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! s r ic ay te et od En esth 4 T A 1 e 20 Th rds a Aw

VOLUME 1/ISSUE 7 - JUNE 2014

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Patient outcomes CPD Article Andrea Pusic explains the creation of the Q-Portfolio to measure patient outcomes in aesthetic medicine. CPD accredited article

Treating Cellulite

The Aesthetics Awards 2014

An in-depth look at the diagnosis, grading and different treatment methods for cellulite

Details of this year’s categories and reasons to celebrate clinical excellence in medical aesthetics

Rosacea Dr John Ashworth discusses the complexities surrounding the management of rosacea


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both collagenbi-polar and elastin minimaltechnology epidermal disruption • Fractionated radiowith frequency • Heat energy is placed effectively into the upper dermis for a significant increase in • Acnecollagen scar treatment with with improvement of variousdisruption textual irregularities elastin minimal • both Heat energy isand placed effectively into theepidermal upper dermis for a significant increase in collagen and elastin with minimal • both Smoother, rejuvenated appearance of epidermal the skin disruption Acne scar treatment with improvement of various textual irregularities ™scar treatment with improvement of various textual irregularities •COAcne RE : • Smoother, rejuvenated appearance of the skin 2 ™ •• Smoother, of precision-control the skin A versatile rejuvenated fractional COappearance system with over the intensity, pattern

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Unique Fusion Mode CO that treats both and deepover skinthe layers simultaneously and depth of ablation •• A versatile fractional system withsuperficial precision-control intensity, pattern 2 and depth of ablation Traditional COMode resurfacing andboth ablation, laser excision lesions and minor dermal •• Unique Fusion that treats superficial and deepofskin layers simultaneously 2 excisions Fusion that treats superficial and deep layers •• Unique Traditional CO2Mode resurfacing and both ablation, laser excision ofskin lesions andsimultaneously minor dermal treatment Fast and effective solution for scar treatment, resurfacing andand wrinkle •• excisions Traditional CO2 resurfacing and ablation, laserskin excision of lesions minor dermal excisions • Fast and effective solution for scar treatment, skin resurfacing and wrinkle treatment • Fast and effective solution for scar treatment, skin resurfacing and wrinkle treatment Photos: Stephen Bassett, M.D. Photos: Alain Braun, M.D.

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Photos: Amy Taub,Post M.D.2 Sublative Treatments Photos: Amy Taub, M.D.

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Photos: Alain Braun, M.D. Post 1 CO2RE Treatment

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Post 1 CO2RE Treatment Photos: Alain Braun, M.D. Photos: Alain Braun, M.D.

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Not for use in the U.S. market. © 2013. All rights reserved. eTwo, Sublative and CO2RE are trademarks of Syneron Medical, Ltd. Syneron and the Syneron logo, Candela and the Candela logo are registered trademarks. PB81281EN Not for use in the U.S. market. © 2013. All rights reserved. eTwo, Sublative and CO2RE are trademarks of Syneron Medical, Ltd. Syneron and the Syneron logo, Candela and the Candela logo are registered trademarks. PB81281EN Not for use in the U.S. market. © 2013. All rights reserved. eTwo, Sublative and CO2RE are trademarks of Syneron Medical, Ltd. Syneron and the Syneron logo, Candela and the Candela logo are registered trademarks. PB81281EN


Contents • June 2014 INSIDER 06 News The latest product and industry news 13 On the Scene Out and about in the industry this month 14 News Special: Health Education England workshop Outcomes from Phase 1 of the HEE review of qualifications

CLINICAL PRACTICE Patient outcomes Page 28

16 Association of Scottish Aesthetic Practitioners, Glasgow Highlights from the ASAP Conference and Exhibition 18 Conference Report: Face, Eyes, Nose Symposium, Coventry The European College of Aesthetic Medicine and Surgery symposium 20 American Society for Aesthetic Plastic Surgery, San Francisco Wendy Lewis provides an update from the ASAPS annual meeting

CLINICAL PRACTICE 22 Special Feature: Treating Cellulite Medical practitioners discuss the causes of cellulite and its treatment

IN PRACTICE Branding Page 54

Clinical contributors

28 CPD Clinical Article A look at the creation of the Q-Portfolio for measuring patient outcomes

Wendy Lewis has authored 11 books on anti-ageing and cosmetic surgery and lectures internationally. She is the president of Wendy Lewis & Co Ltd and founder/editor in chief of Beautyinthebag.com

34 Treatment Focus Mr Simon Ravichandran and Mr Bryce Renwick discuss methods for the treatment of leg veins

Dr Andrea Pusic is a plastic surgeon from New York City. Over the last ten years, she and a team of collaborators have developed the BREAST-Q, FACE-Q, and BODY-Q patient-reported outcome measures.

38 Spotlight On Dr John Ashworth shares his experience on the treatment of rosacea

Mr Simon Ravichandran is a practicing ENT surgeon in Scotland and the clinical director of Clinetix Rejuvenation. Simon is president of the Association of Scottish Aesthetic Practitioners.

40 Clinical Focus Wendy Lewis explores the must-have devices for any clinic 44 Case Study Dr Sarah Tonks details a case of delayed hypersensitivity reaction to dermal filler injections 46 Techniques Dr Sotirios Foutsizoglou and Anouska Cassano on their use of scalp micro-pigmentation 50 Clinical Focus We speak to the authors of the Expert Consensus on Complications of B otulinum Toxin and Dermal Filler Treatment 52 Aesthetics Awards Special Focus The latest news and developments from The Aesthetics Awards 2014

IN PRACTICE 54 Branding Mark Shahid on the importance of achieving a unique brand for your clinic 58 Business Process Kurt Won details how to systemise your business processes 60 Digital Strategy Caelen King explains what patients expect from your digital presence 62 In Profile Dr Johanna Ward on her route into the profession 64 The Last Word Dr Rikin Parekh on the benefits of knowledge from related specialties

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

Mr Bryce Renwick is a surgeon in Vascular and Endovascular surgery. He is involved in the treatment of blood vessel disorders and has an interest in minimally invasive varicose vein treatments. Dr John Ashworth is a dermatologist and fellow of the Royal College of Physicians in London. He is a consultant member of the British Association of Dermatologists. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, based at Beyond Medispa in Harvey Nichols. Dr Sotirios Foutsizoglou is the founder of SFMedica. He specialises in cosmetic surgery and aesthetic medicine, and is a member of the International Society of Hair Restoration Surgery. Anouska Cassano is a micro-pigmentation practitioner specialising in scalp micropigmentation, medical reconstruction, scar reduction and chemical tattoo removal.

NEXT MONTH • IN FOCUS: The patient experience • CPD – Advanced botulinum toxin techniques • Special focus: pain management • Selling skincare

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Editor’s letter It has been another busy and exciting month for the Aesthetics journal, with informative new contributors and articles comprising this issue. Of particular note are the number of educational seminars and meetings that took place over the Amanda Cameron past weeks, enabling practitioners to learn and Editor develop their skills. I was privileged to attend two of them, the Association of Scottish Aesthetic Practitioners conference in Glasgow and the European College of Aesthetic Medicine and Surgery meeting in Coventry. A consistent theme was apparent throughout the course of these meetings: the vital importance of an in-depth knowledge of anatomy for anyone who performs aesthetic procedures. This may seem obvious, but due to the lack of regulation in the industry there is sadly little consistent and comprehensive anatomy training available at present. Knowledge levels are, unsurprisingly, varied in that the facial anatomy syllabus of a trainee plastic surgeon and that of a student nurse is clearly different in scope and so there is a need for procedure specific anatomy training. It is encouraging to see so many courses now focusing on basic anatomy, enabling everyone to obtain the knowledge that they need in order to perform procedures with increased accuracy and patient safety at the forefront. It is not sufficient to learn from textbooks and so it is very gratifying to see senior lecturers in anatomy engaging with aspiring students of aesthetics to enhance their knowledge.

Despite having spent many years in the industry and attended many courses from a huge range of experts, one quote recently made me sit up and think. Mr Jan Stanek, a plastic surgeon who has performed over 3,000 blepharoplasties and so undoubtedly knows the pericocular anatomy well, said he would be reluctant to inject in the tear trough area with a needle. Alongside highlighting anatomical complexities that should be a major consideration for aesthetic practitioners and part of their continued training, this also demonstrates the necessity for discussion around risks and complications. This month we spoke to two authors of the recent ‘Expert consensus on complications of botulinum toxin and dermal filler treatments’. Mr Chris Inglefield and Nurse Marie Duckett explained the reasons for the document’s creation and the process behind its formation, along with the next steps that they believe should be taken. Another key part of a practitioner’s training is based on the measurement of outcomes and so we are delighted to feature our CPD article this month on how to improve your aesthetic practice with patient reported outcome measures (PROM’s), such as symptoms, satisfaction and health-related quality of life. Education and patient wellbeing are at the core of our editorial output each and every month, and we hope that the June issue of Aesthetics provides you, the reader and the practitioner, with a wealth of articles that enhance your day-today medical aesthetic practice. And remember to let me know what you think of the issue by tweeting the team @aestheticsgroup.

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.

Dr Mike Comins is president and Fellow of the British

Mr Dalvi Humzah is a consultant plastic, reconstructive and

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

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

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Nick Lowe is president of the BCDG and a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

dermatologist with over 30 years of experience who practises in London and California. Dr Lowe is Clinical Professor of Dermatology at the UCLA School of Medicine in Los Angeles, as well as director of a clinical research company specialising in skin ageing.

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

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Insider News

Talk Aesthetics #Bestpractice P & D SURGERY / @pdsurgery @aestheticsgroup #talkaesthetics #bestpractice listen carefully, look (examine) with care & treat appropriately #Aestheticnursing J Aesthetic Nursing / @JAestheticNurse Very exciting – two leading aesthetic nurses @daviesemma5 @MarieD247 on the team for new voluntary register @SaveFaceUK #aestheticnursing #Cosmetictrainingreview Revive Clinic / @ReviveClinicUK @aestheticsgroup A lot of treatment can easily be done, but should only be by a trained professional as they know how to manage complications #Keoghreview BAAPS Press Office / @BAAPSMedia 1 year on from #Keogh, let’s #StrollDownMammaryLane to see what the BAAPS said then...

To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com

Industry

Sinclair IS Pharma acquires Silhouette Beauty

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Allergan rejects Valeant proposal

On May 12 Allergan officially rejected the $47 billion takeover offer made by Valeant Pharmaceuticals International the previous month. In the bid, Valeant proposed that the company acquire all of the outstanding shares of Allergan for 0.83 shares of Valeant stock and $48.30 in cash. Allergan later issued a letter to Valeant’s Chairman and CEO Michael Pearson stating the board’s decision to unanimously reject Valeant’s proposal. Allergan communicated that its board felt the proposal undervalued Allergan, which according to the statement, is expected to increase its earnings per share by 20-25% and continue to generate double digit revenue growth in 2015. David Pyott, Allergan’s Chairman of the Board and CEO said, “We are confident in our ability to extend our track record, enthusiastic about the opportunities before us, and believe Allergan is well positioned to deliver compelling value to our stockholders. Furthermore, the Board has determined that Valeant’s proposal creates significant risks and uncertainties for Allergan’s stockholders and believes that the Valeant business model is not sustainable.” In response to Allergan’s rejection of the merger proposal, Michael Pearson claimed that it followed no discussion between Allergan and Valeant and therefore, he said, “We will not stop our pursuit of this combination until we hear directly from Allergan shareholders that you prefer Allergan’s ‘stay the course plan’ to a combination with Valeant.”

Topical

PharmaClinix launches new in-clinic skincare duo

Sinclair IS Pharma has acquired the rights to Silhouette, a private aesthetics company based in Spain and California. Silhouette will add to Sinclair’s existing portfolio of collagen stimulating brands Sculptra and Ellansé, and dermal filler Perfectha. Silhouette’s products are CE marked Class III medical devices. The range includes Silhouette Lift and Silhouette Soft, collagen-stimulating cones on threads designed to give a minimally invasive facelift. Sinclair IS Pharma CEO Chris Spooner said that he expects the acquisition to increase the company’s exposure to aesthetics markets in the US, Korea, Russia, Brazil and Japan as well as aid the existing aesthetics sales and marketing infrastructure in Europe. “Silhouette will complete the recent build-out of our aesthetics business and significantly enhances Sinclair’s technological position and growth prospects in collagen stimulation,” he said.

Professional skincare line PharmaClinix Ltd has launched two new products designed for use in conjunction with aesthetic skin procedures such as IPL, laser, microdermabrasion and chemical peels. The products aim to prevent prolonged inflammation, scarring and post-inflammatory hyperpigmentation. PharmaClinix PreAesthetix Serum is intended to prime the skin for treatment and has been formulated using retinaldehyde, antioxidants, proteins and anti-inflammatories. The PostAesthetix Cream has been developed to resurface the skin after procedures that have induced controlled injury, such as dermal rolling. The cream contains vitamin C, arnica, retinaldehyde and anti-inflammatories, to hydrate and heal injured skin. Shashi Gossan, founder of PharmaClinix, said, “PharmaClinix Pre-Aesthetix Serum helps to prevent damage such as scarring, prolonged inflammation and post inflammatory hyperpigmentation. Applying a cream such as PharmaClinix Post-Aesthetix cream is essential in avoiding damage to your clients’ skin, as it ensures a rapid occlusion seal on the treated skin, maintaining hydration and controlling inflammation.” On her use of the products, Dr Vanita Rattan of The Hyperpigmentation Clinic said, “The combination of these two products gives me consistent good results. The Pre-Aesthetix Serum allows me to know that the client’s skin is in the best possible condition before a treatment and the Post-Aesthetix Cream provides insurance against postlaser burns, especially in darker skins.”

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Aesthetics | June 2014


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News in Brief

Education

New diploma and MSc in Skin Ageing and Aesthetic Medicine to launch in September The Dermatology Centre at the University of Manchester, an internationally recognised centre of excellence, in collaboration with one of the largest clinical dermatology departments in the UK at Salford Royal NHS Foundation Trust, has developed a first-of-a-kind multi-disciplinary Diploma and MSc in Skin Ageing and Aesthetic Medicine, to launch in September 2014. This initiative is aligned with the Keogh recommendations for improved standards in training and education of non-surgical procedures, now under the mandate of Health Education England. Programme directors, consultant dermatologists Dr Tamara Griffiths and Dr Minal Singh, have developed a curriculum with busy clinicians in mind, with a two-year part-time distancelearning course designed for those in full time work. There will be two weeks of face-to-face learning in Manchester, in February and October 2015. Applications are open to consultants, doctors, dentists, and trainees. High quality teaching will be delivered by world-leading faculty, including basic scientists, dermatologists, plastic and maxillo-facial surgeons and psychologists, and will fully equip students with a comprehensive knowledge of skin ageing and aesthetic medicine. The range of topics taught include: basic science and clinical aspects of intrinsic and extrinsic skin ageing; cutaneous rejuvenation strategies such as cosmeceuticals and chemical peels; injectables such as botulinum toxin and fillers; laser, light and other devices; as well as more invasive procedures such as face lifts, liposuction and hair transplantation. Development of skills in patient evaluation and assessment, psychological aspects, recognition and management of complications, ethical and regulatory issues are topics which will also be covered. The programme will focus on the development of analytical and critical thinking skills, for example through the use of comprehensive literature reviews, to enable students to develop sound, evidence-based practice. Further research opportunities will be available through the MSc option, following completion of the Diploma. Novel teaching methods utilise interactive online learning, blogs and e-blackboards with continuous feedback and assessment. Two weeks of on-site training at the Dermatology Centre in Manchester will enable students to have hands-on-experience under the direct supervision of expert tutors, and cadavers will be utilised for anatomy teaching during the on-site training. This programme is a major step forward in provision of high quality, comprehensive training in the area of skin ageing and aesthetic medicine. Its multi-disciplinary, University-based approach is unique, and provides a genuine opportunity for those committed to furthering their knowledge and raising standards of care. The deadline for applications is June 15 2014. See www.manchester.ac.uk/mhs/skinageing for further information. Industry

Epionce launch new microneedling kit Epionce has launched a new microneedling kit for practitioners, featuring the necessary items to perform one treatment. The kit contains a sterile microneedling roller, a sterile kit, anaesthetic cream solution, protective eye shields, a headband and Epionce topical products, along with patient documents. The kit is available in 0.5mm, 1.0mm, 1.5mm, 2.0mm, and 2.5mm needle lengths. Aesthetics | June 2014

Ann Hand appointed as Adare Aesthetics sales manager Adare Aesthetics have appointed Ann Hand as sales manager for the UK and Ireland. Hand will manage the sales of Adare Aesthetics’ range of products including Forma Advanced IPL, Janus Skin Analysis systems and Molemax Mole Mapping devices, Varioderm Dermal Fillers and the MTS medical cosmeceutical skincare range. Hand previously worked for Salongenius, promoting salon management software. Entry is underway for The Aesthetics Awards 2014 Entry for The Aesthetics Awards 2014 opened on May 12. The awards, to be held on Saturday December 6 at the Park Plaza Hotel in Westminster, celebrate those who strive to raise standards in medical aesthetics and demonstrate achievement in product performance and clinical excellence. Further details of the Aesthetics Awards are on pages 52 and 53 of this month’s issue. Entries can be made now via www.aestheticsawards.com. Syneron Candela launch VelaFace Syneron Candela has developed its existing body contouring device VelaShape to provide patients with VelaFace, a newly launched treatment for the lower face. Claiming to firm, tighten and lift the skin, VelaFace uses combined technologies of bi-polar radio frequency, infrared light and a vacuum to treat what is commonly referred to as jowls and a ‘crepey’ neck. New study shows efficacy of NeoStrata Line Lift A new study published by NeoStrata shows the efficacy of topical treatment NeoStrata Active Line Lift in helping to restore volume in the skin’s matrix and improve skin elasticity. The study, published in the Journal of Drugs in Dermatology, coincides with a campaign by UK distributor Aesthetic Source to increase awareness of the product’s benefits for practitioners, in particular for needle-phobic patients looking to treat lines and wrinkles. Addendum A news story in the May issue of Aesthetics journal incorrectly stated that Adrian Baker, winner of the Aesthetic Nurse of the Year at the British Journal of Nursing Awards 2014, is currently training for an independent nurse prescribing qualification. Baker has been a qualified nurse prescriber for 18 months.

7


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Events diary

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Conference

20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014, London www.bcam.ac.uk 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London www.baaps.meetings.org.uk 3rd October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org 6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com

ACE appoints 2015 steering committee The Aesthetics Conference and Exhibition has appointed a new steering committee for the 2015 event. Mr Dalvi Humzah will chair the committee, which includes Dr Raj Acquilla, Dr Tapan Patel and Dr Mike Comins, who will help to direct the clinical educational content of the conference agenda. With plans emerging to include a broader, comprehensive live demonstration line-up and a new programme format, ACE 2015 is set to build on the success of the 2014 event and will offer delegates even more practical and engaging learning. ACE 2014 saw over 1,600 visitors attend presentations and demonstrations from more than 60 speakers on a wide range of clinical and business topics. Delegates were able to gain CPD accredited content and had the opportunity to speak to over 100 exhibitors about exciting, new and established products. Due to take place on Saturday 7 and Sunday 8 March 2015, ACE is the first and largest UK-focused medical aesthetics conference and exhibition in the calendar year, and provides practitioners with the knowledge and advice that they need to enhance both their skills and their practice. Visit www.aestheticsconference.com to keep up to date with the latest developments.

Body contouring

Trend

UltraShape receives FDA clearance UltraShape has become the first non-invasive body contouring treatment to receive clearance from the US Food and Drug Administration (FDA). The system, which uses a handheld ultrasonic transducer to deliver ultrasound energy at a precise depth within the fat layer, was developed by UltraShape Ltd, which was bought out by Syneron Medical Ltd in 2012. Syneron claims that the device has been used in over 220,000 procedures worldwide.

US non-breast implant market to decline A report into the non-breast aesthetic implant market in the United States has found that demand for these procedures will fall steadily between now and 2022, as alternative, less invasive treatments become more prevalent. The Medtech 360 Report, which was carried out by Decision Resources Group, found that facial injectable treatments and fat transfer procedures are increasingly popular in the US, as compared to facial and body contouring implants, which are considered too invasive and more prone to complications. The risk of complications may provide a two-fold reason for the decline of these procedures, as physicians also prefer a low risk option.

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Contact Merz Aesthetics NOW and ask for Belotero . 1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

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BEL093/0314/FS Date of preparation: April 2014


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Acne

Insider News

Botulinum toxin

Phosphagenics completes enrolment in phase 2 acne treatment trial Australian biotechnology company Phosphagenics has completed enrolment for the second phase of clinical trials of its acne vulgaris treatment. The three-month study examines the efficacy of topical acne drug tretinoin, when formulated with Phosphagenics’ proprietary Targeted Penetration Matrix (TPM) delivery system. The treatment will be tested against a leading commercial tretinoin formulation. A total of 54 patients have been recruited for the randomised double blind study at three trial sites in Perth and Brisbane in Australia, and Hamilton, New Zealand. The trial will be completed at the end of this quarter, with results to be announced in quarter three. Previous studies of the formula demonstrated a significant increase in the delivery of tretinoin into the skin, combined with a reduction in skin irritation, when evaluated against the comparator. TPM is a vitamin E-based system that enhances the topical or transdermal delivery of active molecules. The lead products containing the system advancing through clinical trials are two patches for the relief of chronic pain, one of which has been proven able to deliver therapeutic levels of oxymorphone into the bloodstream, a world first. “Dermatological products and particularly those with active ingredients that need to penetrate deeply into the skin but cause irritation, lend themselves perfectly to this technology. They are therefore of great interest to our company,” said Harry Rosen, CEO of Phosphagenics Ltd. “The size of the acne market and the low cost of registering dermatological products justifies the allocation of our expertise and efforts in this area. If we can replicate our initial studies in this phase two trial and beyond, it would result in a substantially superior product with better efficacy for patients and less skin irritation.”

