Aesthetics June 2015

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Plastic Surgeon Mr Adrian Richards outlines his approach for rejuvenating the face

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Wendy Lewis explores the role of social media in aesthetic practice

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Julia Kendrick on database mining for maximising patient retention

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Contents • June 2015 06 News

The latest product and industry news

13 On the Scene

Special Feature Treating Scars Page 21

Out and about in the industry this month

14 Conference Reports

We report on the industry’s latest conferences

16 News Special: BAAPS Audit

A look at the latest audit from the British Association of Aesthetic Plastic Surgeons

CLINICAL PRACTICE 21 Special Feature: Treating Scars

Practitioners discuss their individual approaches to the treatment of scars

26 CPD Business Article

Wendy Lewis explores the utilisation of social media within aesthetic practice

33 The A-Lift

Plastic surgeon Mr Adrian Richards details his technique for achieving natural-looking aesthetic results

36 Aesthetics Awards 2015: Last Chance to Enter

Your final opportunity to enter the most prestigious industry awards

38 Botanical Stem Cells

Dr Vincent Wong highlights the role of stem cells in facial rejuvenation

40 Advanced Injectables: Part II

Dr Emma Ravichandran and Dr Simon Ravichandran address the anatomy and treatment of the lower face using injectables

44 Spotlight On: Fillerina

We explore the new no-needle dermo-cosmetic filler

47 Treating Sexual Dysfunction

Dr Catherine Stone discusses PRP as an effective treatment method for female sexual dysfunction

51 Microsclerotherapy

Aesthetic nurse Clare McLoughlin details the use of microsclerotherapy for the treatment of spider veins A round-up and summary of useful clinical papers

IN PRACTICE 57 VAT Registration

Veronica Donnelly offers insights into VAT registration for aesthetic businesses

60 The Power of Profiling

Clinical Contributors Wendy Lewis has authored eleven 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 Mr Adrian Richards is a consultant plastic and cosmetic surgeon. He is the clinical director of both Aurora Clinics and Cosmetic Courses, one of the the largest non-surgical training providers in the UK. Dr Vincent Wong is an aesthetic practitioner and founder of Harley Street clinic La Maison de l’Esthetique. He has extensive research experience in plastic surgery and dermatology, presenting nationally and internationally.

Dr Emma Ravichandran is a general dental practitioner with a special interest in aesthetics. She co-founded Clinetix Medispa in 2010 and is actively involved in creating a national audit pathway for aesthetic practice.

Dr Simon Ravichandran is an ear, nose and throat surgeon. After training in aesthetics, he co-founded Clinetix Medispa in 2010, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners (ASAP).

Dr Catherine Stone is a cosmetic practitioner with 15 years’ experience, based in Auckland, New Zealand. She also works at the PHI Clinic in Harley St, London, and is a global aesthetic trainer.

55 Abstracts

Marketing Power of Profiling Page 60

Julia Kendrick explains how to organise your patient database to ensure patient retention

Clare McLoughlin is an independent nurse prescriber and advanced procedure aesthetic nurse and trainer. She is also a member of the British Association of Cosmetic Nurses and the British Association of Sclerotherapists.

NEXT MONTH

• IN FOCUS: Sun • CPD: Forehead Rejuvenation • Ingredients in Sunscreen • Handling Online Reviews

63 Employment Law

Shubha Nath highlights key legal points that employers should be aware of when hiring or dismissing staff

66 In Profile: Lou Sommereux

We talk to Lou Sommereux about her journey into aesthetic nursing

68 The Last Word: Misconception of Stem Cells

Dr Ahmed Al-Qahtani looks at the misrepresentation of stem cell skincare products in the media

Subscribe Free to Aesthetics

Last chance to enter for the Aesthetics Awards 2015 Enter before June 30 www.aestheticsawards.com

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

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Editor’s letter As I write the editor’s letter this month, we find ourselves in the middle of the British Association of Dermatologist’s (BAD) sun awareness week. According to a recent survey, covered on p.7 of the journal, 96% of Brits fail to check their skin the recommended once a Amanda Cameron month for skin cancer. Worryingly, 72% admitted Editor to being sunburned in the last year and, as we know, the risk of developing melanoma is more than doubled in these circumstances. With skin cancer resulting in approximately 2,148 deaths annually, and as the weather gradually heats up in time for summer, we should take this opportunity to pause and reiterate the value of using a high SPF; the necessity of relaying this message to patients has never been so important. Continuing in a dermatological vein, our Special Feature this month looks at the treatment of scars (p. 20). Notoriously difficult to treat, scarring can be caused in many different ways and can have a huge impact on a patient’s selfconfidence. Whilst skin is pretty good at healing itself, how you treat it along the way can make a significant difference to a scar’s ultimate appearance. Our article features invaluable advice from practitioners specialising in this treatment.

Sclerotherapy is not talked about much these days, although 20

years ago it was hot news – why might this be? Is it because there hasn’t been much advancement in the administration of treatment, or has it been taken for granted that it is a safe, effective and easily performed procedure? We explore the treatment of spider veins with microsclerotherapy on p.49 and consider how microsclerotherapy as a method has evolved. The Aesthetics team and I are also thrilled to include our first business-related CPD article in this month’s journal.

Social media is becoming an ever-popular method of promoting aesthetic businesses, but, if daunting to some, Wendy Lewis’ guide to the free tools available provides an easy-to-navigate pathway to enhancing awareness of your aesthetic services.

I must take this final opportunity to remind you that entry for the Aesthetics Awards closes on June 30. Read the guide that you’ve received with this issue of the journal for exclusive tips on how to perfect your entry to ensure an elite standard. My advice is to take your time and consider the most relevant information for the category you are entering. Don’t be afraid to emphasise the excellent level of service and innovation you, your team or your product are offering to our specialty – be proud of your achievements and show us why you deserve to win!

Remember as always to give us your feedback.

Tweet us @aestheticsgroup or email editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

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

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

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

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Awards

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Injectables Plastic Surgery Hub @PSHAustralia Great Techniques being presented by @RajAcquilla for “injection facelift” @Cosmetex2015

#ClinicEvent Dr Ravi Jain @DrRaviJain Great to see my #BNI colleagues at @Riverbanks Open Evening. @PatrickFrozenp @simongeorge & Peter from Élan graphics

#Learning Dr Saira Vasdev @DrSairaVasdev Very excited today. Just booked myself on some advanced training modules with @drtapanp #aesthetics #learnfromthebest #patientsafety

One month left to enter the Aesthetics Awards 2015 With entry for the Aesthetics Awards 2015 closing on June 30, entries are flooding in from practitioners, clinics and companies across the specialty. To celebrate the profession, the glamorous ceremony will recognise the highest standards of clinical excellence, product and treatment innovation, and business accomplishments in 2015. Applicants should submit their entries via the Aesthetics Awards website and can submit answers for as many categories as they wish, however, may only enter each category once. Entry is open until June 30, before 2015’s finalists are announced and voting opens in September. A board of renowned aesthetic professionals will then judge each category, with eight awards being simultaneously voted on by Aesthetics journal readers. To be held on December 5 at the Park Plaza Westminster Bridge Hotel, central London, the Aesthetics Awards will provide an evening of entertainment, celebration and appreciation of the profession as a whole, ensuring it is a prime event on the aesthetic social calendar. See pages 36 and 37 for further details and for more information on categories and to enter this year’s awards, visit www.aestheticsawards.com Submental fat

#Training Frances T Traill @FTTraill Amazing day of learning with award winning @pdsurgery and @Anna32Baker #Youareinexperthands #aesthetics

#Allergan Dr Askari Townshend @Dr_AskariT @DavidEccleston great knowledge shared today at #Allergan Ad Board with @LipDoctorClinic @daviesemma5 @drjohnquinn et al. Good work guys

#NationalNursesDay InjectAbility Beauty @InjectAbility Happy #NationalNursesDay! We love our 3 fabulous, talented, caring, educated and beautiful nurses on staff!

FDA approves treatment for fat below the chin The Food and Drugs Administration (FDA) has approved Kybella as a treatment for moderate to severe submental fat. According to the FDA, the drug is identical to the deoxycholic acid that is produced in the body, which works to help the body absorb fats.

The safety and effectiveness of Kybella, also known as ATX-101, was established following two clinical trials that enrolled 1,022 adult participants with moderate or severe fat below the chin. Participants underwent treatment with either Kybella or a placebo for up to six treatments, and results indicated that reductions in submental fat were observed more frequently in those who received Kybella.

The FDA explained that Kybella is a cytolytic drug, which aims to destroy fat cells when injected into submental fat. It also warned that the drug could destroy other types of cells, such as skin cells, if it is inadvertently injected into the skin. Serious side effects include nerve injury in the jaw, which could cause an uneven smile, facial muscle weakness or trouble swallowing, according to the FDA. Other common side effects include swelling, bruising, pain, numbness, redness and areas of hardness in the treatment area. Dr Amy Egan, deputy director of the Office of Drug Evaluation III in the FDA’s Centre for Drug Evaluation, said, “It is important to remember that Kybella is only approved for the treatment of fat occurring below the chin, and it is not known if Kybella is safe or effective for treatment outside of this area.” The FDA added that Kybella should not be used if there is an infection at the injection site, and caution should be taken in patients who have had prior surgical or non-surgical aesthetic treatment of the submental area. Kybella is manufactured

by Kythera Biopharmaceuticals.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Skin cancer

Survey suggests majority fail to check their skin for cancer Around 96% of people in Britain fail to check their skin once a month for skin cancer, according to a survey conducted by the British Association of Dermatologists (BAD).

The results of the survey were released during Sun Awareness Week at the beginning of May. The survey gathered results from 1,018 British people over the summer of 2014, at various national events.

The results indicated that although 84% are worried about skin cancer in the UK climate, 96% did not check their skin monthly as recommended by dermatologists. Results further suggested that 72% of people had admitted to being sunburned last year, while more Botulinum toxin

Laser

Study indicates Botox refrigerated for four weeks does not yield detectable bacteria Results of a study have indicated that storing vials of reconstituted Botox for four weeks was not associated with detectable growth of bacteria or fungi. During the study, published in Aesthetic Surgery Journal, 108 patients underwent injections from 88 consecutive 100-unit vials of Allergan’s Botox, administered aseptically for essential blepharospasm, hemifacial spasm or facial rejuvenation.

Following the treatments, vials with remaining product were then refrigerated for four weeks, before contents were tested for bacterial or fungal growth, using standard test procedures. Although the results showed that the vials did not contain any detectable bacterial or fungal contamination after four weeks of storage, the authors recommend that users do not exceed the 24-hour usage limit, as instructed by the manufacturer.

T H E A R T O F FA C I A L R E J U V E N AT I O N

than a third (40%) have never checked their skin for signs of cancer.

The BAD advocates that educating patients on how to check their skin for cancer is key to addressing rising skin cancer rates. Charlotte Proby, professor of dermatology at Ninewells Hospital and Medical School in Dundee and chair of the BAD Skin Cancer Prevention Committee, said, “Rising skin cancer rates are a major health concern for the UK, and some dermatology departments are stretched to capacity trying to keep up with cases. Many people in the UK are aware of the dangers; however, this has yet to translate into a culture of sun protection and skin checking which would do a lot to curb the incidence and deaths from this disease.”

PicoWay receives FDA clearance for the treatment of pigmented lesions The Food and Drugs Administration (FDA) has approved the PicoWay picosecond laser as a treatment for pigmented lesions. PicoWay is a dual wavelength device, which uses 532 nm and 1064 nm wavelengths. The laser incorporates picosecond (one trillionth of a second) pulse duration in order to generate an ultra-short pulse and high peak power of laser energy on to the skin.

Syneron Candela, the manufacturer of PicoWay, claims that the photo-mechanical impact of the device optimises the fracturing of pigmentation.

Dr Thomas Proebstle, a Germany-based clinical professor of dermatology, has used the PicoWay for pigmented lesions since he acquired the device in 2014. He said, “The efficacy of the PicoWay is excellent, even on dark skin. Receiving FDA approval for the treatment of pigmented lesions gives confirmation of the safety and outcome of the device in a manner that patients can understand.” PicoWay was granted FDA clearance for the removal of tattoos in November 2014.

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Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

@aestheticsgroup Sun protection

NeoStrata adds SPF 50 to its product portfolio Skincare developer NeoStrata has added the Sheer Physical Protection SPF 50 to its Targeted product range. According to NeoStrata, the product protects skin from both UVA and UVB rays, whilst offering long-term skin health benefits. The company claims that titanium dioxide and zinc oxide provide broad spectrum UVA and UVB protection, while bionic and polyhydroxy acids work to strengthen the skin’s barrier function and help preserve skin’s natural collagen and elasticity. Sheer Physical Protection also contains antioxidants such as green tea extract, lactobionic acid and vitamin E, which aim to neutralise free radicals and combat oxidative damage to restore skin quality and texture. According to the company, the SPF is suitable for sensitive skin and all Fitzpatrick skin types, and is free of oil, fragrance, and parabens.

NeoStrata products are available in the UK via AestheticSource.

Vitamin drips

EF MEDISPA announces partnership with Vitamindrip EF MEDISPA has partnered with US-based intravenous micro-nutrient therapy company Vitamindrip to offer a range of drip treatments across its central London locations. According to Vitamindrip, its new range of 10 micro-nutrient mixes have been individually formulated to boost low immune systems, athletic performance and low libido, amongst other indications.

Following an in-clinic consultation, each treatment offered at EF MEDISPA will be tailored to individual patient requirements. Founder of EF MEDISPA Esther Fieldgrass said, “We have been offering clients intravenous vitamin and mineral drips for the past seven years, and pioneered the Drip & Chill lounge, providing clients with the advantages of IV infusions in rehydration and immune boosting treatments, in the comfort of a spa-style environment. Clients are demanding new formulations and we can now offer this for a wider range of conditions.”

Industry

Galderma to enter nutraceutical market Pharmaceutical company Galderma has announced that it will enter the nutraceutical market following the acquisition of certain assets of Innéov Group. The assets comprise, amongst others, nutraceutical brands Nutri-Care D, Duocap and Densiology. Stuart Raetzman, CEO of Galderma, said, “The nutraceutical category has a strong fit with our self-medication business. Many of the Innéov brands are complementary to our existing portfolio of skin health medical solutions. We look forward to expanding our range of nutraceutical products and to serving consumers needs around the world.”

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Vital Statistics 70% of potential patients say looking unnatural is their biggest fear when contemplating cosmetic treatment (Galderma)

29%

of women consider undergoing cosmetic procedures as the result of a milestone life event (RealSelf)

Breast reduction surgery procedures for women increased by 3% in 2014 (British Association of Aesthetic Plastic Surgeons)

Non-surgical fat procedures rose by 42% in 2014 (American Society for Aesthetic Plastic Surgery)

47% of rosacea patients surveyed were unaware of the condition prior to their diagnosis (National Rosacea Society)

Skin burns make up

79.5%

of indoor tanning injuries (JAMA Internal Medicine)

Over the last five years, cosmetic procedures for men increased by 43% (American Society for Aesthetic Plastic Surgery)

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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ACE

New sessions announced for ACE 2016

Aesthetics Industry

Murad partners with The Prince’s Trust

A new addition to the Aesthetics Conference and Exhibition (ACE) agenda has been announced for 2016.

The ‘Treatments on Trial’ programme will comprise two sessions, each focusing on a specific treatment type or patient concern and featuring four suppliers, who will pitch their product or device to the audience of 50 delegates. This brand new format will provide delegates with the ideal opportunity to directly compare products, as the industry’s leading suppliers go head to head. With 20 minutes for each supplier to concisely summarise and demonstrate the benefits that their products offer, sessions will conclude with a 20-minute chaired question and answer panel debate with all four key opinion leaders. Delegates in attendance will have the chance to challenge manufacturers and distributers on the safety and efficacy of their treatment against other similar options, helping them to make an informed decision about the services that they provide. ACE 2016 will be held on Friday April 15 and Saturday April 16 in Central London.

To stay up to date with all the latest announcements regarding Aesthetics events, sign up to receive our weekly e-newsletter at www.aestheticsjournal.com

Skincare manufacturer Murad has chosen The Prince’s Trust as its first charity partner in the UK. To celebrate the announcement, Murad is offering a special edition Prince’s Trust version of its Rapid Collagen Infusion product. Of every item sold, £10 will be donated to the charity. According to the skincare company, Rapid Collagen Infusion comprises micronised collagen amino acids that aim to hydrate and plump the skin, whilst improving the appearance of wrinkles.

The Prince’s Trust supports disadvantaged 13 to 30-year-olds, offering practical and financial support to help develop their self-esteem and skills ready for future employment. Of the news, founder of Murad Dr Howard Murad said, “I am thrilled The Prince’s Trust is our charity partner. At Murad we strive to make younger generations feel worthy of having a bright future and working with The Prince’s Trust means we can support our future generations, by helping young people improve their lives and fulfil their potential.”

Laser

Ellipse introduces new waveband technology device

Intense pulsed light (IPL) and laser provider Ellipse has launched the Nordlys platform in the UK. The device uses both laser and Selective Waveband Technology (SWT) to offer treatments for a variety of indications, including acne, benign vascular lesions, pigmentation, rosacea, skin texture and port wine stains. Each of the six applicators has a different wavelength or area size to aid successful treatment. An Nd:YAG applicator, using a 1064 nm wavelength with an adjustable spot size is also included with the device. Aesthetic practitioner Nicola Jones, a user of the Nordlys platform, said, “The Nordlys by Ellipse eliminates the need for many different lasers due to its ability to address many aesthetic concerns, ranging from permanent hair reduction, melasma, port wine stains, poikiloderma of Civatte and PDT treatments to previously challenging infantile haemangiomas.” She added, “Ellipse is a pioneer of constantly evolving technology and I am delighted to have access to such an outstanding piece of equipment.”

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Events diary 7th – 9th July 2015 British Association of Dermatologists (BAD) Meeting, Manchester www.bad.org.uk/events/annualmeeting

31st July – 2nd August 2015 International Master Course on Aging Skin (IMCAS), Asia www.imcas.com/en/asia2015/congress

19th – 23rd August 2015 American Academy of Dermatology (AAD) Summer Meeting, New York www.aad.org/meetings/2015-annualmeeting/general-information

25th - 26th September 2015 F.A.C.E2F@ce conference 2015, Cannes www.face2facecongress.com/en

26th September 2015 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

3rd October 2015 British Association of Cosmetic Nurses Conference, Birmingham www.bacn.org.uk/events/bacn-annualconference-exhibition

5th December 2015 The Aesthetics Awards 2015, London www.aestheticsawards.com

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Skin cancer

Study supports efficacy of OCT device in diagnosis of BCC Results of a study have indicated that the new multi-beam VivoSight Optical Coherence Tomography (OCT) device can efficiently diagnose basal cell carcinoma (BCC). Published in the British Journal of Dermatology, the results of the research suggested that there was a significant increase (75.3%) in the specificity (the percentage that test negative when BCC is not present) compared to clinical assessment alone (28.6%). According to the results, using a dermoscopy in addition to clinical evaluation only resulted in a 54.3% increase in specificity. Overall, the study indicated that there was an increase in the accurate diagnosis of lesions from 65.8% at clinical evaluation alone to 87.4% by using VivoSight. Creating high definition images of all the layers of the skin, VivoSight aims to show accurate delineation of the size and depth of lesions, thereby potentially reducing the need for biopsies, and allowing the practitioner to assess various skin conditions with little intervention. Andy Hill, the CEO of the manufacturer of VivoSight, Michaelson Diagnostics, added, “The results of the study unequivocally show, for the first time, the clinical value of using OCT in the diagnosis of tumours such as BCC, and can potentially limit the need for biopsy or surgery and, thus, subsequent scarring.” VivoSight has CE/TGA and FDA 510(k) clearance.

Training

Social media

Dr Raj Acquilla to host training session at the Heathxchange Academy Aesthetic practitioner Dr Raj Acquilla is set to deliver toxin and filler training at the Healthxchange Academy on June 20 and 21. As an Allergan country ambassador and international speaker, Dr Acquilla is renowned for his skilful injecting techniques and engaging presentations.

