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VOLUME 4/ISSUE 8 - JULY 2017

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Environmental Influences CPD Dr Raul Cetto conducts a literature review of influences on cutaneous ageing

Special Feature: Sun and Skin Practitioners discuss how to protect different skin types from the sun

HA Overview Dr Tatiana Lapa and Mr Rishi Mandavia explore the different types of hyaluronic acid fillers and their indications

Getting Ready for GDPR Martin Swann provides advice on how to comply with new data protection laws


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Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. https://www.accessdata.fda.gov/cdrh_docs/pdf5/p050052s049a.pdf

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Contents • July 2017 06 News The latest product and industry news 14 On the Scene

Out and about in the industry this month

CLINICAL PRACTICE 16 News Special: Visual Loss

Aesthetics explores a new organisation which aims to support practitioners dealing with visual loss complications following dermal filler treatment

21 Special Feature: Skin Types and the Sun

Practitioners discuss how to protect different skin types from the sun

26 CPD: The Environment and Cutaneous Ageing

Dr Raul Cetto conducts a review on environmental influences on cutaneous ageing and their clinical consequences

31 An Introduction to Medical Microneedling

Dr Olha Vorodukhina details her techniques for medical microneedling

34 Incorportating Nutrition with Body Contouring

Dr Jorge Zafra and Dr Kam Singh share their dietary advice for patients who have undergone a body contouring procedure

39 Beard and Moustache Restoration

Dr Greg Williams discusses facial hair transplant techniques for men

43 Treatments and Herpes Simplex Virus

Dr Cormac Convery outlines the relationship between HSV reactivation following aesthetic treatments and the appropriate methods of prevention

47 PRP Hand Rejuvination

Aesthetic nurse practitioner Claudia McGloin discusses hand ageing and the use of platelet rich plasma treatments

50 Gingival Hyperpigmentation

Dr Sarah Tonks provides an overview of pigmentation on the gums

53 Understanding HA Dermal Fillers

Dr Tatiana Lapa and Mr Rishi Mandavia outline the pharmacology, rheology and application of hyaluronic acid dermal fillers

56 Advertorial: VANIQA®

Hair removal in fair-haired patients A round-up and summary of useful clinical papers

IN PRACTICE 58 Getting Ready for GDPR

Martin Swann provides an introduction to the new data protection legislation

60 Five Tips to Maximise Clinic Success

Business coach Alan Adams advises on how to grow profits in clinic

64 Taking on Energy-based Equipment

Company director John Culbert explains what to consider when looking to purchase energy-based clinic equipment

67 In Profile: Dr Britta Knoll

Aesthetic practitioner Dr Britta Knoll reflects on how she became a mesotherapy specialist

68 The Last Word

Mr Nihull Jakharia-Shah, Miss Priyanka Chadha and Miss Lara Watson explore the validity of HEE’s ‘see 10, do 10’ training requirement

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Clinical Contributors Dr Raul Cetto practises at Clinic 1.6 London specialising in facial aesthetics. He is an honorary researcher and lecturer at Imperial College London and senior clinical lecturer for Harley Academy. Dr Olha Vorodyukhina is a dental surgeon and aesthetic trainer. She is the owner and founder of Shine Medical and Angels Twelve Skin Clinic in Nottingham, as well as the lead aesthetic trainer for Cosmetic Courses in the Midlands. Dr Jorge Zafra has a Master’s degree in Aesthetic and Anti-ageing Medicine from the Universitat de Barcelona, Spain. He has worked as a GP and has a private medical practice, Zafra Medical, which is based in Bristol. Dr Kam Singh has been a GP for 22 years and has a passion for cosmetic medicine and dermatology. He is a national trainer for VASER and currently works with three surgeries, as well as running his own private medical practice, Beau Aesthetica. Dr Greg Williams is the only member of the British Association of Aesthetic Plastic Surgeons (BAAPS) who is a full time hair transplant surgeon. He has more than a decade of experience in hair restoration for burns and trauma. Dr Cormac Convery is the medical director at the The Bloomfield Clinic in Ayrshire and The Ever Clinic in Glasgow and Edinburgh. He is a faculty member in Aesthetic Medicine at QMUL and is an ACE working group member.

57 Abstracts

Special Feature Skin Types and the Sun Page 21

Claudia McGloin is an aesthetic nurse practitioner with more than 20 years’ nursing experience. She is also the clinical director of the Claudia McGloin Clinic and is highly involved in patient safety. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at the Chelsea Private Clinic, she practises cosmetic injectables and hormonal-based therapies.  Dr Tatiana Lapa is the medical director of The Studio Clinic on Harley Street. She has a background in surgery, dermatology and general practice and has conducted trials in specialist centres in Brazil and London. Mr Rishi Mandavia is a trainee ENT, head and neck surgeon and NICE scholar with academic interests in ENT health policy research. He has published more than 20 peer-reviewed studies and book chapters.

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Editor’s letter Welcome to our July issue! By now we should be basking in warm temperatures and keeping safe in the sun – let’s hope so anyway. As this is our sun edition, I thought it would be interesting to look at the latest data on skin Amanda Cameron cancers – did you know that according to Cancer Editor Research UK, in the 1970s, almost half of people diagnosed with malignant melanoma skin cancer survived their disease beyond ten years? Now it’s nine in 10! As well as this, 86% of cases of melanoma skin cancer in the UK are preventable, so as practitioners we need to ensure we have the latest information to relay back to our patients on sunscreen use, as the majority of people apply too little too infrequently! As a guide, adults should aim to apply around two teaspoons of sunscreen if you’re just covering your head, arms and neck and two tablespoons if you’re covering your entire body while wearing a swimming costume. Read our Special Feature this month for more tips on how to manage your patients in the summer

months and prevention and treatment recommendations for different skin types for sun damage (p.21). Our CPD this month by Dr Raul Cetto (p.26) continues with our sun theme – it is a literature review on how environmental factors affect ageing and there’s no surprise that sun and smoking feature highly! It is a fascinating read. You can also learn about dietary advice for patients undergoing body contouring treatments this month with Dr Jorge Zafra and Dr Kam Singh (p.34) and for those who want to understand more about hyaluronic acid, Dr Tatina Lapa and Mr Rishi Mandavia provide a great overview on p.53. You can also enhance your knowledge on developments in general data protection regulations with Martin Swann (p.58), which are coming into effect next year. Entry to the Aesthetics Awards is now closed so I hope you all got your entries in on time! To those who did, best of luck. I’m sure the Aesthetics judges will have a tough job on their hands going through the entries. Finalists will be announced in the September journal. We welcome any feedback you may have on our sun issue – email editorial@aestheticsjournal.com.

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

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

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

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 17 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

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

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

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

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

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

If you are interested in sharing your clinical or business knowledge with our readers then contact the team by emailing editorial@aestheticsjournal.com or calling 0207 148 1292.

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Industry

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Journal Dr Rashpal Singh @DrRashpalsingh @aestheticsgroup great evening read

#Training Dr Giorgia Ratta @drGiorgiaRatta Great training session yesterday evening with @HyalualUK @DrVWong and @DrDanielSister really enjoyed it! #PRP #Redermalization #XelaRederm #Sun Dr Ifeoma Ejikeme @DrEjikeme Don’t forget your Sunscreen today! #goodskintakeswork

#Presentation Jp (Joon Pio) Hong @Jp_Joonpio_HONG Dr Dan Liu presenting on how social media impacts reconstructive microsurgery at #WSRM17 @danielzliu #Conference AnneSmith Aesthetics @auntie_wrinkle I’m currently at the #Galderma #Aesthetics academy annual conference. A day of learning and updates in #Leeds #LeedsNMCon17 #alwaysimproving #Masterclass HA-Derma @ha_dermauk Our first #Profhilo training at @ATA_Scotland went very well… we will be back in #Glasgow soon… thank you @ATA_Scotland @emmaravi_emma #Launch Complete Laser Care @completelaserc We wish to thank everyone who came to #ImageSkinEvent & Launch of our new clinic. We had a fab day, thank you #Sineadcurvystyle for popping in!

JCCP announces new technology partners The Joint Council of Cosmetic Practitioners (JCCP) has appointed new technology partners to assist with data collection. The organisation has partnered with HF Resolution Ltd to manage its Practitioner, Education and Training Registers; and Treatments You Can Trust (TYCT) in partnership with Northgate Public Services to help collect patient data. Interim chair, professor David Sines said, “After an extensive open, independent and transparent procurement process, the JCCP, with support from the Cosmetic Practice Standards Authority (CPSA), has selected HF Resolution, Northgate Public Services and TYCT as its key technology partners. It is very reassuring that we can bring on board these hugely experienced partners with a long track record of activity and credibility in the non-surgical sector.” As part of the new partnership, HF Resolution Ltd, a company that runs consumer redress schemes, will help to transact, deliver and maintain the Practitioner, Education and Training Registers. Managing director of HF Resolution Tim Frome said, “We are delighted to be chosen as the preferred supplier to build and manage the technology platform which will be used to run the Practitioner, Education and Training JCCP registers. We will use our experience in building and running platforms suitable for managing high volume membership schemes to provide the best possible solution to the JCCP. We are fully engaged with the JCCP objectives and look forward to assisting the JCCP in achieving its core aims of improving standards and consumer confidence in the cosmetic industry.” The JCCP Register will officially launch in November 2017. Conference

IAPCAM to hold first symposium in September The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) will host a symposium in September to further educate practitioners on the management and prevention of complications for medical aesthetic treatments. The symposium, which will be the association’s first, will feature a group of national and international practitioners who will provide their advice through presentations and live demonstrations. The event will be chaired by IAPCAM founder Dr Beatriz Molina and co-chaired by Dr Uliana Gout. Dr Molina said, “The IAPCAM will be great to get all the different specialists collaborating to try to standardise the management of complications for best practice. I am sure that after attending this symposium, delegates will be more confident in the management of the different issues, particularly when serious complications occur during treatment of their patients.” Dr Molina added, “This is the first ever symposium to deliver guidelines on management of complications as well as demonstrating on live patients how to inject hyaluronidase. We will also cover other complications from lasers and chemical peels.” The IAPCAM symposium will take place on September 22 at the Royal College of Physicians in London.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Awards

Booking now open for the Aesthetics Awards

Vital Statistics According to data collected by WhatClinic. com, enquiries for male breast reduction surgeries in the UK have increased by 49% over the past two years (WhatClinic, 2017)

On December 2, around 700 professionals from across the aesthetics sector will congregate at the Park Plaza Westminster Bridge Hotel in London to celebrate a night of excellence in the specialty. With entries now closed, booking is open for practitioners, clinics, companies and organisations looking to attend the prestigious ceremony. Guests will be able to enjoy a networking drinks reception, a delicious threecourse meal, entertainment from a top comedian and music late into the night. The ceremony will honour Winners, Highly Commended, and Commended finalists in 26 categories that recognise the hard work that clinics, companies, products, training providers and individual practitioners have displayed in 2017. Dr Benji Dhillon of PHI Clinic, which won The Medfx Award for Best Clinic London in 2016, said, “The Aesthetics Awards is the number one event to go to in the awards calendar so it’s something we couldn’t miss. To be with all of these amazing people and companies is just great – it’s something I definitely wouldn’t miss!” Tickets are selling fast so those interested in attending are encouraged to book a table for their team and clients as soon as possible. If you are still interested in entering the Awards, contact the team to find out more about late entries: support@aestheticsjournal.com. Show your friends that you are attending the best awards ceremony in the specialty and stay up-to-date with all the latest Awards announcements by stating that you are ‘going’ on our Aesthetics Awards Facebook event.

Industry

FDA warns of counterfeit Juvéderm products in the US The Food and Drug Administration (FDA) has issued a public warning of unapproved versions of Allergan’s product Juvéderm. The FDA is aware that unapproved versions of the product, which include Juvéderm Ultra 2, 3 and 4, are being sold and distributed illegally in the US. The product, which consists of hyaluronic acid, should only be injected and sold by, or on the prescription of, a licensed healthcare provider, the agency reported on its website. The warning states that healthcare providers and patients in the US should be wary when using Juvéderm Ultra 2, 3 and 4, as they cannot assure the safety and effectiveness of the products.

63% of men in the US think women mainly wear makeup to trick people into thinking they’re attractive (YouGov, 2017: survey of 5,855 US adults)

Existing customers are 50% more likely to try new products and spend 31% more compared to new customers (Nielson, 2013, survey of more than 29,000 internet respondents in 58 countries)

11.5% of bullying victims have an extreme desire to have cosmetic surgery, according to a study conducted by the University of Warwick (University of Warwick, 2017)

A report from the American Society of Plastic Surgeons (ASPS) said gender confirmation surgeries had risen by 20% in the US (ASPS, 2017)

Women in Australia are more likely to purchase their cosmetics from a chemist, than any other store (Roy Morgan Research, 2017)

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Events diary 4th - 6th July 2017 British Association of Dermatologists 97th Annual Meeting, Liverpool www.bad.org.uk

15th - 16th September 2017 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

23rd September 2017 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

2nd December 2017 The Aesthetics Awards 2017, London www.aestheticsawards.com

27th - 28th April 2018 The Aesthetics Conference and Exhibition (ACE) 2018, London www.aestheticsconference.com Sun

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Rejuvenation

NeoStrata releases new products A new retinol peel and post-procedure restorative treatment has been added to the NeoStrata portfolio. The latest addition to the NeoStrata ProSystem peel range is the Retinol Peel, which contains 3% retinol and aims to reduce fine lines, wrinkles and blemishes to provide a bright, even and clear complexion. Some of the key ingredients for the peel include the company’s NeoCitrate, which aims to enhance collagen and smooth the skin; botanical ingredient bisabolol, which is derived from chamomile and aims to calm and soothe the skin; and vitamin E, a source said to provide the skin with an antioxidant boost, protecting it from free radicals. The second addition, the NeoStrata ProSystem Bionic Oxygen Recovery treatment, aims to encourage post-procedure rejuvenation. According to the company, the product delivers molecular oxygen to increase cellular energy and optimise collagen levels. NeoStrata products are available in the UK through aesthetic distributor AestheticSource. Skin tightening

Drug produced to mimic ‘real sun tan’ A new drug has been developed that aims to mimic sunlight and cause the skin to tan without the damaging effects of UV radiation. According to scientists from Massachusetts General Hospital, the topical drug, known as a Salt-Inducible Kinases (SIK) Inhibitor, is rubbed into the skin to trigger the release of dark pigmentation. The team hopes their discovery could help reduce the risk of cancer and slow the appearance of ageing. They claim that the drug will also work on those with fair skin who are more prone to burning. The drug has been tested on ginger mice, which saw them turn jet black within two days, before fading a week later. The team hope to continue with human trials and want to combine the drug with sun cream, to provide maximum protection against the sun.  Dr David Fisher, one of the researchers, said, “We are excited about the possibility of inducing dark pigment production in human skin, without a need for either systemic exposure to a drug or UV exposure to the skin.” He added, “We need to conduct safety studies, which are always essential with potential new treatment compounds, to give a better understanding of the actions of these agents. But it is possible they may lead to new ways of protecting against UV-induced skin damage and cancer formation.”

Venus Freeze Plus launches Developer and manufacturer of non-invasive aesthetic devices Venus Concept has introduced the new Venus Freeze Plus for skin tightening.   The device is powered by the company’s patented (MP)2 technology, which combines multi-polar radiofrequency with pulsed electric magnetic fields and contains two new features to that of the Venus Freeze. According to the company, these two features, which include real-time thermal feedback equipment and automatic temperature control, enhance patient safety, improve the ease of use for the operator, and can create more constant and predictable results.   The first feature is the realtime thermal feedback equipment within the applicators, which aims to allow for easy and immediate monitoring of skin temperature profile to optimise safety and effectiveness. The automatic temperature control aims to make it easier to maintain a steady therapeutic temperature throughout the treatment, enhancing the consistency and predictability of results. 

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Training

Dalvi Humzah Aesthetic Training launches new course A new cannula masterclass has been introduced by Dalvi Humzah Aesthetic Training. According to the training provider, the masterclass is a specialised practical session, tailored to the safe use of blunt cannula for dermal filler placement. The course aims to cover a variety of techniques for the use of cannula, highlighting concepts of design and exploring indications and recommended sizes in anatomical areas. Each practical session lasts half a day and is led by consultant plastic, reconstructive and aesthetic surgeon, Mr Dalvi Humzah and dermatology and cosmetic nurse prescriber, Anna Baker. Mr Humzah said, “This course will provide practitioners with unique skills in using cannulas efficiently and will provide them with insights to techniques to reduce risks with injectables.” He continued, “We are very pleased to work with one of the leading cannula providers, TSK, and have Wigmore Medical supporting us in providing this course.” The course is open to registered medical professionals with active registration to the General Medical Council, Nursing and Midwifery Council and General Dental Council. The masterclass will take place on September 5 at Wigmore Medical in London. Skincare

DMK launches Fundamental Kits

BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses Thank you to all members who have renewed for the new membership year! If you haven’t yet managed to, or are looking to join the BACN, please contact Membership Manager, Gareth Lewis at glewis@bacn.org.uk. We are offering more services and opportunities than ever, and with our conference coming up soon, it’s the best time to join us.

BACN CONFERENCE 2017 Our Friday workshop sessions and evening reception are open to book onto for all members! A number of interesting and educational sessions are available, however there are limited spaces – don’t miss out. Highlights include Naomi Di Scala from Hamilton Fraser, Victoria Hiscock from AlumierMD and demonstrations from Dr Lee Walker on behalf of Teoxane, and Dr Ian Strawford for Sinclair Pharma. We have also confirmed our speakers for our full conference and exhibition day on Saturday September 16, who include Dr Tapan Patel, Mr Taimur Shoaib, Dr Kuldeep Minocha, independent nurse prescriber Melanie Recchia and Dr Elizabeth Raymond Brown. In addition, there will be more than 50 exhibitors showcasing their latest products and services on the Saturday. BACN members have the main conference on the Saturday included as part of their membership – all you need to do is book your place through the website.

CONGRATULATIONS TO OUR CEO

Skincare manufacturer Danné Montague-King (DMK) has launched three Fundamental Kits. According to the company, each Fundamental Kit focuses on a specific skin concern including acne, hyperpigmentation and age management. The kits contain one in-clinic skin treatment and one month’s supply of DMK Home Prescriptive products for patients to take home. The Home Prescriptive regime aims to stimulate collagen production and regulate cellular turnover. Training courses to gain a DMK Fundamentals certification will be held in Ascot, Berkshire with director of education, Susanne Williams. The training dates will be announced soon. Male patients

Enquiries for men seeking cosmetic surgery treatment rise Private healthcare search engine WhatClinic.com has released data indicating that enquiries for men seeking cosmetic surgery treatments have increased significantly over the past year. According to the search engine, male breast reduction has seen the most enquiries, increasing by 49% over the past year, followed by liposuction, which has increased by 21% over the first quarter of 2017. The number of men interested in abdominoplasty has also risen by 13%. Consultant plastic surgeon Mr Omar Tillo said, “Men who seek cosmetic surgery are often very fit and attend the gym regularly, but may have recently lost a large amount of weight and have residual pockets or areas of stubborn fat, which they find aren’t improving with diet and exercise alone.” 

BACN CEO, Paul Burgess, has been awarded an MBE for ‘services to people with disabilities and the community in Birmingham’. Paul has spent more than 35 years working in a voluntary capacity in Birmingham and the West Midlands, and everyone at the BACN is immensely proud of his achievements.

MEET A MEMBER Nikki Zanna is an independent nurse prescriber. She has been in the nursing profession for 25 years and has specialised in aesthetics for more than six years. Nikki started her aesthetics practice in 2010 when she founded Halo Aesthetics Cosmetic Skin Clinic, a boutique clinic on the outskirts of Milton Keynes where she offers a range of popular treatments in her busy clinic. In addition, Nikki is an Obagi Medical Ambassador and is dedicated to skin health, driven by professionalism and a duty of care. She has been a member of the BACN since 2012 and became a Regional Leader in 2013, covering the South Central area.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Skincare

AlumierMD releases Bright & Clear Solution Skincare developer Alumier Labs UK has introduced the Bright & Clear Solution to its AlumierMD products. The Bright & Clear Solution is a new skin conditioning formula, which aims to enhance skin cell turnover, refine its complexion, brighten and provide antioxidant defence. The active ingredients include lactic acid, which aims to exfoliate dead skin cells and enhance skin renewal to firm and strengthen, and bisabolol and arnica, which is focused on soothing and restoring the skin. It also contains the company’s Lime Pearl, an ingredient rich in alpha hydroxy acid, that aims to smooth, brighten and even the skin’s tone; and Superox-C, an antioxidant that is a source of vitamin C. According to the company, the product is applied twice-daily using a cotton pad after cleansing and before a serum and/or moisturiser. Clinic launch

sk:n launches new clinic in Bournemouth Aesthetic clinic group sk:n has announced the arrival of its 45th clinic in Bournemouth. The clinic has received major investment with new equipment, building restructuring and renovations, as well as staff training. Available treatments will include acne treatments, laser hair removal and rejuvenation treatments. The new clinic is situated in the same location as skincare group Even Lines. Dr Linda Eve, the founder of Even Lines, will continue as the aesthetic doctor and will be the key figurehead at both clinics. Dr Eve said, “sk:n has an excellent reputation, with highly trained staff, a recognised brand, and the very latest technologies and equipment available to customers. The staff are passionate about promoting improved skin health and wellness and Bournemouth is the perfect location to do this.” Peels

Murad introduces Rapid Resurfacing Peels Skincare company Murad has launched extra-strength at-home skin peels. The peels, which aim to reverse the signs of ageing and detoxify the skin, contain a blend of 10% glycolic acid and vitamin C. These ingredients are targeted at retexturising the skin, enhancing radiance, and evening skin tone without irritation or downtime. The product comes in a pack of 16 textured towelettes, which aim to allow for targeted application of active ingredients and removal of surface cells exposed to pollutants that have accumulated throughout the day. To use the product, Murad recommends wiping the towelette over a clean face, neck and chest and then allowing three minutes for full absorption. According to the company, the product should not be rinsed off, but followed with a moisturiser.

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Kelly Tobin, Regional Sales Manager at Med-fx What is Med-fx? Med-fx is the only facial aesthetic provider to offer a full range of the latest specialist products from toxins, fillers, cosmeceuticals and threads to accessories. We combine products, sector knowledge and dedicated support with market-leading know-how to help our customers grow profitable businesses. What does Med-fx offer its customers? A personalised bespoke service. The team has more years’ experience than we’d like to admit and we really get to know our customers and their patients. We build relationships and use our knowledge of the marketplace to help streamline the ordering process and maximise profit and growth in practice. Facial aesthetics isn’t a one size fits all approach and we add real value by offering a complete business service, from impartial onsite advice and guidance to marketing. Where does Med-fx see the aesthetics market in five-years’ time? It is growing at a crazy rate, it’s doubled in the last five years and we expect that to continue as the trend away from surgical procedures to non-invasive, or minimally invasive procedures, continues. What is your number one tip for aesthetics professionals who want to grow their business? Buy from Med-fx! It’s important to understand your patient base and what they want. It’s different across the country and what will work in one location may not work in another. It’s also important to offer a wide range of procedures, like threads, skincare and facial peels, rather than relying on one or two. The successful practices take time to analyse a face and combine treatments to get the optimum look, rather than relying just on toxin or fillers. What would you say is the purpose of facial aesthetics? The purpose is to enhance and restore patients’ natural beauty and not to go too far. Everything in moderation, the idea is to ensure patients look like themselves on a really good day.

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Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Dr Stefanie Williams joins the Aesthetics Editorial Board Dermatologist Dr Stefanie Williams has joined the renowned Aesthetics panel to help steer the direction of educational, clinical and business content within the journal. She is founder and medical director of EUDELO Dermatology & Skin Wellbeing; a multi-award winning skin clinic in London. Dr Williams is a key opinion leader for both dermatology and medical aesthetics, and is a regular speaker at both national and international conferences. She said, “I am delighted to join the Aesthetics editorial board and share my thoughts and ideas to contribute to the ongoing success of the journal.” Editor of Aesthetics Amanda Cameron said, “It is a pleasure to have Dr Williams join our board and share her dermatologic expertise with our readers. She is a great addition to our team.” On the Scene

Minding Your Ps – Pigmentation, Preparation and Peeling, London Aesthetic distributor Wellness Trading held an intimate workshop at the Royal Society of Medicine in Marylebone on June 13 to showcase the mesoestetic dermamelan peel for pigmentation. Dr Lori Nigro led the evening and gave an in-depth presentation on the causes of pigmentation and how to manage patients by looking at their skin types and the levels of melanin present. Dr Nigro said in her presentation, “This is one of the few chronic diseases we see in cosmetic medicine. We are never going to cure pigmentation; we are going to be managing these patients forever. My motivation to use dermamelan is because it’s a pigmenting peel and it is a product that’s effective in all skin types – that’s the most important thing about it.” Private GP and aesthetic practitioner Dr Suren Naidoo, who attended the event said, “I was very impressed with the presentation by Dr Lori Nigro on the different types of hyperpigmentation, diagnosis and management. I have great confidence that when I treat my patients with dermamelan, they will see positive results.” Katie Hassall, the aesthetic trainer for the south, said, “It’s been a successful evening because doctors who currently work with us attended and we got some new interest as well. Hopefully this event will generate some interest into the dermamelan treatment for pigmentation, which has been around for 30 years. Moving forward, these types of events will hopefully get in the diary more often to make people more aware of the treatment.” On the Scene

Cosmex Clinic Summer Showcase, Cambridge Cosmex Clinic in Cambridge opened its doors to existing and prospective patients on the evening of June 7 to showcase its most popular and newest treatments. Aesthetic nurse prescriber, clinical director and owner of Cosmex Clinic Lou Sommereux opened the event, welcomed guests and performed a live demonstration of a lip enhancement treatment using Restylane Kysse. Sommereux said of the event, “The evening was very informative and gave new and existing patients the chance to see live treatments being done and ask any questions they may have.”

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News in Brief Globe AMT unveils new website UK distributor Globe AMT has introduced a new website that features a list of treatments and products that it distributes, including Deka Lasers, SCIBASE and Pixience. Managing director of Globe AMT, Neil Roberts, said, “I am excited to launch the rebranded website for GlobeAMT, reflecting our technological lead in the aesthetic industry.” He continued, “It emphatically places vigour, customer service and value for money at the heart of our offering to the market.” Enhance Insurance employs new business development executive Enhance Insurance has appointed Sharon Allen as its new business development executive. Allen has more than 30 years’ experience within the insurance industry. She said, “Enhance Insurance is growing and I will be integral in growing the team here to offer our customers the best service and prices possible.” Director of Enhance Insurance, Martin Swann, added, “Sharon is a great addition to our team, bringing a wealth of knowledge and industry respect. I am excited to see the Enhance brand and team continue to develop and grow with Sharon’s involvement.” Intraline launches online shop Medical aesthetics company Intraline has launched an online shop where practitioners can select from an array of products ranging from dermal fillers, PDO threads and restorative skincare. Marketing and communications director for Intraline, Amanda Labistour, said, “We want practitioners to have 24/7 service, 365 days a year where they are given the flexibility to order aesthetic products around the clock during their busy schedules.” Facial Injectables market to be worth $17.2 billion by 2025 A new report by market research and consulting company, Grand View Research, has predicted that the global facial injectables market will reach $17.2 billion by 2025. According to the study the growth will be due to advancements in facial rejuvenation procedures and increasing importance of medical aesthetics across the world. Developments in products such as botulinum toxin type A and hyaluronic acid are supposedly expected to help practitioners develop customised treatments for patients and will facilitate the use of combination products to produce market growth. The full report is available on Grand View Research’s website.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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On the Scene

Ozonetherapy Workshop and New Product Launch, Dorking

Mallucci London, Kensington

On June 1, UK distributor Vida Aesthetics invited practitioners to the Mercure Box Hill Burford Bridge Hotel in Dorking for the Ozonetherapy Workshop and New Product Launch. Attendees had the opportunity to learn about how Ozonetherapy works from Dr Irfan Mian and watch a live demonstration of the treatment in action. Following the workshop was the launch of a new range of biorevitiliser and filler products: Plenhyage, Jalucomplex, Auralya and Evanthia. Director of Vida Aesthetics, Eddy Emilio said, “It was great to be able to invite guests to the Ozonetherapy Workshop and New Product Launch. The objectives of the event were to describe Ozonetherapy and the versatility of the ATO3M machine in treating many indications. We also launched a brand-new range of biorevitalisers and fillers, one which uses an alternative to BDDE; it was great to bring our clients up to date with the latest trends and products in the present market.” On the Scene

Guests were invited to the exclusive launch of ‘London’s first superclinic’ in South Kensington on May 24. Mallucci London, founded by plastic surgeon Mr Patrick Mallucci, comprises all aesthetic specialties under one roof. Guests were taken on a guided tour of the facilities in small groups, and were each introduced to the practitioners who will practice there. These include rhinoplasty surgeon Mr Duncan Atherton, facial surgeon Mr Norman Waterhouse, consultant dermatologist Dr Alexis Granite and hair transplant surgeon Dr Thomy Kouremada-Zioga, as well as Mr Mallucci himself. Practitioners introduced the treatments that will take place at the luxurious clinic and the services on offer, which includes breast screening, mole mapping, gynaecology, non-surgical aesthetics and surgical aesthetics. Mr Mallucci answered questions from guests and explained how he created the ‘45/55’ breast ratio, where he led a study that indicated the ideal breast should have 45% of the overall volume above the nipple and 55% of the overall volume below it. The company explains that it has a strong focus on privacy and provides a discreet entrance to the clinic and exit via private payment rooms. For patients who require 100% privacy, the clinic offers exclusive use where there is only one patient on the premises at a time. Mr Mallucci said, “We pride ourselves on offering our patients the best service throughout their journey with us.”