Study shows Botox could alleviate depression A study carried out in Germany has shown that Botox injections could provide significant relief from symptoms of depression, particularly among those sufferers who display high levels of hyperactivity. The study, which was carried out by Dr Tillman Kruger, Dr Axel Wollmer and associates in Germany, showed that by paralysing the facial muscles involved in producing frown lines, Botox injections actually caused the feelings associated with frowning to be reduced. “Emotions are expressed by facial muscles, which in turn send feedback signals to the brain to reinforce those emotions,” Wollmer explained. “By treating the facial muscles with Botox, we can interrupt this cycle.” In the study, which lasted 16 weeks, 15 patients with major depressive disorder were each given one injection of Botox. Symptoms of depression had been reduced by 47.1% after six weeks – based on HAM-D measurements – compared to a 9.2% reduction amongst patients treated with a placebo. By the end of the study, 86.7% of those treated with Botox had experienced at least a partial response, with 33.3% in remission, versus 26.7% and 13.3% respectively in the control group. Patients who displayed signs of dynamic hyperactivity seemed to respond better to treatment with Botox, according to Wollmer, which might include people who bite their nails or play with their hair as well as those who frown a lot. The researchers are currently conducting a metaanalysis of their study.

Melanoma

Research shows that having an established dermatologist may improve self-detection of melanoma A study conducted by students at the University of Pittsburgh School of Medicine has shown that patients with self-detected primary melanoma who have an established dermatologist are more likely to present with thinner lesions at the time of diagnosis than those patients without an established dermatologist. The retrospective cross-sectional study looked at 388 patients with self-detected melanoma and sought to establish whether three factors – having an established dermatologist, how recent the last dermatologic appointment was, and wait time for the appointment – were linked with the invasiveness and depth of the melanoma.

The researchers found that of those patients with an established dermatologist, 63.6% received a diagnosis of melanoma in situ, compared with 44.5% of those without a dermatologist, and they also were more likely to have thinner invasive melanoma – 0.48mm vs 0.61mm. The study found that invasiveness and depth of the melanoma was unrelated to how recent the last appointment was or to wait time. “Education obtained at the dermatology appointment may improve early self-detection of melanoma, and having an established dermatologist may facilitate earlier evaluation of concerning lesions,” the authors concluded.

Aesthetics | June 2014

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SkinCeuticals launches Resveratrol B E SkinCeuticals has launched a new night concentrate that promises to improve skin density, firmness and elasticity within 12 weeks. Resveratrol B E is formulated using the potent antioxidant resveratrol (1%), in combination with vitamin E (1%) and baicalin (0.5%). The company claims that by using a delivery system of hydrotropes, the product offers enhanced penetration of resveratrol, which is notoriously hard to stabilise. According to a dermatologist-controlled clinical trial, Resveratrol B E increases skin density by 18.9%, as shown by ultrasound measurement.

Laser

Lutronic Corporation launch Spectra XT Lutronic Corporation has launched the new Lutronic XT Q-Switched, frequencydoubled Nd:YAG laser, known as the Spectra XT. The latest edition of the Spectra laser, the Spectra XT – or ‘Extended Platform’ – is expected to be CE marked and ready for sale in Europe in June 2014. The system includes several treatment applications including one for tattoo removal, pigmented lesions, melasma, pore-size reduction and skin-rejuvenation. The new XT model features a RuvyTouch 660nm handpiece for pigmented lesions, and a Gold Touch 595nm handpiece for vascular indications such as facial and post-acne redness. Dr UC Yeo from Korea said, “The skin reaction after 660nm is much milder than after 532nm, with lesser chance to make petechiae by mistake. It is especially useful for light-coloured freckles or other epidermal pigmented lesions. This will be a useful treatment option.”

Survey shows rosacea sufferers judged negatively on first look A survey has shown that people with rosacea are more likely to be perceived in a negative light when judged on first impressions than those with clear skin. Two digital perception surveys, showing images of men and women with facial rosacea and people with clear skin, were conducted online in the US between February 6 and February 20. The first was given to 518 adults suffering from rosacea, the second to 1,015 non-rosacea suffering adults. According to the survey, which was developed by the National Rosacea Society and Galderma Laboratories, 22% of people with rosacea were likely to be perceived as shy or quiet and 18% nervous, as compared with those without rosacea (17% and 11%, respectively). A greater percentage of the general population respondents answered that people with rosacea were less likely to be outgoing and less likely to be in a relationship. Perceptions of being relaxed or charismatic were more often given to those with clear skin compared to people with rosacea (77% versus 64% and 75% versus 63%, respectively). “The persistent facial redness of rosacea often causes embarrassment and anxiety for sufferers, and the survey results provide proof that those affected actually avoid going to social events or miss out on special occasions,” commented dermatologist and psychologist Dr Richard Fried. “Without proper treatment, rosacea can worsen over time and potentially lead to depression.”

Awards

New sponsors announced for The Aesthetics Awards 2014

More category sponsors have been announced for The Aesthetics Awards 2014, to be held on December 6 in London. Merz Aesthetics are to support the award for Aesthetic Medical Practitioner of the Year, NeoCosmedix will sponsor Association/ Industry Body of the Year and Oxygenetix are to present the award for Best Clinic London. Vernon Otto, managing director of NeoCosmedix said, “We are delighted to be sponsoring the Association/Industry Body of the Year Award at The Aesthetics Awards 2014. The awards are a fantastic platform for practitioners and really showcase the best in medical aesthetics. We look forward to presenting the winner with their trophy and celebrating 10

clinical excellence in our industry.” Barry Knapp, product formulator and designer of Oxygenetix said “The Oxygenetix team in cooperation with exclusive UK and Ireland Distributor Medical Aesthetic Supplies Ltd are thrilled to be sponsoring the Best London Clinic Award at the prestigious Aesthetics Awards 2014. London clinics are some of the best in the world and I am honoured to be able to show our appreciation at the forthcoming awards and present the award to the clinic with the best medical excellence.” Entries will close on June 30 2014. Visit www.aestheticsawards.com to enter.

Aesthetics | June 2014


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Cellulite

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Acne

MACOM launches new Crystal Smooth legwear MACOM Medical has unveiled a new range of legwear that promises to reduce cellulite. Comprising three products, the Crystal Smooth range is made from Emana fibre, which is woven with bioactive crystals. According to MACOM, these crystals absorb body heat and return it in the form of rays, which penetrate the skin and stimulate microcirculation, cellular metabolism and lymphatic drainage. The company promises that within the first few weeks the wearer will experience increased skin elasticity and collagen production. As well as being marketed direct to consumers for everyday use, the products aim to improve the results of cellulite treatment.

Study shows localised transepidermal cooling reduces sebum by up to 40% In a pilot study carried out by Dr H. Ray Jalian and associates at the Wellman Center for Photomedicine, Massachussets, one cycle of localised cryolysis on the backs of 11 men with normal skin produced a 40% reduction in sebum production. Sebum production fell significantly in the first two weeks post-treatment, but by the fourth week was not notably different from baseline. The findings were presented at the annual meeting of the American Society for Laser Medicine and Surgery. Participants were randomised to be treated on select areas of their backs at temperatures of –10° C or –15° C, and they received either a single 20-minute cooling cycle or two 10-minute cooling cycles with rewarming in between. Some skin areas on the scapulas served as control sites, and each subject had two treatment sites and one control site. Sebum measurements and standardised clinical photos were taken just before treatment and on follow-up visits at three days and at one, two and four weeks. Treatments were performed using the Zeltiq handheld cooling device. Dr Jalian and his team hope that this study could pave the way for further research into selective cryolysis of the sebaceous glands as a noninvasive treatment for acne vulgaris.

Research

Poster data shows phototherapy could be more costeffective than biologics for psoriasis A poster presented at the recent annual meeting of the American Academy of Dermatology (AAD) has shown that prescribing phototherapy instead of biologics for psoriasis patients could prove more cost-effective. The study, carried out by Dr Andrew Shors and colleagues from Group Healthcare Cooperative in Seattle, looked at healthcare costs linked to psoriasis among 2,986 patients aged 18 and over, with a mean age of 51 years. The mean adjusted total annual health care costs associated with patients diagnosed with psoriasis during 2012 were $10,816 compared with $6,772 for controls, according

to the research. Psoriasis patients treated with phototherapy had incremental costs of $3,910.17 relative to all adults diagnosed with psoriasis, whereas patients treated with biologics had incremental costs of $8,118.98. The overall incremental increase in healthcare costs among patients treated with biologics was $12,029 more than all adults diagnosed with psoriasis. “Our study provides evidence for the potential cost savings that could be achieved with greater use of phototherapy as a treatment for psoriasis relative to the use of biologic agents,” the researchers concluded.

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A image sharing app for doctors, Figure1, has launched a new version of its photo and information sharing service, giving users the ability to create profiles and form or join groups related to their institutions or interests. Figure1 was launched in May 2013, after co-founder Dr Joshua Landy expressed concerns that doctors and medical students were using social networking sites to share information about interesting cases, potentially breaching patient confidentiality. “Tens of thousands of times a day patient records and educational images are transferred from healthcare provider to healthcare provider,” Dr. Landy says. “We were thinking of a way to try and preserve and protect that information in an archive that’s searchable and useful.” With the new release, users have the ability to follow cases, and collaborate with doctors around the world.

90%

Meder Beauty Science will relocate the company’s head office from Antibes to London in June 2014. The skincare company’s global distribution network is to be run from Kensington, whilst product manufacturing remains in Switzerland. Founder and dermatologist Dr Tiina Orasmae-Meder believes that Meder’s advanced facial treatments can deliver results comparable to injective treatments, through the use of optimum concentrations of biosynthesised peptides and a protocol that they claim is clinically proven to ensure maximum bioavailability of the active ingredients. Lana Hatouchyk, director of Meder Beauty UK, said, “We are excited about the move and look forward to a closer collaboration with Dr Tiina and the global team as well as the added PR and marketing benefits this will bring to the UK market.”

of 1,675 patients surveyed said that rosacea’s effect on their personal appearance had lowered their selfesteem National Rosacea Society

According to a survey of Harley Street, less than 10% of patients over the past 12 months were international Future of Harley Street Survey

95% of American patients want to know the board certification of their physician

Industry

Meder Beauty Science set to relocate to London

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App

Figure1 app introduces new features

Aesthetics

American Society for Dermatologic Surgery

Of 629 respondents, around 60% were not aware of the proposed new CEN Standard in ‘Aesthetics Surgery Services’ The European College of Aesthetic Medicine and Surgery survey

69.3% of Harley Street businesses have seen an increase in patients over the past 12 months Future of Harley Street survey

Post-procedure

Post-procedural foundation Oxygenetix launches in UK Post-procedural foundation Oxygenetix has launched in the UK medical industry. The foundation, which will be distributed by Medical Aesthetic Supplies, contains an oxygen-enriched formula that aims to speed up the body’s cell production of collagen and elastin, which claims to provide a quicker healing process for patients post-surgery and after cosmetic treatment. It is designed for use after a variety of skin treatments and procedures, including laser hair removal, laser and chemical peels, rhinoplasty, acne and rosacea treatments, burns and facial surgery. The manufacturers claim it is hypoallergenic, non-irritating, and transfer and water resistant, allowing it to stay on for hours. It contains no dyes or parabens, and has an SPF factor of 25, protecting against UVA and UVB rays. The main ingredient within the product is Ceravitae, a charged oxygen complex promoting connective tissue growth in ageing and wounded skin. This also aims to prevent moisture from reaching damaged or irritated skin, whilst permitting oxygen to pass through the affected area. 12

Aesthetics | June 2014

From 2010 to 2012, hair restoration procedures performed on the eyebrow and face (moustache/ beard) increased 13.1% International Society of Hair Restoration Surgery

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The Anti-Ageing Health and Beauty Show, London The Anti-Ageing Health and Beauty Show took place at the London Olympia on May 10-11. The show saw a range of exhibitors presenting their products and treatments, alongside speakers providing live demonstrations and talks. Presentation topics included Frotox by Dr Vincent Wong, the Dracula PRP Facial by Dr Daniel Sister, A New Treatment for Dark Eye Circles by Dr Terry Loong and Skin Tightening by Dr Sach Mohan and Dr Sabika Karim, amongst many others. Dr Terry Loong, exhibitor and speaker at the event, said, “These events are a good opportunity to speak to and educate consumers. Some people may not be ready to come to clinic, and an event like today is a good chance to build relationships with those people. My advice for other practitioners doing this kind of show is not to try and cover all bases; instead, have a niche. Talks are a good way of increasing your visibility and building relationships with patients – and don’t be afraid to show your personality!”

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Body Boot Camp, London Syneron-Candela hosted a workshop to help develop medical practitioners’ use of body contouring device Velashape III on May 12. Body Boot Camp, which took place at the Phi Clinic on Harley Street, invited medical professionals to learn the science behind the treatment, and the various applicators available. Aviv Oren, director of body shaping products at Syneron-Candela, began the day with a comparison of the efficacy of the different models of Vela and provided data, including the example that 16 treatments using a 20W Velasmooth and one treatment with the 150W Velashape III heeded similar results. “It’s better to have one long treatment, where the thermal dose is given for a long time, than five shorter treatments,” he explained. The afternoon provided attendees with a practical session looking at tips and advanced techniques in using the device, and how to gather optimum results from the treatment. Vanessa Bird, national business development manager for the Body Division at Syneron-Candela, said, “This new VelaShape can do a lot more than its predecessors. We’re educating people about this and previous models, and getting across how versatile the VelaShape III can be, then providing practical sessions that teach practitioners how to treat patients. People don’t just present with one issue, they present with a combination; Velashape is a whole body solution.”

Westminster Briefing, London The Westminster Briefing, looking into the government’s response to the Keogh review, took place on May 15. The event included a chair’s introduction by Sally Taber, director at the Independent Healthcare Advisory Services, followed by a policy session with a selection of speakers looking at the government’s full response to the review. The briefing included a Q&A session and a practice session on implementing pan-industry practice and training standards. A full report of the event can be read in next month’s edition of the Aesthetics journal.

The Whiteley Clinic launch, London The clinic launch for Professor Mark Whiteley’s new clinic at One Chapel Place, central London, took place on April 30. The launch included a tour of the new clinic, in which medical professionals were able to watch treatments being undertaken, including a varicose vein treatment and a dermaceutic milk peel. The new facilities comprise The Whiteley Clinic and local anaesthetic and cosmetic procedures division, Absolute Aesthetics. The clinic includes four consulting rooms, an ultrasound room, a treatment room for thread veins and dressings, and two operating theatres, both including endovenous laser equipment and one with the C-arm X-ray equipment for pelvic vein embolisation. The clinic specialises in treating varicose veins, and is one of two clinics in the UK to offer an eyelash transplant treatment. The Whiteley Clinic and Absolute Aesthetics Team includes Professor Mark Whiteley, clinic director and aesthetic practitioner Vicki Smith, consultant plastic surgeon Mr Amir Nakhdjevani, aesthetics physician Dr Kuldeep Minocha, dermatologist Dr Ana Teles, aesthetic practitioner Storm Mann, consultant interventional radiologist Dr Previn Kiwaka, consultant vascular surgeon Mr Gabriele Bertoni and vascular technologist Tim Fernandez-Hart.

Professor Mark Whiteley said, “We are absolutely delighted to have found a permanent London home at One Chapel Place. My team and I are extremely keen to highlight how important it is to seek proper treatment for varicose veins and other venous related conditions and we continue to dedicate significant resource to the research and development of new pioneering procedures.” Vicki Smith, Absolute Aesthetics clinical director, said, “We work with what our patients want. We’re very patient-led as a clinic, so if they want little downtime, we accommodate this. We will be welcoming several new experts to our team at the new clinic, and are looking forward to offering patients a much wider range of cosmetic and minimally invasive treatments and procedures.”

Aesthetics | June 2014

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With the work of Phase 1 complete, Health Education England welcomed stakeholders to a day-long workshop to report back on the outcomes and the proposed framework for future qualifications

Update: Review of the qualifications required for non-surgical cosmetic procedures The second Health Education England (HEE) stakeholder workshop took place on Thursday, May 1 in central London. The non-surgical cosmetic interventions summit was host to over 80 interested parties, representing organisations from all sectors of the medical aesthetics industry. Medical practitioners, manufacturers and distributors, members of industry associations, universities, industry councils and royal colleges all came together to hear the findings of Phase 1 of the project. Chair of the day, Professor David Sines, described the development of this first stage as the work of, “An embryonic group of experts facilitating the process on behalf of HEE”. The project, which held its first stakeholder workshop on February 24 this year, is a review of the qualifications required for non-surgical cosmetic procedures, and the qualifications required to be responsible prescribers. Spurred by the PIP scandal and consequently commissioned by the government, Phase 1 of the project set out to establish a proposed qualifications framework for non-surgical cosmetic procedures. This work focused on five treatment modalities: botulinum toxin, dermal filers, hair restoration surgery, chemical peels and skin rejuvenation, and laser, IPL and LED. HEE performance and delivery manager Carol Jollie opened the workshop with an introduction to the proposed qualifications framework. Jollie communicated to the audience that the qualifications framework and indicative content outlined in Phase 1 is currently divided into these five modalities, with each individual modality based on a foundation qualification (equivalent to Level 4). This is developed upon with additional training specific to individual treatment modalities. These training requirements set out in the framework apply to all practitioners, she said, regardless of previous training. Jollie informed the audience that since the first stakeholder workshop in February, work had been carried out by both an advisory group and an expert reference group, made up of key organisations within the industry to ensure that the indicative content of the proposed foundation level qualification had user and patient concern as the main anchor. Presentations were then given on each treatment modality, outlining the proposed framework and suggested content belonging to each. British Association of Cosmetic Nurses (BACN) representative Andrew Rankin outlined the framework for botulinum toxin and dermal fillers, and emphasised that, “Managing complications is an important theme on-going.” Dr Greg Williams, president of the British Association of Hair Restoration Surgery (BAHRS), went on to discuss hair restoration surgery, a new addition to the project’s remit. Williams addressed the treatment’s recent inclusion by explaining that the Cosmetic Surgery Inter-speciality Committee (CSIC) had taken the view that this treatment would fit better under HEE’s remit given the non-surgical background of the majority of practitioners performing this surgery. Dr Tamara Griffiths followed with a presentation on the proposed framework for chemical peels, micro-needling/skin needling, and mesotherapy. Addressing the review as a whole, Dr Griffiths highlighted the importance of practitioners being aware of what 14

lies outside their competencies, stating, “We do harm to our patients when we deny them the appropriate treatments.” British Medical Laser Association (BMLA) member Jonathan Exley concluded the presentations by addressing the framework for lasers, IPL and LED, describing the project so far as a “marathon of engagement” between stakeholders. Presentations were followed by a Q&A session, which included input from Department of Health advisor Noel Griffin. This hour-long session brought forward many questions from the audience on issues such as the functionality of an adverse event reporting system, the workings of an accreditation system for existing courses, and the lack of hard evidence and figures surrounding the aesthetics industry. The majority of queries were noted and allocated to be addressed in Phase 2 of the project and Griffin, in his post lunch session, promised the audience that, “Anything we do needs to have a complaints procedure in it.” Of the day’s proceedings, Professor Sines, also chair of the expert reference group, said, “I think we have had the opportunity here to have an engaged and honest dialogue. It’s been quite a deep discussion, and allowing an hour for questions was pivotal for its success. The richness of debate was the real value of this exercise.” Sally Taber, director of the Independent Healthcare Advisory Services (IHAS) and member of the expert reference group for Phase 1, described the importance of the project’s work for all practitioners in the field of aesthetic medicine. “It’s important that patients know that they are going to an appropriately qualified person who knows what the substance is, what they are injecting and where they are injecting. People need additional training to do this. I’m a registered nurse, but I certainly wouldn’t embark on thinking I could do a clinic with Botox and dermal fillers this weekend, because I don’t have the qualifications and I don’t have the appropriate training. It’s not routine in any of the three professions that have been discussed – doctors, dentists or nurses – so everybody needs additional training. The additional training is not just for non-registered practitioners.” Plastic surgeon Mr Chris Inglefield agreed that the project is vital not only for establishing a qualifications framework, but also for establishing how to communicate these qualifications to the public. Patient education is key, says Mr Inglefield: “This project is changing how we think,” he said, “and in particular, how we educate the public. We need to ensure that our qualifications instil confidence in the public.” Phase 2, currently in development, looks to establish recommendations for accreditation and course delivery. The next stakeholder workshop will take place in November.

