecare products are safe even for damaged skin. With Meder Beauty you don’t have to wait for results, they are clearly visible in the very first days, no matter what skin problem you’re talking about; from wrinkles and malar bags to acne and double chin. This column is written and supported by

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NeoStrata product launch, London The new Skin Active Retinol + NAG Complex by antiageing skincare company NeoStrata was launched to the media at an exclusive breakfast on May 25 at the Royal Society of Medicine in London. Lorna Bowes, director of AestheticSource, distributor of NeoStrata in the UK, welcomed distinguished guests and introduced Dr Sandeep Cliff, who discussed the science behind the new product. He explained that the NeoStrata Skin Active Retinol + NAG Complex aims to reduce the signs of ageing by increasing the skin’s volume, reducing the appearance of pores, age spots and fine lines, creating firmer skin and reducing blemishes. He said this is achieved via a special encapsulated material that delivers 0.5% of

Dr Nestor’s Medical Cosmetic Centre launch night, Edinburgh

Dr Nestor Demosthenous opened his new clinic’s doors for its official launch on May 26. The clinic, Dr Nestor’s Medical Cosmetic Centre, will offer treatments for male and female facial ageing, skin health concerns and hair restoration surgery. At the launch Dr Demosthenous gave both talks and demonstrations on facial aesthetics, while Dr Lauren Jamieson and Wigmore Medical representative Sara Smith discussed skin health, ZO products and demonstrated the use of enzyme peels. Following the event Dr Demosthenous said, “The evening was encouragingly well received by Edinburgh’s social circles, lifestyle magazine editors, Toni&Guy hair stylists, and local beauty bloggers. Guests were genuinely inquisitive about treatments and skin health. We performed two filler demonstrations over the course of the night to give everyone a chance to see the procedures. Social media was in a frenzy with people tagging and liking our posts.” He continued, “Edinburgh is very much ready to add a new clinic to its growing portfolio of fully dedicated medical cosmetic clinics and I am proud to say we are working alongside colleagues to inter-refer and keep standards high.”

retinol slowly into the skin through diffusion, and this is combined with 4% NeoGlucosamine, a NeoStrata non-acid exfoliator that aims to help build HA and activate enzymes.    During his presentation Dr Cliff said, “The product has retinol and NeoGlucosamine which work together to produce an enhanced response, so you have a product that smoothes out the skin, stimulates collagen and HA, and is coupled with NeoGlucosamine which also enhances HA on the skin and thickens the skin to some extent.” The presentation included before and after photos, detailed case studies and ended with a video of international aesthetic professionals discussing the current industry trends. Following the conclusion of the event, Bowes said, “We had a phenomenal turnout and Dr Cliff did an exemplary job; those who attended now know more about the brand, they know all about our exciting new product launch, they learnt about the misconceptions around glycolic acid and came away with international aesthetic and skincare trends from leading doctors from around the globe. I think we helped them to put together their forthcoming skincare stories.” The NeoStrata Skin Active Retinol + NAG Complex will officially be launched in the UK in September.

Thermi Pre-launch Event, London LINIA Skin Clinic on Harley Street held the Thermi Pre-launch Event on June 9. Practitioners, distributors and suppliers were greeted with a canapé reception, which was followed by a presentation from Thermi European sales director, Pierre Mileur. According to Mileur, the Thermi is a multi-platform radiofrequency device that incorporates five different technologies and includes a thermal imaging camera. Included in the platform is the injectable ThermiTight, which aims to achieve sub-dermal tissue remodelling on the neck, breasts, arms, abdomen, thighs and knees; ThermiRase, that aims to treat the nerves for wrinkle reduction on the forehead and neck and ThermiDry, which aims to disable the axillary sweat glands in the underarms. Also included in the platform is the non-invasive ThermiSmooth, which uses a thermistor-regulated handpiece that aims to achieve dermal remodelling and rejuvenation on the face and body, and the ThermiVa technology, which aims to treat the internal and external areas of the vagina, including treating loose and dry vaginas, a leaky bladder, fallen bladder and orgasmic function. Gynaecologist Dr Mohammad Masood followed Mileur’s presentation, and discussed the ThermiVa. He said, “Women are becoming aware that they have options to treat these things and are often put off by surgical invasive treatments – I think it is a really amazing machine.” Plastic surgeon Mr Miles Berry discussed ThermiTight, noting that he thinks it is a nice alternative to a surgical procedure, and introduced a patient who had recently had treatments on her arms to demonstrate the results. Dermatologist and medical director at LINIA Skin Clinic, Dr Simon Zokaie, then discussed the ThermiSmooth and performed a live demonstration. “The user control is the fantastic part, we are in control of the temperature for as long as we want to treat the patient,” he said. Andy Hay on behalf of Thermi distributor Triangle Surgical also presented training and sales information, which was followed by a question and answer session.

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Sight of Beauty Conference, London International delegates including aesthetic nurses, skin therapists and other aesthetic professionals attended the Sight of Beauty Conference on May 26 at London’s Washington Mayfair Hotel. The event featured a presentation from the founder of Swiss skincare company Meder Beauty Science, Dr Tiina Orasmae-Meder, who discussed non-invasive eyebrow facelift, using the Myo-Fix

program. The Myo-Fix program uses biotechnological peptides: acetyl hexapeptide 8, Leuphasyl (by Lipotec) and Syn-ake (by Pentapharm Ltd) that together aim to smooth out the mimic wrinkles and restore the area to achieve a more youthful and radiant look in around five weeks. “The positives of the non-invasive eyebrow lift is that it is safe, there are fewer contraindications compared to injections, you are in complete control, it can be done during pregnancy or breastfeeding and there are no serious side effects,” Dr Orasmae-Meder said during her presentation. The presentation concluded with a live demonstration of the process, which included a six-step process of applying a cleanser, exfoliator, antioxidants, peptides, a facemask and moisturiser. After Dr Orasmae-Medar’s talk, Dr Antoine Le Galloudec from French skincare company Apot.Care presented a product new to the UK, Optilash serum, that aims to rapidly improve the length, thickness, fullness and health of eyelashes. He explained that to achieve this, the Optilash formula contains P226 polypeptide combined with the Optiwide Complex, containing a combination of matrikine, vitamins and tripeptide GHK, sodium hyaluronate, provitimin B and vitamin H. Following these presentations, delegates enjoyed a talk from sales director, Pavel Gruzdov, who discussed marketing techniques and explained how to best incorporate these products into a clinic.

Facial Aesthetic Conference and Exhibition, London Aesthetics reports on the highlights of FACE 2016 On June 16-19 practitioners from across the UK and abroad gathered at the Queen Elizabeth II centre in central London for four days to discover the latest advancements in antiageing. The Facial Aesthetic Conference and Exhibition (FACE) 2016 provided practitioners with a platform for learning and networking, and included extensive clinical and business agendas, as well as an exhibition showcasing all the latest aesthetic innovations and developments. The clinical programme covered the latest views, developments and technique advice on injectables, body, skin, threads, hair and sexual aesthetics by some of the industry’s most prestigious practitioners. Popular topics included in the agenda were neutraceuticals and skincare by Mr Paul Banwell, facial skin tightening approaches by Dr Raj Acquilla, toxin tips and advice for the upper and lower face by Dr David Eccleston and aesthetic nurse Annie Eccleston, and sexual rejuvenation, which was chaired by Dr Sherif Wakil and included a live demonstration. Consultant dermatologist Professor Nick Lowe presented on the ‘changing face of acne’ and discussed diet and stress, hormones and contraception, and acne in women. He said, “The inflammatory components of acne are probably the most significant for our patients because it’s those components that have been shown to damage collagen and connective tissue, and lead to the potential of scarring. The paramount desire for those of us who are treating acne patients is to the progression of preventing permanent scarring.” Delegates also had the opportunity to engage in panel discussions,

lively debates and question and answer sessions on topics such as the treatment of acne and rosacea, laser hair removal and threads. At the exhibition, distributors, training providers and other companies presented their latest innovations. Siobhan Cunney, director of threads at Intraline, said, “It’s been excellent – great to catch up with practitioners and see all the new products and there have been great talks as well, it’s fantastic.” Exhibitors also conducted workshops throughout the event to give delegates the chance to find out more about their offerings. Eddie Emilio, CEO of Vida Aesthetics, said, “FACE has gone really well – we launched our new collagen booster and we had some speakers at the workshops including Dr Irfan Mian who spoke about threads and Dr Britta Knoll who discussed mesotherapy.” The business agenda took place over three days where delegates had the opportunity to hear talks from international business consultant, Wendy Lewis, on the new rules of the cosmetic consultation, aims and objectives of the Joint Council for Cosmetic Practitioners by Sharon Bennett and Dr Paul Charlson, and tips and tricks to maintain a competitive advantage by Dr Uliana Gout. Summing up the conference as a whole, consultant dermatologist and laser surgeon Dr Firas Al-Niaimi said, “It’s been very enjoyable, I have presented myself, I’ve chaired some sessions and I have also attended some sessions – there’s been a huge variety from different specialities, from dermatology to plastic surgery and aesthetics. We also have sexual health on board now, so it’s a nice mix and integration with aesthetics. The conference had an international flare with plenty of international colleagues in attendance.”

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The Future of the JCCP Aesthetics speaks to the founders of the Joint Council of Cosmetic Practitioners and investigates some of the concerns that surround it In November 2015, Health Education England (HEE), on behalf of the Department of Health (DoH), released its guidance for qualification requirements for the delivery of cosmetic procedures.1 In these recommendations, HEE acknowledged that the cosmetic industry needed a joint professional council to assume ownership of the cosmetic industry standards for education and training, and to ensure the future proofing and continuing validity of the qualification requirements.1 Following this, on January 8, the British Association of Cosmetic Nurses (BACN) and the British College of Aesthetic Medicine (BCAM) announced the concept of the Joint Council for Cosmetic Practitioners (JCCP). Professor David Sines was appointed as interim chair of the voluntary, independent body to establish the organisation. He explains, “The purpose of the JCCP is to provide public protection with non-surgical cosmetic procedures, through establishing standards that will underpin registration of accredited professional providers.” Since its inception, the JCCP has received mixed comments concerned with how the body will work, how it will be funded and how it will remain credible. One of the main questions it has faced is, what difference will it actually make to practitioners and to patient safety? Who is included? The initial group comprised the BACN and the BCAM because, according to CEO of the BACN, Paul Burgess, it was difficult to get others on board at such an early stage. He explains that once they were in a position to go live, and with Professor Sines involved, “It triggered lots of other people to come on board because once they saw that the DoH would back something, they wanted to get on

the train.” Once the foundations of the council were formed, the JCCP gained support from the British Association of Aesthetic Plastic Surgeons (BAAPS), the British Association of Dermatologists (BAD) and the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS). However, as some have pointed out, these associations are not the only ones that need to be represented. In its report, HEE stated that, ‘It is important that this body includes representation from all of the different professions operating across the industry.’1 Chair of the BACN, Sharon Bennett, explains, “A major concern is that the setting up of the JCCP has not been inclusive, with the same old faces putting something together. That’s only because, in the initial phase, the basic structure and framework had to be put into place before we could even think about opening the committees up.” Potential members for the committees are currently being approached and include association groups representing pharmacists, dentists, podiatrists and even beauty therapists. How will it work? “The first thing we have to do is establish a Clinical Standards Authority (CSA), explains Professor Sines. “This needs to be an independent stand-alone organisation that will set the professional and clinical standards – the practice aspects of the treatments by aesthetic practitioners,” he says. Once the CSA and its standards has been established, Professor Sines says the JCCP will have a regulatory function and will be responsible for accrediting practitioners to these standards, by creating a register of accredited practitioners. To join the register, Professor Sines says practitioners must, “Meet the CSA’s

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standards for clinical aesthetic practice, meet the standard for educational proficiency and verify this against the HEE framework, they need to have indemnity, demonstrate ‘good character’ and declare that their premises is ‘safe’. Then they would have to also agree to the conditions of a new Code of Practice that we will be setting up.” Aesthetic healthcare professionals will be encouraged to join the JCCP register and become members. Abiding by HEE’s recommendations, aesthetic beauty therapists who don’t have a healthcare professional qualification will also be included. Professor Sines says, “We would certainly like to give them [beauty therapists] every opportunity to join the register at the level of competence that they can demonstrate based on the HEE framework, which is set at Level 4.” If the JCCP receives a complaint about a registered member, Professor Sines says that for healthcare professionals, there will be an agreement with their professional body, such as the General Medical Council (GMC) or Nursing and Midwifery Council (NMC), that the complaint will also be taken up with them. He explains, “If they find that there is an issue, we will then have a system in place to prevent them from using the register.” He says however, the process may be different with beauty therapists, who do not have a higher registration body. “We would have to then adopt the responsibility of a higher level registration authority so if you are a beauty aesthetic practitioner, and were found to not adhere to the standards then we would remove you from the register,” he says. The management process for deregistering a member is yet to be decided, however the current suggestion is that the practitioner’s competency level for particular treatments might be reassessed and potentially changed before they are completely taken off the register. In parallel with the register, the JCCP will establish an education training subgroup, which Professor Sines says will, “Actually adopt the HEE standards, and set up protocols for accrediting training providers to meet those standards.” Funding At the present time, the non-profit council receives independent sponsorship and a small grant from the DoH for initial development. In the future, Professor Sines says, “All of the funding will be through registration fees and accreditation fees that we will set for the training institutions that wish to become an accredited course. For example, if you are a university course and

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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want to be accredited through the JCCP, then we would be setting an accreditation fee.” There are still discussions taking place on what role companies such as insurance providers, manufacturers and pharmaceutical companies will have. Bennett, however, assures that, “There will be no advantages or leverage given to supporting companies hoping to profit. Transparency is essential to ensure the JCCP honestly and ethically carries out its mission.” Credibility In its recommendations, HEE states, ‘It is important that any new joint professional body is seen to be independent without undue influence from the industry.’ In response to this, president of the BCAM Dr Charlson explains, “We have an independent chair and an independent board so we can be seen as transparent and independent.” He says that credibility would also come from, “Having all the stakeholders who are doing aesthetic procedures on the board and not having people who have an invested interest in the majority.” The JCCP will be separately registered with the Professional Standards Authority (PSA), which provides the

Aesthetics Journal

Aesthetics

governance responsibility for all healthcare professional councils and provides a national trademark for voluntary registers.2 Professor Sines says, “By virtue of that, the DoH are offering their support to any organisation that meets the standards of the PSA. The council itself has to pass a very vigorous process of being formally accredited by the PSA before being set up.” What difference will it make? The ambition of the JCCP is that through increasing education and awareness, most patients will seek treatments only from practitioners that are on the register. With regards to being a part of the register, Dr Charlson says, “For practitioners who are doing procedures properly already, not a lot will change, they will just carry on doing what they are doing,” he continues, “What it will try and do is make people aware of those who are NOT doing it properly so it will increase public awareness that there needs to be a certain standard of practitioner – if that practitioner isn’t on that list then they shouldn’t be doing it.” Upon its inception, Bennett believes the JCCP and CSA will change the industry, “It

will take years but it has to be the best thing to have happened in the UK in cosmetic medicine because we will have everything under one umbrella, one register, one clinical advisory board, and one set of standards that everyone has to work to rather than a number of them from different courses over the UK.” Conclusion Although the fundamental building blocks of the JCCP have been put in place, the body is not expected to be officially up and running until April 2017. Currently the JCCP is in discussions with major industry associations from all types of backgrounds, including those with and without a medical background. Bennett concludes, “This is what the DoH wants, there is too much disparity across the UK and everything needs to come together – by working together we will be very strong.” REFERENCES 1. Health Education England, PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, The Department of Health, (2015) pp.1522. 2. Professional Standards Authority, ‘Our Work with Accredited Registers,’ <http://www.professionalstandards.org.uk/what-wedo/accredited-registers>

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Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Staying Safe in the Sun Practitioners discuss the best advice to offer patients for protecting skin from UV damage and which sunscreens they believe to be most effective As the summer months draw closer patients and practitioners alike will look to make the most of the seasonal heat, but at the same time protect themselves from harmful ultraviolet (UV) radiation. As aesthetic practitioners, how can patients be best advised to stay safe whilst in the sun, and how can this information be incorporated into every patient consultation? Ultraviolet radiation Although basking in the sun is on many people’s minds at this time of year, the UV rays emitted should always remain an important concern. UV radiation is part of the electromagnetic spectrum that reaches the earth from the sun. The wavelengths are shorter than visible light, which is why they cannot be seen with the naked eye.2 They are classified into three main types – UVA, UVB and UVC; UVA has the longest wavelength of the three, followed by UVB and UVC. The UVC rays, which would be the most damaging to humans,1 are so short, that they are absorbed by the ozone layer and do not reach earth.2 As UVA and UVB do penetrate the atmosphere, these are the ones to be wary of. Aesthetic nurse prescriber and founder of Face Cosmetic Training, Jacqueline Naeini, says, “Patients will come to me and say, ‘I want to get a sun tan’, but I tell them about the UV rays; I explain that one way to remember it is UVA for ‘UV Ageing’ and UVB for ‘UV Burning’. I inform patients that 95% of damage to their skin is from UVA whereas 5% of damage is from UVB2,7 – and so many don’t know that.” Dr Sarah Norman, aesthetic practitioner, and owner of BrightNewMe clinic reiterates Naeini’s point, explaining, “I remind patients that UVA is not blocked by glass or clouds, it’s consistently present throughout the year, during daylight hours and throughout all the seasons, irrespective of cloud cover.” UVA rays penetrate deeper into the skin than UVB and play a major part in skin ageing. UVA has Figure 1: 69-year-old truck driver presenting with unilateral photoageing also been shown to damage keratinocytes in the

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basal layer of the epidermis where most skin cancers occur, meaning UVA can also cause skin cancers. UVB is responsible for the darkening and thickening of the outer cell layers,1 and with too much exposure can lead to burning of the skin and skin cancer. “I always use the example of the lorry driver (Figure 1),” says Naeini, referring to the infamous image of a 69-year-old man who spent 28 years as a lorry driver and never used sun protection. This left the man with an exceptionally obvious difference between the two halves of his face, with the side of his face nearest the window heavily wrinkled and pigmented from UVA rays. “It shows the damage UVA has done to his skin and how much it has aged him. This shows patients why we should put sun protection on all year round. I always say to patients that whatever you put on your skin, sun protection is number one.” Preparation Many practitioners incorporate the topic of sun protection into every patient’s initial consultation. Dermatologist and cosmetic practitioner Dr Ariel Haus says, “I always give patients information from the British Association of Dermatology (BAD) and explain how to use sunblock, information on skin cancer and how to check their skin. Part of the homecare of any procedure is always sunblock.” He continues, “I also work for the NHS as well as privately and see a lot of patients with skin cancer, so I see the damage sun can do. I remind patients the only time there is no sun is in the evening – I’m so surprised how many people don’t realise that.” Before contemplating sun protection, dermatologist Dr Tiina Orasmae-Meder informs her patients how to prepare the skin in advance of the summer months. “I recommend that all my patients stop chemical peel treatments and products containing acetic acid and retinoid around April-time. After that, they need to continue to exfoliate and do hydrating treatments.” She explains that it is especially important for patients to be wary of ingredients they use in the summertime, as some, such as acetic acid and retinoids can increase skin sensitivity.8,9 “Vitamin C is a good alternative to acetic acid for the summer period but it’s better to apply it at night because it also can effect sensitivity when initially applied and could lead to issues with pigmentation,” she says. During the summer months Dr Orasmae-Meder advises

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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A survey of 215 individuals conducted online by the BAD indicated that eight out of ten people are failing to adequately apply sunscreen before going out in the sun patients to focus on hydrating products. “If possible patients should apply a hydrating face mask three to four times per week. These masks usually contain lots of anti-inflammatory ingredients such as red grape extract which is really beneficial when the sun has caused the skin to become dry.” Practitioners also advocate analysing the current state of the skin in order to see which treatments would be most beneficial. Dr Haus uses a skin analysis device. He explains, “It shows how much sun damage and UV exposure the patient has had and it’s also useful for mole mapping and checking for changes in the moles. Once we have analysed the skin we create a treatment plan.” Protection There is a vast array of products that claim to protect the skin from sun damage, making it difficult for patients to know which will work best. However practitioners interviewed for this article unanimously agree that there is a substantial difference in quality between sunscreens available on the high street and those available in clinics. Dr Martyn King, director of the Cosmedic Skin Clinic says, “I think the high street products can sometimes be misleading when they only show the sun protection factor (SPF), which only measures how effective the product is at preventing UVB rays when we need full spectrum protection. It could lead some people to think they’re completely covered because the product has a high SPF but in fact the UVA will still be causing damage.” Dr King continues, “I don’t like some of the chemicals put in

Figure 2: 49-year-old female patient showing sun damage – before and during a skin analysis. The image was taken using the Opatra Skin Analysis system. Image courtesy of Dr Martyn King.