On June 20 he will deliver foundation theory toxin and filler training at the Manchester-based academy, followed by a practical foundation session on June 21. Dr Acquilla will then host an ‘Intensive Refresh and Progress’ training session on July 11. The training is the first on offer from a programme of courses on toxins and dermal fillers, organised by the Healthxchange Academy.

Survey indicates that surgeons believe social media causes unrealistic patient expectations A survey has highlighted that many surgeons believe patients are more likely to have unrealistic expectations of results due to social media. According to the results, 85% of surgeons felt that information found on social media by their patients could lead to unrealistic expectations, while 29% claimed their consultations were now more difficult following the advent of social media. It further indicated that 95% of patients used the internet to research the treatment prior to consultation, highlighting that 46% of these patients used social media.

The study concluded that although the internet and social media have led to more informed patients, neither can replace the face-toface consultation and this should remain a detailed process in order to ensure realistic patient expectations, covering both the risks and limitations of aesthetic procedures.

The questionnaire, completed by 128 plastic surgeons across 19 countries, was also completed by 500 patients prior to consultation.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Aesthetics

Tattoo removal

Centros Unico collaborates with Fotona Lasers to offer tattoo removal in its UK clinics Laser hair removal specialist Centros Unico has collaborated with global device manufacturer Fotona Lasers to offer tattoo-removal across its UK clinics. The clinic chain will initially launch Fotona Lasers’ QX MAX laser system, a Q-switched, single pulse laser, in four of its clinics, before rolling it out nation-wide. Managing director of Centros Unico David Smith said, “Our emphasis on the best quality of treatment at an affordable price means that Fotona is a natural choice in the selection of suitable laser equipment.” He continued, “The Fotona QX MAX is not only a world-leading laser for tattoo removal, but also offers a range of additional applications, like pigmentation and skin whitening, that will ensure Centros Unico has a great aesthetic platform and our clients will have access to even more advanced aesthetic procedures.”

Topical

DermacareDirect introduces range of microdermabrasion creams Online skincare distributor DermcareDirect has added three microdermabrasion products to its DermaTx range. According to the company, Brighten, Clarify and Rejuvenate each contain active ingredients to target specific skin concerns, along with professional-grade aluminium oxide crystal abrasives that work towards an effective peeling effect. Brighten contains Sabiwhite and Achromaxyl to target uneven skin tone, sun-damaged and ageing skin; Clarify uses salicylic acid and retinol which aim to improve the appearance of acne, oily skin and enlarged pores; while Rejuvenate contains lactic acid and vitamins C and E, which DermacareDirect claims are suitable for normal to sensitive skin. The company explains that the creams were developed for use alongside the DermaTx Cleanse & Exfoliate 2-in-1 device, to provide a ‘Complete Resurfacing System’. The products can be incorporated into professional protocols and retailed to patients for home use.

Topical

Futurederm launches Age Erased Skincare manufacturer Futurederm has launched a topical serum to target visible signs of ageing. Age Erased contains Argireline, an active ingredient that is used in botulinum toxin and aims to prevent the formation of wrinkles.

Futurederm claims that the product reduces the signs of ageing within 60 seconds and can last for up to eight hours. Owner of Isle of Wight Advanced Aesthetics Elaine Harrison said, “It’s been great to provide my clients with an alternative to invasive wrinkle injections. Age Erased has been a great addition to my business as a daily product.”

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Nadja Collin, Marketing, Sales and Digital PR Manager at MACOM Medical What does MACOM do to stay at the forefront of the compression garment market?

MACOM has been around for eight years now, and although we are still classified as a small business we have grown to become the leading provider of surgical compression garments in the UK. The road to success stems from working closely with plastic surgeons, doctors, nurses and aestheticians, and encouraging their feedback.

We have recently launched our much-anticipated anti-cellulite leggings, Crystal Smooth, which are made of emana® fibre, a patented intelligent material woven with bio active crystals which absorbs body heat and returns it to the skin in the form of far infrared rays. They are worn just like a normal pair of leggings; all the while fighting cellulite, improving lymphatic drainage, increasing collagen synthesis and blood microcirculation.

What benefits do Crystal Smooth bring to your clinic?

Although Crystal Smooth have been scientifically proven to treat cellulite when worn daily, even without a professional treatment, there is strong clinical evidence showing they will significantly enhance the result of any professional cellulite or firming treatment too. They are totally pain free to wear, in fact, it feels like wearing a silky second skin, and, due to their thermo-regulating properties, a patient wearing the leggings immediately after any professional treatment will see optimised results.

What does the future hold for Crystal Smooth?

We are launching a sleepwear range in the same patented cellulite-fighting material as our professional leggings. The sleepwear range will be even more feminine, and the two ranges complement each other by encouraging patients to wear Crystal Smooth as much as possible; the more Crystal Smooth is worn, the more powerful the results. In a recent clinical study, it was documented that after wearing Crystal Smooth leggings daily for six weeks there was an 88% improvement in blood microcirculation. This, in conjunction with our sleepwear, and alongside the aesthetic treatment, will pave the way for some truly incredible results.

This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Topical

Youth Serum launches in UK Cosmeceutical manufacturer iS CLINICAL has launched its anti-ageing formulation, Youth Serum, in the UK. A clinical study evaluated Youth Serum’s ability to encourage collagen synthesis in aged human fibroblasts at the equivalent age of 50 years.

Results of the study, conducted at the Skin Investigation and Technology centre in Hamburg, indicated that the product rebuilds collagen, repairs and protects DNA, and reduces the appearance of fine lines and wrinkles. The Youth Serum formula comprises a blend of copper tripeptide-1 growth factor, vitamins A, E and C, centella asiatica, as well as proteins, extremozymes and proprietary enzymes, which iS CLINICAL claims all have anti-ageing effects. iS CLINICAL is distributed by Harpar Grace in the UK. Training

New date set for Aesthetic Business Network workshop The Aesthetic Business Network has changed the date of its regional business workshop, originally planned for June 16. The event will now take place on September 29 at the Custard Factory in Birmingham. Created by Richard Crawford-Small, founder of iConsult software, the Aesthetic Business Network aims to offer aesthetic business owners creative and effective solutions for their business issues. The group comprises a range of experienced business advisors, including branding expert Russ Turner and Aesthetic Response owners Gilly Dickons and Jo Fisher. Founder of Aesthetic Business Transformations Pam Underdown, who developed the Aesthetic Business Network concept alongside Crawford-Small, said, “I am really excited about our first regional training workshop. Our autumn event will enable all attendees to re-focus their business after the summer period and ensure they are quickly back on track to achieve a great end to the year.” She added, “The workshop will be a masterclass of the latest business and marketing strategies and all attendees will leave with a workable plan of action that is quick and easy to implement the moment they return.”

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News in Brief BTL appoints new UK sales manager Medical device manufacturer BTL Aesthetics has appointed Vanessa Bird as its UK sales manager. Bird, whose background lies in body shaping technology selection, will use her experience to help clients develop with BTL devices. Of her appointment, Bird said, “I know that combining my expertise in non-surgical anti-ageing treatments with the BTL range will help many clinics build their businesses successfully.”

HydraFacial UK announces new brand ambassador Award-winning businesswoman Karren Brady has been confirmed as the brand ambassador of HydraFacial UK for 2015/16.

Director of HydraFacial UK Martyn Roe, said, “With Karren Brady as brand ambassador, we hope to boost awareness of the product and, as a result, increase the already strong demand of HydraFacial treatments around the UK.” The treatment combines cleansing, exfoliation, extraction, hydration and antioxidant protection for revitalised skin.

Courthouse Clinics appoints new clinical director Aesthetic practitioner Dr Amanda Wong Powell has been appointed as the clinical director of Courthouse Clinics. In her new role, Dr Wong Powell will practise primarily at the Wimpole Street clinic in London, though will visit the other clinics regularly. Dr Wong Powell will also assist the Courthouse medical directors in monitoring company medical standards, whilst evaluating new and innovative treatments to expand the services Courthouse Clinics offers.

Topical

SkinCeuticals Double Defence packs now available for clinic retail SkinCeuticals has announced that clinics with company accounts will now be able to stock its Double Defence packs. Each pack contains an SPF and an antioxidant formulation, aiming to protect against photoageing and the appearance of skin ageing. Practitioners will now be able to offer patients a choice from three antioxidant formulations; Phoretin CF, C E Ferulic and AOX Eye Gel, and three sunscreen formulations.

Sunscreen options include; Mineral Radiance Defense SPF 50, Ultra Facial Defense SPF 50 and Mineral Eye UV Defence SPF 30.

Correction In the May issue of Aesthetics we published an article entitled ‘A Review of Vitamin A’ written by Roger Bloxham and Antony Wakeford. The article referenced the NMC standards of proficiency for nurse and midwife prescribers, quoting a section of the guidance that advised that independent nurse prescribers should not prescribe unlicensed medicines. This specific NMC guidance has been superseded by a circular and this statement is therefore incorrect. The correct updated status of the NMC guidance is that nurse and midwife independent prescribers are able to prescribe unlicensed medicines. The authors wish to apologise profusely for this error.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Aesthetics

S-Thetics launch, Beaconsfield Friends, colleagues, local businesses and potential patients were invited to attend the S-Thetics clinic launch in Beaconsfield, Buckinghamshire, on May 2. More than 80 attendees joined aesthetic practitioner and surgeon Miss Sherina Balaratnam, founder of the new clinic, for drinks and refreshments, as Steve Jones, the Lord Mayor of Beaconsfield, cut the ribbon to declare the business officially open. During the afternoon, those who attended had the opportunity to watch demonstrations of skin analysis using VISIA imaging software, and skin tightening with radiofrequency using EndyMed 3DEEP technology. With more than seven years in aesthetic medicine, Miss Balaratnam explained that she plans to promote skin health through her new clinic. Of the event, Miss Balaratnam said, “I’m absolutely delighted to be opening my first medical aesthetic clinic here in beautiful Beaconsfield, which is now my home, and to be part of the local community. My goal is to see my patients learn about and benefit from the treatments we offer, to age well and to enjoy healthy and happy skin.” Beaconsfield resident and guest Annas Eskander added, “It is reassuring to know that such advanced technology is being introduced and used by qualified and skilled practitioners like Miss Balaratnam and I’m delighted that it is now available in Beaconsfield.”

Step Ahead in Aesthetics, Huddersfield The Private Independent Aesthetic Practices Association (PIAPA) joined with Merz Aesthetics to host its Step Ahead in Aesthetics event on April 28 at the John Smith Stadium in Huddersfield.

The day-long event, designed to assist aesthetic practitioners in all aspects of their practice, addressed topics from beneficial medical aesthetic techniques, to marketing, regulation and business support. The main feature of the day was a question and answer session with Bristol-based aesthetic practitioner Dr John Quinn, which explored the complications associated with hyaluronic acid (HA) fillers. This was then followed by a demonstration of how to use HA fillers to treat volume loss in the brow, mid-face and peri-orbital regions.

Other sessions focused on utilising social networking platforms for marketing, and a discussion of the new Nursing and Midwifery Council’s revalidation process took place. Simon Offei, regional business development manager for Merz, also talked to delegates about how to use personality profiling to excel their communication skills when meeting new patients and business associates.

PIAPA chair Yvonne Senior said, “‘It was great to once again host a conference focused on learning and progress that was received so well by members and attendees. Both PIAPA and Merz really care about the progression of aesthetic practitioners and enjoy being able to support each other through interactive and participatory learning in meetings like this, in a time of integral changes within the profession.”

BACN Super Meeting, Bristol The British Association of Cosmetic Nurses (BACN) held its first South West and Wales Super Meeting at the Novotel Bristol City Centre on May 8.

The meeting, supported by Merz Aesthetics and Church Pharmacy, began with an update on the Nursing and Midwifery Council’s revalidation process, followed by a presentation from vice chair Andrew Rankin on using hyalase in practice. Delegates were then introduced to Church Pharmacy’s e-prescribing system, DigitRx. Co-director of Church Pharmacy Zain Bhojani said, “The BACN nurses are a critical part of our business, so being able to present to them the latest in e-Prescribing technology has been great for both parties.”

After lunch, ophthalmologist and aesthetic practitioner Dr Tahera Bhojani led a demonstration with Merz’s Belotero dermal filler for eye and cheek rejuvenation.

Jayne Laferla, aesthetic nurse and regional leader for the South West and Wales, concluded, “It is a big thing to take a day out of your clinic, but when you can get so much information, training, CPD points and an update on BACN activity all as part of the new BACN Membership Package, it is well worthwhile.”

ELLANSÉ and Perfectha National Training Day, London Global pharmaceutical company Sinclair Pharma invited practitioners to attend its ELLANSÉ and Perfectha National Training Day at the Royal Society of Medicine in London on April 24. Throughout the day, guest speakers presented their practical and clinical knowledge of the dermal filler products, offering delegates the opportunity to view procedure demonstrations in the afternoon. Among the speakers who presented, aesthetic practitioner Dr Askari Townshend spoke on the efficacy and safety of ELLANSÉ in the morning, whilst nurse prescriber Sharon King discussed the basis of Perfectha and E-brid technology in the afternoon. Discussions and presentations further focused on identifying suitable patients for treatment with ELLANSÉ whilst also addressing new trends in aesthetics. “We are committed to providing a gold standard of education for our medical clinicians to pass onto their clients,” said Katrina Ellison, brand manager for Sinclair Pharma. “Attendees were impressed with the calibre of speakers and the level of knowledge and practical expertise they were able to share.” During the event, Dr Townsend argued that, “ELLANSÉ is genuinely new technology, not just old technology with a different stamp. It gives great volume that really lasts.”

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Face, Eyes & Nose Congress, Coventry Aesthetics editor Amanda Cameron reports from the fresh cadaver dissection and lecture course, hosted by the University Hospitals Coventry & Warwickshire NHS Trust It was a privilege to attend the first day of the Face, Eyes & Nose (FEN) congress, which took place from May 13-17. The day comprised an array of engaging topics, which were supported by the British Association of Aesthetic Plastic Surgeons (BAAPS), the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and the UK Association of Aesthetic Plastic Surgeons (UKAAPS). The agenda offered delegates a window into the latest techniques, ranging from non- and minimally-invasive surgical facial aesthetics, and surgical and non-surgical rhinoplasty, through to aesthetic reconstruction for facial burns and face transplantation. During the day, Professor Andy Pickett gave an update on the developments with botulinum toxin, including a review of the current literature and the plethora of novel indications – covering dermatology, lower face rejuvenation and fibroblast expression. Consultant plastic and reconstructive surgeon Mr Lucian Ion then gave a fascinating overview of the benefits of 3D imaging. As Mr Ion explained, we are living in times of change where social media and ‘selfies’ have made a huge difference to patient expectations, and distorted images now influence what is considered ‘normal’.

Mr Ion pointed out that tools such as 3D imaging are extremely valuable in helping patients decide on a cosmetic surgery

treatment plan during the consultation process. Plastic and cosmetic surgeon Mr Alex Karidis gave a very thorough talk on the support that is needed throughout a patient’s facelift journey.

He argued that the actual surgery was a very small part of the process and that his support team was critical in alleviating the concerns and fears of patients. Interestingly, he noted that he never discharges his patients as he feels he always has something to offer them following treatment. Professor Andrew Burd then presented a thought-provoking talk on facial reconstruction following acid attacks. He talked through the management of these cases and stressed that facial form and function following surgery is critical. Professor Burd concluded by emphasising that a patient may look beautiful following a procedure, but if they are so damaged that they cannot eat, the surgeon has not done a good reconstructive job. There was also an interesting discussion on using fillers for tear trough and mid-face hollows from the president of the European College of Aesthetic Medicine and Surgery (ECAMS), Dr Peter Prendergast, and Mr Andrew Batchelor gave a high-quality, highly entertaining and relevant presentation on avoiding litigation. All in all, FEN comprised a very full agenda with many eminent speakers, and the course director, consultant plastic surgeon Mr Rana Das-Gupta, is to be congratulated on yet another year of delivering an impressive programme.

ASAP conference, Glasgow Dr Sam Robson reports on the highlights from the fourth annual Association of Scottish Aesthetic Practitioners conference Taking place on May 8-9, the annual Association of Scottish Aesthetic Practitioners (ASAP) conference was held at the Radisson Blu Hotel in Glasgow. There was a friendly, intimate air to the conference, with an audience comprising a mixture of doctors, dentists and nurses, with many new faces present. The varied agenda covered clinical practice, business development, tax updates and an opportunity to watch international experts showcase their talent for rejuvenating a face. Founder and chairman of ASAP Dr Simon Ravichandran and his wife, Emma Ravichandran, smoothed over any cracks and compered both days’ proceedings excellently. Bryce Renwick gave a brilliant presentation on microsclerotherapy and, having grasped the attention of all those present, took the opportunity to drive the message home on good patient care. He responded well to questions from the floor, which highlighted that thorough assessment before treatment is key. Veronica Donnelly spoke on understanding VAT, giving fresh hope to those of us worrying about HMRC. Ann McNall gave an interesting overview of postgraduate aesthetic medicine training. With nurse revalidation and appraisal now a ‘hot topic’, the meeting seemed an appropriate arena for raising such awareness. Featured on both days, Dr John Quinn was widely considered to be the star attraction of the weekend. He was consistently fluent and informative throughout, remembering to deliver educational messages and jokes on both

days in his charming, unique style. The presentation given by the Blowmedia team reminded me of just how many ways we can use digital media to market our clinics. Covering websites, social media, e-marketing and the importance of brand awareness, I realised that the generation of ‘technologically literate’ practitioners are leading the way. The Blowmedia team stressed that protected time must be set aside for this aspect of communication to really be effective.

One of the only disappointments of the day was witnessing the lack of respect shown by some members of the audience during presentations. A shocking lack of awareness of etiquette, talking and making phone calls through some of the speakers presentations, and continuing to take photos of the slides, despite repeatedly being requested not to, was very inconsiderate and unprofessional. I would hope that this doesn’t happen again in the future. The venue and catering were surprisingly good, and I was pleasantly delighted to feel it had been worth giving up one of my precious Saturdays in order to attend. ASAP will definitely be on my educational calendar next year.

Dr Simon Ravichandran, the founder and chairman of ASAP, told Aesthetics, “The 4th annual ASAP conference was a resounding success. The agenda of live demonstrations, coupled with industry updates and top-level business insights, has raised the bar yet again.”

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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The Changing Face of Beauty With the latest BAAPS audit showing a 9% drop in the number of cosmetic surgical procedures performed in 2014, Ruth Donnelly asks whether the nation’s tastes are changing in favour of non-surgical alternatives The British Association of Aesthetic Plastic Surgeons (BAAPS) published the findings of their 2014 audit in January, with a surprising revelation: after rising steadily for ten years, the number of people undergoing cosmetic surgery last year plummeted by 9%.1 “The difference between 2013 and 2014 may seem surprising, but the dramatic doubledigit rise last year was clearly a post-austerity ‘boom’, and figures are now returning to a more rational level,” says former BAAPS president Rajiv Grover. However, could there be more to it? With the range of non-surgical treatments expanding and increasing in efficacy almost by the month, and with big name products such as Botox and Restylane now well established and largely trusted by patients, could it be that consumer focus has shifted away from surgery and towards minimally invasive treatments?

Blurred lines Given the current lack of regulation regarding medical aesthetic procedures, it is practically impossible to get a true approximation of the number of people undergoing non-surgical cosmetic treatments each year. While the British Association of Cosmetic Nurses (BACN) and British College of Aesthetic Medicine (BCAM) do carry out audits, they don’t audit the number of procedures performed in the same way that BAAPS does. Even if they did, a like-for-like comparison may well be wildly inaccurate, as one patient might have four botulinum toxin treatments within a year, which would appear as four separate procedures within an annual audit, whilst a facelift patient is unlikely to return within a decade. This means that a surgical audit offers a much more realistic idea of the number of patients choosing to undergo surgery than a non-surgical audit is able to produce of non-surgical procedures.