Aesthetics | June 2014


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Association of Scottish Aesthetic Practitioners Conference and Exhibition We report on some of the highlights from the conference programme of the third ASAP event The Association of Scottish Aesthetic Practitioners Conference and Exhibition, held at the Royal College of Surgeons in Glasgow, provided the 60 delegates attending with a programme packed with education. The conference, founded by Mr Simon Ravichandran, Frances Turner Traill and Jackie Partridge in 2011, featured lectures and live demonstrations from a number of clinical and business experts. The main programme began with a session delivered by Dr John Quinn on managing filler injection complications. The presentation contained clear, practical and theoretical knowledge and experience, accompanied by Dr Quinn’s self-deprecating touch, which kept the audience educated and entertained. He reminded delegates that complications will inevitably occur during the course of a practitioner’s career and that knowing how to respond quickly and effectively is crucial. He argued that although we ideally work in an environment of evidence-based medicine, sadly this is often found to be lacking in medical aesthetics. He explained the steps of avoiding complications, beginning with a reminder of basic aseptic technique and proceeded to discuss swelling and bruising, vascular compromise and discolouration. Dr Quinn highlighted the importance of a strong knowledge of facial anatomy, accompanied with a slow injecting speed. Following this, Dr Heather Muir gave a presentation looking at facial assessment from a dental perspective. This offered a whole new approach for many delegates with regards to what to consider and when to refer. Dr Muir focused on the influence of the teeth and bone anatomy, along with the role that the skull plays in the effects of aesthetic treatment. She looked at the profile of the teeth and lower jaw and applied some of the dental classifications to common issues that patients present with in aesthetics, such as using Angle’s classification of occlusion. Dr Muir also explained her process of facial assessment of patients, where she analyses their smile dynamics and assesses the visibility of the teeth. She treats this area with filler and toxin, but stressed that practitioners should be aware that some patients may need dental treatment to restore the teeth and thus the facial contours. A session by Dr Askari Townshend on biostimulation followed, accompanied by a live Sculptra demonstration, and Denise Daddario of Silhouette Beauty went on to present a live demonstration of the Silhouette Soft thread lift. Dr Katie Goldie then performed a very interesting demonstration of treatment of the lower face with Radiesse and Belotero. She addressed the issues of chin augmentation and dealing with the oral commissures, in order to ensure that the area is treated as a whole, and the chin does not look like a lone structure. Her demonstration of different injection techniques produced dramatic 16

Aesthetics Journal

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and impressive results and provided watching delegates with much to consider. The afternoon sessions were varied, with a selection of practical business tips, including accounting advice from VAT expert Veronica Donnelly, and advice on prescribing in aesthetics from pharmacist Brendan Semple. John Castro’s presentation on marketing centred on social media’s increasing role in brand and business promotion. He discussed his research into the market, where he found that the most important aspect for patients’ choice of a practitioner is trust in the clinic and those in charge of their care. The day ended with a Skinposium, which consisted of several companies talking on the benefits of their skincare range, both in terms of ingredients and branding. Dr Sam Robson, medical director at Temple Medical and delegate at the conference, said of the event, “It was an interesting meeting with a stimulating and thoughtprovoking agenda. Dr John Quinn both educated and entertained as he presented the complications of using dermal fillers, and Brenda Semple reminded us of our obligations as prescribers and the risks of putting commercial gain above ethical considerations. The meeting had a relaxed environment, which allowed opinions and ideas to be aired, shared and openly challenged.” Organiser, Mr Simon Ravichandran, said, “Our main objective with this conference was to pull together a group of like-minded practitioners and share ideas and concepts with an educational backdrop. What really made this event successful from our point of view was the enthusiasm and participation of the delegates, who didn’t hold back from asking difficult questions.”

  

   

       

       

   


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Face, Eyes, Nose Symposium We report from the first day of the annual meeting hosted by the European College of Aesthetic Medicine and Surgery (ECAMS) on 8 May, which focused on non-surgical facial aesthetic treatments. The third annual ECAMS Face, Eyes, Nose Symposium, taking place at University Hospital, Coventry and Warwickshire between 8 and 11 May, saw 60 surgeon and physician delegates from South Africa, Australia, South East Asia, the USA and Europe attend to further their learning on facial aesthetic treatments, oculoplasty and rhinoplasty. Dr Peter Prendergast, Dublinbased cosmetic doctor and president of ECAMS, said, “The Face Eyes Nose 2014 aesthetic symposium attracted aesthetic doctors, plastic surgeons, maxillofacial surgeons, dermatologists, ENT surgeons and others interested in picking up pearls from international leaders in aesthetic medicine and surgery. Mr Das-Gupta put together a superb programme and directed the course with precision.” The first day of the symposium focused on non-surgical facial aesthetics, and began with an introductory address by course director and consultant plastic surgeon, Mr Rana Das-Gupta. He explained that, due to demand from delegates, the meeting this year would include both more non-surgical procedures and cadaver dissections. Plastic surgeon Mr Dionysios Tsakonas, based in Greece, began the day’s lectures by discussing the importance of facial anatomical knowledge in aesthetics. He spoke about the relevance of elements such as facial proportions, landmarks, the anatomy of the skin, neurovascular anatomy and avoiding feminisation in men. The importance of skincare was discussed by cosmetic surgeon Mr Nick Percival, who emphasised that this should be a key focus for surgeons, as skin heals better when it is healthy. He examined how ageing and environmental factors including photodamage, hormones and acne, can affect the skin’s quality and highlighted the importance of using the right products with effective ingredients for the appropriate skin type. Mr Jan Stanek, plastic surgeon, discussed the historical developments of chemical 18

peels and ran through different peel depths and agents, including caustic, metabolic and toxic. He advised that you should not treat any deeper than the reticular dermis, and highlighted indications of peels, including keratosis, dyschromias, scarring, acne and ageing. He also spoke about the stages of healing post-peel, including coagulation, re-epithelialisation, granulation, angiogenesis, and collagen remodelling. Dr Prendergast lectured on facial contouring using fillers, emphasising the benefits of the non-surgical approach with pan facial volumisation. He described his treatment of the tear trough and mid-face area using needles and cannulas and explained that he uses large quantities of product but in small deposits all over the face. He stressed that hyaluronic acid should be used in small deposits in the tear trough area, at a slow injection speed and under low pressure. Plastic surgeon Mr Dalvi Humzah delivered a lecture on advanced botulinum toxin procedures, before Dr Yannis Alexandrides discussed using the Iovera device to deliver cold cryotherapy, or ‘Frotox’. Lovera contains hollow cannulas, which penetrate the skin deeply, delivering liquid nitrous oxide at low temperatures into the temporal branch of the facial nerve. By treating the peripheral nerves with cold temperatures, the frontalis and corrugator muscles are inhibited from working. The role of ultrasound in a surgeon’s practice, specifically Ultherapy, was discussed by Mr Alex Karidis. Cheek dimple creation was then explained by cosmetic surgeon Mr Shailesh Vadodaria, who described the process, whereby a punch-like biopsy is taken from the inner cheek and sutured to create a depression. He noted complications, including scarring, bleeding and injury to the facial nerve, and explained that only location of the dimple can be defined, not size and shape. He said, however, that it is a simple procedure taking 30 minutes and good results are seen after three months. Aesthetics | June 2014

Aesthetics

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French facial surgeon Dr Frederic Braccini spoke on non-surgical rhinoplasty, and discussed the art of nose reshaping with fillers and botulinum toxin. He explained that it is a quick procedure providing good patient satisfaction, but as it is a highly vascular area, care needs to be taken to avoid necrosis, by delivering slow injections of filler and massaging the area afterwards. Stepping away from clinical topics, plastic surgeon Mr Andrew Batchelor went on to advise on avoiding litigation, highlighting the importance of the three Cs; Competency, Consent and Conduct. He emphasised that

From left: Dr Peter Prendergast, Dr Shailesh Vadodaria, Dr Timothy Marten, Dr Rana Das-Gupta

Two intensive days of lectures at FACE EYES NOSE preceded the hands-on cadaver dissections

doctors should be able to demonstrate the scope of their training and experience by keeping a training log, and highlighted the importance of managing complications and obtaining written consent for every before and after photograph each time it’s used. His talk was highly informative and quoted some very interesting cases. Delegates were awarded six CPD points per day following completion of the course. Dr Prendergast said of the event, “ECAMS was delighted to have this very prestigious event on our 2014 calendar. Our college is dedicated to bringing doctors and surgeons practical training of the highest quality to raise the standard in this very evolving and exciting field.” Mr Humzah added, “The Face, Eyes, Nose 2014 Conference is a unique course with an impressive list of national and international speakers who lecture and demonstrate using hands-on cadaver training. The faculty are all of a high calibre, and the delegates this year were a truly international and multi-disciplinary group, reflecting the inclusive nature of aesthetics.” Details of next year’s ECAMS aesthetic symposium will be announced on their website soon.


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With highlights including talks on surgical scaffolding and advanced techniques for non-invasive body shaping, Wendy Lewis reports on The Aesthetic Meeting 2014

American Society for Aesthetic Plastic Surgery (ASAPS) annual meeting San Francisco is best known for its foggy skies, steep rolling hills, cable cars, and the Golden Gate Bridge. In April 2014, the city by the bay welcomed the American Society for Aesthetic Plastic Surgery (ASAPS) for its annual conference at the Moscone Center. A comprehensive full-day programme called “Cosmetic Medicine: The Challenge of Living in a Photoshop World”, covering laser technologies followed by live filler demonstrations, began proceedings at the Aesthetic Meeting 2014. The morning session was led by San Francisco plastic surgeon Dr Michael Kulick, accompanied by an impressive line up of plastic surgeons and dermatologists. Structuring the session as a problem/solution forum, he included sessions on treating ethnic skin, pigmentation, removing tattoos, rosacea, acne, hair loss, fine wrinkles, skin laxity, restoring skin tone, texture and colour, and revolumising the face with fat and fillers. Dermatologist Dr Mitchel Goldman, based in La Jolla, California, presented his work on treating acne with IPL, outlining his long-term success in managing acne with light-based devices without the use of topical or systemic medications. Dr Roxanne Sylora from Orlando, Florida demonstrated her approach to skin laxity through the implementation of ThermiTight Injectable RF, which uses ThermiRF technology. Newcomer NeuBelle from Serene Medical was introduced at ASAPS as a combination bipolar radiofrequency (RF) energy with stimulation energy in a handheld probe. This is FDA-cleared for precisely locating a motor nerve and for simultaneously using RF to interrupt the signal pathway of the nerve to the muscles that are controlled by that nerve. Thus, it is being used to smooth forehead creases by deactivating the facial nerves involved. My favorite session at ASAPS year after year is ‘Premier Global Hot Topics’, or simply ‘Hot Topics’, a six-hour course run by the Aesthetic Surgery Education and Research Foundation (ASERF). This features clinical studies and evidence-based medicine, trends, emerging technologies and innovations, looking to the future of the aesthetic surgical specialty. 20

The exciting area of scaffolding technology for soft tissue support received a lot of attention. This is an emerging area in aesthetic and reconstructive surgery and the range of options in human, porcine and synthetic materials is expanding. Of note, GalaFLEX is an absorbable resilient mesh designed to reinforce weakened soft tissue with 70% strength retention at 12 weeks. Allergan’s Seri Surgical Scaffold was shown to have interesting applications in many areas of plastic surgery, including breast reconstruction, revision breast surgery, and for surgery following massive weight loss. Fenestrated AlloDerm from LifeCell was presented as a pre-perforated human tissue matrix product option for doctors who currently make their own perforations before placing it. Optrix tissue processing technology used in the Meso Biomatrix porcine-derived surgical mesh was discussed for soft tissue regeneration in several clinical applications. Another controversial topic of discussion was cellulite reduction and non-surgical fat removal technology using radiofrequency, cryotherapy and ultrasound. Two new technologies to target cellulite were introduced. Xiaflex from Auxillium Pharmaceuticals is in phase 2 of development for the treatment of cellulite. Xiaflex (collagenase clostridium histolyticum) is a prescription drug that is used to treat adults with Dupuytren’s contracture by releasing the cords in the hand responsible for this condition. The technology from Cabochon Aesthetics, recently picked up by Ulthera, was presented by plastic surgeon Dr Simeon Wall from Shreveport, Louisiana. The device received FDA clearance for short-term improvement in the appearance of cellulite in the buttocks and thighs, and will be marketed under the brand CellFina by the end of 2014. An update on the Refine Suspension System for the breasts was presented by Dr Bruce Van Natta from Indianapolis, Indiana. This unique breast lifting system consists of three sutures; one is placed below the collarbone and held by the fascial cover of the pectoral muscle. Two additional sutures are placed through the breast tissue, anchored in the Aesthetics | June 2014

glandular tissue, pulled up to lift the tissue, and then tied to the upper suture to hold them in place. The potential negative impact of biofilms on textured breast implants, as well as on dermal fillers, was explored with extensive research presented by Dr Anand Deva of Sydney, Australia. His data was compelling and a cause for some degree of alarm over how this may further affect practitioners and patients. Another theme of the meeting was the use of technology, such as Google Glass, and how it applies to the field of aesthetic surgery in and outside of the operating room. Several plastic surgeons presented novel objective methods of measurement that they have implemented in their clinics to determine patient outcomes and satisfaction. Plastic surgeon Dr James Grotting from Birmingham, Alabama described a new tool he has used to assess the outcomes of facial aesthetic surgery. This was developed by Dr Andrea Pusic, associate professor at Cornell University, who created a questionnaire/survey tool to enable surgeons to better understand the impact that facial aesthetic treatments may have on a patient’s quality of life. The next ASAPS conference will be held on May 14-19, 2015 in Montreal, Canada. www. surgery.org Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on antiageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications.


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References 1. Rzany B et al, Dermatol Surg 2012;38: 1153–1161 2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26 (*Results taken from a mean value across all treatments performed in study) 3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93


Clinical Practice Special Feature

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Aesthetics

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Cellulite: the common patient complaint Medical practitioners discuss the practical difficulties associated with treating cellulite and examine its causes, diagnosis and grading, as well as the range of treatment options they have chosen to use in their clinics. David Jacobs reports

The term ‘cellulite’ was first used in the 1920s to describe the alteration of the skin surface of the legs characterised by an ‘orange peel’ or dimpled effect1. Cellulite it is a common cosmetic problem as Mr Hassan Shaaban, consultant plastic and laser surgeon at Laser Plastic Surgery, explains, “It is estimated that 80% of women above the age of 20 have it. In the majority of ladies, [it appears] in the outer thighs, the back of the legs, the buttocks and the front of the legs, and less on the inner thighs.” Cellulite mainly affects women – in fact, some practitioners have never seen a man attend for treatment. Mr Shaaban points out, however, that cellulite does not always mean excess fat and affects slim women in the same way that it does those who are overweight. Kelly Swann, aesthetic nurse prescriber and co-owner of Swann Beauty, confirms that, “My key patient group is Caucasian women between the ages of 30 and 55, although some do fall outside of this range. Both men and women suffer, although women are more predisposed due to their anatomy and hormonal differences.” Dr Ayham Al-Ayoubi, from the London Medical and Aesthetic Clinic, sees a similar profile among his patients: “80% of patients are ladies in their 40s and 50s with around 10% being ladies aged 25 to 30, and around 10% aged 60+.” He adds, “I’ve seen patients in their 20s who have had bad cellulite and have had the problem from the age of 14 or 15 when hormonal changes kick in.” Dr Al-Ayoubi sees 10-15 cellulite cases for Cellulaze laser treatment per month and about 100 cases for a course of Velashape; practitioners report that they see more patients as the summer months approach. As Dr Elisabeth Dancey, medical director at Bijoux MediSpa, explains, “Spring is the time of year when your cellulite clients start arriving. Young and old, they come seeking smooth thighs for the summer holidays.” Practitioners also report that women are generally concerned about cellulite even though

it’s not a medical condition and causes no physical harm. Kelly Sullivan at Courthouse Clinics feels that it rates between eight and 10 out of 10 on a ‘worry scale’ and can affect people’s confidence significantly. As Anne Marie Gillett, non-surgical director at Transform Cosmetic Surgery, explains, “Magazines are always portraying women with perfect skin and highlighting when celebrities suffer from cellulite. Clients often worry about showing their thighs on holiday or in the summer when wearing skirts, dresses or shorts.” One of the challenges for practitioners is that whilst clients seek the ‘perfect answer’ for cellulite, initial expectations are impossible to meet; as yet, cellulite treatments cannot completely cure the problem.

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Aesthetics | June 2014

THE PRINCIPAL CAUSES OF CELLULITE Mr Shaaban explains that the exact causes of cellulite are unclear and unlikely to be attributable to a single factor. “Abnormal vascular patterns, biochemical changes or cellular dystrophy have been suggested as causes,” he says. “However, cellulite has a strong hereditary predisposition and this could be the main cause.” Kelly Sullivan at Courthouse Clinics advises that causes may include poor diet, smoking, slow metabolism, lack of physical activity, hormonal changes, dehydration, the percentage of total body fat, and the thickness and colour of skin. With so many causes attributable to lifestyle, Sullivan’s explanation points towards a range of controllable risk factors that patients should be made aware of as part of any effective treatment regimen. Along with other contributors, she advises, “Stick to a healthy diet, increase hydration and exercise regularly.” Dr Dancey confirms this holistic approach, explaining that, “Legs are prone to cellulite owing to our sedentary lifestyle. They are dependent upon exercise and abdominal/pelvic muscle tone to ensure perfect lymphatic and venous drainage.” She adds, “New research has confirmed our suspicions that regular activity throughout the day ensures good cardiovascular health. One hour in the gym will not counter the effects of a 12-hour-day spent on your bottom. Diet may also contribute via the stimulation of fat storage.” Of course it’s one thing advising clients to make lasting lifestyle changes but, as personal commitment is involved, quite another to expect compliance; and non-compliance partly explains why cellulite can be difficult to treat successfully. The need to involve patients in their own treatment is highlighted by Dr Carolyn Berry, medical director at Firvale Clinic. “It’s getting across to people that yes, you can give them treatment, but they want to ‘hand’ you their cellulite and say, ‘there you are, get on with treating it’; they’ve got to get involved actively as well. So there’s a patient component to it.”


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Clinical Practice Special Feature

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Aesthetics Journal

The challenges of treating cellulite are also highlighted by Mr Shabaan who explains that, “Cellulite is one of the most difficult cosmetic problems to treat due to the complex nature of the condition. The core structure of cellulite is unique as it features three different problems in the same area: the expansion of fat cells within their tight compartments (causing fatty bulges); the shortening of skin septa (causing skin dimpling); and the loss of skin thickness and elasticity (giving the appearance of loose sagging skin). This clinical feature makes it difficult for women to rid themselves of, or even to hide, cellulite.” According to Dr Al-Alyoubi, “If cellulite is going to develop, then sadly it will develop.” He explains that treatments and lifestyle changes will help to correct it and whilst these won’t cure or prevent the problem, they will help to limit its Label: Accent HD3D spread. Asked to describe a particularly successful case, Dr Al-Alyoubi highlights dramatic improvement, but not a cure. The case involved a female in her 40s who had initially been treated using Velashape but achieved only ‘minimal improvements’. 18 months ago, after switching treatments to a combination of Velashape and Cellulaze laser, he noted, “The improvement was so dramatic that we converted her from Grade 3 to Grade 1, which usually I don’t promise my patients, but the combination of therapies, plus good lifestyle, achieved significant improvement. The [differences in the] ‘befores’ and ‘afters’ were outstanding.” DIAGNOSING SEVERITY OF CELLULITE PRIOR TO TREATMENT The majority of practitioners consulted use a three-point graded scale. Grade 1 indicates that you need to pinch the skin to see cellulite and Grades 2 and 3 are split into mild, moderate and severe levels. Severe Grade 3 indicates large pockets of fat and very badly indented skin, where cellulite can be seen at any standing position or movement and under any lighting. Dr Britta Knoll and others highlight the value of photo documentation and measurements, particularly when explaining to patients the status of the cellulite observed. Mr Shaaban explains that he organises treatment plans around the use of the Modified Muller Nuremberger Scale (ie, Grades 0-3) and examines patients when they are standing under good lighting conditions. However, even when using a standard scale, such as Muller Nuremberger, diagnosis of severity is principally achieved by examination. Dr Al-Ayoubi also uses the three-point graded scale, Before

After

Before

After

Treatment with Cellulaze, copyright™ Dr Ayham Al-Ayoubi

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Aesthetics | June 2014

Aesthetics

aestheticsjournal.com

however, he points out, “There is not an objective measure to look at cellulite – it’s more subjective. We can do an ultrasound of the skin and fat tissue but from a practical point of view you’re not going to perform an ultrasound on every patient and grade the condition by the depth of the cellulite in the septum; so practically it’s better to divide it into three based on appearance.” TREATMENT OPTIONS AND THEIR OUTCOMES Mr Shaaban divides treatment for cellulite into three main groups: “creams and lotions (that have zero/ minimal effect); external therapy, which includes ultrasound, radiofrequency, and external laser (which have limited success as they have no effect on fibrous bands); and Cellulaze.” He describes Cellulaze as, “The first treatment modality that addresses all components of cellulite. It dissolves fat bulges, divides fibrous bands to release skin dimples and also tightens the skin through the stimulation of collagen formation.” The laser probe is inserted under the skin through two or three ‘stab’ like incisions”, but Mr Shaaban describes it as “an effective, safe treatment, showing an immediate result that continues to improve with time.” Dr Al-Ayoubi combines Cellulaze with Velashape and says that, whilst other treatments may improve cellulite by one grade, by initially using Cellulaze and then four weeks later a course of Velashape, his clinic has achieved reductions from Grade 3 to 1. He reports that 80% of his clients come to the clinic having already tried topical creams, massage and herbal medicines that have had no effect. And as Dr Berry explains, “Massage and topical treatments will make the skin look temporarily better; they are a temporary fix and that includes caffeine-containing products.” Dr Knoll recommends topicals, including those with high dose caffeine, but only for home treatment; and stresses that they must be combined with medical treatment to have the most effect. Cellulaze is performed as a day-case procedure under a local anaesthesia, or IV sedation in an operating theatre under sterile conditions. Mild bruising, swelling and numbness is expected after surgery but it settles within a week. Dr Al-Ayoubi says that his 200 clients are even happier with the results two to three years later as the process continues to work. Mr Shaaban introduced Cellulaze to UK in July 2011 and presented his result at BAAPS meeting in September 2012. Three years on, none of his cases showed recurrence of cellulite.2,3,4 Patients leave Dr Al-Ayoubi’s clinic with MACOM Crystal Smooth Legwear compression garments, which help create a gentle heat and so improve blood circulation as well as fat and lymphatic drainage. Dr Al-Ayoubi says that a patient will