Aesthetics Journal

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NICE Guidelines A summary of some of the NICE guidelines surrounding sun protection:4 • When possible, only a limited amount of time should be spent in strong sunlight. It is preferable to spend more time in the shade. • Protection from the sun can be achieved by covering up with suitable clothing, seeking shade and applying sunscreen. • Suitable clothing includes: a broad‑brimmed hat that shades the face, neck and ears, a long‑sleeved top, and trousers or long skirts in close‑weave fabrics that do not allow sunlight through. It also includes sunglasses with wraparound lenses or wide arms that have the CE Mark. • Sunscreen is not an alternative to covering up with suitable clothing and seeking shade, but it does offer additional protection. • Sunscreen should meet minimum standards for UVA protection – the label should have the letters ‘UVA’ in a circle logo. Preferably, the label should state that it provides good UVA protection (for example, at least ‘4‑star UVA protection’ but some brands use the term ‘broad spectrum’ which encompasses both high UVA and UVB protection). It must provide at least SPF 15 to protect against UVB. • The amount of sunscreen needed for the body of an average adult to achieve the stated SPF is around 35ml or six to eight teaspoons of lotion. • Sunscreen needs to be reapplied liberally, frequently and according to the manufacturer’s instructions. This includes straight after being in water and after towel drying, sweating or when it may have rubbed off. • If someone plans to be out in the sun long enough to risk burning, sunscreen needs to be applied twice to exposed areas of skin: half an hour before, and again around the time they go out in the sun. This includes the face, neck and ears (and head if someone has thinning or no hair), but a wide‑brimmed hat is better.

sunscreens so in my clinic we stock Universkin which is mineral based – containing zinc oxide and titanium dioxide – and that protects you for both radiation types.” Universkin is a skincare range that the manufacturers say can be personalised to suit every patient’s needs. Each combination starts with the base serum, which contains 11 ingredients including hyaluronic acid, vitamin E and Omega 3, and then other ingredients can be added in from a range of 19 actives. Dr King explains, “I find that some products can feel a bit ‘powdery’ but Universkin goes on very nicely and doesn’t feel dry or powdery. It has no preservatives and its paraben free, so it really is quite a calming product.” Dr Norman tends to recommend Obagi SPF 50 to her patients, as she finds that this can be applied easily onto the skin and is non-comedogenic. “I like the Obagi SPF 50 as it’s not greasy, it’s fragrance free and unlike many high factor products it doesn’t appear white on the skin which is important. I also offer patients Zein Obagi Skin Health (ZOSH) broad spectrum SPFs which have a tint.” She continues, “A lot of my patients say they don’t really want to be wearing a factor 30 or 50 as they say it looks ‘too white’, but

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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“Patients will come to me and say, ‘I want to get a sun tan’, but I tell them about the UV rays; I explain that one way to remember it is UVA for ‘UV Ageing’ and UVB for ‘UV Burning’” Jacqueline Naeni, aesthetic nurse prescriber

the Obagi SPF appears sheer. It also has a PA+++ rating, which is the highest protection from UVA.” Many patients will be familiar with certain brands using a star rating to indicate the level of UVA protection (1-5), but there is another system, the Protection Grade of UVA (PA), that most medical-grade products use. The star system, which is said to have been originally devised by Professor Brian Diffey of Newcastle University,4 is a measure of how much UVA is absorbed when testing products in the laboratory. The PA system, created in Asia, works by assessing the darkening of the skin following application of sunscreen, directly measuring the effect of radiation on the skin.3 Another product with a high PA rating is the NeoStrata Sheer Physical Protection SPF 50, which Naeini recommends to her patients. “I use the NeoStrata Sheer Physical Protection because it’s a mineral sunscreen and suitable for all skin types. The texture is really fine and transparent so patients feel comfortable when putting their makeup on over the top of it.” She continues, “I very much go on what the patient wants, I let them have a look and a feel and then it’s their preference; if they’re having a Skin Tech Easy Phytic skin peel I’ll recommend a Skin Tech Melablock HSP SPF 30 or 50, if they’re using the Exuviance skincare range then I would recommend the Exuviance SPF – they’re all good and they’ve all got a broad spectrum. The reason why I use them is because they also fit in with the NICE guidelines.” Application A survey of 215 individuals conducted online by the BAD indicated that eight out of ten people are failing to adequately apply sunscreen before going out in the sun.5 The survey also suggested that 70% of people fail to reapply sunscreen every two hours as recommended. “I don’t believe people apply as they should,” says Naeini. “I think people believe if they put it on in a morning then that’s enough for the rest of the day, but it needs to be reapplied every two hours according to NICE guidelines.” Dr Norman agrees, “I always say to my patients use a ‘big gloop’ and use it ‘liberally and fastidiously’. Dr King says, “If you’re on holiday and in and out of the water all the time or in a very hot climate then you need to apply frequently. I think the best advise for most people for all-year-round is to apply it in the morning as part of their regime and get into the habit of that.”

Aesthetics Journal

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What to be aware of What many patients may not realise is that certain compounds can make the skin even more sensitive by reflecting UV rays on to the skin; meaning sun cream should be reapplied even more frequently. Naeini says, “15% of harmful rays are reflected from the sand and 5-10% of harmful rays are reflected from the water, so that’s even more of a reason to reapply regularly. When patients are on skiing holidays they need to be aware that 75% of harmful rays are reflected back from the snow, so they need to make sure they’re definitely putting sun protection on and covering up.”10 Dr Norman says that patients should also be wary of using makeup as a form of sun protection. “Research shows that you would actually need to apply seven times the amount of normal foundation and 14 times the normal amount of powder in order to get the full SPF that’s written on the products11 – and most patients don’t want to be caked with makeup and powder.” Another major concern is how vitamin D can be absorbed if people are wearing sunblock. According to NICE, one in five adults may be vitamin D deficient.6 Dr Haus says, “It’s important to make sure that patients are still getting vitamin D. I always advise patients to get some exposure before 10am and after 4pm; between those times they must use sun protection. If patients are already quite low then I would advise they use supplements.” Conclusion Overall, the level of education patients have when it comes to sun protection is varied and not uncommonly minimal, but Dr King thinks that people are starting to become more aware, “Vitamin D levels are checked in general practice a lot more often now, it’s a much easier test to do, and its actually very rare to find anybody with a normal vitamin D level; nearly the whole nation is deficient. This tells me people are paying a lot more attention now to staying out of the sunlight, so I think that health messages from years ago might have actually stuck.” He continues, “But the problem is, a lot of people will go for a brand they know or what’s a good price or what’s on offer, instead of actually looking at the ingredients and the real evidence behind it.” Dr Norman concludes, “I quite often remind patients of the Australian ‘Slip! Slop! Slap!’ awareness campaign – slip on a top, slop on cream and slap on a hat. Sometimes people also add on ‘Seek! Slide!’ – seek the shade and slide on glasses and that’s just my way to always remind people they can’t just rely on the sun cream.” REFERENCES 1. Who, Ultraviolet radiation and the INTERSUN Programme, World Health Organisation, (2016) <http:// www.who.int/uv/faq/whatisuv/en/index2.html> 2. Dr John H. Epstein & Stephen Q. Wang, UVA & UVB, Skin Cancer Foundation, (2013) <http://www. skincancer.org/prevention/uva-and-uvb> 3. Cosmetic scientist’s blog, UVA Protection – What Do the Ratings Mean? Colin Beauty Pages, (2013) <http://colinsbeautypages.co.uk/uva-protection-what-do-the-ratings-mean/> 4. NICE, Sunlight exposure: risks and benefits, NICE guidelines, (2016) <https://www.nice.org.uk/ guidance/ng34/chapter/2-Supporting-information-for-practitioners> 5. BAD, Brit’s slapdash approach to sunscreen putting lives at risk, British Association of Dermatologists, (2016) <http://www.bad.org.uk/News.aspx?sitesectionid=154&itemid=8469> 6. NICE, Millions of people at risk of low vitamin D need better access to supplements to protect health, says NICE, NICE press release, (2014) <https://www.nice.org.uk/news/press-and-media/millions-ofpeople-at-risk-of-low-vitamin-d-need-better-access-to-supplements-to-protect-health-says-nice> 7. Jennifer Zhao, The Difference Between UVA and UVB Rays, Global Research, (2011) http://www. geglobalresearch.com/blog/the-difference-between-uva-and-uvb-rays 8. Amy Wiggin, How Retinol Can Change Your Skin, Birchbox, (2014) https://www.birchbox.com/ magazine/article/how-retinol-can-change-your-skin 9. Bul. S, Acetic acid general information, Health Protection Agency, (2010) <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/315396/acetic_acid_general_information. pdf> 10. Cancer Research UK, Am I at risk of sunburn? Cancer Research UK, (2015) <http://www. cancerresearchuk.org/about-cancer/causes-of-cancer/sun-uv-and-cancer/am-i-at-risk-of-sunburn> 11. Susan, P. Clark, Sunscreen and Your Makeup Routine, WebMD, (2012) <http://www.webmd.com/ beauty/sun/sunscreen-and-your-makeup-routine?page=2>

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Acne and Diet Dr Anjali Mahto discusses the relationship between acne and diet and explains how practitioners can consider diet when treating patients Acne is one of the commonest skin disorders and affects nearly 80% of the population at some point in their lives.1 It has substantial and well-recognised effects on quality of life including low self-esteem and confidence.2 As a result, finding new and effective treatments remains of paramount importance. Questions about diet and its role in acne are extremely frequent in consultations; it is therefore important that healthcare practitioners understand and are able to explain the current evidence in this area. Early history Through the years, the relationship between diet and acne has been highly controversial. In the late 1800s and early 1900s, dermatology textbooks frequently recommended dietary restriction as part of the treatment of skin disease.3,4 At this time, we did not fully understand the pathogenesis of acne and any advice given was based on observational and anecdotal evidence.

A Malaysian case control study in participants aged 18 to 30 years found that milk and icecream consumption was significantly higher in patients with acne compared to controls

Early research from 1931 reported that patients with acne had impaired glucose tolerance.5 Further studies demonstrated an improvement in acne severity following a restricted carbohydrate diet.6,7 In the 1940s6 and 1950s,7 observational and case studies reported an association between milk consumption and acne severity in addition to improvement in acne if a low-saturated fat diet was followed. Before the 1960s, dietary advice was therefore a standard part of acne therapy.8 Patients were discouraged from eating a wide range of foods including chocolate, fats, sweets and carbonated drinks. However, despite this advice, many researchers remained unconvinced of the association citing lack of evidence. Two pivotal research studies, often quoted in the literature, resulted in the potential diet-acne association being dispelled as myth for almost fifty years. This was a turning point in the long and often contentious history of the diet and acne relationship. Study by Fulton et al. The first of the two papers was published in 1969 by Fulton et al.9 It investigated the effect of chocolate on acne in a crossover singleblinded study. Participants (n=65) with mild to moderate acne were assigned to eat either a milk chocolate bar or placebo daily for four weeks. After a three-week rest period, subjects then consumed the alternate bar for four weeks. Acne improvement was scored as worsened or improved if the total number of lesions increased or decreased by 30%. From their results, the researchers determined that chocolate did not affect the clinical course of acne. Whilst on the surface the results were accepted, the study itself had important methodological flaws. Firstly, the duration of the study was too short. Most acne clinical trials should last a minimum of 12 weeks to allow for the natural history of blackhead/whitehead formation and evolution.10 The placebo bar was deemed to be an inappropriate control because it had similar total sugar and fat content as the chocolate bar. The control bar had a relatively high quantity of partially hydrogenated vegetable oil, which contains high levels of trans-fatty acids that contribute to inflammation.11,12 No consideration was made of the subjectsâ&#x20AC;&#x2122; baseline diet. Study by Anderson et al. In 1971, the diet-acne relationship was further challenged by Anderson et al.13 University students (n=27) with a self-reported history of dietary acne triggers were asked to consume chocolate,

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016

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milk, roasted peanuts, or cola for one week under supervision. The study did not specify how many individuals were subdivided into each group. The researchers mapped acne lesions onto a sheet of paper before and after the study treatment. After one week, the participants did not show new flares of their acne leading to the conclusion that diet did not affect acne development. The study by Anderson had a small sample size, and the participants were subdivided into even smaller groups of unknown size making it very unlikely the study had adequate statistical power. There was no control group, randomisation or statistical analysis. The study was not blinded and no comparison was made with baseline dietary habits. These studies, even with their flaws, were sufficient to dissociate the diet and acne link.8 Textbooks were revised and little research was done in the area for many years.10 The link was re-visited around the turn of the 21st century due to increasing knowledge of acne pathogenesis, new epidemiological evidence, and a thorough critical analysis of old research. Observational data It has been noted that certain populations that follow a ‘huntergather’ type diet do not suffer with acne. A cross-sectional study in 2002 looked at 1,300 subjects from two non-Westernised societies – the Kitavan Islanders of Papua New Guinea and the Ache hunter-gatherers of Paraguay.14 These individuals underwent skin examinations by a doctor trained in diagnosing acne. No cases of acne were reported amongst this group. The researchers suggested that the absence of acne may have been a consequence of their diet. 14 Unfortunately, no control group was utilised, making it difficult to determine whether this finding was indeed due to diet or other factors such as the environment or genetics.14 Certainly, the findings may have carried more weight if the subjects were given diets rich in carbohydrates and dairy with subsequent acne development. There is also other epidemiological evidence reporting low acne prevalence amongst populations living in rural villages. Canadian Inuits,15 pre-World War II Okinawans,16 and Zulu17 populations have not traditionally suffered with acne. However, acne prevalence has increased after adopting a more Western diet of processed food, animal products and dairy.18-20

REFINED CARBOHYDRATE

HYPERINSULINAEMIA

IGFBP3

IGF-1

SREBPC1

ANDROGENS

SEBUM

ACNE Figure 1: Relationship between acne and refined carbohydrates

Aesthetics

Acne prevalence has increased after adopting a more Western diet of processed food, animal products and dairy Refined carbohydrates and acne Emerging evidence suggests that high glycaemic index diets may be associated with acne. The glycaemic index (GI) was developed in 1981 and is a relative comparison of the potential of various foods to increase blood glucose based on equal amounts of carbohydrates in the food.21-23 In 2007, a randomised control trial with 23 Australian males aged 15-25 years examined the impact of low GI diet on acne.24 Those randomised to the low glycaemic load diet had significant improvement in acne severity in addition to weight loss, decrease in free androgen level, and improved insulin sensitivity at 12 weeks. The study was small in size and it is uncertain if the findings can directly be extrapolated to females. In 2012, a 10-week randomised control trial was conducted on 32 Korean subjects aged 20-27 years.25 Those following the low GI diet had a statistical improvement in acne severity with no change in body weight. Histological examination was carried out and the researchers found sebaceous gland size and inflammatory cytokines were also decreased in the low GI diet group. Diets with a high GI index cause an increase in blood sugar levels. This results in high levels of insulin, which stimulates insulin like growth factor 1 (IGF-1), whilst simultaneously suppressing insulin growth factor binding protein 3 (IGFBP-3).26 IGF-1 promotes androgen bioavailability, which increase sebum production and secretion leading to acne development.26 IGF-1 also stimulates sebum production by increasing the expression of steroid response element-binding protein-1c (SREBP1c) in sebocytes.27 In addition, IGFBP-3 normally serves as an inhibitory molecule of IGF-1 and androgens. Insulin induced suppression of IGFBP-3 results in higher levels of insulin and androgens, further contributing to sebum synthesis (Figure 1).26,27 Dairy and acne The evidence linking dairy and acne is weaker than the refined carbohydrate link.10 To date, there has been no randomised controlled trial examining the role of dairy consumption and acne. There are, however, several observational studies that suggest that certain dairy products – skimmed milk in particular – may aggravate acne. A retrospective study from 2005 analysed self-reported data from more than 47,000 females asked to recall their high school diet.28 The study concluded that women who consumed at least two glasses of skimmed milk a day had a 44% increased risk of reporting acne. The study was heavily criticised for its design

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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If a patient feels there is an association between their diet and acne severity, they should be encouraged to keep a food diary for at least 12 weeks and the same research group conducted follow-up prospective trials. They found that acne was associated with the intake of milk – in particular, skimmed milk. Skimmed milk appears to be more comedogenic than full-fat milk. Hypotheses for this observation include differences in concentration of milk protein such as whey and casein.31-33 A Malaysian case control study in participants aged 18 to 30 years found that milk and ice-cream consumption was significantly higher in patients with acne compared to controls.29 In fact, subjects who consumed milk or ice-cream at least once a week were found to have a four-fold risk of having acne. Interestingly, there seemed to be no association with cheese or yoghurt. The proposed mechanism of action is similar between dairy and high GI foods. Dairy products may cause diet-induced hyperinsulinaemia and promote acne via the IGF-1 mediated pathway.8 Additionally, milk itself contains growth-stimulating hormones such as IGF-1, which remain high even after pasteurisation and digestion.30 Whey protein is rich in the aminoacid leucine, which may act via the mammalian target of rapamycin complex 1 (mTORC1) to induce cell growth, androgen secretion and sebum production.31-33 Where are we now? There is still a large void in our knowledge of the link between diet and acne. Whilst significant progress has been made in the past two decades re-examining the association, gaps in research remain. The most recent American Academy of Dermatology guidelines for managing acne state that, “Given current data, no specific dietary changes are recommended in the management of acne.”34 However, the same guideline recognises that there is emerging data in this area (strength of recommendation B, level of evidence II).