Added to that, these industry organisations – even the BACN, which has 800 members and growing – represent a relatively small proportion of the total number of people performing medical aesthetic treatments in this country. With beauty salons on every

high street in the UK offering laser hair removal, facial injectables and more, it is reasonable to assume that any numbers produced by the official governing bodies can be multiplied several times to get close to the true figure.

An upward trend However, the few statistics available suggest that non-surgical procedures are on the up. The Harley Medical Group, who offer both surgical and non-surgical procedures and so can be considered as an impartial source in this respect, reported a 10% increase in the number of non-surgical treatments performed last year.2 Bernadette Harte, non-surgical manager at the Harley Medical Group, attributes this upsurge to a more demanding public that knows what it wants. She says, “What patients are looking for is subtle enhancement, where they can go back to work the next day... they cannot afford the downtime [associated with surgical procedures].”

Marketing matters It is also true, however, that the Harley Medical Group increased its advertising spend on the non-surgical side last year, and as BCAM president Dr Paul Charlson explains, marketing activity can muddy the waters. “I have seen an increase in my own practice,” Dr Charlson states, “but it’s difficult to judge because I’ve made changes in my practice in the last year, I’ve changed my advertising and I’ve got a higher profile.”

As one of the largest cosmetic surgery and non-surgical providers in the UK, it is unlikely however that the Harley Medical Group would invest money in advertising without good reason and, in fact, a OnePoll survey commissioned by the group in 2014 showed that 17% of UK women were considering nonsurgical aesthetic treatments,2 compared to 9% considering cosmetic surgery,2 so it is likely that their increased marketing spend was based on prediction of a trend.

A more sophisticated market?

One suggestion by BAAPS for the drop

Aesthetics aestheticsjournal.com

in surgery last year was that the market is becoming more sophisticated, with the public becoming “more thoughtful, cautious and educated in their approach to surgery,” according to Mr Grover. Many non-surgical practitioners seem to support this view. Dr Charlson, for example, says, “People realise the potential of what you can do now. People don’t come to me and say I want Botox, they’re saying ‘what can you do around my eyes?’” Sharon Bennett, nurse prescriber and chair of the BACN, has a different view.

“Patients believe they are better educated, and they certainly have a lot of information, but it’s not always correct.” Bennett believes that it is the practitioners themselves who are becoming better educated about alternative or combination treatments, which may be able to provide patients with improved overall aesthetic results.

Operating with caution Another possible reason for this shift from surgery is that surgeons themselves are offering more non-invasive options. As Dr Charlson contends, “I think more and more surgeons are beginning to see the value of performing non-surgical procedures instead, to put off surgery to a later date.”

In the wake of the PIP scandal, however, which most of the practitioners interviewed suggested was a possible reason for the fall in breast augmentation operations performed last year (23%1), is there a more pressing reason for surgeons to expand their minimally-invasive offering? “I suspect that insurance costs and the attitude of the insurance industry to cosmetic surgery means that surgeons are becoming more cautious about who they choose to operate on, and are probably treating fewer patients as a result,” Dr Charlson speculates.

Best face forward It remains to be seen whether the BAAPS figures represent a one-off blip in an otherwise upward trajectory for cosmetic surgery, or whether patients really are becoming more reluctant towards surgery, but reports from the industry show a booming specialty that continues to grow.

Whether this is due to a savvier public, better-educated practitioners or more reluctant surgeons, or – more likely – a combination of each, the future looks very bright for medical aesthetics.

REFERENCES 1. The British Association of Aesthetic Plastic Surgeons, Tweak not Tuck, (UK: BAAPS, 2015) <http://baaps.org.uk/about-us/press- releases/2039-auto-generate-from-title> 2. References available via the Harley Medical Group

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

See us at Stand 19

4th - 7th June

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Treating Scars Present in a variety of shapes, sizes and severity, scars can mark a physical and psychological burden. We ask six aesthetic practitioners to share their approaches to treatment “Let’s start by saying that scaring is a permanent condition,” says dermatologist Dr Maria Gonzalez, “because you can never bring the skin back to what it was before the scar was there. That is something I tell everybody before we even embark on treatment – I don’t want patients to have unrealistic expectations.”

Managing and maintaining realistic expectations is paramount in the treatment of scars in aesthetics. As multifactorial as they are unpredictable, scars represent a psychological and physical challenge that requires a case-by-case approach, and a plethora of clinical tools. Scars are, of course, not uncommon. A scar is the mark of a wound that has healed, where, following a break in the body’s tissues, collagen is produced in order to build up over the damaged area and heal it. Scars can be caused by an injury to the skin, or develop as a consequence of certain skin conditions. For a period of three months, or sometimes longer, this new collagen continues to form.1 As beneficial as this healing process is to the human body, some scars represent a cosmetic burden; an unwanted mark that patients seek to remove.

Aesthetic practitioners treat a variety of external scarring. This can range from scars caused by accidents to post-surgical scarring, stretch marks, and scars caused by acne. Scars themselves can be further divided into: flat, pale scars, which are the most common; hypertrophic scars, those that remain raised and red for a number of years; and keloid scars, perhaps the most difficult to treat of Before Fraxel 1550 all.1 These are the scars that grow and expand beyond the boundaries of the original wound, explains medical director of the Mayfair Practice Dr Jamshed (JJ) Masani, and this is due to an excess of scar tissue being produced. Dr Gonzalez adds, “Whether you get keloid scars from acne or from some other traumatic cause, keloid scars are tricky business. When you treat them they seem fine, but they tend to re-grow at some point later on. It’s very difficult for both for the practitioner and patient.”

Acne scars fall into further categories, explains Dr Gonzalez. “There are the scars that look like craters – we call them boxcar scars – where the sides of the walls are parallel,” she says, “Rolling scars are those scars that are tethered, so the skin actually has a ‘dip’. And finally the ice pick scars; if you see acne patients, the name is very fitting – you are able to see what look like little holes on the face.”

How the scar was obtained, how the patient’s

skin reacted to the wound, and its subsequent path to healing are all factors to consider when choosing the best approach to treatment.

In the face of many variables, consultation is key. Dr Carolyn Berry, medical director of Firvale Clinic, establishes the history of the scar, how long it has troubled the patient, how it effects their lives and what spurred them to come for treatment, before taking a full medical history and examining the scar in order to establish the correct treatment. “That very much depends on the type of scar,” she says, “and the problem, because there’s quite a variation with regard to what we are dealing with.”

The ‘problem’ can often be the accompanying psychological effect of the physical symptom. Research has shown that one in two women suffer on-going psychological issues due to stretch marks and scarring.2 Young and Hutchison found that ‘patients are highly concerned about scarring following routine surgery, with most patients valuing any improvement in scarring’.3 These psychological factors will have an effect on the patient’s needs and expectations, and is something that all practitioners interviewed agree should be addressed at the initial consultation.

“Acne scarring has a major psychological impact on those affected,” says Dr Gonzalez. “Younger patients are much more severely affected than older ones. Many female patients wear thick layers of makeup at all times in order to camouflage the problem. Young men often restrict One month post treatment #4

Images courtesy of Solta Medical Aesthetic Center

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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their activities because they struggle with face-to-face interactions, assuming that everyone is looking at their face. Many of my patients also use sunbeds heavily because they believe the tan hides the scarring. This, of course, is only damaging their skin more. Successful treatments can have a major impact on patients’ self-esteem, completely transforming their lives.”

Prevention The type of scar in question determines the controllable variables. For accidental scarring, for example, aesthetic practitioners can provide no prevention as such. For post-surgical scars, the scenario is different.

Scarring can be divided into factors the practitioner can control, and factors outside of that control, says plastic surgeon Mr Alex Karidis.

“Scarring is inevitably unpredictable,” he explains, “as surgeons, we work towards improving our techniques, which in turn leads to better outcomes in terms of scars.”

Surgical planning, he says, is central for maintaining as much control as possible. One aspect of this is the avoidance of tension between the skin edges when closing an incision. “Tension kills the prospect of a good scar. Whenever you have tension in any given point in an incision you’re likely to get stretched scars, thickened scars, hypertrophic scars and ultimately, even possibly, keloid scars. I want to plan in such a way that my skin edges are not under unnecessary tension.”

“Technique is really important,” Mr Karidis continues. “The more trauma you subject your tissue to the more inflammatory responses you are going to get from the body.” These individual factors, he says, can make the different between an unsightly and subtle scar.

For acne scars, treatment of the underlying infection is central to the prevention of scars, or further scarring, explains Dr Gonzalez. “If you have severe acne, you need to be appropriately treated to switch that acne off, to prevent further scarring. If you are not able to switch that acne off, the patient will continue to have problems,” she says.

Plastic surgeon Ms Angelica Kavouni agrees, prescribing her acne scarring patients with topical products, antibiotics taken orally, and depending on the case, red light and blue light therapy in order to address bacteria.

Treatment For the treatment of keloid scars, Dr Gonzalez deploys the use of a protein injection. “Hypertrophic and keloid scars tend to respond better to injected triamcinolone [acetonide (TAC)], a steroid injection,” she explains. “If the keloid scars are very hard and large they can be hard to inject, so I tend to use a pulsed dye laser (PDL) first, to soften the scar, and then inject the triamcinolone following that. Triamcinolone is an old treatment, but still amongst the most successful treatment there is for keloid scars.”

For the treatment of depressed acne scars, such as rolling scars where Before

Aesthetics

“Technique is really important,” Mr Karidis continues. “The more trauma you subject your tissue to the more inflammatory responses you are going to get from the body.” the skin shows a dip, both Dr Gonzalez and Dr Masani use the method of subcision, “Which means you put a needle in and cut out all the fibrous tissue. Otherwise, the scar will just pull the skin down,” explains Dr Masani. Following subcision, Dr Masani goes on to treat the majority of his acne patients with carboxytherapy and a fractional modality. “It could be laser, such as the Legato from Alma Lasers, or it could be a mechanical piece of equipment like Dermapen [a micro-needling device]. With Dermapen you’re making several holes mechanically, whereas with the Legato, you’re using radiowaves to make holes.

You’re using three modalities that are completely different.”

Stretch marks are often not considered scars in the traditional sense.

These are, however, the main area of concern for the majority of Dr Berry’s patients. The most severe of these cases, she says, can often be found on the abdomen, following childbirth. In her treatment protocol, Dr Berry deploys the use of a fractional CO2 resurfacing laser, combined with injections of platelet rich plasma (PRP). “I find that using PRP and injecting it immediately afterwards makes a huge difference in the effect and in the healing process,” she says. “One probably needs to do that at least twice to see the results, or if the stretch marks are very bad then three times, maybe four.” Dr Berry allows, on average, a month to six weeks between each treatment.

If further action is necessary, Dr Berry adds another stage to the treatment in the form of Silhouette Soft Sutures.

“I may put Silhouette Soft sutures in the abdomen to improve tightness,” she explains. “Because stretch marks are atrophic scars, we can get quite an improvement with the [fractional CO2

After

Before and seven months after treatment using a combination of laser resurfacing and the use of injectable PRP plasma and platelet therapy.

Images courtesy of Dr Carolyn Berry

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Immediately after

Keloid scar excised by radiosurgery before and immediately after treatment.

Images courtesy of Dr JJ Masani

resurfacing laser and PRP] treatment, but sometimes you want to get an improvement in the collagenisation, in the actual tissue, and an improvement in the elasticity. The sutures also improve collagenisation and improves the long-term result.” The choice between the differing modalities can often be down to skin type, as Dr Berry points out, with issues such as post-inflammatory hyperpigmentation (HIP) affecting the choice of treatment. “The caveat with the treatment I described is that it works very well in Fitzpatrick Type I-III (fair), but for your Fitzpatrick Type IV-VI (brown to black skin) unfortunately the C02 laser is not a good idea because of pigmentation problems, and so it becomes more difficult. For these patients you have to look at needling and PRP, or something of that nature. For Fitzpatrick Type IV-VI I tend to do needling, Dermaroller or Dermastamp, depending what the scars look like.” Treatment is often a multi-layered approach and Dr Gonazalez explains that whatever method you adopt, they’re all, essentially, doing the same thing; “You’re remodelling the collagen, and over time you’ll see a slow improvement,” she explains.

Aftercare “We know that massaging helps, because of the pressure effect,” explains Mr Karidis, who encourages patients to carry out this practice at home. “The pressure effect helps to close down the blood vessels in the scar. It’s the natural evolution of scars – you get blood pumping into the area to heal it, once it’s healed the feedback mechanism pulls back on the blood vessels and the blood vessels shrink, and then the blood stops going to the wound, hence why it fades and becomes less red, then it flattens down and the collagen re-aligns itself within the scar. So the massaging will help to a) compress the blood vessels and b) to re-align collagen fibres as well. It aids the whole process.” Ms Kavouni agrees, “In general, it helps the skin to overcome the injury because effectively that is what the skin is trying to do – overcome an injury.” Silicone gel, such as Silgel (favoured by Mr Karidis) and Kelo-cote (used by Dr Gonzalez), are used by plastic surgeons post cosmetic surgery, and by aesthetic practitioners often for new scars, in order to aid with the healing process. “Silicone dressings and gels are not new, but we know that they suppress scarring, particularly in patients prone to keloid scars, after surgery,” says Dr Gonzalez. “You can use a silicone gel or silicone dressing, and that seems to be very useful in either reducing the possibility of keloid scar formation, or correcting it completely in some people.”

Other topicals can be applied to the scars, but the practitioners generally agree that though often effective, there is not enough scientific evidence behind these to measure their effect. “We know that Vitamin E, whether it’s in a cream or a serum form, can help scars to thin out a little bit,” says Mr Karidis. “But it’s all empirical; we don’t always know the precise scientific reasons for how they all interact

with scars, why they work in some instances, and why they work in some people and not in others.” Depending on the type of scar or scarring in question, aftercare can also involve the use of a cosmetic camouflage. In the knowledge that most patients will want to use cosmetics and concealers following treatment, especially if their scars are facial ones, Dr Terry Loong, medical director at The Skin Energy Clinic, advises the use of a post-procedure foundation and accompanying products that contain oxygen complex ceravitae that aim to speed up the body’s cell production of collagen and elastin.

“I always recommend my patients use Oxygenetix foundation after their treatment,” she explains. “It provides great coverage while allowing the skin to breathe and supporting its repair.”

Results For scars caused by surgery, Ms Kavouni stresses the importance of a proactive approach. “Any patient that has surgery with us has a Fraxel treatment on their scar, 6-8 weeks following the procedure, as part of their package,” she says. “Myself and a number of other doctors take a proactive approach, instead of waiting for the scar to be bad and then deal with it.”

“With surgical scars, I tell patients that scar management has evolved significantly, so we should really expect a great improvement and expect to see a fine line,” she explains. “Acne scars tend to be more demanding, because it has happened over a period of time, and quite often by the time the patient comes to see me the skin has been affected in many areas, and there isn’t much healthy skin between the scars. Although we have made some improvements, I think it’s realistic to say that you’re probably looking at about a 60% improvement overall.” For accidental scarring, stretch marks and in particular acne scarring, a multi-layered approach is fundamental to securing good results. “Because there are so many different types of scars in acne, and different treatment modalities, you can’t look at a one treatment approach,” says Dr Gonzalez. As with all aesthetic treatment, but particularly in such a complex arena, understanding your patient’s needs is of overriding importance. “That’s key in everything we do,” says Dr Berry, “find out what the patient needs and wants, and their expectations; because if you do that you’re going to have a much more successful outcome.” Though scars themselves are irreversible, aesthetic practitioners are in this way able to ensure that their accompanying burden fades with time.

REFERENCES 1. National Health Service, Scars (UK: www.nhs.uk, 2013) <http://www.nhs.uk/conditions/Scars/ Pages/Introduction.aspx> 2. Nursing in Practice, Psychological impact of stretch marks and scarring revealed (www.

nursinginpractice.com, 2010) <www.nursinginpractice.com/article/psychological-impact- stretch-marks-and-scarring-revealed> 3. Young VL, Hutchison J., ‘Insights into patient and clinician concerns about scar appearance:

semiquantitative structured surveys’, Plast Reconstr Surg, 124(1) (2009), pp. 256-65.

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The symbiotic relationship between aesthetic medicine and social media Author and aesthetic business consultant Wendy Lewis examines the areas of growth, possibility and caution to consider when combining social media with aesthetic practice ABSTRACT Patients interested in aesthetic treatments are increasingly seeking advice on social media platforms, and rely on easily accessible online information. Aesthetic medicine is one of the industries increasingly influenced by social media, as evidenced by the popular website RealSelf, an online community founded in 2006.1 In this article I will explore the basis and evolution of social media marketing for aesthetic medicine, and provide an introduction to the free tools available to aesthetic practitioners, as well as identify potential pitfalls to avoid. Understanding the advantages of being present and active in social media allows the practitioner to stay on top of new developments, and elevate his or her profile amongst patients. In my experience of working with practitioners and clinics, effective marketing requires an integrated approach that today must include a robust online presence.

The goal of this article is to aid aesthetic practitioners in operating and growing their businesses through the use of free key social networking platforms. This article will illustrate the most relevant social media concepts and principles needed to master real-life challenges that aesthetic practitioners face in todayâ&#x20AC;&#x2122;s competitive, patient-driven environment. There has been a power shift in the doctor-patient relationship and the internet has become the great equaliser. In the digital age, reviews and ratings have the power to persuade or dissuade patients from choosing one clinic over another.1 INTRODUCTION Social media allows aesthetic practitioners and their patients to interact in unprecedented and evolving ways. It serves to establish a more personal relationship between practitioners and their existing patients, as well as potential new patients.

However, to many clinic managers and practitioners, social media represents a sea of confusion that is hard to navigate.

Understandably, tweeting, pinning, posting and blogging can be daunting to the busy aesthetic practitioner. From Facebook to Flickr, Twitter to Tumblr, rapidly expanding platforms are emerging for practitioners to distribute educational and relationship-building material to existing and potential patients. Consumers are increasingly savvy about their wants, needs and options, and they demonstrate a growing desire to search for aesthetic procedures and providers online â&#x20AC;&#x201C; long before making a phone call or setting foot in a clinic.

Aside from nurturing a more personal relationship, social media

sites can also work to facilitate health information and services.

Through the dissemination of education materials, I have witnessed social media aiding patient education and collaboration, as well as helping with recruitment.

With the staggering number of people and businesses active on social media channels, it is also getting harder for aesthetic practices to stand out in the digital world. It takes ingenuity and a creative mindset to build a community and keep them engaged. A campaign with the right tone and relevance can create affordable, meaningful engagement with audiences, when compared with the cost of traditional advertising. We are able to compare this more effectively by looking at paid for social media advertising.

For one company, using Facebook tools to target online ads cut new customer acquisition costs by 39%.2 As such, social media marketing plays an important role in marketing for an aesthetic practice. There are not many other ways to reach thousands of potential patients all over the world without spending a fortune on advertising and PR. However, that being said, although most social media marketing may not seem expensive at first glance since participation is free, it does requires commitment and, as a practitioner, your time is your most valuable resource.

SOCIAL MEDIA PLATFORMS The way your clinic communicates to patients and the goals you set for your practice will help you to increase patient awareness of the services and treatments on offer, as well as promote your lead generation activities to attract new patients online.

Social media represents an ideal opportunity to promote your clinic and expertise, especially as it has become a preferred method of sharing information among healthcare consumers.4, 5 However, as this evolving marketing tactic is constantly changing, it can be overwhelming. The best approach is to break down social media into platforms that are mandatory and those that are optional, based on the clinicâ&#x20AC;&#x2122;s primary and secondary target audiences, goals, budget, and manpower. To do this, we must first understand how these free platforms operate, and be clear on their primary function.

With more than one billion monthly active users, 945 million mobile users, and 757 million daily users,6 Facebook remains the biggest social platform, but there are other platforms growing in importance to aesthetic clinics, including LinkedIn, Pinterest, Instagram, Google+, and YouTube. As a minimum, it is a worthwhile investment in your time to reserve your name and clinic listing on all major social media networks, even if you are not planning to be active on all of them at the current time.