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Clinical Practice Special Feature

typically see a difference after four to six months with Cellulaze treatment alone, but by adding the Velashape and the MACOM garments, improvements are noticeable after just four to six weeks. Furthermore, he remains convinced that the future of cellulite treatment is with lasers with a wavelength that targets the cellulite septum and fat tissue, and is of the opinion that with other technologies (eg, RF, ultrasound and infrared) the energy does not distinguish between cellulite and other tissue. Dr Knoll explains that she uses mainly mesotherapy as well as injection lipolysis. She deploys a range of products and adapts the selection and composition according to the individual needs of the patient. However, she is interested in treating any diseases or constitutional problems underlying the cellulite, such as venous lymphatic insufficiency, and stresses that at the examination stage she determines what type of cellulite the patient presents since, “There is a big variety of pathophysiologic types of cellulite and it’s important we see what type it is - some are much harder to treat than others - and from the tissue quality determine, by examination and touch, the number and composition of treatments.” she explains. Courthouse Clinics use Accent HD 3-D. This involves variable high power radiofrequency (RF), which deep heats the skin whilst preventing

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superficial burning, and increases the metabolism of toxins that have built up. Sullivan describes it as “safe on all skin types” and “extremely effective” and says, “Most clients see an improvement in one or two treatments that can be given during a client’s lunch break.” She also describes the RF procedure as pain-free, requiring no down time, and regards it as a ‘three-in-one therapy’ that can also be used to treat fat and tighten skin. At Bijoux Medi-Spa, cellulite treatment has shifted from mesotherapy to RF, although Dr Dancey says that the best outcomes are achieved by a combination of both. Best performed on a weekly basis for about 10 sessions, then adjusted to once per month, she explains that mesotherapy, whilst not a difficult technique, does require practice to succeed. It also has two particular advantages: low cost and the fact that medications used in the injections, “complement the action of the RF device, so better results are achieved in a shorter time,” she says. The downsides are a risk of bruising, slight discomfort and the need to keep the site clean and dry until healing has occurred. A combination of RF and mesotherapy is also offered at Swann Beauty where Kelly Swann uses Venus Freeze RF, as she believes that topicals are ineffective stand-alone treatments. Swann says that her clients see RF as a ‘warming massage’ and that this helps compliance. Side-effects are likely to be minimal and confined to possible redness of the skin. Swann recommends one or two treatments weekly, followed by maintenance sessions every couple of months and explains that these are important if results are to be maintained. At Transform Cosmetic Surgery, Gillett uses Lipotripsy as a stand-alone treatment now she has seen growing evidence of its effectiveness. Advising clients to have two treatments per week and around eight to 12 sessions, Gillett likes Lipotripsy because, “It’s non-invasive, pain-free, quick to administer and has no down time. It also has Level 1b clinical evidence and proven outcomes.” Dr Carolyn Berry at Firvale Clinic adds, “No one treatment is the panacea. I am really excited about Coolsmooth, a new head for the Zeltiq CoolSculpting. I use the Endymed 3DEEP quite a lot – a normal course would be six treatments, or more if the cellulite is really bad – and I think it works quite well, but sometimes I’ve used Dermaroller in combination to help.” CHOOSING A TREATMENT FOR YOUR CLINIC The key message is to select a technology that is, above all, safe and efficacious. Sullivan explains that, for her clinics, she wanted a device to, “Treat all skin types and skin colour”, and “one that was pain-free with little down time.” Gillett stresses the need to research the clinical data to determine whether the device had proven results, whilst Dr Al-Ayoubi affirms the need for FDA and MHRA approval. Swann also highlights the need to keep clients in mind; some treatments might be a harder ‘sell’ than others, and some might be too expensive either for the clinic to purchase or for clients to afford. The need to produce a clear business plan to support the purchase of new proven technology was uppermost for Dr Berry, and as she says, “Unless you get reproducible results… no product is worth investing in.”

Inno TDS products can be delivered by mesotherapy or nappage to improve cellulite

Despite advances, cellulite remains impossible to ‘cure’, but it can be improved, maintained and prevented from worsening through a combination of treatments and good lifestyle choices, in terms of diet and exercise. In a challenging area of aesthetics, the market’s new technologies and treatments may offer hope in the future for the many hundreds of women regularly seeking help to diminish this body concern.

REFERENCES 1. De Godoy, José Maria Pereira and De Godoy, Maria de Fátima, ‘Evaluation of the Prevalence of Concomitant Idiopathic Cyclic Edema and Cellulite’, Int J Med Sci., 8(6) (2011) <http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3156991/> pp. 453-455. 2. Shaaban, Hassan, ‘White Paper: Smartlipo TriPlex™ for Body Contouring and Treatment of Cellulite Using Three Wavelengths – A Case Study’, (2014), Available from: Cynosure 3. DiBernardo, Barry E., ‘Treatment of Cellulite Using a 1440-nm Pulsed Laser With One-Year Follow-Up’, Aesthetic Surgery Journal, 31: 328 (2011), < http://aes.sagepub.com/content/31/3/328> 4. DiBernardo, Barry, ‘White Paper: Treatment of Cellulite Using the Cellulaze™ Nd:YAG 1440nm Wavelength Laser: Two Case Reports’, (Montclair, NJ, New Jersey Plastic Surgery: 2011), Available from: Cynosure

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Clinical Practice CPD Clinical Article

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Towards Evidence-Based Practice in Cosmetic Surgery Using the Q-Portfolio of Patient-Reported Outcome Measures Jonathan Schwitzer, BA , Anne F. Klassen, DPhil, Stefan J. Cano, PhD, Andrea L. Pusic, MD MHS ABSTRACT: As cosmetic treatments continue to grow in popularity in the UK, the process must be guided by high-level evidence regarding procedural outcomes and possible adverse effects. To address this lack of data, clinically meaningful and scientifically sound patient reported outcome measures (PROMs) should be used. The Q-Portfolio is made up of condition-specific PROMs, developed to measure key outcomes that matter to cosmetic patients. The Q-Portfolio consists of three instruments: BREAST-Q, which measures outcomes in cosmetic and reconstructive breast surgery patients; FACE-Q, which measures outcomes important to surgical and non-surgical facial aesthetic patients; and BODY-Q, which measures outcomes in obese, bariatric and body contouring surgery patients. Q-Portfolio scales are short, easy to complete, and easily incorporated into routine clinical practice. As accurate and reliable measurement of patient-reported outcomes is crucial to ongoing practice improvement and research in cosmetics, the use of Q-Portfolio scales has the potential to improve treatment outcomes and increase treatment transparency. BACKGROUND: Cosmetic treatments are becoming increasingly popular in the UK. According to the British Association of Aesthetic Plastic Surgeons (BAAPS), over 50,000 cosmetic surgery procedures were performed in 2013, an increase of nearly 17% from 20121. Breast augmentation remains the most popular cosmetic surgical procedure despite the recent Poly Implant Prothèse (PIP) breast implant scandal, increasing by 13% last year. Of all procedures, liposuction, the primary form of body contouring, increased the most, with a 41% growth from 2012.1 Additionally, according to the Department of Health, the cosmetics industry generated revenue of £2.3 billion in 2010, which is expected to increase to £3.6 billion by 2015, with non-surgical cosmetic procedures accounting for 75% of this total.2 While the cosmetics industry has seen tremendous growth, change appears to be coming. The recently released Department of Health Review of the Regulation of Cosmetic Interventions led by National Hospital Service (NHS) medical director Sir Bruce Keogh identified numerous concerning issues within the industry. His solutions to improve the system include: increased industry regulation and oversight, improved training, and providing patients with proper redress should adverse events occur. These recommendations aim to raise standards and enforce tighter regulations in the cosmetic industry.3 One of the main limitations identified by the Keogh review is the lack of reliable and comprehensive data regarding the outcomes of cosmetic treatments, including a lack of evidence supporting 28

the efficacy of common cosmetic procedures and medical complications, as well as the impact of cosmetic treatment on the long-term psychological health of patients.3 Without such information, fully informed patient consent cannot be obtained prior to procedures, nor can patient safety be ensured. In response to these concerns, BAAPS recently established the National Institute of Aesthetic Research (NIAR) based at the Royal College of Surgeons to investigate and provide scientific evidence for cosmetic treatments, which will be accessible to the public, increasing cosmetic procedure information and transparency.4 As the aesthetic field moves towards greater implementation of evidence-based medicine, it is essential that the research community collect information about procedural outcomes and possible adverse effects. In assessing outcomes of cosmetic procedures, and specifically satisfaction with the result, two perspectives need to be considered: the patient’s and the physician’s. Should one have primary importance? Is a procedure only considered a success if both patient and clinician consider it to be so? Historically, the research community has generally favoured the opinions of the provider. However, in the setting of aesthetic procedures, which are elective in nature, this balance needs to shift to include the patient perception of satisfaction.5 The primary desired outcomes for patients undergoing cosmetic interventions include improved satisfaction with appearance, a reduction in the signs of ageing, and/or enhanced quality of life6-8. Therefore, in contrast to other fields of medicine and surgery, objective measures of outcome (e.g. physical function and health status) are not as important for evaluating aesthetic procedures. Rather, primary outcomes for assessing cosmetic procedures include satisfaction with appearance and health-related quality of life, which refers to multiple domains that include psychosocial wellbeing, sexual well-being, and physical well-being, all of which are relevant in the setting of aesthetics.5 To address the lack of available outcome data in cosmetics, and to fully capture the patient perspective, clinically meaningful and scientifically sound PROMs can and should be used to measure outcomes of surgical and non-surgical procedures.9 PROMs are questionnaires that measure concepts, such as satisfaction, healthrelated quality of life and adverse effects of treatment by asking patients directly, without clinician interpretation.10 In addition to their role in research studies, when used in healthcare encounters, these instruments can provide patients with the opportunity to report their concerns directly to their health provider, who can use the results in clinical decision-making.11 PROMs are being increasingly used to collect data for academic and research purposes, quality metrics, and in clinical care, including in the aesthetic setting. A number of countries have implemented

Aesthetics | June 2014


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the use of PROMs into data collection nationally.12 For example, in 2008, the UK used the BREAST-Q in a large-scale voluntary audit of approximately 8000 women who had mastectomy and/or breast reconstruction in 2008.13 Since then, a mandatory audit in NHS hospitals has begun, involving the use of PROMs among patients having hip and knee replacement, groin hernia repair, or varicose vein surgery,14 with more procedures likely to be added to this list over time.12 The value of a PROM and the data it can provide is largely dependent on the reliability, responsiveness and validity of the questions it asks. Whenever possible, condition-specific measures are preferable, as they can provide more meaningful clinical data than generic PROMs designed for use with any patient.5,15-16 A recent UK Department of Health sponsored literature review identified that there are very few available condition-specific PROMs for use with cosmetic patients. Specifically, the review identified nine cosmetic surgery-specific measures, only three of which were recommended for use based on the development and validation process i.e., our team’s BREAST-Q and FACE-Q, and the Skindex.17 The BREAST-Q, which was developed in 2008, measures outcomes in the breast surgery patient. The FACE-Q, which was developed in 2010, measures outcomes important to surgical and non-surgical facial cosmetic patients. The Skindex is a PROM used to measure quality of life in patients with skin diseases, including general and cosmetic dermatology as well as cutaneous malignancy.18 All three of these measures are multidimensional scales that provide scores for different domains of importance to patients, as opposed to a utility measure that incorporates preferences or values for individual health states and expresses health in terms of a single index for use in health economic studies.19 Our goal in developing PROMs for plastic surgery was to create a set of short, easy to complete, clinically meaningful scales that are scientifically sound (i.e., valid, reliable, and responsive to clinical change), for use in research, audit and clinical care. All of our PROMs have been developed with strict adherence to international guidelines for PROM development and validation as outlined by the Medical Outcomes Trust20,the U.S. Food and Drug Administration10 and International Society for Pharmacoeconomics and Outcomes Research21-22 so that they can be used in academia, by the pharmaceutical industry, and in clinical care. These methods have made it possible for us to maximise the scientific quality and clinical meaning of the instruments produced. We have undertaken processes to ensure our scales measure issues that patients care most about in the words that they use and understand best. For example, we developed a 10-item scale to measure satisfaction with facial appearance that can be used with patients before and after any type of surgical and non-surgical cosmetic treatment.23 This scale was developed from a pool of approximately 3000 preliminary items developed following qualitative interviews with 50 patients who had one or more surgical and/or non-surgical facial aesthetic procedures. The final 10 items in our scale includes descriptors (e.g., symmetry, balance, proportion) and scenarios (e.g., in photographs, under bright lights) that patients used to describe their face. For instance, the item “How fresh your face looks” was developed because the word ‘fresh’ was used by numerous participants to describe their facial appearance. As one participant said, “…once you have Botox, it just seems to open up the face and makes it look brighter or - for me… fresher, maybe that’s a good word, more fresh, rather than tired looking.” This scale has been shown to be reliable and valid 30

Aesthetics Journal

Aesthetics

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in a heterogeneous sample of 499 facial aesthetic participants. In addition, in a sample of facelift patients, clinically important improvements were found six months after treatment (i.e., 94 out of 97 patients who had facelifts reported significant improvement in satisfaction with appearance).23 Our PROMs measure concepts important to patients and clinicians such as patient satisfaction with appearance, the results and outcome of the procedure, body image, health-related quality of life, and satisfaction with the care and information received related to the procedure. Involvement of patients and clinicians in all stages of measure development has been critical in ensuring content validity. In the first phase, a conceptual framework is developed and a pool of items (questions) is generated based on a systematic literature review and in-depth qualitative interviews with patients and experts.24-26 These concepts are then converted into questionitems, forming a lengthy questionnaire, which is field-tested in a large sample of patients (for example, breast surgery patients for the BREAST-Q and facial aesthetic patients for the FACE-Q). With data from the field test, we determine the short set of items that represent the best indicators for each scale based on their performance against a standard set of psychometric criteria. This completes the development of the instrument and allows for initial exploration of the scale’s psychometric properties (i.e., validation). In the next phase, the measure is administered to a further sample of patients, and the scales are psychometrically evaluated to determine data quality, scaling assumptions, targeting, reliability, validity, and responsiveness, with the goal to understand the strengths and weaknesses of the new PROM. 15,24,27 Q-PORTFOLIO: Our team has thus far created three PROMs for use with cosmetic patients: BREAST-Q, FACE-Q and BODY-Q. Each condition-specific tool is composed of numerous scales that can be used to evaluate key aspects of outcome for aesthetic and reconstruction patients. The scales are designed to function independently, meaning that only those scales that are most important and relevant to the research or clinical objectives at hand need to be selected and administered. This structure facilitates comprehensive yet pragmatic assessment of outcomes that matter to patients, while minimising respondent burden and improving targeting. Scales are scored on a 0 to 100 continuum, with higher scores indicating higher satisfaction or better health-related quality of life. Below is a brief description of each of the three PROMs. BREAST-Q: The BREAST-Q, made available in 2008, is our most established PROM. This PROM is designed for pre-operative and postoperative breast surgery patients.15,24,27 It has separate modules for the following procedures: breast augmentation (with or without mastopexy), breast reduction (or mastopexy without an implant), breast conserving therapy (lumpectomy and/or radiotherapy), breast reconstruction, and mastectomy without reconstruction. BREAST-Q scales measure patient satisfaction with breasts, healthrelated quality of life, body image, pre-operative expectations, and satisfaction with care. The BREAST-Q has been translated into 14 languages, and validated in over 15,000 patients. It has been used worldwide in clinical trials and quality improvement programs. Continued validation of the BREAST-Q requires further psychometric examination, including comparisons with objective clinical data, comparisons of administration techniques (combined versus

Aesthetics | June 2014


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individual mailings) and formal cross-cultural validations of translated versions of the BREAST-Q. Additionally, as the BREAST-Q can continue to be refined to improve the measurement performance of its subscales while the current version is being used, scores generated from future versions of the BREAST-Q will be directly comparable to the present version to retain continuity.28 FACE-Q: The FACE-Q measures outcomes important to patients undergoing any type of surgical and non-surgical facial procedure, e.g., facelift, rhinoplasty, and blepharoplasty; injectables such as botulinum toxin and lip/ line fillers; laser skin resurfacing and chemical peels.8, 23,29 Over 40 independently functioning scales and adverse effects checklists have been developed to measure four domain areas: appearance, health-related quality of life, adverse effects and process of care. Appearance scales measure satisfaction with facial appearance overall and satisfaction with specific anatomic areas, such as the nose, lips, cheeks and forehead. Other scales measure signs and appearance of ageing, patient expectations (how their appearance and life might change following treatment), satisfaction with care and information received, health-related quality of life, including social function and psychological well-being, and adverse effects. The scales can be employed before and/or after treatment to evaluate treatment effectiveness, as well as at multiple post-treatment time points to evaluate treatment results over time. FACE-Q has already been used in multiple international clinical trials, and has been translated into French, German, and Italian. Limitations of the FACE-Q development and validation process include that the validation study had more female than male participants, and many participants had had multiple prior facial aesthetic procedures. While these two sample characteristics reflect the nature of cosmetic consumers in the general population, they limit our ability to describe outcomes specific to any particular procedure or for males.8,23 Future research using FACE-Q scales is needed to measure the risks and benefits of the vast array of facial aesthetic procedures.

Clinical Practice CPD Clinical Article

BODY-Q: The BODY-Q was developed for use with obese, bariatric and cosmetic body contouring surgery patients.22,30-31 The BODY-Q can be used to measure patient concerns at any point in the weight loss trajectory, from before bariatric surgery to after body contouring. In addition, the scales can be used to measure outcomes following cosmetic liposuction, which is one of the most rapidly growing aesthetic treatments in the UK. Following an extensive systematic literature review to identify published PROMs for body contouring surgery patients32, and qualitative interviews with cosmetic body contouring patients and post-bariatric patients, a conceptual framework was developed composed of three major themes: (1) appearance (body, abdomen, upper arms, back, buttocks, upper thighs, hip and outer thighs, excess skin and body contouring scars); (2) health-related quality of life (body image, physical symptoms and physical, social, psychological, and sexual function); and (3) process of care (satisfaction with information, doctor, medical team and office staff). Following this, preliminary items and scales were developed and shown to plastic surgeons and patients who were asked to examine thoroughly and provide feedback to ensure that the scales would be useful to clinicians and that they are optimally understood by patients.30-31 The BODY-Q scales are currently being field-tested in a large sample of obese, bariatric and body contouring patients in Canada, the United States, and the UK. A limitation of our sample is that recruitment does not include non-surgical body contouring procedures at this time. CONCLUSIONS: Accurate and reliable measurement of patient-reported outcomes is crucial to ongoing practice improvement and clinical research in cosmetic procedures. The Q-Portfolio of PROMs was developed using rigorous qualitative research that involved in-depth interviews with condition-specific patients as well as extensive expert input and quantitative evaluation using modern psychometric methods to identify the best indicators of outcome. PROMs address the lack of available valid and reliable condition-specific outcome tools for

FACE-Q

BREAST-Q

BODY-Q

Satisfaction with Facial Appearance Overall

Satisfaction with Breasts (Augmentation patients)

Satisfaction with Abdomen

How balanced your face looks?

How natural your breasts look?

How your abdomen looks when you are dressed?

How your face looks at the end of your day?

The firmness of your breasts?

The shape of your abdomen?

How rested your face looks?

The size of your breasts?

How your clothes fit your abdomen?

How your face looks in photos?

The position of your implants on your chest (too high or too low)?

How your abdomen looks from the side (i.e., profile view)?

How your face looks under bright lights?

How much cleavage you have when you wear a bra?

How your abdomen looks when you are naked?