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Dr Anjali Mahto is a consultant dermatologist at the Cadogan Clinic in London. She is on the General Medical Council specialist register for dermatology and has a specialist interest in acne and aesthetics. Dr Mahto is trained to consult all skin, hair and nail problems in children and adults. REFERENCES 1. Tan J, Bhate K, A global perspective on the epidemiology of acne. Br J Dermatol 2015; 172:3-12. 2. Dalgard F, Gieler U, Holm U et al, ‘Self-esteem and body satisfaction amongst late adolescents with acne: results from a population survey,’ JAAD 2008; 59(5):746–751. 3. Williams HC, Dellavalle RP, Garner S. ‘Acne vulgaris,’ Lancet 2010; 379(9813):361-372. 4. Mallon E, Newton JN, Klassen A, et al., ‘The quality of life in acne: a comparison with general medical conditions using generic questionnaires,’ Br J Dermatol, 1999; 140(4):672-676. 5. Campbell G, ‘The relation of sugar intolerance to certain diseases of the skin,’ Br J Dermatol 1931; 43(6):297-304. 6. Robinson HM, ‘The acne problem,’ South Med J, 1949; 42(12):1050-1060. 7. Hubler WR, ‘Unsaturated fatty acids in acne,’AMA Arch Derm 1959;79(6):644-646. 8. Burris J, Reitkerk W, Woolf K, ‘Acne: The role of medical nutrition therapy,’ Jour Acad Nutr Diet, 2013; 113:416-430. 9. Fulton J, Plewig G, Kligman A, ‘Effect of chocolate on acne vulgaris,’ JAMA 1969; 210(11):2071-2074. 10. Bowe W, Joshi S, Shalita A, ‘Diet and acne,’ JAAD, 2010; 63: 12-141. 11. Treloar V, ‘Diet and acne redux,’ Arch Dermatol, 2003; 139:941-943. 12. Treloar V, ‘Comment on the commentary: diet and acne,’ JAAD, 2008; 59: 534-535. 13. Anderson PC, ‘Foods as the cause of acne,’ Am Fam Physician, 1971;3(3):102-103. 14. Cordain L, Lindeberg S, Hurtado M et al., ‘Acne vulgaris: a disease of Western civilization,’ Arch Dermatol, 2002;138:1584-90. 15. Shaefer O, ‘When the Eskimo comes to town,’ Nutrition today, 1971; 6(6):8-16 16. Steiner PE, ‘Necropsies on Okinawans: Anatomic and pathologic observationsm’ Arch Pathol 1946; 42(4):359-380. 17. Cunliffe WJ, Cotterill JA, ‘The acnes: clinical features, pathogenesis and treatment,’ Rook A, Major Problems in Dermatology, Philadelphia, PA: WB Saunders Co; 1975: 13-14. 18. Verhagen AR, Koten JW, Chaddah V et al., Skin diseases in Kenya, ‘A clinical and histopathological study of 3,168 patients,’ Arch Dermatol 1968; 98(6):577-586. 19. Ratnam AV, Jayaraju K, ‘Skin diseases in Zambia,’ Br J Dermatol, 1970;101(4):449-453. 20. Park RG, ‘The age distribution of common skin disorders in the Bantu of Pretoria, Transvaalm,’ Br J Dermatol, 1968; 80(11):758-761. 21. Attia N, Tamborlane W, Heptulla R et al. ‘The metabolic syndrome and insulin-like growth factor 1 regulation in adolescent obesity,’ J Clin Endocrinol Metab, 1998; 83: 1467-71. 22. Liu S, Willett WC, ‘Dietary glycaemic load and atherothrombotic risk,’ Curr Atheroscler Rep, 2002;4:454-61. 23. Brand-Miller J, Thomas M, Swan V et al., ‘Physiological validation of the concept of glycaemic load in lean young adultsm,’ J Nutr, 2003;133:2728-32. 24. Smith R, MannN, Braue A et al. ‘The effect of a high-protein, low glycaemic laod diet versus a convention, high glycaemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial,’ JAAD, 2007; 57:247-256. 25. Kwon H, Yoon J, Hong J et al., ‘Clinical and histological effect of low glycaemic load diet in treatment of acne in Korean patients: a randomized, controlled trial,’ Acta Derm Venereol, 2012; 92:241-246. 26. Melnik B, ‘Western diet –induced imbalances of FoxO1 and mTORC1 signalling promote the sebofollicular inflammasomopathy acne vulgaris,’ Exp Derm, 2016; 25:103-104. 27. Melnik B, ‘Linking diet to acne metabolomics, inflammation, and comedogenesis: an update,’ Clin Cosm Inves Derm, 2015; 8:371-388. 28. Adebamowo CA, Spiegelman D, Danby FW et al., ‘High school dietary dairy intake and teenage acne.’ JAAD 2005; 52: 207-214. 29. Ismail NH, Manaf ZA, Azizan NZ, ‘High glycaemic load diet, milk and ice cream are related to acne vulgaris in Malaysian young adults: a case control study,’ BMC Dermatol, 2012: 12:13. 30. Melnik BC, Schmitz G, ‘Role of insulin, insulin-like growth factor-1, hyperglycaemic food and milk consumption in the pathogenesis of acne vulgaris,’ Exp Dermatol, 2009; 18(10):833-841. 31. Hoppe C, Molgaard C, Michaelsen KF, ‘Cow’s milk and linear growth in industrialized and developing countries,’ Annu Rev Nutr, 2006;26:131-173. 32. Melnik BC, ‘Evidence for acne promoting effects of milk and other insulinotrophic dairy products,’ Nestle Nutr Workshop Ser Pediatr Program, 2011;67:131-145. 33. Melnik BC, ‘Dietary intervention in acne: attenuation of increased mTORC1 signaling promoted by Western diet,’ Dermatoendocrinol, 2012;1(4):20-32. 34. Guidelines of care for the management of acne vulgaris, JAAD 2016, Article in press.

What advice should we give our patients? As always, the most important thing for a healthcare practitioner is to listen to their patients. If a patient feels there is an association between their diet and acne severity, they should be encouraged to keep a food diary for at least 12 weeks. The idea that diet has a role to play should not be dismissed and an open discussion of where we are with the scientific literature should be had. Whilst acne should never be treated with diet alone as robust large, randomised, control trials remain lacking, it may provide an adjunctive measure to tried and tested validated treatments that already exist for this troublesome disease.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Spotlight On: earFold Following Allergan’s acquisition of the earFold device, Aesthetics investigates the efficacy of the implant and how it can be used in practice The standard surgical procedure for pinning back ears is said to have originated in the 5th century BC, when Ayurvedic physician Sushruta developed the first otoplastic techniques.1 Through the centuries the treatment and technique for surgically altering prominent ears has been refined and improved, but it has not been without its drawbacks and complications. Mr Norbert Kang, consultant plastic and reconstructive surgeon and inventor of the earFold device, for the use of surgeons, wanted to improve upon the standard treatments available for correcting prominence of the ear as he felt that these treatments can often cause problems, He explains, “When it comes to pinnaplasty procedures it’s like me saying to a patient with hip pain, ‘I can do your hip replacement, but you’re going to have to accept (up to) a 20% complication rate and there’s a one in five chance that you might need to go back to the operating table, and the outcome after that might still not be quite right but you’ll just have to accept it.’ That wouldn’t be acceptable for most surgical procedures but for many years, that’s what we’ve been expecting our patients with prominent ears to put up with.” In 1994, Mr Kang was part of a team carrying out a standard pinnaplasty operation on a teenage girl. She was due to be treated under local anaesthetic, but when she saw the needles and clinical setting she panicked and asked to be put under general

anaesthetic instead. With the backing of her parents, the team carried out the patient’s wishes, but sadly, once under the anaesthetic, she never woke up. It was this experience that spurred Mr Kang to create the earFold, a non-invasive device for the treatment of prominent ears “It’s one of the occasions that’s stuck in my mind,” said Mr Kang. “It wasn’t the ear pinning itself which was fatal, but just because she wanted her ears pinned back we gave her a procedure which carries with it a risk of death, due to the use of general anaesthetic. No one should die just because they are bothered by how they look.” Consultant plastic surgeon Mr Nilesh Sojitra, who has been trained by Mr Kang on using the earFold, explains that the ‘device started off as a coat hanger which Mr Kang created in his garage’. “He started off by bending the cartilage and putting stitches in the ear to correct the prominence, and then he thought, if there was something he could make, that would do the same job, then why not?” Mr Kang explains, “I was presented with a problem and thought, ‘how can I solve it?’ so I brought together lots of different strands of information I had and put them together in one place.” How it works The procedure for earFold, which is suitable for adults and children above the age of seven, works by folding back the ear through the insertion of a small implant made of nitinol metal alloy. Nitinol belongs

to a class of materials called Shape Memory Alloys (SMA) and these alloys can be made to remember a particular shape; hence, the earFold implant has been designed to a pre-set shape, and when released, the implant grips the cartilage and folds the ear into the desired new shape. The implant is also coated in 24-carat gold to reduce its visibility through the skin. Most patients will require one or two implants, depending on the look they wish to achieve. The implants are permanent fixtures and are designed to be completely biocompatible in the patient’s ear, although Mr Sojitra explains that some patients who have had the implant removed for medical or other reasons have still retained some of the results. For instance, one woman who started a chemotherapy treatment for cancer decided to have the implants removed, yet still retained some of the shape. The consultation: preFold During the consultation the patient and surgeon can decide together on the best position for the implant to achieve the desired outcome. Unlike consultations for a pinnaplasty procedure, practitioners can demonstrate the outcome to patients by using the preFold positioning tool. The positioning tools are made out of the same nitinol material as the implant and are placed on the ear using clear, self-adhesive strips, but can be moved to any position on the ear until the patient is satisfied with the location and how they look. This allows the surgeon to show the patient almost exactly what the ear will look like once the implants are in place. Dr Sojitra explains, “When you see patients for a pinnaplasty they ask questions such as, ‘How far back will they go? Will it look fake? Will they look stuck to my head?’ but using the preFold can give them a really good idea of how it will almost exactly look.”

Figure 1: The preFold device being used on Patient A

Once the patient is happy, the position of the implant is then marked on the skin with a marker pen. This initial assessment will then be repeated on the day of surgery to confirm the desired correction.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Pilot study A study led by Mr Kang, which was published in The American Society for Aesthetic Plastic Surgery,2 examined the safety and behaviour of the implant in vivo. The nonrandomised study recruited 39 patients, of which 22 were adults and 17 were children, ranging from ages seven to 57. From that, 37 patients were followed for a minimum of 18 months. Eighteen patients asked for their implants to be left in place permanently and 27 patients agreed to have their implants removed at six, 12 or 18 months after insertion, to see whether the implants had a permanent moulding effect on the cartilage. Complications affected eight patients and included extrusion, infection, hypertrophic scarring, and ‘Spock-ear’ formation. No new complications have been reported since the conclusion of the study. Patients were described as being ‘overwhelmingly satisfied’ with the outcome of the treatment.

Before

After

Figure 2: Patient A before and after treatment with the earFold device

The procedure On the day of the procedure, the patient’s ear(s) is cleaned with an antiseptic solution and a drape is placed over the ear to create a sterile operating area. A local anaesthetic injection is then used to numb the ear. Once the skin is numb, a small incision is made, around 10mm in length, and the skin is lifted away from the cartilage to create a tunnel, which creates space for the introducer. The introducer is then used to position the implant and release it. Once the implant is released and in place, it adopts its predetermined curve, which folds back the ear cartilage to reduce the prominence of the ear, thereby creating or enhancing the natural shape of the antihelical fold. The incision is then closed with two or three dissolvable stitches and simple adhesive dressings are applied. “Once we’ve done the treatment, so many patients are reduced to tears,” explains Mr Sojitra. “They don’t have to wait for a week for the bandage to come down like they would after surgery. Of course, there is some bruising and swelling as it settles down, but there is with most procedures.” He adds, “It’s a process that takes only five minutes per ear if you exclude the planning. I used the earFold to treat someone recently who had a wedding at the end of the month, if it was a

standard procedure, she wouldn’t have been able to have her ears corrected in time.” Possible complications Mr Sojitra explains, “You don’t have any of the risks that are associated with general anaesthetic, which can be the biggest drawbacks when it comes to traditional surgery. The patient will only have a very small scar in the front of the ear, instead of a long scar at the back of the ear; which has the associated risk of keloid scarring that can be devastating for the patient. Since we started using the earFold, we haven’t seen any keloid scarring in the 3,000 implants we have done so far.” The patient is likely to experience some discomfort once the local anaesthetic wears off and this may continue for a couple of days. Patients are advised to take painkillers if they feel any pain. Bruising and swelling should also be expected but should settle in seven days. Some sensitivity may be felt for up to 12 weeks post surgery. Surgical correction of prominent ears carries a 24.4% chance of recurrence;3 surgeons using earFold implants have reported a 0% recurrence rate to date, according to unpublished data studying 403 patients. Mr Sojitra said, “The problem with the surgery is that the stitches can slip, loosen or snap and the ear could get pulled; that’s why patients

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must avoid contact sports for at least three months. Patients also need to wear a ‘tennis band’ at night for at least three months, but even so, the ear could pop-out at anytime. The bonus with the implants is that once that clip is on the ear, there is no chance of recurrence.” Infection can be a complicating factor but patients are now given antibiotics before the procedure, which has decreased the amount of instances to virtually zero. “There were also some early cases where the implant had eroded through to the skin, but this was more-so in patients who had risk factors, such as heavy smokers,” explained Mr Sojita. “A lot of the problems, in general, have been put down to a learning curve; we’ve learnt a lot from the first 15/20 patients that were treated. For instance, there was originally issues with seeing the implant under the skin, so then we plated it in 24-carat gold which seems to have resolved the problem.” Conclusion The earFold potentially presents a revolutionary and less invasive alternative to traditional ear correction, with more studies being carried out to improve the current method. Mr Kang says, “We’re currently doing clinical studies that look at patient satisfaction and how we can refine what we’re doing; looking at the aesthetic outcomes as well as the safety. I think the biggest hurdle is getting people to understand from a technical aspect how it works and then to use it judiciously in a careful and considerate manner.” He concludes, “We’re pretty confident we can correct ear prominence, we’re pretty confident we can do it safely, but it’s a different thing to say we can do both of those things and still make the ears look beautiful. So that’s what we will continue to work on.” Before surgeons can use earFold they must attend a vigorous training programme with the Allergan Medical Institute, which involves a half-day of presentations on the earFold procedure, practical sessions on using preFold, and applying earFold to silicone ears (and sheep’s ears) as well as sitting in on a live procedure with an earFold expert, such as Mr Kang. Training is now taking place for plastic, ENT and maxillofacial surgeons wanting to use the device in practice. References 1. Rinzler, CA, The Encyclopedia of Cosmetic and Plastic Surgery. (2009). New York City: Facts on File 2. Kang NV, Kerstein, Treatment of Prominent Ears with an Implantable Clip System: A Pilot Study, The American Society for Aesthetic Plastic Surgery (2016) <http://www.ncbi.nlm.nih.gov/ pubmed/26673575> 3. Andjelkov K, Sforza M, Zaccheddu R, Lazović G, Colić M, No recurrence in otoplasty: is this possible? Journal of the Serbian Medical Society, (2010) <http://www.ncbi.nlm.nih.gov/ pubmed/21179908>

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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*stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 2. Ulthera System Instructions for Use, 1001393IFU Rev H 3. Lee HS, et al. Dermatol Surg. 2011;1-8 4. Data on File: ULT-DOF-008 – Ultherapy Mechanism of Action White Paper 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 7. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 8. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed May 2016 9. CE Certificate 3808396CE01, DEKRA April 2012 Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

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Aesthetics Journal

Melasma: A Brief Overview of Classification and Treatment Modalities Dr Maryam Zamani highlights the different forms of melasma and the variety of treatment options currently available Facial pigmentation is cosmetically important and can have considerable psychological impact. Melasma is a commonly acquired hypermelanosis of the skin characterised by browngrey patches predominately found on sun-exposed areas of skin.1 Melasma is also the most common cause of facial pigmentation2 and is a cutaneous disorder affecting all races with particular prominence in darker skinned individuals (Fitzpatrick skin types IV to VI) such as Hispanic and Asian ethnicities.1,3 Women are predominately affected with a 90% predisposition to men, but the reason for this is currently unclear.27 While the pathogenesis of melasma is not known, there are multiple factors that can influence its presence such as hormones, genes and UV radiation; exacerbation of melasma is inevitable after prolonged sun exposure.2 Pregnancy, oral contraceptives, oestrogen/ progesterone therapies, photosensitising and anticonvulsant medication, thyroid dysfunction, cosmetics and some drugs can also influence melasma.1,2,4 Some studies have indicated that higher levels of oestrogen receptor expression were found in affected skin in women on the oral contraceptive pill.28 Melasma results from the increased deposition of melanin in the epidermis, in the dermis within melanophages, or both.5 One hypothesis is that a significant portion of melasma patients have an underlying hyper vascularity contributing to melanocyte dysfunction.6 Categorising melasma There are three clinical patterns of melasma: centrofacial pattern, malar pattern and the mandibular pattern. The centrofacial pattern is the most common and affects the forehead, cheeks, upper lip, nose and chin. The malar pattern affects the cheeks and nose, and the mandibular pattern involves the ramus of the mandible.1 It is not known why these patterns occur.   Historically, the Wood’s lamp examination can be used to further differentiate melasma into four histological types depending on the depth of pigment deposition:1,7 The Wood’s lamp is a dermatologic tool whereby ultraviolet light is shone onto the skin in a dark room to observe fluorescence. It can be used for a number of skin problems including melasma. 1. Epidermal melasma: this is the most common form of melasma and is characterised by increased melanin in the epidermal layers whereby the pigmentation intensifies under the Wood’s light. 

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2. Dermal melasma: this has melanophages throughout the dermis and does not intensify under the Wood’s light.1,8  3. Mixed type melasma: this has a combination of epidermal and dermal pigmentation.  4. Indeterminate type melasma: this is where the pigment is apparent in the Wood’s light in skin types VI.9  Melasma may also be classified as transient and persistent types. The transient type disappears within one year of cessation of hormonal stimuli like pregnancy or oral contraceptive pills while the persistent type continues to persevere more than a year after the hormonal stimuli has been removed.5  

Treatment options Because of the dermal involvement of hypermelanosis, melasma is often difficult to treat and relapses after treatment is discontinued. This recurrence can happen immediately or over the course of a year. All patients with melasma should be counselled about the natural course of the disease and the necessity for longterm management.5 Careful history about precipitating factors should be taken with discontinuation of aggravating agents such as medications, contraceptives and UV exposure. Treatment goals for melasma are the suppression of melanogenesis and the removal of excess melanin present in the epidermis and dermis.10 The use of broad spectrum UVA and UVB sunscreen is imperative to melasma sufferers to help prevent further pigment stimulation. Epidermal pigmentation can often be removed with various chemical exfoliation techniques as long as melanin production is also simultaneously suppressed. The greater challenge is the treatment of dermal melanin.  Topical medications modify various stages of melanogenesis, with the most common mode of action being inhibition of the enzyme tyrosinase.5 Lightening agents such as hydroquinone, tretinoin, azelaic acid and corticosteroids can be used alone or in combination to have a synergistic efficacy on hyperpigmentation.11 Topical hydroquinone 2-4% in combination with tretinoin 0.05 to 0.1% has been an established treatment protocol.2 Despite controversies regarding hydroquinone-induced ochronosis, hydroquinone remains the most effective topically applied bleaching agent approved by the FDA.4 Depigmentation becomes evident only after five to seven weeks of therapy and should be continued for a minimum of three months, and often for up to one year.5 Irritation is the most common complication. Tretinoin promotes the rapid loss of pigment through epidermopoiesis and increased epidermal turnover.12 Right cheek before Right cheek after However, clinically significant lightening only becomes apparent after 24 weeks and has common side effects like Left cheek before Left cheek after burning, dryness, scaling and erythema. Sunscreen is advised during treatment. Topical steroids Figure 1: Image shows patient with melasma in combination with other on the cheeks, before and three months after a therapies has a synergistic skin peel treatment and maintenance skincare

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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effect and helps to reduce irritation from tretinoin.5 Topical azelaic acid 15-20% can be as effective, and one study indicated it was more successful than monotheraphy with After hydroquinone but without the same irritation to the skin.13 Inhabitation of tyrosinase is key and topical azelaic acid has Figure 2: Patient with melasma no depigmentation effect on on the cheeks, before and three normally pigmented skin because months after a skin peel treatment it selectively affects abnormal and maintenance skincare melanocytes.5,14 Kojic acid alone or in combination with glycolic acid or hydroquinone has also shown good results.2 Kojic acid, used in concentrations of 1-4%, is a potent antioxidant that also inhibits the production of freetyrosinase thereby inhibiting melanogenesis.15 Glycolic acid is an alpha hydroxy acid that has skin lightening properties when used in a 5 to 10% concentration. It directly reduces melanin formation by tyrosinase inhibition but should be used cautiously because of the risk of inducing hyperpigmentation from excessive skin irritation.10,16,17 Mequinol, N-acetyl-4-cysteaminylphenol, and arbutin are other hydoquinone deriviatives that have also been used successfully in the treatment of hyperpigmented disorders. Other new and experimental agents including ascorbic acid, niacinamide, liquorice derivatives, and flavonoids have been used to affect melanin pigmentation.5  Trichloroacetic acid, Jessner’s solution, alpha-hydroxy acid preparations, kojic acid alone or in combination also show good results by reducing hyperpigmentation and recurrences.2 Peels are best used in conjunction with a topical pigment suppressing preparation. Various combinations of topical agents have been studied. The most widely used and extensively studied combination therapy is a formulation with hydroquinone, retinoic acid and corticosteroids.18 Clinical studies indicate improved outcomes with triple combination therapy compared to 4% hydroquinone alone.10 Laser and IPL treatments Laser treatments and intense pulse light (IPL) therapy are other modalities that are used to help improve hyperpigmentation with varying success.2 Treatment with high energy pigment specific lasers, ablative laser resurfacing and fractional lasers can result in high rates of post inflammatory hyper and hypopigmentation with significant rebound melasma.10 Q-switched lasers can target melanosomes without damaging surrounding tissue structures. Its high pressure acoustic wave leads to melanocyte death but has a high incidence of hyperpigmentation, hypopigmentation and rebound melasma.10,19,20,21  IPL has also been used to treat melasma; however it is not possible to target dermal melanosomes with IPL. Consequently, IPL will produce transient improvement in epidermal pigmentation but not dermal pigmentation and may induce post inflammatory hyperpigmention.10,22,23 Similarly, ablative resurfacing lasers and fractional resurfacing lasers showed early promise in treating melasma but long-term follow-up studies have suggested that there is a high incidence of rebound melasma and post inflammatory hyperpigmentation.10 Kauvar studied combination microdermabrasion with low-fluence QS laser in conjunction with hydroquinone-based skincare with refractory melasma, with 80% of patients maintaining melasma clearance for up to 12 months.10, 24