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Figure 1: Four steps to engagement Below are four steps that I have found to be effective when utilising social media to connect with your patients.

Step 1: Choose your Platform Create profiles on all relevant platforms as well as creating your own clinic blog.

Step 2: Connect Start connecting with colleagues, partners, professional organisations and vendors. Encourage them to share your content with their networks to grow your online presence, which in turn, will help to increase your search engine ranking (SEO).3 This, in simple terms, means how high your clinic website will appear organically in online search results – the higher your ranking, the more visible you are.

Step 3: Content Be constant in your posting – be this once every day, once or

Figure 2: Summary of top five social platform demographics7* The following statistics are taken from a survey of 1,597 participants: 1. Facebook: 66% of men and 77% of women surveyed use Facebook.

87% of participants aged 18-29 and 73% aged 30-49 use Facebook.

2. Twitter: 24% of men and 21% women surveyed use Twitter. 37% of participants aged 18-29 and 25% aged 30-49 use Twitter.

3. Instagram: 22% of men and 29% of women surveyed use Instagram.

53% of participants aged 18-29 and 25% aged 30-49 use Instagram.

4. Pinterest: 13% of men and 42% of women surveyed use Pinterest.

34% of participants aged 18-29 and 28% aged 30-49 use Pinterest.

5. LinkedIn: 28% of men and 27% of women surveyed use LinkedIn. 23% of participants aged 18-29 and 31% aged 30-49 use LinkedIn. * Source: Pew Research Centre’s Internet Project September Combined Omnibus Survey, September 11-14 & September 18-21, 2014. N=1,597 internet users 18+

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twice a week. The frequency will depend on the resources and time available, and this should be established in your social media marketing plan. Make sure to keep your network engaged. Link your social media accounts so posts will be shared on individual feeds. You can do this by using an online tool such as Hootsuite, Pagemodo or Social Oomph, which allows you to manage all your online platforms in one place – by scheduling posts and sharing content across all.

Step 4: Engage If someone replies or posts on any of your pages, ensure that you respond in a timely manner. From my experience, this means replying within 24 hours, or preferably less. Reply with links to articles containing relevant information / videos that correspond with the user’s query (or helpful links to your clinic pages), or invite them to follow or connect with your network. Share engaging posts, visually appealing graphics and video content that is of interest to your target audience.

Facebook Facebook is the number one global social media network. It is a virtual meeting ground where friends, family, and colleagues come to read what you choose to share.

Aesthetic clinics and practitioners have embraced Facebook, although it has historically been fraught with potential privacy issues and challenges – of who can see what content, and how to manage negative or inappropriate posts, and protect your business page from spammers – that have forced Facebook to tighten up their policies. 8 Introduced in January 2015, Facebook’s Privacy Basics feature provides a step-by-step tutorial to help users understand what happens when they share a Facebook status, image or video. It tells users how to specify whom they want to share particular content with, and how to manage content they may be tagged in by friends. It is also very easy to monitor a page on Facebook and to block, report, or hide any negative posts or inappropriate content.

Business pages are where the information about your clinic needs to be posted, and I would recommend, from working within the industry, that this is updated daily. Posts could include information about your clinic, products and treatments offered, special training, patient seminars; content that engages your audience. Facebook is the ideal outlet to keep up with your loyal patients and attract new ones, through targeted ads and boosted posts. Of all the social channels in use today, Facebook offers a highly sophisticated paid-for advertising service that is widely considered the gold standard.

The platform allows business owners to create targeted ads for different audiences, set a daily or campaign budget and measure the results across devices in a relative cost effective way when compared to traditional print or broadcast advertising.9 Twitter The advantages Twitter offers include brevity (140 characters) and immediacy (users can communicate with each other in real-time).

This can be beneficial for dissemination of medical information and time-sensitive news. As on Facebook, however, practitioners and those who represent aesthetic clinics must exercise restraint if tempted to engage an irate patient in this public forum. Once something is tweeted and retweeted by another user, it is forever in the public domain and cannot be retracted.

Every tweet can either hurt or help your clinic image. Make sure you therefore put a lot of thought into what you tweet. It is advisable to steer clear of controversy, political views, religion and negative comments. If you have interesting content, Twitter is a great tool for quickly spreading the word. Retweeting and sharing other users’ content is

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Even if the internet provides ample information, it cannot replace the face-to-face consultation, which always should remain a detailed process, covering both risks and limitations of alternative procedures quite simple, and if a user with a lot of followers retweets you, your content has the potential to be seen by a lot of additional users.

As with all social platforms, with Twitter it is important not to simply share your own links or media hits. To attract followers, it is essential to also share interesting, relevant content from other Twitter users to keep your followers engaged and interested.

To ethically build a meaningful base of followers on Twitter, your Twitter strategy should focus on three broad categories: Content, Engagement and Rewards.10 Good content in this respect is content that is easily shareable. It should be compelling and quality information that is of interest to your followers; engagement can be nurtured with your audience by asking questions, engaging in debate and dialogue, and even asking for retweets. Rewards can also be offered by way of social-media-only deals (last-minute appointments, package treatments or a gift with purchase of products) or by posting behind-the-scene images of the clinic that are exclusive to your social media audiences.

Instagram Launched in 2010, this photo-sharing site allows individuals, organisations and businesses to post their own photos and repost photos they consider engaging or potentially of interest to their followers. As on Twitter, hashtags function as subjects for each post and provide a link to related posts that use the same hashtag. While individual clinics, aesthetic products and patient advocacy groups are wellrepresented among these users, this platform skews a very young audience and is favoured by celebrities.

Instagram, like Pinterest (discussed next), is a visual social media platform that is based entirely on photo and video posts. The network, which Facebook owns, has more than 300 million active users,11 many of whom post about food, art, travel, fashion and pop culture. Instagram, unlike many other platforms, is almost entirely mobile. There is a web version, but you cannot take photos or create new posts, and other functions are limited.

Getting started on Instagram is challenging because it requires something to take photos of, other than before-and-after photos of your patients. For aesthetic practitioners, this could include photos

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of your clinic, community events, your clinic or brand represented at exhibitions, your team at award ceremonies, a staff birthday, or any other snapshots that lend themselves to creating attractive images. Instagram users are elitists when it comes to photos; only the best and most attractive images will get liked and shared so keep that top of mind when selecting what to post. Instagram is only getting bigger, more important, and influential.12 However, this is a platform where more artistic niches excel, so it may not be the best fit for every clinic. If you want to succeed with Instagram, it is important to choose someone to manage your content who has a good eye for detail and has at least basic photography skills so that the photos and videos posted are high quality.

Pinterest If your business is product-based, i.e. skincare, cosmetics, home care devices, etc.

Pinterest can be helpful to promote sales and encourage usage. This platform consists of digital bulletin boards where users can save and display content they like in the form of pins. Users create and organise their boards by category, so, for example, as a personal user, one might have a board dedicated to food where they pin recipes, another board dedicated to photography they find interesting and so on. Although some research suggests that posting to this platform multiple times per day is beneficial, this is dependant on the industry.13 For aesthetics, this can be a fairly lowmaintenance platform in terms of ‘pinning’ – as we are often not dealing in the realms of big brands. I would suggest considering it as complementary to your main social media channels and consider posting a few times a week, or as and when you have good content to share that suits your online message. Pinterest is very visually oriented; every post has to be an image or video.

However, keeping your boards organised and search-friendly by adding hashtags can be time-consuming, so you will need to factor this in.

LinkedIn With new social networks sprouting up constantly, LinkedIn is a platform that often gets underutilised or put on the back burner. But it can be extremely powerful if you take the time to uncover all of the platform’s hidden features. The social network is primarily centred on business-to-business relationships. It enables users to connect and share content with other professionals, including colleagues, potential employers, business partners, and new employees. It can also be an excellent marketing tool. The design of Company Pages has changed a lot over the years. Make sure yours is set up correctly and optimised for the newest layout, featuring a compelling and high-quality banner image. The best ways to be active on LinkedIn are to join groups that are relevant to your clinic, aesthetic medicine, as well as personal and professional interests, and to comment on discussions.

YouTube YouTube, which is owned by Google, has upwards of 1 billion users14 and is a unique source of information distribution and communication. The influence of YouTube on personal health decision-making is generally

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well established,15 with footage catering to all aspects of health and wellbeing, be these treatment videos, patient experiences or informative advertisements. The visual nature of this video-sharing site has proven a natural fit for dermatologists, plastic surgeons and other aesthetic physicians. It’s well known that online sites draw more traffic with images than text, and the brief video format is ideal for illustrating aesthetic products and procedures or helping patients get acquainted with your practice. A 2014 study revealed more than 100 dermatology-related videos on the site, generating nearly 50,000,000 views.15 Popular topics included skin cancer/ tanning awareness and educational/demonstration videos relating to skin conditions.

Google + Google + is Google’s own attempt to go social. Having your practice on Google+ is more about SEO value than reaching patients or engagement, as Google+ isn’t really a social media platform in the traditional sense.

It is more often used as a tool for boosting search engine ranking and visibility, as the information you publish on here may be used

by Google when online users search for your clinic. To get started, create a page for your clinic. Optimising your Google+ page and profile, by providing as much detail about your clinic as possible, is essential for using this platform to your advantage. 16 Google+ is composed of ‘Circles’, similar to networks, so that you can share various types of information to specific circles. For example, you may have circles divided into friends, family, colleagues, staff, distributors and suppliers, etc. You can invite users to join your circles, although they can add you without you adding them back.

Google + also has features to help you broadcast your updates to targeted audiences. Similar to Twitter, Google + keeps track of what’s trending and hashtags can be used to make your posts searchable.

Google+ is constantly evolving and offers value as a platform to enhance a clinic’s search results and post optimised content. For these purposes, it is important to have a presence in this powerful network.

PRIVACY AND LEGAL CONSIDERATIONS Despite the potential benefits of social media, practitioners should also be aware of potential pitfalls when using these powerful platforms. Privacy compliance is important, and practitioners must keep all patient details anonymous. It is also important to be sensitive to the different backgrounds of those who follow social media accounts because messages have the potential to be misunderstood if not worded carefully. Furthermore, patients should be informed that private information regarding their care cannot be discussed online. Practitioners should also be cognisant of any rules and regulations their organisation may have regarding social media use. Following these simple recommendations can allow clinics to reap the myriad of benefits that social media can offer.

A practitioner’s personal actions as well as his or her’s clinic’s actions on any online forum do carry a risk of negatively affecting their reputation and there may even be legal consequences in certain circumstances. It is therefore important to stay abreast of general professional guidelines for social media that are constantly under evaluation.19 For example, to protect your licensure

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Figure 3: Social platforms – format types For posting on each of these social media sites, I would recommend deploying the following formats, in terms of the type of content posted:17 Facebook – paragraph, link, video or photo, hashtag(s) • Blog – short paragraph of 500 words approx., image • Youtube – original video, a line or two of text • Twitter – 140 characters (like a text), hashtag(s) • Instagram – photo, a line or two of text, hashtag(s) • Pinterest – image, boards, hashtag(s) • Linkedin – paragraph, link • Google+ – a line or two of text, image, video, hashtag(s)

Figure 4: Posting guidelines17 These are intended as basic guidelines for clinics that are manageable, although there is no definitive rule. In general, if you are tracking engagement, you will be able to see if you are posting too frequently and irritating your fan base so they are not reading your content or unliking your page. The number of times you post as well as the actual timing of your posts can spell success or failure. Certain times are better than others, based on your target audience. The only way to really know what the optimum times of day are is to follow the analytics.18 The majority of these social platforms will have in-built analytic tools (to varying degrees of detail) which will provide information on clicks, views and feedback regarding your posts.

• • • • •

Facebook – Daily Twitter – 2-3 times per day Google+ – Daily YouTube, Pinterest, Instagram – Weekly LinkedIn – Weekly

and reputation, it is imperative to check with the professional associations or organisation you maintain membership in periodically, as well as your malpractice insurance carrier. This is an evolving area in medicine and the law is unable to keep up with the speed at which the exchange of information online and in public forums is increasing.

Keep in mind that the individual practitioner is responsible for his own behaviour. Therefore, any staff member who may be posting on social media in your name, or external consultant, PR or marketing agency engaged to manage your online platforms, should be well versed in the guidelines that apply to your clinic and specialty.20 For example, the clinic staff and practitioners should preserve the appropriate boundaries of the doctor-patient relationship when interacting with patients online and ensure that patient privacy and confidentiality are strictly maintained. Posting about specific cases or revealing any patient data or identifying comments that could be misconstrued as a breach should be discouraged. It is also vital

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that medical professionals refrain from offering medical advice or suggesting any action or remedy that would require a consultation with a practitioner first. If you are unclear on the best guidelines to follow while navigating these unchartered waters, it is best to consult with your solicitor.

Online interaction with patients about their medical treatment and care in your clinic, such as email exchanges, are widely accepted.

However, these conversations should never occur on a social networking platform or open forum.

Practitioners should be discouraged from interacting with current or past patients on social networking sites such as Facebook or Twitter. For example, it is frowned upon to reach out to ‘friend’ a patient. Let the patient do the engaging; such as liking your professional business page. Practitioners must use caution to keep their business accounts (which users may ‘like’ and follow without any breaches of the practitioner-patient relationship) and personal accounts separate and distinct to avoid confusion. If a patient tries to friend the practitioner on his personal Facebook profile, common practice is to not accept the friend request but rather to direct the patient to your business page for the clinic. It is vital to adhere to the same principles of professionalism online as the practitioner and clinic staff would do offline.

CONCLUSION Use of the internet in general, and social media more specifically, are seen as playing a growing role in aesthetic medicine as primary sources of information sought out by consumers about treatments and practitioners. Ultimately this trend has resulted in more informed patients, but there is also a danger of fostering unrealistic expectations. Information posted online by individual sources is not subject to rigorous standards or policing so, in effect, information is stated with impunity. Even if the internet provides ample information, it cannot replace the face-to-face consultation, which always should remain a detailed process, covering both risks and limitations of alternative procedures.

Despite the potential benefits of social media, clinicians should also be cognisant of potential pitfalls when using any of the

To attract followers, it is essential to also share interesting, relevant content from other Twitter users to keep your followers engaged and interested

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various platforms. Compliance with patient privacy regulations is critical, and practitioners must remember to keep all patient details anonymous. Content and responses have the potential to be misunderstood if not worded carefully. Furthermore, patients should be informed that any private or specific information regarding their care, treatment, or individual concerns and complaints may not be discussed online in an open forum. Practitioners should be aware of any rules and regulations that the professional organisations they belong to may have regarding social media use. Following these simple rules will allow practitioners to reap the many benefits that social media can offer, while remaining risk averse.21 Social media can be a very powerful tool in medicine. It not only helps disseminate medical information to consumers, but it can also help practitioners connect with people, colleagues and organisations to enhance visibility for career advancement, media contacts, research opportunities and other partnerships.

Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy. Lewis is an international figure in the field of medical aesthetics, and is a frequent presenter at national and international conferences. In 2008, she founded Beautyinthebag.com and has served as editor in chief. The author of eleven books, her next, Aesthetic Clinic Marketing in the Digital Age will be published in the winter of 2015.

REFERENCES 1. Schlichte, MJ., et al, ‘Patient use of social media to evaluate cosmetic treatments and procedures’,

Dermatology Online Journal, 21(4) (2015) 2. Burg, N., How to measure your social media return on investment (US: www.forbes.com, 2013) <https://www.forbes.com/sites/capitalonespark/2013/04/25/how-to-measure-your-social-media-return- on-investment> 3. Redsicker P., 18 social media resources to improve your search engine ranking (www.

socialmediaexaminer.com, 2014) <https://www.socialmediaexaminer.com/social-media-seo> 4. Hanson CL, West J, Thackeray R, Barnes MD, Downey J., ‘Understanding and predicting social

media use among community health center patients: a cross-sectional survey’, J Med

Internet Res, 16(11) (2014) 5. Marrie RA, Salter AR, Tyry T, Fox RJ, Cutter GR., ‘Preferred sources of health information in persons

with multiple sclerosis: degree of trust and information sought’, J Med Internet Res, 15(4) (2013) 6. Protalinski, E., Facebook passes 1.23 billion monthly active users, 945 million mobile users, and 757

million daily users (thenextweb.com, 2014) <https:// thenextweb.com/facebook/2014/01/29/facebook- passes-1-23-billion-monthly-active-users-945-million-mobile-users-757-million-daily-users> 7. Duggan, M., Ellison, N., Lampe, C., Lenhart, A., Madden, M., Demographics of Key Social Networking Platforms (www.pewinternet.org, 2014) <https://www.pewinternet.org/2015/01/09/demographics-of- key-social-networking-platforms-2> 8. Zaucha, D., Facebook Privacy Update 2015: The Real Story (www.pagemodo.com, 2014) <http://www. pagemodo.com/blog/facebook-privacy-update-2015-the-real-story> 9. Facebook, Easy and effective Facebook Adverts (US: www.facebook.com, 2015) <https://www.

facebook.com/business/products/ads> 10. Luke Chitwood, 9 ways to grow your Twitter following (ethically) (thenextweb.com, 2014) <http:// thenextweb.com/twitter/2014/01/06/9-ways-grow-twitter-following-ethically> 11. Systrom, K., 300 Million: Sharing Real Moments (US: blog.instagram.com/, 2014) <http://blog.instagram. com/post/104847837897/141210-300million> 12. Lewis, W., Social Studies with Wendy Lewis: Navigating today’s digital touch points (www.

plasticsurgerypractice.com, 2015) <https://www.plasticsurgerypractice.com/2015/02/social- studies-wendy-lewis-navigating-todays-digital-touch-points> 13. Bennett, S., How Often Should You Post to Pinterest, Twitter, Google+ and Facebook?

[INFOGRAPHIC] (www.adweek.com, 2015) <http://www.adweek.com/socialtimes/social- media-post-frequency/615992> 14. YouTube, Statistics (www.youtube.com) <https://www.youtube.com/yt/press/statistics.html> 15. Boyers LN, Quest T, Karimkhani C, Connett J, Dellavalle RP, ‘Dermatology on YouTube’, Dermatol

Online J, 15;20(6) (2014) 16. Thomas, J., 3 Ways to Use Google+ to Increase Search Rankings (www.socialmediaexaminer.com,

2014) <http://www.socialmediaexaminer.com/use-google-increase-search-rankings> 17. Lewis, W., Aesthetic Clinic Marketing in the Digital Age (UK: CRC Press), Forthcoming 2015) 18. Lee, K., The social media frequency guide: how often to post to facebook, twitter, linkedin, and more

(www.fastcompany.com, 2014) <http://www.fastcompany.com/3029019/work-smart/the-social-media- frequency-guide-how-often-to-post-to-facebook-twitter-linkedin-a> 19. American Medical Association, Opinion 9.124 - Professionalism in the Use of Social Media (US:

www.ama-assn.org/, 2011) <http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/ code-medical-ethics/opinion9124.page?> 20. Payette MJ, Albreski D, Grant-Kels JM., ‘“You’d know if you ‘friended’ me on Facebook”: legal, moral,

and ethical considerations of online social media’, J Am Acad Dermatol, 69(2) (2013), pp. 305-7.

21. Choi, E., Making the Most of Social Media (www.physiciansweekly.com, 2013) <http://www. physiciansweekly.com/physicians-social-media/#sthash>

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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

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

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

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

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

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

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

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

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

Adverse events should also be reported to Galderma (UK) Ltd.

AZZ/021/0313

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example could be two wooden beams connected at a 45 degree angle, with a bar across the middle for extra support in order to prevent the legs from bowing out.

We find that the A-frame concept helps us focus on three of the four aspects of facial ageing; volume loss, active lines and gravity changes. As we age, our face shape inverts from a triangle with its apex facing downwards into one with its apex upwards and its base downwards (Figure 1). To counter this ageing triangle inversion we focus our treatments in a similar pattern – the A-frame. The A-frame subdivides the face into treatment focus areas which lie along the limbs of the extended A. In addition, the cross line of the A ends outside the triangular limbs of the A. To obtain a natural harmonious panfacial rejuvenation, we ask our practitioners and delegates in training to focus their treatment on these areas.