Conference Report

Institute Hyalual Redermalization workshop, London Institute Hyalual held a Redermalization workshop at its London clinic on June 6. Attendees were greeted with drinks and canapés while they listened to a presentation to learn more about the company and its products and see live demonstrations of the Xela Rederm process, ‘Redermalization’. Dr Vincent Wong showcased his experience using threads for non-surgical breast procedures and Dr Daniel Sister spoke about his new protocol of combining PRP with Redermalization. Head of sales and marketing at Hyalual, Katie Bennett said, “I hope that the people who came gained some new information on different ways to use Redermalization, for example moving from botulinum toxin and fillers to something a bit more innovative.” She continued, “Hopefully the attendees will be able to understand more natural ways of treating patients, whilst also getting good results at the same time.”

British Association of Sclerotherapists 2017 Conference, Windsor The Eton College Rowing Centre in Berkshire played host to the British Association of Sclerotherapists (BAS) Conference on May 18. Among the highlights was vascular surgeon Mr JeanFrancois from Paris, who gave a presentation on 3D imaging of the venous system. A session on sclerotherapy for ankles, feet, hands, arms, chest and the face from consultant vascular surgeon and BAS president, Mr Philip Coleridge Smith was well received, with many practitioners asking questions about the effectiveness and risks of these treatments. After the conference, Mr Coleridge Smith said, “We are delighted to have hosted an event that has been a great success all round! We were very well supported by vascular surgeons, aesthetic doctors and nurses, not only from local areas, but also from Ireland, Scotland and even Baghdad.” He added, “Delegates heard about several new technologies, and brushed up on their knowledge and, perhaps more importantly, learnt new practical sclerotherapy skills. It’s not easy to appeal to such a diverse audience, but all our speakers went down well. The superb venue also came in for its share of plaudits; I’m certain we will meet there again.” The next BAS meeting will take place in Spring 2018.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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ASAP Conference, Glasgow The Association of Scottish Aesthetic Practitioners (ASAP) held its sixth annual conference on an unseasonably warm weekend on May 26 and 27. For the first time, the congress was located at the University of Strathclyde at The Technology and Innovation Centre in Glasgow, Scotland, where a variety of workshops, presentations and live demonstrations took place alongside an exhibition. On the Friday, delegates attended four different workshop agendas hosted by sponsors of the congress that

focused on complications, skin science and aesthetic treatments, aesthetic technologies and business. Presenters spoke on behalf of companies including Healthxchange, Syneron Candela, Hamilton Fraser, Wigmore Medical, BTL Aesthetics and Image Skincare. An intimate ‘expert’ masterclass, sponsored by Merz Aesthetics and Rosmetics, was concurrently run alongside these agendas. Conference chairs Dr Emma Ravichandran and Dr Simon Ravichandran with Dr Aamer Khan, Dr Kate Goldie and Dr Vincent Wong presented their knowledge on PRP, threads, dermal fillers and botulinum toxin. Dr Emma Ravichandran said, “This masterclass was really good. Everyone who attended practised some of their new knowledge and performed fullface rejuvenation treatments on their own patients under the supervision of the trainers.” Delegate Dr Adrian Rippon said this masterclass was his

highlight, “It was a caring and approachable level of training which will raise the standards of my practice.” On Saturday, delegates saw an entertaining presentation by Dr Ash Dutta, who engaged the audience with his multidisciplinary approach to neck rejuvenation and a live demonstration from Dr Vincent Wong on the upper third of the face using Bocouture dermal fillers on a male model. Dr Emma Ravichandran also did a presentation on tissue remodelling using Profhilo and discussed why practitioners should be addressing skin concerns earlier. Then Dr Irfan Mian performed a mid, lower face and neck lift using Meso Trax threads, which was well received by the audience. Dr Emma Ravichandran said of the congress, “It was great that despite it being the warmest weekend of the year that people still decided to come indoors. It was really nice to see delegates who made their way up to Scotland from London, because it’s usually the other way around!” Delegate Dr Iwona Reid said, “ASAP exceeded my expectations. I left feeling inspired and with lots of enthusiasm and ideas.” The next ASAP conference will take place on May 11 and 12 next year.

Facial Aesthetic Conference and Exhibition, London Aesthetic practitioners from across the globe descended on London for the annual Facial Aesthetic Conference and Exhibition (FACE) in London on 16-18 June. The three-day event featured a number of agendas, which included injectables, antiageing/business, skin, threads, hair, aesthetic gynaecology and equipment – all aimed at educating practitioners on the latest innovations within the specialty. As well as this, delegates could explore the large exhibition floor to network with company representatives and learn about all the new products on the market. Highlights of the skin agenda included a lively debate from consultant dermatologist Dr Firas Al-Niaimi, dermatologist Dr Stefanie Williams and board certified dermatologist Dr Zein Obagi. In the session, the renowned practitioners discussed a wide range of dermatologic concerns such as rosacea and acne, debating best practice methods for each. The injectables agenda featured numerous clinical topics that included treating the mid-face, lower face and upper face, using pen injectors, the art of injectable consultations, combining PRP with succinic acid and hyaluronic acid, anatomy, treating men, injecting the feet and non-surgical rhinoplasty. Treating the neck was a popular topic – aesthetic plastic surgeon Dr Michael Kane presented on injecting the platysmal bands with botulinum toxin on the Saturday, followed by a live demonstration by Dr Kate Goldie, while on Sunday, consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah described key anatomical

landmarks of the neck, detailing what makes it attractive and performed a live demonstration of how to rejuvenate this area use Profhilo. Professor Hema Sundaram also spoke on the benefits of using Profhilo, suggesting that it is a complementary treatment to dermal filler injections and said it can ‘finesse results’. While talking about using dermal filler, Professor Sundaram shared before and after photographs of some of her patients’ results and critiqued her own work to the audience; pointing out areas that could have benefitted from further treatment. A panel of six highly experienced aesthetic practitioners then took to the stage to discuss the management of complications. They each shared a case study of a complication they had experienced following injectable treatments such as botulinum toxin, dermal fillers and threads, detailing how they managed it, while providing the audience with key takehome messages. For delegates wanting to add new equipment to their clinic, they could choose to learn about numerous devices on the market. These included an array of lasers, including picosecond for tattoo removal, imaging devices, IPL, radiofrequency, cryolypolis and ultrasound devices, as well as the new Tixel; a thermo-mechanical action device that aims to rejuvenate skin with minimal pain and downtime. To give attendees a valuable take-home message, Mr Humzah stressed the importance of understanding that while conferences provide an excellent opportunity to discover new techniques, they should not be used as formal training and practitioners should seek appropriate training courses before attempting a new technique. He said, “Conferences are here to make you think about what you want to learn and how you want to develop – then you go and train in those areas.”

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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The AIIVL Consensus Group

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trained to recognise symptoms, institute immediate actions and refer patients without delay to dedicated specialists for definitive and supportive management’.3 So while there is guidance, advice and suggestions to prevent and manage visual loss complications from a range of respected and valuable sources, two years on from the world literature review of cases, there is still no standard protocol for aesthetic practitioners to follow.

The AIIVL Consensus Group Concerned about these possibilities, a group has formed that aims to provide guidelines and offer advice on how to manage this serious complication. The Aesthetics Interventional Induced Visual Aesthetics finds out more about the new Aesthetics Loss (AIIVL) Consensus Group launched last month after being formed by consultant Interventional Induced Visual Loss Consensus Group plastic, reconstructive and aesthetic Cases of visual loss surgeon Mr Dalvi Humzah, consultant ophthalmic surgeons Mr Most practitioners would agree that, although rare, visual loss is Raman Malhotra and Mr Saj Ataullah from the UK, chief orbital and likely to be the most serious complication that can occur as a result ophthalmic surgeon Dr Robert Goldberg from the US and plastic of vascular occlusion following dermal filler treatment. Last month, a surgeon Dr Andy Chaing from China. Mr Humzah says, “Working new group was launched that aims to support aesthetic practitioners together over the last year it became clear that there is no consistent in preventing and managing cases of blindness following a dermal management pathway for this rare but life-changing complication. filler treatment. Aesthetics asks, why is this needed and how can Many practitioners will not be aware of any management pathways it help the specialty? In 2015, a review of the world literature on all for this problem that is an extreme emergency.” The group has reported cases of vision changes from fillers was conducted in order analysed the literature and experimental work surrounding visual to highlight key aspects of the vascular anatomy to be aware of, as loss complications and, based on the results, has produced a well as discuss prevention and management strategies.1 management pathway for patients experiencing visual loss following The results showed that 98 cases of vision changes from filler had a dermal filler treatment. According to Mr Humzah, one of the main been identified globally, with 65 of those leading to unilateral vision sources of their advice has been based on the research conducted loss and only two cases being reversible. Autologous fat was the most in 1999 by Rumelt et al.4 He said that, “We looked at their principles common filler type to cause vision changes (47.9%) amongst the cases and what you can learn from it. They advised that you need to be identified, while hyaluronic acid was indicated as the second most quick and aggressive in your treatment; based on their research, common cause; responsible for 23.5% of the complications. The sites it is suggested that to preserve complete vision the patient would that were high risk for complications were the glabella (38.8%), nasal needed to be treated within 97 minutes. To save partial vision, they region (25.5%), nasolabial fold (13.3%) and forehead (12.2%).1 would need to be treated within six hours.” According to the literature reviewed, no treatments were found to be Mr Humzah says, “The suggested guideline from the AIIVL covers consistently successful in treating blindness. The authors concluded general advice as well as specific interventions to help both the that, ‘although the risk of blindness from fillers is rare, it is critical for practitioner and patients. We will continue to review the literature injecting physicians to have a firm knowledge of the vascular anatomy and cases in order to develop our recommendations.” and to understand key prevention and management strategies’.1 What does the group advise? What advice is available? Along with providing clinical advice on how vision loss can occur and A number of training courses, associations and literature do offer prevention methods practitioners should take to minimise the risk of advice on how to prevent and manage a visual loss complication; blindness during or after a dermal filler treatment, the AIIVL Group for example, a study published in February 2017 in Aesthetic outlines a protocol to follow should the complication present. Plastic Surgery highlights the case of a 64-year-old female who As a matter of priority, the group emphasises the importance of suffered blindness and hemiparesis following injection. As a result, practitioners checking their dermal filler consent forms and ensuring it recommends the incorporation of a ‘blindness safety kit’ in that the risk of blindness is made clear. Mr Humzah says, “Practitioners aesthetic clinics, which details a step-by-step protocol to follow in should also ensure that this is discussed in consultation so patients the event of a complication.2 are fully aware of the risks. Remember that the whole facial network In addition, a review committee of plastic surgeons, aesthetic is interrelated; you don’t consent patients at your own peril.” He also practitioners, ophthalmologists and dermatologists from Singapore, emphasises the need for practitioners to keep clear and accurate published an article in August 2016 in the Singapore Medical notes of all treatments, as well as taking high quality before and after Journal that proposes a course of action based on existing photographs, so that they can provide evidence of their safe practice knowledge. The article notes, ‘It is proposed that injectors must be should a claim arise. The AIIVL Group then outlines the two scenarios

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


Aesthetics

in which practitioners will become alerted to a case of visual loss – while the patient is still in clinic and when they are at home – and how to handle each situation. For both, the group members instruct that the practitioner should call the emergency services immediately. If the patient is in clinic, then the practitioner should stop injecting straightaway. They then advise that the practitioner should then get the patient to ‘rebreathe’ through a paper bag, which aims increase the C02 level in the blood, which will cause the retinal arteries to vasodilate and could help dislodge any blockage causing the visual loss. As well as this, the group suggests that patients should take oral aspirin to stop blood clotting and the practitioner should perform an ocular massage, again to help move any blockage. For patients at home, the practitioner should tell the patient or their friend/family member how to perform an ocular massage.5 The AIIVL Group acknowledges that many hospitals will be unfamiliar with this type of emergency so has put together specialist guidance, which is freely available to all aesthetic practitioners, to keep in their clinics and pass on to staff and the ophthalmic surgeon dealing with the case, should it occur. What happens next? Mr Humzah emphasises that once a practitioner has followed the protocol and handed the patient over to emergency services, their responsibility doesn’t end there. “You must provide ongoing support to the patient and their family,” he says, explaining, “This will be a very traumatic time for them so the worst thing their practitioner can do is disappear. Make sure they understand that you are doing your best and working with the hospital team to provide the very best medical care. Don’t forget you will also need to inform your insurance provider, the manufacturer of the product and the Medicines & Healthcare products Regulatory Agency (MHRA).” As discussed, while the chance of being faced with a visual loss complication is rare, the AIIVL is determined to make practitioners as prepared as possible for this worst-case scenario. The group’s members say that they will continue to work together to produce and share the safest, most up-to-date recommendations for the aesthetic community – the aim is to have the guidance peerreviewed and published on a freely accessible open source as soon as possible. Mr Humzah concludes, “We need to talk openly about cases of blindness when they happen – the more we talk about complications happening, the more we can learn from each other. Ideally, if practitioners keep documenting their experiences and pointing out what they do differently in each case, then we could eventually find the golden key as to what works best. Hopefully the AIIVL Consensus Group’s guidance gives people a starting block to work from, which will be continually updated and moved forward in an evidence-based way.” Note: This article is not inclusive of all the AIIVL Consensus Group’s guidelines and should not be used in place of them or any other medical training. For more information, please contact the group directly. REFERENCES 1. Beleznay K, Carruthers J, Humphrey S, Jones D, ‘Avoiding and Treating Blindness From Fillers: A Review of the World Literature’, Dermatologic Surgery, 41 (2015), pp.1097-1117. 2. Prado G, Rodriquez-Feliz J, ‘Ocular Pain and Impending Blindness During Facial Cosmetic Injections: Is Your Office Prepared?’, Aesthetic Plastic Surgery, 41 (2017), pp.199-203. 3. Loh KT, Chua JJ, Lee HM, Lim JT, Chuah G, Yim B, Puah BK, ‘Prevention and management of vision loss relating to facial filler injections’, Singapore Medical Journal, 57 (2016), pp.438-443. 4. Rumelt S et al., ‘Aggressive systemic treatment for central retinal artery occlusion’, American Journal of Ophthalmology, 128 (1999), p.733-738. 5. Data available on file via The Aesthetics Interventional Induced Visual Loss Consensus Group.

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Dr Askari Townshend explains, “Type I is much more likely to develop a skin cancer than a type VI, and this is because it doesn’t have the same protection, as the melanin in the skin is what protects it.”2 He explains, “I tell patients that a tan is your skin telling you it is damaged – you’ve gone out in the sun, damaged your skin, and your skin has responded by ‘throwing up’ its protection, which it does by creating more pigment in the skin.”

How skin types react to UV Skin types I-IV Light and dark skins can react differently to sun exposure. Consultant dermatologist Dr Justine Hextall explains how skin types I-IV respond, “In lighter skins, signs of sun damage include wrinkling and sagging, thread vein formation and solar lentigines, amongst others. For those who have skin type I and red hair, they produce pheomelanin and that is largely ineffective in protecting the skin against UV exposure.”3 Those with lighter skin types are also more likely to present with signs of ageing before their dark-skinned counterparts. Consultant dermatologist Dr Sandeep Cliff says, “Dark skinned patients look much more youthful for longer; they have inherent protection, therefore ageing is much more delayed then it would be in Caucasians.” He adds, “Generally, I am seeing younger and younger patients with sun damage – recently I saw a patient aged 14 with skin cancer and I am also seeing patients with premature skin ageing at the age of 21.”

Skin Types and the Sun Aesthetics speaks to practitioners about how best to treat pigmentation caused by UV exposure in the different Fitzpatrick skin types

Skin types V-VI When it comes to darker skin types, Dr Hextall says, “How the skin reacts to sun exposure is dictated mainly by the amount of melanin produced by melanocytes and the type of melanin. Those with type VI skin produce mainly all eumelanin that is very dark and highly effective at blocking UV photons and protecting the skin against UV damage.” However, she points out that, “It is a common misconception in patients that skin types IV to VI do not need sun protection. Whilst darker skin has less skin wrinkling and sagging, skin pigmentation is more of an issue. This can present, for example, as sun spots or melasma.” Kaidbey et al4 demonstrated that the black epidermis (Fitzpatrick type not specified), on average, provided a SPF of 13.4. The photoprotective role of melanin was evaluated by comparing the transmission of UV radiation through black and Caucasian skin samples. UVA transmission was measured using fluoranthene, which causes a phototoxic response to UVA wavelength. UVB was measured by monitoring erythema produced by either a 150-watt

In 1975 Dr Thomas Fitzpatrick developed a system to evaluate a patient’s response to ultraviolet (UV) exposure in terms of the degree of burning and tanning.1 This system became known as the Fitzpatrick scale and, since then, it has been widely used by aesthetic practitioners to help them determine the strength of certain treatments such as chemical peels and lasers. In this article, Aesthetics speaks to five practitioners about how different skin types react to overexposure to the sun and how to most effectively and safely treat pigmentation.

The Fitzpatrick scale The Fitzpatrick skin type system specifies six skin types, ranging from type I, which is skin that never tans and always burns through to type VI, which always tans and never burns (Figure 1). Aesthetic practitioner

Skin Type

I

II

III

IV

V

VI

Skin Colour

White or very pale Pale white (usually with freckles)

Pale to light olive

Light to moderate brown

Medium to dark brown

Black

Hair Colour

Red or blonde

Blonde (can be dark)

Dark brown

Brown or black

Dark brown or black

Black

Eye Colour

Blue, green, grey

Blue or brown

Brown or green

Brown

Brown

Dark brown

Description

Burns very easily, rarely tans

Usually burns, tans gradually

Sometimes burns, average tanning

Rarely burns, tans with ease

Very rarely burns, tans very easily

Does not burn, tans very easily

Figure 1: The Fitzpatrick Scale13

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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xenon arc or FS-20 sunlamps. It was found that on average, five times as much ultraviolet light (UVB and UVA) reaches the upper dermis of Caucasians as reaches that of black skin.

Pigmentation Pigmentation, defined simply as ‘colouring’, can present differently, depending on the skin type. Nurse prescriber Elizabeth Rimmer explains, “All skin types can develop pigmentation. Those with more fair skin (I-IV) may have freckles, and when they are younger, people may say ‘how cute’ these make a person look, but then as they get older and are exposed to more UV rays, they enlarge and age a person’s face.” Dr Townshend says, “The patients I see who have skin types IV to VI have often spent their lives not using sun protection because they thought they didn’t need it and now they have dyschromia, in other words, their skin is no longer that nice even brown or black tone. Instead, they have developed areas of light or dark patches, giving a mottled appearance.”

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Skin cancer The biggest and most concerning effect of over-exposure to the sun is skin cancer. According to data released by Cancer Research UK in 2014, malignant melanoma mortality rates have increased by 156% since the early 1970s.5 “The most common problem I see in my NHS practice is skin cancer,” says Dr Cliff, adding, “Although it is more common in lighter skins, it is also seen in a percentage of dark skinned patients – from what I have read up to 10-15% of all skin cancer patients have dark skin – these tend to be melanomas.”6 Melanoma, which presents as a mole that turns cancerous, is often associated with patients who have short bursts of acute sun exposure,7 “They are likely to be people who go on holiday once a year, roast in the sun, and over time it increases the risk of melanoma,” continues Dr Cliff. “Remember, most melanoma arises de novo – 30-40% of melanomas arise from existing moles, the others develop from normal skin.”8

Treatment Preparation Before any treatments take place, practitioners say that preparation must be considered to achieve the best results. They also advise that it is vital to ensure that any treatments chosen will not cause further damage to the skin. Aesthetic practitioner Dr Rita Rakus advises, “I firstly do a Visia scan to see what’s going on beneath the skin. Then, preparation can vary and it depends at what level the skin is damaged. Vitamin A is great for preparing the skin and you would use different strengths depending on the extent of the damage. I use the Obagi Nu-Derm system as the key ingredient is vitamin A, which targets dark spots effectively.” Rimmer says using something that will begin to reduce the pigmentation is ideal, “Something with hydroquinone or a retinol and a tretinoin that will get the skin as healthy as possible. Fairer skin can sometimes have treatment without preparation but the best results have had some.” Lasers and IPL When it comes to treating dyschromias using lasers or lights, Dr Townshend splits patients into two groups: light skinned patients (I-IV) and dark skinned (V-VI). He says, “Intense pulsed light (IPL) and lasers are very good for treating pigmentation, however, you do need to be careful because if you treat melasma with lasers or lights you can make it worse.” Dr Hextall advises to, “Make sure you carry out a patch test if using IPL or laser therapy and always ask about pain. Discomfort can be a very important indicator of a safety issue. If you are concerned, stop and wait and assess the skin. Consider cooling the skin and maybe apply an anti-inflammatory treatment.” Dr Townshend uses the 3JUVE in his clinic, which has a 585 nm IPL handpiece. He says, “It is a simple and straightforward system and not only treats the brown marks but you can treat broken vessels and photodamage, and also red and brown marks at the same time, which is a condition called poikiloderma.” Poikiloderma is a skin condition that consists of areas of hypopigmentation (loss of colour), hyperpigmentation (excess of colour), telangiectasias (spider veins) and atrophy. It is most frequently seen on the chest or the neck.9 Dr Townshend explains, “IPL is fantastic for this condition, whereas, in my experience, lasers generally treat either dark or red marks, not both at the same time.” Dr Townshend also notes that, “If you have dark skin, the laser or IPL

unit doesn’t know how to differentiate between the pigment in the skin and the mark you want to get rid of. You don’t want to leave patients even worse because you have punched a hole in the pigment they wanted to keep – so light skin can be treated with these devices much more easily and safely.” Dr Hextall treats her patients with the Lumenis M22, a modular multi-application platform. She explains, “It is an incredibly versatile platform that allows me to treat an individual with IPL followed by fractional laser with no more effort than pressing a button on the screen. I am more confident to use the M22 on skin types IV to VI because I can choose my specific wavelength with the multiple filters available to me. As the pulses are fractionated, I can deliver optimal energy to a specific target safely.” Chemical peels An alternative to lasers and IPL is chemical peels. Dr Hextall says, “I have had some success with The Perfect Peel (medium depth) that combines glutathione, kojic acid, TCA (trichloroacetic acid), retinoic acid, salicylic acid, phenol, and a blend of minerals and vitamins. However, I am always very cautious about chemical peels on skin types IV to VI – due to the risk of post-inflammatory hyperpigmentation – and I will always pre-treat with a tyrosinase inhibitor as this blocks the production of melanin.” For Rimmer, skin peels are her preferred Before

After

Figure 2: Patient before and 15 weeks after been treated with the ZO pigmentation kit and three areas injected with botulinum toxin. Images courtesy of Elizabeth Rimmer.

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@aestheticsgroup Before

After

Figure 3: Images show patient before and 24 weeks after treatment with the Obagi Nu-Derm System with 1.0% retinol. Images courtesy of Obagi Medical.

choice, “I offer chemical peels and tend to use The Perfect Peel or pHformula, depending on the individual. Some peels are fine to use without preparation but if the patient has dark skin then they would definitely need a few weeks of preparation in order to avoid further risks of pigmentation.” Hydroquinone For some patients with skin dispigmentation and melasma, Dr Hextall will advocate a short course of skin lightening cream. She explains, “I will either use Pigmanorm or The Perfect Peel Bleaching Cream; this prescription-only lightening cream combines 4% hydroquinone with liquorice, arbutin and kojic acid.” Dr Townshend is also an advocate of hydroquinone products, saying, “A big mainstay for me in my practice is hydroquinone; if used in the right way, with the right protocol, hydroquinone is a fantastic treatment for anyone with photodamage.” He continues, “It doesn’t matter whether you have light or dark skin, it can be used for everyone, it is relatively safe, has no downtime, is reasonably affordable and they can do it at home rather than coming to the clinic.” When treating with hydroquinone, Dr Townshend uses ZO products Melamin and Melamix, and recommends applying twice a day, every day. He says, “It needs to be used for several weeks to see any change. I tell my patients they won’t see anything at all for four to six weeks and then they will get improvement for several months.” Patients must avoid continued strong sunlight and wear SPF. Those who are pregnant or breastfeeding should not use the product.10 Dr Rakus uses the Obagi CRX system for her patients, which contains a 4% hydroquinone. “They are great products because you can wear them all summer,” she continues, “The CRX also contains vitamin C, glycolic acid and an SPF. It is a nice, gentle help and you won’t go red, peel or get dry skin.” Dr Rakus also recommends the Obagi CRX because, “It is one of the few products that will rejuvenate the internal DNA structure of the cell – so it gives you true, repaired, newer skin.”11, 12 For those who have more severe pigmentation, Dr Rakus uses the Obagi Nu-Derm, “You’ve still got the hydroquinone in it and you also have hyaluronic acid, tretinoin, and SPF and it is slightly stronger.” Dr Rakus uses this on darker skin types but says it is very patient dependent, “It depends on the patient’s social life, because there is sometimes a teething period initially, and it can cause skin to become a little dry and a little red. So you can choose a lighter, slightly weaker regime but it will take longer – the patient has to make the choice.”

Maintenance Once patients have been treated and their skin has improved, it is essential they use maintenance treatments to retain the results. Dr Hextall says, “I would recommend sun cream and advise on active

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topical serums, depending on issues we are trying to correct. I may recommend some LED light therapy as a maintenance therapy, around six treatments over six months. A top-up treatment with IPL or photofractional laser may only be needed once or twice a year, but it will depend on the individual and, as always, requirements may change with time.” Dr Rakus says, “I would tell patients they must wear SPF 50+. I advise they use the Obagi Sun Shield Matte SPF 50.” Dr Cliff adds, “I offer patients the NeoStrata Sheer Physical Protection SPF 50. It is a broad-spectrum UVA/UVB protection with a sheer tint that blends with the skin's natural tone. It has additional antioxidant benefits, so you have the sunblock to protect against more UV exposure, but at the same time you have antioxidants to help prevent damage to DNA, so it is a double whammy. It is also suitable for all skin types and it doesn’t leave a white sheen on the skin.”