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Conclusion Melasma is a common, chronic hyperpigmentation disorder with significant negative psychological consequences. While there is a plethora of therapeutic options, treatment is often challenging, requiring long-term therapy with no specific, effective, universal treatment.25 In my experience triple therapy using hydroquinone, tretinoin and topical steroids is most effective in improving melasma long term. However patients should be made aware that results are often unsatisfactory, with frequent remissions and rebound hyperpigmenation. One of the main obstacles to developing an effective therapy is the limited ability to destroy dermal melanosomes without producing inflammation that could exacerbate the melasma.4,10 Dr Maryam Zamani is a board certified ophthalmologist with experience in oculoplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine, US, and has worked at Cardiff University in facial aesthetics. REFERENCES: 1. Achar A, Rathi  SK,  Melasma: A clinic-epidemiological study of 312 cases, Indian Journal of Dermatology, (2011) Jul-Aug; 56: 380-382. 2. Perez-Bernal A, Munoz-Perez MA, Camacho F, Management of Facial Hyperpigmentation, American Journal of Clinical Dermatology, (2000) Sept-Oct; 1(5): 261-8. 3. Mosher DB, Fitzpartick TB, Ortonne JP, Hypomelanoses and hypermelanoses, Freedburg IM, Eisen AZ, Woeff K, Editors. Dermatology in General Medicine, 5th ed, New York: McGraw-Hill; (1999) pp. 945–1016. 4. Grimes PE, Melasma: etiologic and therapeutic considerations, Archives of Dermatology, (1995) 131:1453–7. 5. Bandyopadhyay D, Indian Journal of Dermatology, (2009) Oct-Dec; 54(4): 303-309. 6. Wu DC, Fitzpatrick RE, Goldman MP, Confetti-like sparing: a Diagnostic Clinical Feature of Melasma, Journal of Clinical Aesthetic Dermatology, (2016) Feb; 9(2): 48-57. 7. Lapeere H, Boone B, Schepper SD, Hypomelanosis and hypermelanosis, Wolff K, Goldsmith LA, Katz SI, Editors, Dermatology in General Medicine, 7th ed, New York: McGraw-Hill (2008) p. 635. 8. Sivayathorn A, Melasma in Orientals, Clinical Drug Investigation, (1995) 10(Suppl 2):24–40. Q. 9. Pregnano F, Ortonne JP, Buggiani G, Lotti T, Therapeutic approach in melasma. Dermatology Clinics, (2007) 25:337-42.  10. Kauvar AN, The evolution of melasma therapy: targeting melanosomes using low-fluence Q-switched neodymium-doped yttrium aluminium garnet lasers, Seminars in Cutaneous Medicine and Surgery Journal, (2012) 31:126–132. 11. Gupta AK, Gover MD, Nouri K, Taylor S, The Treatment of Melasma: a review of clinical trials. Journal of the American Academy of Dermatology (2006) 55 (6): 1048-1065. 12. Rigopoulos D, Gregoriou S, Katsambas A, Hyperpigmentation and melasma, Journal of Cosmetic Dermatology, (2007) 6:195–202. 13. Verallo-Rowell VM, Verallo V, Graupe K, Lopez-Villafuerte L, Garcia-Lopez M, Double-blind comparison of azelaic acid and hydroquinone in the treatment of melisma, Acta DermatoVenereologica, (1989) 143:58–61. Suppl (Stockholm). 14. Halder RM, Richards GM, Topical agents used in the management of hyperpigmentation, Skin Therapy Letter, (2004) 9:1-3. 15. Kahn V, Effect of kojic acid on the oxidation of KL-DOPA, Norepinephrine and dopamine by mushroom tyrosinase, Pigment Cell & Melanoma Research, (1995) 8:234-40. 16. Sarkar R, Kaur C, Bhalla M, et al, The combination of glycolic acid peels with a topical regimen in the treatment of melasma in dark-skinned patients: A comparative study, Dermatologic Surgery, (2002) 28:828-832. 17. Usuki A, Ohashi A, Sato H, Ochiai Y, Ichihashi M, Funasaka Y, The inhibitory effect of glycolic acid and lactic acid on melanin synthesis in melanoma cells, Experimental Dermatology, (2003) 12:43-50. 18. Kligman AM, Willis I, A new formula for depigmenting human skin, Achieve Dermatology, (1975) 111:40-8. 19. Grekin RC, Shelton RM, Geisse JK, et al, 510-nm pigmented lesion dye laser, Its characteristics and clinical uses, Journal of Dermatologic Surgery and Oncology, (1993) 19: 380-387. 20. Taylor CR, Anderson RR, Ineffective treatment of refractory melasma and postinflammatory hyperpigmentation by Q-switched ruby laser, Journal of Dermatologic Surgery and Oncology, (1994) 20:592-597. 21. Kopera D, Hohenleutner U: Ruby laser treatment of melasma and post inflammatory hyperpigmentation, Dermatologic Surgery, (1995) 21:994. 22. Li YH, Chen JZ, Wei HC, et al, Efficacy and safety of intense pulsed light in treatment of melasma in Chinese patients, Dermatologic Surgery, (2008) 34:693-701. 23. Wang CC, Hui CY, Sue YM, et al, Intense pulsed light for the treatment of refractory melasma in Asian persons, Dermatologic Surgery, (2004) 30:1196-1200. 24. Kauvar AN, Successful treatment of melasma using a combination of microdermabrasion and Q-switched Nd: YAG lasers, Lasers in Surgery and Medicine, (2012) 44:117-124. 25. Cayce KA, McMichael AJ, Feldman SR, Hyperpigmentation: an overview of the common afflictions, Journal of the Dermatology Nurses’ Association, (2004) Oct; 16(5): 401-6, 413-6; quiz 417. 26. Stratigos AJ, Dover JS, Arndt KA, Lasers and aesthetic dermatology [in German]. Hautarzt 54:603613, 2003 27. Kristlova. H, Melasma in Men, Journal of Pigmentary Disorders, Mini Review, (2014) Supplement 28. Susan Stevenson & Julie Thornton, Effect of estrogens on skin aging and the potential role of SERMs, Journal of Clinical Interventions in Aging (2007) <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2685269/>

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Advertorial SkinCeuticals

SkinCeuticals – The Perfect Partner for Your Aesthetic Practice Great aesthetic results rely on sophisticated combinations of treatments and advanced skincare. Here, Linda Blahr - SkinCeuticals’ Education & Science Manager - introduces one of their core protocols and how it can complement and enhance your practice. The SkinCeuticals philosophy is about achieving the best possible patient results by combining stateof-the-art clinical protocols, professional treatments and advanced homecare. Our integrated skincare programme is built around clinical procedures, intended for use both before, during and after

IN DEPTH: SkinCeuticals Microneedling Protocol This treatment is designed to complement in-clinic microneedling therapies, and is customizable according to the treatment objective. Due to the skin-sensitizing nature of these treatments, this treatment should be performed at the practitioner’s discretion only. Step 1: CLEANSE SkinCeuticals Product: SIMPLY CLEAN Cleanse skin thoroughly using one pump of cleanser. Remove gently with warm water. Step 2: DEGREASE Saturate two 4x4 rough gauze pads with degreasing solution (alcohol or medical acetone) and degrease the entire face. Applying firm pressure, degrease the skin beginning at the forehead and work down to the chin. Ensure skin is dry before initiating the microneedling treatment. Step 3: TREAT SkinCeuticals Product: HYDRATING B5 Starting with the forehead, apply 2-3 drops of Hydrating B5, then microneedle the area. More drops can be applied if needed to

KEY BENEFITS: • By combining Hydrating B5 during the microneedling process, the hyaluronic acid will be introduced through the skin barrier where it can instantly work to improve hydration, elasticity and firmness • Immediate post-procedure application of

in-clinic treatments to help maintain and complement results. In recent years, microneedling has enjoyed a surge in popularity and is now one of the most popular aesthetic treatments on the market. However, aside from fears of a painful procedure - the top patient concerns revolve around the after-effects: will there be redness, bruising or swelling? How quickly can I return to work or social engagement? How long is the downtime? These are major considerations which can block patients from making a treatment decision, but you can help them overcome this by using an integrated protocol of SkinCeuticals products before, during and after the procedure to maximise the efficacy and minimise those unwanted side-effects.

provide additional slip and glide. Move to the cheek and apply 2-3 drops of Hydrating B5, then start the microneedling process. Continue with the chin, followed by the nose, and then the other cheek, each time applying 2-3 drops of Hydrating B5 before starting the needling process. Step 4: REMOVE Gently remove blood with antiseptic. Alternatively, to gently remove the pin point bleeding after the microneedling, apply Hydrating B5 Masque for 2 minutes and remove it with soft gauzes afterwards. In addition, this unique gel masque will cool & moisturise the treated areas and support a comfortable skin sensation after the needling. Step 5: PREVENT SkinCeuticals Product: C E FERULIC® Apply 3-5 drops to the treated area. Step 6: SOOTHE SkinCeuticals Product: Phyto Corrective Apply 3-5 drops to the face, neck, and chest. Step 7: PROTECT SkinCeuticals Product: Mineral Radiance UV Defense SPF50 or Mineral Matte UV Defense SPF30. Apply liberally to face, neck, and chest.

C E Ferulic® helps to reinforce the skin’s protection against damaging free radicals • Phyto Corrective is a light, oil-free serum with botanical extracts which helps to soothe and calm irritated skin – vital for minimising that post-procedure redness and potential downtime

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the national health system. As a plastic surgeon I specialise in corrective breast surgery and almost every day I witness first-hand how this type of surgery improves the psychological and often physical health of my patients. This improvement has also been reported in scientific studies.2

What conditions and operations does cosmetic surgery encompass? 

Breast Surgery Mr Adrian Richards details the different types of breast surgery procedures and demonstrates treatment outcomes with patient case studies This article will provide an overview of the different types of breast surgery and the reasons why patients seek these. Although this topic is most relevant to cosmetic surgeons, it is also useful for nonsurgical aesthetic practitioners who may discuss initial concerns with an existing patient and will therefore be able to give them a brief introduction of information before referring to a surgical colleague.

What is cosmetic breast surgery?       The Cambridge English dictionary defines cosmetic surgery as ‘any medical operation that is intended to improve a person’s appearance rather than their health.’1 But some questions to consider are: does this include psychological as well as physical health? Would breast reconstruction following a double mastectomy improve a patient’s psychological health? And, should the NHS fund this surgery?   Looking at Figure 1, would surgery for the patient with breast asymmetry improve her psychological health? Should the NHS fund surgery to reduce the size of larger breasts causing back and shoulder symptoms (Figure 2)? Why in most regions is breast reconstruction after mastectomy funded by the NHS but surgery for breast asymmetry, tuberous breast deformities (Figure 3) and debilitating large breasts often not funded? In my opinion there is a strong argument for selected cases being performed within

Figure 1: Breast asymmetry

Firstly, although breast reconstruction is essentially a cosmetic procedure it is classified as reconstructive rather than cosmetic so will be excluded from this discussion.  The main procedures are: breast enlargement, breast reduction, breast uplift, breast uplift with enlargement, removal of breast implants, removal of breast implants with an uplift, exchange of breast implants, areolar reduction, inverted nipple correction, nipple reduction and correction of the male breast (gynaecomastia). These operations occupy more than 80% of my working hours.  Breast enlargement  The most common procedure is breast enlargement with more than 30,000 cases per year in the UK.6 In the US it is estimated that 4% of women have breast implants.3 In the UK there is no official data but an estimated 600,000 women have had breast implant surgery. This an estimate figure,11 which assumes 30,000 UK women have had implants each year for the past 30 years. This puts the UK at number nine in the list of countries with the most breast implants per capita.4  What does breast implant surgery involve?  Surgery has become more refined; recovery time is quicker and the latest sixth generation silicone implants are available in a wide variety of shapes and sizes to suit all physiques. In most cases surgery is performed as a day procedure and patients are back to work within a week. 3D scanning is an exciting recent development that allows people to see how they would look with a variety of implants following surgery. In my practice all patients undergo a 3D scan. This measures Figure 4: 3D chest scan showing appearance with a and assesses their variety of implants chest wall and breast tissue and suggests an optimum implant for them. They can then see their chest in 3D with various sizes and shapes of implants (Figure 4). Our patients then try the implants in specially designed bras under their own clothing to help them determine the ideal implant for their

Figure 2: Breast hypertrophy and asymmetry

Figure 3: Tuberous breast deformity 

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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physique and lifestyle. Following surgery patients can exercise normally, breastfeed, have mammograms and in the majority of cases do not lose nipple sensitivity. The ability to breastfeed is preserved because the implants are placed behind the breast tissue and the connection between the breast glands, which produce milk, and the nipple is preserved. Nipple sensation is reduced in approximately 5% of women following breast enlargement.12 Loss of sensation depends on the route the nerves (that supply sensation to the nipple) travel, from the chest wall, and this cannot be predicted. During the operation I will often see these nerves and make every effort to preserve them. Breast reduction  This operation is one of the most satisfying procedures for both patient and surgeon and few patients regret having it performed. Symptoms from a large bust include: back and neck ache, poor posture, intertrigo (skin infection where the breast lies against the upper abdomen), difficulty in finding clothes that fit, and exercise difficulty.  In my practice, surgery is performed as a day case or with an overnight stay, with the use of absorbable stiches that do not need to be removed. Some patients prefer to stay overnight in an hospital environment and this can be arranged. Modern surgical techniques involve much less blood loss and bruising than they did previously. This means that it is very unusual to have any bruising following surgery. Breast uplift surgery (mastopexy)  This operation is similar to a breast reduction in that the nipples are lifted and reduced in size and the breast skin tightened. In a reduction, breast tissue is removed whereas in an uplift only skin is removed and the breast tissue preserved and re-shaped. Breast uplift with enlargement  This is one of the most challenging procedures for a breast surgeon and the one with most litigation associated with it. Why? The problem is that the surgeon is both trying to reduce and tighten the breast tissue and skin whilst stretching it with an implant.  It can be performed as either a one or two stage procedure. The

Figure 5: Before and after breast uplift

Figure 6: Before and after breast uplift with enlargement

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Breast reduction is one of the most satisfying procedures for both patient and surgeon and few patients regret having it performed benefits of a one stage procedure are a single operation and recovery; the down sides are limited size of implants, a higher revision rate, an increased risk of complications and arguably a worse cosmetic result. For this reason many surgeons prefer to perform a two stage procedure with the uplift performed first followed by an implant three to four months later.  Removal of breast implants  Within the region of 600,000 women in the UK who have breast implants, each implant has an average lifespan of 15 years, so removal of the implants is becoming more of an issue.  Whilst implants do not need to be removed at 15 years, many manufacturers recommend that they are. In addition, most women develop more natural breast tissue as they age and this combined with implants can make them feel too busty and matronly. For this reason many women decide to have their implants removed.  The good news is that the breast skin shows a remarkable ability to retract naturally when the implants are removed. Skin, by its nature, is stretchy and expands as we grow and put on weight and contracts as less stretch is put on it.  In most cases, when breast implants are removed, the breasts return, within months, to a similar appearance as prior to surgery. In some cases there is excess skin and a low nipple position, thus a breast uplift is needed at the time of the breast implant removal.  Exchange of breast implants  As many implants are now reaching recommended time for removal, many women are electing to have their implants exchanged. This reached a peak in 2012 with the PIP crisis.7   The crisis occurred when inspections revealed that the implants, created by French company Poly Implant Prothese (PIP), were composed of sub-standard, often non-medical grade industrial components. It is not known exactly how many women in the UK received these implants, as at that stage, there was no compulsory implant registry.  I personally operated on more than 350 women following the crisis, removing a wide variety of defective implants. Many of the women had systemic symptoms from the ruptured implants. On the Aurora clinics YouTube channel we have videos showing how the implants looked on removal. Many UK women are still unaware they have PIP implants or have decided not to have them exchanged. 

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Areolar reduction  The areolar is the brown area around the nipple. The average diameter of a normal areolar is 4-4.5cm.8 Many women feel their areolas are too wide, too low or of an abnormal shape.  In most cases surgery is performed under a local anesthetic with patients awake. In some cases a permanent stich is inserted to hold the areolar in its narrowed size and shape following surgery. 

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Before

Aesthetics aestheticsjournal.com After

Figure 7: Before and after breast implant removal Before

After

Inverted nipple correction  Approximately 10% of women in the UK have inverted nipples.5 This can be embarrassing and cause difficulty breast-feeding. The condition can Figure 8: Before and after areolar reduction also affect men. In most cases nipple inversion Before After develops in puberty as the breast develops and remains throughout adult life. If nipple inversion occurs later in life it can be a sign of underlying breast pathology and possible cancer. If this occurs, it is important to exclude cancer and we would advise the patient to visit their GP before any further action is taken.  We have developed a procedure performed Figure 9: Before and after correction of an enlarged bifid nipple under local anesthetic to reliably and permanently correct inverted nipples. In the majority of cases nipple sensation is Summary    preserved but the ability to breastfeed is not; this is because the milk In my career I have focused on bowel, hand, burn and cancer ducts are divided during the operation. Tight, shortened milk ducts surgery, but I can honestly say that breast surgery has proved are the cause of inverted nipples as they tether the nipple inwards. the most rewarding. For a surgeon, it combines artistry with technical ability; for a patient it can make real and longstanding Nipple reduction  improvements to their mental and physical health. In addition, Enlarged protuberant nipples can cause embarrassment for women technical advances in surgical technique, implant quality, and and men alike. Typically, people with this condition will avoid activities patient education systems such as the 3D scanner, continue to in which they show their chest and tight clothing. Correction is again push the speciality forwards. I would like the take home message performed under local anesthetic with minimal downtime.  from this article to be that breast surgery treats real functional and psychological problems. It provides a long-term solution to these Gynacomastia  and is a rewarding speciality for surgeon and patient alike.  This is a common disorder of the endocrine system and affects up to Mr Adrian Richards is a consultant plastic and cosmetic 70% of adolescent boys.9 Fortunately 75% of cases resolve within two surgeon and clinical director of both Aurora Clinics and 10 years of development without treatment. Cosmetic Courses. In 2015 Mr Richards was named in world’s Top 500 Most Influential Cosmetic Doctors by I do not specialise in the treatment of gynaecomastia but several international cosmetic surgery website RealSelf. surgeons within our group do. For mild cases without significant skin excess Vaser liposuction has proved extremely effective.  REFERENCES   For more severe cases with skin excess as well as breast enlargement 1. Cambridge Dictionaries Online, Cosmetic surgery, (2016) <http://dictionary.cambridge.org/dictionary/ english/cosmetic-surgery> surgical excision is often required. Unlike Vaser liposuction this has the 2. Rick Nauert, Psychology of Plastic Surgery, PsychCentral, (2016) <http://psychcentral.com/ news/2013/03/12/psychology-of-plastic-surgery/52507.html> down-side of involving some scarring on the chest skin. 