Figure 1. Example items take from 3 scales measuring satisfaction with appearance of the face (FACE-Q), breasts (BREAST-Q augmentation module) and abdomen (BODY-Q). Each scale is scored from 0-100 with higher scores indicating greater satisfaction with appearance. Aesthetics | June 2014

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As accurate and reliable measurement of patientreported outcomes is crucial to ongoing practice improvement and research in cosmetics, the use of Q-Portfolio scales has the potential to improve treatment outcomes and increase treatment transparency. cosmetic procedures, so that generic instruments, which do not capture cosmetic patients’ main concerns, do not become the mainstay in aesthetic research. With an ever-growing range of aesthetic interventions and products, treatment decisions and discussions with patients should ideally be guided by high-level evidence. The incorporation of PROMs into clinical practice and research is fundamental to this approach if we are to understand the impact that such treatments have on patients’ appearance and health-related quality of life. Based on our development process and validation data, we believe that these new instruments will advance knowledge about outcomes that matter most to aesthetic patients and thereby further evidence-based practice. The Q-Portfolio scales are short, easy to complete, and can be easily incorporated into routine clinical practice. The integration of PROM improves patient–clinician communication and can enhance patient care and outcomes.33-35 In addition to their use in clinical practice, these instruments will have broad application in clinical research. The recommendations described in the Keogh review3 have been designed to protect both patients and clinicians with the goal of ensuring high quality treatment. The use of Q-Portfolio PROMs has the potential to improve treatment outcomes and help to ensure patient safety through increased transparency. As patient and consumer confidence is key to the success of the cosmetics industry, the use of PROMs could help ensure the continued success of this field. Andrea Pusic, MD, is a plastic surgeon from New York City. Her research focus is on measurement of patient-reported outcomes in surgery. Over the last ten years, she and a team of international collaborators, including Anne Klassen, DPhil, and Stefan Cano, PhD, have developed the BREAST-Q, FACE-Q, and BODY-Q patient-reported outcome measures. Jonathan Schwitzer is Dr. Pusic’s research fellow.

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REFERENCES: 1. The British Association of Aesthetic Plastic Surgeons, 2013 Annual Audit: Britain Sucks, (BAAPS, 2014) <http://baaps.org.uk/about-us/audit/1856-britain-sucks> 2. Bunn S., Parliamentary Office of Science and Technology, Cosmetic Procedures-Post Note, 444; (www. parliament.co.uk, 2013) <http://www.parliament.uk/business/publications/research/briefing-papers/POST- PN-444/cosmetic-procedures> 3. Keogh B., Review of the Regulation of Cosmetic Interventions, (Dept of Health, 2013). 4. Juttla B., ‘National Institute of Aesthetic Research launched at BAAPS annual meeting’, Prime: International Journal of Aesthetic and Anti-Ageing Medicine, (September 2013) <https://www.prime-journal.com/national- institute-of-aesthetic-research-launched-at-baaps-annual-meeting/> 5. Alderman A., Chung K., ‘Measuring Outcomes in Aesthetic Surgery’, Clin Plastic Surg, 40 (2013), pp. 297-304. 6. Cano S., Browne J., Lamping D., ‘Patient-based measures of outcome in plastic surgery: current approaches and future directions’, Br J Plast Surg, 57 (2004), pp. 1-11. 7. Ching S., Thima A., McCabe R., et al., ‘Measuring outcomes in aesthetic surgery: a comprehensive review of the literature’, Plast Reconstr Surg, 111(1) (2003), pp. 469-80. 8. Panchapakesan V., Klassen A.F., Cano S.J., Scott A.M., Pusic A.L., ‘Development and psychometric evaluation of the aging appearance appraisal scale: a new PRO instrument for facial aesthetics patients’, Aesthet Surg J 33(8) (2013), pp. 1099-109. 9. Cano S.J., Klassen A., Pusic A.L., ‘The science behind quality-of-life measurement: a primer for plastic surgeons’, Plast Reconstr Surg, 123 (2009), 98e-106e. 10. U.S. Department of Health and Human Services Food and Drug Administration, Guidance for industry patient-reported outcome measures: use in medical product development to support labeling claims, (ispor. org, 2009) <http://www.ispor.org/workpaper/FDA%20PRO%20Guidance.pdf> 11. U.S. Food and Drug Administration, Patient Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims, (ispor.org, 2009) <http://www.fda.gov/downloads/Drugs/ GuidanceComplianceRegulatoryInformation/Guidances/ucm071975.pdf> [Accessed June 1, 2010] 12. Black N., ‘Patient reported outcome measures could help transform healthcare’, BMJ, 346:f16 (2013) 13. Jeevan R., Cromwell D., Browne J., et al., Fourth Annual National Mastectomy and Breast Reconstruction Audit 2011, (Leeds: The NHS Information Centre, 2011) 14. NHS Health & Social Care Information Centre, Patient reported outcomes program, (hscic.gov.uk, 2014) <www.ic.nhs.uk/proms> 15. Pusic A.L., Klassen A.F., Scott A.M. et al., ‘Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q’, Plast Reconstr Surg, 124 (2009), pp. 345–353. 16. Pusic A.L., Lemaine V., Klassen A.F. et al., ‘Patient-reported outcome measures in plastic surgery: use and interpretation in evidence-based medicine’, Plast Reconstr Surg, 127 (2011), pp. 1361–1367. 17. Morley D., Jenkinson C., Fitzpatrick R., A structured review of patient-reported outcome measures used in cosmetic surgical procedures, (Report to Department of Health, 2012) 18. Chren M.M., Lasek R.J., Quinn L.M., Mostow E.N., Zyzanski S.J., ‘Skindex, a quality-of-life measure for patients with skin disease: reliability, validity, and responsiveness’, Journal of Investigative Dermatology, 107(5) (1996), pp. 707-713. 19. Cano S., Klassen A., Scott A., Thoma A., Feeny D., Pusic A., ‘Health Outcome and Economic Measurement in Breast Cancer Surgery: Challenges and Opportunities’, Expert Reviews in Pharmacoeconomics Outcome Research, 10(5) (2010), pp. 583-594. 20. Scientific Advisory Committee of the Medical Outcomes Trust, ‘Assessing health status and quality of life instruments: attributes and review criteria’, Qual Life Res, 11 (2002), pp. 193-205. 21. Patrick, D.L., et al., ‘Content validity--establishing and reporting the evidence in newly developed patient- reported outcomes (PRO) instruments for medical product evaluation: ISPOR PRO Good Research Practices Task Force report: part 1--eliciting concepts for a new PRO instrument’, Value Health, 14(8) (2011), pp. 967-77. 22. Patrick, D.L., et al., ‘Content validity--establishing and reporting the evidence in newly developed patient- reported outcomes (PRO) instruments for medical product evaluation: ISPOR PRO Good Research Practices Task Force report: part 2--assessing respondent understanding’, Value Health, 14(8) (2011), pp. 978-88. 23. Pusic A., Klassen A.F., Scott A.M., Cano S.J., ‘Development and psychometric evaluation of the FACE-Q Satisfaction with Appearance Scale: a new PRO instrument for facial aesthetics patients’, Clin Plast Surg, 40 (2013), pp. 249-260. 24. Klassen A.F., Cano S., Pusic A., ‘Satisfaction and quality of life in women who undergo breast surgery: a qualitative study’, BMC Women’s Health, 9:11 (2009) 25. Klassen A.F., Cano S.F., Scott A., Snell L., Pusic A.L., ‘Measuring patient-reported outcomes in facial aesthetic patients: development of the Face-Q’, Facial Plast Surg, 26 (2010), pp. 303-309. 26. Klassen A.F., Cano S., Scott A., Johnson J., Pusic A.L., ‘Satisfaction and quality of life issues in body contouring surgery patients: a qualitative study’, Obes Surg, 22 (2012), pp. 1527-1534. 27. Breast-Q, Memorial Sloan-Kettering Cancer Center, <https://webcore.mskcc.org/breastq/domains.html> 28. Cano S., Klassen A., Scott A., Cordeiro P., Pusic A., ‘The BREAST-Q: further validation in independent clinical samples’, Plast Reconstr Surg, 129(2) (2012), pp. 293-302. 29. Klassen A.F., Cano S.J., Scott A.M., Pusic A.L., ‘Measuring outcomes that matter to facelift patients: development and validation of FACE-Q appearance appraisal scales and adverse effects checklist’, Plast Reconstr Surg 133(1) (2014), pp. 21-30. 30. Klassen A., Cano S., Scott A., et al., ‘Satisfaction and Quality-of-Life Issues in Body Contouring Surgery Patients: a Qualitative Study’, Obes Surg 10 (2012), pp. 1527-34. 31. Klassen A., Cano S., Scott A., Tsangaris E., Johnson J., ‘Introducing the BODY-Q: A Patient-Reported Outcome Instrument for use in Obese, Bariatric and Cosmetic Body Contouring Surgery Patients’, Clin Plast Surg, In Press. 32. Reavey P.L., et al., ‘Measuring quality of life and patient satisfaction after body contouring: a systematic review of patient-reported outcome measures’, Aesthet Surg J, 31(7) 2011, pp. 807-13. 33. Marshall S., Haywood K., Fitzpatrick R., ‘Impact of patient-reported outcome measures on routine practice: A structured review’, J Eval Clin Pract, 12 (2006), pp. 559–68. 34. Valderas J.M., Kotzeva A., Espallargues M. et al., ‘The impact of measuring patient-reported outcomes in clinical practice: A systematic review of the literature’, Qual Life Res 17 (2008), pp. 179–93. 35. Greenhalgh J., Meadows K., ‘The effectiveness of the use of patient-based measures of health in routine practice in improving the process and outcomes of patient care: A literature review’, J Eval Clin Pract, 5 (1999), pp. 401–16. More information about the BREAST-Q is available at www.BREAST-Q.org More information about the FACE-Q is available at www.theFACEQ.org. For more information about the BODY-Q contact Dr. Anne Klassen at aklass@mcmaster.ca DISCLOSURE: The FACE-Q is owned by Memorial Sloan-Kettering Cancer Center. Stefan J. Cano, Ph.D., Anne F. Klassen, D.Phil., and Andrea L. Pusic, M.D., M.H.S., are co-developers of the FACE-Q and, as such, receive a share of any license revenues based on Memorial Sloan-Kettering Cancer Center’s inventor sharing policy.

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Aesthetics Journal

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The Management of Leg Veins Mr Simon Ravichandran and Mr Bryce Renwick discuss the treatment of leg veins with various modalities Leg veins are increasingly becoming part of the workload of the UK-based aesthetics clinic. This is due, in part, to a reduction in the NHS management of uncomplicated veins in various regions, but also due to a greater patient awareness of veins. This awareness has dual components. The first component is associated with an increasing interest in our own body image that is multifactorial in nature, and evidenced by increased presentation for aesthetic treatments in general. The second component is an increased awareness of the ease with which leg veins can be treated, as the public gains knowledge of nonsurgical developments. The reasons given for presentation are many, with aesthetic concerns being the main driver, particularly at the time of year when people are planning for good weather. Other concerns related to veins include an aching sensation in the legs, particularly when the patient has been standing for prolonged periods of time, and also an associated itching or swelling with general decreased quality of life. DEMOGRAPHIC It is difficult to put a reliable figure on the proportion of the population who suffer from leg veins. Prevalence studies are rare and reported incidences vary between 2.6% in women and 2% in men1, with other

studies suggesting greater than 50% prevalence in both men and women2. The definitions of varicose veins also vary, and this may play a part in the differing results from prevalence studies. One definition describes a varicose vein as “a dilated subcutaneous vessel greater than or equal to 3mm in diameter in the standing position”3. This considerably underestimates the prevalence of presentation to an aesthetics clinic with leg veins, as the bulk of ‘varicose vein’ consultations actually involve mainly superficial spider or thread veins. However difficult it is to get an idea from study of the literature, the presentation to the author’s clinic is currently >95% female, with an age range of between 35 and 69. Increasing age typically correlates with a more extensive problem on presentation, as does increasing number of pregnancies. TREATMENTS The treatment protocol in our clinic involves a consultation with a doctor, either myself (Mr Simon Ravichandran) or our vascular surgeon (Mr Bryce Renwick). Before a treatment plan is decided upon, a thorough history is taken, and a discussion takes place regarding the expectations of the patient and the expected outcomes. As with all aesthetic interventions, a clear setting of expectations is paramount to patient satisfaction. Assessment of the

Classification of varicose veins; CEAP grading.4 CEAP C0

No visible or palpable signs of venous disease

CEAP C1

Telangiectatic or reticular veins

CEAP C2

Varicose veins

CEAP C3

Oedema

CEAP C4a

Pigmentation or eczema

CEAP C4b

Lipodermatosclerosis or atrophie blanche

CEAP C5

Healed venous ulcer

CEAP C6

Active venous ulcer

CEAP S

Symptoms (Including ache, pain, tightness, heaviness and muscle cramps)

CEAP A

Asymptomatic

CEAP E/A/P

Classifies venous problems on the basis of Aetiology, Anatomy, Pathophysiology

34

Aesthetics | June 2014

veins involves direct inspection, with the patient standing. Photographs are taken and documentation is made indicating the location and nature of the veins. We categorise veins in terms of their depth and size: spider veins are thin, typically 1mm or thinner, and superficial, and the deeper the veins are, the bluer they become. Larger subcutaneous blue veins are often soft to palpate and compression will show reduction in surrounding superficial veins. An ultrasound scan of the lower limb venous system is undertaken on all patients to identify any issues which will impact on treatment. Specific detail is noted at the sapheno-femoral junction, in order to identify incompetence of the valve, which indicates a lower likelihood of success. IPL We use three different modalities for the treatment of leg veins in our clinic: IPL with a vascular filter, microsclerotherapy and ultrasound guided foam sclerotherapy (USGFS). My experience with IPL has shown good results with very superficial and small veins, but poorer results with deeper and larger veins. IPL is useful for rapidly treating a larger area. Typically, higher fluences are required for a vessel of similar calibre on the face, and superficial blistering of the skin is not uncommon. The likelihood of burns with subsequent scarring and or pigmentation changes increases with darker skin types, and with sun exposure5. Often a good result is initially produced, but early recurrence (within three months) occurs. In these circumstances, closer inspection of the area will often reveal an underlying larger feeding vessel that needs to be treated. Given the availability of other treatments which can result in better outcomes, I tend to advise patients with spider veins greater than 1.5mm, and with spider veins with evidence of deeper feeder veins, to undergo a sclerotherapy treatment first, then use IPL to remove any remaining vessels if required. I use an unravelled paperclip as a vein measuring tool; with a vessel larger than the diameter of the wire, I would recommend sclerotherapy over IPL. Larger spider veins are treated with


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*Gold et al, Journal of Drugs in Dermatology, 2013


Clinical Practice Treatment Focus

@aestheticsgroup

Aesthetics Journal

Aesthetics

aestheticsjournal.com

COMPARISON OF TREATMENT MODALITIES Treatment

Vessel Characteristic

Benefits

Risks/Downsides

IPL / LASER

Small superficial spider vessels, typically smaller than 1.5mm

Quick, effective, non-invasive

Purpura / blistering of skin / burns. Not to be used on tanned skin

Microsclerotherapy

Superficial vessels 1 - 3mm

Quick, very effective, usually painless

Extravasation of sclerosant can cause pain, discolouration and scarring

USGFS

Deeper vessels and varicosities

With appropriate level of expertise, it can be used to address the entire truncal system

Compression stockings required. Risk of extravasation with tissue damage. Small risk of P.E

EVLT

Deeper vessels and varicosities

With appropriate level of expertise, it can be used to address the entire truncal system

Expensive and there is a learning curve. Longer to perform treatments

EVRF

Deeper vessels and varicosities

With appropriate level of expertise, it can be used to address the entire truncal system

Expensive and there is a learning curve. Longer to perform treatments

Stripping / Avulsion

Usually reserved for complicated / very severe and recurrent disease

Usually excellent results in the hands of a skilled surgeon

Operating theatre procedure, scarring and longer recovery time

microsclerotherapy. For this treatment, a solution of sodium tetradecyl sulfate (STS) (Fibro-vein 0.2%) is injected under direct vision into the vessel using a 29G or 30G needle. STS is intensely irritant and causes damage to the endothelium of the blood vessel, leading to its subsequent collapse and destruction6. Immediate obliteration of the vessel is often identified. The damaged vessels typically undergo a browny discolouration before being removed by phagocytosis. Most patients find this treatment relatively painless and an immediate return to normal activities is permitted. Large bulging subcutaneous vessels are best treated by USGFS. In this technique a solution of sodium tetradecyl sulfate (Fibro-vein 1%) is mixed with a gas to create a foam. This foam is then injected into a dilated vessel via a cannula or by hand injection and under ultrasound guidance. Endothelial irritation ensues, followed by vessel sclerosis. In both cases it is necessary to compress the treated area with a graduated compression stocking for a period of days to weeks after the treatment. Compression of the leg and the treated vessel maximises the clinical and cosmetic result, whilst minimising the risk of DVT. DISCUSSION There is a rapidly increasing demand for a ‘whole body’ holistic approach in the management of the ageing population in the aesthetic clinic setting. As people are active now for longer than in previous generations, there develops a mismatch between the 36

Photo 1: This shows a combination of very superficial thin red spider veins, some slightly deeper and larger purple veins with no real significant obvious deep veins. This we would happily treat with microsclerotherapy followed by LASER or IPL if required.

Photo 2: Shows a collection of veins which is more predominantly deeper bluish vessels that are feeding a smaller number of superficial thread veins. We would treat this with USGFS to the larger vessels then microsclerotherapy if still required at a later visit.

age people feel, and the age they may look. Although this is a relatively new concept in our understanding of ageing psychology, it is clear that there are significant benefits to quality of life in addressing these concerns. The treatment of unsightly leg veins, varicose or otherwise, is a key element in the provision of a whole body aesthetic service. Varicose veins can be safely and effectively treated in the aesthetic clinic if one remains aware of the limitations of office-based techniques, and practises within one’s limitations set by education, training and experience. The best results can be achieved when the practitioner combines knowledge of the venous system

and pathogenesis of the presenting veins, with a detailed clinical and ultrasonographic assessment of the venous system and the application of the correct treatment. Mr Simon Ravichandran is a practicing ENT surgeon in Scotland and the clinical director of Clinetix Rejuvenation. Simon is president of the Association of Scottish Aesthetic Practitioners. Mr Bryce Renwick is a surgeon in Vascular and Endovascular surgery. He is involved in the treatment of blood vessel disorders and has an interest in minimally invasive varicose vein treatments.

REFERENCES 1. Brand, F.N., Dannenberg, A.L., Abbott, R.D., Kannel, W.B., ‘The epidemiology of varicose veins: the Framingham Study’, Am J Prev Med, 4(2) (1988), pp. 96-101. 2. Kuhlmann, A., Prenzler, A., Hacker, J., Graf von der Schulenburg, J. M., ‘Impact of radiofrequency ablation for patients with varicose veins on the budget of the German statutory health insurance system’, Health Econ Rev, 3;3(1):9 (2013). 3. Gloviczki, Peter, Comerota, Anthony J., et al., ‘The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum’, Journal of Vascular Surgery, 53 (16S), 2S-48S. 4. Eklof, B., Rutherford, R.B., Bergan, J.J., et al., ‘Revision of the CEAP classification for chronic venous disorders; consensus statement’, J Vasc Surg, 40(6) (2004), pp. 1248-52. 5. Alexis, A.F., ‘Lasers and light-based therapies in ethnic skin: treatment options and recommendations for Fitzpatrick skin types V and VI [Review]’, Source British Journal of Dermatology. 169 (SUPPLEMENT 3) (2013), pp. 91-97. 6. Albanese, Giustino, Kondo, Kimi L., ‘Pharmacology of Sclerotherapy’, Semin Intervent Radiol, 27(4) (2010), pp. 391–399.

Aesthetics | June 2014


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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014


Clinical Practice Spotlight On

@aestheticsgroup

Aesthetics Journal

Aesthetics

aestheticsjournal.com

Management of rosacea Dr John Ashworth shares his experience and advice on the symptoms and treatment of rosacea Rosacea comes in several different forms but the underlying common denominator is probably an over-reactive blood vessel network in the superficial layers of the skin. This sensitivity within the blood vessels leads to the common features of redness, flushing, burning, visible thread veins, bumpiness and spots, and eventually thickening of the skin tissues with dilatation of the pores. Additionally, similar pathology can cause the eyes to become sensitive or irritable. Some degree of rosacea is almost ‘normal’, by which I mean that amongst fair-skinned populations, factors including cold, wind and hot showers can precipitate facial flushing and redness or redness on the upper chest, which could be considered as a very minor variation of rosacea. Of course, it is important to remember that the perception of normality varies from patient to patient and one patient’s unacceptable rosacea is another patients ‘healthy glow’. At the other end of the spectrum are patients with undoubted severe disease. SYMPTOMS Various words are used by patients to describe the sensation of suffering from rosacea: fullness, burning and flushing being the most common. All of these feelings most likely relate to abnormally excessive blood flow through the superficial vessels just below the skin surface. Individual red elevated bumps or spots are present in a more severe form of rosacea and this can lead to some confusion with a variety of other skin conditions including adult acne. Rosacea spots, unlike adult acne spots, usually do not contain any pus, that is to say they do not have a yellow head, they are simply red bumps on the surface of the skin and therefore they do not Rosacea symptoms discharge. Some patients suffer • Redness from overlap conditions between • Burning the two, which complicates their • Flushing diagnosis. • Sore eyes When rosacea has been present • Raised spots for a number of years, the blood • Visible thread veins vessels then become permanently Rhinophyma

38

and more severely distended so that they are visible not just as vague pinkness across the face but as individual red or purple vessels. These can be seen by the naked eye and, sometimes, can become quite dilated and very easily visible; typically this occurs across the nose and cheeks. Sometimes this more severe form of rosacea is associated with greatly increased sebaceous glands across the nose, leading to a dimpled appearance of the surface skin and thickening of the nose tissues so that sometimes the nose can become exaggerated in size; this is called rhinophyma. PRECIPATING FACTORS There is often lively debate among medical professionals about what causes or precipitates rosacea and the truth of the matter is that every individual patient is different. The common misconception that rosacea is universally linked to excessive alcohol is certainly untrue.1 What is true is that alcohol can make the skin flush in certain individuals and in those individuals this can lead to a rosacea tendency in due course. The same can also be said of spicy foods, excessive exercise and hot drinks.1 TREATMENTS Rosacea treatments Antibiotics either by mouth • Antibiotics - oral or on the skin surface in the • Antibiotics - skin gels/ form of a gel or cream are very creams often effective but do need to • Physical (laser or IPL) be continued for a prolonged • Associated disease period of two or three months • eg seborrhoeic minimum in most patients. dermatitis Antibiotic therapy probably • Isotretinoin does not work by killing off bacteria but is more likely to work through a more complicated anti-inflammatory set of mechanisms.1 Physical destruction by Laser Therapy or Intense Pulsed Light Therapy (IPL) usually is effective in reducing the redness and visible blood vessels of rosacea in the more advanced stages of this problem. These treatments can also be effective in reducing redness even when the vessels are not so large that they are seen by the naked eye, therefore these treatments can cause an improvement even in the relatively early stages of this condition. DEMODEX For many years the role of demodex in rosacea has been debated. This is a tiny organism that lives in the skin pores of some patients and when skin biopsies of rosacea have been studied demodex has been seen on the skin biopsies in some

Aesthetics | June 2014


Rosacea with some surface scaling and dryness

cases.1 However it is unclear whether this can cause rosacea or whether it is a secondary effect that occurs after the rosacea is present. This debate continues in some quarters.