Summary In summary, Dr Townshend says, “The first thing is ‘a stitch in time saves nine’. Protecting at an earlier age is really important, and the problem is that the messages so far have all been about skin cancer. That is a really important message but we all know that young people don’t respond to those types of messages because when you are young, you think are going to live forever.” He continues, “I think as an add on to the skin cancer message, it should say ‘do you want to look as good as you can for as long as you can? If so, cover up’.” Dr Cliff agrees, saying, “If you put pictures in front of patients of people with excess wrinkling, photoageing and said to them, ‘this person had too much sun exposure’ I guarantee they would stop using sunbeds and having excess sun exposure – this is the big trick that has been missed by advertising campaigns. Young people don’t think about the prospect of skin cancer, but they are very tuned into their appearance and looks, so if you tell them that by doing this you will look aged, they will avoid it.” Dr Townshend concludes, “A slow bake is better than a quick fry – I explain to patients you will still tan with your sun cream on, just take it easy; you will still look golden and lovely. Doctors are very good at telling people off, but actually, I love to tan, I look healthier and I feel good – but let’s just tell our patients to do it sensibly, not to burn, and do it without getting the pigmentation.” REFERENCES 1. Silone Sachdeva, Fitzpatrick skin typing: Applications in dermatology, (2009) <http://www.bioline.org. br/pdf?dv09029> 2. BAD, Sunscreen fact sheet, (2017) <http://www.bad.org.uk/for-the-public/skin-cancer/sunscreen-factsheet> 3. Alessandra Napolitano, Lucia Panzella, Giuseppe Monfrecola & Marco d’Ischia, PheomelaninInduced Oxidative Stress: Bright and Dark Chemistry Bridging Red Hair Phenotype and Melanoma, Pigment Cell & Melanoma Research (2014) <https://www.researchgate.net/publication/262197919_ Pheomelanin-Induced_Oxidative_Stress_Bright_and_Dark_Chemistry_Bridging_Red_Hair_ Phenotype_and_Melanoma> 4. Kaidbey KH, Agin PP, Sayre RM, Kligman AM. Photoprotection by melanin—a comparison of black and Caucasian skin. J Am Acad Dermatol. 1979;1(3):249–260. 5. Cancer Research UK, skin cancer statistics, (2017) <http://www.cancerresearchuk.org/healthprofessional/cancer-statistics/statistics-by-cancer-type/skin-cancer> 6. Charlotte Pooler, Malignant Melanoma, Porth Pathophysiology: Concepts of Altered Health States, Lippincott Williams and Wilkins, (2009) 7. Cancer Research UK, Risks and causes of melanoma (2017) <http://www.cancerresearchuk.org/aboutcancer/melanoma/risks-causes> 8. Gary M. White, Melanocytic Nevi, (2017) <http://www.regionalderm.com/Regional_Derm/files/nevus. html/> 9. Amanda Oakley, Poikiloderma of Civatte, DermNet New Zealand, (1998) <http://www.dermnetnz.org/ topics/poikiloderma-of-civatte/> 10. Hydroquinone topical Pregnancy and Breastfeeding Warnings, Drugs.com (2017) <https://www.drugs. com/pregnancy/hydroquinone-topical.html> 11. S. Bruce, S Barkovic, Open-Label Study Evaluating the Anti-Aging Effects of a 3-Product, 2-Step Retinol-Rejuvenation System Following 3 Months of Treatment in Subjects With Photodamage, J Drugs Dermatol, (2017) <https://www.ncbi.nlm.nih.gov/pubmed/28095529> 12. Pearl Grimwa, JoAnne Watson,Treatment of Mild or Moderate Melasma in Darker Skin with a 4% Hydroquinone Skin Care System Plus 0.025% Tretinoin Cream, <https://www.obagi.com/sites/default/ files/clinical/docsp4581_grimes_mel003_eposter_for_winter_2012_aad_uploaded_to_aad_with_ photos_as_pdf.pdf> 13. Aesthetic Laser Training, British Skin Foundation, (2017) <http://aestheticlasertraining.co.uk/courses/ vtct-fast-track/lectures/unit-1-lhr/l6/>

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Environmental Influences on Cutaneous Ageing Dr Raul Cetto conducts a literature review on the studies dicussing environmental influences on cutaneous ageing and their clinical consquences Factors that contribute to ageing Ageing is a process affected by both intrinsic and extrinsic factors which cause a progressive loss of structural integrity and physiological function.1 Intrinsic ageing: Chronological ageing influenced by internal physiological changes over time caused by variable predetermined genetic influences.2 Extrinsic ageing: Ageing caused by external, environmental influences such as exposure to sunlight, cigarette smoking, air pollution and sleep. These, to variable degrees, can be controlled to regulate cutaneous ageing.2

Background and objectives Cutaneous ageing is the result of two microscopically and macroscopically distinct biological processes that occur concurrently: intrinsic ageing and extrinsic ageing caused by external factors. The external or environmental factors that have been found to cause extrinsic ageing include sunlight exposure, cigarette smoking, air pollution and sleep deprivation.1 The majority of literature focuses on UV light exposure and cigarette smoking as a reliable extrinsic cause of accelerated cutaneous ageing, with much dedication to the pharmacological prevention and treatment of such changes.1,3-7 There have also been landmark characterisations of the histological findings that one may associate with these particular environmental stimuli, however there is a limited body of research concerned specifically with the clinical evaluation of extrinsic cutaneous ageing. Therefore, this article proposes to review original literature seeking to assess the causative relationship between environmental factors and their quantitatively or qualitatively measured clinical manifestation.

Extrinsic factors that contribute to skin ageing Sun exposure Photoageing is the term used to describe the histological and clinical consequences of chronic UV exposure. Kligman and Kligman devised the term ‘photoageing’ in 1986 to distinguish this particular skin ageing process from the intrinsic or chronological skin ageing process that had already been extensively examined by that time.8 Photoageing occurs through disorganisation of the collagen fibrils that constitute most connective tissue, and the accumulation of abnormal, amorphous, elastin-containing material; a condition known as actinic elastosis.9,10 Another prominent feature of photoaged skin is the replacement of mature collagen fibres by collagen with a distinct basophilic appearance. This is called basophilic degeneration.11 Changes induced by chronic sun exposure can occur well before signs of intrinsic skin ageing are seen. The clinical features are deep wrinkles on the forehead and static frown lines (seen with no facial

motion); telangiectasia, particularly on the nose, cheeks and chin and an almost pathognomonic leathery skin with laxity, solar lentigines and actinic keratosis.8,11-14 The most prominent clinically evident epidermal changes are pigmentary alterations and hyperpigmentation. The depth and severity of these changes depend on the degree of sun exposure and are considered to be irreversible.11 Smoking In 1971, Daniell reported that tobacco smoking had a deleterious effect on the skin and described the pattern of wrinkles that were a typical clinical feature seen in cigarette smokers.15 The typical clinical features characterising ‘smoker's face’ are reported to include facial wrinkles, prominence of underlying bony contours because of atrophic skin, and a ‘plethoric, slightly orange, purple, or red and uneven complexion’.16 The pattern of wrinkles seen in cigarette smokers differs from those of non-smokers. The wrinkles are narrower and deeper and smokers have more sharply contoured crow’s feet and more prominent perioral lines because of the repeated act of inhaling the cigarette. These wrinkles radiate at right angles from the lips and eyes.15 Smoking causes skin damage primarily by decreasing capillary blood flow to the skin, which, in turn, creates oxygen and nutrient deprivation in cutaneous tissues.17 It has been shown that those who smoke have fewer collagen and elastin fibres in the dermis causing skin to become less elastic, thus causing the described ‘slack’ appearance.17 Pollution Ambient particulate matter (PM) represents another environmental threat to the skin. Adverse effects of PM on health are a serious concern; the health consequences have been shown to include a higher risk for pulmonary and cardiovascular diseases.18 The health effects of ambient PM exposure on human skin in, and on skin ageing in particular, has not yet been studied in depth but it has been theorised that these particles could be carriers for chemicals and metals that are capable of localising in mitochondria and generating reactive oxygen species.18 The harmful effects of pollution are being substantiated by an increasing number of researchers worldwide.18-23 Sleep deprivation Sleep is important for physiological renewal of multiple body systems. The effects of chronic poor sleep quality on human skin function and visible signs of ageing have not been elucidated well yet.24 There are only a small number of well-designed studies regarding the clinical manifestations of sleep deprivation on the skin, which are discussed below.24-27

Method Initial search strategy The database MEDLINE was searched via PubMed and the same

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search was conducted using EMBASE via OVID, Google Scholar and Scopus. These databases were all used to ensure that the literature search was sufficiently rigorous and identified all the relevant studies.28 The search criteria are detailed below. All titles were then analysed and all papers with reference to extrinsic or environmental factors were isolated. The references for all of these papers were also searched for further relevant papers using the same criteria i.e. the presence of keywords pertaining to extrinsic or environmental causes of ageing. All relevant articles published in peer-reviewed journals, which were available in English, were included. Only original research was included. Search criteria 1. [Skin OR cutaneous OR dermal] AND [aging OR ageing] 2. [Skin OR cutaneous OR dermal] AND [environmental OR environment OR smoking OR tobacco OR sun OR UV OR sleep OR extrinsic] 3. [Skin OR cutaneous OR dermal] AND [wrinkles OR age] 4. [Wrinkles OR wrinkling OR face OR facial] AND [environmental OR environment OR smoking OR tobacco OR sun OR UV OR sleep OR extrinsic OR premature] Exclusion criteria Animal models were excluded, as were all purely in vitro experiments. All review articles were excluded, and only original research was included. Case studies and all Level 3 evidence (studies with no control group) were also excluded, thus book chapters that fall on a scale between expert opinion and review were also excluded. Papers by authors that declared a conflict of interests, i.e. funding by a private company, were also excluded. Methodological appraisal of studies The methodology of each paper was evaluated using the relevant methodology checklist designed by the National Institute for Health and Care Excellence (NICE).28 Papers were excluded if they were found to have poor research methods on review. Examples of poor research methodology include the presence of selection bias causing a systematic difference between the comparison groups, detection bias causing bias in how outcomes are ascertained, diagnosed or verified, or investigator bias caused by poor blinding practice.

Results This review finds that there are several well-designed case control studies that highlight the histological differences between skin in sun exposed areas and unexposed skin, which has undergone mostly intrinsic or chronological ageing. There is a paucity, however, of research focusing on how these histological and chemical changes manifest as clinical signs. Moreover, the majority of the histological studies control for confounding variables by using skin biopsies from two different sites of the same subject,3,4,13 i.e. volar wrist and buttock, and these sites are arguably incomparable. It has been shown that there are obvious regional differences in the morphology of the skin in photoageing at any given site.29 There is also considerable histological difference between these sites and facial skin,29 and therefore any conclusions drawn from these studies have relatively limited generalisability to facial skin. In 1995, Bhawan et al., attempted to quantify various histologic parameters in photo-exposed and photo-protected facial skin biopsies. These

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two samples were more anatomically related than sites chosen in other histologic studies. They found that epidermal changes consistent with photoageing were significantly increased in the sun exposed skin (by paired t-test p<.0001).30 This paper represents the soundest methodology of papers seeking to characterise the histological consequences of photoageing; however, there is still a lack of correlation with clinical manifestation or qualitative measurement of ageing. Smoking and UV exposure Cross sectional studies have been interesting in this area as they tend to concentrate more on clinically relevant differences between two groups. In 2001, Yin et al. studied 83 subjects collecting data on extrinsic ageing factors of smoking and UV exposure using a questionnaire.31 It is difficult to accurately estimate how much UV exposure patients had, but relatively easy to stratify subjects into discreet groups of sun exposure depending on factors such as their upbringing, job, hobbies and lifestyle, which this study did well, according to patient reported data. Facial skin appearance was also grouped according to a clinical scale rather than histological analysis. These measurements were paired with histological analyses. The results showed that an average daily sun exposure of two hours was associated with an increase in wrinkling with an odds ratio of 2.65 (95% CI1.00-7.00).31 They found that the odds ratio between tobacco smoking and wrinkling was larger than that between sun exposure and wrinkling, which is consistent with Daniellâ&#x20AC;&#x2122;s study of 1971.15 This was the first study of good quality to seek to correlate environmental factors with clinical signs of damage. It studied the severity of wrinkling in 1,104 subjects with a history of habitual cigarette smoking, after adjustment for age and outdoor exposure. The association between cigarette smoking and wrinkling was striking in both sexes soon after age 30. Habitual smokers of 20 pack years or more (a â&#x20AC;&#x2DC;pack yearâ&#x20AC;&#x2122; is the equivalent of 20 cigarettes a day for one year) aged between 40 and 49 were as wrinkled as non-smokers aged 60 to 69.15 The majority of studies find that smoking and sun exposure are both positively correlated with skin ageing, whatever the clinical measure of skin ageing used.6,7,15,31-37 In 2012, Ekiz et al.,38 based in Turkey, found that in a sample of 574 participants (337 women, 237 men; aged 18-89 years), chronic sun exposure and cigarette smoking both significantly and independently contributed to the formation of facial wrinkles. Kennedy et al.,6 who recorded elastosis and telangiectasia as a marker for skin ageing in 966 Dutch subjects in a case-controlled study in 2003, concluded that lifetime sun exposure was significantly associated with the development of elastosis and telangiectasia in both men and women. Smoking was strongly associated with the amount of elastosis among both sexes and the amount of telangiectasia among men.6 Chung et al. investigated the independent effect of cigarette smoking on wrinkling in a Korean population, which involved 407 participants.7 Participants with more than a 30 pack-year smoking history showed a 2.8x increase in the prevalence of wrinkles and those with a smoking history of more than 50 pack years showed a 5.5x increase. Sun exposure longer than five hours a day were also found to be strong independent factors for wrinkling in this study. However, the results of a UK cross sectional study with 792 subjects over 60 years old was carried out in 2002, disagree with this held standard.5 A range of phenotypic and environmental data was collected by interview. The skin was assessed by examining the face, neck and dorsum of the hand and scored on a 10-point ordinal

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A twin study concluded that the twin who smoked showed significantly poorer facial skin texture when compared to the twin who was a non-smoker scale, according to the presence of certain stigmata of extrinsic ageing. Cumulative sun exposure was assessed by asking subjects to estimate their average time outdoors. This large random sample study concluded that cigarette smoking, but not sun exposure, is a strong predictor of skin ageing.5 The subjects in this study were randomly selected from the Health Authority register, which excludes the bias in other studies that recruited largely from dermatology clinics.3,14,39,32,40 Recruiting from dermatology clinics may introduce a selection bias to study methodology. These dermatology patients, it can be argued, do not represent the general population as they have chosen to engage with health professionals in a clinic to seek treatment for actual or perceived skin disorders. They may selfreport features of their own skin differently to the general population, and are more likely to have engaged in treatments to treat skin disorders or improve the appearance of their skin. A willingness to seek professional treatment may be indicative of a healthier overall lifestyle. In other areas of medical research, there is a wellestablished tendency to avoid recruiting from medical speciality clinics in order to avoid selection bias of this nature, as it is difficult to control for on statistical analysis.41 Pollution Ambient particulate matter represents an emerging extrinsic cause of skin ageing. Adverse effects of PM are currently being researched in many areas of medicine and represent a well-known harmful precipitant of disease in others, such as respirator medicine.19,20,42,43 The major mechanism by which ambient PM exerts its effect is through the generation of oxidative stress, which is a known contributor to extrinsic skin ageing.44 Particles in the nano size range, particularly from traffic sources, are considered among the most harmful components of ambient PM because these particles can serve as carriers for organic chemicals and metals that localise in mitochondria and generate reactive oxygen species.44 In 2010, Vierkötter et al. hypothesised that long-term exposure to air pollution might lead to extrinsic skin ageing through oxidative stress.45 Skin ageing signs were investigated in 400 women aged 70-80 in Germany using the validated SKINEXA Score (score of intrinsic and extrinsic skin ageing). This score includes skin ageing signs that are characteristic for extrinsic and intrinsic skin ageing, and has been previously shown to be capable of differentiating between extrinsic

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and intrinsic skin ageing.46 A significant association was found between traffic-related airborne particles and signs of extrinsic skin ageing. The study provided convincing epidemiological evidence that traffic-related particulate matter represents an important environmental factor that contributes to extrinsic skin ageing. Sleep Sleep’s effect on ageing has also been studied; Oyetakin et al.24 conducted a study that recruited 60 healthy Caucasian women and graded their sleep quality using the Pittsburgh Sleep Quality Index (PSQI).47 The SCINEXA Score was used to assess intrinsic and extrinsic skin ageing. ‘Good’ sleepers had significantly lower intrinsic ageing scores than ‘poor’ sleepers (P<0.001), however the difference in extrinsic ageing scores between the two groups did not reach statistical significance (P=0.06).24 This suggests that, in fact, sleep deprivation affects physiological or intrinsic skin ageing rather than extrinsic skin ageing. More work needs to be done to replicate this study, as most studies in this area do not use validated clinical skin quality scores, rather perceived attractiveness or general perceived health scores either self-rated or as rated by others. They do, however, universally show that poor sleep quality caused by sleep apnoea or enforced deprivation of sleep lead to poorer outcomes on perceived health and attractiveness outcomes used.24-27,48,49 Extrinsic factors in combination It is likely that a combination of extrinsic factors will cause a greater effect on facial skin. In fact, Yin et al. found that when excessive sun exposure (more than two hours per day) and heavy smoking (more than 35 pack years) occurred together, the risk for developing wrinkles was 11.4 times higher than on separate exposure.32 Monozygotic twins offer a rare opportunity to control for genetic susceptibility and exposure variables, which often stand as major confounders in population-based studies. A study of 79 pairs of twins was carried out by Okada et al. in 2013 regarding the effects of smoking on skin ageing.50 Confounding factors were controlled including sunscreen use, sun exposure, alcohol intake, and stress. It was found that the smoking twin consistently had worse scores for the stigmata that constitute ‘smoker’s face’ (p<0.0001).50 A very similar twin study by Ichibori et al. in 2013 supported these conclusions.51 He concluded that the twin who smoked showed significantly poorer facial skin texture when compared to the twin who was a non-smoker (P=0.04).51

Study limitations Discrepancies in outcomes may be found because of several areas for potential bias and limitations in methodology. The subject recruitment methods are variable. Several studies have recruited patients from a dermatology clinic list. Whilst these studies excluded any subjects with skin pathology, it could be postulated that this group of patients are more aware of their skin health and therefore do not represent the population as a whole, as previously discussed. Similarly, recruiting study subjects through advertising such as in the study by Oyetakin-White et al. in 2015,24 could introduce volunteer bias. Rosenthal and Rosnow have repeatedly examined differences between volunteers and non-volunteers.52,53 They reported that, in general, volunteers are more educated, come from a higher social class, are more intelligent and are more approval-motivated and therefore

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may behave differently in terms of skin health, which may have confounded results of those studies using skin analysis and selfassessment or interview of volunteer subjects. Adequate blinding of the researchers to the research groups was described in all the studies reviewed; however, many of the scales were visual and performed by researchers, who due to their knowledge of the subject content, may have become unblinded unintentionally when assessing some of the subjects. As discussed previously, many of these studies’ control for confounding variables by using skin biopsies from two different sites of the same subject3,4,13 i.e. volar wrist and buttock, and these sites are arguably incomparable. There has been shown to be striking regional differences in the structure of the skin that influence the morphologic photoageing at any given site.29

Conclusion The literature discussed suggests that there is a strong relationship between sunlight exposure and smoking, and the clinical manifestations of histological findings of extrinsic ageing. Sun exposure, cigarette smoking, exposure to pollution and sleep deprivation can all be controlled by the patient and therefore must be addressed by the medical practitioner when designing protocols

REFERENCES 1. Farage MA, Miller KW, Elsner P & Maibach HI, ‘Intrinsic and extrinsic factors in skin ageing: a review’, Int J Cosmet Sci, 30, 87–95 (2008). 2. Bergfeld WF, ‘The aging skin’, Int J Fertil Womens Med, 42, 57–66 (1997). 3. Fisher GJ, et al., ‘Molecular basis of sun-induced premature skin ageing and retinoid antagonism’, Nature, 379(6563): 335-339, <http://hdl.handle.net/2027.42/62525> 4. Bernstein EF, Underhill CB, Hahn PJ, Brown DB & Uitto J, ‘Chronic sun exposure alters both the content and distribution of dermal glycosaminoglycans’, Br J Dermatol, 135, 255–262 (1996). 5. Leung W & Harvey I, ‘Is skin ageing in the elderly caused by sun exposure or smoking?’ Br J Dermatol, 147, 1187–1191 (2002). 6. Kennedy C, et al., ‘Effect of smoking and sun on the aging skin’, J Invest Dermatol, 120, 548–554 (2003). 7. Chung JH, et al., ‘Cutaneous photodamage in Koreans: influence of sex, sun exposure, smoking, and skin color’, Arc. Dermatol, 137, 1043–1051 (2001). 8. Kligman LH & Kligman AM, ‘The nature of photoaging: its prevention and repair’, Photodermatol, 3, 215–227 (1986). 9. Calderone DC & Fenske NA, ‘The clinical spectrum of actinic elastosis’, J Am Acad Dermatol, 32, 1016–1024 (1995). 10. Ohnishi Y. et al., ‘Expression of elastin-related proteins and matrix metalloproteinases in actinic elastosis of sun-damaged skin’, Arch Dermatol Res, 292, 27–31 (2000). 11. Berneburg M, Plettenberg H & Krutmann J, ‘Photoaging of human skin’, Photodermatol Photoimmunol Photomed, 16, 239–244 (2000). 12. Rijken F, Pathophysiology and prevention of photoaging the role of melanin, reactive oxygen species and infiltrating neutrophils, Utrecht University, 2011 <https://dspace.library.uu.nl/handle/1874/205688> 13. Chung JH, et al, ‘Modulation of skin collagen metabolism in aged and photoaged human skin in vivo’, J Invest Dermatol, 117, 1218–1224 (2001). 14. Fisher GJ, et al., ‘Mechanisms of photoaging and chronological skin aging, Arch Dermatol, 138, 1462–1470 (2002). 15. Daniell HW, ‘Smoker’s wrinkles. A study in the epidemiology of ‘crow’s feet’’, Ann Intern Med, 75, 873–880 (1971). 16. Metelitsa AI & Lauzon GJ, ‘Tobacco and the skin’, Clin Dermatol, 28, 384–390 (2010). 17. Morita A, ‘Tobacco smoke causes premature skin aging’, (2007), Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan 18. Vierkötter A, et al., ‘Airborne particle exposure and extrinsic skin aging’, J Invest Dermatol, 130, 2719–2726 (2010). 19. Baudouin C, Charveron M, Tarroux R & Gall Y, ‘Environmental pollutants and skin cancer’, Cell Biol Toxicol, 18, 341–348 (2002). 20. Farris PK, & Krol Y, ‘Under Persistent Assault: Understanding the Factors that Deteriorate Human Skin and Clinical Efficacy of Topical Antioxidants in Treating Aging Skin’, 355–367. 21. Valacchi, G. et al., ‘Ozone exposure activates oxidative stress responses in murine skin’, Toxicology 179, 163–170 (2002). 22. Valacchi, G. et al, ‘Induction of stress proteins and MMP-9 by 0.8 ppm of ozone in murine skin’, Biochem Biophys Res Commun, 305, 741–746 (2003). 23. Valacchi G, Weber SU, Luu C, Cross CE & Packer L, ‘Ozone potentiates vitamin E depletion by ultraviolet radiation in the murine stratum corneum’, FEBS Lett, 466, 165–168 (2000). 24. Oyetakin White P, et al, ‘Does poor sleep quality affect skin ageing?’, Clin Exp Dermatol, 40, 17–22 (2015). 25. Kontogianni K, Messini-Nikolaki N, Christou K, Gourgoulianis K, Tsilimigaki S & Piperakis SM, ‘DNA damage and repair capacity in lymphocytes from obstructive sleep apnea patients’, Environ Mol Mutagen, 2007 Dec;48(9):722-7. 26. Axelsson J & Olsson A, ‘Beauty sleep: experimental study on the perceived health and attractiveness of sleep’, BMJ, 2010; 341. 27. Chervin RD, et al. ‘The face of sleepiness: improvement in appearance after treatment of sleep

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to treat the cutaneous signs of ageing, to achieve lasting results. They must also be aware that the signs of intrinsic ageing are largely independent of modification of exogenous influences. More investigation needs to be done to determine the effects of factors such as pollution and sleep deprivation as the literature is scarce. There are also several environmental factors that anecdotal evidence would suggest contribute to the acceleration of extrinsic cutaneous ageing; particularly psychological stress, poor nutrition and obesity. These areas may produce interesting results, as all three have been linked to the development of disease in other bodily systems. Dr Raul Cetto practises at Clinic 1.6 London specialising in facial aesthetics and skin ageing. He is an honorary researcher and lecturer at Imperial College London and senior clinical lecturer for Harley Academy. Dr Cetto has also been awarded a diploma in Otolaryngology and Head and Neck Surgery from the Royal College of Surgeons.

apnea’, J Clin sleep Med JCSM Off Publ Am Acad Sleep Med, 9, 845 (2013). 28. National Institue for Clinical Excellence, The guidelines manual: appendices B – I. (2012), <https://www.nice.org.uk/guidance/pmg6/resources/the-guidelines-manual-appendices-bipdf-3304416006853> 29. Bhawan J, et al, ‘Histopathologic differences in the photoaging process in facial versus arm skin’, Am J Dermatopathol, 14, 224–230 (1992). 30. Bhawan J, Andersen W, Lee J, Labadie R & Solares G, ‘Photoaging versus intrinsic aging: a morphologic assessment of facial skin’, J Cutan Pathol, 22, 154–159 (1995). 31. Yin L, Morita A, & Tsuji T, ‘Skin premature aging induced by tobacco smoking: the objective evidence of skin replica analysis’, J Dermatol Sci, 27, 26–31 (2001). 32. Yin L, Morita A & Tsuji T, ‘Skin aging induced by ultraviolet exposure and tobacco smoking: evidence from epidemiological and molecular studies’, Photodermatol. Photoimmunol Photomed, 17, 178–183 (2001). 33. Koh JS, Kang H, Choi SW & Kim HO, ‘Cigarette smoking associated with premature facial wrinkling: image analysis of facial skin replicas’, Int J Dermatol, 41, 21–27 (2002). 34. Smith JB, & Fenske NA, ‘Cutaneous manifestations and consequences of smoking’, J Am Acad Dermato, 34, A32 (1996). 35. Kadunce DP, et al., ‘Cigarette Smoking: Risk Factor for Premature Facial Wrinkling’, 840–844 (2016). 36. Leow Y & Maibach HI, ‘Cigarette smoking, cutaneous vasculature and tissue oxygen: an overview’, Ski Res Technol, 4, 1–8 (1998). 37. Emster VL, et al., ‘Facial Wrinkling in Men and Women, by Smoking Status’, American Public Health Association, (1995), < http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.85.1.78> 38. Ekiz Ö, et al., ‘Factors influencing skin ageing in a Mediterranean population from Turkey’, Clin Exp Dermatol, 37, 492–496 (2012). 39. Seddon JM, et al., ‘Evaluation of Skin Microtopography as a Measure of Ultraviolet Exposure’, Investigative Ophthalmology & Visual Science, May 1992, Vol.33, 1903-1908. 40. Seo JY, et al., ‘Ultraviolet radiation increases tropoelastin mRNA expression in the epidermis of human skin in vivo’, J Invest Dermatol, 116, 915–919 (2001). 41. Junghans C, et al., ‘Primary care Recruiting patients to medical research: double blind randomised, BMJ, 2005; 331. 42. Cantor KP, et al., ‘Air pollution and risk of urinary bladder cancer in a case-control study in Spain’, Occup Environ Med, 2008;65:56–60. 43. Beelen R, et al., ‘Long-Term Exposure to Traffic-Related Air Pollution and lung cancer risk,’ Epidemiology, 2008 Sep;19(5):702-10. 44. Donaldson K, et al., ‘Combustion-derived nanoparticles: a review of their toxicology following inhalation exposure,’ Part Fibre Toxicol, 2, 10 (2005). 45. Vierkötter A, et al., ‘Airborne particle exposure and extrinsic skin aging’, J Invest Dermatol, 130, 2719–2726 (2010). 46. Vierkötter A, et al., ‘The SCINEXA: a novel, validated score to simultaneously assess and differentiate between intrinsic and extrinsic skin ageing’, J Dermatol Sci, 53, 207–211 (2009). 47. Buysse DJ, Reynolds CF, Monk TH, Berman SR & Kupfer DJ, ‘The Pittsburgh Sleep Quality Index: A New Instrument for psychiatric Practice and research’, Psychiatry Res, 28, 193–213 (1988). 48. Olsson A, ‘Cues of Fatigue: Effects of Sleep Deprivation on Facial Appearance Cues of Fatigue: Effects of Sleep Deprivation on Facial Appearance, Sleep, 2013, 1;36(9):1355-6. 49. Edwards BA, et al., ‘Aging and sleep: physiology and pathophysiology’, Seminars in respiratory and critical care medicine, 31, 618–633 (Thieme Medical Publishers, 2010). 50. Okada HC, Alleyne B, Varghai K, Kinder K & Guyuron B, ‘Facial changes caused by smoking: a comparison between smoking and nonsmoking identical twins’, Plast Reconstr Surg, 132, 1085–1092 (2013). 51. Ichibori R, et al., ‘Objective assessment of facial skin aging and the associated environmental factors in Japanese monozygotic twins’, J Cosmet Dermatol, 13, 158–163 (2014). 52. Rosenthal R, & Rosnow RL, ‘The volunteer subject’, Artifacts Behav Res, 48–92 (2009). 53. Rosnow RL, Rosenthal R, McConochie RM & Arms RL, ‘Volunteer Effects on Experimental Outcomes’, Educ Psychol Meas, 29, 825–846 (1969).