I would like the take home message from this article to be that breast surgery treats real functional and psychological problems

3. Mona Chalabi, Dear Mona, What Percentage of Women Have Breast Implants, FiveThirtyEight, (2014) <http://fivethirtyeight.com/datalab/dear-mona-what-percentage-of-women-have-breast-implants/> 4. Rebecca Hafer, Top 10 Countries With The Most Breast Implants, The Richest, (2014) <http://www. therichest.com/expensive-lifestyle/celebrity-beauty-2/top-10-countries-with-the-most-breastimplants/?view=all> 5. Steven Goodman, Inverted Nipples, Embarrassing Issues (2016) <http://www.embarrassingissues. co.uk/InvertedNipples.html> 6. Clinic Compare, Breast Augmentation Surgery, (2015) <http://breastimplants.cliniccompare.co.uk> 7. Fergus Walsh, PIP breast implants: ‘serious lessons must be leanred’, BBC News, (2012) <http://www. bbc.co.uk/news/health-18057761> 8. Ross Farhadieh, Neil Bulstrode, Sabrina Cugno, Gynaecomastia and tuberous breast, Plastic and Reconstructive Surgery: Approaches and Techniques (2015) p.526 9. Antony Zehetner, Tamoxifen to treat male pubertal gynaecomastia, International Journal of Pediatrics and Adolescent Medicine (2015) pp.152-156 10. Shulman, DI; Francis, GL; Palmert, MR; Eugster, EA; Lawson Wilkins, Pediatric Endocrine Society Drug and Therapeutics Committee, Use of aromatase inhibitors in children and adolescents with disorders of growth and adolescent development, (2008), Pediatrics 11. Esther Addley, ‘These are just ordinary women’ – how breast surgery hs soared in the UK, The Guardian, (2011) http://www.theguardian.com/society/2011/dec/21/british-women-breast-surgery-rising 12. Nancy Bruning, Effects of Implants on Nearby Tissue, Breast implants: Everything you need to know (2002), Hunter House: Alameda

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Combining HA with Sodium Succinate Dr Reza Mia discusses the benefits and presents a case study on the outcomes of using hyaluronic acid with sodium succinate As most aesthetic practitioners are aware, injecting hyaluronic acid (HA) into the skin stimulates the restoration of the dermis by increasing the amount of collagen â&#x20AC;&#x201C; through fibroblast stimulation â&#x20AC;&#x201C; in the skin, which promotes improved water retention to volumise the skin at various levels.1 HA is made up of repeating disaccharide units and is part of the family of glycosaminoglycans.2 HA also directly attracts water into the skin to further increase skin turgor and hydration.2 This reduces the visible signs of ageing, such as fine lines and loose skin.3 The effect of the accumulation of free radicals and the inhibition of several metabolic processes must be kept in mind as these factors promote skin ageing and lead to the hyposynthesis of collagen and elastin.4 However, the use of HA alone may not reduce many of the effects of ageing. Sodium succinate can provide an antioxidant effect by actively blocking free radicals and stimulating sluggish metabolic processes in the skin, therefore aiming to reduce the signs of ageing.4 This article will demonstrate how the combination of HA and sodium succinate, using specific injection techniques, can effectively act against the three mechanisms of skin ageing.

Mechanisms of ageing The dermis ages in three crucial ways:

1. Dehydration and volume loss: decreasing levels of HA in the skin result in decreased water retention, which contribute to a loss of volume and the exacerbation of wrinkles and other signs of ageing. 2. Deceleration of metabolic processes: this leads to slower regeneration of collagen and elastin in the skin and accelerated ageing. 3. Accumulation of free radicals: results in deterioration in the colour and texture of facial skin, causing premature ageing by damaging the cells and their DNA.4

Combining HA and sodium succinate It has been suggested in an in vitro trial, when combined, HA and sodium succinate act synergistically to stimulate fibroblast cells to increase (in both number and metabolic activity) with greater effect when compared to HA mono-component therapy.5 The

Sodium succinate can provide an antioxidant effect by actively blocking free radicals and stimulating sluggish metabolic processes in the skin, therefore aiming to reduce the signs of ageing

effect on the metabolic processes can include strengthening cellular respiration, normalising ion transport, increasing protein synthesis and increasing energy production, through the stimulation of the Krebs cycle in mitochondria.5 The Krebs cycle is essential for cellular respiration; taking place in the mitochondria, the cycle converts pyruvate (from glycolysis) to produce nicotinamide adenine dinucleotide (NADH) and adenosine triphosphate (ATP) through a number of reactions and intermediate molecules â&#x20AC;&#x201C; succinate is one such molecule forming the complete chain in the cycle.6 This should then translate to the restoration of cells, an increase in skin elasticity, firmness and tightness, improved colour and texture, as well as a reduction in the signs of ageing and fatigue.4

Treating the three signs of ageing The effects of the combination on the previously mentioned mechanisms of ageing can be summarised as below: 1. Dehydration and volume loss: HA aims to increase the collagen structure and density in the skin, partly through functional hypertrophy, thereby increasing hydration and volume.5 2. Deceleration of metabolic processes: the succinic acid stimulation of the Krebs cycle aims to reverse this deceleration and increase both the number of fibroblasts as well as their metabolic processes. This in turn can result in an increased output of cystine, arginine, lysis, glycine, methionine, threonine, collagen, elastin and phenylalanine.5 3. Accumulation of free radicals: the antioxidant effect of the combination aims to counteract the free radical accumulation and protect the cells from damage by the free radicals.5

Clinical studies Studies have suggested that using HA with sodium succinate can increase skin tightness, reduce sagging and moisturise the skin.4,5 In these studies, increased skin elasticity was observed in participants treated with mono-component HA products, whereas in skin treated with a HA product that included sodium succinate, a significant improvement in overall skin quality was observed due to an increase in its turgor and elasticity, improved hydration and colour correction. Results in older patients were more visible, and accelerated healing of skin defects were seen at skin biopsy sites after treatment in

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up to 100% above baseline amino acid levels is seen as well.4,5

Techniques The techniques used to achieve successful results are based on multiple intradermal injections of HA with sodium succinate. The full range of injection techniques is extensive, however some examples are explained below. Figures 1 and 2 show examples of the facial injection techniques. Figure 1 illustrates the method used to create adjacent areas of rejuvenated tissue that interact with each other to produce a tightening and lifting effect. This is used when treating indications such as increased nasolabial fold depth or mid-face volume deficiency. Figure 2 illustrates the method used to treat crow’s feet in the periorbital region. The combination process can be applied to the body, as well as the face. Hands, neck, décolletage, arms, legs, abdominal skin and breasts are just are some of the areas that may be treated using the combination. Figure 3 depicts a technique used to increase the density of abdominal skin to tighten the area following weight loss. Figure 4 portrays an uneven technique where greater emphasis is placed on the upper area of the breast in order to tighten the skin to a greater extent than the skin on the lower aspect of the breast. The patterns used are determined by an assessment of the patient’s skin, which separate them into tired, wrinkled, muscular and deformational ageing phenotypes.8 Whilst many patients can be categorised under more than one type of ageing, most are likely to be categorised predominantly under one type, which would guide the choice of treatment.

Figure 1: Facial injection techniques to create tightening and lifting effect

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Figure 2: Facial injection techniques to treat crow’s feet

Figure 3: Techniques Figure 4: Techniques to to increase the density tighten and lift the skin of abnormal skin around the breast following weight loss

all study patients when compared with the same biopsy areas before treatment. A recent study indicated that the treatment has a more noticeable impact in comparison with mono-component HA products.4 Semi-quantitative histological analysis of skin biopsies in all patients also suggested the greater influence of HA and sodium succinate on the structure of the dermis and capillary network of the skin. The number of fibroblasts appeared to increase by 300% versus the 200% increase shown with products containing only HA. An increase of

Figure 5: Patient A before, during and after treatment using hyaluronic acid and sodium succinate in the lateral periorbital region.

Tired ageing The tired ageing type consists of loose, saggy skin under the eyes, dark periorbital circles, crow’s feet, reduced skin tone and density, deep nasolabial folds and wrinkles along the border of the lower jaw. Wrinkled ageing The wrinkled ageing type consists of more superficial skin wrinkles on the forehead, cheeks, chin, glabellar area, temporal zone, preauricular area and the perioral region. Here there is a distinct absence of the heavy, droopy skin seen in the other phenotypes. Muscular ageing The muscular ageing type occurs as a result of highly active facial muscles, which increase the appearance of the general facial contours, dynamic wrinkles, sagging cheeks and hypertrophy of facial muscles.

Deformational ageing The deformational ageing type, on the other hand, includes general ptosis of the soft tissues, jowls, bags under the eyes, marionette lines, degradation of the facial contours, eyebrow ptosis and eyelid ptosis.

In practice Through combining HA with sodium succinate, and incorporating the proper injecting techniques, patients treated at my practice have seen positive results. While treating cheeks, jowls, nasolabial folds, crow’s feet, forehead, buttock, shoulder, chest and neck areas, I have noted improved results in the firmness, hydration, density, tone, pigmentation and texture of the skin. Patients have also noted an improvement in the appearance of acne scars and stretch marks, which reportedly feel smoother to the touch. I have also seen a visible improvement in these areas. Although the HA and sodium succinate combination can produce added benefits to a variety of different areas, there are certain areas that would benefit more from other methods that should be considered instead. In my opinion, platelet rich plasma (PRP) is better suited for use on the lower eyelid closer to the medial border where HA-containing products might result in a puffy, oedematous result. Stretch marks and hypertrophic scars with severe collagen deficiency would also benefit from alternating treatment with products containing a higher percentage of HA.

Complications

Figure 6: Patient B falls under the wrinkled ageing phenotype. Images depict before and after treatment using hyaluronic acid and sodium succinate in the periorbital, glabellar, cheek, jowl and nasolabial fold regions.

As with any injectable product, extra care should be taken with any patient taking chronic medications that might increase the tendency to bleed or bruise. Patients with known sensitivity or allergy to HA or succinic acid should be tested before using the product and general precautions should be taken, as one would with any injectable HAcontaining product. The product should not be injected routinely in

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


Clinical Practice News

the medial aspect of the tear trough as this could result in excessive oedema. Only experienced medical practitioners should inject in this area and limited quantities should be used. Aftercare may include simple steps, such as sitting down facing an air conditioner to soothe the skin, elevating the face by sleeping on two or three pillows when the face has been injected and avoiding sources of heat such as saunas, fireplaces and showers. Where bruising has been observed or is expected, I have personally found that products that contain Arnica have aided in reducing the time taken for the bruising to resolve. I have also observed that an inflammatory response leads to better subjective results and longevity of those results. Therefore, anti-inflammatories should be avoided. It has been shown that mechanical stimulation of the fibroblasts by HA leads to an increase in their activity7 and thus, at least theoretically, inflammation has a positive effect on the amount of collagen induced by the product if it is accepted as a further source of mechanical stimulation. Conclusion The addition of succinic acid to a HA-injectable range has, in my opinion provided medical aesthetic practitioners with a useful tool to use in our arsenal against the signs of ageing. The clinical trials have produced favorable results, which I have been able to see myself in practice. Although the patients in these studies and images were treated exclusively with one HA and succinic acid product, patients in clinical practice would be treated with a range of products and treatments to provide synergistic effects, which one product alone could not provide. I have used HA and succinic acid in combination with other treatments such as PRP, dermal fillers, botulinum toxin, energy devices, chemical peels and other treatments to produce healthy, natural results in patients based on their individual needs. Dr Reza Mia graduated from the University of Witwatersrand with a medical degree and later received an MBA from the University of Liverpool. Dr Mia has participated in global studies assessing dermal filler techniques and specifies in the scientific development, manufacturing and service provision in antiageing therapy, aesthetic medicine, rejuvenation, correction and restoration of the skin.

Disclosure: Dr Mia is the key opinion leader for Institute Hyalual South Africa, the manufacturer of Hyalual and Xela Rederm. REFERENCES 1. Wang, F. et al, ‘In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic aced dermal filler injections in photodamaged human skin’, Arch Dermatol. 143(2007). 2. De Maio, M. & Rzany, B., (2006) ‘Injectable fillers in aesthetic medicine’, Springer, Berlin. 3. Narins, R.S. et al., (2008) ‘Persistence and improvement of nasolabial fold correction with nonanimal stabilized hyaluronic acid’, Dermatol Surg, (2008), pp.52-8. 4. Liskina I.V. et al., ‘Comparative Clinical-morphological research of the effects made on skin by hyaluronic acid containing substances’, The Ukranian Magazine of Dermatology, Venerology & Cosmetology, 2(2010), pp.64-70 5. Berezoskiy, V.A, et al, ‘Connected to the question of human skin physiological renovation,’ The Ukrainian magazine of dermatology, venereology & cosmetology, 3(2011). 6. Holt, Z. (2012) ‘Krebs Cycle Broken Down’, <http://understandingbiologyandlife.blogspot. co.za/2012/12/krebs-cycle-broken-down.html> 7. Turlier, V, et al, ‘Association between collagen production and mechanical stretching in dermal extracellular matrix: in vivo effect of cross-linked hyaluronic acid filler, A randomised, placebocontrolled study’, J Dermatol Sci. 69(2013), pp.187-94. 8. II Kolgunenko.Moskva, A Small Encyclopedia of Beauty, (1996), pg.259–271 (available only in Russian).

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Using advanced technology, these settings accommodate specialist needle configurations and automatically adjust needle speed and frequencies. This is crucial when performing medical tattooing treatments to suit the different structure and tolerance of the skin. All pigments used in the field of permanent cosmetics and medical tattooing are produced under extremely tight guidelines to ensure they are of the highest industry standard and quality. They use medical technology to ensure they are more hygienic, cost effective and altogether safer for performing treatments and adding colour in to the skin. A permanent cosmetic artist must be professionally trained by a reputable company who specialise in the field of paramedical permanent cosmetics in order to carry out medical tattooing Karen Betts details how medical tattooing can treatments. In this article I focus on two frequently help build the confidence of people affected by requested medical tattoo treatments; facial deformity and shares some of her most the improvement of the appearance and symmetry to a cleft lip, and the restoration successful case studies of eyebrows on a burns victim. Medical tattoo treatments It is important to note that in both of the following case studies Occasionally people experience an event in their life that results in a I performed a consultation prior to the treatment to determine change to a feature in their appearance. Some may have a medical patient expectations, to ensure that there were no further surgeries condition, or the results of a medical condition that has affected their scheduled, that the skin was healthy and that there were no other appearance, and they have a desire to improve this aesthetically. medical contraindications. Medical tattooing, an advanced form of cosmetic tattooing, is an option that can facilitate a desired change or restoration of Case study one – cleft lip appearance. It works hand-in-hand with the plastic reconstructive Cleft palate affects 1 in 700 births worldwide.1 It occurs when the industry. Firmly established as being part of the medical aesthetics two plates of the skull that form the hard palate (roof of the mouth) genre, medical tattooing offers a range of treatments for people who are not completely joined, and in most cases, a cleft lip is present.2 have experienced medical conditions including: The appearance of cleft lip can affect a person’s confidence • Enhancement of lip symmetry due to a cleft lip throughout their life. • Restoration of the areola complex Medical tattooing can serve to improve the appearance and • Restoration of the appearance of hair loss due to alopecia symmetry of the lip, which in turn helps diminish the visual effects (includes restoration of eyebrows, eyelash definition, simulation and promotes a new found feeling of self-assurance. I believe cleft of scalp hair) lip treatments to be one of the most challenging and rewarding • The diminishment of the appearance of scar tissue due to skin treatments in the medical tattooing industry. trauma, including burns Patient A was born with a cleft lip. It affected her confidence • Vitiligo colour restoration (typically very minor areas and most throughout her life, but through medical tattooing treatment I was successfully performed on lips) able to improve this by altering the appearance and symmetry of her lips. Treatments are carried out using a computerised permanent The first consideration for Patient A’s treatment was the pigment cosmetics device, which has individual programme settings. colour; it’s incredibly important to select a colour that blends

Medical Tattooing

Figure 1: The correct colour is selected for Patient A

Figure 2: A template is established using a lip pencil

Figure 3: A line is lightly tattooed into the skin

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Needle selection is a critical consideration for any treatment. Initially, in order to work through scar tissue I selected smaller needle groupings; the smaller the needle the more crisp the result well with the patient’s own natural lip tone (Figure 1). This can provide an improved shape with the same or similar colour. Next, I considered an appropriate approach to drawing the new lip line and the various techniques for achieving the appearance of symmetry (Figure 2). Once I have established a template (using a conventional lip pencil) and confirmed the symmetry, the line was Before

After

Figure 4: Patient A before and immediately after treatment

lightly tattooed into the skin using a gentle pressure (Figure 3). Needle selection is a critical consideration for any treatment. Initially, in order to work through scar tissue I selected smaller needle groupings; the smaller the needle the more crisp the result. I used a ‘3-micro’ needle which enabled me to create a fine line. The finer the line, the less noticeable the tattooing will appear. I then used a ‘9-magnum’ needle, which has a larger needle grouping to give softer results, for the blending in of the full colour of the lips inside the parameters of the new lip contours. The speed in which the hand moves is very important; the slower the hand speed, the more consistent the pressure will be on the skin, whereas a firm stretch will result in more even distribution of pigment. I used tight circular motions close to the template line that was drawn on the skin above the patient’s natural lip line, throughout the treatment I performed routine checks for the boundaries established. This was to ensure the shading movements were placed adjacent to the border of the newly tattooed lip line. Accuracy and attention to detail is of paramount importance. Once the treatment was complete I took photographs to compare the before and immediately after and ensure the treatment was aesthetically agreeable for Patient A. At this juncture Patient A was provided with detailed aftercare instructions to optimise the healed result including the use of a barrier cream healing balm to keep the area moist and hydrated,

Aesthetics

as the area tends to exfoliate and peel a few days following the treatment. A top-up appointment was scheduled for 45-60 days post procedure. As illustrated in Figure 4 the visual appearance of Patient A’s lips was dramatically improved. Patient A’s response to her new appearance was extremely positive. She said the treatment had ‘changed her life’ and she had become much more ‘confident and happy when meeting new people’. Some complications can arise following medical tattooing, but as long as the skin being tattooed is healthy and any surgical treatments are well healed with a doctor or medical practitioner’s clearance to proceed, complications are not anticipated. There is always the possibility of a herpes simplex virus 1 (HSV-1) breakout when tattooing the lips. If that were to occur, the patient would be advised to see their general practitioner for direction and medication. Additional medical tattooing treatment(s) to achieve the desired density and consistency of colour over the scar tissue may also be needed – this is determined at the top up appointment. Scar tissue can be unpredictable when it comes to retaining pigment, which is why a second application is always scheduled to fine tune the colour and add more pigment to any areas that may have healed unevenly. Generally, a review is not needed for another 12-18 months following this. Case study two – burns patient The next case study is Patient B, who was 10 years old when she was in a plane crash that killed her family and left her with severe scarring. Skin that has been burned must be evaluated to determine what needle grouping and pigment colours will accommodate the texture of the scar and the temperature of the skin colour. Most patients have a ‘cool’ skin undertone (placed further along the Fitzpatrick scale). But once burn damaged, the temperature is even cooler and pigment will appear differently through the scar tissue. It is vital to understand the history of the scar treatment received and the degree of the burn, and whether any further treatments are planned. Patient B received second (injury extending into the underlying layers of the skin) and third-degree (injury extending Before

After

Figure 5: Patient A before and after an eyebrow tattooing treatment

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Skin needling can soften the whiteness of scarring through the introduction of natural melanin, reduce raised scars and provide a number of benefits to skin that has been traumatised to all layers of the skin) burns to 45% of her face and body. She has had more than 50 operations since the plane crash; including surgery to separate her fingers where the skin had melted, fusing them together, and pins to straighten her bones. Having experienced body image distress for many years Patient B decided she would like her eyebrows medically tattooed. I worked with Patient B’s medical care providers to understand as much as possible about her medical history, and with the information I was able to devise a suitable plan for Patient B’s treatment. When treating scarred skin it is always crucial to manage the patient’s expectations. I always advise that they may need more than two sessions and that some areas of the damaged skin may never hold pigment. The same applies to burn survivor work; it’s important not to over-promise and to always be realistic with the probable results that can be achieved. I always consider the language I use, the questions I ask and how I proceed with each and every treatment. With this in mind, the following considerations were taken into account for Patient B: • Burns survivors all experience different levels of body image distress which may involve grief, sadness, anxiety and worry. All these feelings are normal but don’t assume you know what they are feeling. • Do not ask intrusive questions: remember, the patient may not wish to discuss or explain what happened to them. • Give the patient time to get used to the area where you have drawn the template before you start the treatment. Take into consideration that this may be an emotional experience for them so leave yourself plenty of time for the consultation and aftercare. • For any type of scarring, a skin needling procedure is recommended. Skin needling can soften and reduce raised scars and provide a number of benefits to skin that has been traumatised.