THE LEADING LIGHT IN LED PHOTOTHERAPY

THE FUTURE Rosacea with papulles and nodules without pustules Treatments such as brimonidine topical gel are now available which can constrict the surface blood vessels, and these may have some future benefit in the management of rosacea with anecdotal evidence appearing very positive. One patient has recently said “On day one of treatment my redness improved and I saw my freckles again for the first time in years.” However these need to be tested on large numbers of patients in order to reach a firm conclusion about their benefits. OVERLAP CONDITIONS Adult acne and another condition called seborrhoeic dermatitis often co-exist with rosacea and require parallel but different treatment protocols. An individual patient will often migrate across the spectrum between these different conditions, requiring varying treatments possibly on a week-to-week basis depending upon the appearance. This is where an experienced patient has the advantage over an inexperienced one and this comment can also be applied to the attending medical staff. There is no one treatment that is correct for all patients at all times. NATURAL HISTORY The natural history is for rosacea to slowly fade away and it is not usual to see patients beyond middle age continuing to suffer from active inflammatory rosacea. However, it is quite common to see patients with the dilated vessels on the skin surface left over from rosacea in previous years. These can also be treated in the same way using Laser/IPL. Dr John Ashworth has worked as a full time dermatologist since 1982. He was a member and later elected a fellow of the Royal College of Physicians in London, and is also a consultant member of the British Association of Dermatologists and the British Society of Dermalogical Surgeons. He has gained several awards and prizes throughout his career and has over twenty publications. REFERENCES 1. Rook Textbook of Dermatology; (Wiley-Blackwell; 7th Edition), Chapter 44; p 44.1-44.19

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Clinical Practice Clinical Focus

@aestheticsgroup

Aesthetics Journal

Aesthetics

aestheticsjournal.com

Left to our own devices Wendy Lewis asks leading UK and US-based medical aesthetic practitioners which technologies they believe are a must-have in any clinic OUR PANEL: Dr Ellen Marmur (EM) Leading dermatologist and dermatologic surgeon in New York City, USA Dr David J. Goldberg (DG) Dermatologist, New York, New Jersey, Boca Raton Dr Michael Gold (MG) Dermatologist, Nashville Dr Rita Rakus (RR) Aesthetic doctor, London Dr Vic Narurkar (VN) Dermatologist, San Francisco

MiraDry

BTL Vanquish unit

40

WL: For a new medical aesthetics clinic, what are the most important technologies to invest in and why? EM: Intense pulsed light (IPL) or broadband light (BBL) is a great first technology to start with because it treats multiple common issues, such as redness and lentigines. DG: An IPL because it can be used to treat unwanted red and brown colours as well as unwanted hair. No one other machine does as many things. One good rule to follow is to get a machine that has good cooling connected to the handpiece for safety. A second machine should be for non-invasive body contouring. Prime examples of machines that do not always require physiciansâ&#x20AC;&#x2122; direct involvement are Zeltiq Coolsculpting and BTL Vanquish. MG: I always say that new doctors should have an IPL system first as it is one of the most versatile machines we have. We can treat vascular and pigmentation issues, and rejuvenate the skin with them. We can do more with an IPL than almost every other machine and many IPLs today are part of platform technologies where we can add on as needed, which is very important. I also think that most new clinics should offer laser hair removal, as this leads to referrals for other cosmetic procedures. Some think that laser hair removal is done in too many clinics and not something they should do, but for over 20 years, doing five to ten procedures per day, it is still viable in my clinic. After that, one must look at what one wants to do. If you are in resurfacing mindset, then a fractional CO2 or erbium may be useful. I think ablative fractional is more useful than non-ablative fractional but each person needs to decide what will work best in their hands. I also like the sublative radiofrequency (RF) device; it is my go-to for acne scars, another big part of my practice. So you should look around and see what might work best for you. RR: Solta Fraxel technology for safety, proven track record, support and reliability. The service is top notch and the results are awe-inspiring. Fraxel has a good steer on what customers want and the foresight to introduce both technological improvements to existing equipment and new treatment offerings ahead of time. There are lots of competitors on the market but Fraxel really does stand out from the crowd in our opinion and our patients are seeing the benefits every day. Aesthetics | June 2014

VN: The first technology that I advise investment in is a vascular device as it is the workhorse of a practice, treating a range of issues including facial vessels, red scars, angiomas and post procedure bruising. Secondly, you need a skin resurfacing device that matches the demographics of the practice. For example, an urban and more diverse ethnic practice would benefit from non-ablative fractional lasers while an older, less diverse population may benefit from an ablative fractional laser. Thirdly, you need a non-invasive fat reduction device. There is a high demand for this treatment, and now there are multiple technologies that can address these issues, such as Coolsculpting, Solta Liposonix, Syneron Ultrashape.

WL: What criteria do you use to evaluate if a laser or light-based system is a good fit for your clinic? DG: I consider whether it treats an entirely new group of patients rather than simply takes a group of patients who are already being treated with another class of technology that does the same. For example, we purchased MiraDry for hyperhidrosis because we were not using any other technology for hyperhidrosis. MG: The first thing I do is to see if I have patients who might benefit from the technology. If someone is selling a tattoo laser and I do not want to do tattoos, then I wonâ&#x20AC;&#x2122;t consider it. But if I am doing a lot of tattoos and I use a traditional Q-switched 1064-532, and they are selling a Q-switched ruby, that might be a good machine to add. I also want to test the machine on my own staff or patients to make sure it does what the company says it is going to do. Every machine acts differently, and I want to make sure it does what I need it to do. EM: Safety and efficacy. RR: First and foremost, we look at the safety and reliability of the technology, and whether it has a proven track record of delivering good results. We also like to invest in those devices that provide lasting results and that wow factor: anything we offer has to make a difference to our patients. It is also important to look into our treatment offering and see if there are any natural gaps that the new device can fill, such as a different skin concern or treatment area. Clinical before and after shots are vital, not only for our


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PSORIASIS: Before & After 8 Treatments

ROSACEA: Before & After 1 Treatment

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Clinical Practice Clinical Focus

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own assessment but for our patients who are the real critics and rightly so. VN: When adding a new device, we will consider any unmet need in our practice; anything for which there is a high demand and we are not currently offering another option. For example, our last new purchase was the Coolsculpting device, as we did not have a non-invasive option for this consideration. The next, or equally important consideration is to make sure that the device makes sense financially. Good return on investment (ROI) is key.

WL: What is most important to you in terms of economics, support and marketing when buying a new device? EM: I trust the more established companies to stand by their machines and market them well to consumers. DG: Most important in this economic environment is ROI. After that, I look at the company’s reputation and service. MG: I think reliability and company support are key to any laser sale. If the machine is not reliable, it is not for me. I do not like machines that go down and take a long time to be repaired. It is important to make sure you get the proper warranty from the company; two or three years is now the norm for me. I want new machines to be versatile, to have new components and to do something different. I also want to be able to market something different to my patients, and to differentiate my practice from others in my community. RR: The support of the company is very important, in terms of service, marketing and training. An investment in capital equipment should be viewed in the long term, so maintaining a good relationship with the manufacturer or distributor is key. Of course we need a return on our investment, that goes without saying, however it can come down to the company’s PR and marketing support as to whether a treatment becomes a big ticket in high-demand or a poor relation to others in our offering. Companies need to support their clinics in this way. However, if it truly works for our patients, it will work for us. VN: The most important factors are efficacy and consistency, followed by reliability and cost. This is true for any aesthetic procedure. Sales and marketing support are an added value.

WL: What technologies are the workhorses of your practice and why? EM: I use my Solta Thermage Total Tip, Lumenis LightSheer diode, and Sciton Joule with BBL non-stop. Now my Coolsculpting is getting busy too. DG: Newer potassium-titanyl-phosphate (KTP) lasers such as Cutera Excel V are very safe and offer the diversity of a pulsed dye laser (PDL) without the disposables of a PDL. IPL systems are also great workhorses. We do a lot with non-ablative fractional devices because they can be used for photodamaged skin and acne scars with minimal downtime. MG: I use my IPL machines every day for photorejuvenation and everything else that needs vascular or pigment therapy. I treat a lot of acne and use my photopneumatic (PPx) acne devices like Solta’s Isolaz five to ten times per day; I have had tremendous success clearing very difficult acne patients. I also use my Syneron Sublative RF for acne scars, which are a big part of my practice, and I consider this the best option for that indication. RR: Thermage, Fraxel and Ultherapy are mainstays in my clinic because they all produce excellent results with high patient satisfaction and very few post-treatment problems. They are not necessarily the newest on the market, but the intelligent customer is 42

Aesthetics Journal

Aesthetics

aestheticsjournal.com

not sold by fads, they want the very best the industry has to offer and sometimes new doesn’t mean better. VN: The Fraxel ReStore Dual Laser produces dramatic and consistent results for photodamage of the face, neck, chest and hands, as well as acne scars, surgical and traumatic scars and hyperpigmentation. It is safe in all skin types and a perfect fit for an urban practice. We also use the Excel V 532nm laser because in a dermatology practice, vascular lesions are the most common condition to be treated. These include facial telangiectasias, rosacea, red scars, cherry angiomas, poikiloderma of civatte and rare entities such as port wine stains. It requires fewer treatments and does not produce purpura, and the contact cooling makes it very comfortable. The Clear and Brilliant permea laser is our most popular laser for younger patients who are starting to see signs of sun damage and for melasma. It is safe in all skin types, has a rapid recovery of less than 24 hours and also reduces pore size.

WL: What are the top laser and light-based treatments you do in your clinic? EM: I use my Solta Thermage Total Tip for a subliminal face neck and eye lift, Lumenis LightSheer diode for laser hair removal, and Sciton Joule with BBL for sun spots and wrinkles and polishing resurfacing. I do combination therapy body sculpting with Coolsculpting plus Liposonix for hard to grasp areas, even the lower abdomen and underarm back area. DG: We have non-invasive and minimally invasive body contouring; from Coolsulpting and Vanquish to laser lipolysis. We also use KTP and IPL treatments for facial erythema, and lastly, fractional resurfacing. MG: In my practice, it is IPL, acne, skin tightening, skin resurfacing and fat contouring. RR: We do a lot of Fraxel for skin rejuvenation, Lumenis Total FX for scars, and Syneron ELOS IPL for veins and hair removal. We have a very diverse and exceptional treatment portfolio for our clients and everything we offer, we believe to be the best on the market. I travel the world talking to peers and attending conferences to ensure we are always at the forefront of aesthetics. I’m constantly on a crusade for my clients. VN: In my office it is photorejuvenation for which I use multiple devices such as the Palomar Starlux, Max G IPL, Excel V and Clear and Brilliant laser. For skin resurfacing I exclusively use the Fraxel ReStore or RePair, and non-invasive fat reduction with Coolsculpting.

Coolsculpting Control Unit with CoolCore applicator Zeltiq

Aesthetics | June 2014

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Clinical Practice Case Study

@aestheticsgroup

Aesthetics Journal

Aesthetics

aestheticsjournal.com

Delayed hypersensitivity reactions Dr Sarah Tonks presents an investigation into immune reactions to dermal fillers Introduction An increasing number of people are seeking medically driven solutions for aesthetic problems and, despite manufacturers claims that dermal fillers are non immunogenic, unwanted adverse effects do occur. The ideal dermal filler should be safe – non allergenic, non immunogenic, non carcinogenic, non teratogenic and non migratory. All dermal fillers present in the market are able to provoke inflammatory reactions, including collagen, silicone, polylactic acid, polyacrylamide, hyaluronic acid (HA) and methacrylate. The true prevalence of this is unknown. HA belongs to a group of glycosaminoglycans which are components of the ground substance and can be obtained from both animal and non-animal sources. In theory, HA which is obtained by bacterial fermentation is free of the risk of transmitting diseases between species or eliciting allergic reactions in patients sensitive to food such as beef, chicken and eggs. However both types of HA may contain hyaluronin associated proteins, therefore hypersensitivity reactions do exist. Wang et al1 showed that glycosaminoglycans may be immunogenic and directly provide the signals necessary to begin an immune response. We do not normally produce immune responses to our own tissues but superantigens bypass the mechanisms which maintain self-tolerance. A cell surface receptor for HA called CD44 has been shown to be expressed by human mast cells2 which also regulates the diffusion of nutrients, metabolites and hormones between cells. It also regulates cell proliferation and motility by regulating cell/cell and cell/matrix interactions via CD44. Another study showed that some HA preparations may induce pro-inflammatory cytokines interleukin-12 and tumour necrosis factor and therefore could trigger a preexisting inflammatory process due to the presence of contaminating DNA.3 High molecular weight HA molecules are anti inflammatory and anti angiogenic, whereas the very low molecular weight degradation products stimulate synthesis of new blood vessels, inflammatory cytokines and inflammatory response in macrophages and dendritic cells. Over-expression of CD44 has been linked to malignant neoplasms and HA is present in large amounts in malignancy. The manufacture of NASHA gel changed in 1999 to decrease the levels of trace proteins to six times lower than previously.4 Levels of protein contaminants in Restylane in 2001 were 13-17μg/mL which was the same quantity as products derived from rooster comb sources, demonstrating that the HAs we use clinically are not free of imperfections.2 Clinically, cutaneous 44

CLINICAL CASE: A 31-year-old woman presented with an oedematous swelling in both malar regions, the upper and lower lip and the chin, which had developed over a period of 24 hours. The patient had no history of allergies. The swelling was identified as being present in areas which had received hyaluronic acid dermal filler five months previously, and present in no other areas. She had a history of use of three different hyaluronic dermal filler brands; Restylane (Q Med), Juvederm (Allergan) and Belotero (Merz). Treatment of prednisolone 10mg bd and chlorphenamine 4mg qds for three days was instituted. The swelling subsided without further incident and has not recurred despite the patient going on to have further treatments with different hyaluronic acid dermal fillers. reactivity to HA was demonstrated by challenge intradermal skin testing in patients who had previous experienced a suspected hypersensitivity of HA. The results were positive in four of the five patients tested, approximately eight weeks after injection.5 Conclusion The aetiology of these immune reactions is incompletely understood. It was thought that these reactions were an immune response to protein impurities of the bacterial fermentation process. However recent work has suggested that it may be the hyaluronic acid itself causing the reaction. Glycosaminoglycans such as hyaluronic acid are not species specific and so were thought to be non immunogenic and not to elicit cellular responses.6 However it has been shown that glycosaminoglycans could act as “superantigens” and provide signals to start an immune response themselves.7 In a predisposed host it is possible that repeated application of different dermal fillers may be related to the development of a hypersensitivity reaction. Care must be taken to recognize the possible rare side effects of treatment with hyaluronic acid and a protocol to the treatment of these effects should be established. Perhaps further Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with consideration should dual qualifications in both medicine and be given to double dentistry, based at Beyond Medispa in Harvey skin testing. Nichols, she practises cosmetic injectables and hormonal based therapies. REFERENCES 1. Wang JY, Roehrl MH, ‘Glycosaminoglycans are a potential cause of rheumatoid arthritis’, Proc Natl Acad Sci USA, 29 (2002), pp.14362–14367. 2. P. Friedman, E. Mafong, A. Kauvar, R. Geronemus, ‘Safety Data of Injectable Nonanimal Stabilized Hyaluronic Acid Gel for Soft Tissue Augmentation’, Dermatological Surgery, 28 (2002), pp. 491-494. 3. Filion MC, Phillips NC, ‘Pro-inflammatory activity of containing DNA in hyaluronic acid preparations’, J Pharm Pharmacol 53 (2001), pp. 556–561. 4. Friedman PM, Mafong EA, Kauvar AN, Geronemus RG, ‘Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation’, Dermatol Surg 28 (2002), pp. 491-494. 5. N. Lowe, C. Maxwell, M. Duick, K. Shah, ‘Hyaluronic acid skin fillers: adverse reactions and skin testing’,Journal of the American Academy of Dermatology, 45 (2001), pp. 930-3. 6. J Alijotas-Reig, V Garcia-Gimenez, ‘Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long term follow up and review of the literature’,.Journal of European Academy of Dermatology and Venereology. 22 (2008), pp. 150-161 7. J. Alijotas-Reig, M Fernandez-Figueras, ‘Inflammatory, immune-mediated adverse reactions related to soft tissue dermal fillers’, Seminars in Arthritis and Rheumatology, 43 (2013), pp. 241-58.

Aesthetics | June 2014


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Clinical Practice Techniques

@aestheticsgroup

Aesthetics Journal

Aesthetics

aestheticsjournal.com

The role of Scalp micropigmentation treatment in Follicular Unit Transplantation Dr Sotirios Foutsizoglou and Anouska Cassano explain how micro-pigmentation can be used as a complementary treatment to hair restoration Although the first hair restoration procedures of intact hair follicles were described by Japanese physicians Okuda and Tamura in the 1930s, modern hair grafting can be divided into three major periods.1 • The plug era • A transition period of progressively smaller unit minigrafting and micrografting • A final period of follicular unit transplantation (FUT) Many hair transplant surgeons participated in the process of the reduction of graft size to minigrafts, culminating in large sessions of the use of very small minigrafts. The last and current stage of FUT, utilising the natural growth pattern of human scalp hair, was initiated in 1988 by Dr Bobby Limmer and the methodology of strip donor harvest, microscopic dissection of individual units of one to four hairs, and implantation of these grafts into needle tunnel recipient sites was reported in 19942. Today, FUT constitutes the primary method of hair restoration technique performed worldwide. Strip Method, or FUT, is the hair transplant technique whereby the surgeon applies local anaesthetic to the donor area s/he wants to take the hair from, usually the occipital ‘permanent’ zone. A thin strip of hair-bearing skin is then removed, which is subsequently slivered under the microscope into follicular grafts. These follicular unit grafts are then placed into pinprick incisions in the recipient area.