The ‘A-Lift’ Mr Adrian Richards describes how the ‘A-lift’ can help aesthetic practitioners master natural-looking results The A-frame concept The concept of the ‘A-lift’ is one that we use to train our team at Aurora Clinics, and four of our trainers also include this in our training programmes for our delegates at Cosmetic Courses. It was a concept we created which we find helps us to focus on the important

facial areas requiring treatment, resulting in natural and long-lasting rejuvenation for the patient. The ‘A-lift’ is based on the A-frame concept, a basic structure which is shaped as a letter ‘A’ and designed to bear a heavy weight, regularly used in construction.1 An

The A-frame zones (Figure 2) The limbs of the A-frame lie along the facial areas we believe should be treated in order to achieve a natural facial rejuvenation.

Over-treatment of one area with insufficient focus on another can produce an unnatural appearance. In my experience, almost 100% of my male and female patients in their 50s would like to look like they did five to 10 years previously. However, only a small number of these patients choose to have treatments that can achieve this. There are multiple reasons that could influence these choices, however, amongst patients I have spoken to, a major factor is a fear of looking unnatural.

By adopting the A-frame technique, my staff and I believe we can achieve natural-looking results for our patients. The apex of the A is

Figure 1:

Images demonstrate how face shape changes with age, from a triangle with its apex facing downwards into one with its apex facing upwards and base facing downwards.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Figure 2

and underlying muscle. In our experience, a sub-cutaneous bleb of toxin will diffuse downwards into the muscle.

Since we have been teaching sub-cutaneous placement, we have noted that it is more comfortable for the patient, produces less bruises and trauma and reduces the risk of toxin diffusion into orbit, which can result in weakness of the eye muscles. Working downwards, the next focus areas lie at the ends of the extended transverse limb of the A-frame – the cheeks. Some faces are less 1. Glabella 3. Nasolabial Folds asymmetrical than others, and 2. Cheek 4. Marionette Lines we feel it is very important to Augmentation 5. Pre Jowl Salcus assess patients thoroughly and record their level of located above the glabella. When looking facial symmetry prior to any treatment. In at the face, we naturally tend to focus on most cases, there is only one opportunity to the eyes and area between them, and less obtain a picture prior to the patient having on the peripheral area of the face. Many of undertaking a treatment.Where possible, my patients who have had their prominent we ask our patients to bring in pictures of ears corrected have reported that their themselves over the years. This allows us to friends and family could not identify what had assess their facial volume changes over time. changed following the procedure. While their Our aim is restore their youthful volume, not friends and family knew they looked different, add more volume than they ever had as this often slimmer as prominent ears tend to can produce an unnatural appearance. widen the face, they did not realise it was the We then assess the volume loss within each ears that had changed. Following the shape of the fat compartments of the cheek and of the A-frame downwards, we reach the aim to restore the loss with a standard cheek cheeks, nasolabial folds, oral commissures, augmentation. In my clinics, we prefer to use a marionette lines and, finally, jowls. cannula to deliver the product, as we believe I will now detail how I target these areas in this gives us more control whilst minimising my ‘A-lift’ treatment protocol. trauma. For many years, my colleagues and

While each face is different, they all have some degree of asymmetry and each requires a bespoke treatment plan The ‘A-lift’ treatment technique Adopting the ‘A-lift’ technique, the glabellar is treated in most cases with our standard five-point toxin pattern. This involves a single sub-cutaneous injection over the procerus and two sub-cutaneous injections into each corrugator. There is very little subcutaneous fat in this area between the skin

I have found that facial rejuvenation with fat transfer is a popular technique, and this is predominantly performed with cannula rather than needle.

Further down the face, our next areas of focus, along the limbs of the A-frame, are the nasolabial regions. Again our preference is to treat these areas, together with the oral

Aesthetics aestheticsjournal.com

commissures and marionette lines, with cannula rather than needle. The benefits to this technique are that only a single point of entry is required and less trauma is produced with the blunt-ended cannula.

Care is taken in the nasolabial, oral commissure and marionette areas to avoid adding too much volume. As mentioned previously, transfer of volume from the upper to the lower face is a feature of facial ageing.

Excess volume in the lower face can age a patient’s appearance, rather than encourage rejuvenation. Most of our patients treated in accordance with the A-frame principles will also have toxin treatment to the depressor anguli oris (DAO) muscle. Relaxing this depressor muscle at the corner of the mouth produces an anti-ageing anti-gravity upturn of the mouth, lessening the amount of dermal filler required.Care is taken to avoid toxin affecting the depressor labii inferioris (LAO), which lies medial to the DAO. Inadvertent relaxation of this muscle will cause the centre of the lip, rather than the corners of the lip, to move upwards, producing an unnatural appearance. The base of the A-frame lies below the jowls, and we use a three-point sub-cutaneous injection technique one centimetre below the jaw line and jowls. Again our preference is to use a moderate dose of toxin in this region, reducing the downward pull of the platysma on the jowls.

Conclusion When training our team of practitioners in clinic or delegates on our courses, we ask them to focus on the A-frame structure and adopt the ‘A-lift’ technique in practice. While each face is different, they all have some degree of asymmetry and each requires a bespoke treatment plan. By using the A-frame principles, we believe that we can achieve natural pan-facial rejuvenation with our aesthetic treatments. This helps to avoid the unnatural over-treated appearance we see so often, which is often cited as a major reason for potential patients delaying or avoiding aesthetic treatment.

Mr Adrian Richards is a consultant plastic and cosmetic surgeon. He is the clinical director of both Aurora Clinics one of the fastest growing plastic surgical companies in the UK and Cosmetic Courses, the largest non-surgical training provider in the UK. REFERENCES 1. Oxford Dictionaries, A-frame (UK: Oxfordictionaries.com,

2015) <http://www.oxforddictionaries.com/definition/english/A- frame>

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

A perfect match.

“Perfectha works for me because it’s very gentle with natural, long-lasting results.”

Sophie Anderton

A complete HA range perfectly designed for your needs Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. United Kingdom www.sinclairispharma.com Date of preparation: May 2015 UK/SIPPER/15/0005

Aesthetics Awards Special Focus

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Don’t miss your chance to win a prestigious Aesthetics Award in 2015 With just one month to go before entry closes, don’t miss the opportunity to be recognised for your achievements at the Aesthetics Awards 2015. The Awards celebrate the best in medical aesthetics; championing clinical excellence, practice achievement and outstanding product performance. Being selected as a finalist, or chosen as a winner, demonstrates your commitment to raising standards within your field and shows existing and potential customers that you are highly regarded amongst your peers and clients.

The Aesthetics Awards will be held on Saturday December 5 at the Park Plaza Westminster Bridge Hotel in central London. The occasion will honour all finalists, as well as announcing those that have been Commended and Highly Commended in their category, and presenting the winners with their trophies on stage in front of 500 members of the medical aesthetics industry.

Hear from some of last year’s winners about what winning an Aesthetics Award has meant to them: Aesthetic Medical Practitioner of the Year 2014 “Winning the 2014 Aesthetic Medical Practitioner of the Year Award was an amazing professional achievement, which I was both honoured and very privileged to receive. To be recognised as the worthy winner amongst such a high standard of doctors in the aesthetic industry has had a very positive effect on my business, with increasing numbers of patients seeking treatments from my clinic. The 2014 Aesthetics Awards night was a spectacular evening celebrating the best in the industry and it was a great joy to be part of such a wonderful event.”

Dr Linda Eve

The Church Pharmacy Award for Clinic Reception Team of the Year 2014 “I attended the Aesthetics Awards 2014 with my reception team, and the anticipation coupled with actually winning the award for best clinic reception was just fantastic for team morale. My team of reception staff work hard to deliver excellent customer care, and to have this recognised at such a prestigious event has been such a treat for us all. They continue to be motivated and are already excited at the prospect of entering the awards this year. Our patients give us excellent and constructive feedback on the service we provide at Temple. Winning the award has confirmed to our patients that they have made the right choice in coming to us for treatment. Referencing the Awards in our marketing and PR has endorsed the message to the local population that we are an award winning clinic and a centre of excellence. The experience of being a finalist and a winner was really exciting, and we loved being in the running for top Scottish aesthetic clinic – that in itself was something to be proud of, and winning the reception award was just amazing!

The anticipation was part of the fun in the lead up to Christmas and the Awards are one of the highlights in our clinic calendar. The food, the entertainment and the whole ambience made for a very enjoyable evening.”

Dr Sam Robson, Temple Medical This year the Clinic Reception Team of the Year Award is sponsored by Church Pharmacy

This year the Aesthetic Medical Practitioner of the Year Award is sponsored by Sinclair Pharma 36

Equipment Supplier of the Year 2014 “We’re very proud of our award winning devices, and this was a great celebration for the team. We offer our customers reliability and honesty: both from the BTL team, and our products and services – so we’re proud to see that rewarded again. It has really made an impact on our profile and we’re delighted. We have the clinical evidence to back us and we have the client testimonials, but it’s all down to what the consumer thinks at the end of the day. After entering the awards, it was great to be a finalist, and humbling to be the winner.

It was fantastic to see so many industry leaders in one room, celebrating and sharing news.”

Lee Boulderstone, BTL Aesthetics Aesthetics | June 2015

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Aesthetics Awards Special Focus

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Find your categories and enter now: • • • • • • • • • • • • •

Cosmeceutical Range/Product of the Year • The Oxygenetix Award for Best Clinic London • Best Clinic Wales The Sterimedix Award for Injectable Product of the Year • The SkinCeuticals Award for Best Clinic Ireland Treatment of the Year • The AestheticSource Award for Best Clinic Group (3 clinics Best Treatment Partner or more) Equipment Supplier of the Year • Best Clinic Group (10 clinics or more) The Janeé Parsons Award for Sales Representative of the Year • The Church Pharmacy Award for Clinic Reception Team of the Best Customer Service by a Manufacturer/Supplier Year Distributor of the Year • Training Initiative of the Year The Neocosmedix Award for Association/Industry Body of the Year • The Institute Hyalual Award for Aesthetic Nurse Practitioner The 3D-lipomed Award for Best New Clinic, UK and Ireland of the Year Best Clinic Scotland • The Sinclair Pharma Award for Aesthetic Medical Practitioner The Epionce Award for Best Clinic North England of the Year • Product Innovation of the Year The Dermalux Award for Best Clinic South England • The Schuco International Award for Special Achievement will be decided by the Aesthetics team.

There will be no entry process for this award.

•

• •

How to Enter Visit www.aestheticsawards.com today to check the entry criteria for each category and download the questions. You can enter as many categories as you wish but 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 can only enter each category once and multiple entries 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 judges when deciding on Winners and those who should receive Commendations and High Commendations. The list of finalists will be announced in the September issue of the Aesthetics journal, after which the voting and final judging process will begin.

Enter Now! www.aestheticsawards.com Entries close 30th June Entries must be completed on the Aesthetics Awards website no later than June 30. If you have any questions regarding the entry process call our support team on 0203 096 1228 or email support@aestheticsawards.com

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Changing The Face Of Ageing With Botanical Stem Cells Dr Vincent Wong outlines the role of botanical stem cells in skin health and rejuvenation The incorporation of stem cells into skincare products is, in my opinion, probably the most exciting cosmeceutical revolution that has occurred within the past decade. However, as the idea of applying animal or human cell extracts (even if it is homologous) may seem unappetising to some, scientists have now introduced us to the concept of botanical stem cells. It is important to note, however, that botanical stem cell products do not actually contain stem cells from plants. Instead, the active ingredients are peptides and growth factors extracted from those cells grown in a culture.

The initial development of botanical stem cells in serums and creams began in 2008, with the introduction of extracts taken from the Uttwiler Sp채tlauber apple, a Swiss varietal developed in the eighteenth century to have an especially long shelf life.1 In a study published in the International Journal for Applied Science,1 the apple stem cell concoction increased in vivo cell turnover and UV resistance, thus indicating a stimulating and protective effect on the human skin.

It is believed that plant stem cell extracts can effectively stimulate collagen synthesis and cell renewal as they contain a 1,000 times higher concentration of antioxidants compared to other botanical extracts.1,2 Many plant stem cell extracts have since been discovered, for example, edelweiss, melon and raspberry. Here, we explore three of the most widely studied botanical stem cell extracts found in serums and creams following the discovery of apple stem cell extracts.

Gotu Kola (centella asiatica) Gotu kola (centella asiatica) is a small herbaceous plant found in the wetlands of Asia. Centella asiatica (CA) is widely used as a medicinal herb throughout India, China, Indonesia and Africa. Its medicinal uses include the treatment of varicose ulcers, eczema, and psoriasis. The high concentration of pentacyclic triterpenoid found in CA is mainly believed to be responsible for its wide therapeutic actions.2,3 In 2006, Shetty et al investigated the effect of CA in normal and dexamethasone-suppressed wound healing.2 In this study, performed on Wistor albino rats using incision, excision and dead space wound models, CA was found to increase tissue strength significantly compared to controls. Furthermore, CA-treated wounds were also found to epithelialise faster, with a significant increase in wound contraction. Backed by histology findings, CA also showed the ability to overcome the wound-healing suppressing action of dexamethasone.2 Apart from assisting in wound healing, CA also has an effect on melanogenesis.3 In 2005, Park et al conducted a study with results suggesting that asiatic acid (a pentacyclic triterpene found

Aesthetics Journal

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in CA) has the ability to induce apoptosis in human melanoma cells through a series of mediation reactions. Almost a decade later, a study on mouse melanoma conducted by Kwon et al indicated that asiatic acid inhibits microphthalmia-associated transcription factor, a protein that is responsible for regulating melanin synthesising enzymes.4 In terms of skincare and anti-ageing properties, CA extracts exhibit anti-hyaluronidase and anti-elastase activities in the skin.5 Kim et al suggested that CA extracts can also regulate stress-induced premature senescence by preventing repression of DNA replication and mitosis-related gene expression.6 In another study, the effects of CA on human fibroblast cells were assessed.7 The results showed that collagen and fibronectin synthesis were significantly stimulated in the fibroblast cells incubated with CA for 48 hours, further enhanced with the addition of glycolic acid and Vitamins A, C and E. The protective effect of CA on DNA from ultraviolet light-induced damage has also been demonstrated, alongside a reduced expression of inflammation markers (interleukin1-alpha) and a clear densification of collagen network in human papillary dermis.8 Hibiscus (H. sabdariffa) Hibiscus is a flowering plant that is native to warm-temperate, subtropical and tropical regions of the world. It is used widely in south east Asia for medicinal purposes and is most well known in medicine for its diuretic and anti-hypertensive properties.9 For almost two decades, the effects of hibiscus on tumour cells have been investigated, with study results demonstrating its role as a chemopreventive agent against tumour promotion.9,10 Recently, Chiu et al studied the effects of hibiscus extract in melanoma cells.11 In this study, hibiscus extract demonstrated the ability to induce autophagic cell death in melanoma cells, indicating the potential of hibiscus extract being developed as an anti-melanoma agent. Hibiscus also plays an important role in wound management. Despite having no antimicrobial properties, hibiscus extract showed significant and dose-dependent wound healing activities, possibly due to its high antioxidant contents and their anti-inflammatory properties.12 Ozkul et al recently published a study that analysed the role of hibiscus extract in UVC exposure in rats. The levels of serum enzymes, renal function tests and some oxidant/antioxidant biomarkers of skin, lens and retina tissues of UVC-exposed rats (four hours daily) were monitored within the study.13 As expected, oxidative stress parameters were escalated after UVC exposure. Interestingly, co-administration of hibiscus extract significantly reversed the levels of these parameters in all tissues.

Grape seed Grape seeds are extremely rich in polyphenols, secondary plant metabolites which have demonstrated chemo-preventive and/ or chemotherapeutic effects in a number of cancer cell cultures and animal models.14 Polyphenols are also well known for their antioxidant, anti-inflammatory and anti-microbial activities. These beneficial biological properties have made grape seed an attractive ingredient for cosmetics and skincare products. Many in vitro studies using dermal fibroblasts or epidermal keratinocytes cell lines have also explored and suggested the inhibition of dermal protease and photoprotective activities of grape seed extracts.15 Grape seed extracts have also been shown to induce vascular endothelial growth factors, thereby accelerating wound healing.16 Exposure to UVB radiation can cause significant cellular DNA damage, resulting in reduced cell viability and apoptosis. In keratocyte cell lines, pre-treatment with grape seed extract for 30 minutes before UVB exposure significantly lowered lipid peroxides

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levels and DNA photolesions compared to control, thus, increasing cell viability and significantly reducing the number of cells undergoing apoptosis.17 Similar results were also recorded in human studies, where fewer sunburn cells and mutant p53-positive epidermal cells, and more Langerhans cells, were observed in cutaneous areas on the back of volunteers treated with grape seed extract 30 minutes before exposure to two minimal erythema doses of solar simulated radiation.18 Conclusion Current evidence suggests that grape seed, hibiscus and CA stem cell extracts can play important roles in maintaining skin health. From healing properties to photoprotection and neocollagenesis, botanical stem cells may offer a safe and effective alternative for patients who are uncomfortable with the idea of applying animal or human stem cell products. The potent organic and naturally sourced ingredients mean that exposure to potentially harmful chemicals such as parabens can be avoided. It is important to understand that using botanical stem cell products is not a matter of simple swap (i.e. we are not replacing our skin stem cells with those obtained from plants) – in fact, we are using the growth factors and peptides from botanical stem cells to protect our own tissue and to stimulate our skin cells to be active again. In my opinion, botanical stem cell technology is certainly one of the main directions for future skincare development.

Dr Vincent Wong is an aesthetics practitioner and the founder of Harley Street clinic La Maison de l’Esthetique. He has extensive research experience in plastic surgery and dermatology. Dr Wong has presented his work at several national and international conferences.

REFERENCES 1. D. Schmid, C. S. ‘Plant Stem Cell Extract for Longevity of Skin and Hair’, International Journal

for Applied Science, 134(5) (2008), pp. 30-35.

2. Shetty BS, U. S. ‘Effect of Centella asiatica L (Umbelliferae) on normal and dexamethasone-

suppressed wound healing in Wistar Albino rats’, Int J Low Extrem Wounds, 5(3) (2006), pp.

137-43.

3. Park BC, B. K. ‘Asiatic acid induces apoptosis in SK-MEL-2 human melanoma cells’, Cancer Lett, 218(1) (2005), pp. 81-90.

4. Kwon KJ, B. S. ‘Asiaticoside, a component of Centella asiatica, inhibits melanogenesis in

B16F10 mouse melanoma’, Mol Med Rep, 10(1) (2014), pp. 503-7.

5. Nema NK, M. N. ‘Matrix metalloproteinase, hyaluronidase and elastase inhibitory potential of

standardized extract of Centella asiatica’, Pharm Biol, 51(9) (2013), pp. 1182-7.

6. Kim YJ, C. H. ‘Centella asiatica extracts modulate hydrogen peroxide-induced senescence in

human dermal fibroblasts’, Exp Dermatol, 20(12) (2011), pp. 998-1003.

7. P, H. ‘The effect of Centella asiatica, vitamins, glycolic acid and their mixtures preparations in

stimulating collagen and fibronectin synthesis in cultured human skin fibroblast’, Pak J Pharm Sci., 27(2) (2014), pp. 233-7.

8. Maramaldi G, T. S. ‘Anti-inflammaging and antiglycation activity of a novel botanical ingredient

from African biodiversity (Centevita™)’, Clin Cosmet Investig Dermatol, 12(7) (2013), pp. 1-9.

9. Tseng TH, H. J. ‘Inhibitory effect of Hibiscus protocatechuic acid on tumor promotion in

mouse skin’, Cancer Lett, 126(2) (1998), pp. 199-207.

10. Tseng TH, L. Y. ‘Evaluation of natural and synthetic compounds from East Asiatic folk

medicinal plants on the mediation of cancer’, Anticancer Agents Med Chem, 6(4) (2006), pp.