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• Selecting an appropriate size needle grouping to ensure proper penetration through scar tissue; remember, smaller needles can penetrate the skin better if there is obvious scar tissue, however, some scar tissue can also be fragile as the structure of the skin is unstable, and this would warrant using a larger needle causing less trauma to the skin. • Tattooing the eyebrows in a natural, realistic pattern using a hairline stroke technique. Following the treatment I checked Patient B’s eyebrows for symmetry and shading coverage. The eyebrows were then photographed and the before and after results were compared (Figure 5). As with Patient A, aftercare instructions were provided with a companion aftercare product to enable the area to heal, and a topup appointment was scheduled for 45-60 days post procedure. Follwing her eyebrow treatment Patient B had two more medical tattooing treatments: eyeliner and her nipple and areola. Patient B was extreamly happy with the results, saying she couldn’t ‘believe the transformation’ and that her eyes ‘look so much more lifted and the eyebrows help express emotions’ now. As previously expressed, some complications can arise with medical tattooing treatments. For burns patients the hairline eyebrow strokes can blur due to the condition of the skin, it can sometimes even exfoliate out completely. Although medical complications are not anticipated, if healing was delayed or the area required medical attention, the patient would be advised to see her general practitioner. For any type of scarring, I always also recommend a skin needling procedure. Skin needling can soften the whiteness of scarring through the introduction of natural melanin, reduce raised scars and provide a number of benefits to skin that has been traumatised.3 Conclusion As you can see from the case studies outlined, medical tattooing has benefits on many levels for different people. It is not just skin deep; it’s about giving people back their confidence and boosting their self esteem. Medical tattooing is a passion of mine and I feel honoured that my skills in this area enable me to work with medical patients and support chosen charities, helping people affected by cancer and those living with altered facial appearance. Karen Betts is one of the pioneers in permanent makeup and medical tattooing with over 20 years’ experience. Throughout her career, Betts has worked alongside numerous charities and performed a number of medical treatments, which help transform lives. She has won many awards, which include ‘Industry Leader Award 2015’. REFERENCES 1. Right Diagnosis, Statistics by Country for Cleft palate, (2016), <http://www.rightdiagnosis.com/c/ cleft_palate/stats-country.htm> 2. Centers for Disease Control and Prevention, Facts about Cleft Lip and Cleft Palate, Birth Defects, (2015) <http://www.cdc.gov/ncbddd/birthdefects/cleftlip.html> 3. Horst Liebl and Luther C. Kloth, Skin Cell Proliferation Atimulated by Microneedles, J Am Coll Clin Wound Spec, (2012) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921236/>

The treatment entailed the following: • Selecting a pigment colour appropriate for Patient B’s skin undertone and desired result. • Drawing an eyebrow template design that would be followed during the tattoo procedure.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Case Study: Treating Female Patterned Hair Loss Dr Lisa Godfrey shares her experience of using PRP to successfully stimulate hair growth in a female patient Introduction This case study will detail the treatment of a 59-year-old female (Patient A) who presented to my clinic with progressively thinning hair, which she was becoming increasingly concerned about. Her medical history revealed nothing abnormal. Clinical examination revealed thinning hair on the crown and frontal part of the scalp. The hair that was present was shorter and thinner in nature (miniaturised hair) (Figure 1).

of two years, meaning that Patient A was becoming increasingly self-conscious. A diagnosis of female pattern hair loss (FPHL) was made based on the clinical picture and the history given by the patient. Female pattern hair loss FPHL is the most common form of hair loss in women and the incidence increases with age. It is characterised by a reduction of hair thickness over the crown and frontal part of the scalp. The severity can

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be graded according to the Ludwig scale (Figure 2) and Patient A was classified as Grade I on the scale.1 FPHL is common, with the highest prevalence occurring in postmenopausal women. Hormones and genetic predisposition are believed to contribute to FPHL, but the mechanism through which these factors lead to the condition is not fully understood. Most women with FPHL do not have abnormal levels of serum androgens.2,3 Classic presentation of FPHL follows slow, progressive transition of terminal hairs on the crown and frontal part of the scalp to miniaturised hairs and vellus hairs, resulting in a visible reduction in hair coverage on the scalp. The occipital scalp and frontal hairline are often relatively spared.4 This hair loss can lead to psychological distress so the importance of treating these cases should not be overlooked. The diagnosis of FPHL is usually made clinically, based upon the patient history and physical examination, which demonstrates a reduction in hair density in the characteristic distribution and an increased prevalence of miniaturised hairs. Skin biopsies are not usually performed,5 but some authors recommend it.6 In this case, the goal of treatment was to arrest hair loss progression and stimulate hair regrowth by stimulating the dermal papilla, which sits below the hair follicle. The dermal papilla is mesenchymallyderived tissue with inductive properties. As the human scalp contains approximately 100,000 to 150,000 hair follicles, there are many papillae to target. The dermal papilla induces the development of hair follicles in the foetus and appears to play an important role in follicular cycling and hair growth (Figure 3).7

Figure 1 demonstrates how Patient A initially presented. It can clearly be seen that her hair is thinning and, according to the history provided, this has been getting progressively worse over a period

Grade I: Visible hair thinning on the crown, situated 1-3cm behind the frontal hairline.

Grade II: Pronounced reduction of the hair on the crown within the area seen in Grade I.

Figure 2: The Ludwig scale Figure 1: Patient A before treatment

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016

Grade III: Full baldness within the area seen in Grades I and II.


DO YOU SOMETIMES WISH THAT LASER HAIR REMOVAL TREATMENT WAS EVEN BETTER? Now it can be...

LHR + VANIQA The hair-removing combination more effective than laser alone*

* Complete or almost complete hair removal achieved with eflornithine-laser combination in 93.5% (29) sites vs 67.9% (21) sites treated with laser alone in double-blind right-left comparison study (n=31). 1 Reference: 1. Hamzavi I et al. J Am Acad Dermatol 2007; 57(1): 54-59. Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing). Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women. Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects. Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product. For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application. The condition should improve within eight weeks of starting treatment. Paediatric populations: The safety

and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/ renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxybenzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency

UKEFL3585 Date of preparation: June 2016.

using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain. Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500. Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk. Date of Revision: 10/2015. Item code: UKEFL3336

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 Almirall Ltd.

Available from Wigmore Medical Limited


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Follicular orofice

Upper portion (infundiulum)

Sebaceous duct

Hair shaft

Sebaceous gland Arrector pili muscle Middle portion (isthmus)

Outer root sheath

Inner root sheath

Hair matrix Lower portion

Hair bulb Dermal papilla

Figure 3: The dermal papilla

Treatment Patient A was informed of the possibility of providing treatment with PRP in an attempt to encourage hair regrowth in the thinning area. PRP is completely autologous. It is a concentration of platelets in plasma obtained from a patient’s blood, which is then used as a treatment for the same patient. PRPs are a rich source of growth factors and other important biological proteins promoting angiogenesis, chemotaxis, cell proliferation and differentiation. PRP has been researched and used in various fields of medicine and has emerged as a novel treatment modality. There is evidence to suggest that it is effective in the treatment of hair loss conditions by promoting hair regrowth.8,9,10 The patient was fully consented and a treatment regimen of three treatments three weeks apart was planned and undertaken. I chose to deliver the injections to the area needed utilising mesotherapy.

My preferred mesotherapy method is the use of the U225 mesotherapy gun. Injections can be delivered by hand, but patients report that the U225 is virtually painless making the procedure as comfortable as possible. Also, it is extremely easy to vary the depth of the needle and adjust the droplet size of product being delivered, ensuring that each injection is consistent. While there are a number of PRP technologies available, I chose to use PRGF-Endoret (plasma rich in growth factors-endogenous regenerative technology). There are more than 100 peer-reviewed published studies regarding PRGF-Endoret, indicating its effectiveness in various fields of medicine. Out of more than one million treatments performed worldwide, there have never been any adverse effects reported. I have used this product for many years, within dentistry as well as aesthetic medicine, and have

PRP treatment of FPHL should be looked upon as a favourable treatment option as it is completely autologous with no reported adverse effects

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only seen positive results in healing and tissue regeneration and rejuvenation. PRGF-Endoret is a PRP obtained by taking small volumes of the patient’s blood and then placing the blood into a specialised centrifuge. Only one, short (eight minutes) centrifuge stage is required, unlike some other PRPs that require more than one centrifugation. After the blood has been spun, different layers are observed in the tube. The first layer seen is the strawcoloured plasma. Just below the plasma a greyish ‘buffy’ layer can be observed, this is the white blood cell (WBC) layer that has been separated from the rest of the plasma by the centrifugation process. The third layer is the haematocrit, the red cell layer of the blood after separation. Although the plasma is all the same colour, it is actually split into two layers. The rationale for this is that the platelets are concentrated along a gradient with a greater concentration towards the bottom of the plasma layer than the top. These layers are named Fraction 1 (F1), the platelet poorer part of the plasma with a platelet concentration x1 of physiological blood and Fraction 2 (F2) the platelet richer part of the plasma with a concentration of platelets two to three times that of physiological blood.11 Each formulation that is obtained has great biological activity based on:

1. The PRP that is obtained has a rich source of growth factors responsible for tissue regeneration. 2. Formation of a fibrin matrix occurs within the tissue being treated, which acts as a provisional tissue scaffold to house the cells necessary to promote new tissue formation and allow a gradual, sustained release of growth factors over two weeks following the initial growth factor release by activation of the platelets.12 As mentioned previously, the WBCs are separated from the plasma during the centrifugation stage. This is unlike other types of PRP, which incorporate WBCs. Advantages of using PRP that do include WBCs are that they can protect the body from infection. The disadvantages of PRPs that include WBCs are: • Increase in inflammatory mediators.13 • Increase in pain. • Interferes with inter-platelet interactions necessary for aggregation and release of growth factors.13,14 • Fibrin matrix and membranes formed are disorganised and weaker.13,14

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Technique The protocol I used for injecting Patient A was to: • Take two 9ml tubes of blood which obtained 4ml F1 and 4ml F2. • F2 was activated with calcium chloride and injected at a depth of 5mm, 3mm and 1mm. (As I did not have a scalp biopsy to determine depth of the hair follicle, I wanted to ensure that I covered all layers through the scalp). The needle depth on the mesotherapy delivery gun used can be easily altered to allow for these different depths.

Figure 4

Figure 4: Clinical appearance three weeks after the first treatment Figure 5

Figure 6

Figures 5 and 6: Before and after three PRGF

treatments Figure 7

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• At 5mm and 3mm F2 was injected via a single pulse mode. • At 1mm depth F2 was injected using a high frequency mode. The manufacturers of the U225 recommend using a single shot and high frequency mode in the same treatment to enhance desired results. • Gauze soaked in activated F1 was used as a dressing for 10 minutes following each procedure. Doing this allows for absorption of the F1 into the microwounds created and aims to soothe any areas of micro-trauma created by the needle of the mesotherapy gun.

Results The patient did not report any discomfort throughout any of the three separate procedures. There were no adverse events during or post procedure, such as bleeding, pain or swelling, and healing was uneventful. After the first treatment evidence of hair regrowth was observed; new tufts of hair were identified upon clinical examination (Figure 4). Patient A was extremely happy with the results achieved (Figures 5 & 6) and further examination and photographs will be taken at three months post treatment to assess hair regrowth and thickness. This has been a very rewarding case to treat. Since having treatment, Patient A has been able to grow and style her hair, and her confidence has increased significantly. She sends me regular photographs of the progression of her hair growth (Figure 7) and reports that her hairdresser is amazed with the difference. There are numerous options for the treatment of FPHL5 including various medications and adjunctive therapies such as hair transplantation, camouflage and light therapies. PRP treatment of FPHL should be looked upon as a favourable treatment option as it is completely autologous with no reported adverse effects, there is no downtime associated with the procedure and treatment can be performed relatively quickly and easily in a painless manner. However, further research is needed, with more objective measurements of hair regrowth than presented within this case report.

Dr Lisa Godfrey is a medical aesthetic practitioner and dental surgeon. She is also a clinical trainer for Cosmetic Courses and is passionate about education. Godfrey has an interest in performing independent research in practice and has just completed the second year of the MSc in non-surgical facial aesthetics at UCLAN.

Disclosure: Dr Godfrey is a key opinion leader on PRGF-Endoret for BTIBiotechnology and is the company’s clinical trainer for the UK. REFERENCES 1. Ludwig E., ‘Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex’, Br J Dermatol, 97 (1977), p.247. 2. Futterweit W, Dunaif A, Yeh HC and Kingsley P., ‘The prevalence of hyperandrogenism in 109 consecutive female patients with diffuse alopecia’, J Am Acad Dermatol., 19 (1988), pp.831-6. 3. Schmidt JB, Lindmaier A, Trenz A, Schurz B and Spona J., ‘Hormone studies in females with androgenic hairloss’, Gynecol Obstet Invest, 31 (1991), pp.235-9. 4. Price VH., ‘Androgenic Alopecia in women’, J Invest Dermatol Symp Proc., 8 (2003), pp.24-7. 5. Mesinkovska NA and Bergfeld WF., ‘Hair: What is New in Diagnosis and Management? Female Pattern Hair Loss Update: Diagnosis and Treatment’, Dermatol Clin, 31 (2013), pp.119-127. 6. Dinh QQ and Sinclair R., ‘Female pattern hair loss: current treatment concepts’, Clin Inter Aging, 2 (2007), pp.189-199. 7. Paus R and Costarelis G., ‘The biology of hair follicles’, N Engl J Med. 199; 341: 491. 8. Li ZJ, Choi HI, Choi DK, Sohn KC, Im M, Seo YJ, et al. ‘Autologous platelet-rich plasma: A potential therapeutic tool for promoting hair growth’, Dermatol Surg, 38 (2012), pp.1040-6.   9. Pietrzak WS, Eppley BL., ‘Platelet rich plasma: Biology and new technology’, J Craniofac Surg, 16 (2005), pp.1043-54.   10. Sánchez-González DJ, Méndez-Bolaina E, Trejo-Bahena NI., ‘Platelet-rich plasma peptides: Key for regeneration’, Int J Pept (2012), pp.1-12.   11. Anitua E. Plasma Rich in Growth Factors: preliminary results of use in the preparation of future sites for implants. Int J Oral Maxillofac Implants. 1999; 14: pp 529-535 12. Anitua E, Sanchez M, Orive G, Andia I., ‘Delivering growth factors for therapeutics’, Trends Pharmacol Sci, 29 (2008), pp.37-41. 13. Anitua E, Zalduendo M, Prado, M, Alkhraisat and Orive G., ‘Morphogen and proinflammatory cytokine release kinetics from PRGF-Endoret fibrin scaffolds: Evaluation of the effect of leucocyte inclusion.’, J Biomed Part A, (2014), pp.1-10. 14. Anitua E, Zalduendo M, troya M, Padilla S, Orive G., ‘Leukocyte inclusion within a platelet rich plasma plasma-derived fibrin scaffold stimulates a more pro-inflammatory environment and alters fibrin properties’, PLoS ONE, 10(3) (2015), pp.1-19. FURTHER READING • Venning VA and Dawber RP., ‘Patterned androgenic alopecia in women’, J Am Acad Dermatol., 18 (1988), pp.1073-77. • Amy McMichael, Female pattern hair loss (androgenetic alopecia in women): Pathogenesis, clinical features, and diagnosis, (US, uptodate.com, 2016) <http://www.uptodate. com/contents/female-pattern-hair-loss-androgeneticalopecia-in-women-pathogenesis-clinical-features-anddiagnosis?source=see_link#H352182242> • Jerry Shapiro et al, Evalutation and diagnosis of hair loss, (US, uptodate.com, 2015) <http://www.uptodate.com/contents/ evaluation-and-diagnosis-of-hair-loss?source=related_ link#H1871668>

Figure 7: Image sent by patient after treatment

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


Advertorial Radara

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Radara – Your Perfect Aesthetic Partner When it comes to facial aesthetic treatments, market research has shown that the eye areas are far and away the top priority for patients. It’s often the first reason a patient will come into the clinic, concerned about those first signs of wrinkles, tiredness and puffiness. Yet no matter what non-surgical procedure your patients are having – their skin quality, skin health and maintenance of results are paramount to your success. Patients are increasingly keen to prolong the results of their aesthetic treatments through at-home regimens, so finding the right partner treatment is vital to getting real patient satisfaction and loyalty. This is where Radara comes in: it is a true step-change in skin rejuvenation and offers the perfect follow-up and maintenance treatment for every aesthetic patient. Specifically tailored for the periorbital area, Radara is an innovative, targeted and painless approach to skin revitalisation using a new micro-channelling technology. This at-home treatment is a one-month regimen of microchannelling patches and a high purity, naturally-derived hyaluronic acid serum which delivers an average 35% reduction in lines and wrinkles after just four weeks.1 What is MicroChannelling? Unlike traditional microneedling which can require topical anaesthetic and cause erythema, oedema and pain – Radara uses a non-invasive, micro-channelling alternative with minimal disruption of the epidermis. Radara’s ultra-thin, flexible patches are coated with microscopic plastic structures (similar to needles) less than 0.5mm long. When applied, these painlessly create thousands of tiny microchannels in the skin. The HA serum then flows through the microchannels to the deeper layers where it restores and replenishes natural elasticity, hydration and support. Dermatological tests showed:i • An average 35% reduction in lines and wrinkles after four weeks, with some results seen as early as two weeks • 81% of patients reported skin felt smoother • 88% of patients reported skin felt firmer • Radara patches almost doubled the efficacy of the HA serum • Treatment was well tolerated, with no reported side-effects • Improvements in skin health continued for a further four weeks post-treatment 54

Who Can Use Radara? Radara can integrate seamlessly into the patient’s normal skincare regime, taking just five minutes to apply each night for a period of four weeks. Thanks to the quick, easy and painless application, Radara makes the ideal choice across the whole spectrum of aesthetic patient needs: New Patients • Radara offers a non-invasive treatment and an introduction to aesthetic clinics and the range of other suitable procedures • An initial ‘stepping stone’ Needle-Phobics / Non Toxin or Filler Patients • Radara offers a way to treat their lines without needles, pain or downtime • Allows patients to achieve a ‘natural’ look with no stark contrast • Builds patient’s confidence in treatments and aesthetic clinics Existing Toxin/Filler Patients • Gives an effective at-home maintenance treatment to enhance overall effect of treatment and also address static lines • Allows the opportunity to bring the patient back at week 4 and 8 for skin analysis, top ups and to discuss further treatments The Innovators • For those looking for the latest new treatment trends and interested in new technologies So whether your patients are still needing that interim stepping stone to having a full aesthetic treatment, or if they’re experienced innovators looking for the next new skincare trend – Radara offers the perfect solution to deliver great results and complement your ongoing aesthetic treatment programme.