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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An Introduction to Medical Microneedling

Proliferative phase In the proliferative phase, immature granulation tissues containing plump active fibroblasts form. Fibroblasts quickly produce abundant type III collagen which fills the defect left by an open wound. Granulation tissue moves, as a wave, from Dr Olha Vorodukhina shares her experience, the border of the injury towards the centre. technique and protocols for medical microneedling The fibroblasts produce less collagen and become more ‘spindly’ in appearance. They Medical microneedling, also known as collagen induction begin to produce the much stronger type I collagen. therapy, has been widely used in aesthetic medicine for many years. The first recorded use of microneedling was in 1905 by Maturation phase German dermatologist Ernst Kromayer. He experimented with Type III collagen is largely replaced by type I. Collagen which was various-sized dental burs mounted on motor-driven flexible cord originally disorganised is cross-linked and aligned along tension equipment and used this technique to treat scars, birthmarks and lines. This phase can last a year or longer. hyperpigmentation.1 By 1995, a new technique was discovered by Dr Desmond Fernandes for the treatment of wrinkles and scars Anatomy and physiology with the use of hypodermic needles. Around the same time, Dr Skin consists of three main layers: epidermis (superficial Fernandes developed a small needle stamp to induce collagen cellular layer), dermis (deep connective tissue) and hypodermis production. This later led to the development of our modern (subcutaneous tissue).2 As we age we produce less elastin and 1 microneedling devices. Microneedling has become a mainstream hyaluronic acid, while collagen is broken down and lost, leading procedure for many aesthetic practitioners. According to RealSelf, to prominent signs of ageing. a community-driven website composed of reviews, and information about aesthetic treatment, there was a 57% increase in interest in the treatment by readers in 2016.6 Microneedling devices There are now a wide variety of microneedling devices Mechanism of action available for aesthetic practitioners, including manual rollers, Mechanical remodelling of the skin using a medical microneedle automated rollers and derma-stamps. From my experience, I penetrates at the correct depth, dependent on skin condition, in have found that automated rollers produce excellent results order to reach the dermis and stimulate production of collagen, and offer the following benefits for patients:8,9 elastin and hyaluronic acid. The treatment works by causing • Reduced discomfort and recovery time compared to controlled micro-injuries which stimulates a healing response in the manual rollers body, detailed below:3 • Adjustable needle length for optimum results • Shorter treatment time – the practitioner can achieve Clotting phase erythema and bleeding quicker in comparison to Healing of a wound following the micro-injury begins with clot mechanical rollers formation to stop the bleeding to close and protect the wound. • No need to charge the battery (on most devices) Clotting is followed by neutrophil (immune cell) invasion, which is the body’s way to protect the wound and prevent infection.

Needle depth Inflammation phase In the inflammatory phase, macrophages and other phagocytic cells kill bacteria, debride damaged tissue and release chemical factors, such as growth hormones, that encourage fibroblasts, epithelial and endothelial cells to divide. Treated area

Thin skin

Thick skin

Forehead

0.5mm

0.8mm

Nose

0.5mm

0.6mm-0.8mm

Eyelids

0.25mm

0.25mm

Cheeks

0.8-1mm

1.3-1.5mm

Lips

0.6mm

0.8mm

Chin

1mm

1.5mm

Neck

0.8mm

1mm

Décolletage

0.5mm

1mm

Acne scars

1.5mm

1.5mm-1.8mm

Scars

n/a

2mm

Figure 1: The table shows the average depth we would use when treating with a needling system according to the recommended protocol for the Derma FSN pen.

The average epidermis depth in the face is 0.3-1mm. Therefore, we need to use an average of 0.75-1.5mm needle length to reach the epidermis and achieve a positive response to the treatment. However, if we are treating acne scarring or thicker, oilyprone skin, we may need to use a needle depth of 1.5mm and sometimes even 2mm to achieve optimum results (Figure 1).7 Protocol It is worth noting, that due to blood produced from this type of procedure, you may find that patients feel nervous about undergoing the treatment for the first time. It is only a very small amount, but can appear worse than it actually is. This is despite it actually being a minimally invasive procedure with minimal side effects. As with any aesthetic procedure, patient selection and preparation is key. Body regeneration and the healing processes slow down with age, therefore, in order to avoid a delayed healing process and possible complications such as hyperpigmentation, erythema and dryness of the skin, prescriptive skincare is required. It is not good practice to treat skin without any form of preparation (Figure 2),

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Age group

Recommended skincare for skin preparation

Duration of skin preparation

Number of initial treatments

Maintenance

25-35

• Epidermal growth factor • Moisturiser • SPF 50+

Two weeks prior to treatment

One treatment

Two treatments per year

36-45

• Epidermal growth factor • Moisturiser • SPF 50+

Two weeks prior to treatment

Course of three treatments, four to six weeks apart

Same skincare as prior to treatment and additional prescriptive skincare if required. Three treatments per year or repeat course annually

46-55

• Epidermal growth factor • Moisturiser • SPF 50+

Four weeks prior to treatment

Course of three treatments, four to six weeks apart

Three treatments per year or repeat annually

56-65

• Epidermal growth factor • Moisturiser • Skincare with ceramides will be optimal to help with moisture retention in the skin and to prevent skin dehydration • SPF 50+

4-6 weeks prior to treatment

Course of three to five treatments, three to five weeks apart

Four treatments per year or repeat course annually

Figure 2: Skin preparation, number of treatments required and maintenance procedure dependent on age group, as recommended by SkinMed.4

particularly if you are treating patients who are aged 35 or over or those who have skin conditions such as acne, melasma, scarring or rosacea. Microneedling on active acne may result in the spread of acne and infection, can worsen rosacea and without correct skincare can aggravate melasma. Introducing skin preparation alongside a course of microneedling treatments provides better and longer lasting results. Hydration is essential, as patients often report dryness in their skin during the recovery period, so I would recommend that patients use a hyaluronic acid-based moisturiser and vitamin E products. With correct preparation, this can be reduced or in some cases eliminated completely. The skin preparation, number of treatments required and maintenance care following microneedling treatment differs depending on skin type and condition, and can be broadly categorised into four age brackets (Figure 2). If the original treatment has been done as a course, maintenance can be completed as a single treatment two to three times per year, or the whole course can be repeated again, depending on what the individual patient requires. Immediately before the procedure we apply topical anaesthetic over the entire surface area which we leave on for 20 minutes. We then remove this with antiseptic to ensure that the skin is clean and ready to lubricate. A serum is then added to the skin as a lubricant to help the needles slide without catching. The serum aims to reduce post-treatment erythema and helps for a quicker recovery. Following the procedure, the final step is the application of SPF 50+. It is important to ensure that the patient has verbal and written post-treatment instructions before they leave clinic, as well as the appropriate skincare regime to use at home.5 Microneedling can be safely used in combination with dermal fillers, platelet

Microneedling case study Patient: 35-year-old female Skin type: Fitzpatrick Type II. Oily, sensitive skin which is prone to acne. As a teenager the patient suffered with acne, which later resulted in facial scarring. Medical history: Clear of contraindications Treatment protocol Skin preparation prior to treatment: Tebiskin OSK Cleanser, Tebiskin OSK Cream, epidermal growth factor, Tebiskin Hyal, SPF 50+. After two weeks of skin preparation, the patient had a course of three microneedling treatments. Maintenance regime: Six monthly treatments using the Derma FSN pen. Six weekly chemical skin peels using the Easy Phytic skin peel that combines glycolic, mandelic, lactic and phytic acid. Skincare the same as prior to the course of treatments. Results: From my point of view, I could see that the patient’s skin had a more even tone and felt much softer, which resulted in a more feminine appearance. From the patient’s point of view, she described feeling better about her skin, it felt much tighter and she experienced less breakouts. She also explained that when she applied makeup it was much more easier to apply with a smoother appearance. There was a reduction in the appearance of her acne scarring and her pores were much tighter. The epidermis level appeared much thicker and more even due to the encouragement of new cell production.

Figure 3: Patient before treatment

Figure 4: 18 months after the course of microneedling treatments following maintenance regime to maintain the results

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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It is important to ensure that the patient has verbal and written post-treatment instructions before they leave clinic, as well as the appropriate skincare regime to use at home

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rich plasma therapy, a course of skin peels and treatments such as mesotherapy and Profhilo.

Contraindications and adverse effects Without adequate preparation, microneedling can result in complications and adverse effects. These include erythema and oedema after the treatment, infection, hypo- or hyperpigmentation and scarring.10 Contraindications for this treatment include: bleeding disorders, active acne, active herpes simplex, skin infection, eczema, psoriasis and severe rosacea. Great care should also be taken with treating people aged 65 or over with very fine skin. The older the age group, the longer the skin preparation is recommended prior to treatment.10 Although from my experience this treatment has been demonstrated to be safe and suitable for all skin types, great care needs to be taken treating Fitzpatrick skin types IV-VI. Longer preparation will be required, with the use of lightening creams to control melanin.

Conclusion The basis for any cosmetic intervention is healthy skin. Even the most expert, high-quality toxin and filler treatments will not produce optimum results on pigmented, uneven skin tone. Microneedling provides excellent results for a wide range of skin types and conditions. However, skin preparation prior to mechanical remodelling should be seen as best practice. Dr Olha Vorodyukhina is a dental surgeon and aesthetic trainer. She is the owner and founder of Shine Medical and Angels Twelve Skin Clinic in Nottingham, as well as the lead aesthetic trainer for Cosmetic Courses in the Midlands. Dr Vorodyukhina is also a frequent speaker at national and international conferences. REFERENCES 1. Ninne Notto, A Brief History of the Derma Roller, (2017) <http://dermarollerqmd.com/history-ofdermaroller/> 2. Keith L. Moore, Arthur F. Dalley, Clinically Oriented Anatomy, 4th Edition, (2000). 3. WK Stadelmann, AG Digenis, GR Tobin, American Journal of Surgery, Physiology and healing dynamics of chronic cutaneous wounds (1998). 4. SkinMed announces the launch of DermaPen, (2017) <http://www.skinmed.co.uk/skinmed-news/ dermapen.php> 5. Cosmetic Courses, Dermaroller Training, (2017) <http://www.cosmeticcourses.co.uk/course/dermaroller/> 6. Emily L. Foley, Are Microneedles the New Lasers? Doctors Talk About the Next Big Aesthetic Trend, RealSelf Trends, (2015) http://trends.realself.com/2015/10/06/microneedling-dermaroller-doctorbeauty-2016/ 7. Imran Majit, Microneedling and it’s application in Dermatology, Prime Journal, (2014) 8. Automated microneedling device -a new tool in Dermatologist kit. Journal of Pakistan Association of Dermatologists 22(4):354-357 (2012) 9. Heinz Freier & Andreas Pachten, Microneedling in the medical and cosmetic field, Prime Journal, (2015) 10. Imran Majit, Microneedling and it’s application in Dermatology, Prime Journal, (2014)

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will therefore also achieve more successful results after treatment if they develop healthy living habits. The following recommendations are to be carried out in conjunction with the routine aftercare of VASER and other liposuction procedures. You must make sure that the patient is not allergic or sensitive to the supplements, oils and foods recommended.

What should the patient eat after treatment?

Incorporating Nutrition with Body Contouring Treatments Dr Jorge Zafra and Dr Kam Singh share their dietary advice for patients who have undergone a body contouring procedure After a body contouring treatment, recommending appropriate aftercare advice to your patients is crucial to a speedy recovery and the avoidance of potential side effects or complications. Providing detailed dietary advice can have a significant impact on patients’ aesthetic outcomes. In my role as a VASERlipo surgeon, alongside Dr Kam Singh, who is a national trainer, we have developed an aftercare diet plan to improve patients’ results, delivering a holistic approach to body sculpting. The plan has been developed to be implemented specifically after VASERlipo, however it can also be used in combination with other body contouring treatments such as cryolipolysis, ultrasound or radiofrequency treatments.

Why is nutrition important after a body contouring procedure? Non-surgical body contouring treatments are an excellent way to get rid of the excess body fat in specific areas and eliminate some fat cells. However, in no way are they able to completely prevent weight gain in the future, as it is the individual’s responsibility to maintain the results achieved with the treatment.1 Adults have a fixed amount of fat cells in their body that body contouring treatments aim to eliminate permanently; although, if a patient does not follow a healthy diet and exercise regularly, the remaining fat cells in the body can develop and contribute to weight gain. From my clinical experience, it has been noted that patients who don’t modify their daily routine with healthy habits after liposuction procedures will have a propensity to gain weight in parts of the body that were not treated and were not previously problematic.2 Patients

A body contouring procedure may be taxing on a patient’s body, so they will need to make wise food decisions so that the tissues and skin can heal better during the recovery period. The body needs proteins to generate new cells, and eating foods high in protein can help the overall recovery process as proteins are required for the structure, function, and regulation of the body’s tissues and organs.3 Eating smaller portions throughout the day and avoiding overlyprocessed foods can help maintain the weight with ease. A diet comprising the following foods that have a higher content of protein may help maintain the results if combined with a regular exercise routine. Recommended sources of protein • Lean meat (beef), fish (salmon or tuna) or poultry (chicken or turkey) • Vegetable source proteins (soy beans, nuts, lentils and chick peas) • Dairy proteins (Greek yoghurt and cottage cheese) • Whole grains (brown rice, quinoa and oatmeal) • Vegetables and green leaves • Fresh and dried fruit • Use of olive oil, coconut oil and ghee butter General recommendations Breakfast is the most important meal of the day and helps to maintain a good metabolism, so you should definitely advise patients not to skip this.5 Starting the day with a tea instead of a coffee is highly recommended, as drinking coffee first thing in the morning stimulates hydrochloric acid production which, over the course of the day, can lead to lower absorption of proteins.6 Recommend a morning tea that is high in antioxidants and that has a natural diuretic effect; it will help detox the body from the toxins after treatment and reduce fluid retention. Drinking plenty of water and walking is also essential. An ideal supplement to help with the regeneration of skin cells is vitamin C, so we advise an intake of 500mg in the morning and 500mg in the evening. Daily sufficient vitamin C intake is 100-300 mg/day, but oral dose is limited by intestinal absorption so by taking a 500mg tablet of vitamin C twice a day, we reach the recommended daily level and avoid higher doses in tablet form that are likely to cause diarrhoea.7 For lunch, eating proteins and carbohydrates as well as vitamins is important and adding a side salad is a good choice. When cooking the meals, we advise using a griddle instead of frying. In addition, having fresh undercooked vegetables is advisable as cooking vegetables changes their chemical composition, lowering antioxidant compounds (especially water-soluble and heat-sensitive nutrients, such as vitamin C, glucosinolate, and polyphenols) and their bio-accessibility.8 Patients should ensure that they are getting the recommended daily levels of vitamin C, which is 100-300 mg/day through their diet or additional supplements.7 Eating salads and protein in smaller portions for dinner is advisable. Likewise, olive oil and lemon juice are good seasonings.9

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Advise the patient to reduce salt consumption and replace normal table salt that has been manufactured for sea salt. Suggest that the patient avoids all processed foods, white sugar, milk and all white flours as these have higher concentrations of sodium and additives that are likely to cause fluid retention.9 After the completion of the diet plan, we encourage that patients

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continue with healthier lifestyle and diet choices. To sweeten food and drinks, replacing sugar with natural honey sugar is ideal. A tablespoon of raw honey contains 64 calories, is fat-free, cholesterol-free, and sodium-free. Its composition is roughly 80% carbohydrates, 18% water, and 2% vitamins, minerals, and amino acids.9 Some other general recommendations are as follows.

Two-week meal plan Based on the above discussion and recommendations, we have put together a two-week meal plan that offers a balanced and nutritious diet that we consider an ideal addition to the aftercare instructions of VASERlipo or other liposuction procedures. Providing your patients with a clear plan to follow can make it easier for them to adopt a healthy routine immediately after treatment, ensuring the best aesthetic results are achieved and maintained. This plan can be varied and modified according to patient requirements, although we recommend practitioners do so with a thorough understanding of nutrition.

Week Two

Breakfast:

Hibiscus tea. Oatmeal with nuts and raisins.

Brunch:

Cottage cheese with honey on seeded bread. Plenty of water.

Lunch:

Salmon fillet and risotto. Green tea.

Breakfast:

Omelette and toast with olive oil and sliced tomato.

Dinner:

Green leaf salad with grilled lean meat, fish or poultry. Hibiscus tea.

Brunch:

Hummus with carrots and celery.

Breakfast:

Green tea. Scrambled eggs and a piece of fruit.

Lunch:

Oven-cooked lamb leg with thyme, served with onions and potatoes.

Brunch:

A handful of olives and freshly squeezed or pressed juice. Hibiscus tea.

Dinner:

Fish stew with roasted peppers.

Lunch:

Spaghetti with pesto and grilled chicken. Plenty of water.

Breakfast:

Oatmeal with dried fruit and nuts.

Dinner:

Oven baked salmon served with steamed vegetables. Hibiscus tea.

Brunch:

Red juice (Blueberries, strawberries, blackberries and apple). Toast with cottage cheese.

Breakfast:

Chai masala tea. Toasted seeded bread with olive oil, tomato and avocado.

Lunch:

Hake served with risotto (rice cooked with mushrooms, garlic and onion). Consommé julienne and yoghurt with honey.

One or two pieces of fresh fruit and a handful of almonds. Green tea.

Dinner:

Brunch:

Breakfast:

Omelette with cottage cheese and chives.

Brunch:

Mixed fruit shake with yoghurt.

Lunch:

Broiled poultry served with mushrooms.

Dinner:

Zucchini purée and quinoa salad.

Breakfast:

Avocado and tofu on toast.

Brunch:

Skyr yoghurt with fresh fruit and honey.

Lunch:

Vegetable lasagne.

Dinner:

Grilled turkey served with broiled pepper.

Breakfast:

Two poached eggs and salmon.

Brunch:

Freshly squeezed or pressed fruit juice and a handful of almonds.

Lunch:

Lentil stew with meat and vegetables.

Dinner:

Quinoa salad with parsley and feta cheese.

Breakfast:

Piadina with mozzarella, fresh spinach, tomatoes and basil.

Brunch:

Green juice (spinach, pineapple, celery, apple and orange) and nut mix.

Lunch:

Tuna steak served with olives and side salad.

DAY 10

DAY 9

DAY 8

Select any tea with breakfast and dinner, drink plenty of water with all meals.

Spinach lasagne and vegetable soup. Plenty of water.

Dinner:

Quinoa and green leaf salad. Hibiscus tea.

Breakfast:

Green tea. Fresh fruit smoothie. Toast with cottage cheese and olive oil.

Brunch:

Greek yoghurt with honey and goji seeds. Hibiscus tea.

Lunch:

Lean protein meat, fish or poultry with asparagus. Plenty of water.

Dinner:

Leeks vichyssoise and a piece of fruit. Hibiscus tea.

Breakfast:

Chai masala tea. Oatmeal with dried fruit and nuts.

Brunch:

Green juice (spinach, pineapple, celery, apple and orange) and two poached eggs. Hibiscus tea.

Lunch:

Spanish omelette served with a side salad. Plenty of water.

Dinner:

Grilled fish served with baked artichoke. Hibiscus tea.

Breakfast:

Green tea with mint. Toast peanut butter and jam.

Brunch:

Smoothie of banana, strawberries and blueberries. Hibiscus tea.

Lunch:

Quiche Lorraine served with a side salad (sliced tomato and avocado). Plenty of water.

Dinner:

Salmon served with vegetable stew.

Dinner:

Guacamole (avocados, tomatoes, red onions, lime juice and coriander) on leaf of lettuce.

Breakfast:

Chai masala tea. Greek yoghurt with sliced fruit (banana and peach).

Breakfast:

Homemade banana and egg pancakes.

Brunch:

Handful of dried nuts and freshly squeezed or pressed juice. Hibiscus tea.

Brunch:

Skyr smoothie bowl with chia seeds, berries and coconut flakes.

Lunch:

Beef stew served with smashed potatoes and baked courgette. Plenty of water.

Lunch:

Chicken fajitas (corn flour tortilla, grilled chicken and peppers).

Dinner:

Pumpkin purée with gouda cheese. Hibiscus tea.

Dinner:

Salad (basil, rocket, tomato and minced boiled egg).

DAY 13

DAY 12

DAY 11

Lunch:

DAY 14

DAY 7

DAY 6

DAY 5

DAY 4

DAY 3

DAY 2

DAY 1

Week One

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Case study Progress of a 50-year-old female patient who has undergone VASERLipo treatment on 360º abdomen and fat transfer to buttocks. No complications during or after the treatment. Patient followed Zafra Medical aftercare diet plan and recommendations. Figure 1 shows visible improvement of swelling and bruising. 30 days after the procedure shows visible viability of fat transfer, definition of abdomen and flanks, achieving an hour-glass figure. Patient happy with results after VASERlipo, following appropriate aftercare and diet plan of Zafra Medical.

Day 0

Day 4

Day 30

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Artichoke Benefit: diuretic, high fibre content, antioxidant, helps avoid constipation The phytonutrients in artichokes (100g) provide potent antioxidant benefits, have dietary fibre, and provide around 12% of the recommended daily intake of vitamin K, folic acid, and vitamin C.3,4 Goji berries Benefit: vitamins, antioxidant, high fibre content These berries contain eight of the nine essential amino acids. A single four-ounce serving provides nearly 10% of your daily protein intake (0.8g of protein per kilogram of body weight). For fruit, this is a surprising amount of protein. They are also a source of vitamin C, fibre, iron, vitamin A, zinc, and antioxidants and the carbohydrates in goji berries are complex carbs. This means your blood sugar will rise slowly, reducing your risk of a sugar crash afterwards.10 Masala chai tea Benefit: antioxidant and digestive Improving digestion, chai enhances the immune system, fights inflammation and has antioxidant properties. It has also been suggested that chai has antibacterial and anti-cancer effects. The black tea in chai is rich in antioxidants and the spices in chai have been used for thousands of years to promote general health and well-being, as well as to treat various ailments.3,4

Summary

Figure 1: Progress of a 50-year-old-patient before, four days after and 30 days after VASERlipo and Zafra Medical diet plan. Images courtesy of Zafra Medical – Dr Jorge Zafra.

Quinoa Benefit: high protein content Quinoa is one of the most protein-rich foods we can eat. It is a complete protein containing all nine of the essential amino acids. It contains a high amount of fibre and is known to relieve constipation. Quinoa also contains iron and lysine (which is mainly essential for tissue growth and repair), is rich in magnesium, high in riboflavin (B2), and has a high content of manganese, which is an antioxidant.3,4 Chia seeds Benefit: helps prevent weight gain Chia seeds deliver a massive amount of nutrients with very few calories. They contain a decent amount of zinc, vitamin B3 (niacin), potassium, vitamin B1 (thiamine) and vitamin B2. They also contain fibre, protein Omega-3, calcium, manganese, magnesium, and phosphorus.3,4 Hibiscus Benefit: depurative and digestive Hibiscus tea is high in vitamin C and has a natural diuretic effect, helping reduce the fluid retention and depurating toxins. It is also used as a laxative or a digestive supplement, which could help you avoid surgery-related constipation. Additionally, you can use hibiscus tea to alleviate menstrual cramps, normalise high blood pressure, help purify arteries and kidneys and lower high cholesterol.3,4

Eating a healthy, balanced diet has a positive effect on the overall health and wellbeing of the patient, not only on their weight. Introducing a diet plan that is balanced and nutritious, while being rich in protein and vitamins following a body contouring procedure, will improve aesthetic results and help to ensure that patients do not gain weight in untreated areas that were not previously problematic. Dr Jorge Zafra has a Master’s degree in Aesthetic and Anti-ageing Medicine from the Universitat de Barcelona, Spain. He has worked as a GP and has had a vast international and multicultural experience throughout his medical career. His private medical practice, Zafra Medical, is based in Clifton Village in Bristol. Dr Kam Singh has been a GP for 22 years and has a passion for aesthetic medicine and dermatology. As well as being a national trainer for VASER, he continues to work as a full-time GP, with three surgeries and his private medical practice, Beau Aesthetica that is based in Leicester. REFERENCES 1. Hoyos, Alfredo, Prendergast, Peter, High Definition Body Sculpting Art and Advanced Lipoplasty Techniques, London: Springler, 2014. 2. Dixit VV, Wagh MS, ‘Unfavourable outcomes of liposuction and their management’, Indian Journal of Plastic Surgery, 2013;46(2) pp.377-392. 3. Tresguerres, Jesus, Medicina Estética y Antienvejecimiento, Madrid: Panamericana, 2012. 4. Bailey, Christine, Lift Your Mood With Power Foods, London: DBP, 2014. 5. Thomas, Elizabeth A. et al., ‘Usual Breakfast Eating Habits Affect the Response to Breakfat Skipping in Overweight Women’, Obesity, 23.4(2015) pp.750–759. 6. Jan De Vries, Stomach & Bowel Disorders, Mainstream Publishing, 2004. 7. Oudemans-van Straaten, Heleen M, Angelique ME Spoelstra-de Man & Monique C de Waard, ‘Vitamin C Revisited’, Critical Care, 18(2014) p.460. 8. Boeing, Heiner et al., ‘Critical Review: Vegetables and Fruit in the Prevention of Chronic Diseases’, European Journal of Nutrition 51.6(2012) pp.637–663. 9. Hoffman, Richard & Mariette Gerber, ‘Food Processing and the Mediterranean Diet’, Nutrients, 7.9(2015) pp.7925–7964. 10. Ramalingum, Nelvana & M. Fawzi Mahomoodally, ‘The Therapeutic Potential of Medicinal Foods’, Advancs in Pharmacological Sciences, 2014.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Aesthetics Journal

but if we look back even further, beards have a longer history. In primitive times, facial hair kept men warm and protected the face from the elements,4 and in many ancient societies, sporting a beard was considered a sign of honour. Men began experimenting with beard styles as early as the 16th century5 and, during the 19th century, they became a symbol of respect and power, thanks to the likes of President Lincoln and other high-profile men.6 Beards regularly switch from being on trend to passé but, for the past few years at least, the trend seems to have firmly remained ‘in’. It seems to be unrelenting and with this comes a rise in enquiries for a range of treatments, as men realise that not everyone is blessed with the natural ability to grow a full beard or, as discussed in more detail below, has had the ability taken away from them. At the Farjo Hair Institute where I practise, enquiries for facial hair transplants come from a mix of men with a variety of background stories. At the initial consultation, motivation and expectations are discussed and many requests are declined as unsuitable for a variety of reasons.

Beard and Moustache Restoration

Not recommended for beard transplant

Dr Greg Williams provides an overview of patient suitability and treatment for beard and moustache hair transplantation using Strip FUT and FUE procedures Beards and moustaches are often regarded as an indicator of a man’s age, masculinity and social dominance. Studies into the evolution of human behaviour have suggested that masculinity ratings increase linearly as facial hair increases, and that men with full beards are considered to be more attractive partners for long-term relationships.1,2,3 While these may be bold, sweeping generalisations, an inability to grow – or a sudden loss of – facial hair can be a concern for men. Exhibiting facial hair at some stage in a man’s life is becoming a rite of passage. As such, experienced hair transplant surgeons such as myself are noticing that the demand for beard-boosting treatments and transplants is rising. The so-called ‘hipster movement’ has also been associated with the growing trend for beards over recent years, Before

Aesthetics

Alopecia areata Alopecia areata results in hair loss in small, circular patches. Whilst alopecia areata affects both genders, hair loss in the beard area – occasionally referred to as alopecia barbae – is limited to men. It is widely thought that alopecia areata is an autoimmune disorder which results in hair follicles being attacked, as the body mistakenly interprets them as foreign bodies.7 Although dermatologists have mixed views and are still actively studying the condition, it has strong genetic links and appears to be hereditary.8 Emotional turmoil and stressful situations are believed to intensify the symptoms,9 but the root cause and why it only affects certain people is not fully understood. Although men with alopecia areata in the beard area may be inclined to enquire about hair loss treatment, they would not be advised to progress with a transplant. Beard transplant methods move hair follicles from a hair-dense area to a bald area, but there is a chance that transplants may not grow in areas of alopecia areata or initial growth might not be sustained. For those with alopecia areata in the scalp, many doctors will advise patients to start with steroid injections that contain corticosteroids – an anti-inflammatory medicine which is essentially a man-made version of a hormone usually produced by our adrenal glands.10 This suppresses the immune system so that the hair follicles have the opportunity to grow back. However, this – along with topical and oral corticosteroid – is not widely recommended for facial use as the face

Immediately after

Figure 1: Images show left, front and right side of the patient’s beard before a Strip FUT transplant.