347-65.

11. Chiu CT, H. S. ‘Hibiscus sabdariffa Leaf Polyphenolic Extract Induces Human Melanoma Cell

Death, Apoptosis, and Autophagy,’, J Food Sci, 80(3) (2015), pp. 649-58.

12. Builders PF, K.-T. B. ‘Wound healing potential of formulated extract from hibiscus sabdariffa calyx’, Indian J Pharm Sci, 75(1) (2013), pp. 45-52.

13. Ozkol HU, K. I. ‘Anthocyanin-rich extract from Hibiscus sabdariffa calyx counteracts UVC-

caused impairments in rats’, Pharm Biol, (2015), pp. 18, 1-7.

14. Olaku OO, O. M. ‘The Role of Grape Seed Extract in the Treatment of Chemo/Radiotherapy

Induced Toxicity: A Systematic Review of Preclinical Studies’, Nutr Cancer, (2015) 16, pp. 1-11.

15. Zillich OV, S.-W. U. ‘Polyphenols as active ingredients for cosmetic products’, Int J Cosmet Sci,

(2015) pp. 1-10.

16. Khanna Savita, V. M. ‘Dermal wound healing properties of redox-active grape seed proanthocyanidins’, Free Radical Biology and Medicine, 33(8) (2002), pp. 1089-96.

17. Perde-Schrepler M, C. G. ‘Grape seed extract as photochemopreventive agent against UVB-

induced skin cancer’, J Photochem Photobiol B, 118 (2013), pp. 16-21.

18. Yuan XY, L. W. ‘Topical grape seed proanthocyandin extract reduces sunburn cells and

mutant p53 positive epidermal cell formation, and prevents depletion of Langerhans cells in

an acute sunburn model’, Photomed Laser Surg, 30(1) (2012), pp. 20-5.

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Advanced Injectables Part II Following last monthâ&#x20AC;&#x2122;s article on mid and upper facial rejuvenation, Dr Emma Ravichandran and Dr Simon Ravichandran share their anatomical approach to lower facial rejuvenation, as presented at ACE 2015 Introduction Facial rejuvenation procedures employing the use of dermal fillers and botulinum toxins often neglect the lower face. Simple procedures that address the nasolabial and mesolabial folds, as well as simple lip augmentation procedures, have been the prominent mainstays of treatment. Whilst this approach has some benefit in rejuvenation, it often ignores the underlying anatomical and physiological processes that can occur with ageing, resulting in artificial camouflaging. Understanding the anatomy of the area, as well as understanding the properties of the rejuvenation agents we use, will allow a more tailored approach to the individual patient, and a more natural rejuvenating outcome. In last monthâ&#x20AC;&#x2122;s article we discussed facial rejuvenation of the upper two thirds of the face, and how understanding anatomy and the rheology of products are essential when employing advanced injectable techniques. This article will continue with the same approach to describe the anatomy of the lower third of the face, and its application to facial rejuvenation procedures. In our exploration of the topic, we will describe the rejuvenation techniques and products we used during our Expert Clinic at the Aesthetics Conferences and Exhibition (ACE) 2015.

Background Our Expert Clinic patient was a 45-year-old woman, who was medically fit and well, was not receiving any current medication and had no history of allergy. She had received toxin treatment to the upper third of her face more than a year ago, and a hyaluronic acid (HA) filler injected into her lips more than three years ago.

Her expectation was to achieve a natural rejuvenation of her face with minimal downtime. Our assessment identified areas of subtle volume change in the forehead, temple, eyebrow, malar, perioral and jawline that were contributing to early signs of facial ageing.

Lips and perioral area The perioral region may be described as the area of the face from the subnasal and the nasolabial folds to the lower border of

the chin.1 The approach to lip and perioral rejuvenation needs a thorough assessment to identify the contributions of each ageing process, and an algorithmic, stepwise approach to treatment. The goal of a lip augmentation or rejuvenation procedure is to restore a natural shape and to contour the lip.2 Simply injecting dermal filler into the correct compartments of the lip itself is not sufficient â&#x20AC;&#x201C; one must consider the surrounding perioral tissues that provides support to, and thus contributes to, the appearance of the lip.

Furthermore, one must consider the ageing changes of these perioral tissues and attempt to rejuvenate these areas to preserve a harmonious, balanced appearance. The cause of the aged appearance of the lip is multifactorial. Subcutaneous volume loss in the body of the lips will cause thinning and hollowing. Tissue laxity will cause descent of the upper lip. Flattening of the philtrum columns will yield a lengthened appearance.3 Inversion of the lips can be seen as a result of bony resorption of the maxilla and mandible, or changes in the position of the anterior teeth. Perioral rhytids will develop as a result of loss of support of the vermillion border and will be increased as a result of environmental factors such as smoking and sun damage.4,5 Our patient had well positioned and proportioned lips. She had a mild asymmetry of her upper lip caused by protrusion of her upper left central tooth, and had early perioral lines developing

Rejuvenation of the jawline is increasingly becoming part of routine aesthetic practice

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Understanding the anatomy of the area, as well as understanding the properties of the rejuvenation agents we use, will allow a more tailored approach to the individual patient and a more natural rejuvenating outcome when her lips were pursed. Our management plan, based on the assessment, was to use Belotero Balance, a highly cohesive and moderately elastic filler, to increase the support of the vermillion.

We prefer this product as it can be injected superficially with low risk of tyndalling effect, and its tissue integration provides a more natural feel. We have also performed this treatment with Juvéderm and Teosyal dermal fillers but find the placement needs to be slightly deeper. The filler was injected using a 25G 1.5 inch cannula with an entry point at the lateral edge of the lip made with a 23G needle. The product was placed as superficially as possible into the hypodermis. Belotero Soft was also used in this area but injected much more superficially. The intradermal placement of Belotero Soft with a 30G needle using a ‘blanching technique’ increases the dermal support of the vermillion, and the same technique was also used to smooth and contour some very fine lines in the upper lip. Both techniques replaced support and reduced lines without increasing the projection or volume of the lips. A further 0.2ml of Balance was deposited at the wet-dry border on the right hand side to evert and restore symmetry of the lips. This was achieved using the 25G cannula through the same entry point used for the vermillion. We find that using cannula significantly reduces the amount of post-procedural swelling and bruising a patient may expect.

Figure 1: Blue dots indicate position of toxin injection. Purple lines show placement of Belotero Intense placed with 25G cannula in the mesolabial region. White dots show placement of supraperiosteal Radiesse. Yellow shows superficial placement of Belotero Balance in lip chin hollow area.

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Sublabial area Reduction of lower third height and, thus, reduction in the relative proportion to the rest of the face may occur due to a decrease in the body height of the mandible, in addition to the attrition or loss of teeth. Contraction of the mentalis muscle can project the profile of the chin, and often square the lower border of the chin.

It will increase the labiomental groove and add to the appearance of a shorter lower third of the face. Loss of deep fat in the sub orbicularis oris and submental areas contributes to a loss of lower third face tissue support, as evidenced by mesolabial hollows, and sublabial hollowing and prominence of a mental crease. Descent of the oral commissure may result from descent and herniation of the nasolabial fat and development of a perioral mound.6 Activity of Depressor Anguli Oris (DAO) can further pull on the oral commissures and combine with subcutaneous fat thinning to accentuate a mesolabial hollow. Deep lines and wrinkles occur as a result of photoageing, loss of volumetric support and repeated obicularis contractions.7 Our patient had a well-proportioned lower third of her face. She had a strong mentalis muscle that was contributing to the development of the mental crease, projecting the chin profile and squaring the chin, resulting in a masculine appearance. Our treatment plan for this area was to soften the chin to create a more feminine lower third of the face. Eight units of Bocouture were injected into the mentalis to soften and feminise the face. Eight units of Botox would have exactly the same result. We currently use a single injection point in the midline of the mental protuberance. 0.1ml boluses of Radiesse were injected supraperiosteally with a 27G 1.5 inch needle laterally to the midline to restore the contour and support the body of the mandible. We could have achieved a similar effect with any lifting dermal filler such as Belotero Volume, Juvéderm Voluma or Emmervel Volume. 0.2ml of Belotero Intense was injected subcutaneously using a 25G 1.5 inch cannula to soften the mental crease and support the lower lip. Juvéderm 4, or Teosyal Deep Lines may also be used in this area. 2 x 2 units of Bocouture relaxed the DAO and 0.2ml of Belotero Intense was placed subcutaneously in the mesolabial area with a 25G 1.5 inch cannula to support the corners of the mouth and blend the mid and lower thirds of the face.

Jawline Rejuvenation of the jawline is now increasingly becoming part of routine aesthetic practice. The ideal youthful appearance is of a straight line that clearly defines the face-neck junction. The two main aesthetic concerns are the development of a jowl and blunting of the jawline definition. Jowl formation is a multifactorial process

Fig 2: Blue dots represent six units of Bocouture toxin used in lower boarder of masseter for massateric debulking. Red line marks the anterior border of the masseter.

Fig 3: Red line represents the jowl area where placement of filler is avoided. White lines represent threads of Radiesse placed subcutaneously using a 25G cannula. White blocked area represents supraperiosteal bolus of Radiesse in the pre-jowl sulcus.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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with contribution to the descent of tissues from the subcutaneous compartment, caused by laxity of the fibrous septae and herniation of fat compartments, superficial musculoaponeurotic layer (SMAS) and sub-SMAS laxity, and descent of the buccal fat pad.8 Bony resorption of the pre-jowl area of the mandible accentuates the appearance.9 The overall blunting of the jawline is caused not only by the jowl, but also has contribution from the pull of platysma, the development of submental fat, and the bony changes that effect the mandible, namely loss of height of the mandibular ramus, loss in height of the mandibular body, and increase of the mandibular angle.9,10 Rejuvenation of the jawline, then, is a complex process that can utilise three separate approaches. We can ‘push up’ by augmentation of parts of the mandibular skeleton, ‘pull’ by revolumising the mid face and cheek to lift lax tissues, and ‘relax’ the downwards pull of platysma with neck toxin.

Our patient had a similar bigonial distance to the bizygomatic distance, which was giving her face a square, masculine appearance. Based on anecdotal evidence, we are of the opinion that whilst a squarer jaw is considered attractive in a Caucasian woman in the western world, the face should remain feminine in its proportions and the chin should reflect a soft pointed appearance. Masseteric debulking was carried out at ACE for our patient. This treatment is minimally invasive and slims the lower face by reducing the bigonial distance, and, in the case of our patient, feminises and rejuvenates the face by restoring an inverted triangle shape.11 We used 3 x 6 units of Bocouture injected at each inferior masseter border. This results in a partial weakness of the masseter muscle with subsequent reduction in the bulk of the muscle fibres. We find that the best results are obtained with an initial programme of treatments every three to four months until the desired level of bulk reduction is achieved. Thereafter the treatment need only be performed infrequently. This treatment may also be used as part of a management programme for temporomandibular joint (TMJ) dysfunction or bruxism. In our experience the treatment lasts six to eight months before a repeat treatment is indicated.

Jawline sharpening The blunting of the youthful sharp demarcation between jaw and neck can be restored to some degree using dermal fillers. Fillers can be placed in the pre-jowl sulcus, or at any position along the mandibular edge, and can be placed superficially or deep. For our patient we wanted to create a sharper definition without any volumetric widening of the jaw and we have found that this is best achieved with small volume superficial threads in the hypodermis.

There was a slight amount of early jowling that was addressed with deep bolus injections in the pre-jowl sulcus. Care is taken to avoid volumisation over the jowl itself, as this is likely only to exaggerate the undesired appearance. We used a 25G cannula to place

The blunting of the youthful sharp demarcation between jaw and neck can be restored to some degree using dermal fillers

Aesthetics Journal

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superficial threads of Radiesse in the subcutaneous layer of the jawline. Radiesse is preferred due to its high viscosity, which means significant lift is seen with small amounts of product, and because it stimulates a degree of neocollagenesis to provide a longer-lasting support to the overlying skin.12 The anatomical structure of concern in this area is the facial artery. This is easily palpable as it crosses the lateral border of the mandible anterior to the insertion of the masseter. Vascular injury can be avoided in this area by the use of blunt tipped cannulae.13,14 The superficial revolumisation depot injections were made directly onto the periosteum in the prejowl sulcus, an area of mandibular bony resorption that contributes to the early jowl appearance.9 Only 0.1cc were required on each side. These boluses were placed using a 27G needle with entry perpendicular to the skin.

Discussion Optimum results in aesthetic medicine stem from an ability to design and execute a treatment plan that exceeds the patient’s expectations. A sound understanding of applied anatomy is paramount to understanding the processes by which the rejuvenation occurs. Today’s practitioner needs to have a full knowledge of anatomy that he or she can link together with knowledge of products and a variety of techniques to create patient-specific, tailored treatment plans with exceptional outcomes.

Dr Emma Ravichandran qualified as a general dental practitioner in 2000, before establishing an interest for aesthetics in 2007. She co-founded Clinetix Medispa in 2010 and, alongside teaching and training commitments; she is actively involved in creating a national audit pathway for aesthetic practice.

Dr Simon Ravichandran is as an ear, nose and throat surgeon, specialising in rhinology. He trained in aesthetic medicine in 2007 and co-founded Clinetix Medispa in 2010. Dr Ravichandran has established the Scottish Advanced Aesthetic Training Programme with Glasgow University, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners.

REFERENCES 1. Rohrich, Rod J Pessa, Joel E, ‘The anatomy and clinical implications of perioral submuscular fat’,

Plastic and reconstructive surgery, 124(1) (2009), pp.266-71.

2. Alistair Carruthers, Jean Carruthers, Ada R. Trinidade de Almeida (2013) In: Carruthers, J and

Carruthers A, Soft Tissue Augmentation, 3rd ed. New York: ELSEVIER. p.132-133.

3. Iblher N, Stark GB, Penna V, ‘The aging perioral region - do we really know what is happening?’,

Nutr Health Aging, 16 (2012), pp.581-5.

4. Survadevara AC, ‘Update on perioral cosmetic enhancement’, Current opinion in Otolaryngology

and Head and Neck Surgery, 16 (2008) pp.347-351 5. Friedman O, ‘Changes associated with the aging face’, Facial Plastic Surg Clin 12 (2005) pp.371- 380.

6. Sullivan, Patrick K, Hoy, Erik A, Mehan V, Singer David P, ‘An Anatomical Evaluation and Surgical

Approach to the Perioral Moundin Facial Rejuvenation’, Plastic and Reconstructive Surgery, 126(4)

(2009), pp.1333-39.

7. Carruthers J, Carruthers A, ‘Botulinum toxin (Botox) chemodenervation for facial rejuvenation’,

Facial Plast Surg Clin 9 (2001) pp.197–204.

8. Mendelson BC, Freeman ME, Wu W, Huggins RJ, S’urgical anatomy of the lower face: the

premasseter space, the jowl, and the labiomandibular fold,’ Aesthetic Plast Surg, 32

(2008) pp.185-95.

9. Mendelson B, Wong C, ‘Changes in the Facial Skeleton With Aging: Implications and Clinical

Applications in Facial Rejuvenation’, Aesth. Plast Surg, 36 (2012), pp.753-760.

10. Roshanak Ghaffari, ‘Mandibular Dimensional Changes with aging in Three Dimensional

Computed Tomographic Study in 21 to 50 Year old Men and Women’, Journal of Dentomaxillary

Radiology, Pathology and Surgery, 2 (2013).

11. Jeffrey Ahn, ‘Botulinum Toxin for Masseter Reduction in Asian Patients, Arch Facial Plast Surg, 6

(2004) pp.188-191.

12. Coleman K, Voigts R, Devore DP, Termin P, Coleman WP, ‘Neocollagenesis after injection of

calcium hydroxylapatite composition in a canine model’, Dermatologic Surgery, 34 (2008), Suppl 1:S53-5.

13. Grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Baumann L, ‘The risk of alar necrosis

associated with dermal filler injection’, Dermatol Surg, 35 (2009) Suppl 2: pp.1635–1640.

14. Coleman SR, ‘Avoidance of arterial occlusion from injection of soft tissue fillers’, Aesthet Surg J.

22 (6) (2002), pp.555–557.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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“Patients now realise that there are so many expensive skincare brands on the market which often claim things they don’t do. I think our patients are becoming more mature and sophisticated in their search for products.”

Spotlight On: Fillerina Aesthetics explores the efficacy of the new no-needle dermo-cosmetic filler gaining traction in the UK

Introduction Since its launch in March 2015, Fillerina has attracted a wide range of interest in both the beauty and aesthetic markets. And while some may argue effective marketing and PR efforts can of course increase the popularity of a product, Fillerina users have cited the double blind randomised trial as its driving force.

The topical gel filler aims to plump the skin without the use of needles. The Swiss-developed formula comprises a blend of six hyaluronic acids (HAs), which aim to increase tissue volume in cheeks and lips. According to the manufacturer, Labo, the gel also contains peptides that aim to stimulate collagen production and soften the appearance of lines and wrinkles.

A study into the cosmetic filling efficacy of Fillerina was published in the Journal of Cosmetic Dermatology in December 2014.1 Results indicated that Fillerina was, ‘able to provide an improvement in the appearance of chronoaged skin in subjects showing mild-tomoderate clinical signs of ageing skin on the face.’

Aesthetic practitioner Dr Elisabeth Dancey stocks Fillerina in her London-based clinic, Bijoux Medi-Spa. She notes that regardless of what the product is, most patients become more interested once they know it is supported by scientific research. She says,

Methodology Led by Dr Fulvo Marzatico, the placebo-controlled, double-blind, randomised clinical trial was carried out on 40 healthy Caucasian women, showing mild to moderate clinical signs of ageing. The study explains that only subjects who used SPF 15 during the summer period, had no obvious skin disease, no known history of atopic dermatitis and/or skin elastosis of the face were enrolled.

Participants were between the ages of 25 and 55 years old, with the active group’s mean age residing at 47.7 ± 5.7 years old, while the placebo group’s mean age was 46.3 ± 6.8 years old. The study excluded subjects using topical products containing moisturising and/or anti-ageing actives. Five Fillerina products were tested (Gel Filler, Nourishing Film, Day Cream, Night Cream and Eye/Lip Cream), which each contained sodium hyaluronate crosspolymer and a mixture of HA at different molecular weights as cosmetic active ingredients. Participants were instructed to apply the product themselves and were allowed to continue the use of regular make-up products, providing the products didn’t claim any anti-ageing effect.

As a primary endpoint, skin sagging/loss of volume of face contours, cheekbones and lips were measured using a morphometric image analysis technique to depict the efficacy of Fillerina. Wrinkle volume and depth were measured using a 3D microtopography imaging system as a secondary endpoint. The study authors explain that the imaging system has an overlap feature, which allows precise matching of photos taken at different visits. Frontal facial images were taken using a digital reflex camera and participants’ positions were regulated using a stereotactic device. According to the study, each measurement was carried out at baseline, seven, 14 and 30 days after treatment, apart from lip volume and wrinkle depth/volume, which were also assessed three hours after the first product application. Fillerina was applied under temperature- (22 ± 2°C) and relative humidity- (50 ± 10%) controlled conditions, and treatment was terminated eight to 12 hours before any skin assessments were made. Results following treatment are shown in Figure 1.

Study conclusion The study’s discussion stated that Fillerina, ‘Improved the skin sagging of both the face and cheekbones contours, the lips

Figure 1:

Time post application

Effects of Fillerina use

Three hours

Seven days

14 days

30 days

Increase in lip volume

8.5%

11.3%

12.8%

14.2%

Decrease in skin sagging of the face contours

N/A

–0.443 ± 0.286 mm

–1.124 ± 0.511 mm

–1.326 ± 0.649 mm

Decrease in skin sagging of the cheekbone contours

N/A

–0.989 ± 0.585 mm

–2.500 ± 0.929 mm

–2.517 ± 0.927 mm

Increase in cheekbone volume

N/A

0.875 ± 0.519 mm

2.186 ± 0.781 mm

2.275 ± 0.725 mm

Decrease in wrinkle volume

N/A

–11.3%

–18.4%

–26.3%

Decrease in wrinkle depth

N/A

–8.4%

–14.5%

–21.8%

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

Aesthetics

volume, and decreased wrinkle depth and volume.” The authors of the study explain that the product may be more successful in diminishing the skin sagging on cheekbones, compared to face contour skin sagging, however explain that this relative response on different sites may have been noticeable due to the skin sagging severity and the extent of the two skin sites.