One Month Supply (x60 patches, x1 HA serum pump) | Trade price £99 For stockist enquiries, please contact Wigmore Medical on 020 7491 0150, www.wigmoremedical.com For further information please contact: info@radara.co.uk E: www.radara.co.uk |Twitter: @radaraUK REFERENCES 1. Innoture Ltd – Data on file

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A summary of the latest clinical studies Title: Body Dysmorphic Disorder in aesthetic rhinoplasty: Validating a new screening tool Authors: Lekakis G, Picavet VA, Gabriëls L et al. Published: The Laryngoscopy, May 2016 Keywords: Body dysmorphic disorder, aesthetic, cosmetic surgery, dysmorphophobia, questionnaire, rhinoplasty, screening Abstract: To validate a new screening tool for body dysmorphic disorder (BDD) in patients seeking aesthetic rhinoplasty, we performed a prospective instrument validation study in an academic rhinology clinic. The Body Dysmorphic Disorder QuestionnaireAesthetic Surgery (BDDQ-AS) is a seven-item short questionnaire validated in 116 patients undergoing aesthetic rhinoplasty. Screening was positive if the patient acknowledged on the BDDQ-AS that he/ she was concerned about their appearance (question 1 = yes) and preoccupied with these concerns (question 2 = yes) and that these concerns caused at least moderate distress or impairment in different domains of daily life (question 3 or 4 or 5 or 6 ≥ 3 or question 7 = yes). Construct validity was assessed by comparing the BDDQ-AS to the Sheehan Disability Scale and the Derriford Appearance Scale-59. To determine concurrent validity, the BDDQ-AS was compared to the Yale-Brown Obsessive Compulsive Scale Modified for BDD. Finally, the predictive value of the BDDQ-AS on satisfaction 12 months after rhinoplasty was evaluated using a visual analogue scale and the Rhinoplasty Outcome Evaluation. Reliability of the BDDQ-AS was adequate, with Cronbach alpha= .83 for rhinoplasty patients and .84 for controls. Sensitivity was 89.6% and specificity 81.4%. BDDQ-AS-positive patients (n = 55) were more impaired in daily life and experienced more appearance-related distress and dysfunction compared to BDDQ-AS-negative patients. Moreover, they had more severe BDD symptoms. Finally, BDDQ-AS-positive patients were less satisfied after surgery compared to BDDQ-AS-negative patients. We hereby validated a new screening tool for BDD in an aesthetic rhinoplasty population. Title: Multi-polydioxanone (PDO) scaffold for forehead wrinkle correction: A pilot study Authors: Ko HJ, Choi JY, Moon HJ, Lee JW, Jang SI, Bae IH et al. Published: Journal of Cosmetic and Laser Therapy, May 2016 Keywords: Multi-polydioxanone, forehead, scaffold, wrinkle Abstract: Forehead wrinkles are the result of contracture of the frontalis muscle and the skin ageing process. Currently, hyaluronic acid filler and botulinum toxin are the main materials used for correction of these wrinkles. In addition, polydioxanone (PDO) thread has also been applied for this treatment. In order to evaluate the efficacy and safety of multi-PDO scaffold in animal and human skin, we tested PDO insertion in rat and mini-pig models and human volunteers with forehead wrinkles. A stent-shaped multi-PDO scaffold was inserted under the panniculus carnosus of rat dorsal skin and the subcutaneous layer of mini-pig dorsal skin and forehead wrinkles in three human volunteers. Histological analysis at 12 weeks revealed evidence of de novo collagen synthesis, which was consistent with clinical results on photo evaluation. Stent-shaped multi-PDO scaffolds may be another effective and safe treatment modality for reduction of forehead wrinkles.

Title: Reflectance confocal microscopy for scarring and non-scarring alopecia real-time assessment Authors: Ardigò M, Agozzino M, Franceschini C et al. Published: Archives of Dermatologic Research, May 2016 Keywords: Alopecia, diagnosis, non-scarring alopecia Abstract: Clinical management of alopecia represents one of the major issues in dermatology. Scalp biopsies are not easily accepted because of the high bleeding and sensitive anatomical area. Trichoscopy is routinely used for diagnosis of alopecia, but in several cases lacks to provide sufficient information on the status of the disease. Recently, reflectance confocal microscopy demonstrated its usefulness for the evaluation of several inflammatory skin condition and preliminary reports about alopecia have been proposed in the literature. The aim was to identify the confocal features characterising scarring and non-scarring alopecia. Reflectance confocal microscopy from 86 patients affected by scarring (28 lichen planopilaris and 9 lupus erythematosus) and non-scarring alopecia (30 androgenic alopecia and 19 alopecia areata), were retrospectively, blinded evaluated. Good concordance between different readers on the confocal criteria has been assessed. Statistical significant features, specific for scarring alopecia and non-scarring alopecia have been identified. In this study, data on reflectance confocal microscopy features useful for the differential diagnosis between scarring and non-scarring alopecia have been identified. Further studies are still required. Title: A study of the efficacy and safety of a fractional 1064-nm Q-switched Nd:YAG laser for photoageing-associated mottled pigmentation in Asian skin Authors: Won KH, Lee SH, Lee MH, Rhee DY, Yeo UC, Chang SE Published: Journal of Cosmetic and Laser Therapy, June 2016 Keywords: Fractional 1064-nm Q-switched Nd:YAG Laser, associated mottled pigmentation (PMP); melasma; photoaging Abstract: Laser toning using low-fluence 1064-nm Q-switched neodymium-doped yttrium aluminum laser (QSNY) has gained popularity in the treatment of photoageing and associated mottled pigmentation (PMP). However, hypopigmentation or lack of efficacy has been reported depending on the fluences used. To compare a novel fractional 1064-nm QSNY with conventional 1064-nm QSNY for the treatment of photoaging associated mottled pigmentary lesions except epidermal lesions of lentigines and freckles through a randomized, split-face, double-blind study. Thirteen Asian women were treated every week for 6 weeks with fractional 1064-nm QSNY on one side of the face and conventional 1064-nm QSNY on the other side. We evaluated the pigmentation area and severity index (PSI), melanin index, erythema index, and the patient’s global assessment of improvement. At 3 months post-treatment, the PSI score improved compared with baseline, by 14.48% on the conventional 1064-nm QSNY side and 21.81% on the fractional 1064-nm QSNY side. Both groups showed improvements in the melanin index. Both fractional 1064-nm QSNY and strict low fluence of conventional 1064-nm QSNY are moderately effective against PMP and other photoaging signs. Fractional laser toning shows better subjective outcomes than conventional toning.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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welcome, not just celebrities – but if you mention you are looking for more ways to showcase the work you do and potentially work with some well-known faces, this is a good place to start.

How to Use Celebrity Endorsement to Boost Business PR consultant Julia Kendrick takes a look at tried and tested tactics of celebrity endorsement and gives her top tips on how to effectively harness ‘star power’ to build your clinic brand When it comes to celebrities, more often than not they are used by the mainstream media to demonstrate the cartoonish, exaggerated or ghoulish effects of bad surgery. Yet increasingly, the UK aesthetic industry is using good quality celebrity endorsement, with the likes of Sharon Stone for Galderma and Karen Brady for HydraFacial. But is celebrity endorsement only achievable for big brands, or in trendy clinic hotspots like LA or Harley Street? No – in fact, celebrity marketing is well within your grasp and this article will prepare you for if and when the lightning strikes!

Why use celebrity marketing? Nowadays, a great deal of products we use are associated with a celebrity endorsement or ‘brand ambassador’. The critical premise here is to make consumers feel that they can emulate the celebrity lifestyle by buying the fragrance, the clothes, or the food: we all want a little bit of that A-List feel in our own lives. By coupling the right celebrity face with your clinic and brand, you can achieve an instantaneous business boost, outshine your competition and gain visibility amongst a much larger network of potential audiences than through your own marketing alone.

Finding your ‘celebrity’ The ideal scenario is that a local or, even national, celebrity just happens to walk through your clinic door – but this is only relatively likely if you are in Harley Street or certain London hotspots. The vast majority of clinic celebrity endorsements arise through good old-fashioned word-of-mouth, so start by reaching out to your key suppliers, business partners and of course your patients to see who they might have connections with. Be subtle in your approach – as any new patient recommendations should always be

A match made in heaven? Once a celebrity crosses your threshold, don’t automatically assume that any publicity is good publicity. The success of a celebrity endorsement rests entirely on whether they align with, and appeal to, your existing patient base. If there is a mismatch, the endorsement will not deliver the business benefits and even worse, it could damage your reputation. You need to protect your brand and carefully consider: • Would the majority of your ideal patients want to look like/emulate this celebrity? • Do they resonate with your patients in terms of age, socioeconomic status, personality, lifestyle and career? • Have they had a lot of previous cosmetic procedures elsewhere? Going back to the ‘ghoulish’ danger signs, you want to steer clear of anyone who looks over-done, especially if all the work wasn’t yours to begin with! • Would you be happy with their final result being publically acknowledged as your work? • Do you have matching values? • Are they easy to get along with, or are you continually fearful that something will backfire? Seal the deal So you’ve found a celebrity who is a good fit, but what next? The answer is to treat them like a normal patient. Give them the same level of care and excellence as you would for any other patient; build up the relationship and establish a rapport before asking them for anything. Remember, as with many aesthetic patients they may be reticent even to admit publically that they have had cosmetic procedures – so the approach here must be softly, softly. It can sometimes take years before a celebrity will be comfortable acting as an ambassador, so judge carefully when to approach them. Ideally, their great experiences as a patient may prompt them to approach you proactively and offer their testimonial or endorsement – so much so, the better. When it comes to payment, if the celebrity is a new introduction there will usually be an expectation to have their treatment for free, in return for promoting you and your services through a number of means. Make sure you nail this down in writing so that expectations are clear on both sides. If a key supplier or manufacturer has connected you to the celebrity, ask them to cover the cost of the product for you, again, with the clear understanding of being credited in subsequent publicity. The process You need to be crystal clear what you would like your celebrity to do and how you will use the information. You may just wish to publically confirm that they are one of your patients, or get them to post on social media, or give their image and testimonial for your clinic marketing and website. The key is to be clear and take their lead on what they are comfortable with, and above all, NEVER do anything without their expressed, written permission lest you get a nasty lawsuit. Celebrities will usually have their own agent or PR team who will work with you to develop a contract and legal consent form that outlines and agrees the scope of activities. Make sure it clearly stipulates how and where any text, images or videos may be used

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Real life best practice Dr Victoria Manning, River Aesthetics Celebrity: Meg Matthews How did you find your celebrity? A makeup artist we work with mentioned that one of her clients, Meg Matthews, was interested in getting a treatment for her 50th birthday. One of our supplier partners is always looking for celeb case studies, so we got their PR team to connect with Meg’s PR team on our behalf to set up the treatment. What activities did you secure with them? We were contracted to do a thread lift for Meg, which she would tweet about and then participate in a local and national media interview. However, she loved her treatment so much that she wanted a second thread lift for her neck and this was promoted through her PR team, who secured a photoshoot and interview with the Sunday Times Style, alongside multiple tweets from Meg. How did you maximise this opportunity? Once the article hit the shelves it was on our website, social media channels and patient newsletters. We used boosted posts on Facebook and got between 2,500 and 8,500 views over that period. What has been the result for you and your clinic? We got 40 bookings in the 48 hours immediately afterwards and there has been a significant uplift in our social media followers and website hits. Meg has agreed to do a video testimonial for our website and has also referred another two celebrity friends to us for treatment! Any key learnings or tips? Your celebrity’s look has got to be achievable and match your patient base so you don’t alienate people. Also, make sure you are prepped to deal with an upsurge in enquiries; we had to outsource our calls as the phone was ringing off the hook! Dr Sach Mohan, Revere Clinic Celebrity: Kelly Brook How did you find your celebrity? Kelly was recommended to see us by another celebrity client of ours. Kelly has been with us for six years and only recently felt comfortable about ‘going public’, so it was a long-held relationship in the first place. What activities did you secure with her? She agreed to do a number of posts across her social media channels (Twitter, Instagram) and talk about the results and experiences she’s had with us. How did you maximise this opportunity? We retweeted and maximised the social media exposure – one tip would be that there will always be ‘trolls’ putting up offensive comments with this kind of topic, so make sure you have a good social media strategy in place for how you handle these kind of comments. What has been the result for you and your clinic? This was part of our broader marketing strategy and it has definitely helped our brand, but we are not reliant on celebrity profiling and want to ensure it’s always kept to a tasteful level! Any key learnings or tips? Never ask a celebrity to be your case study – it needs to come from them. We waited six years for Kelly, so just be patient. Also make sure they really represent your brand image and don’t alienate your patient base!

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in this country (and beyond, if online), ownership, copyright, usage rights and the period of use and get a signed copy from all parties. The celebrity must also understand they can withdraw their consent at any time. There is no cast-iron rule about whether or not you should expect to pay a celebrity for endorsing you – ideally they should offer to do this for free (as otherwise the association lacks credibility and value) but don’t make assumptions: test the water either directly or through their PR/management team. Prepare There’s no point getting an upsurge in patient enquiries on the back of celebrity work if you can’t capture these leads. Brief your team on when celebrity activities are taking place, so they can plan accordingly and ensure the phones are manned. If in doubt, outsource to a reputable call handling service such as Aesthetic Response, who are the only full enquiry management service for aesthetics, or MyRuby who are an appointment bookings service, who can help cover you during times of high call volumes and ensure none of those valuable leads slip through the net. Similarly, make sure you take note of your current patient enquiry levels, conversions, website analytics and social media followings so you can benchmark any changes as a result of the endorsement. Maximise the results You need to get the maximum mileage out of your celebrity endorsement in order to ramp up your visibility and create opportunities with the local and national media. Prepare in advance so you don’t get overwhelmed at the time, and think about the following: • Adding their imagery, written or video testimonial onto your website homepage • Create a pre-planned social media posting schedule for before, during and after coverage appears ◊ Tag the celebrity, brand, company, journalist and media outlet ◊ Like and retweet everyone who posts about it ◊ Consider paying for boosted posts on Facebook to increase visibility – this can cost as little as £2 but you can set your budget for how much to spend, and how long to boost the post for • Create a press release and approach local and national media with the story • Include relevant imagery/testimonials in your patient newsletter and clinic marketing materials

Conclusion For me, the most important thing is to ensure the celebrity is a good fit for your brand and clinic patient base. Without this alignment, you won’t get a lovely halo effect, so much as an oppressive shadow, so remember – don’t get starstruck, make sure they’re right for you and then go for it! Julia Kendrick has 10 years of experience in public relations and communications, and is the founder of Kendrick PR Consulting, a consultancy service specialising in medical aesthetics and healthcare PR. A previous winner of the Communiqué Young Achiever Award, Kendrick is passionate about delivering award-winning client campaigns.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Audio Branding Audio branding consultant Dan Lafferty explains how clinics can tap into the emotional power of sound to boost marketing efforts Audio is rarely regarded as anything more than an afterthought when it comes to marketing and branding. Understandably, visual collateral tends to assume prominence, simply because it is so well established as a core element of the marketing mix. Medical aesthetic clinics will invest in websites, corporate brochures, email, direct mail and print advertising, but rarely create audio to match. What you might not realise is that audio is an extremely potent tool for enhancing brand recall and recognition, primarily because our hearing is such a powerful emotional sense. In fact, humans are hard-wired to trust their sense of hearing more than their sense of sight.1 A study conducted as part of the Hearing Body project at the University College London found participants could have their perceptions of their own body image distorted by changes in sound.2 In one test, the pitch created by a person’s footsteps was made higher or lower – when lower, they were tricked into believing they were heavier and said their steps felt more laboured.1 This power translates to business too. For example, further research has indicated that companies that match their brand to music are 96% more likely to be remembered.3 So why is sound too often ignored? Largely, this situation occurs due to the existence of several common misconceptions about its application in marketing. Don’t underestimate the power of sound The biggest misconception is the belief that audio branding is the preserve of large multinational organisations with vast advertising budgets at their disposal. In fact, many people confuse the entire audio branding discipline with ‘sonic logos’, those catchy jingles created by companies to feature throughout their advertising. One of the best examples of this is the Intel jingle, which is now widely recognised throughout the world, becoming a potent tool for brand recall. But sonic logos are only one small element, meaning the idea that audio branding can only benefit recognisable megabrands

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is largely a misnomer. By far the largest application of audio branding is on the telephone – and this concerns companies of all sizes, including medical aesthetic clinics, for which the phone still represents a prominent source of inbound enquiries and patient liaison. When a customer calls to make an enquiry, they will rely on their sense of hearing to forge an initial impression of an organisation. If the company gets it wrong, it could prove seriously damaging, especially since research conducted by global research consultancy TNS on behalf of my company, PH Media Group, suggested that 73% of British consumers will not do business with a company again if their first call is not handled satisfactorily.4 Common mistakes include leaving the customer to listen to silence, rings or beeps while they wait on hold. Even voice and music messages can have a detrimental effect if they are repetitive, poorly designed or provide too little information to keep the customer engaged. Similarly, it is important to give thought to what customers hear on premises. What they hear while they are having a treatment will play a key role in helping them to forge an impression of the overall experience. Playing the radio or inappropriate music may impact negatively on the professionalism of the clinic, rather than creating the ideal environment for customers. Make all the right noises Given the implications of providing a poor-quality audio presence, there are business benefits to be gained from following a best practice approach. This is particularly true considering the lack of awareness around applications of audio in marketing. Companies who create a powerful audio profile can use it as a key differentiator, helping them to stand out in a crowded marketplace. When introducing audio branding, medical aesthetic clinics should approach the process much in the same way they would visual branding. That is to say they should start by considering the company’s values and the image it needs to portray and work forwards from there, creating voice and music that matches these core values. As with any other element of marketing, brand congruence is key. Clinics should create an audio presence that fits comfortably with existing elements of visual branding and ensures patients are presented with a coherent, consistent brand they can trust. Clinics can either go about this by themselves or choose to partner with a specialist who has a clear understanding of their brand and how this might translate to audio. Occasionally, businesses will create their own audio brand by simply choosing pre-produced voice and music, but this ignores the subtleties of their individual brand and creates a profile that blends into the crowd rather

Common mistakes include leaving the customer to listen to silence, rings or beeps while they wait on hold

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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than standing out. Ultimately, it all boils down to the perceptions associated with the different attributes related to voice and music, whether it’s tone, tempo, pitch or any other variables. Find your voice When it comes to voice, the key variables are gender, age, tone and accent, and there are a number of combinations that can be used to convey different meanings. A feminine voice, for example, is typically perceived as soothing and welcoming, so can be used to communicate a sense of dedicated, compassionate service, especially when combined with a soft, informal tone. On the other hand, a deeper, masculine voice is most frequently perceived as authoritative, so can be particularly effective in conveying a sense of professionalism and competency when allied with a corporate tone.5,6 The temptation for medical aesthetic clinics might be to follow industry stereotypes and opt for a feminine voice simply because it matches typical preconceptions of the industry. This might not be a bad thing given the predominantly female customer base, however it is more important to consider the unique identity of the brand and develop a solution that fits with it. A corporate, male voice might be best suited for a clinic that prides itself on high levels of professionalism and expertise first and foremost, but there is a risk they may come across as too stuffy or unfriendly to some patients. There is also the factor of age to consider. Perhaps unsurprisingly, an older voice is generally perceived as more knowledgeable or wise, while a younger voice can deliver vibrancy and energy, perhaps reflecting a fresh approach. Accent too has a role to play, whether received pronunciation or heavy in dialect. Regional accents can also be a powerful tool for reinforcing identity where a clinic has a strong presence rooted in a particular geographical area, helping to assert a sense of provenance and belonging, speaking to customers in a manner they relate to. Choosing music to match Voice does not often work in isolation and it is also important to select the appropriate music to reinforce the desired brand characteristics. Often, clinics will choose popular tracks to be played on the phone and on premises, believing this represents the best way to engage with patients. But the problem is that popular tracks come with emotional baggage, as people will often attach feelings, both positive and negative, to a piece of commercial music. For example, a patient might attach a certain song to a particularly difficult time in their life and it may result in a negative perception being created in their subconscious. Using commercial music, no matter how positive or upbeat it may initially seem, is a lottery of the individual’s previous experience of the track. Instead, in the same vein as voice, a company should look to create a music track that is tailored to their exact needs and requirements. The physical attributes of the track – whether major, minor, fast, slow, loud or quiet – are used to communicate emotional meaning and complement the characteristics of the accompanying voice. For example, a clinic striving to convey a relaxed, informal image might be best served choosing music that is largely soft yet uplifting and motivational. Those aiming for a more corporate, professional image could opt for something with a more corporate, authoritative feel, veering more towards major than minor and more controlled in style. Different combinations of the above attributes can make a track convey authority, confidence, empathy or a number of other attributes, in a manner that a commercial track is unlikely to achieve. This also applies to music heard in the clinic – the type of tracks used will help