Figure 2: These images show the transplant incisions and immediate post-op results with grafts.

12 months after

Figure 3: 12-months after Strip FUT treatment, which involved 902 follicular units.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


@aestheticsgroup Before

After

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sufficient. Physical trauma, including surgery, can result in permanent hair loss. The hair follicles are damaged and often replaced with scar tissue, meaning hair will no longer grow from that particular patch. For patients in these circumstances, beard hair transplants are the only permanent solution. Most commonly though, it’s those men whose beards just aren’t as naturally thick as they would like them to be, or who have patches of decreased density that they want filling in, who request hair transplants.

Beard and moustache transplant methods

Figure 4: Before and 12 months after strip FUT treatment, involving 471 follicular unit grafts. The procedure was indicated due to secondary scarring alopecia as a result of a surgical scar following skin cancer excision.

is particularly susceptible to the side effects of this treatment,11 such as bruising, discolouration and worsening of skin disorders, such as acne and rosacea. Trichotillomania Another example of when an individual may not be right for hair restoration surgery is when they suffer from trichotillomania. Trichotillomania is a condition where a person feels compelled to pull their hair out and is impulse-controlled. In terms of hair loss, the condition is characterised by an intense and repeated urge to pull out scalp hair, eyelashes, eyebrows, nose hair, pubic hair or facial hair, such as a beard or moustache.12 Pulling your own hair out in this way is often a response to a stressful situation and it is done habitually, sometimes without even realising. The noticeable bald patches which result regularly trigger a patient’s interest in hair transplant surgery to cover them up. While surgery may fix aesthetic symptoms temporarily, it fails to tackle the true cause of the hair loss, so treatment should not be recommended in this instance as, with all likelihood, the compulsion will return and the patient will once again find themselves without hair. Trichotillomania is an impulse control disorder and has been linked to behaviours associated with obsessive compulsive disorder (OCD), which can cause negative feelings and emotional distress, such as anxiety and depression.13 As such, it is a psychological condition and unfortunately not fixable with a hair loss treatment alone. Surgeons approached about trichotillomania surgeries should suggest counselling initially. Dermatological conditions Inflammation of the skin, for any reason, can cause hair on the scalp, body and face to thin and fall out. In general, patients with any sort of active dermatological condition, such as scarring alopecia and frontal fibrosing alopecia, are not suitable candidates for a hair transplant. Referral to a dermatologist is advised in these cases and, if fully treated, the candidate could be reconsidered for a transplant.

Recommended for beard transplant So, who is right for a beard transplant? Of course, there are many instances when a beard transplant offers patients the perfect solution. Patients who have experienced trauma or facial injury, possibly from burns or scarring through previous surgery, tend to be suited to a beard transplant. In these cases, there is usually no underlying condition that may cause hair loss to be repeated after treatment and good results can be achieved, providing the density of donor hair is

The main surgery options for beard and moustache transplantation include strip follicular unit transplantation (Strip FUT) and follicular unit extraction (FUE). Sufficient donor hair is required for each method, which is usually taken from the back of the scalp. If a patient has male pattern balding on the scalp, they would need to consider what their priority is – the head hair or facial hair? When reviewing a prospective patient, the first question I find that they often ask is which method is the most suitable. FUE During an FUE hair transplant, individual hair follicle grafts are removed from the donor area – usually spread out from most of the back and sides of the scalp – and then individually transplanted to the recipient area. This procedure was developed in the late 1990s, to avoid the linear scar that is associated with Strip FUT.14 One of the things that some people view as a drawback of FUE is that, for large cases requiring thousands of grafts, the whole donor area will need to be shaved on the day of the transplant. Transplanted grafts can be expected to last as long as they would do in their original location i.e. at the back of the head. Strip FUT Strip FUT surgery involves the surgeon removing a thin strip of hair-bearing scalp skin from the donor area – the back of the patient’s head – before separating the follicles under high-powered microscopes and re-implanting them in the recipient area. The main benefit of strip FUT is that the hairs are taken from the most dense and most ‘future-proofed’ part of the scalp. On the other hand, if there is enough density in the area of the beard under the jawline then these hairs will make the best ‘match’, but can only be harvested by the FUE method.15 Over the years, strip FUT practice has been continually refined and, these days, a skilled surgeon should be able to achieve a fine linear scar in the majority of procedures. However, many patients can be put off by the prospect of the wide donor scars they see online and social media which could be produced by doctors who are not as experienced as others. Both the Strip FUT and FUE methods have advantages and disadvantages and we recommend that patient suitability is best discussed with a hair transplant surgeon who utilises both techniques regularly in their day-to-day practice.

Risks Like any procedure, beard transplants carry an element of risk, but the associated risks in this instance are usually outweighed by the resulting boost in confidence. Possible side effects of surgery include infection, pain at transplant site, redness, scars and bruising, but these are relatively minimal with any discomfort being short-term. There are no known significant or long-term health-related side effects of having a beard transplant; however aesthetic complications can arise if the procedure is carried out by inexperienced doctors. For example, the potential for the grafts not surviving, the potential for hair to grow

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


Aesthetics

in the wrong direction or angle, and the risk of a difference in the appearance of the transplanted and natural hairs in terms of colour and quality.

Alternative treatments In addition to the procedures previously discussed, there are a variety of non-surgical options. For example, micropigmentation can be used to add to the appearance of beard density and create a look of fullness. This technique is a very viable treatment for those who don’t require, or want, a transplant. During micropigmentation, deposits of pigment are injected into the dermal layer of the skin to create the appearance of stubble.16 It aims to replicate the look of shaven hair but is by no means three-dimensional. It is, however, a flexible treatment, allowing patients to request the shape and profile they would like to achieve. Whilst topical treatments, such as finasteride and minoxidil, are available to stimulate hair growth on the scalp, these medications are not suitable for facial use and would therefore be unsuitable to treat missing facial hair. Hair transplantation is the only method that is permanent and provides the patient with tangible beard hair, with the natural look, feel and behaviour of what has been lost or never had.

Summary Hair transplantation is a specialist treatment that requires a vast amount of training by accredited bodies, which are limited worldwide. Practitioners who wish to pursue training in this area should only do so if it will be part of their core treatment offering. Those who do not carry out facial transplants regularly can jeopardise their ability to achieve consistently good results. Dr Greg Williams is a full-time hair transplant surgeon with more than a decade of experience in hair restoration for burns and trauma, hereditary male/female pattern hair loss and alopecia. He is a member of the British Association of Aesthetic Plastic Surgeons and is the current president of the British Association of Hair Restoration Surgery. REFERENCES 1. Neave, N., & Shields, K. (2008). The effects of facial hair manipulation on female perceptions of attractiveness, masculinity, and dominance in male faces. Personality and Individual Differences, 45(5), 373-377. 2. Addison, W. E. (1989). Beardedness as a Factor in Perceived Masculinity. Perceptual and Motor Skills, 68(3), pp.921-922. 3. Barber, N. (2001). Mustache Fashion Covaries with a Good Marriage Market for Women. Journal of Nonverbal Behavior, 25(4), pp.261-272. 4. Gowing, T. S. (1854). The Philosophy of Beards. 5. Martin, C. (2011). A Gentleman’s Guide to Beard and Moustache Management. 6. McBride, S. G. (2015). Masculinity and Facial Hair in Nineteenth-Century America. <http:// ushistoryscene.com/article/beards/> 7. National Institute of Arthritis and Musculoskeletel Diseases. (2015). What Is Alopecia Areata? <https://www.niams.nih.gov/health_info/Alopecia_Areata/alopecia_areata_ff.pd> 8. National Alopecia Areata Foundation. (n.d.). What is Alopecia Areata? <https://www.naaf.org/ alopecia-areata/faqs> 9. Botchkarev, V. A. (2003). Stress and the Hair Follicle: Exploring the Connections. The American Journal of Pathology, 162(3), pp.709-712. 10. Chang, K., Rojhirunsakool, S., & Goldberg, L. (2009). Treatment of severe alopecia areata with intralesional steroid injections. Journal of Drugs in Dermatology, 8(10), pp.909-912. 11. National Institute for Health and Care Excellence. (n.d.). British National Formulary – 13.4 Topical corticosteroids. <https://www.evidence.nhs.uk/formulary/bnf/current/13-skin/134-topicalcorticosteroids> 12. NHS Choices. (2014). Trichotillomania - Overview. <http://www.nhs.uk/conditions/trichotillomania/ Pages/introduction.aspx> 13. OCD UK. (n.d.). Trichotillomania (TTM). <https://www.ocduk.org/trichotillomania> 14. The Farjo Hair Institute. (n.d.). FUE Hair Transplant. <https://www.farjo.com/hair-loss-treatments/ fue-hair-transplant/> 15. The Farjo Hair Institute. (n.d.). Strip FUT Hair Transplant. <https://www.farjo.com/hair-losstreatments/strip-fut-hair-transplant/> 16. The Farjo Hair Institute. (n.d.). Micropigmentation. <https://www.farjo.com/blog/scalpmicropigmentation-now-available-at-farjo/>


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Aesthetics

Aesthetic treatments and HSV Aesthetic procedures such as lasers, injectables, microneedling and chemical peeling often involve limited or deliberate, controlled trauma to the skin, which has the potential to trigger cold sore recurrence. When a cold sore appears after an aesthetic treatment, it can be devastating for the patient due to discomfort, pain and potential scarring of a cosmetically sensitive area. There is a particular risk of scarring after ablative procedures.2,3 As an example, during facial dermal filler injections, virus reactivations can be provoked by direct damage to the axon by the needle. In addition, tissue manipulation and inflammatory reaction after filler injection could play a role in viral reactivation. The traumatic damage is believed to mainly cause infection reactivation, but the hyaluronic acid itself has been demonstrated to act as a protective agent, preventing viral replication.7 Virus reactivation will appear in the area where the filler has been injected (the most common sites are the perioral area and the nasolabial folds).8 In some cases, virus reactivation can extend and thus affect neighbouring areas. The viral outbreak is commonly observed 24 to 48 hours after Dr Cormac Convery discusses the relationship filler injection. Despite the possibility of reactivation, for many of these procedures the risk is low. For example, between HSV reactivation and aesthetic figures from the FDA suggest that the frequency of treatments and outlines appropriate methods occurrence is less than 1.45% of cases for dermal filler of prevention injections to the lip.8 However, aesthetic treatments do have the potential to increase the possibility of a Patients having elective aesthetic procedures often have a low patient developing cold sores and despite there being a low risk of this tolerance for complications, particularly those that have a negative happening, it is vital that this is reduced as much as possible to maintain impact on their long-term aesthetic outcome such as scarring. patient comfort and to reduce the risk of scarring. Aesthetic procedures that cause trauma to the skin have the potential to activate cold sore recurrence. Cold sores are a common Minimising the risks of HSV affliction and are usually caused by herpes simplex virus (HSV) type Minimising the risk of cold sore reactivation and awareness of 1 (usually oral herpes), with the minority (10%) being caused by HSV this is extremely important, as is having an index of suspicion, type 2 (usually genital herpes).1 Many primary infections of HSV-1 are depending on the procedure, and of the likelihood of reactivation. asymptomatic, while recurrent infections can present as cold sores at Practitioners must acknowledge that patients have a low tolerance the vermillion border.1 Although cold sores may not cause any longof complications after aesthetic procedures and even a small risk term skin damage, they do have the potential to cause scarring at the of scarring must be taken seriously, and managed with an initially infected area.2,3 preventative approach. This article will detail the aesthetic treatments that are likely to cause a I conducted a literature search to determine the effectiveness of reactivation of HSV-1 (the main cause of cold sores). The appropriate prevention for aesthetic treatments. The findings suggested that prevention methods and protocols of HSV will also be explained it is common practice in laser resurfacing for all patients to be and an investigation into practitioner awareness of these treatment treated prospectively with antivirals to prevent reactivation and protocols will be presented. dissemination of HSV-I.9

Aesthetic Treatments and Herpes Simplex Virus

Causes of HSV It is estimated that two-thirds of the global population under 50 are infected with HSV-1.4 Primary infection usually occurs in childhood through non-sexual contact, for example by sharing towels or utensils, but it is better known as a condition that spreads through kissing. If symptoms do present with primary infection, they occur two to 20 days after exposure. These may include a prodrome of fever, oral lesions (herpetic gingivostomatitis)5 and regional lymphadenopathy. Recurrent lesions, usually referred to as herpes labialis, present as a cluster of vesicles on the lip or vermillion border. These recurrent infections can be triggered by a number of factors including fatigue, bright sunlight, menstruation and trauma.6

It is important to note that the studies outlined below include participants who had not reported a history of HSV-1, however because their primary infection may have been subclinical and they may not currently show symptoms of HSV-1, they are still relevant to include. Study 1: Two groups of patients receiving CO2 laser resurfacing were observed (P=121). The group with a known history of HSV (27) were prescribed 250mg of famciclovir for seven days, while another group (94) with no known history was prescribed 125mg.10 There was only one case of HSV-1 reactivation, which came from the group with no known history.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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According to the ACE guidelines, asking about history of infection and eruption frequency should be mandatory during assessment and on the consent form – patients should be aware that a positive history of cold sores impacts management Study 2: 60 patients with and without a known HSV-1 infection (study did not specify exact numbers of each), used famciclovir 250mg for 14 days as a preventative treatment for the same procedure. Authors did not report any cases of HSV-1 in any patients.3 Study 3: 120 participants (number with and without known history unspecified) who also received laser resurfacing treatments were prescribed valacyclovir 500mg for either 10 or 14 days did not report HSV-1 reactivation. The authors also reported that 70% of participants who didn’t report a history of HSV-1, actually were serology positive for previous infection.2 Study 4: Another study considered other methods of resurfacing, including laser (CO2, Er:YAG), chemical peeling, dermabrasion, or a combination of these techniques.11 In total, 84 patients (number with and without known history unspecified) who presented for facial resurfacing were enrolled, and were randomly assigned to start valacyclovir 500mg twice daily either the morning before or the morning of the procedure. Valacyclovir was 100% effective in the prevention of HSV reactivation in both regimens with no adverse effects reported.11 Study 5: For the above studies, prophylaxis has generally been successful, however one example shows it did not work so well, with the reactivation rate being much higher compared to other studies. 99 patients (number with and without known history unspecified) who had a full-face laser or perioral resurfacing procedure received either 500mg or 250mg famciclovir twice daily, beginning 24 hours prior to laser resurfacing and continuing for 10 days. The study found an overall 10% reactivation rate. The subgroup with a history of known HSV-1 infection had a reactivation in 33%, while those with no known history of infection had a 5% reactivation rate.12 A limitation to some of these studies is that they did not provide information on which participants had a history of HSV-1 and which did not. However, from the evidence presented, prophylaxis appears to reduce reactivation of HSV. There appears to be no studies

Aesthetics Journal

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considering prevention of HSV reactivation in micro-needling therapy. I could not find any studies that considered aciclovir; instead they all used valaciclovir or famciclovir. A lot of current evidence is extrapolated form laser treatments and we must be cautious to assume it applies to other treatments in the same way. HSV prophylaxis protocol The Aesthetic Complications Expert (ACE) Group has a protocol for aesthetic treatments, which is the only one to be found that recommends prophylaxis in the following circumstances:13 • More than three spontaneous eruptions per year • Previous eruption at any time, as a result of a procedure • Lip augmentation and HSV eruption at any time • Facial resurfacing procedures; including anything that breaches the skin carrier, and specifically medium or deep peels (based on the older classification), fractional laser, microneedling and microdermabrasion • Patients who are immunocompromised or have a weakened immune system The group recommends first line prophylaxis of aciclovir 400mg twice daily (three times if immunocompromised or high risk). As mentioned, I could not find any studies for the use of aciclovir for prevention in aesthetic treatments, however it is commonly used as a first line treatment for HSV-1 outbreaks and herpes zoster. Further study is required to develop an evidence base for the use of aciclovir in HSV prophylaxis. Valaciclovir 500mg daily (twice daily if immunocompromised or high risk) is recommended by the ACE Group as a second line.

Awareness of HSV protocols Through my training role, I have noticed a surprising number of aesthetic practitioners who seem unaware of the potential need for HSV prophylaxis. This has prompted reflection on, and consideration of, ways to raise standards for all practitioners and outcomes for patients. To gauge knowledge and awareness of the need for HSV prophylaxis and to also establish what approaches were being used, I conducted a survey of aesthetic practitioners using an online survey tool. There were 59 respondents, who were each asked six questions relating to their clinical practice and protocols for treating patients. The data indicated the following: • 98% always ask about a history of cold sores • 88% reported that a positive history of cold sores affects their management of the patient • 78% follow some kind of protocol for prevention whilst giving aesthetic treatments • 67% of respondents prescribe prophylaxis, 8% have someone else prescribe and 10% refer to a GP • 34% of respondents reported prescribing aciclovir 200mg twice daily for five to seven days, 17% prescribe 400mg twice daily for five to seven days and 13% prescribe 400mg five times daily for seven days While 98% said they ask about a history of cold sores, only 88% said it affects management; this suggests that there is limited understanding of the relevance of the question. Almost 78% said they follow a protocol but only 16.95% prescribe following the ACE Guideline. It is unclear what other protocol is being followed, as no other protocol was found in published literature. 10% refer to a GP for prophylaxis

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while nearly 14% selected ‘other’ which included use of a topical over the counter aciclovir cream. Neither of these options represent appropriate care of a patient because the average GP will not know what to do in regards to aesthetic treatments, and topical over-thecounter aciclovir cream is not effective as a prophylactic agent.1 This data suggests that there is low awareness of the risk of HSV reactivation. According to the ACE guidelines, asking about history of infection and eruption frequency should be mandatory during assessment and on the consent form – patients should be aware that a positive history of cold sores impacts management. Evidence does not support the use of topical prophylaxis1 and there is no evidence base for the use of oral aciclovir in prophylaxis. I suggest the routine adoption of the ACE Group protocol with further, ideally prospective comparative study, to include the usage of oral aciclovir. I would also highlight that referral or signposting to the GP, without agreed sharedcare and protocol, is unlikely to result in best care of the patient.

Conclusion This paper presents evidence that suggests that some practitioners have inadequate awareness of this simple, yet important aspect of patient management. While not a common issue, scarring resulting from herpetic eruption is avoidable. Practitioners should follow a protocol and there should be subsequent evaluation of this protocol, as well as further prospective studies on the use of aciclovir for prophylaxis.

Aesthetics Dr Cormac Convery is the medical director at the The Bloomfield Clinic in Ayrshire and The Ever Clinic in Glasgow and Edinburgh. He is a faculty member in Aesthetic Medicine at QMUL, an ACE working group member, and collaborates with La Belle Forme group for training and research interests. REFERENCES 1. NICE, ‘Herpes simplex – oral’, 2016, <http://cks.nice.org.uk/herpes-simplex-oral> 2. Beeson WH, Rachel JD, ‘Valacyclovir prophylaxis for herpes simplex virus infection or infection recurrence following laser skin resurfacing, Dermatol Surg, (2002) 28(4):331-6. <http://www.ncbi. nlm.nih.gov/pubmed/11966791> 3. Bisaccia E, Scarborough D, ‘Herpes simplex virus prophylaxis with famciclovir in patients undergoing aesthetic facial CO2 laser resurfacing’, Cutis, (2003). 72(4):327-8, <http://www.ncbi.nlm. nih.gov/pubmed/14604087> 4. World Health Organisation, ‘Globally, an estimated two-thirds of the population under 50 are infected with herpes simplex virus type 1’, 2015, <http://www.who.int/mediacentre/news/ releases/2015/herpes/en/ 5. Primary Care Dermatology Society, ‘Herpes Simplex’, 2017 <http://www.pcds.org.uk/clinicalguidance/herpes-simplex> 6. King M (2015), ‘Going viral’, Aesthetic Medicine, March 2015, <http://www.cosmedic-clinic.co.uk/ wp-content/uploads/2015/07/Herpes.pdf> 7. Cermelli C, Cuoghi A, Scuri M, et al., ‘In vitro evaluation of antiviral and virucidal activity of a high molecular weight hyaluronic acid’, Virology Journal, BioMed Central Ltd, 2011. 8. Gazzola R, Pasini L & Cavallini M, ‘Herpes Virus Outbreaks After Dermal Hyaluronic Acid Filler Injections’, Aesthetic Surgery Journal, (2012) 32(6):770-772. 9. Nestor MS, ‘Prophylaxis for and treatment of uncomplicated skin and skin structure infections in laser and cosmetic surgery’, J Drugs Dermatol, (2005). <http://www.ncbi.nlm.nih.gov/ pubmed/16300226> 10. Wall SH, Ramey SJ & Wall F, ‘Famciclovir as antiviral prophylaxis in laser resurfacing procedures’, Plast Reconstr Surg, (1999) 104(4):1103-8. <http://www.ncbi.nlm.nih.gov/pubmed/10654754> 11. Gilbert S. & McBurney E, ‘Use of valacyclovir for herpes simplex virus-1 (HSV-1) prophylaxis after facial resurfacing: A randomized clinical trial of dosing regimens’, Dermatol Surg, (2000) 26(1):50-4. <http://www.ncbi.nlm.nih.gov/pubmed/10632686> 12. Alster TS & Nanni CA, ‘Famciclovir prophylaxis of herpes simplex virus reactivation after laser skin resurfacing’, Dermatol Surg, (1999) 25(3):242-6. <http://www.ncbi.nlm.nih.gov/pubmed/10193975> 13. King M, Prophylaxis and treatment of herpetic infections, Aesthetic Complications Expert Group, 2017, <http://acegroup.online/wp-content/uploads/2016/01/Herpes-infection-v1.1.pdf>

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PRP Hand Rejuvenation

affects the epidermal and dermal layers following exposure to the sun, chemicals and smoking and can cause actinic keratosis, solar lentigines, hypopigmentation, and solar purpura.6

When should treatment be considered? A patient should be considered for a hand rejuvenation treatment if their hands: • Are wrinkled and skin loses its elasticity and appears thin and crepey • Have prominent veins and tendons due to loss of volume • Have age spots

Aesthetic nurse practitioner Claudia McGloin discusses hand ageing and the use of platelet rich plasma treatments for rejuvenation

However, as we all know, prevention is better than cure, so hand rejuvenation treatments should start before the signs of ageing present with the use of moisturisers and sun protection on a daily basis.

Our hands are constantly exposed to factors like chemicals and the sun, so it’s no wonder that people often say that they give away our age more so than any other part of the body. After Madonna’s ageing ‘Mitts’ were heavily featured in the media,1 I found that many people became more aware of hand aesthetics and began requesting treatment for this area. In this article, I will look at platelet rich plasma (PRP) for hand rejuvenation, which is becoming popular as a natural procedure for rejuvenating ageing hands.5

Treatments There are many medical aesthetic procedures available for treating ageing hands and the type of procedure selected for the patient will depend on what indication we are looking to treat. For example, loss of volume and obvious veins would be addressed using dermal filler, while for pigmentation, a chemical skin peel or a laser treatment might be considered. Some of the procedures available for hand rejuvenation include: intense pulse light (IPL), microdermabrasion, chemical peel, dermal filler, laser, skin needling, fat grafting, mesotherapy, skincare and PRP. My personal favourite treatment for rejuvenating the hands is PRP because it is a natural procedure and it allows for the body to heal and repair itself. In my experience, patient selection is key and it may be a better option for younger patients up to the age of 50. This is because sometimes with older patients, they have lost the elasticity and volume in their skin and you might need to address this using a filler or a combination of treatments; whereas younger patients might want a more hydrating and rejuvenating effect. PRP works especially well for the forehead, cheeks, neck, décolletage, knees, elbows and hands and is a good treatment for skin revitalisation, scars (including acne scars) and stretch marks. It is also good for promoting hair growth and for non-healing wounds.7,8,9 PRP is very actively researched; new studies are being published on

Hand ageing It is common knowledge that sun damage is a large culprit of ageing. In my experience, patients tend to look after their face and neck more, and neglect their hands, despite hands being the most visible area of the body, other than the face.2 The skin on our hands is affected by both intrinsic and extrinsic ageing factors, leading progressively to a loss of structural integrity and physiological function. Intrinsic ageing of the skin occurs as a natural consequence of physiological changes over time at variable, yet genetically-determined rates. Intrinsic ageing affects the deeper soft tissue, decreasing skin elasticity, volume and dermal vascularity. This can result in wrinkles, thinner and lax skin, prominent veins, joints and tendons.6 Extrinsic factors are, to varying degrees, controllable and for the hands, include exposure to sunlight, pollution or nicotine, which damages skin by discolouring it, and miscellaneous lifestyle components such as diet and overall health.3,6 Extrinsic ageing

Anatomy of the hand

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Thenar space (deep to flexor tendons and 1st lumbrical muscle)

Probe in dorsal extension of thinner The hand and wrist are made up space deep to adductor pollicis muscle of many different bones, muscles 1st dorsal interosseous muscle and ligaments that enable a Septum separating thinner from midpalmar space wide range of movements. Practitioners should have sound Common palmar digital artery knowledge of the anatomy before treating the hands of patients Proper palmar digital arteries and nerves with any injectable procedure.4 Special note must be taken to Annular and cruciform parts of fibrous sheath over avoid tendons because I have (synovial) flexor tendon sheaths found that if injected they can cause pain, swelling and bruising. Insertion of flexor digitorum profundus tendon Avoid veins and arteries, which are often prominent and easily Insertion of flexor digitorum superficialis tendon seen on the back of the hand, because it will cause bleeding Midpalmar space (deep to flexor tendons and lumbrical muscles) and bruising.

Proper palmar digital nerves of thumb Fascia over adductor pollicis muscle Superficial palmar branch of radial artery and recurrent branch of median nerve to thenar muscles Ulnar artery and nerve

Common palmar digital branches of median nerve Hypothenar muscles Common flexor sheath (ulnar bursa) 5th finger (synovial) tendious sheath

Figure 1: The nerve and muscles of the wrist and hand

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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an almost daily basis (I have found more than 22,000 worldwide on Pubmed and 33,000 on Wiley Online Library) and cover almost every field of medicine including dental, orthopeadic, eye laser surgery, plastic surgery, cardiac surgery and most commonly, to treat sports injuries and hair loss. However, there seems to be limited research on PRP for hand rejuvenation – I could not find any studies online so this is an area that I believe could be studied in the future.

What does PRP do? PRP, colloquially known as self-stimulated serum and vampire therapy, allows the body to heal faster and more efficiently. It does this by stimulating DNA repair, which can heal scars and make dry, lacklustre skin look and feel younger. Plasma, which comprises 55% of blood fluid, is mostly water (90% by volume), and also contains dissolved proteins, glucose, mineral ions, hormones, carbon dioxide (plasma being the main medium for excretory product transportation), platelets, and blood cells themselves.7,8,9 As it is a concentration of platelets, it is also a concentration of the seven fundamental protein growth factors actively secreted by platelets to initiate all wound healing.7,8,9 Platelets are the first responder to any trauma in the body and so, by injecting the platelets directly to the site requiring treatment, you are tricking the body into thinking a trauma has occurred and the growth factors will start to work immediately to stimulate and rejuvenate.7,8,9 PRP proticol for hands A small amount of blood (I usually take 18mls with our kit) is drawn from the patient’s arm into a sterile tube in the same manner as a standard blood sample. The tube containing the patient’s blood is placed into a centrifuge and spun to separate the plasma and platelets from the blood cells. After a few minutes, the plasma and concentrated platelets are removed from the tube and re-introduced into the patient at the site of injury, which may be a scar or obvious lines or wrinkles or areas that require rejuvenation. I firstly use a topical anaesthetic to numb the patient’s hands prior to injecting. I use a 30 gauge needle for injecting and use micro droplets of PRP into the area requiring treatment. Lidocaine is not mixed with the PRP. I use 10ml of plasma that is injected into each hand (5ml per hand). Patients may bruise, but I advise the use of Arnica both prior to and post procedure to reduce the chance of bruising. Once the PRP has been injected, I massage the hand with a gauze soaked in some PRP. I find that using topical PRP helps the reduction of bruising and redness following injection. The treatment lasts 30 to 45 minutes and can be applied to any skin type or colour. Following a PRP treatment, the results are noticeable within three to four weeks and one procedure of PRP can last up to 12 months so patients are advised to have yearly procedures. They may have a second procedure if they desire at six months. PRP is a generally safe procedure that gives natural results and there is no risk of allergic reactions, as you cannot be allergic to your own blood and your body will not reject it. In addition, there is limited downtime associated with PRP treatments and it can be combined on the same day or at another time with other procedures such as fillers, microneedling, mesotherapy and chemical peels.