The authors note that a slight worsening of skin sagging was apparent in the placebo group, but suggest that this could be due to normal variation of skin sagging.

The authors concluded that, ‘This study provides the first evidence that the use of six types of hyaluronic acid at different molecular weight (Fillerina) is able to provide an improvement in the appearance of chronoaged skin in subjects showing mild-tomoderate clinical signs of skin ageing on the face.’

Using Fillerina Since the publication of the study, Dr Dancey has begun selling the product through her clinic. “The response to it has been pretty good so far,” she says. And while she doesn’t recommend Fillerina as an alternative to traditional injectable HA fillers, which can offer a concentrated volume of filler in precise areas, she does note that it has its own benefits. “The value of Fillerina is that it replaces the lost volume in all areas of the face, which is almost impossible to do with fillers.” Dr Dancey explains the product is easy to use and highlights the fact that the study found no side effects. “I recommend it to all my patients, mainly from the age of 35 when most people start to age, although this can be younger,” she says. Dr Dancey adds that she advocates users follow the manufacturers’ instructions for use, in accordance with the study’s research. The at-home kit contains 14 doses of 2ml gel filler, 14 doses of 2ml nourishing film and two precision applicators. Users are recommended to use the treatment once daily for 14 days in order to achieve noticeable results. Dr Dancey also advices users to apply the nourishing film to “really push the product into their skin”, before being able to wear other cosmetic products as normal. Fillerina is available in three grades of strength; the first aims to treat moderate wrinkles and signs of skin sagging, the second targets visible wrinkles and sagging, whilst the third aims to improve the appearance of deep set wrinkles and severe skin sagging. Dr Dancey, however, only stocks the strongest grade. “Personally, I only stock the strongest grade because I think if you’re going to do something for your skin, you’re going to want the best version,” she explains. “If I’m going to do something, I do it properly.” With dermal fillers being listed as the most requested non-surgical aesthetic procedure in 2014,2 with a 131% increase in requests since 2013,2 it seems unlikely that the demand for plumper skin will be slowing down any time soon. And for patients unwilling or unable to undergo injectable treatments on a regular basis, products such as Fillerina could offer wellsupported, safe and effective alternatives.

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Quote from Journal of Cosmetic Dermatology ‘The study demonstrated the positive filling effect of Fillerina in decreasing the clinical signs of skin aging and in improving the face volumes’

Edited by Zoe Draelos

Disclosure: Dr Elisabeth Dancey is the medical director of Medical Aesthetic Group, the UK distributor for Fillerina.

REFERENCES 1. Marzatico F et al, ‘Anti-aging and filling efficacy of six types hyaluronic acid based dermo-

cosmetic treatment: double blind, randomized clinical trial of efficacy and safety’, Journal of

Cosmetic Dermatology, 13 (2014), pp. 277-287.

2. Whatclinic.com, Yearly Roundup: Medical Aesthetics Trends UK – Jan 2015 (UK: Whatclinic.com, 2015) <https://about.whatclinic.com/wp-content/uploads/2015/03/2014-non-surgical-round-up- UK-FINAL.pdf>

For further information about Fillerina please contact: Medical Aesthetic Group on 02380 676733 or visit www.magroup.co.uk

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balancing and, if necessary, seek advice from a CBT practitioner. We need to keep in mind that female sexual arousal is multifactorial,11 often with psychological and emotional as well as physical factors, so there is no one ‘magic bullet’ treatment.

Treating Sexual Dysfunction with PRP Dr Catherine Stone outlines treatment methods for improving orgasm in women, and details the use of PRP for effective outcomes in a range of gynaecological indications Introduction A healthy sex life is thought to have significant benefits to both the mind and body. Sexual dysfunction such as anorgasma, dysparenuria, decreased libido and vaginal dryness, along with urinary stress incontinence (USI), can occur after childbirth or during menopause and may be prevalent in up to 43% of women.1 Sexual dysfunction in both men and women can result in a reduction in sexual intimacy in a relationship, which may then negatively affect family life and self-esteem.2 While there are many treatments available for erectile dysfunction in men, there are currently no Food and Drugs Administration (FDA) approved treatments for sexual dysfunction in women.

Current methods for improving sexual dysfunction A variety of different substances have been injected into the peri-urethral area to help treat both USI and female sexual dysfunction. Calcium hydroxyapatite crystals are FDA approved for peri-urethral injection to treat USI, however issues such as urinary obstruction, erosion, infection and granuloma formation requiring surgical removal can occur,3,4 and no studies show improvement in sexual function – unsurprisingly, as they are not intended for this use.

Hyaluronic acid (HA) fillers have been injected into the Grafenberg Spot (often referred to as the G-spot) on the anterior vaginal wall to enhance a woman’s orgasmic intensity.5 While a pilot study on the treatment found that 87% of women reported enhanced sexual arousal or gratification,5 the American College of Obstetricians and Gynecologists published a paper in 2007 condemning this kind of treatment, which was reaffirmed in 2014.6 The paper argued that there was no valid reason to perform the procedure, and highlighted that it had not been proven to be safe or effective through randomised controlled studies. In addition, they noted that women should be informed of the lack of data supporting the efficacy of the procedures and their potential complications.6 Other off-label treatments for female sexual dysfunction have included hormone treatments with vaginal estrogen creams, and transdermal testosterone patches, prescribed by a clinician specialising in this area. The testosterone dose for women should only be a small fraction of that required for men,7 and side effects can include hirsuitism, acne, virilisation and potentially increased cardiovascular risk.8 With both testosterone and estrogen treatments, there is a concern of an increased risk of breast cancer.9 Cognitive and Behavioural Therapy (CBT) is another tool for managing sexual dysfunction.10 In our clinic, we encourage our patients to see a specialist in hormone

PRP: Background A recent pilot study has shown that injections of Platelet-Rich Plasma (PRP) may be a safe and effective treatment for improving sexual function.12 In multiple studies, PRP has been shown to be effective and without any serious side effects in the areas of orthopedics13, sports medicine, wound care14-16, dental surgery, ophthalmology and in many cosmetic procedures.17-24 PRP is isolated from a small sample of blood (about 10-20ml) taken from the patient, and centrifuged in a specialised tube. There are many different preparations available, however at our clinic we use a patented system comprising a tube that contains a gel to separate the red cells from the platelets and plasma. Other means of preparing PRP use non-gel tubes, or an all-in-one machine that separates the PRP for you. We have found the tubes with the separating gel to be the cleanest and easiest way to isolate the appropriate levels of platelets and plasma. The resulting PRP is usually clear and straw-coloured, and can be activated with either calcium chloride or calcium gluconate to create a ‘Platelet-Rich Fibrin Matrix’ – the small amount of added calcium initiates fibrinogen cleavage and fibrin polymerisation. Once the calcium is added, you have about 10-12 minutes to inject the solution before it solidifies into a fibrin clot.

This ‘scaffolding’ helps to localise the growth factors, essentially increasing the local concentration in the target tissues to help guide tissue regeneration.25,26 The gel-like consistency of the fibrin clot may also give a more sustained volume effect than with plain PRP. In our practice, we have stopped activating the PRP for cosmetic procedures as, for skin rejuvenation, it can be painful and the gel consistency is not necessary, but we continue to use calcium chloride for our sexual dysfunction procedures.

The PRP is a non-viscous fluid, which flows easily into the tissues and can be administered with a small-bore needle, increasing the comfort of the procedure.

Once in the tissues, the PRP releases active growth factors which attract and activate pluripotent stem cells in the area of injection, stimulating neoangiogenesis, fibroblast

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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growth, glandular proliferation and new neuronal growth, resulting in rejuvenation and even enhancement of damaged or undamaged tissue.27 PRP is completely autologous, so as yet there are no known contraindications to the treatment. There have been no reports of granuloma, infection, or any other serious side effects with PRP in the medical literature documenting its use – at least when FDA-approved preparation kits are used – although it is imperative that PRP is prepared in properly-sterilised tubes.

Using PRP for gynaecologic concerns Anecdotal evidence from patients suggest this procedure can be helpful for:28 · · · · ·

USI Reduced sensation Decreased arousal Anorgasmia Vaginal dryness

· · · ·

Reduced sexual desire Dyspareunia Lichen sclerosis Fissures post episiotomy

Before starting a PRP gynaecologic procedure, a strong topical anaesthetic cream is applied to the anterior vaginal wall and the clitoris after retracting the clitoral hood. Almost complete anaesthesia can be achieved if you leave the cream on for 20 minutes while arranging and preparing the PRP, and we aim for an almost painless treatment. PRP is then injected into two very specific sites: one on the anterior vaginal wall and the second in the clitoris. (See Figure 1 for external vaginal anatomy). With the gel-separating PRP kit that we use, generally around 5-6ml of PRP can be isolated from a 10ml blood collection. The first injection is peri-urethral and I have found that this can have an immediate impact on USI due to the volume effect of the PRP – injecting the fluid between the vaginal wall and the urethra changes the vesico-urethral angle in the same way a surgical sling does. By increasing blood flow and cellular regeneration in this area, it is also designed to improve the function of the Skene’s glands, which are the female tissue equivalent of the prostate in men, and play a significant role in female ejaculation. This first injection is usually completely painless. The second injection goes into the proximal corpus cavernosum of the clitoris, with the PRP spreading distally into the hidden part of the clitoris – the glans of the clitoris, or the visible part, is only the tip of the iceberg. (Figure 2) The clitoris is usually about 10cm long, with about 8,000 nerve endings and two corpus cavernosa Figure 1

Frenulum of clitoris

Openings of paraurethral (Skene’s) ducts

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which surround the urethra and extend into the pelvic area, including the vaginal walls. This may explain the ‘tightening’ of the vagina that many women experience.

Results of PRP treatment Following the treatment, there is no downtime. The patient can resume sexual activity almost immediately after the procedure, although I recommend waiting until the effects of the local anaesthetic cream have dissipated. From my experience, there is often an immediate improvement in USI and arousal, due to the volume effect of the PRP. This may dissipate over a few days and then slowly improve again over the next three to five weeks, with full effect often achieved at around three to five months. Potential side effects may include, as with any injection, spot bleeding (we provide a sanitary pad for any spotting or discharge, and to prevent local anaesthetic cream from staining their underwear), bruising, tenderness, a warm or burning sensation in the area (this usually settles within minutes/hours), temporary localised numbness due to the local anaesthetic effects, and hypersexuality or increased arousal, especially in younger women with previously normal or close to normal sexual function. We ask all of our patients to complete two surveys – the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale – Revised (FSDS-R) before treatment, at six weeks, three months, six months and 12 months, which over time will help to build a clearer picture of the effects of PRP. The pilot study for this procedure shows a 65% success rate with one treatment, which increases to 85-90% satisfaction after two treatments.12 Conclusion While this procedure is still in its infancy, results look very promising; we have been achieving excellent results in clinic so far. Because the PRP is autologous – using the body’s own healing system with almost no serious side effects – it seems inherently safer than other options for treating sexual dysfunction. I always tell my patients that it is just one tool that can be used, and other treatment modalities may also be required or more suitable. I would suggest, though, that this procedure needs more definitive research, which is currently underway with Dr Charles Runels, the founder of these specific procedures. With so few options available to women with sexual dysfunction, it’s good to know we can offer something simple, safe, quick and almost painless that can help them in what is usually a private and personal struggle, which impacts on both family life and relationships.

Figure 2: Glans clitoris

Mons pubis Prepuce of clitoris

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Anterior commissure of labia majora Urethral opening

Glans of clitoris Exterior urethral orifice

Corpus cavernosum

Bulb of vestibule Vaginal orifice

Labium min Crus clitoris

Vestibule of vagina Vestibular fossa Frenulum of labia minora Perinealraphé (over perineal body)

Labium maj Opening of greater vestibular (Bartholins) gland Hymenal caruncle Posterior commisure of labia majora

Vaginal opening

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Dr Catherine Stone is a cosmetic physician with 15 years’ experience, based in Auckland, NZ. She also works at the PHI Clinic in Harley St, London. Dr Stone trained with Dr Charles Runels, the inventor of these techniques, and is currently one of four global trainers for this procedure.

14. Hom DB, Linzie BM, Huang TC, ‘The healing effects of autologous platelet gel on acute human

skin wounds’, Arch Facial Plast Surg, 9(3) (2007), pp. 174-183.

15. O’Connell SM, Impeduglia T, Hessler K, Wang XJ, Carroll RJ, Dardik H, ‘Autologous platelet-rich

fibrin matrix as cell therapy in the healing of chronic lower extremity ulcers’, Wound Repair Regen,

16(6) (2008), pp. 749-756.

16. Cervelli, Valerio MD; Lucarini, Lucilla MD, ‘Use of Platelet-Rich Plasma and Hyaluronic Acid in the

Loss of Substance with Bone Exposure’, Advances in Skin & Wound Care, 24(4) (2011), pp. 176-181 REFERENCES 17. Redaelli, Alessio, ‘Face and neck revitalization with Platelet-rich plasma (PRP): clinical-outcome in a 1. Edward O. Laumann, PhD; Anthony Paik, MA; Raymond C. Rosen, PhD, ‘Sexual Dysfunction in the

series of 23 consecutively treated patients’, Journal of Drugs in Dermatology (2010)

United States: Prevalence and Predictors, JAMA, 281(6) (1999), pp. 537-544.

18. Azzena B, Mazzoleni F, Abatangelo G, Zavan B, Vindigni V, ‘Autologous plateletrich [Using Regen 2. Basson, R. ‘Sexual desire and arousal disorders in women’, N Engl J Med, 354 (2006), pp. 1497-

prepared platelet-derived growth factors (a single-spin centrifuge) to rejuvenate the face & 506.

neck] plasma as an adipocyte in vivo delivery system: case report’, Aesthetic Plast Surg, 32(1) 3. Gafni-Kane, Adam MD; Sand, Peter K. MD, ‘Foreign-Body Granuloma After Injection of Calcium

(2008), pp. 155-161.

Hydroxylapatite for Type III Stress Urinary Incontinence’, Obstetrics & Gynecology, 118(2,2) (2011), 19. Cervelli V, Gentile P, Grimaldi M, ‘Regenerative surgery: use of fat grafting combined with platelet-

pp. 418-421.

rich plasma for chronic lower-extremity ulcers’, Aesthetic Plast Surg, 33(3) (2009), pp. 340-345.

4. Alijotas-Reig, Jaume MD, PhD, ‘Foreign-Body Granuloma After Injection of Calcium 20. Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gentile P. Autologous platelet-rich

Hydroxylapatite for Treating Urinary Incontinence’, Obstetrics & Gynecology, 118(5) (2011), pp. 1181-

plasma mixed with purified fat graft in aesthetic plastic surgery. Aesthetic Plast Surg. 33(5) 1182.

(2009), pp. 716-721.

5. The G-Shot, G-Shot Overview (The G-Shot, 2015)<http://thegshot.com/physicians> 21. Cervelli V, Gentile P, ‘Use of cell fat mixed with platelet gel in progressive hemifacial atrophy’, 6. American Congress of Obstetricians and Gynecologists, ACOG Committee Opinion: Vaginal

Aesthetic Plast Surg, 33(1) (2009), pp. 22-27.

“Rejuvenation” and Cosmetic Vaginal Procedures (US: American Congress of Obstetricians and 22. Cervelli V, Gentile P, Scioli MG, et al, ‘Application of platelet-rich plasma in plastic surgery: clinical

Gynecologists, 2007),<http://www.acog.org/Resources-And-Publications/

and in vitro evaluation’, Tissue Eng Part C Methods, 15 (2009), pp. 1-9.

Committee-Opinions/Committee-on-Gynecologic-Practice/Vaginal-Rejuvenation-and- 23. Oh DS, Cheon YW, Jeon YR, Lew DH, ‘Activated platelet-rich plasma improves fat graft survival in Cosmetic-Vaginal-Procedures>

nude mice: a pilot study’, Dermatol Surg, 37(5) (2011), pp. 619-625.

7. Davis SR1, van der Mooren MJ, van Lunsen RH, Lopes P, Ribot C, Rees M, Moufarege A, 24. Danielsen P, Jørgensen B, Karlsmark T, Jorgensen LN, Agren MS, ‘Effect of topical autologous

Rodenberg C, Buch A, Purdie DW. ‘Efficacy and safety of a testosterone patch for the treatment of

platelet-rich fibrin versus no intervention on epithelialization of donor sites and meshed split-

hypoactive sexual desire disorder in surgically menopausal women: a randomized,

thickness skin autografts: a randomized clinical trial’, Plast Reconstr Surg, 122(5) (2008), pp. 1431-

placebo-controlled trial.’ Menopause, 13(3) (2006), pp. 387-96.

1440.

8. Brand JS, van der Schouw YT, ‘Testosterone, SHBG and cardiovascular health in postmenopausal 25. Roy S, Driggs J, Elgharably H, Biswas S, Findley M, Khanna S, Gnyawali U, Bergdall VK, Sen women’, Int J Impot Res, 22(2) (2010), pp. 91-104.

CK. ‘Platelet-rich fibrin matrix improves wound angiogenesis via inducing endothelial cell 9. Tamimi RM, Hankinson SE, Chen WY, et al. ‘Combined estrogen and testosterone use and risk of

proliferation.’ Wound Repair Regen. 2011 Nov; 19(6):753-66.

breast cancer in postmenopausal women’, Arch Intern Med 166 (2006), pp. 1483-9.

26. Anthony P. Sclafani, MD; ‘Safety, Efficacy, and Utility of Platelet-Rich Fibrin Matrix in Facial Plastic 10. ter Kuile MM1, Both S, van Lankveld JJ, ‘Cognitive behavioral therapy for sexual dysfunctions in

Surgery’, Arch Facial Plast Surg. 2011; 13(4):247-251. women.’ Psychiatr Clin North Am, 33(3) (2010), pp. 595-610.

27. Anthony P. Sclafani, MD; Steven A. McCormick, MD, ‘Induction of Dermal Collagenesis, 11. Basson R, ‘Testosterone therapy for reduced libido in women’, Ther Adv Endocrinol Metab, 1(4)

Angiogenesis,and Adipogenesis in Human Skin by Injection of Platelet-Rich Fibrin Matrix’, Arch

(2010), pp. 155–164.

Facial Plast Surg, 14(2) (2012) 132-136.

12. Runels CE, Melnick H, Roy L, DeBourbon E, ‘A Pilot Study of the Effect of Localized Injections of 28. King, M.,Tolson, H., Runels, C., Gloth, M., Pfau, R., Goldstein, A., ‘Autologous Platelet Rich Plasma

Autologous Platelet Rich Plasma (PRP) for the Treatment of Female Sexual Dysfunction’, J

(PRP) Intradermal Injections for the Treatment of Vulvar Lichen Sclerosus’ (Forthcoming 2015)

Women’s Health Care, 3:4 (2014) 13. Sclafani AP, Romo TR III, Ukrainsky G, et al. ‘Modulation of wound response and soft tissue

ingrowth in synthetic and allogeneic implants with platelet concentrate’, Arch Facial Plast Surg,

7(3) (2005), pp. 163-169.

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COMPOSED • CONFIDENT • MY CHOICE

PURIFIED1• SATISFYING2,3,4 • CONVENIENT5

Now approved for crow’s feet lines Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU 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) and lateral periorbital lines seen at maximum smile (crow’s feet 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. Glabellar Frown Lines: 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. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to 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. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually 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). Glabellar Frown Lines: 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, 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). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,

dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. 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: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August 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. 1183/BOC/DEC/2014/DS Date of preparation: December 2014

PURIFIED1• SATISFYING2,3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

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Microsclerotherapy Clare McLoughlin details the treatment of spider veins using microsclerotherapy With spider veins affecting up to half of all adults, and awareness of the wide range of non-surgical aesthetic procedures available increasing, more and more patients are turning to treatments such as microsclerotherapy for a cure. But what is microsclerotherapy, and does it really work?