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to mould the customer’s perception of their experience. As such, using bespoke tracks rather than commercial music allows a clinic to have much greater control over the environment they create on premises. It must be remembered that commercial tracks are written for an entirely different purpose, so will not accurately reflect a company’s brand values in the same way as bespoke music. Don’t fall foul of fatigue Although the appropriate combination of music and voice can have a profound effect on customers, one potential pitfall to be aware of is the possibility of fatigue. Despite its emotional power, sound feels less intrusive than bold visual advertising and it is widely acknowledged that sound can have a lasting effect on the customer’s subconscious, causing them to assimilate marketing messages without even knowing they are doing so. In my professional opinion, however, it can be argued that if a customer hears the same audio messages constantly, whether on the phone or on premises, they will reach a point where they simply switch off and the audio will no longer have the desired effect. Therefore, it is important to regularly refresh audio to ensure that it continues to resonate with patients. This can be done to reflect seasonal trends and promotions, helping to make audio branding more targeted, while being careful to make sure it does not stray off brand. A wider example of how this can be done successfully is the recent move by retail giant Tesco to change the sounds on its self-service checkouts to Christmas ones during the festive period. The move garnered the company a large amount of media coverage and aimed to generate goodwill among customers, reinforcing a customer-centred approach by displaying a strong sense of humour. Conclusion Research has suggested 54% of British consumers believe a company sounds more professional if it uses bespoke voice and music over the telephone.4 Audio branding is no longer restricted to the largest businesses, and clinics can either independently try to develop their audio brand or choose to work with an appropriate specialist. Examples like the one describing Tesco’s approach to audio branding detailed above show exactly what kind of impact sound can have on us throughout our interactions with business. Patients will be exposed to audio both when calling up to make an enquiry and when visiting the premises for an appointment, so it is important to ensure any sounds they hear communicate the desired messages and brand values. If both voice and music are created in a way that complements one another and reinforces existing brand values, it can help to differentiate a company from the competition. Dan Lafferty is director of music and voice for PH Media Group and has worked as an audio branding consultant for the past six years, advising companies on how best to use sound as part of the marketing mix. He has worked extensively on the psychology of sound, studying how audio can help to shape consumer behaviour. REFERENCES 1. ‘As Light as your Footsteps: Altering Walking Sounds to Change Perceived Body Weight, Emotional State and Gait’, UCL Interaction Centre, p.6. 2. Tajadura-Jumenez, A, Basia, M, Deroy, O, et al, ‘As Light as your Footsteps: Altering Walking Sounds to Change Perceived Body Weight, Emotional State and Gait’ (2015), <https://www.ucl. ac.uk/uclic/research/CHI2015/Tajadura-Jimenez.pdf> 3. Dr Adrian C. North, Dr David J. Hargreaves, independent survey at Leicester University. 4. TNS UK Business Onlinebus Survey (S6477 - 260121843), Call Handling Standards, (September 2014), pp.11-15. 5. Garber, M, ‘Why We Prefer Masculine Voices (Even in Women),’ The Atlantic, (2012) <http://www. theatlantic.com/sexes/archive/2012/12/why-we-prefer-masculine-voices-even-in-women/266350/> 6. Louet, S, ‘Your Voice: Your Passport to Aythority,’ Science AAAS, (2012) <http://www.sciencemag. org/careers/2012/01/your-voice-your-passport-authority>

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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The Importance of Understanding your Patients Professional coach and facilitator Adrian Wales details how understanding different personality types in patients and clinic staff can help to achieve a harmonious workplace and provide better care Nowhere is it more important to truly understand both yourself and the other people around you than in the medical profession. Practitioners and support staff deal with a complex variety of patients of every age, background, race and culture every day, and all their unique needs and wants, differing expectations and sometimes rather unusual demands. Some patients may be very demanding, occasionally arriving late, some asking numerous questions, others extremely sensitive, some very cheerful and smiley, others more reserved and downbeat, and occasionally, patients who can be very rude. And, of course, the clinic teams themselves are also made up of so many different types of individuals, having different levels of education, a diverse range of beliefs, and manifold behaviour patterns; each having their own distinct motivation for doing the job they do, which, in turn, plays a vital role in their approach to their patients. Trying to empathise with and relate to such a potentially bewildering variety of patients can be very stressful, in a specialty that is already highly demanding and constantly changing. How helpful would it be to be able to recognise and satisfy the needs of the impatient patient, the one who is likely to want to know every small detail of the treatment process, the ones who need lots of reassurance and the patients who really appreciate directness and honesty? Also, think about how valuable it would be to really know and appreciate the strengths and unique skillset of every member of your team; to comprehend why some appear more process-oriented, while others seem to prize knowledge and intellect. For some, duty and responsibility is the main driver for their work, while others always want to put people first, no matter what the rules and procedures say. In this article I shall explore the history of personality profiling and how to incorporate a new way of thinking into your clinic to give a real insight into the unique requirements of your patients.

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History of personality profiling Personality profiling is a fascinating and revealing way of really understanding people, which has been developed and used for more than 2,000 years. Since ancient times, humans have sought to explain behaviour by categorising personalities into distinct types. In some of the earliest known writings, including the Bible, there are passages indicating a basic awareness that people have different personality types. But perhaps it’s no coincidence that the Greek physician Hippocrates, often referred to as the ‘father of western medicine’ was also one of the first to recognise the fundamental differences in the psychological makeup of people and the important link with their physiological health as far back as 400BC.1 Hippocrates’ research suggested that there were four basic personality types, or temperaments. He proposed that each temperament was formed by an inequality of the secretions coming from the heart, the liver, the lungs and the kidneys, even though at that time he may not have had much knowledge about the existence of such physiological processes as surgical operations hadn’t been undertaken.1 Then, around 200A.D. Galen, a prominent Greek physician in the Roman Empire, picked up this work and went on to name the temperaments after the four secretions, which embodied the different personality types: 1 Sanguine (blood from the heart) – buoyant, cheerful, hopeful Choleric (yellow bile from the liver) – angry, cantankerous, testy Phlegmatic (phlegm from the lungs) – listless, indifferent, passive Melancholic (black bile from the kidneys) – dejected, gloomy, morose Incredibly, in various forms, the four different personality types have continued to be used right up to the modern day, albeit somewhat more tactfully described. Hippocrates’ work proved to be the basic foundation for most of the current personality profiling tools, and his work was picked up and developed by the psychologist Carl Jung in 1921 who further developed the four different personality types and provided the foundation for more contemporary versions, including MyersBriggs (MBTI), DiSC and True Colors.2 And, just as Hippocrates’ ancient work paved the way for the development and

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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For some, duty and responsibility is the main driver for their work, while others always want to put people first, no matter what the rules and procedures say understanding of how to treat physical ailments, his initial studies on identifying the basic personality differences of individuals enabled many to be able to understand themselves and others, build strong and productive relationships based on appreciating each others’ differences, communicate effectively in personal and professional circles and thus increase their self-worth, confidence and value to their team. How does personality-profiling work? While there are a number of different personality profiling methods, they invariably involve some type of assessment, often a questionnaire completed by the individual, either online or on paper. However, some of the more modern methods are designed to be used by workplace teams. For example, the True Colors system uses cards with different colours, images and descriptions, designed to help the person connect with the characters portrayed.4 Gold: These are people who need to be responsible. They want to be of service and care for others. They value structure, duty and stability. Blue: These people need to be authentic. They seek harmony in their relationships and are sensitive and empathetic. Green: These are people who need to be innovative. They are often analytical, logical and intellectual types – the problem solvers. Orange: These are people who need to be skillful; they are active, competitive, energetic and always looking for variety in their lives and work. A certified facilitator will be sent to a business to lead the seminar, which usually lasts for around three hours. In a typical True Colors workshop participants in the learning discover their own colour ‘spectrum’, understanding what are their primary drivers and thus being able to identify their main values, needs, strengths and characteristics.4 This happens by taking an assessment test, during which they indicate whether certain characteristics are similar or dissimilar to them. They also review cards that have pictures of mimes portraying certain characteristics on one side and colours on the other. They then spend time with colleagues who are similar in personality, picking up and reflecting on the natural synergies in this exercise, before working with others who are very different to them. This is invaluable in understanding the connections we can have with people who may, on face value, appear to have little in common with us but, on closer examination, have many elements to their personality which we can ‘strike a chord’ with. 

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In the workplace, this learning translates into far more effective and cohesive teams. Where once the natural differences in people’s motivation, values and ways of working appeared divisive, with greater understanding teams learn to harness their diversity in positive ways. They can often agree the best people to use in a particular situation, depending on the issue. Perhaps more analysis is called for, maybe a good organiser, perhaps a pragmatist or an individual with a natural feel for a persons’ needs.   With patients, it is often far easier to recognise their individual wants with our greater knowledge of different personality types. And in understanding why some may appear more needy, more impatient, more cantankerous or more interested in procedures we can significantly enhance the quality of their individual care, leading to a greater satisfaction with the service we give. In a team environment, there is a great opportunity for course attendees to discover their ‘true colours’ together, learning, not just about their own unique personality type, but also their colleagues, thus promoting deeper communication and understanding. Conclusion Personality profiling has now been used extensively in many private and public sector industries, including the medical profession, both in the UK and in other countries. In fact, a programme was recently developed to specifically help build resilience, manage stress and increase staff engagement using personality profiling for a London-based NHS Trust. As well as helping staff to understand themselves and colleagues better, thus improving team working and communication, the programme also looked at how different personalities deal with change, something that is a constant in most professions and particularly in the medical profession.3 This has proved to be particularly beneficial for staff engaged in patient care, with participants in the training feeling more in touch with their patients, better engaged, more resilient, having greater understanding and feeling their unique contribution within the team is both recognised and appreciated more. Participants in the programme also reported an increased empathy with patients, more productive relationships with colleagues and an ability to identify negative triggers and stressful situations that enabled them to develop healthier coping mechanisms. There was, overall, a greater satisfaction with the work environment and increased emotional awareness. The physical and mental health and wellbeing of patients is paramount in the medical profession. Being able to recognise patients’ core values and individual preferences can only enhance the care they receive. The starting point, though, is having the ability to recognise the differences in both our colleagues and ourselves. This is essential to maintain our energy and our fulfilment at work, celebrate our team strengths and provide the very best in patient care. Adrian Wales is a director at LPD Associates Ltd. He has worked extensively in leading, coaching and developing teams for more than 25 years. Wales is a licensed True Colors facilitator and his work has taken him into health, education and business, promoting cultures of high performance within supportive and healthy environments. REFERENCES 1. C, George Boeree Early Medicine and Physiology, neurophysio (2002) 2. http://webspace.ship.edu/cgboer/neurophysio.html 3. McLeod, S. A, Carl Jung, Simply Psychology, (2014) <www.simplypsychology.org/carl-jung.html> 4. Guy’s and St Thomas’ NHS Foundation Trust, The Difference is You Development Programme 5. Education World, Do you know your students’ ‘True Colors?’ Administrator’s Desk, (2016) <http:// www.educationworld.com/a_admin/admin/admin230.shtml>

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Booking now open for the Aesthetics Awards 2016 With more than 600 of the best industry professionals in medical aesthetics gathered in one venue, don’t miss your chance to attend the prestigious Aesthetics Awards 2016. While entry has closed and finalists are being chosen, booking has opened for the mot esteemed celebration in medical aesthetics. The Aesthetics Awards 2016 will be held at the Park Plaza Hotel, Westminster Bridge on Saturday December 3 and will present the perfect occasion to celebrate the achievements of the past year with peers, friends and colleagues. Guests will enjoy a drinks reception, a performance from a top comedian and a formal sit-down dinner, before the evening’s main event will begin. Once the winners have been announced, guests can enjoy music and dancing late into the night. The Aesthetics Awards 2016 promises to be a night to remember.

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What the experts say...


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“You should embrace little detours because it’s all part of the journey” Dr Stefanie Williams relives her route into dermatology and aesthetic medicine and provides insight on the differences between aesthetics in the UK and Germany When Dr Stefanie Williams began studying medicine in her home country of Germany, she thought her future career would belong in neurology. “I did my doctoral thesis on Parkinson’s disease and then discovered I didn’t really want to do neurology anymore as you have a very limited type of patient,” explains Dr Williams. She went on to do an elective in dermatology and immediately fell in love with skincare. “I just absolutely love dermatology because it’s so varied and there are so many different aspects of skin – I love skin – it’s like a hobby to my profession.” Dr Williams completed her higher specialist training in dermatology after having worked in several German university departments including Bochum, Ulm and Hamburg. She completed her German dermatology ‘exit exam,’ a separate compulsory qualification, in Hamburg. “After five years of postgraduate training and finally specialising in dermatology I started working in Germany in dermatology clinics, where I also did some aesthetic work, and then I came over to England about 12 years ago because I married an English man.” When Dr Williams arrived in England she began working as a local consultant dermatologist in the NHS in Surrey, where she saw a big difference in dermatology practices between the two countries. “In the UK, GPs filter out what seems to be 90% of all patients,” she explains, whereas in Germany, dermatologists don’t necessarily have the GP as a ‘gatekeeper’ so patients can book straight in with a dermatologist to discuss whatever skin worries they have. “I did hardcore NHS dermatology – it was very interesting but I didn’t really enjoy it because I found the amount of constraints frustrating.” Dr Williams says she was disappointed that she couldn’t treat people with skin conditions such as milder rosacea and acne as they were considered “not so serious” even though they still needed the attention of a dermatologist. “German dermatologists very often have an overlap of medical dermatology and aesthetics and do aesthetic work on the side or even spend half of their time doing it – it’s nice to have that overlap.” But the number of dermatologists doing aesthetics in the UK is much lower. Dr Williams says, “Most dermatologists here are really focused on medical work, and may even consider aesthetic work as being somewhat ‘dirty’. In a way, it’s perceived as ‘going to the dark side,’ which is interesting.” In 2007 Dr Williams decided to greatly reduce her NHS work and setup her first clinic, European Dermatology London, which has grown from a room in a local GP practice in Putney to a brand new flagship clinic in Vauxhall – rebranded as Eudelo, in March 2016. “With opening our main clinic in Vauxhall, we went very much against the grain and slightly against the ‘old school’ Harley Street but it’s working really well.” Dr Williams says one of the best things about being in aesthetic medicine is that it goes hand in hand with her dermatology training. “A recent patient of mine came for a botulinum toxin treatment and I noticed she had a skin cancer on her neck and she didn’t know at all! We arranged for it to be taken out urgently – which was very lucky for her – that’s the great thing about having a background in medical dermatology.”

Outside of clinical practice, Dr Williams is an associate lecturer and researcher at the University of the Arts London in the department of cosmetic sciences. She is also a member of several societies and is passionate about educating others. “It’s so important that you educate yourself by going to conferences, listening to your colleagues and being a part of certain societies and membership organisations so you can stay on top of new developments, and it’s fun as well!” Keeping up with education, Dr Williams says, is one of the hardest parts of being a part of the aesthetic industry, but explains that it is something that defines a good practitioner, “Someone may have injected for 20 years and think they are really experienced but unless they constantly update their knowledge, they might be worse than somebody who has only done it for five years but has constantly kept up-to-date with new developments.” Although Dr Williams says the industry is extremely competitive, she hasn’t found it too difficult to stand out. “There are lots of people dabbling in and out of it and I think there is huge competition, but at the same time I think if you are doing your job well, it is not too hard to find a place.” When asked what her biggest accomplishment has been so far, Dr Williams says, “I would say that my three children are my biggest achievement in life, but in regards to my work I am incredibly proud of creating Eudelo.” To be successful, Dr Williams stresses that training is key, “I would advise people to initially work in a bigger team with experienced people around them where they can observe other practitioners – don’t just open up your own practice.” Her best advice to practitioners is, “Keep watching other injectors inject and accumulate as many hours as you can because you can’t learn a technique any other way.” What treatment or technology do you most enjoy? I love doing facial contouring using fillers but I really like doing it conservatively, I hate the ‘pillow cheeks’ that you see everywhere at the moment. Do you have an industry pet hate? People pumping up or freezing patients’ faces or injecting without looking at the bigger picture of skin regeneration and actually slowing down the ageing process. What is your advice to other practitioners? Keep your knowledge up-to-date, keep watching and observing people and take note of their techniques. Learn as much as you can. Would you have done anything differently? No because I think you learn from your mistakes – you should embrace little detours because it’s all part of the journey! What is your favourite thing about your job? The difference you can make to patients’ lives in the increase to their self-esteem and confidence.

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Aesthetics Journal

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The Last Word Independent nurse prescriber Kelly Saynor discusses the importance of a cooling-off period and debates the related ethical and legal dilemmas “I’d like you to go away and think about it.” A potential patient blinks at me in surprise, and says that they want the treatment now. “Yes and I’d like you to go away and think about it,” comes my reply. Perhaps surprisingly to some, this conversation plays out in many aesthetic clinics on a fairly frequent basis and I regularly turn away one to two would-be patients each month. Whilst most patients are well-informed, having thoroughly researched the type of treatment they’re hoping to receive, some come rushing through the door wanting their procedure to be carried out immediately. I recently had a patient who wished to progress with a medium-level chemical peel. She had little appreciation of the five-toseven-day downtime period that would be required post-peel, thinking that a ‘weekend at home’ would suffice. For a very busy public relations professional who had to attend three or four public events in any given week, this was a tall order! After some reflection and considerable diary shuffling, she did go on to have a very successful peel about six weeks later, however examples such as this perfectly highlight the fact that time to cogitate is essential – particularly when treatment affects patients’ everyday lives (albeit for a short time) in ways they just may not have considered. Guidance In June last year, the General Medical Council (GMC) released the draft of its first set of guidelines for doctors offering surgical and non-surgical procedures in response to The Keogh Review in 2013. The guidance was officially released in April this year and came into effect in June and said that practitioners should give patients, ‘The

time and information they need to reach a voluntary and informed decision about whether to go ahead with an intervention’. It added that the amount of time needed for reflection depends on ‘The invasiveness, complexity, permanence and risks of the intervention, how many intervention options the patient is considering and how much information they have already considered’ and that a practitioner must tell the patient they can change their mind at any point.1 More guidance aimed specifically at surgeons was also released in April, and recommended that they should implement a two-week coolingoff period before any surgery is carried out.2 The importance of the ‘cooling-off period’ Giving the patient time to reflect and think about a potential treatment after a consultation is, in my opinion, our moral and ethical responsibility as practitioners. Cooling-off periods are important for a myriad of reasons; but ensuring that the patient has given due consideration to the treatment they wish to have, and that their expectations of the results are realistic, are of paramount importance. After an initial consultation, a tremendous amount of information has been imparted and it’s essential that the would-be patient has enough time to digest the facts. In terms of how long a cooling-off period should be, I wouldn’t say there’s a one-sizefits-all approach; I often suggest anything from a couple of days to a week or more. It can depend less on the treatment and more on the individual – if I have a suspicion that a particular patient is acting on impulse, has widely unrealistic expectations or doesn’t have a proper understanding of any downtime

post treatment, I will insist on a longer time frame. This is especially true where aesthetic treatments such as botulinum toxin, fillers and lip enhancers are concerned. Often patients expect that botulinum toxin can be administered immediately – they’re unaware that it can only be given with a prescription, and therefore is not always available ‘there and then’. Some people can get frustrated when I ask them to return at a later date to be treated, but from experience I know cooling-off periods can build stronger patient relationships. Not only do they increase patient-practitioner trust, they also promote a certain sense of realism in the expected outcome. People who rush into treatment often expect dramatic results, which may lead to disappointment. Ultimately we strive for happy patients and cooling-off periods are an essential building block in nurturing this longterm relationship. Conclusion The GMC guidance that came into play on June 1, as well as The Keogh Review, do represent a positive way forward for a number of issues, including cooling-off periods, and give reassurance to those who are committed to working ethically and promoting best practice. It’s important to reiterate at this point that the new measures only affect formally-trained doctors. As a registered nurse practitioner, do I welcome such a move? Wholeheartedly. Do I feel that my own industry, as well as others not mentioned in these documents, are in urgent need of similar independent governance? Absolutely. Of course, when insisting on a cooling-off period, it’s possible that if the patient is desperate to undergo the procedure, they will simply go to another clinic. As medical practitioners however, we have a duty of care, which dictates that we must know when to say ‘no’ and give patients time to reflect upon the possible procedure. At best, we could be accused of placing profits before ethics, at worst we could be blamed for perpetuating body dysmorphia in vulnerable patients. Kelly Saynor is a cosmetic nurse and independent prescriber with more than 13 years’ experience. She is the founder and owner of Renew Medical Aesthetics in Cheshire and is also clinical lead at UK-based distribution company, Medica Forte. REFERENCES 1. General Medical Council, Guidance for doctors who offer cosmetic interventions (April 2016) <http://www.gmc-uk.org/ guidance/ethical_guidance/28687.asp> 2. Royal College of Surgeons, Professional Standards for Cosmetic Surgery (April 2016) <bit.ly/RCScosmeticstandards>

Reproduced from Aesthetics | Volume 3/Issue 8 - July 2016


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Date of Preparation: October 2015


Aesthetics July 2016