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injecting. Choose whatever method works for you and makes you feel most comfortable. The injection techniques for hand volume restoration include: • Tenting: injecting a single bolus by pinching the skin
 • Serial puncture: injecting the filler in a series of small volumes along a line • Microdroplets: injecting minute amounts of filler at a large number of points
 • Tunnelling or linear retrograde threading: once the needle is at the appropriate depth, injecting the filler along a line in a retrograde fashion (i.e. while withdrawing the needle)
 • Fanning: without withdrawing the needle, several threads are injected radially 
 I prefer to use mainly needle, precisely injecting blebs where I need to.

Conclusion As we know, many people look after their face and neck and may seek aesthetic treatment in these areas first, however the hands often reveal significant signs of ageing. I’m seeing more and more patients who want a natural approach to antiageing that will give them a gradual rejuvenating effect without downtime and without the risk of allergic reactions or rejection. Non-surgical procedures such as platelet rich plasma are a fantastic natural option for hand rejuvenation treatments. As with all hand rejuvenation treatments, the patient’s individual ageing concerns must be taken into consideration before deciding on a treatment plan.  Claudia McGloin is an aesthetic nurse practitioner with more than 20 years’ nursing experience. She holds dual nursing registration in both the UK and Ireland and specialised as an advanced trauma and orthopaedic nurse practitioner before further developing her career as an advanced medical aesthetic nurse practitioner. She is also the clinical director of the Claudia McGloin Clinic and highly involved in patient safety. REFERENCES 1. Bianca London, ‘Women rush to banish their ‘Madonna Mitts’: Rise in anti-ageing procedures on HANDS’, Daily Mail Online, 2013, <http://www.dailymail.co.uk/femail/article-2396983/Rise-anti-ageingprocedures-HANDS-women-rush-banish-Madonna-Mitts.html> 2. Web MD, ‘The Effects of Aging on Skin’, 2017, <www.webmd.com/beauty/cosmetic-procedures-agingskin#1> 3. M.A. Farage, K.W. Miller, P. Elsner & H.I. Maibach, ‘Intrinsic and extrinsic factors in skin ageing: a review’, International Journal of Cosmetic Science, 2008, <http://onlinelibrary.wiley.com/doi/10.1111/ j.1468-2494.2007.00415.x/full> 4. Bodice SM, Hatef DA, Rohrich RJ, ‘Dorsal hand anatomy relevant to volumetric rejuvenation’, Plast Reconstr Surg, 2010;126:163-8. 5. Ulrich Kühne and Matthias Imhof, ‘Treatment of the Ageing Hand with Dermal Fillers’, J Cutan Aesthet Surg, 2012, 5(3): 163-169. 6. Farage MA, et al, ‘Intrinsic and extrinsic factors in skin ageing: a review,’ Int J Cosmet Sci, 2008, 30(2):87-95. 7. Cash TF, Price VH, Savin RC, ‘Psychological effects of androgenetic alopecia on women:Comparisons with balding men and with female control subjects’, J Am Acad Dermatol, 1993;29:568–75.  8. Lachgar S, Moukadiri H, Jonca F, et al., ‘Vascular endothelial growth factor is an autocrine growth factor for hair dermal papilla cells’, Journal of Investigative Dermatology, 1996;106(1):17–23.  9. Cameli, Norma, Mariano, Maria, ,Cordone, Iole et al., ‘Autologous Pure Platelet-Rich Plasma Dermal Injections for Facial Skin Rejuvenation: Clinical, Instrumental, and Flow Cytometry Assessment’, Dermatologic Surgery,  2017 46:6, p 826–835.

PRP injection technique in the hands Knowledge of the anatomy and function, together with appropriate technique of injection, leads to confident treatment, optimal results and a lower risk of complications. Some practitioners use a cannula, while others use a needle to inject. Mesoguns are also popular for

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by chemical agents,6 bur abrasion using a dental handpiece,7 by scalpel,8 cryosurgery,9 electrosurgery,10 gingival grafts11 and lasers.12

Pathophysiology Prior to the removal of gingival hyperpigmentation the relevant pathophysiology should be established.

Treatment of Gingival Hyperpigmentation Dr Sarah Tonks provides an overview of pigmentation on the gums and details treatment options available The health and appearance of the gingiva are essential components of an attractive smile. Dark gums may cause complaints from patients regarding their appearance, even though this may be physiological rather than pathological. Visible oral melanin pigmentation can be seen in darker-skinned individuals and the gingiva is the most frequently pigmented intraoral tissue.1 It is infrequent in lighter skinned individuals. The source of the pigmentation is variable, however the most common is melanin.2

Cause Melanocytes are located in the epithelial basal cell layer. They convert tyrosine to melanin via the tyrosinase enzyme, which is then stored in basal cells as melanosomes.3 The degree of pigmentation depends on the activity of the melanocytes; genetics, hormonal regulation and sun exposure all play a part in this.3 There have been more than 150 genes identified which influence pigmentation and their activation relies on various epigenetic factors.4 Oral pigmentation can involve any part of the oral cavity and, aside from physiological causes, these can include iatrogenic mechanisms such as implantation of amalgam (used in dental fillings), Peutz-Jeghers Syndrome (PJS) which is an autosomal dominant condition of hamartomatous polyps in the gastrointestinal tract and hyperpigmented macules on the lips and oral mucosa, and local irritations such as smoking, benign nevi and melanoma. The colour of the gingiva can range from light brown to blue-black depending on the source and depth of the pigment.5 The gingival pigmentation can be removed if the patient desires for aesthetic reasons and several methods have been described including; cauterisation

The successful removal of gingival pigmentation has been reported by various methods, however repigmentation was reported with almost all methods

PJS (Intrinsic process) This is an autosomal dominant condition characterised by the association of gastrointestinal polyposis, mucocutaneous pigmentation and cancer predisposition. Hyperpigmented macules appear in childhood as dark blue to dark brown lesions around the mouth, eyes and nostrils, in the perianal area and on the buccal mucosa. They may also occur on the fingers. These macules are rarely present at birth but become more obvious around age five but then may fade during puberty. Noteably, approximately 65% of individuals with PJS have melanocytic macules on the buccal mucosa. Histologically there are increased melanocytes at the epidermaldermal junction with increased melanin in the basal cells. Those with PJS are not at risk of malignancy from the melanocytic macules but are at risk of a number of epithelial malignancies such as colorectal, gastric, pancreatic, breast and ovarian cancers.5 Melanocanthoma is a rapidly growing flat or slightly raised lesion. There is a higher incidence in people with darker skin and those infected with HIV. Melanocanthoma can mimic malignant melanomas clinically so a biopsy must be performed.13 Amalgam tattoo (extrinsic process) An amalgam tattoo is a blue/grey/black flat macule which is soft and painless. It is demarcated from the surrounding mucosa and is usually less than 0.5cm in diameter. It may be visible on dental radiographs in the case of larger lesions. There may be a longterm inflammatory response, in which case macrophanges engulf the amalgam and attempt to move the material out of the area and the lesion appears to clinically enlarge. If there is no apparent connection with nearby amalgam-filled teeth then a biopsy is essential to exclude melanocytic neoplasia.3 Hyperplastic or neoplastic processes Melanocytic macules may be single or multiple and can occur anywhere in the oral cavity. Nevi are uncommon in the oral cavity and appear as brown and black elevated

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Smoker’s melanosis Smoker’s melanosis is due to long-term tobacco smoking and is distributed along the gingiva in the upper and lower anterior teeth. It is treated by smoking cessation and the hyperpigmentation disappears in a few months.

on a nitrogen cooled swab is applied for five seconds in a rolling motion. During the procedure it is recommended that patients wear protective glasses and the vital teeth are protected with a periodontal dressing.17

Conclusion papules. They should be excised to exclude other serious pigmented lesions. Oral melanomas are uncommon and similarly arise from melanocytes in the basal layer of the squamous mucosa. Patients are normally between 40-70 years old at presentation. Melanoma of the oral mucosa is the most aggressive cancer of the head and neck and at the time of diagnosis, 50% of oral malignant melanomas have already spread to the lymph nodes, usually to the neck.13 Cutaneous melanomas are linked to sun exposure, however, oral melanomas have no relationship to chemical, thermal or physical events such as smoking, alcohol, irritation or poor oral hygiene. Most oral melanomas are thought to arise de novo.14 Iatrogenic oral pigmentation Most oral pigmented lesions are benign and pigmentation is due to excessive production of melanin. These lesions are usually seen most often in young or middle-aged women. This is a focal hyperpigmentation and limited to the basal epithelium and there is some overspill of the pigment to the subepithelial connective tissue.14 It is important to distinguish these lesions from malignant melanoma.

Treatment The successful removal of gingival pigmentation has been reported by various methods, however repigmentation was reported with almost all methods.2 There are a limited number of articles available featuring each different methodology and most are case reports. In a 2014 systematic review of 61 publications by Lin et al, it was found that electrosurgery (0.74% recurrence), cryosurgery (0.32% recurrence) and laser surgery (1.16% recurrence) were more reliable for treating gingival hyperpigmentation than other methods such as bur abrasion (8.99% recurrence) and scalpel surgery (4.25% recurrence) in terms of recurrence.2 The definite mechanism of repigmentation has not yet been clarified. Migration of melanocytes from the surrounding tissues could be a possible mechanism for repigmentation.15 The required depth of epithelial dissection for treating gingival pigmentation must be

more than 0.31mm deep, less than this and the basal cell layer will not be reached. It is thought that this is the reason that chemical cautery, bur abrasion or the use of a scalpel may not be able to remove the cells in the basal layer. The same review looked at CO2 laser, diode laser, Nd:YAG and Er:YAG which have all been used to treat gingival hyperpigmentation. Of the three, the diode laser had the lowest recurrence rate (0.19%) in the laser group, it is thought because it has a spectrum of 810 nm and melanin has an absorption spectrum of 351-1064 nm.2 In the case of amalgam tattoo, these lesions can be removed surgically or with Q switched ruby or alexandrite laser.13 Cryosurgery freezes tissue to destroy it, which leads to the denaturation of proteins and cell death by freezing the cytoplasm of the pigmented cells. Electrosurgery uses an electric current to cut, coagulate or desiccate the tissue which disintegrates melanin cells in the basal and suprabasal layers of the tissue.14 In the aesthetic clinic it is more likely that laser or cryosurgery would be used to remove pigmentation as these are the most readily available treatment modalities. Prior to removal it is essential to ensure that the lesion is benign, which may include referral to a dentist for confirmation prior to treatment. Treatment with diode laser The laser settings should be 810 nm, pulse frequency 20,000 Hz, pulse width of 15 microseconds or interval cycle of 50 microseconds. Practitioners should ensure 810 nm specific safety glasses are worn. At a distance of 12-15mm the laser is activated until there is a visible tissue reaction. There will be a slight immediate blanching of the tissue. This should be continued until the entire area has been covered. There should be no pain, and the tissue afterwards will feel like something warm has just been eaten.16 Treatment with cryotherapy The treatment area can be isolated with cotton rolls and topical anaesthesia, such as lidocaine (10%), can be applied for 10 minutes before treatment. Liquid nitrogen

Gingival pigmentation can be a cosmetically troubling naturally occurring phenomenon. For some patients, it may be appropriate to treat this pigmentation in the aesthetic clinic, potentially giving more confidence in smiling. Treatment can be straightforward and minimally painful, and many aesthetic clinics will already have the necessary equipment to carry out this procedure. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at the Chelsea Private Clinic, she practises cosmetic injectables and hormonal based therapies.  REFERENCES 1. Hedin, C. A. & Axéll, T. Oral melanin pigmentation in 467 Thai and Malaysian people with special emphasis on smoker’s melanosis. J. Oral Pathol. Med. 20, 8–12 (1991). 2. Lin, Y. H. et al. Systematic Review of Treatment Modalities for Gingival Depigmentation: A Random-Effects Poisson Regression Analysis. J. Esthet. Restor. Dent. 26, 162–178 (2014). 3. Dummett, C. O. & Barens, G. Pigmentation of the oral tissues: a review of the literature. J. Periodontol. 38, 369–78 4. Bennett, D. C. & Lamoreux, M. L. The color loci of mice--a genetic century. Pigment cell Res. 16, 333–44 (2003). 5. McGarrity, T. J., Amos, C. I. & Baker, M. J. Peutz-Jeghers Syndrome. GeneReviews(®) (University of Washington, Seattle, 1993). 6. HIRSCHFELD, I. & HIRSCHFELD, L. Oral pigmentation and a method of removing it. Oral Surg. Oral Med. Oral Pathol. 4, 1012–6 (1951). 7. Bishop, K. Treatment of unsightly oral pigmentation: a case report. Dent. Update 21, 236–7 8. Deepak, P., Sunil, S., Mishra, R. & Sheshadri. Treatment of gingival pigmentation: a case series. Indian J. Dent. Res. 16, 171–6 9. Kumar, S., Bhat, G. S. & Bhat, K. M. Comparative Evaluation of Gingival Depigmentation using Tetrafluoroethane Cryosurgery and Gingival Abrasion Technique: Two Years Follow Up. J. Clin. Diagn. Res. 7, 389–94 (2013). 10. Kathariya, R. & Pradeep, A. R. Split mouth de-epithelization techniques for gingival depigmentation: A case series and review of literature. J. Indian Soc. Periodontol. 15, 161–8 (2011). 11. Novaes, A. B., Pontes, C. C., Souza, S. L. S., Grisi, M. F. M. & Taba, M. The use of acellular dermal matrix allograft for the elimination of gingival melanin pigmentation: case presentation with 2 years of follow-up. Pract. Proced. Aesthet. Dent. 14, 619–23; quiz 624 (2002). 12. Hegde, R., Padhye, A., Sumanth, S., Jain, A. S. & Thukral, N. Comparison of surgical stripping; erbium-doped:yttrium, aluminum, and garnet laser; and carbon dioxide laser techniques for gingival depigmentation: a clinical and histologic study. J. Periodontol. 84, 738–48 (2013). 13. Krahl, D., Altenburg, A. & Zouboulis, C. C. Reactive hyperplasias,precancerous and malignant lesions of the oral mucosa. JDDG 6, 217–232 (2008). 14. Lin, Y. H. et al. Systematic Review of Treatment Modalities for Gingival Depigmentation: A Random-Effects Poisson Regression Analysis. J. Esthet. Restor. Dent. 26, 162–178 (2014). 15. Perlmutter, S. & Tal, H. Repigmentation of the gingiva following surgical injury. J. Periodontol. 57, 48–50 (1986). 16. Ahmad, D. B. M. Remove Gingival Pigmentation with a Diode Laser. Clinical 360 (2014). Available at: file:///Users/sarahtonks/ Downloads/Remove Gingival Pigmentation with a Diode Laser. pdf. (Accessed: 16th April 2017) 17. Rahmati, S., Darijani, M. & Nourelahi, M. Comparison of surgical blade and cryosurgery with liquid nitrogen techniques in treatment of physiologic gingival pigmentation: short term results. J. Dent. (Shiraz, Iran) 15, 161–6 (2014).

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Regenyal Laboratories’ patented gentle cross-linking process, combined with the use of dialysis, means that Regenyal products contain 30% less BDDE than other fillers and also have the lowest levels of endotoxins and proteins which leads to fewer complications. To learn more, visit belle.org.uk or email to mail@belle.org.uk

Alessandrini A, Zazzetta M. (2015). Biorivolumetria® seen under a microscope. In vitro tests to evaluate regenerative effect of Biorivolumetria® products. La Medicina Estetica. 39 (3), pp41-45. 2 Independent laboratory results on batch testing. Held on file at Regenyal Laboratories. 1


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fillers. The enzymes can be classified by their mechanism of action: mammalian (endo-BetaN-acetylhexosaminidase), leech/hookworm (endo-Beta-D-glucuronidase) and microbial (Hyaluronate lyase).17 The most commonlyused preparation in the UK is Hyalase, originating from sheep testes.18 However, microbial and human hyaluronidases appear to have advantages in terms of safety and reduced immunogenicity.16

Understanding HA Dermal Fillers Dr Tatiana Lapa and Mr Rishi Mandavia outline the pharmacology, rheology and application of hyaluronic acid dermal fillers In 2015, hyaluronic acid (HA) dermal fillers accounted for more than 92% of all filler treatments in the US.2 A growth in HA filler popularity likely reflects their excellent safety profile, efficacy and ease of administration. This article provides a background to HA dermal fillers, including regulation, their physical characteristics and uses, as well as other commonly used FDA-approved classes of dermal filler.

Regulation In a report published in 2013, the Department of Health (DOH) highlighted the lack of regulation around dermal fillers as ‘a crisis waiting to happen’.1 In the UK, dermal fillers are classed as a device, rather than drug, and can be used for cosmetic purposes without being subject to CE standards, Care Quality Commission (CQC) regulation or the EU General Product Safety Directive.1 In the absence of regulation, practitioners often look towards guidance provided by the FDA. However, the FDA has only approved 16 HA fillers for specific indications; and it is widely acknowledged that practitioners work on the basis of clinical judgement rather than this guidance.3

Pharmacology HA in the body HA is a naturally-occurring component of the extracellular matrix. It is a glycosaminoglycan (GAG) polymer consisting of repeat disaccharide units of glucuronic acid and N-acetylglucosamine. HA polymers vary considerably in length. The weight of HA polymers influence their behaviour within the tissues; polymers with high molecular mass are believed to reduce inflammation and angiogenesis, whilst polymers with low molecular mass interact to increase inflammation and angiogenesis.4 Approximately 50% of the body’s total HA is in the skin.5 HA acts as a scaffold for the extracellular matrix, providing rigidity, hydration and turgor whilst allowing cellular movement and regeneration.6 It is also important in protecting the skin from free radical damage, particularly against UVA and UVB.4 HA is rapidly metabolised in the tissues, with one third of total body HA being turned over daily.7,8 Levels of HA are determined by the balance between enzymes that create it (synthase HAS1, HAS2 and HAS3) and those that break it down (hyaluronidases HYAL1, HYAL2 and HYAL3).6 Hyaluronidases are enzymes licensed for enhancing penetration of subcutaneous or intramuscular injections, local anaesthetics and infusions and reduce swelling.16 However, they are also widely used ‘off-label’ in aesthetic medicine to dissolve hyaluronic acid

HA dermal fillers HA dermal fillers consist of long chains of hyaluronic acid. Most dermal filler products will consist of HA cross-linked with a chemical such as 1,4-butanedioldiglycidyl ether (BDDE) for Restylane, Belotero and Juvéderm, divinyl sulfone (DVX) for Hylaform, 1,2,7,8-diepoxyoctane (DEO) for Puragen, and suspended in a physiological or phosphate-buffered solution.18 The product is then processed as a homogeneous gel or a suspension of particles in gel carriers. Variability in methods used to manufacture HA fillers have given rise to differences in properties such as degree of cross-linkage, particle size and concentration. These properties are vital in determining the clinical performance of the filler.19 Chains of hyaluronic acid are linked using hydrogen bonds, forming stable complexes.9 This may provide some advantages in limiting the risk of hypersensitivity reactions, because of the lack of chemicals used in the manufacturing process may be more acceptable to some patients. HA fillers can be classified according to their particulate forms: either monophasic or biphasic gels. Monophasic gels consist of a single ‘phase’ of HA. They can be either monodensified, HA is mixed and cross-linked in a single step e.g. Juvéderm and Teosyal, or polydensified, HA goes through two stages of cross-linking e.g. Belotero. Biphasic gels such as Restylane and Perlane consist of two ‘phases’ of HA, cross-linked HA of a specific size which is then suspended in non-crosslinked HA acting as a carrier.20,21 There is much debate over the clinical effectiveness of monophasic or biphasic hyaluronic acid fillers and it is likely that no single method is superior to another, rather that the different physical properties of dermal fillers are more suitable for different clinical indications.

Dermal filler rheology Rheology is the study of the physical characteristics that influence the way materials behave when subject to deforming forces. Once injected, fillers are subject to shearing, vertical compression

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Aim

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Desirable properties

Aesthetics aestheticsjournal.com Rheological properties

Mid-face

• Deep dermal or subdermal injection • Restoring volume • Achieving projection

• • • •

Fine Lines and Lips

• Restoring volume in intradermal and sub-dermal planes

• Non-bulking • Easy moulding and spread of product

• Low viscosity (for ease of injection) • Low-medium elasticity • Low cohesivity e.g. Belotero Balance, Juvéderm Volbella, Restylane Kysse, Restylane Refyne, Teosyal RHA 2, Teosyal Global Action

Lower Face

• Restoring volume in deep dermal or subdermal planes

• Easily mouldable • Minimal projection • Non-palpable

• Low viscosity (for ease of injection) • Moderate elasticity • Low-medium cohesivity e.g. Belotero Intense, Juvéderm Volift, Restylane Refyne, Teosyal Global Action, Teosyal RHA 3

Nose and Chin

• Nasal and chin projection

• Minimal lateral spread • Maximal vertical projection

• Low viscosity (for ease of injection) • High elasticity • High cohesivity e.g. Belotero Volume, Juvéderm Voluma, Restylane Lyft, Teosyal Ultimate

Withstand shear deformation Withstand compression Minimal displacement Maintain shape

• Low viscosity (for ease of injection) • High elasticity • Medium-high cohesivity e.g. Belotero Volume, Juvéderm Voluma, Restylane Lyft, Teosyal Ultimate, Teosyal Ultra Deep

Table 1: The desirable physical characteristics of dermal fillers according to treatment areas.

and stretch from muscle movements, compression and gravity.22 It is our role as practitioners to understand the way fillers will behave when injected into a particular area or layer of the skin and to choose the most appropriate dermal filler to achieve the desired aesthetic result. Fillers used to treat different parts of the face have very different desirable qualities. For example, when treating the deep subdermal layers of the cheeks, it is important that the filler gives good volume and projection without spreading too easily through the tissues. Conversely, when injecting into superficial dermal layers, it is important that fillers can easily spread through the tight connective tissue in order to sit smoothly in the upper layers of the skin. A number of factors affect the physical characteristics of HA dermal fillers. These include: • Elastic modulus (G’): The ability to recover the original shape after shear deformation.23 • Viscous modulus (G”): The inability to recover the original shape after shear deformation.23 • Complex modulus (G*): The total ability of material to withstand deformation. It is defined as the sum of the elastic modulus (G’) and viscous modulus (G”).23 • Cohesivity: The strength of the cross-linking adhesion forces that hold the individual HA units together. Cohesivity is determined by the concentration of HA and the degree of cross-linking. High cohesivity helps the filler maintain vertical projection.22

Non-HA fillers There are other fillers available that are not made from HA. These are outlined below. Polymethylmethacrylate Polymethylmethacrylate (PMMA) are non-absorbable microspheres which, when injected into the subdermal plane, stimulate fibroblasts to encapsulate each microsphere and therefore augment tissue volume by fibroplasia.10 Artefill, the only FDA-approved PMMA filler, is a suspension of PMMA beads in bovine collagen. It is approved for the correction of nasolabial folds and acne scars.3 The earlier versions of Artefill caused unacceptably high rates of granuloma formation (up to 2.5%).10 Skin testing is generally advisable prior to treatment due to risk of sensitivity to bovine collagen. Furthermore,

the filler is permanent and requires surgical removal in the event of complications or need for correction. Collagen Collagen can be derived from porcine, bovine or human donors. Collagen fillers can be mixed with PMMA or another gel carrier. These fillers are approved for a variety of uses including injection superficially for the correction of scars and wrinkles, as well as deep dermal injections for the correction of deep folds and facial contours. Poly-L-lactic acid (PLLA) PLLA is an absorbable polymer which stimulates fibroblast production and generation of collagen, and results usually last for around two years.11 For optimal results, multiple treatment sessions are often required. The main concern with PLLA is a delayed development of palpable nodules. However, a study by Woerle et al. on 300 patients followed-up over five years reported that with adequate dilution, longer hydration time, addition of lidocaine and proper handling of the vials, the incidence of nodule formation is below 1%.27 Similar recommendations were made by Alessio et al.28 The only filler that contains PLLA is Sculptra, which was approved by the FDA in 2004 for the correction of facial lipoatrophy in patients with HIV.12 Calcium hydroxylapatite (CaHA) Radiesse is the only CaHA filler approved by the FDA. It was first approved in 2006 for the correction of facial lipoatrophy in patients with HIV, and for moderate wrinkles and skin folds.3 Radiesse is composed of 30% calcium hydroxylapatite microspheres suspended in a 70% gel carrier. It is a synthetic compound, similar in structure to bones and teeth. Radiesse is non-immunogenic, hence does not require patch testing, and is fully degraded and excreted by the body. The corrective results last for approximately 12 months.11 Others Whilst this article aimed to address hyaluronic acid fillers and other commonly used FDA-approved classes of fillers, there are other less common types of dermal filler that have not been addressed in this article. Some of these include: polycaprolactone, autologous fat transfer, dextran particles, polyacrylamide gel and agarose gel.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Considerations prior to treatment Although dermal fillers are widely used and generally considered safe, there are certain considerations prior to treatment. Contraindications such as active infection and known allergy to the filler product or constituents such as lidocaine, should be identified.24 Additional factors that may impact on treatment and recovery following treatment should be identified and optimised if possible. This includes physical (e.g. immunosuppression, autoimmune disease, dermatological problems, diabetes) and psychological health (e.g. body dysmorphia, depression, anxiety) health problems.