Strip Method: A) during donor strip harvesting and B) immediately after a two-layer closure of the resulting scalp defect

DEALING WITH THE AESTHETIC COMPLICATIONS ASSOCIATED WITH FUT Visible scarring in the donor area (usually the parieto-occipital fringe or ‘permanent area’) is the most common patient complication encountered in hair transplantation using the FUT technique3. Visibility is predominantly influenced by the width of scar, the number of scars and the follicular density of the donor area; a large scar might be easily hidden within the middle of the dense donor area, whereas even a 46

fine one might be obvious in sparse hair at the periphery of the donor region. Whilst prevention (Table 1) is the key to limiting scar visibility, a range of corrective measures are available to treat unsightly scarring. If there are multiple scars, one way to improve the appearance is by simultaneously excising two closely spaced scars, thus converting them into a single scar. A different option is to surgically revise individual scars that are atypically wide. Implicit in this approach is the belief that a meticulous surgical technique, with a focus on reducing wound tension, will result in a finer scar. Interestingly, botulinum toxin has also been used to decrease scarring by reducing the wound tension created from multiple muscular vectors4. TABLE 1. KEY POINTS TO OBTAIN MINIMAL DONOR SCARS • Close the wound with minimal tension • A long and narrow strip usually heals much better than a short and wide strip • Try to preserve as many blood vessels and nerves as possible • Choose a slightly higher donor zone within the ‘permanent’ donor rim, rather than one near the nape of the neck. • Use two-layered closure in strips wider than 1cm, in scalps with minimal laxity, in repeat excisions, and in patients with hyperelasticity of the scalp • Wide strips (>1.2cm) should only be made by experienced surgeons • In subsequent procedures when the former scar is removed, the width of the donor strip should usually be slightly reduced to prevent widening of the new scar • Use trichophytic closure If wide scarring persists despite the above measures, then an entirely different approach is to place follicular units within the scar. These can be obtained from strip excision, or from scalp or body FUE. A final option, if the aforementioned fails too, or if the patient is unwilling to go through another procedure, is to tattoo the skin to match the colour of the hair. SCALP MICRO-PIGMENTATION Scalp micro-pigmentation, or scalp tattooing, is a semi-permanent micro-pigmenting technique that offers an alternative option for both men and women suffering from hair loss, who are not appropriate candidates for hair transplant surgery or who do not want it. However, scalp micro-pigmentation is increasingly being used as a complementary treatment to hair restoration surgery, either to add the illusion of additional density and enhance the overall result of the

Aesthetics | June 2014


ELEGANT • FULFILLED • MY TIME

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or

rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1139/BOC/NOV/2013/LD Date of preparation: March 2014


Clinical Practice Techniques

@aestheticsgroup

Aesthetics Journal

and lifestyle choices and other variables can affect the longevity of the treatment. The pigments used for HPT are designed to fade over time. This makes it possible to adjust the tone and colour of the implanted ‘hair follicles’ Before HPT® After HPT® and change the hairline, if applicable, to be patient’s surgical procedure, or to camouflage more ‘age appropriate’ for patients as they existing scarring from older transplant mature. HPT is a multi-treatment procedure surgeries where the patient has declined the that usually requires two to three sessions option of a scar revision procedure. to complete. Depending on the size of One specific technique, Hair the area to be treated and the extent of a microPigmentation Treatment (HPT), involves patient’s hair loss or scarring, each session the use of a digitally controlled needle that will take two to four hours. The treatment applies medical grade hypoallergenic colour in itself is not painful, as the pigment is pigment into the scalp. Unlike a traditional implanted only in the epidermis. However, tattoo that would use ink, HPT is performed no longer than four-hour sessions are using specially designed pigments that will recommended as there is a residual build not have the colour change or migration up of ‘irritation’ that can eventually make that is commonly seen with a body art the patient’s scalp feel sore. We have used tattoo. The pigments used for HPT are of HPT effectively to help a number of patients a pharmaceutical quality and fulfil the most camouflage their transplant scarring, which demanding quality and security regulations, is either strip scarring, or hole punch or plug complying with category 1 of EU Cosmetics marks left after older hair transplant surgery Directive and European Directive ResAp techniques. For successful scar camouflage 2008(1). The pigments are dermatologically procedures it is important to understand and microbiologically tested and contain high how to assess the scar. The first step is quality mineral pigments. Additionally, they to examine the scar and decide whether are sterile, hypoallergenic and do not contain micro-pigmentation is suitable, or if another any kind of artificial preservatives, aromatic treatment such as excision or laser is more amines or heavy metals. appropriate. It is of paramount importance Although it may appear to be a similar to understand the different types of scars technique to body art tattooing, tattoo inks and how they have been created in order are not subject to the same stringent testing to decide the best HPT technique to treat and regulations as the pigments used in HPT. them.Depending on the age or severity of In addition tattoo needles and treatment the scar(s) we may need to improve the depth into the skin are very different. Both texture and flatten these scars with microtechniques use needles to implant colour, but needling, mesotherapy or PRP prior to that is where the similarity ends. Traditional referring the patient to a micro-pigmentation body art tattoos have the tendency to change specialist. HPT is only appropriate for the colour. If it was black to start with, very often treatment of scars that are more than a year they will turn blue as a result of migration due old and are fully healed. Hypertrophic scars to the type of ink used and the tissue level at present as raised scars within the border which the tattoo was implanted. HPT is not of the trauma or incision. Hypertrophic implanted at a deep level on the scalp; the scarring will almost always need a medical simulated hair follicles are implanted in the treatment prior to HPT. Keloid scarring very top layers of the epidermis. presents as raised scar tissue outside the For general scalp micro-pigmentation border of the trauma site or incision and is treatments, we would expect HPT to last a contraindication to HPT as there is a high between one and three years. After this, the risk of precipitating further scarring5. patient will require some minor maintenance The aim of re-pigmenting a scar is to blend or touch ups to ensure their treatment is kept in the damaged skin and reduce the contrast looking its best. However, it is impossible to between the scar and the healthy scalp and predict the exact length of time the treatment surrounding hair. However, as highlighted will last, as each patient’s biology is different previously, scars by their very nature are 48

Aesthetics | June 2014

Aesthetics

aestheticsjournal.com

unpredictable to work on. Unlike healthy undamaged skin, the scar area may grab the pigment resulting in possible migration or occasionally it may reject the pigment and push the colour out. SUMMARY Many of the aesthetic and medical complications in hair restoration surgery are preventable through conservative planning and careful surgical technique. However in the relatively short list of potential aesthetic complications following a FUT procedure, scar widening or unsightly scarring in the donor site is the most frequently encountered complication even in the hands of the best hair transplant surgeon. HPT has been added to our armamentarium to help us achieve a satisfactory outcome when all the medical and surgical measures to reduce visible scarring have failed, or in cases where patients are unwilling to undergo a scar revision procedure. Patients who fall in the aforementioned category are potentially good candidates for HPT and can be referred to experienced micropigmentation practitioners specialising in the areas of scalp micro-pigmentation and scar camouflage. The key benefit of HPT Scalp microPigmentation is that the treatment will give the patient almost instant results whilst still leaving options open for other treatments should the patient wish to explore alternatives in the future. Dr Sotirios Foutsizoglou is founder and medical director of SFMedica. He specialises in aesthetic medicine, is a member of the International Society of Hair Restoration Surgery and performs hair transplant surgery on Harley Street. He is lead trainer in advanced non-surgical procedures with KT Medical Aesthetics Training Group. Anouska Cassano is a highly experienced micropigmentation practitioner specialising in areas such as scalp micro-pigmentation, aesthetic permanent makeup and medical reconstruction. She is the technical expert of the Confederation of International Beauty Therapy and Cosmetology. REFERENCES 1. Unger, W.P., Shapiro, R., Unger, R., et al., Hair Transplantation, 5th edn (London: Informa Healthcare, 2011) 2. Limmer, B., ‘Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation’, J Dermatol Surg Oncol, 20 (1994), pp. 789-93. 3. Bernstein, R.M., Rassman, W.R., ‘Follicular unit transplantation: patient evaluation and surgical planning’, Dermatol Surg, 23 (1997), pp. 771-84. 4. Arnold, J., ‘6th annual meeting of the ISHRS’, H t Forum, 6;4(1998) 5. Ezaki, T., ‘Advantages and disadvantages of hair transplant surgery on treatment of male baldness’, Jpn J Aesthet Plast Surg 19 (1997), pp. 99-117.


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Clinical Practice Clinical Focus

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Aesthetics Journal

Aesthetics

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We speak to some of the authors of the new complications in injectables document to find out about the reasons and process behind its creation and the plans for future developments

Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment In May 2013, a multi-disciplinary expert group from the Merz Aesthetics Partnership in Practice Conferences came together to discuss feedback gained from these events. This indicated that delegates and practitioners were keen to learn more about handling and recognising complications, and so the expert group, consisting of plastic surgeons, doctors, dentists, dermatologists and nurses, began the process of creating a document that encapsulates this information. The group that created the Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment document1 includes plastic surgeons Mr Chris Inglefield and Mr Santdeep Paun, nurses Fiona Collins and Marie Duckett, aesthetic doctor Dr Kate Goldie, dentist Dr Gertrude Huss and dermatologist Dr Stefanie Williams. On the necessity of the document, Duckett says, “There didn’t seem to be any document that you could go to. In clinical studies, the majority of information will focus on the findings and then there may be a couple of sentences at the end on complications. Most of the time we’re dealing with the face so complications, no matter how small, are significant. Practitioners want to deliver treatments with a minimum amount of distress to the patient, and major distress for patients occurs when they suffer complications, even if it is just plain bruising; sometimes a bruise can be a significant event.” The group spent six months collating research articles from various sources for the document and, with the help of a medical writer and an educational grant from Merz Aesthetics, published their findings in March 2014. The document was then dispersed at a series of regional conferences In London, Manchester, Edinburgh and Dublin. Although Merz provided the funding in order to publish the 50

document, Duckett emphasises that it is an independent piece of work. Mr Inglefield says of his reasons for taking part in the project, “Our goal was to bring together specialists from all backgrounds who are passionate about safety in our industry. We recognised that there was incomplete or absent recommendations for the management and reduction of adverse events in toxin and filler treatments. Our aim therefore was to produce a consensus document which provided practitioners of all levels evidence-based recommendations.” Duckett adds, “Nowadays, we inject wider areas of the face than we did previously. You have to do everything in your power to make sure that every time you pick up a needle or syringe, that you are providing the safest possible treatment for your patient.” The document is split into two parts, ‘Recognising and Minimising Complications’ and ‘Complications: Risk Reduction and Treatment’, and includes potential

You have to do everything in your power to make sure that every time you pick up a needle or syringe, that you are providing the safest possible treatment for your patient. complications and case studies for specific patient complaints such as crow’s feet, forehead lines and tear trough, followed by advice on how to avoid and deal with these adverse events. It also includes an A-Z quick guide of complications at the back of the document. “We’ve tried to make the document very user friendly,” Duckett says. “Anatomical images accompany each section, which clarify exactly what the safe and danger zones are on the face. The A-Z guide acts Aesthetics | June 2014

like a glossary, and for everything that’s covered, algorithms have been included so that readers know what course of action to take. It’s laid out in a logical fashion to help practitioners mark the face, so they know the ideal areas to inject.” Mr Inglefield adds, “The Consensus document has been developed as a reference and quick guide in the management of adverse events in toxins and fillers. My initial advice is to read through the document to be familiar with all the contents. This can then be used as a quick reference for safe treatment and managing all adverse events.” The expert group plan to continue their work and produce an updated version of the guide. “We will update the document as new data becomes available,” Mr Inglefield says. “The Expert Group will continue to look at areas where we can produce a consensus document for use by practitioners, for example in the use of needles vs cannulas. We can also provide a go-to resource for opinion from the media, government and industry for both patients and practitioners.” As well as updating the document as practices and products develop in the market, Duckett suggests the group will also concentrate on making the document more readily accessible for direct use in practice. “We’d like to increase the indexing and algorithms, to make it easier for people if they need to find something quickly.” She also suggests that they may produce a similar document for other treatments in the future. “We’ve just covered botulinum toxin and dermal fillers, but there may be a case of doing something with lasers or radiofrequency,” she says. “This hopefully is not the end of this document and it is something that should evolve.” The second edition of the document with further additions is expected to be available in June or July. REFERENCES 1. Inglefield, C., Collins, F., Duckett, M., Goldie, K., Huss, G., Paun, S., Williams, S., Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment (London, 2014)


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Aesthetics Awards Special Focus

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Entries are open for The Aesthetics Awards 2014. The awards, which will be held on Saturday December 6 at the Park Plaza Hotel in Westminster, recognise those in the field of medical aesthetics who have demonstrated clinical excellence, practice achievement, and outstanding product performance. By celebrating those that are raising standards, The Aesthetics Awards provide an aspirational event in the professional calendar, alongside a fantastic opportunity to promote your brand or clinic to your customers as a leader in the industry.

Aesthetics Journal

Aesthetics

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Closing date for entries Entries must be completed on The Aesthetics Awards website on or before 30 June 2014. If you have any questions please call our support team on 0203 096 1228 or email support@aestheticsawards.com

The categories for The Aesthetics Awards 2014 are as follows: • Cosmeceutical Range/Product of the Year

• Best Clinic Scotland

• Injectable Product of the Year

• The Church Pharmacy Award for Best Clinic North England

• Treatment of the Year

• The Dermalux Award for Best Clinic South England

• Equipment Supplier of the Year

• The Oxygenetix Award for Best Clinic London

• The Janeé Parsons Award for Sales Representative of the

• Best Clinic Wales

Year, supported by Healthxchange Pharmacy

• Best Clinic Ireland

• Best Customer Service by a Manufacturer/Supplier

• The Institute Hyalual Award for Aesthetic Nurse

• Distributor of the Year

Practitioner of the Year

• The NeoCosmedix Award for Association/Industry Body of the Year

• The Merz Aesthetics Award for Aesthetic Medical Practitioner of the Year

• The Pinnell Award for Product Innovation

• Clinic Reception Team of the Year

• Training Initiative of the Year

• The Aesthetic Source Award for Lifetime Achievement

• The 3D-lipomed Award for Best New Clinic, UK and Ireland

How to Enter All entries must be made via the Aesthetics Awards website www.aestheticsawards.com. You can enter as many categories as you wish but you may only enter yourself, a company you work for as an employee, contractor or agency, an employee who works for your company or a product made or distributed by your company. Entries made on behalf of a third party will not be accepted. You should only enter each category once. Multiple entry forms for the same clinic, company, individual, treatment or product will be disregarded. All entries must be accompanied by the supporting evidence requested in the entry form. This information will be used to select the finalists and by the judges when deciding on the winners, highly commended and commended. The list of finalists will be announced in the September issue of Aesthetics journal, after which the voting and final judging process will begin.

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Aesthetics | June 2014


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Aesthetics Journal

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Aesthetics Awards Special Focus

The highly anticipated Aesthetics Awards 2013 featured over 140 finalists competing in 23 categories. Here, some of the winners tell us what the award has meant to them both personally and professionally. The Brinkenhoff Award for Lifetime Achievement and Services to the Industry

This year the Lifetime Achievement Award is sponsored by Aesthetic Source

For 2013 the Lifetime Achievement and Services to the Industry award was given in memory of Gayle Brinkenhoff and Dr John Curran was invited to the stage to present this very special award to his close friend and colleague Dr Patrick Bowler. A previous winner of an Aesthetics Award, the huge number of nominations that he received were a true testament to Dr Bowler’s popularity and the respect that he commands amongst his peers. This high opinion was shared by the Aesthetics Awards team, who all agreed he was a worthy winner. “My Aesthetics Award in 2013 for Lifetime Achievement truly came as a complete surprise. It made me reflect on my working life in the aesthetics field and showed that what I took to be normal daily work had been officially recognised as of benefit to some people! These types of awards are important not only for personal satisfaction but also give an opportunity to give public attention to our endeavours in developing and maturing our growing industry.”

Dr Patrick Bowler Best New Clinic

This year the award for Best New Clinic is sponsored by 3D-lipomed

The award for Best New Clinic, which celebrates recently launched clinics in the UK that have provided an outstanding level of care to their patients, was presented to The Skin Energy Clinic’s Dr Terry Long. The clinic’s commitment to patients and their holistic approach to skin and anti-ageing was demonstrated by a huge 99 out of 100 score by our mystery shopper who commented, ‘I could hardly have been dealt with more efficiently.’ “Winning Best New Clinic Award last year was a wonderful surprise. I believe the key to the clinic’s success is our continuous effort to ensure patients are really listened to, educated and ultimately empowered. It’s important that they are able to make the right decisions for themselves. Winning the award also gave me the confidence to commission a PR agent to take the clinic to the next level. Being more visible in the public arena has opened many doors for myself and the clinic and I am very excited about the future. The award has also helped my credibility as new patients know they can trust me and my team. We are highly recommended after all! I would hugely recommend entering awards and doing your best to win. Even if you end up being a finalist, you are still able to use that as part of your marketing campaign and in turn it can boost your credibility. No one will know how good you are without knowing who or where you are in the first place. So go for it!”

Dr Terry Loong Aesthetic Nurse Practitioner of the Year

This year the Aesthetic Nurse Practitioner of the Year Award is sponsored by Institute Hyalual

Managing Director of Syneron Candela, Michaela Barker, presented the award for Aesthetic Nurse Practitioner of the Year to a delighted Sharon King from Cosmedic Skin Clinic in Tamworth. The winner for this category was decided by Aesthetics journal reader votes and The Aesthetic Awards team and Sharon won on both accounts with one voter commenting “Sharon is an excellent practitioner” and another stating that she is “extremely professional and knowledgeable”. “It was a real joy and privilege to go up on stage and accept the award for Aesthetic Nurse Practitioner of the Year. I consider the award as being as much for my clinic team as for myself and so it was wonderful for us to be held in such high esteem by others in the profession and recognised for our hard work. My patients were so excited and proud when I was able to tell them that I had won and new patients see the trophy in my clinic and know that they are in the right place to receive an excellent standard of care. It is such a great honour to hold the title this year as there are so many fine nurses that do a fantastic job and I wish the incoming Aesthetic Nurse of the Year every success.”

Sharon King Aesthetics | June 2014

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In Practice Branding

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Aesthetics Journal

Mark Shahid explains the importance of creating a unique brand for your clinic through the use of logos, straplines and imagery

Developing Your Brand Identity Sometimes we spend so much time focusing on the core elements of our business that we forget about how we are perceived by the outside world. Professionals in the aesthetics industry will know all too well about the incessant pursuit of perfection and the truth is your patients will form an opinion of you and your business based on a combination of how well you treat them and how you present yourself. You could be offering the best service they’ve ever had, but if they feel that there’s something unsettlingly off-piste about your visual presence, they will be left with a feeling of uncertainty and insecurity about your business. This will often subconsciously lead to a lack of commitment at the most crucial decision making stage. First impressions count and having a strong visual presence will help to propel your business ahead of your competition. A well-considered brand identity will create an emotional connection with your

customers. In the short time you have to impress a new patient, be that on your website, or within the clinic walls on the first consultation, creating a strong visual identity which can be quickly absorbed is key to a successful brand. Creating A Successful Brand Identity We have found that the best way to begin thinking about a brand identity is to go through a research and exploration process. To begin, create a mind map of your business and of how you would like it to be perceived by your target audience. In doing this, think about where you would like to sit amongst your competitors, as well as outlining your customers’ profile. You should already have a lot of these answers pinned down in your initial business plan, including what your Unique Selling Point (USP) is and how you would like to portray this in your brand. You can use these elements of your mind map as

A mind map can help you portray fundamental parts of your business within your brand

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inspiration for compiling the visual features of your new brand. One commonly shared opinion for the majority of brand developers is that the initial research and exploration of a business is the most important part of the branding process. Following the creation of your mind map, begin constructing your ‘kit of parts’. These are the creative elements that will form your identity, including imagery, colour palette and typography, and at the forefront of a great brand is that all-important logo. Here are three tips for creating your first logo/mark: 1) Target your audience Assuming you have now completed research about your target audience, you will hopefully have a clearer understanding of what your customers will respond well to. Design elements like typography and colour can be tweaked to invite the right audience later on in the process so try not to overthink it at this stage. You should ideally be thinking of concepts at this early stage of the branding process and thinking about the more creative elements later. A concept can be as simple as an idea or a ‘look and feel’ for the logo or mark. Some of the world’s most familiar logos were conceived with just a principle and were developed to create the final brands we all know and recognise. Therefore your initial idea could be as simple as a single word or phrase, which acts as an ambassador for your business. This doesn’t have to be part of the final name, logo or tagline of your business, but may well form part of it at some point in the process. Just remember that at this point it is crucial that you are connecting with the types of people who you would like to become your loyal patients. If you are able to carry out some consumer insight sessions, you will have a major advantage as you will already have a good idea of what moves your potential patients emotionally and what will make them responsive to your brand. Good examples: Dove, Nice and easy. 2) Keep it simple Some of the world’s most memorable logos are comprised of a single, simple, memorable motif. It’s no secret that the simplicity of these ubiquitous logos is part of the success of the brands that they represent. The more digestible your logo or mark, the more likely someone will recall your brand when it is presented in different marketing contexts.


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In Practice Branding

You’ll also thank yourself for a simple logo when it comes to designing your marketing collateral and when you are attempting to squeeze your new logo into the top left corner of your website. Good examples: Apple - A simple apple with a bite says very little about computers and technology, but implies the playful, tech-with-a-difference company that eventually grew to take over the world. Nike - The Swoosh was originally designed to represent the ‘wing of a greek goddess of victory’. This simple and elegant motif has aptly targeted its glory-seeking audience. McDonalds - The ubiquitous ‘M’ or ‘Golden Arches’ is simple and memorable and shows that a logo doesn’t have to have a direct correlation with the product or service. 3) Make it extensible A logo that is extensible is one that can be extended for use for potential sub-brands, sister companies or a range of products. You never know when you may want to expand your business and it will help to have a logo that can be easily adapted to create new, related services. This is another good reason to strive for simplicity in your logo; a good logo will not only sit in harmony alongside other parts of the brand (strapline, imagery, etc), but will also execute nicely across a range of different sub-brands or products. Good examples: Soap and Glory - This brand of cosmetics for the younger female generation is self aware, very current and immensely conscious of the competition. Priding itself on being unique, the imagery used on the bottles, the words used to describe the product and the quirky product names are all an extension of the brand. Creating a strapline A good strapline will sit alongside your logo and tell your audience exactly what you are here to do in a few short words; it will be your elevator pitch to the whole world. Using the same approach as you used to create your logo, think carefully about your audience and use this prior knowledge as leverage to concisely deliver a message in the appropriate, considered tone. Whilst there are no hard and fast rules to how long your strapline should be, some of the world’s biggest brands achieve this in just three to four words, so bear this in mind before you attempt to list every one of your services: keep it concise and keep it memorable. 56

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In the short time you have to impress a new patient, be that on your website, or within the clinic walls on the first consultation, creating a strong visual identity which can be quickly absorbed is key to a successful brand. A good way to ‘test out’ your potential strapline is to create a list of the best contenders and send these off for feedback. Always think about your audience before finalising anything. Good examples: These straplines embody everything that their product/service represents. Think Different - Apple’s aim in the 1980/90s was to change the way we think about computing; their strapline said everything about the company at that time. Just Do It - Nike have always been about winning, from their logo to their products; they knew that if they could somehow associate their brand with success, then their audience of sporty types would respond. Open happiness - Coke has strongly pushed its brand to represent everything that is joyful and positive, including Christmas. For what is essentially just a brown, sugary, fizzy drink, this product is almost entirely carried by the effect the brand has on the world’s eternal pursuit of happiness.

can achieve this by simply picking up the phone or creating a quick survey that you ask relevant, trusted people to complete. It’s worth offering something in return for their time to incentivise people to complete your survey. Getting advice from a good brand agency that has worked in your field can help in this situation. This will save a lot of undoing later on in the branding process. Social media is full of opinions, so don’t forget to head to the Twitter-sphere and launch a mini-campaign to get feedback. You’ll find a lot of helpful, friendly advice on there, and this won’t cost you anything. Finally, one of the most painful slices of advice I have to serve on the subject of branding is don’t be afraid to start again. Even if you have invested a lot of time and brain power into your initial drafting stage, sometimes the best place to go is back to the drawing board if you feel that your brand has drifted away from where you want it to be. Conclusion

Overcoming Difficulties

Creating a great brand may seem like a daunting task at first, but it can also be great fun. As long as you keep your eye on your business objectives and heed the advice of a trusted professional in the field, you will be on your way to creating a strong and confident brand that will grow as your business grows. From my experience, there is nothing more satisfying than holding up a new business card, or visiting your newly branded website or shop for the first time, providing a buzz that reminds you of why you started your own business in the first place. If you feel an emotional connection with your visual identity and your patients do too, that’s when they’ll come back for more.