Complications To a greater or lesser degree, all dermal fillers are associated with certain risks. Beyond the common complications of redness, bruising and swelling, there are important risks that patients should be consented for. Infections following filler treatment are uncommon25 but may be caused by bacteria, viruses, fungi or even biofilm mediated.13 Infective agents can hide within a biofilm, protected from the reach of the immune system and antibiotics, causing granulomatous inflammation, abscesses, nodules and recurrent infection.13 Biofilms are resistant to penetration with antibiotics, hence treatment often requires surgical debridement or excision of the foreign material, thus highlighting the major advantage of the easilydissolved HA fillers. An abnormal tissue reaction can lead to the formation of nodules or granulomatous inflammation. Granulomatous inflammation is a type 4 hypersensitivity reaction, mediated by macrophage or T-cell interaction.14 Treatment may involve cortisone injections, triamcinolone acetonide injections or topical use of 5-florouracil.13 In some cases, surgical excision may be necessary. Anaphylactic reactions, although rare, are a possibility. Prompt action can save patients with anaphylaxis and therefore up-to-date anaphylaxis management training and equipment are vital for any practitioner practising injectable procedures. A disruption of the blood flow through a tissue compartment due to arterial embolisation (AE) impeding arterial blood flow, can cause pain, blanching, mottling, tissue necrosis and ulceration. Embolisation of filler product has been reported, leading to complications such as extensive necrosis, blindness and stroke.15 Strategies to reduce the risk of intravascular injection of filler include: • Aspiration prior to injection, even if the needle or cannula is primed with filler, can help identify a blood flashback and hence location of the needle tip within a blood vessel.26 • Use of a large diameter cannula rather than a narrow needle. A blunt-tip cannula with a wide bore is less likely to pierce blood vessels and is better able to aspirate for flashback.26 • Small aliquots of filler injected into one area. Large volume injections into a blood vessel can cause fatal consequences.26 • Slow injection of filler to reduce pressure damage and risk of intravascular injection.26 • Retrograde injection is considered safer than anterograde injection of filler as it has a lower risk of intravascular injection.26

Summary Hyaluronic acid is present in abundance in the skin. To make HA a useable product in cosmetic treatments, HA is stabilised with crosslinking proteins, usually 1,4-BDDE. This makes HA more resistant to degradation and therefore enables it to last for several months in the skin. Different technologies used for manufacturing HA dermal

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fillers have facilitated the development of fillers with very different properties. Furthermore, non-HA fillers have certain advantages such as a longer duration of effectiveness and generation of collagen in the skin. Using dermal fillers with the most suitable properties for the indication can help clinicians get the best results from their treatments. Dr Tatiana Lapa is the medical director of The Studio Clinic on Harley Street. She has a background in surgery, dermatology and general practice. Dr Lapa has a keen interest in research and has conducted trials in specialist centres in Brazil and London, and has published and presented her academic work internationally. Mr Rishi Mandavia is a trainee ENT, head and neck surgeon and NICE scholar with academic interests in ENT health policy research. Mr Mandavia is also a NICE specialist advisor in its guidelines and quality development programmes and has published more than 20 peerreviewed studies and book chapters. REFERENCES 1. Health DO, ‘Review of the Regulation of Cosmetic Interventions’, pringer International Publishing, 2013, <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_ Regulation_of_Cosmetic_Interventions.pdf> 2. Surgeons ASOP, ‘Plastic Surgery Statistics Report, 2016 Sep 16 <https://d2wirczt3b6wjm.cloudfront.net/ News/Statistics/2015/plastic-surgery-statistics-full-report-2015.pdf> 3. FDA. Dermal Fillers Approced by the Center for Devices and Radiological Health, (2011) <https://www.fda. gov/medicaldevices/productsandmedicalprocedures/cosmeticdevices/wrinklefillers/ucm227749.htm> 4. Erickson M, Stern R, ‘Chain gangs: new aspects of hyaluronan metabolism,’ Biochem Res Int, 2012. 5. Reed RK, Lilja K, Laurent TC, ‘Hyaluronan in the rat with special reference to the skin’, Acta Physiol Scand, 1988 Nov;134(3):405–11. 6. Triggs-Raine B, Natowicz MR. Biology of hyaluronan: Insights from genetic disorders of hyaluronan metabolism. World J Biol Chem. 2015 Aug;6(3):110–20. 7. Laurent TC, Laurent UB, Fraser JR, ‘Serum hyaluronan as a disease marker’, Ann Med, 1996 Jun;28(3):241–53. 8. Schiller S, Dorfman A, ‘The metabolism of mucopolysaccharides in animals. IV. The influence of insulin’, J Biol Chem, 1957 Aug;227(2):625–32. 9. IBSA, Profhilo, 2017 <http://www.ibsaderma.com.ua/en/pdf/Brochure_medico_Profhilo_en.pdf> 10. Lemperle G, Romano JJ, Busso M, ‘Soft tissue augmentation with artecoll: 10-year history, indications, techniques, and complications’, Dermatol Surg, 2003 Jun;29(6):573–87. 11. Ballin AC, Brandt FS, Cazzaniga A, ‘Dermal fillers: an update’, Am J Clin Dermatol, 2015 Aug;16(4):271–83. 12. Lisa C. Kates, and Rebecca Fitzgerald, Poly-L-Lactic Acid Injection for HIV-Associated Facial Lipoatrophy: Treatment Principles, Case Studies, and Literature Review (2008) <https://oup.silverchair-cdn.com/oup/ backfile/Content_public/Journal/asj/28/4/10.1016/j.asj.2008.06.005/2/28-4 397.pdf?> 13. DeLorenzi C, ‘Complications of injectable fillers, part I,’ Aesthet Surg J, 2013 May;33(4):561–75. 14. Alijotas-Reig J, Fernandez-Figueras MT, Puig L, ‘Inflammatory, immune-mediated adverse reactions related to soft tissue dermal fillers’, Semin Arthritis Rheum, 2013 Oct;43(2):241–58. 15. DeLorenzi C, ‘Complications of injectable fillers, part 2: vascular complications’, Aesthet Surg J, 2014 May;34(4):584–600. 16. Cavallini M, Gazzola R, Metalla M, Vaienti L, The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers. Aesthet Surg J. (2013) Nov;33(8):1167–74. 17. MEYER K, RAPPORT MM. Hyaluronidases. Adv Enzymol Relat Subj Biochem. 1952;13:199–236. 18. Yeom J, Bhang SH, Kim B-S, Seo MS, Hwang EJ, Cho IH, et al. Effect of cross-linking reagents for hyaluronic acid hydrogel dermal fillers on tissue augmentation and regeneration. Bioconjug Chem. (2010) Feb;21(2):240–7. 19. Edsman K, Nord LI, hrlund K, L rkner H, Kenne AH. Gel Properties of Hyaluronic Acid Dermal Fillers. Dermatologic Surgery. 2012 Jul;38(7pt2):1170–9. 20. Prasetyo AD, Prager W, Rubin MG, Moretti EA, Nikolis A. Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. Clin Cosmet Investig Dermatol. 2016;9:257–80. 21. Mansouri Y, Goldenberg G. Update on Hyaluronic Acid Fillers for Facial Rejuvenation. Center for Devices and Radiological Health. Available from: <http://www.mdedge.com/cutis/article/101904/aestheticdermatology/update-hyaluronic-acid-fillers-facial-rejuvenation> 22. Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg. (2015) Apr;41 Suppl 1:S120–6. 23. Kablik J, Monheit GD, Yu L, Chang G, Gershkovich J. Comparative physical properties of hyaluronic acid dermal fillers. Dermatologic Surgery. 2009 Feb;35 Suppl 1:302–12. 24. Lafaille P, Benedetto A. Fillers: Contraindications, Side Effects and Precautions. J Cutan Aesthet Surg. India: Medknow Publications; 3(1):16–9. 25. Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. (2008) Jun;34 Suppl 1:S92–9. 26. Kim H-J, Seo K, Lee H-K, Kim J. Clinical Anatomy of the Face for Filler and Botulinum Toxin injection. Cutis. illustrated. (2015) Aug 1;96(2). 27. Woerle B, Hanke CW, Sattler G. Poly-L-lactic acid: a temporary filler for soft tissue augmentation. J Drugs Dermatol. 2004 Jul;3(4):385–9. 28. Alessio R, Rzany B, Eve L, Grangier Y, Herranz P, Olivier-Masveyraud F, et al. European expert recommendations on the use of injectable poly-L-lactic acid for facial rejuvenation. J Drugs Dermatol. 2014 Sep;13(9):1057–66.

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Amplifying Laser Efficacy: Partnering with Vaniqa® (eflornithine) Insights & Key Learnings from the ACE Masterclass with Dr Maria Gonzalez In aesthetic practice, hair removal can be seen as a ‘peripheral’ service, yet in my clinic we are seeing a huge demand from patients, making it one of our top treatment offerings. I believe this trend is in part due to the significant cultural pressure on women to have less hair in general – let alone those who have been diagnosed with female facial hirsutism (FFH) which affects between 5 and 15% of women1 and can impact across a broad age range. I see lots of younger women in clinic who are upset by their facial hair. Unwanted facial hair is a major social issue: patients can become isolated and have a deep sense of shame some even have encountered hostility at work, so this is an issue I take very seriously. Efficacy of Laser Hair Removal (LHR) LHR is an efficacious hair removal method and while many patients can achieve excellent results, there are limitations depending on patients’ skin and hair types which can mean some must still rely on additional methods of hair removal. I would classify around 30% of my patients as ‘difficult to treat’: these tend to have fair or red hair, or are perhaps in an older age category with white hair. It can also be difficult to achieve a satisfactory result for Asian patients using LHR alone, as these patients tend to have fine facial hair alongside darker skin tones (skin types 4 – 5). For these ‘difficult to treat’ patients, I believe it is important to consider adjunct therapies to amplify the efficacy of LHR. Amplifying Laser Efficacy: Partnering with VANIQA® (eflornithine 11.5% cream) For ‘difficult to treat’ patients who are not achieving sufficient results through LHR alone, we can now offer an additional adjunctive option in the form of VANIQA® (eflornithine 11.5% cream). VANIQA® is the only topical non-hormonal prescription FFH treatment proven to slow the growth of facial hair. This FDA-approved cream is suitable for all skin and hair types, including dark, coarse, and light vellus hair.2,3,4 Regrowth rates differ significantly between the face and other areas of the body: from three months on the legs, to as little as 4-6 weeks for facial hair regrowth - often leading to patient Adapted from Hamzavi et al, 2007 disappointment and 56

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frustration. VANIQA® offers practitioners a valuable option to help prolong the time between treatment and hair regrowth. It works by inhibiting ornithine decarboxylase, preventing synthesis of polyamines which are essential for hair growth.4 As VANIQA® is not a depilatory cream, the specific method of action means it can be used alone or in combination with any other hair removal methods or treatments.2 When used in combination with LHR, VANIQA® is proven to enhance results: clinical studies have demonstrated a significant 30% improvement in results following LHR and VANIQA® combination treatments.5 When used twice-daily between and after laser hair removal treatments, VANIQA® delivers significantly faster, more complete results than LHR alone – meaning that patients were ‘hair-free’ for a longer time (vs LHR alone).5 Conclusion VANIQA® can provide a valuable adjunct treatment option for those patients who struggle to achieve excellent hair reduction results with LHR alone. As a simple twice-daily and cosmetically acceptable treatment, VANIQA® can be easily incorporated into patient’s skincare regimes and has a generally well-tolerated safety profile for long-term use.6 Consistency is key, so it’s important to manage patient expectations around usage and adherence to treatment, however in general I find that this treatment combination of VANIQA® and LHR delivers good results for those more challenging patients. Find Out More Discover more about how VANIQA® can support your treatment approach for female facial hirsutism by visiting https://vaniqa.co.uk/ VANIQA® is available from Wigmore Medical: pharmacy@wigmoremedical.com T: 020 7491 0111 | F: 020 7491 2111

REFERENCES 1. Azziz R. Obstetrics & Gynae 2003; 101: 995-1007. 2. Shapiro J, Lui H. Skin Therapy Letter 2005/6; 10: 1-4. 3. Smith S, et al. Dermatol Surg 2006; 32: 1237-43. 4. VANIQA Summary of Product Characteristics. Available at: www.medicines.org.uk/emc/medicine/21243. Accessed Mar 2017 5. Hamzavi I et al. J Am Acad Dermatol 2007; 57: 54-9. 6. Schrode K et al. Poster 294 presented at 58th AAD Congress, 2000, 10-15 March, San Francisco; USA,.

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A summary of the latest clinical studies Title: The Kinetics of Reversible Hyaluronic Acid Filler Injection

Treated with Hyaluronidase Authors: Juhasz MLW, Levin MK, Marmur ES Published: Dermatologic Surgery, June 2017 Keywords: Hyaluronic acid, hyaluronidase, dermal filler Abstract: Hyaluronidase is an enzyme capable of dissolution of hyaluronic acid (HA). There is a lack of evidence-based research defining time- and concentration-dependent reversal of HA filler using hyaluronidase. The objective of this study was to explore the efficacy of different concentrations of hyaluronidase in digesting commercially available HA-based reversible fillers-Belotero Balance (BEL), Juvéderm Ultra XC (JUVXC), Juvéderm Ultra Plus (JUVX+), Juvéderm Voluma XC (JUVV), Restylane-L (RESL), Restylane Silk (RESS), and Perlane/ Restylane Lyft (RESLYFT). This was a blinded randomized study involving 15 participants. Participants received HA filler injection into their back, followed by no secondary injection, or injection with normal saline, 20 or 40 units of hyaluronidase. Using a 5-point palpation scale, the degradation of HA filler was monitored over 14 days. In the authors' study, there is a significant decrease in HA filler degradation using 20 and 40 units of hyaluronidase compared with no secondary injection or normal saline. There is no significant difference in HA filler dissolution when comparing 20 to 40 units of hyaluronidase. Lower concentrations of hyaluronidase may be just as effective as higher concentrations to degrade HA filler in situations where the reversal of cutaneous augmentation with HA filler arises.

Title: Successful Treatment of Becker's Nevus With Long-Pulsed

1064nm Nd:YAG and 755nm Alexandrite Laser and Review of the Literature Authors: Wulkhan AJ, McGraw T, Taylor M Published: Journal of Cosmetic and Laser Therapy, May 2017 Keywords: Becker’s Nevus, hyperpigmentation, lasers Abstract: Becker's Nevus is an aesthetically troublesome condition secondary to hyperpigmentation and hypertrichosis. Although several lasers have been employed with varying degrees of success, the exact devices and treatment parameters have yet to be elucidated. The objective of this study was to assess the combination Nd:YAG and alexandrite

PRESCRIBING INFORMATION (Please consult the Summary of Product Characteristics (SmPC) before prescribing.) Vaniqa 11.5% Cream eflornithine 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

laser as a safe and efficacious treatment for Becker's Nevus. In a 20-yearold Fitzpatrick Skin Type IV male, a Becker's Nevus was treated with six sessions of long-pulsed 1064nm Nd:Yag laser at six-week intervals followed by five sessions of long-pulsed 755 nm alexandrite laser at threemonth intervals. This patient experienced a significant reduction in both hyperpigmentation and hypertrichosis after these treatment sessions. No serious adverse events were reported. This case supports the use of combination long-pulsed 1064nm laser and 755 nm laser as a safe and efficacious treatment for Becker's Nevus.

Title: Development of an Atrophic Acne Scar Risk Assessment Tool Authors: Tan J, Thiboutot D, Gollnick H, Kang S et al. Published: Journal of the European Academy of Dermatology and

Venereology, May 2017 Keywords: Acne, atrophic, scar Abstract: Acne scarring is usually avoidable when acne is managed early and effectively. However, acne patients often fail to seek early treatment. This study presents the development and assessment of a tool aiming to assess the risk of atrophic acne scars. A systematic literature review of clinical risk factors for acne scars, a Delphilike survey of dermatological experts in acne and secondary data analysis were conducted in order to produce an evidence-based risk assessment tool. The tool was assessed both with a sample of young adults with and without scars and was assessed via a database crossvalidation. A self-administered tool for risk assessment of developing atrophic acne scars in young adults was developed. It is a readily comprehensible and practical tool for population education and for use in medical practices. It comprises four risk factors: worst ever severity of acne, duration of acne, family history of atrophic acne scars and lesion manipulation behaviours. It provides a dichotomous outcome: lower versus higher risk of developing scars, thereby categorising nearly two thirds of the population correctly, with sensitivity of 82% and specificity of 43%. A potential benefit is to encourage those at risk to self-identify and to seek active intervention of their acne. In clinical practice, we expect this tool may help clinicians identify patients at risk of atrophic acne scarring and underscore their requirement for rapid and effective acne treatment.

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 propylparahydroxy-benzoate 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 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, Harman House, 1 George Street, Uxbridge, Middlesex, UB8 1QQ, UK. Tel: (0) 207 160 2500. Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk Date of Revision: 04/2017 Item code: UKEFL3336a

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.

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by the clinic (within its network, website, computer/phone devices and patient files), has been rendered unintelligible to any third party, for example, when a file has been embedded with an encryption, the obligation to notify the ‘data subjects’ is less onerous than when there is no encryption of the data. This means that you will still have to notify them, but if it’s encrypted you won’t have to send exact details of what has been compromised and what measures you are putting in place to monitor it.

Getting Ready for GDPR Medical malpractice and risk specialist Martin Swann provides an introduction to the new data protection legislation, sharing his five top tips to prepare practices for compliance The new European Union (EU) General Data Protection Regulations (GDPR) come into force on May 25 2018, meaning that the time for your practice to fully understand what’s coming and plan is now! GDPR is compulsory for all businesses and is arguably the most significant amendment to data protection regulations for more than 20 years. Brexit is not going to remove these obligations; Theresa May has made clear that EU law will translate into our own domestic regulations5 and burying our heads in the sand won’t make it go away.

new regulations. Mandatory compliance will come into force from May 2018 and will replace the current Data Protection Act 1995 (DPA).7

About GDPR

Notifications: Mandatory notifications for all businesses in the event of a breach or loss. For example, loss or theft of a client file, malware, unauthorised access to the clinic’s network, loss of a mobile phone, laptop or data stick that has client data on its hard drive. Breaches must be reported to the regulator without undue delay and, where feasible, within 72 hours of becoming aware. Each country will appoint its own regulator; the UK’s is currently the UK Information Commissioner’s Office (ICO), however it has not yet been confirmed if this will remain so once the GDPR regulations come into force. There will also be an obligation to notify the ‘data subject’, which could be a patient or client of the breach. Where the data held

The EU GDPR was first introduced by the European Parliament in 2012.6 The intention of the new regulation was to strengthen data protection across the EU, unifying the protection of the personal data for its citizens and residents including the export of data outside the EU. One of the primary objectives of the GDPR was to give control back to individuals over the collection and use of their personal data. The aim was to simplify the regulatory environment for business trading internationally by unifying the regulation within the EU. The new GDPR regulations became law on April 27 2016,2 but businesses were given a two-year transition period to get themselves ready for compliance with the

What is changing? One of the first things to make clear about these new regulations is that no business is exempt. The regulations bring in many significant changes that practitioners and clinic owners will need to understand and plan for before they are applied in 2018. These changes include:2

Consent: Increased requirements for consent of personal data. Data subjects must already express their permission for the business to hold their data, but consent from the patient must now be more detailed and you have to have explicit consent for its exact use. This consent must also be easily withdrawable.2 Plan: Implied obligation for all businesses to have a plan/process for dealing with breaches and data losses. Some professions, such as those who have a professional regulatory body, do have this obligation already, but the fines and penalties now are much more punitive. The company’s plan needs to include a process for identifying how the breach occurred, what data was compromised, a strategy for notifying the data subject and regulators, and fixing/mitigating the vulnerabilities that caused the breach (if any). Mitigation: Increased obligations around security of data, including ongoing mitigation in regards to risks of a breach such as penetration testing, vulnerability sweeps, staff training, updating virus software and data encryption. This is usually undertaken by your IT provider/support company or third party, however some larger clinics may manage this in-house. Data processors: Increased administrative requirements and obligations for data processors; including the ability to be able to provide a full audit trail for data held. Personal data: Definitions of what is considered personal data has now become more specific. More information of this is outlined in the regulations.2 DPO: Some businesses may now need to appoint a data protection officer (DPO), such as if you are a public authority or carry out large scale systematic monitoring of

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individuals (for example, online behaviour tracking).8 This person must be within their organisation and be trained to deal with data compliance and breaches, which can be obtained from specialist providers. It could be a current staff member that takes on this responsibility or a new employee, depending on the amount of data you are holding. Penalties: The new regulation significantly increases the stakes in terms of fines for failure to comply. Under the current DPA, as enforced by the ICO, the maximum monetary penalty that could be served is £500,000 for a serious data breach.7 Under the new GDPR, the maximum fine for simply failing to alert the necessary regulatory authority of a data breach within 72 hours could be €10 million (around £8.5 million) or 2% of a company’s global revenue; whichever is greater. However, fines can rise to €20 million (£17 million) or 4% of global revenue, whichever figure is higher, if it is deemed that suitable remedial action has not been taken following a breach.2  

Top 5 tips for preparing your practice for GDPR The ICO has produced a handy 12 step guide to GDPR,4 which can be downloaded from its website. Below are my top 5 tips to think about, which incorporate some of those described in the guide. 1. Understand your obligations Depending on whether you are deemed the data processor (access data and process it) or controller (responsible of holding and deeming how it should be controlled), these obligations will differ.9 If you are relying on third party suppliers for data storage, who can be a data processor or controller (such as back-ups and email management/archiving), ensure your contracts with these suppliers fully reflect the intended services and contractual responsibilities being provided by these suppliers. If they are being contracted to securely store your data, ensure that your contract with them confirms this.  2. Confirm the legal basis with which you obtain and use personal data As I have explained above, consent must now be explicit. Ensure that the right permissions have been obtained for the data you use to market your clinic’s products and services. If you don’t have the right consent, get this in place now before the new regulations apply. You can do this by getting patients to sign consent when they are next in clinic for an appointment.

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3. Identify changes you need to implement To ensure compliance with GDPR, undertaking a GAP analysis of your current processes and controls is advisable.3 A GAP analysis identifies the ‘gaps’ you may need to fill to comply with the new regulations and involves the collation and protection of data, against the requirements within the new regulations. This will provide you with useful data to produce a road map for achieving compliance with GDPR. You will be looking to understand where your practice sits in regards to compliance with the new regulations and what changes to things like process, security, training and planning you need to make or put in place to comply. It is likely that additional costs will need to be incurred to comply, and identifying this now will aid with budgeting for these. 4. Securely protect the data you hold You must ensure that you have a process for regularly identifying any vulnerabilities of your network and mitigating these. Also, ensure that any data stored on the hard drives of mobile or portable storage devices is encrypted and be aware that suitable access controls need to be in place, for example passwords or remote authentication. It is worth pointing out that the obligations created by these new regulations around security of the data held will apply to all personal data held by your practice, including any historic paper records.   5. Prepare for data security breaches Have a plan or ‘breach response’ in place to deal with security breaches. Have this as part of your general business continuity/ disaster recovery plan to deal with the occurrence of a breach or loss of data, including notification to the regulators. As mentioned, this is an implied obligation of the new regulations and failing to have suitable provisions in place could leave you facing an investigation and/or a hefty fine. To prepare for a data security breach, you might want to seek advice to assist you in dealing with the breach and to avoid the risk of a costly investigation and/or fine by the regulators. To access this support, while also assisting with the costs that you will incur following a breach, you can either employ a breach response provider or you can alternatively purchase cyber insurance protection.

differ greatly from product to product. Most standard cyber insurance policies will include access to a 24/7 breach response helpline and coverage of the costs incurred following a breach. This could involve forensic examination of your network, rectification costs, notification and monitoring costs, business interruption and loss of income following a breach and cyber fraud and extortion. They will also usually cover the costs incurred if you are investigated by the regulator following a breach.

Summary It is clear that failure to comply with these new regulations could prove costly for your practice. Whilst May 2018 may seem like a long way off, the time to get your practice ready for compliance with GDPR is now. Every business that uses personal data will be required to comply, so the sooner your practice starts planning for compliance, the easier it will be to achieve before the deadline. Disclosure: Martin Swann is the divisional director of Enhance Insurance.  

Martin Swann is the divisional director of Enhance Insurance and has been insuring medical and healthcare professionals and businesses for more than 15 years. Swann has extensive experience in risk identification, mitigation and management and provides advice on how best to reduce the risks faced by your practice. REFERENCES 1. EUGDPR, ‘GDPR Portal: Site Overview’, 2017 <http://www. eugdpr.org> 2. Official Journal of the European Union, REGULATION (EU) 2016/679 OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 27 April 2016, <http://eur-lex.europa.eu/legalcontent/EN/TXT/PDF/?uri=CELEX:32016R0679&from=EN> 3. Guardum Ltd, 2017, <http://www.guardum.com> 4. ICO, Preparing for the General Data Protection Regulation, 2017 <https://ico.org.uk/media/for-organisations/documents/1624219/ preparing-for-the-gdpr-12-steps.pdf> 5. Theresa May, Theresa May’s Brexit speech in full’, The Telegraph, 2017, <http://www.telegraph.co.uk/news/2017/01/17/ theresa-mays-brexit-speech-full/> 6. EU Data Protection Supervisor, ‘The History of the General Data Protection Regulation’, <https://edps.europa.eu/data-protection/ data-protection/legislation/history-general-data-protectionregulation_en> 7. Legislation.gov.uk, ‘Data Protection Act 1998’, <http://www. legislation.gov.uk/ukpga/1998/29/contents> 8. ICO, Accountability and governance, 2017, <https://ico.org.uk/ for-organisations/data-protection-reform/overview-of-the-gdpr/ accountability-and-governance/> 9. ICO, Data controllers and data processors: what the difference is and what the governance implications are, <https://ico.org.uk/ media/for-organisations/documents/1546/data-controllers-anddata-processors-dp-guidance.pdf>

Insurance There are a number of insurers who offer cyber liability insurance, however cover can

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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purposes, used in a way that is adequate, relevant and not excessive’. You’ll also need to give them the opportunity to opt-out of any communications at any time – for example, a clear ‘unsubscribe’ button under each newsletter or mailshot you share.

2. Communicate with your patients

Five Tips to Maximise Clinic Success Business coach Alan Adams provides a basic overview of how to retain patients and grow clinic profits Many of the plastic, maxillofacial and aesthetic clinic owners I speak to are so busy working in their business that they rarely find the time to work on it. They may be technically excellent – exceptional in some cases, and they rightly focus on staying at the very forefront of their specialism. Yet, their clinics are not always the most profitable, nor are they as busy as they could be in terms of patients coming through the door. Why? Because they’re so busy ‘being busy’ in their practice that they have no time left to focus on the commercial side of the clinic. Plus, there are many practitioners who have limited sales and marketing strategy, or if they do, it is often simplistic, due to their lack of expertise in this area. In this article, I will share with you some simple and straightforward strategies that can help you to make your clinic more profitable. This can be done without making major changes, as we’ll be focusing instead on the power of minor changes over time. By making just a small improvement in each of the areas detailed below, you can hugely enhance your business.

1. Gather customer data The first area to consider is the data your business has available as, in my experience, it is one of the most valuable and easilygained resources. In essence it does not

matter if you record your patients’ details on a simple Excel spreadsheet, or a state-ofthe-art customer relationship management (CRM) system. What is vital is that it works for you, and is kept meticulously up-to-date. This data can then be used to target your existing and potential clients. Who should you be adding to your database? Quite simply – anyone that you and your wider team has ever engaged with. It may be people who have visited your website, have made an enquiry, who you have met with at a show or event, or someone you have had an initial consultation with, and who has been referred to you. You will always need to adhere to The Data Protection Act1 to collect and use data like this, which offers guidance on your legal responsibilities. For example, you have an obligation to ensure data is safely stored and that you have permission to actively use this data. You can secure patient permission to collect and use their information by adding a box in consent forms that says, ‘Are you happy for us to contact you by email/post/ phone?’ which allows them to tick and sign to confirm. You should capture all the data that’s relevant to you and your business, including the patient’s full name, email address, date of birth, previous services used and phone number. Although it should be noted that The Data Protection Act states that data should be ‘used for limited, specifically stated

The second area you should consider is communication. You now have an expanded list of contacts on your database and will need to decide how to communicate with all the contacts on it. The key here is to communicate often enough that you are on their mind, but not so often that it feels pressured. This is very much down to you and your own individual clinic, and how often you feel your contacts would prefer to be communicated with – whether by text, phone, email or post. Again, you can find out what they prefer by asking them. For example, if you’re an aesthetic practitioner offering a more accessible and repeatable treatment, it is probably appropriate for you to communicate more frequently than someone in a specialist area of surgery. All you need to do to work out the right level is test and measure. If you’re finding that you are getting a lot of unsubscribes for weekly emails, try sending them fortnightly instead and compare numbers until you get very few people unsubscribing, and lots of positive enquiries coming through.

3. Offer value, not a hard sell Before any potential (or past) patient becomes a current patient, there are a few important things that need to happen. Firstly, they need to trust you. To help develop this trust, your communication should focus on stories and topics that showcase your

Who should you be adding to your database? Quite simply – anyone that you and your wider team has ever engaged with

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


Donâ&#x20AC;&#x2122;t ignore the glaringly obvious! Changes to data protection laws are coming. Pain and discomfort are avoidable if you take the necessary precautions to minimize the risk. With the new EU General Data Protection Regulations (GDPR) looming, NOW is the time to prepare your business for the significant changes to data protection legislation.

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At Enhance we have the skills and knowledge to help your business not only prepare for GDPR, but also put in place the necessary protection needed to minimize any pain associated with a data breach.


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Talk to your team about communicating with patients in regards to the additional services and products you have within your clinic

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above, and run some offers, promotions, advertisements, issue a press release, or networking, and so on. Or if you wanted to increase the spend of current patients, you could look at encouraging them to consider other add-on services or packages. While all the outlined recommendations require some commitment of time to get everything set up, the costs to do so are minimal as you can choose to do this all yourself; resulting in the increase in revenue becoming profit for the business owner.

Conclusion credentials, training, expertise and ability. Good examples include award-wins, PR articles in newspapers and magazines, and industry accolades. In addition, referrals from existing happy patients are extremely valuable. So, if you are not already asking for referrals in a formal way, then this is certainly something to think about next time you speak to any of your current patients. Provide guidance Any potential patient needs to understand how you can help them. Bear in mind that we can all be motivated by either the fear of something (for example, it could be the fear of ‘looking old’ or having wrinkles) or an opportunity (for example, the desire to be more physically attractive). For the former group of individuals, you need to demonstrate how you can help them avoid or reduce signs of ageing, whilst for the latter you should talk about your expertise in, say, lip enhancements or browlifts, which can help these individuals gain something, so these are important to include in all your messaging. You should listen carefully to their concerns and address them appropriately.