Once you have sketched a few ideas, get some good, honest feedback. Whilst friends and family are great at supporting us throughout our decisions in life, it sometimes helps to get some frank, impartial comments from someone who is emotionally disconnected from you and your business. This can help give a new perspective on your brand that you may have missed. You

Mark Shahid is the lead developer at Harrogate-based design agency Blowmedia. Collaborating with brands of all sizes for eleven years, Mark has worked with start-ups to small established brands, developing brands from the research and exploration stage right through to building websites and producing other marketing collateral.

Choosing Imagery Imagery plays an important part in a brand. Before rushing to an online stock image library, think about the exploration of your brand that you have already undertaken. Use this to your advantage as you select imagery for website or marketing collateral; if, for example, your brand is all about being quirky and unique, choosing a clichéd image of a smiling man in a suit won’t get you very far.

Aesthetics | June 2014


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In Practice Business Process

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Aesthetics Journal

How to make your clinic less dependent on you Kurt Won explains how having designated systems in place to document your processes can help your business function more cohesively and give you more freedom The word ‘system’ can be overwhelming and is associated for the most part with technology systems such as patient booking systems, customer relationship management (CRM) applications and accounting systems. While technology plays an important part, having systems in place in your clinic or practice is not just about spending money on technology.

What makes an effective system? In order for a system to work, it must have a process (a series of steps) that consistently delivers the desired results. Think about your body as an example: there are many systems like the respiratory system, nervous system and digestive system. In order for the respiratory system to function properly, you need to first breathe in air, air then passes through your lungs, and so on. If one of these steps stops working, your body may fail, and each system is interrelated: this same principle applies to your business.

Why document processes? You’re not expected to have all these systems perfected immediately: it takes time to document, test, develop and refine each process in a business. It is important, however, that you start documenting the proven processes that make your clinic run effectively on a daily basis. The problem for some practitioners and clinic owners is that they are the system, and most of the knowledge about how to run the business resides in their head. This means that if they are unavailable, the business cannot run effectively, if at all. Once the information is clearly documented, you reduce the risk of your business stalling if a key person leaves or is absent for extended periods. If you are looking to set up a chain of clinics or practices, having documented processes that are proven to work is vital in helping your other clinics duplicate your current business success without you having to be present at all times, which will provide brand consistency and maintain high standards.

Various systems essential for a thriving clinic or practice • Compliance (ensuring that you are complying with appropriate regulations) • Accounting (keeping track of cash flow and profits) • Marketing (promoting your treatments, exposing your business and building relationships) • Sales (acquiring, re-booking and retaining patients and product sales) • Operational (delivering your treatments) • Customer Service (creating satisfied patients and successful complaint resolution) • Training (training your team to deliver, serve or run the business)

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How do you document processes? Start by writing down the tasks you carry out routinely on a daily basis, then as you carry out the task, note down each essential step in completing the task. If preferred, use a dictaphone to record the steps and ask a member of staff to transcribe it for you. Here’s an example of what a documented process for a new patient enquiry by phone may look like: ✓ Designated staff answers call with friendly greeting ✓ Ask where the patient found out about the clinic ✓ Take basic contact details ✓ Record main concern and treatment of interest ✓ If appropriate, answer questions ✓ If appropriate, check calendar to book consultation ✓ If appointment is booked, confirm date and time ✓ Send confirmation via email or text ✓ Record new patient information in patient management system If you outsource some of your work, make sure that you insist that your contractor provides you with a documented process or manual for what they are doing. If, for example, you outsource your marketing and it’s bringing you results, get an agreement in place to make sure your marketing executive documents their processes, especially if they have committed you to using a specific CRM system. This will ensure that if something happens with the relationship or if the contractor goes out of business, it doesn’t cost your business too much time to hire someone new to do the job.

Testing and evolving your documented processes Once you have documented the first draft of your process manual, I suggest you test it out. First test it out yourself by following each step you have written down to completion. As you go through each step, you may find you left something out or you need to expand instructions. The next step is to ask a member of staff to follow the instructions to complete the task. Monitor them as they progress through the process and take feedback and notes on


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Benefits of documenting processes: • Makes it easier for you to delegate low value tasks to staff • Speeds up training of new staff members • Reduces key person risk and serves as a checklist for your team to ensure all tasks are completed • Serves as a way to hold staff and the team accountable in running the clinic or practice in a way that produces predictable results • Frees up your time to think about strategies to further grow the business • Provides a potential buyer of, or investor in, your business with confidence of continued success

what can be improved. This will help you to improve and bullet-proof your process document. Remember that to run a sustainable business in a fast-changing world, it’s

Aesthetics

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always important to be willing to update and evolve your processes and not get stuck in old ways that may not be effective anymore. There are also many apps that can help you do more and achieve more with less energy and time required from you. Let’s take marketing as an example. Here are a few apps that can help you streamline your marketing efforts: • Email marketing: Instead of sending individual emails to patients, use applications like MailChimp, Constant Contact, Office AutoPilot or Infusionsoft. All you have to do is write an email or newsletter and use customised fields to personalise it to your patients. There may also be a patient management system that can send personalised emails to your list. • Social media: Instead of posting individual tweets or Facebook posts, use applications like Hootsuite or Tweetdeck that allow you to write multiple posts, upload them and schedule them in advance.

In Practice Business Process

What benefits will this bring? If you have a systematic process for getting great results when treating patients and you want to expand your capacity by hiring another doctor or clinician, then having a documented process manual will ensure your patients get consistent results. Obviously, if it’s a proprietary method of your own it is advisable to have agreements in place that protect your intellectual property. Taking the time to compile and document your business processes now will free up time in the future. When you decide to build your team and delegate lower value tasks, having these documented processes will mean your business will not be exclusively dependent on you. Kurt Won is the co-founder and co-CEO of SalesPartners UK, a multi-award-winning business consultancy that has helped over 850 business owners and entrepreneurs to make and keep more money, by driving sales, increasing profitability and building championship business teams. He has spoken at various aesthetic and beauty conferences. (www.salespartnersuk.com)


In Practice Digital Strategy

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With the online sphere constantly evolving to provide patients with the most instant and accessible services to date, WhatClinic.com CEO and founder Caelen King asks, is your clinic keeping up? These are three common misconceptions that can easily be resolved by embracing the latest known online trends and technological advancements, in order to ensure that you are meeting your patients’ expectations.

ONLINE VISIBILITY

Great expectations Ten years ago you could broadly rely on two things to ensure a steady customer base at your clinic: a good location and word of mouth recommendations. Today, if you believe that these alone are enough to sustain your business, you are putting your future practice in jeopardy. We speak to hundreds of clinics % increase in volume of every day, and know that despite enquiries on WhatClinic.com for the booming marketplace lots medical aesthetic treatments of clinics are simply not getting % increase in enough patients through the door. A Procedure past 12 months recent government report estimated that the value of the non-surgical Dermal fillers 200% treatment market in the UK would Chemical peel 67% rise to £2.7 billion by 2015. We see Laser skin resurfacing 42% this growth first hand; last year Wrinkle reduction 50% more than 15 million people visited Dermabrasion 33% WhatClinic.com to find and compare clinics. In the past 12 months we have seen a 37% increase in the volume of enquiries for all sorts of medical aesthetic treatments in the UK, with a particular focus on filler treatments. Why therefore are some clinics looking at empty treatment rooms and finding white space in their diaries? The answer is that online resources are the first and best resource for any patient thinking about having a treatment, and yet many medical aesthetic clinics don’t fully understand or embrace their true online visibility.

Three myths clinic owners believe are true: My website lists all my treatments so therefore I am being found online for those treatments. FALSE. Negative reviews should be ignored. My real patients know how great we are. FALSE. It’s better to hide my prices until I can talk to the patient in my clinic. FALSE.

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Just because you have an attractive website featuring lots of information about your clinic does not necessarily mean your online presence is strong. To ensure that your information is reaching the correct audience you need to think about the steps potential patients might take to reach your website, if they do not know the direct URL. For instance, if you offer dermal fillers and your clinic is in Bolton, try searching for ‘dermal fillers Bolton’ online. Is the user presented with your clinic website at the top of the page or are your competitors listed above you? Boosting the presence of your website is crucial, and this can be done with the aid of online tools such as Google Adwords and Google Analytics, or can be achieved by working with an SEO analyst. The truth is, building a website is relatively cheap. However, building a website that gives you visibility for what matters takes time, costs a considerable amount and needs to be constantly updated. Just having a website is no longer enough if you want to attract the right kind of customer. A simple health check for your website is key. Look at it on a smartphone, tablet, and then on a desktop computer. Think about the information a potential patient may be looking for and make edits in your content management system or request that your website developer make this easily accessible. Is your clinic phone number prominent on every page? Do you have a list of all your treatments and up to date prices? Have you shared some patient reviews? There are almost 4,000 UK medical aesthetic clinics listed on WhatClinic.com. 1,100 of these clinics have never logged in or added any information about their businesses, all of which is free to do. They may not even know their free listing exists. Managing your online brand is step one to increasing visibility and you should make the most of all opportunities. In any online space that your business is listed, ensure that you have edited, added or updated information where possible. Set yourself monthly reminders to check these platforms, making sure that you are providing the most up to date and relevant information for your patients.

PATIENT REVIEWS Reviews are both an opportunity and a threat. Either way, they should never be ignored. Social media has allowed us to embrace reviews, and turn our happiest customers into advocates, but it also


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means that the unhappy customer can be easily found by others searching for your site. However, negative reviews only have real significant power if they stand alone, and believe it or not, a single negative review in a sea of positive reviews actually adds authenticity to the positive ones. As a clinic owner or manager you should start soliciting reviews now, ensuring that prospective patients find an online presence that is both reputable and positive. Find the websites that Google sources its reviews from and point your customers to those sites. Print a message asking them to review your clinic online on the back of your receipts and reminder cards.

PRICE AND AVAILABILITY This is probably the most contentious issue we come up against time and again. Clinics often don’t want to publish prices for various reasons, however I always advise clinic owners to do so and be transparent around pricing. 72% of medical aesthetic clinics on our site have added pricing, and we’ve found that these clinics consistently win more enquiries from the visitors to our site. Putting your ‘starting from’ prices online will mean that when someone calls or emails you having been to your site, the enquiry just got that much better. That customer already knows more, which makes it a more qualified lead. Quoting a price and hanging up is also an error. Letting them know the price, and then telling them you have availability tomorrow, and asking them whether they would like to make an appointment is a much better idea. A potential customer may take time to nurture but

In Practice Digital Strategy

if they turn into a loyal client, the effort you and your staff put in at the outset will be more than worth it. Transparency is also key when it comes to your appointment availability. Clinics who think strategically and who want to attract the best patients will do so by publishing this online. When two clinics have similar treatments and pricing on offer, the online patient will almost certainly choose the clinic that has availability on display. Even though they may well still phone to ask for an appointment, they will be reassured that once they have phoned they will not have an issue making an appointment, and it will not be a wasted call. We see this from clinics that have already added the ‘Publish availability’ feature to their listing on WhatClinic. com. And when this has been added to clinics’ own websites or Facebook pages they have reported a real difference to the volume of patient enquiries. The medical aesthetic consumer is rapidly becoming more and more empowered by technology. There are some clinics that have embraced these changes, and many that have not. This divide is only set to increase as patients expect transparent pricing, access to reviews, availability information and multiple ways to book, day or night. Embrace these changes now to make sure you don’t get left behind. Caelen King is CEO and Founder of WhatClinic. com, a clinic comparison website that helps empower patients with access to information on price, availability and independent reviews.15 million people visited WhatClinic.com last year to find the treatment they wanted. In the UK 37,600 clinics are listed on WhatClinic.com, across dental, medical aesthetic, plastic surgery, beauty and more.

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In Practice In Profile

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“Hard work is the basis of everything” Dr Johanna Ward, medical director of clinic chain The Skin Clinic and winner of Rising Star at the Aesthetics Awards 2013, explains her route from Oxford English graduate to aesthetic doctor and stresses the need to have a focused approach When nearing the end of her undergraduate degree in English Literature at the University of Oxford, Dr Ward decided that she wanted her life to take a different direction. “Without telling anybody one day, I got on a bus before my finals and interviewed in London for medical school and got offered a place,” she says. She graduated from Oxford in 1999 and went on to complete six years of medical study at Guy’s, King’s and St Thomas’, graduating from medical school in 2005. She continued her career by training to be a general practitioner, then decided to complete training in botulinum toxin and dermal fillers when a friend offered her a job in her aesthetic clinic. Dr Ward soon decided that she wanted to turn her attention to aesthetics full time. “I was still doing general practice and I was getting so busy that I had to make a decision,” she explains. “I didn’t feel that seven minute consultations with my patients was professionally fulfilling, either for myself or for them, and I soon realised that I enjoyed medical aesthetics much more than my NHS work.” So she decided to set up her first clinic in Sevenoaks, Kent. “Several people told me I was mad to walk away from my GP job and the career security it offered. But I knew that it was what made me happy and I can’t say that I’ve regretted a single second,” she says. She went on to set up her second skin clinic in Brentwood a year later. Alongside aesthetics, Dr Ward remained an active part of the local dermatology community, and still currently works at an NHS dermatology unit one day a week. “I am passionate about anything to do with skin and I think it’s really important to be involved in the NHS and give back to the community,” she explains. Additionally, Dr Ward hasn’t neglected her undergraduate education; she explains how her English degree has complemented her medical career. “It’s a wonderful combination,” she says. “I do a lot of writing on dermatological conditions and aesthetics, which combines my writing skills and medical knowledge and experience. Many doctors don’t think outside of the NHS career box but there are several great ways to earn a living in medicine. Medical journalism is a growing specialty and something that I’m interested in.” As a demonstration of her growing success, Dr Ward went on to win the award for Rising Star at the Aesthetics Awards 2013. “The awards are a great way of recognising both outstanding individuals and innovators in our industry who are dedicated to clinical excellence,” she says. “Winning a professional award gives you a voice, which can be used to bring about change. For example, it allows you to help with things such as speaking out about regulation and encouraging the industry to be taken seriously as a medical profession. Receiving the Rising Star award was humbling and an honour.” And Dr Ward’s focused approach, combined with having care and consideration for her patients, is why she has got to where she is. “Hard work is the basis of everything, and being clinically sound is important,” she says. “Also, I think if you’re a genuinely kind and caring person, that shows through. I always give my time generously to my clients and tailor treatments precisely to them; it’s a very personal service and I think patients value professional integrity and honesty more than anything.” 62

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Q&A What’s your favourite treatment?

Dermal fillers, as you can craft and create something really exquisite and beautiful. I also love treating acne as its so rewarding professionally. Acne affects young people at a time in their lives that is so pivotal, when they’re forming their identity and trying to establish themselves socially. Facial conditions can be very debilitating and treatment can be quite life changing. What’s your favourite thing about the aesthetics industry?

It’s dynamic and exciting, no two days are the same and you get to meet lots of wonderful people. Also you never know what new treatments are around the corner. I love going to conferences because they’re an opportunity to find out what’s new and what to invest in next. What do you dislike about it?

It’s disappointing that we are not taken seriously as a medical specialty. Many of us are as dedicated to our work as any other medical specialist and it takes years to become clinically sound and experienced. It would be wonderful if the government formalised our training to help regulate the industry and protect the public from poor practice. What’s been the biggest lesson of your career?

My philosophy has always been to under-promise and over-deliver, because then people will always be happy. Private medicine, especially aesthetics, is completely different from NHS work. Expectations are very high and are related to the fact that people are paying considerable amounts to get a good outcome. What advice would you pass on to young doctors?

Hard work gets you everywhere. Think outside the box and know that anything is possible if you have the passion and drive. Also, know when you’re out of your depth and when to ask for help. If you don’t ask questions, you’ll never learn. Don’t ever try to take shortcuts or guess, because shortcuts and risks don’t work in medicine.


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In Practice The Last Word

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The medical aesthetics industry is enriched when practitioners bring knowledge from related medical specialities into the field of aesthetics.

The last word Skills and knowledge acquired from related specialties benefit both the individual practice and the profession as a whole, argues Dr Rikin Parekh As an undergraduate dental student I firmly believed that I had picked the right career pathway for me, after carrying out extensive work experience beforehand. The idea of expressing myself artistically, working with patients and being part of a solid team, all whilst doing a job that was well respected and offered great flexibility and security with the potential of being remunerated well, was all very attractive. Three years after graduating in dentistry back in 2003, I dipped my toe into the field of facial aesthetics, with my first course in botulinum toxin and dermal fillers. At the time, like most dentists who enter the industry, I saw the opportunity to offer extra value to my patients, providing them with a service that was complementary to the dentistry being undertaken, together with adding a new income stream into the practice. After six years in the NHS, my passion for dentistry had slowly taken a back seat, due to what I saw as increased red tape, targets and stress, alongside ever decreasing true interaction with patients. Because of this I left, and entered private dental practice. After commencing my Masters course in Cosmetic Restorative Dentistry and performing more and more cosmetic dentistry, I found that the demand for facial aesthetics at the practice was increasing and the two complemented each other perfectly. With the help and guidance of several of the leading manufacturers of botulinum toxin and dermal fillers, I was able to build on my knowledge and skills. In doing so, I felt a renewed passion for my work; I had a thirst 64

for knowledge again, a drive to be the best I could be and to provide the best possible treatment outcomes for my patients. With an ever-expanding aesthetics industry and the new products, machines, devices and treatments available, it is crucial to be continually developing your knowledge and skills. In entering the field I made it a priority to know as much as I could about everything available on the market, to know about the newest trends and techniques, and to attend as many international and domestic conferences and courses as possible. I had some key mentors and looked up to some of the leading figures in the industry, wanting to replicate their techniques and the results that they were achieving. This finally led to me setting up my own facial aesthetics business in central Manchester and as my knowledge, experience and skills grew, so did my loyal patient base. Job satisfaction became a huge priority for me and the shift in passion from dentistry to facial aesthetics became more of a reality. I still worked in dentistry at this time, as I needed to maintain an income whilst my business developed. Alongside working for myself, I also became the lead nonsurgical clinician at a plastic surgery group in Manchester and also worked in their London clinic, whilst doing cosmetic dentistry for a sister company. This time last year I was approached by investors to set up Regency Aesthetics in Upper Wimpole Street, Central London and was appointed as medical director. I am now a full time aesthetic practitioner and currently Aesthetics | June 2014

don’t carry out any dentistry work. People often ask whether my current career path is a waste of all my dental training, but I firmly believe that I wouldn’t be doing what I do now without my dental degree. I have skills that have transferred from dentistry: good manual dexterity, an acute eye for attention to detail and artistry, the ability to build rapport with patients together with an extensive and crucial knowledge of head and neck anatomy and physiology. I believe all these qualities only enhance my skills and ability as an aesthetic practitioner. The industry is comprised of many aesthetic practitioners from different specialties. Whether they are nurses, doctors or dentists, they have usually found themselves in the industry due to similar reasons as I did. Many have left their original vocation, others balancing their facial aesthetics work alongside their original careers. Many will use the skills and knowledge they’ve acquired previously and apply them to their aesthetics career but will also have to be continually learning and developing new skills in order to deliver the best results for their patients. The medical aesthetics industry is enriched when practitioners bring knowledge from related medical specialities into the field of aesthetics. This can provide a solid and vital grounding in medical skills and knowledge, coupled with a new perspective and a thirst for learning, driving us all to be the best practitioners we can be. Then, if we are willing to work hard enough and navigate the obstacles, there is the potential to, as Rumi put it, “Let the beauty of what you love be what you do”. Dr Rikin Parekh is a respected practioner of facial aesthetics in the UK. He was lead nonsurgical clinician at Surgicare Manchester and London, and lead dentist at The Hospital Group, Newcastle. He’s now medical director of Regency Aesthetics, London and is actively involved in training doctors, dentists and nurses across a number of non-surgical procedures. He is a KOL for ZO Skin Health and the Hyalual Institute.


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