4. Increase targeting efforts Once you have done all the above, the next stage is to turn potential patients into existing ones. I would suggest that you have a timeline worked out that highlights when each individual contact was communicated with, when and how they were followed up, and by whom. This could be compiled on a spreadsheet or CRM system. You should avoid any potential confusion or inconsistency by developing scripts for your team and creating templates for emails and letters wherever possible. I advise my clients who are practitioners to give specific thought to their potential patients’ issues and opportunities. By

identifying people’s motivations, you are in a much stronger position to be able to offer them what they are looking for. To provide further encouragement to book an appointment at your clinic, you could share more in-depth insights into what the end result will look like, send over testimonials, enable them to speak with past patients, or perhaps offer some kind of additional support.

5. Enhance customer spend potential Think about how often people use your services, and look at what you can do to increase this number. The work you have already done will help you understand why your patients come to you in the first place, so use that knowledge to encourage them to come back more often. Talk to your team about communicating with patients in regards to the additional services and products you have within your clinic. This could be through additional add-ons, or as part of a package – bundling your services and offering them to clients as a package can be an effective way of increasing their spend with you. Do give some thought to how you want to position each of the packages too, so for example, the cheapest package you offer might be £2,000, the middle £4,000, and the highest £10,000. What you include within these packages is up to you, but studies have shown that people are much more likely to pick the middle option (Centre Stage effect).2 While I know this all sounds great, it also sounds like a lot of hard work. However, it’s all quite minimal, as you do not need to implement every idea I have shared with you straightaway. The best thing to do is to focus enough in each area to increase your current figures by 10%. This might be through increasing the number of patients by 10% – in this instance you’d look at communicating with them through methods I mentioned

To recap, it’s all about making small changes that could have a significant impact on your business. These changes are as simple as asking your customers if they’re happy for you to contact them (and how), and using this data to keep in touch with them, reminding them about any offers you’re running and building trust by offering them genuine advice and guidance. It’s about ensuring that your existing database is aware of any other services you offer, and then encouraging them to explore these. Plus, it’s about increasing the amount you do, as all of the people you’re contacting could turn into hot leads, and subsequently, new clients. We are in a truly beautiful business, and with a few ‘nips and tucks’, your clinic can offer the service that your patients want, and you the lifestyle that you wish. Whatever you do, keep focusing on sculpting your ultimate clinic, and good luck! Alan S Adams is an awardwinning business coach, professional speaker, and bestselling author. The publication of his third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic focuses on the medical, cosmetic and aesthetic clinic sector. He was a finalist in the The Association of Professional Coaches, Trainers & Consultants’ Coach of the Year Awards, and has been recognised by Enterprise Nation as a Top 50 Advisor in the UK. REFERENCES 1. GOV.UK, The Data Protection Act (2017) <https://www.gov.uk/ data-protection/the-data-protection-act> 2. Rodway, Schepman & Lambert, Preferring the One in the Middle: Further Evidence for the Centre stage Effect, (2012)

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


Treatment Options • Wrinkles and fine lines • Skin discolouration • Sun damaged skin

• Skin tone and texture • Age spots • Acne scars

Why Tixel®?

What is Tixel®?

(Pure Natural Heat)

• Tixel is similar in effectiveness to fractional lasers.

• Tixel is a novel, thermal fractional skin rejuvenation system powered by Novoxel’s patented technology.

• It is a cost effective, sterile, fractional device for controlled evaporation of tissue.

• Treatment is fast (15-30 minutes).

• Compared to laser, Tixel treatment is safe with:

• Tixel is lightweight, portable, and highly versatile. • Tixel can treat delicate skin, including peri-orbital, eye lids, neck, décolleté and the back of the hands safely with very low levels of pain.

• Less charring and crusting • Less pain without anaesthesia or cooling • Less downtime and post-procedure care • No irradiation, just pure natural heat

What Tixel® customers say “As an Aesthetic practitioner with over 15 years, experience, introducing Tixel to my practice is really exciting, it makes minimal discomfort, quick recovery fractional skin resurfacing treatment acceptable and practical for all my patients, who tell me that their skin feels more alive after Tixel treatment, this perfectly complements their existing toxin, filler and other treatments.” Dr Rupert Gabriel, Snowberry Lane Clinic, Melksham

“Tixel is a real game-changer! Excellent results with minimal downtime”

“Having seen how well patients have tolerated Tixel treatment and how satisfied they are with the results, we decided it was a must for our clinic”

Dr Harryono Judodihardjo, Cellite Clinic, Cardiff

Dr John Tanqueray, Mulberry House Clinic, Northampton

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Taking on Energybased Equipment Aesthetic device company director John Culbert explains the factors to consider when deciding whether to purchase energy-based clinic equipment If you already have your own clinic, you have taken the first leap into the world of commerce as an independent practitioner. The next step, to take the second leap, is to expand; this will lead you to decide whether or not to broaden your treatment offering. This may include treatments such as hair removal, laser resurfacing, body contouring or skin resurfacing, which are all provided through aesthetic equipment.

Benefits of expanding your treatments In my experience, most practitioners will start by using injectables, but there are many advantages of expanding your offering: • Provides a more comprehensive and efficient service: In many cases, injectables alone cannot provide the optimum result and a combination treatment is more beneficial. • Makes the business more saleable: A business that has few revenue earners is totally dependent upon that person being available to work. By introducing other treatments provided by additional personnel, the business generates additional revenue from the new treatments; continues to generate revenue when the founder is on holiday, training or ill and enables more comprehensive

treatment plans to be developed with the patient. If the founder who is selling the company generates less of the revenue, then you have a much more attractive and valuable proposition for selling the clinic; assuming that the staff would move over to the new business. • Protects the business from existing and new competitors: Every time you say no to a customer making them go elsewhere for a treatment, you are giving an opportunity to your competition. The better you can satisfy your customers’ needs, the lower the chance is that they will need to look elsewhere. This is also generally accepted as much easier and cheaper than recruiting new customers.

Tips for purchasing equipment If this is your first step into the aesthetic equipment market, you need to do your market research and should not rely on the equipment sales person to do it for you as they are likely to push the benefits of their own device. You should consider the following factors. Current patients Think about your current typical patients and determine whether they would be potential candidates for the new treatment.

£

Sales

Profit

Introduction

Growth

Maturity

Decline

Time Figure 1: The product life cycle curve.6 Profit starts below the line because you have to invest before you can make sales.

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As complementary treatments are added to your portfolio, there will be patients who want to spend more but are limited by their cash flow. It is easy to remove this restriction by implementing 12 months’ ‘interest-free’ finance for sales (meaning that the customer receives interest free credit and interest is paid by the business and not the customer) and patients often find it easier to make regular and smaller monthly payments. At Cosmex clinic, we make credit available to all patients booking a course of treatments over £1,000. Obtaining 12 months ‘interest free credit’ has few constraints and is available from several companies. Typically, the customer will pay 10-20% deposit and the overall cost to the business is around 6.5%. In my experience, this can be more than compensated by the increased business and improvement in cash flow. For example, all funds less the service change are received within two to four days. Product life cycle When you are purchasing any sort of equipment, whether it is an energy-based device or not, understand that it has a life cycle with four stages: introduction, growth, maturity and decline.6 The profitability of any product is fundamentally related to its point on the product life cycle curve as shown in Figure 1. Introduction phase The initial phase refers to when a product is first introduced to the market. It would not generally be sensible for a new business to take the risk of investing in equipment that is in its introduction phase, because this could be too early for patients to have an understanding and knowledge of the treatment and practitioners may have to educate the market. Products are also often disproportionately expensive. One might choose to introduce equipment at this stage if they are confident in the brand or if they are helping to test or review the equipment. Price negotiations might also be more likely at this stage. Growth phase Products in their growth phase will generally provide the best return upon investment. In this phase, treatment costs are high and revenue can still grow even as competitors move into the market. As profits grow companies can invest more in promotional activities to boost sales and awareness. Mature products A product may become ‘mature’ when more competitors move in and the market becomes

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saturated. With a high number of practitioners offering a certain treatment, either your prices must reduce or the number of treatments must increase to maintain interest. If the technology is still relevant then a new machine is not required unless the technology becomes obsolete or too inferior to retain existing business or gain new business. Decline Eventually, the market for a product will start to shrink. This is mainly due to new entrants with better technologies and better results or saturation (all customers who would buy, have bought the machine). When a product is in its decline, it will cause decreased revenue at a reduced margin with potential for ongoing and increased maintenance costs due to unforeseen events such as breakdowns and upgrades. By this point, the manufacture warranty would have also ceased. This will make the product uneconomic to retain. Safety approvals Check to see if the product has approval from the FDA, Medical CE or CE. There are three main elements to approvals: electrical safety (tests to ensure the product is safe to use), electromagnetic compatibility (ensures that an electromagnetic device cannot cause a problem with another nearby device) and clinical effectiveness. For FDA approval, the first of an energybased treatment type sold in the US will need a clinical trial, which is quite onerous, but then many of the follow-on products will use a comparative approach and bypass the clinical trials.5 Current Medical CE is similar; therefore, unless you are an early adopter, there is little difference between the FDA and Medical CE routes to approval. Although there are plans to tighten the Medical CE approval, this will not take effect for a few years. CE approval does not cover the clinical aspects of the product. It does show that the manufacturer has checked that these products meet EU safety, health or environmental requirements, is an indicator of a product’s compliance with EU legislation and allows the free movement of products within the European market.1-5 Competition When starting your business, location is key as you don’t want heightened competition in the local vicinity before you have even begun to build your brand. Research what your competition is doing and whether or not they are offering the same products

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and services as you. If they are missing something, this might be an opportunity for you to fill this gap. The supplier Ideally your supplier will be based in the UK and certainly in the EU as you would need to resource from a local importer or manufacturer. Purchasing outside the EU means you are the importer and are liable for the safe operation and functioning of the equipment. Can you calibrate the machine? Can you ensure it is functioning correctly and safely? If not, you could face serious implications; for example, in the event of causing a major injury, the importer will usually be the person that has to prove they took reasonable steps to ensure the product is safe. If they cannot, then they may be deemed to be negligent.

cost of ownership including purchase cost of the machine, maintenance after warranty, consumables and handler training. A trend coming from the US is pay-per-use. Printers have been sold very cheaply for many years with the manufacturers making their profit on the consumables. This approach is now gaining momentum in the aesthetics market because it can ensure more consistent treatment quality and generate additional revenue for the supplier. If you choose this, it does mean that the cost of consumables needs to be considered when comparing competing products. The other major factors to consider are the out-of-warranty costs of calibration and repair, either through a maintenance contract or a one-off service. It is suggested that you work out the five-year cost of ownership.

Summary Conformity When purchasing energy-based equipment, the supplier should be able to issue you with a signed certificate of conformity and ideally a calibration certificate. This states that the product meets the required specifications. Warranty A positive sign of reputable equipment is a good warranty. Two years on site is beneficial, and three is better still, but all equipment should have a minimum of 12 months. Good warranty indicates that the company is confident in the quality of their product. In my experience, if a company has a reasonable product, the supplier should be happy to offer an extended warranty. Training Any reputable supplier should offer, as standard, training to the user to ensure safe and effective operation of the equipment. This is generally done onsite at the client’s premises. Extended training if required can be recommended through third party training organisations. Consumables and total cost of ownership Ask the sales person to give you a written list of all consumables and the consumables cost, life expectancy and warranty. Even a consumable must be fit for purpose, and some are expensive. An example of energy-based equipment consumable can be the replacement cartridges for HIFU machines. If the consumable cost is very high, then the overall running costs would drain profit margins. When purchasing any new equipment, it is important to work out the total

Energy-based treatments are becoming increasingly important and are probably essential if the intention is to grow the business and provide the optimum treatment for patients. The machines that provide these treatments tend to be expensive capital investments that are alien to many practitioners and take many people well outside their comfort zone. Consider the general-purposed framework above to aid with the purchase of energy-based equipment for your market to ensure the optimum return on investment. Disclosure: John Culbert is the founder and director of energy-based provider Cambridge Stratum. John Culbert is the CEO of Cambridge Stratum Ltd and business director of Cosmex Ltd. Culbert has been responsible for three business startups and was previously divisional manager of Sanyo Information Systems at its computer division. REFERENCES 1. Jull Thomas, New Regulations for CE: The Changing Landscape for Medical Devices in Europe, 2016, <https://www.mdtmag.com/ blog/2016/09/new-regulations-ce-changing-landscape-medicaldevices-europe 2. Medical Devices Legal, ‘The results are in: EU Study on Corruption in Healthcare Sector’, 2014, <https:// medicaldeviceslegal.com/2014/03/10/the-results-are-in-eustudy-on-corruption-in-healthcare-sector/> 3. Transparency International, ‘Health System Regulation’, <http:// ti-health.org/health-system-regulation/> 4. PMI, ‘GLP: THE DIFFERENCE BETWEEN PMA AND 510(K) PATHS’, 2012, <http://www.pmipreclinical.com/glp-differencepma-510k-paths/> 5. GOV.UK, ‘Guidance: CE Marking’, Department for Business, Energy & Industrial Strategy. 2012 <https://www.gov.uk/ guidance/ce-marking> 6. Product Life Cycle Stage, 2017, <http://productlifecyclestages. com/>

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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“Aesthetics is a marvel that allows practitioners to embellish patients elegantly, effectively and make them happy again” Dr Britta Knoll details her love for aesthetics and how she became a mesotherapy specialist For aesthetic practitioner Dr Britta Knoll, her passion for her job meant she only took one week off work following the birth of her daughter in 1992, although she notes that this is not something that she would recommend! “Looking back, if there was anything I could have done differently I would have worked less! It’s not good to be in work-mode every weekend,” she says. Originally from Bavaria in Germany, Dr Knoll has spent the last 30 years specialising in mesotherapy. She studied medicine from 1976-1982 at the Friedrich Alexander University of Erlangen, and, following this, was awarded a one-year scholarship at the Centre Hospitalier Universitaire de Rennes, France. After her training, Dr Knoll went on to work at a complementary medicine cancer clinic, where she gave further support to cancer patients in the rural Chiemsee lake area, about one hour from Munich. “The clinic was in the private sector and had 100 beds – I was in a highly responsible position as assistant medical director,” she explains. It was during this time, in 1983, that Dr Knoll also began studying mesotherapy with Dr Michel Pistor at the Société Française de Mésothérapie – a professional medical association for the treatment. She explains that she first discovered the uses of mesotherapy as a treatment for healing various diseases during her one-year scholarship. She says, “I overheard my colleagues speaking about a doctor – Dr Pistor – who had become famous for using a new method derived from the German neural therapy (a form of alternative therapy). I was curious to get more information about his new ideas so I contacted him and he invited me to his clinic, and very quickly I recognised the incredible potential of mesotherapy in treating diseases.” She continues, “I didn't anticipate that treating with mesotherapy would become my mission in life.” In 1983, Dr Knoll, among others, founded the Deutsche Gesellschaft für Mesotherapie (DGM), and she began to organise workshops and training in mesotherapy as the president of the new society. She explains, “These kinds of societies are recognised as benevolent and their job is to share methods, promote professional and patient education, scientific research and represent the members' interests.” Dr Knoll says that creating and presiding over the DGM is what she believes to be her biggest achievement to date, “It now has more than 1,000 members and it started at zero – it unifies practitioners through a quite simple but truly spoken ingenious medical method.” After five years, in 1988, she decided to move to Munich to further her career. However, this move was hard. “The city had the highest density of medical providers in Germany,” she says, noting, “It was difficult to start a new practice focused on an ‘exotic new method’ (mesotherapy) that nobody had ever heard about.” Dr Knoll’s interest in the aesthetics side of her career began in 2006,

when she attended the International Mesotherapy Congress in Madeira. From there, Dr Knoll incorporated mesotherapy for aesthetic treatment into her clinic. For somebody who used to treat severe chronic diseases, psychosomatic and pain problems at the start of her career, aesthetic medicine has been for Dr Knoll what she describes as “heaven”. “It really is the icing on the cake,” Dr Knoll says, adding, “Aesthetics is a marvel that allows practitioners to embellish patients elegantly, effectively and make them happy again! I think this is the strongest motivation for me to do well in this specialty.” Dr Knoll is proud to have revolutionised the original French protocols of mesotherapy that were created by Dr Pistor, by adding active ingredients originating from natural and holistic medicine. This has been her favourite area of interest since the beginning of her professional career. “Step by step, alongside other mesotherapy, pharmacology and technology specialists and during a continuous international exchange, we developed the modern injectable products, mesoguns and applications that are now available and widely used,” she explains. Although extremely experienced, Dr Knoll still believes continual education is of utmost importance, “Medical aesthetics is a very dynamic field with such a high number of innovative and interesting tools, that everyone who is seriously involved in it needs life-long learning, communication with peers and updates in theory and practice.” When asked what motto or ethos she works by, she quotes the hippocratic oath taken by physicians, “It's the very old motto of Latin ‘primum non nocere’, which means to do no harm. To me, this means, first, don't damage your patient; second, don't do things to them you would never risk doing to yourself.”      Do you have any words of advice for people looking to get into the industry? If you want to sell something, which is what we need to do in   the business, do it in a smart way and obey the fair-play rules. What’s the best piece of career advice you’ve ever been given? Never give up!   Do you have an industry pet hate? Manufacturers who encourage beauticians to inject.   What aspects of the industry do you enjoy the most? I enjoy the permanent quest for improvement.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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The Last Word Mr Nihull Jakharia-Shah, Miss Priyanka Chadha & Miss Lara Watson explore the validity of the HEE’s ‘see 10, do 10’ training requirement and argue whether this is sufficient for ensuring patient safety and satisfaction HEE’s ‘see 10, do 10’ injectable training

to be able to safely deliver these cosmetic injectables independently.2,5

Health Education England’s (HEE) 2015 ‘Qualification Requirements for Delivery of Cosmetic Procedures’ dictates that a minimum of a Level 7 qualification is required for ‘comprehensive use’ of botulinum toxin and dermal fillers.1 Level 7 qualification requires a practitioner to be able to ‘deal with complex issues, make sound judgements, and act autonomously in implementing tasks at a professional level’. To achieve this, one must attend a certified training programme, which covers the basic principles of aesthetic procedures and the consultation process, as well as modality specific training. Following this, trainees are required to observe 10 treatments for 10 different patients and perform 10 treatments for 10 different patients (under the supervision of a certified observer and covering all treatment types) for both botulinum toxin and dermal fillers.2 This is often referred to as ‘see 10, do 10’. Until now, botulinum toxin and dermal filler courses have generally ranged from a single day to two days in length, with no predetermined requirements for the number of treatments observed or practiced to validate certification. To standardise training and ensure adequate practitioner experience, the regulatory bodies now advise that observing 10 and performing 10 procedures, is satisfactory for a practitioner

Is this adequate for injectable treatments? To assess whether this level of exposure is adequate for generating a satisfactory level of competence, we must determine the learning curve for these procedures. Hopper et al. outlined the ideal learning curve for surgical procedures (Figure 1) where a measured outcome improves as the number of cases increases, until a plateau is reached.3 The acceptable level of competence must meet a predetermined level relative to the measured outcome, however it can fall below the plateau as the highest level of competence can usually only be reached through direct, independent experience. Hopper et al. then plotted learning curves for a variety of surgical procedures, determining the number of cases needed to reach the plateau for each procedure. The simplest procedure, laparoscopic fundoplication, required only 20 cases before plateau was reached. Botulinum toxin and dermal filler treatments are non-surgical procedures. Therefore, it could be assumed that a practitioner would need less than 20 cases to reach a high standard of practice. However, an inconsistency between learning curves is the measured outcomes used. The measures can

C

Measured outcome

B

Acceptable standard D

E

Primary learning curve Secondary learning curve A

Case number

Figure 1: The ideal learning curve for surgical procedures described by Hopper et al.3

Aesthetics aestheticsjournal.com

be defined under two categories; process based, such as time taken to complete the procedure (the most commonly used measure) and patient outcome measures, such as comfort throughout the procedure. The latter is more difficult to measure as data is usually qualitative.3 Many documented learning curves cannot be translated to aesthetic procedures as the commonly used outcome targets for the NHS do not apply to the private industry, for example the length of time spent on a procedure is not as important as there are no sustainability pressures on private aesthetic services. For aesthetic practice, patient outcomes are paramount and measures such as patient satisfaction or comfort throughout the procedure would be stronger indicators of a practitioner’s competence. The ‘see 10, do 10’ does not dictate the need for follow-up assessments with critical appraisal of results and the decision to provide further treatments to ‘topup’ or modify effects.1 It could be argued that this is where the current training requirements for cosmetic injectables are lacking. The practical delivery of these injections is relatively simple but the critical analysis of results and decision making about further/ corrective treatments requires a deeper understanding of the complex interplay between the biochemical action of these products and the resulting effects on dynamic facial aesthetics and the development of the ‘aesthetic eye’. In our opinion, a flaw in the ‘see 10, do 10’ requirement is that it assumes all trainees have a similar learning curve, which is not the case.

Improvements Two ways around this pitfall are to introduce formal and standardised assessments of practical skills or to ensure that the current requirements cater to trainees with the slowest learning curves, ensuring that everyone who has completed the course will be of a minimum standard. At present, there is no standardised assessment of practical skills; trainees will be assessed by their course supervisor and passing will be at their discretion. This is subjective and creates disparity between trainee standards. However, formal assessment requirements do exist, dictating that trainees should be assessed in simulated learning environments and receive a portfolio of evidence upon completion, which contains feedback from supervisors and patients.2 Also, all supervisors must be proficient in the skill being taught and they are personally responsible for signing off each candidate. It could be said

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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that this creates incentive to ensure trainees are of a certain standard as an incident of malpractice could have legal implications for supervisors. In light of these issues and the lack of published information available on the origins of the ‘see 10, do 10’ requirement, further studies are needed to assess the learning curves of practitioners learning botulinum toxin and dermal filler procedures, plotting patient safety and satisfaction measures against case numbers, in order to determine if 10 cases allows for everyone to meet a baseline level of competence. Supervisors The HEE cosmetic practice guidelines contain professional requirements for supervisors, these include; having obtained the qualifications for which they are teaching, being proficient in the area of practice with a minimum of three years of post-qualification experience and having delivered the procedure at least 150 times, as well as evidence of accreditation and continuous professional development.2 The supervisor must also undertake specific training to become a supervisor; however, the guidelines outline that this training is to be ‘determined by the education provider’, which could be considered a vague and ambiguous statement.2 Although these requirements encourage a high level of supervisor proficiency, as a national scheme we believe that there should be more specific requirements for supervisor training and greater involvement of external regulatory bodies ensuring all courses adhere to the requirements and the training process is standardised. A number of agencies are currently developing and delivering external regulatory services and we feel this should be a priority to protect the validity of the Level 7 training pathway. Alongside person requirements, it should be noted that quality assurance procedures are equally important in verifying a course’s reliability and validity. The Qualifications and Credit Framework system provides information on how to conduct internal audits of assessments and course safety.4 It is important that measures are taken to ensure that these frameworks are adhered to, working alongside regulatory bodies such as the Office of Qualifications and Examinations Regulation (Ofqual). Weighting of ‘see 10, do 10’ Another contentious aspect of the requirements is that observation is given the same weighting as practising, with 10 of each

Aesthetics Journal

Aesthetics

needed. Observing an action is known to accelerate the acquisition of a skill and, as such, forms an important part of the learning process. However, it is widely reported that experiential learning is the best way to develop and maintain a skill as real patient learning offers a wider variety of learning outcomes.3 This is especially the case in a ‘supported participation’ learning scenario i.e. performing a task under supervision, where active feedback is available. Thus, although an ideal training programme should encompass both observational and experiential learning processes, there should be an emphasis on practical opportunities for mechanical skills such as injecting botulinum toxin or dermal fillers. Disparity between the effectiveness of observational and experiential training in botulinum toxin and dermal filler courses is enhanced by the quality differences; observation requires only one demonstrator for every 10 trainees, whereas practising must be done in a 1:1 ratio.2 Therefore, in our opinion, changes to increase the effectiveness of training could be introduced by either reducing the number of observed procedures and/or increasing the number of practised procedures, depending on the impact each change has on learning curves and the time and cost effectiveness of training.


Summary An important aspect of the new guidelines is HEE’s plan to introduce the new qualification requirements on a national scale and to encourage compliance from old and new practitioners.1 Practitioners who are already delivering botulinum toxin or dermal filler injections are required to either apply for official recognition of their knowledge and skills or apply to a course provider for official recognition of prior learning.1 This is important in increasing the validity of the new requirements as it promotes a national standardised level of training, which has been long required for cosmetic practice. However, details of how compliance will be governed have not been published, leaving scope for underqualified and potentially unsafe practitioners to continue delivering these procedures. In conclusion, we believe the current ‘see 10, do 10’ system for botulinum toxin and dermal filler training dictated by HEE does support professional development in some ways, but there are gaps in the system that are likely to be having a detrimental effect on the validity of these training requirements. The problems include a failure to incorporate reasonable

measures to determine the number of cases required to gain satisfactory competence in the procedures and a lack of differentiation between observational and experiential learning methods. Adherence to quality assurance procedures is a crucial factor and may help develop the current ‘see 10, do 10’ system to overcome its existing limitations. Further studies are required to define a series of learning curves for botulinum toxin and dermal filler procedures, analysing trends in patient-related outcome measures against case numbers as well as trainee perspective. In our opinion, this should be reviewed in conjunction with information on different training methods to create more reasonable and effective training requirements, which will optimise resource usage and maximise patient safety. Disclosure: Miss Priyanka Chadha and Miss Lara Watson are co-directors of the training provider Acquisition Aesthetics and Mr Nihull Jakharia-Shah is the educational and academic representative. Mr Nihull Jakharia-Shah is the educational and academic representative for Acquisition Aesthetics training academy. He has completed a BSc degree in Regenerative Medicine and Innovation Technology. Miss Priyanka Chadha is co-director of Acquisition Aesthetics and works as a plastic surgery registrar in London having ranked number one in the country for national training applications. Her CV comprises national and international prizes and presentations and higher degrees in surgical education and training. Miss Lara Watson is codirector of Acquisition Aesthetics and is persuing a career in maxillofacial surgery. Currently in the final year of the Dentistry Entry Programme for Medical Graduates at King’s College, London, Miss Watson has been awarded an academic distinction for the course to date.

Reproduced from Aesthetics | Volume 4/Issue 8 - July 2017


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Utilising patented VYCROSS® technology,3 Juvéderm® VOLITE is injected intradermally and can be used for areas such as the face, neck, décolletage and hands.4 When your patients glow on the outside, they feel great inside.2,5

References: 1. Allergan Data on File INT/0655/2016. Juvéderm® VOLITE Clinical Study (V12-001), 6 months top line, patient satisfaction results. Sep, 2016. 2. Allergan Data on File INT/0653/2016. Juvéderm® VOLITE Clinical Study (V12-001), 6 months top line, summary. Sep, 2016. 3. Lebreton P, 2004. Réticulation de polysaccharides de faible et forte masse moléculaire; préparation d’hydrogels monophasiques injectables; polysaccharides et hydrogels obtenus. Publication number: WO 2004/092222 A2. 4. Juvéderm® VOLITE DFU. 73140JR10, Revision 2016-02-19. 5. Allergan Data on File INT/0448/2016(1). Allergan Skin Quality Market Research Insights. Jul, 2016. 6. Allergan Data on File INT/0773/2016. Juvéderm® VOLITE Names. Oct, 2016. 7. Goodman GJ et al. Plast Reconstr Surg. 2015;136:139S–48S. Footnotes: * Based on FACE-Q satisfaction with skin mean score improvements at Month 1= 64.6%, Month 4= 60.3%, and Month 6 = 57.7% (p<0.001). Baseline satisfaction was 43.5%.1 † After a single treatment, which included initial (n=131) and top-up administered at Day 30 (n= 31).2 ‡ Study conducted using Juvéderm® VOLITE B without lidocaine.6 Added lidocaine enhances patient comfort during injections and has no substantive effect on the rheological properties of HA products.7 § Smoothness is defined as the absence of fine lines. ‖ Cheek skin hydration (secondary endpoint) improved significantly from baseline at Months 1, 4 and 6. Skin smoothness (primary endpoint) improved in patients at Month 1 (96.2%), Month 4 (76.3%) and Month 6 (34.9%). Five of the 10 cheek skin elasticity parameters (secondary endpoint) improved significantly from baseline at Month 1 and 4 but not Month 6.2 Please refer to the Juvéderm® VOLITE Directions For Use for further information.4

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