What is microsclerotherapy?

The word sclerotherapy comes from the Greek ‘scleros’, which means ‘to make hard’. It is a treatment designed to tackle problem veins, from minor spider veins to small varicose veins, through the injection of a liquid into the vein in order to destroy it. Sclerotherapy leads to the vein becoming inflamed and hard to the touch before being absorbed by the body.1 Microsclerotherapy is one of the most effective and well-established treatments for telangiectasia – or spider veins – an issue that affects up to 50% of all adults.2 Although spider veins can cause discomfort in some, for many patients, these small dilated blood vessels are an unsightly problem that they wish to have removed through procedures such as foam sclerotherapy, microsclerotherapy, laser therapy or even surgery. Microsclerotherapy differs from sclerotherapy in that it uses micro-needles to specifically target telangiectasia, rather than larger varicose veins.

Microsclerotherapy is most effective in the treatment of spider veins on the legs, and involves the injection of a solution, or ‘sclerosant’, with a very fine needle into the problem blood vessel. The injected solution is designed to destroy the endothelium triggering thrombosis and subsequent fibrosis, causing the vessel to close and fade away.3 The use of graduated compression hosiery supports and promotes the healing process, minimising undesirable side effects such as the development of post-sclerotherapy thrombi and general inflammation.4 a ten minute walk immediately after treatment, and then 72 hours continuous compression. This is followed by compression for two weeks during the day.

Some of the most common sclerosants used today include sodium tetradecyl sulfate, polidocanol, 23.4% saline, a mixture of 25% dextrose with 10% saline, and chromated glycerine,5 – a far cry from the solutions and techniques adopted in the very first attempts at sclerotherapy, which took place more than 300 years ago. In 1682, D. Zollikofer of St Gallen, Switzerland, reported that he had injected an acid solution into a vein to create a thrombus, the very first recorded attempt at sclerotherapy.6 Following the development of the hypodermic syringe in the 1850s, sclerotherapy became more widespread and in 1853, doctors Cassaignaic and Debout used injectable solutions of

perchloride of iron to treat varicose veins and reported some success with their new therapy.7 Throughout the late 19th century and into the early 20th century, the popularity of sclerotherapy increased, as did the number of solutions used as sclerosants.

However, demand for sclerotherapy treatment reduced significantly in 1933 when Foxon published results of a followup survey of injection treatments. These results showed a recurrence rate of 63% in varicose veins treated via sclerotherapy,7 demonstrating the significant lack of success of some of the early sclerosants used.

The sclerosants used in microsclerotherapy today (including hypertonic saline, sodium tetradecyl sulfate, polidocanol and chromated glycerin8) are a new generation of ‘tried and tested’ sclerosants, developed since the 1950s alongside strict pharmaceutical licensing laws that had previously been lacking in the development (and subsequent approval for use) of a wide range of ‘medical’ solutions. It is due to these new safe and effective sclerosants, as well as the improvements in aftercare and support, that 80% of patients who have undergone contemporary microsclerotherapy treatments have reported a noticeable improvement in the look of their spider-veins.8 This significant improvement in statistics from the early twentieth century figure can be seen as a contributing factor to its recent surge in popularity as a recognised and trusted treatment for telangiectasia.

Microsclerotherapy today is a widespread and well-established treatment for spider veins, and with organisations such as the British Association of Sclerotherapists9 working hard to raise and maintain standards of responsible practice in sclerotherapy, and establishing a code of conduct for practitioners, microsclerotherapy has gained a reputation as a safe and effective treatment for telangiectasia on the legs. Save Face, an organisation that aims to help members of the public to locate safe, fully trained, licensed and insured practitioners for non-surgical procedures state (in relation to microsclerotherapy treatment) that it is reasonable to expect a 40-80% improvement in the appearance of spider veins following a microsclerotherapy treatment, though in many cases, multiple treatments are required.3 However, as with all medical procedures, there are some small risks associated with microsclerotherapy that the patient needs to be aware of prior to treatment.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

@aestheticsgroup Before and four weeks following one treatment of microsclerotherapy

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Before and four weeks following one treatment of microsclerotherapy

What are the risks associated with microsclerotherapy?

Common short-term side effects in the hours immediately following a microsclerotherapy treatment include redness, welts similar to insect bites appearing at the puncture sites, and a prickling or itching sensation across the area that was treated.3 These symptoms tend to subside spontaneously within hours of the treatment being performed, as long as the correct aftercare instructions are carried out. Longer lasting side effects following microsclerotherapy include bruising and brown pigmentation of the treatment area, caused either by haemosiderin deposition as red blood cells break down, or by post-inflammatory hyperpigmentation.2 I have found that the incidence can be minimised with compression hosiery and by expressing retained clots at 14 days.

This staining can occur in up to 15% of all sclerotherapy treatments; staining that is not usually permanent, but that can take between six and 18 months to fade.2 Telangiectatic matting is another side effect that can occur as a result of microsclerotherapy. This happens when vessels are partially damaged and remain under pressure from feeding vessels, leaving a ‘matted’ area of tiny visible blood vessels that resemble a bruise. In my experience, telangiectatic matting usually clears as vessels in the area are successfully closed, within six to 12 months.

As with all medical treatments involving medicated solutions, microsclerotherapy brings with it the potential for an allergic reaction,2 from relatively minor symptoms of itching and redness following treatment, to a full blown anaphylactic response that can occur as soon as the sclerosant is introduced to the system. There have been several reported cases of anaphylactic reactions to the sclerosant used, specifically in ultrasound-guided foam sclerotherapy, including one case of a 62-year-old woman

who had previously undergone exactly the same treatment but had shown no adverse reactions to it – in this case, the woman required resuscitation with adrenaline.10 However, as there are a number of potential sclerosants available for use, practitioners can work to avoid the issue of allergic reactions as much as possible through a detailed consultation prior to treatment, discussing the medical history of the patient and potentially testing the patient’s tolerance to the sclerosant using a small amount of the solution in contact with the skin. The NHS website also lists some further rare, but potential side effects of sclerotherapy (more particularly applicable to the use of higher concentrations in larger volumes used to treat varicose veins, either in liquid or as a foam), including blood clots, headaches, lower back pain, fainting, transient visual disturbances and in extremely rare cases, transient ischaemic attacks.11 How effective is microsclerotherapy?

The risk of serious side effects from microsclerotherapy treatment is extremely low (the occurrence of allergic reactions – from minor hives through to anaphylaxis – reported as having happened as a direct result of sclerotherapy treatment has been recorded as just 0.3%7), and even if the patient does experience some haemosiderin staining or telangiectatic matting as a result of the treatment, the likelihood is that these will fade without further intervention within 12 months.2 The majority of telangiectasia treated with microsclerotherapy will also fade – in my experience, many patients report that they begin to see an improvement after about four weeks, though it can take two to three months for the full effects of the treatment of the spider veins to be seen. In many cases, further treatments may be necessary to treat an area of telangiectasia, and I usually recommend that patients budget for

around four treatments, though the number required does vary depending on the severity of the case.

Microsclerotherapy, despite the small risks associated with it, remains one of the most popular, safest and most effective ways to treat telangiectasia available today. As professional bodies such as the British Association of Sclerotherapists provide standards and education – and medical practitioners are required to evidence CPD to maintain their professional accreditations – patient education and treatment outcomes can only improve, driving confidence and demand.

Clare McLoughlin is an

independent nurse prescriber and advanced procedure

aesthetic nurse and trainer with more than a decade of experience in the aesthetic field. Clare has been performing sclerotherapy for more than 14 years and is a member of the British Association of Sclerotherapists. She is also a member of the British Association of Cosmetic Nurses.

REFERENCES 1. The Whiteley Clinic, What is Ultrasound Guided Foam Sclerotherapy? (UK: www.thewhiteleyclinic.co.uk) <http:// www.thewhiteleyclinic.co.uk/procedures/ultrasound-guided- foam-sclerotherapy> 2. British Association of Sclerotherapists, Patient Information Page

(UK: www.bassclerotherapy.co.uk) <http://www.bassclerotherapy. co.uk/index.php?page=patient-information> 3. Save Face, Useful Downloads: Sclerotherapy Fact Sheet (UK:

www.saveface.co.uk) <http://www.saveface.co.uk/downloads> 4. Kern, P., Ramelet, A.A., Wütschert ,R and Hayoz, D.

‘Compression after sclerotherapy for telangiectasias and

reticular leg veins: A randomized controlled study’ Journal of

Vascular Surgery, (2007) 5. Zimmet, S.E., ‘Sclerotherapy treatment of telangiectasias and

varicose veins’, Techniques in Vascular and Interventional Radiology, 6(3) (2003), pp. 116–120.

6. Goldman, M.P. et al., Sclerotherapy: Treatment of Varicose and

Telangiectatic Leg Veins (Elsevier Health Sciences, 2011).

7. Sharmi, S., and Cheatle, T., Fegan’s Compression Sclerotherapy

of Varicose Veins (London: Springe-Verlag, 2003).

8. British College of Aesthetic Medicine, Sclerotherapy, (UK: www.

bcam.ac.uk, 2010) <http://www.bcam.ac.uk/about-aesthetic- medicine/treatments/sclerotherapy.asp> 9. British Association of Sclerotherapists, Home, (UK: www.

bassclerotherapy.co.uk) <www.bassclerotherapy.co.uk> 10. Scurr, J.R.H. et al., ‘Anaphylaxis Following Foam Sclerotherapy:

A Life Threatening Complication of Non Invasive Treatment for

Varicose Veins’, European Journal of Vascular and

Endovascular Surgery, 34(2) (2007), p. 249.

11. National Health Service, Varicose veins - Treatment (UK: www.

nhs.uk) <http://www.nhs.uk/Conditions/Varicose-veins/Pages/ Treatment.aspx>

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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A summary of the latest clinical studies Title: Oxidative Stress in Aging Human Skin Authors: M Rinnerthaler, J Bischof, MK Streubel, A Trost, K Richter Published: Biomolecules, April 2015 Keywords: Oxidative stress, skin, ageing, UV irradiation Abstract: Oxidative stress in skin plays a major role in the aging process. This is true for intrinsic aging and even more for extrinsic aging. Although the results are quite different in dermis and epidermis, extrinsic aging is driven to a large extent by oxidative stress caused by UV irradiation. In this review the overall effects of oxidative stress are discussed as well as the sources of ROS including the mitochondrial ETC, peroxisomal and ER localized proteins, the Fenton reaction, and such enzymes as cyclooxygenases, lipoxygenases, xanthine oxidases, and NADPH oxidases. Furthermore, the defense mechanisms against oxidative stress ranging from enzymes like superoxide dismutases, catalases, peroxiredoxins, and GSH peroxidases to organic compounds such as L-ascorbate, α-tocopherol, beta-carotene, uric acid, CoQ10, and glutathione are described in more detail. In addition the oxidative stress induced modifications caused to proteins, lipids and DNA are discussed. Finally age-related changes of the skin are also a topic of this review. They include a disruption of the epidermal calcium gradient in old skin with an accompanying change in the composition of the cornified envelope. This modified cornified envelope also leads to an altered anti-oxidative capacity and a reduced barrier function of the epidermis.

Title: Treatment of Periorbital Wrinkles With a Novel Fractional Radiofrequency Microneedle System in Dark-Skinned Patients Authors: SJ Lee, JI Kim, YJ Yang, JH Nam, WS Kim Published: Dermatologic Surgery, April 2015 Keywords: Periorbital, radiofrequency, rejuvenation, microneedling Abstract: Periorbital wrinkles as a result of photoaging are a frequent cosmetic concern. Recently, the fractional radiofrequency microneedle system was introduced as a new device for facial rejuvenation, and it has received much recognition for its unique “deep dermal heating with epidermal sparing” feature. The purpose of this study was to examine the clinical efficacy and safety of the system for the treatment of periorbital wrinkles in Korean patients. Twenty Korean patients (Fitzpatrick skin Type IV-V) with varying degrees of periorbital wrinkles were enrolled in this study. The patients were treated 3 times at 4-week intervals with the system. Changes in periorbital wrinkling were evaluated by 2 independent experts with digital images of the subjects’ faces using a 5-point Wrinkle Assessment Scale. At the end of the study, the patients rated their satisfaction with the overall treatment outcome on a numerical scale. All patients completed the treatment regimen and were satisfied with the treatment.

Most patients improved according to clinical and photographic assessments performed 6 months after the treatment. Two patients (10%) reported mild hyperpigmentation. The system may be an effective and safe treatment option for periorbital wrinkles in darkskinned Korean patients.

Title: Combination therapy of methotrexate plus NBUVB phototherapy is more effective than methotrexate monotherapy in the treatment of chronic plaque psoriasis Authors: A Soliman, E Nofal, A Nofal, F El Desouky, M Asal Published: Journal of Dermatological Treatment, April 2015 Keywords: Methotrexate, narrowband ultraviolet B, psoriasis, MTX Abstract: The efficacy of methotrexate (MTX) plus narrowband ultraviolet B (NBUVB) phototherapy in treatment of chronic plaque psoriasis has been rarely assessed. The objective of this study is to compare the efficacy of MTX/NBUVB phototherapy versus MTX monotherapy in treatment of chronic plaque psoriasis. Forty patients with psoriasis were enrolled into the study and classified into group A receiving oral MTX and group B receiving oral MTX plus NBUVB. Onset of improvement was ≤70% of baseline PASI. End point clearance was 90 % reduction in PASI or up to 6 months. Side effects were reported. Follow up for 12 weeks for assessment of relapse was done. Of 40 patients, 35 completed the study. A higher clearance rate was achieved in patients of group B versus group A (100% versus 83%). A significant difference was reported regarding the onset of improvement and the duration required for clearance (p < 0.001) in favor of the MTX/NBUVB group. Patients in group B had a highly significant lower cumulative dose of MTX than the monotherapy group (p < 0.05). No significant difference as regard side effects and relapse was reported. MTX remains the mainstay in the treatment of psoriasis in developing countries and its combination with NBUVB offers a cheap and a beneficial therapeutic option.

Title: Benefits of plasma rich in growth factors (PRGF) in skin photodamage: Clinical response and histological assessment Authors: B Díaz-Ley, J Cuevas, L Alonso-Castro, M Calvo, L RíosBuceta, G Orive, E Anitua, P Jaén Published: Dermatology and Therapy, April 2015 Keywords: PRGF, growth factors, platelet-rich plasma, skin photodamage Abstract: Skin ageing is characterized by small and fine wrinkles, roughness, laxity, and pigmentation as a result of epidermal thinning, collagen degradation, dermal atrophy, and fewer fibroblasts. Plasma rich in growth factors (PRGF) is an autologous plasma preparation enriched in proteins obtained from patient’s own blood aimed at accelerating tissue repair and regeneration. To evaluate the benefits of PRGF in skin photodamage, 10 healthy volunteers were treated with three consecutive intradermal injections of PRGF in the facial area. Clinical outcomes and histological analysis were performed. A statistically significant increase in the epidermis and papillary dermis thickness was seen after PRGF treatment (p < 0.001). Skin thickening was observed in all patients studied, being more intense in the group of patients with photodamage (p < 0.001). After PRGF treatment, a reduction of the average area fraction of solar elastosis was observed in patients with clinical and histological signs of skin photodamage (p < 0.05). No changes were observed in the number of CD31, XIIIa factor, cKit, CD10, nor p53-positive cells. The improvement score after PRGF use was 0.75 (9/12) for the group of patients with signs of skin photodamage. Intradermal PRGF infiltration appears to be an effective treatment for the photodamaged skin.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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2. The primary purpose of the services is the protection, maintenance or restoration of the health of the person concerned.2

Should I be VAT registered?

Veronica Donnelly provides an insight into value-added-tax registration and tax-exempt treatments Too many aesthetic businesses do not understand value-addedtax (VAT) and how it affects their businesses, and, as a result, pay too much VAT. This article will set out the UK VAT rules and how they impact your business, recent EU case law and the information you need to get your VAT accounting right in order to deal with any review by HM Revenue and Customs (HMRC).

Why am I registered for VAT? This is a question which aesthetic practitioners need to ask themselves. When you charge a patient for services you are likely to charge a set price and then give HMRC the VAT out of that price. But what if the supply you make should be exempt from VAT? You would be giving HMRC up to 17% (VAT inclusive amount) of your turnover incorrectly. Also, the VAT registration threshold is calculated on the basis of your taxable turnover only,1 so if you exclude the exempt income, you might not be required to be registered for VAT at all. So how do you know which supplies are exempt from VAT? The VAT exemption for aesthetic services is determined by two tests, both of which must be met: 1. The services must be provided by, or provided by a person supervised by, a person registered or enrolled on a statutory register of medical practitioners, and are within the profession in which you are registered to practise;2 and

HMRC have issued guidance which states they will generally accept that cosmetic services are exempt where they are undertaken as an element of a health care programme. Where services are undertaken purely for cosmetic reasons, they will be standard rated.3 The first test is reasonably straightforward, as you will know if you are on a statutory register as a surgeon, doctor or a nurse and whether or not you are operating within your area of expertise.

For example, the sale of products will be standard-rated as you do not need to be a medical professional to sell these. Equally, the provision of services such as business advice to colleagues does not require a medical qualification and so would fail the test.3 The second test has proven more problematic in the past for a number of reasons. Historically, HMRC had generally considered this test from the patient’s perspective – i.e why did your patient want the treatment? There can be any number of answers to that question and, certainly in HMRC’s view, few of them fell within the primary purpose of protection, maintenance or restoration of the person concerned. However, HMRC does not have the final say in determining how VAT law should be interpreted and this patientfocused viewpoint has been successfully challenged in court.4 VAT is ultimately a European tax: its application in the UK is a condition of our being in the European Union and the UK law is drawn from EU law.4 In the case of any dispute as to VAT liability, the final say rests with the Court of Justice of the European Union (CJEU) and any decision it releases is binding on all member states.4 In February 2012, the Swedish revenue authorities took a case related to a Swedish clinic to the CJEU to determine whether the supplies of its cosmetic services were exempt from VAT or taxable.5 Those services included plastic surgery, liposuction, face lifts, permanent hair removal and skin rejuvenation by pulsed light, anti-cellulite treatments, and Botox and Restylane injections, among others.

According to the CJEU judgment, whether or not an operation or treatment qualifies as “purely cosmetic” is determined by the professional opinion of the surgeon or medical professional providing the treatment, and not the patient’s (subjective) opinion.5 In fact, it went so far as to say “the subjective understanding that the person who undergoes plastic surgery or a cosmetic treatment is not in itself decisive of the purpose if determining whether that intervention has a therapeutic purpose.” In other words, the patient is not a medical professional and could not know if his/her treatment will protect, maintain or restore their health. The CJEU went on to say, “Since that is a medical assessment, it must be based on the findings of a medical nature which are made by a person qualified for that purpose”. This was/is important as it puts the onus on the aesthetic practitioner to determine whether the treatment is for the protection, maintenance or restoration of health, and the opinion of the patient is much less significant.

The CJEU also found that the concept of “therapeutic purpose” is not to be strictly interpreted, and that there may be an underlying psychological reason for health problems to be corrected by the surgery.5 Some care must be taken with this, as the medical professional would still need to be acting within his medical qualification and be suitably qualified to identify psychological conditions and their treatments in order to meet the exemption criteria.

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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HMRC assessments So where does that leave the aesthetic industry in the UK? Well, first of all, you now have two clear tests to meet for exemption to apply, and both are much easier to evidence than before. It is important to remember that any treatment which does not meet these two tests will still be standard rated for VAT. It is essential that your records back up any decision to consider any treatment as exempt from VAT. Bear in mind that if you are VAT registered and make an error in your VAT accounting, HMRC can issue assessments for the previous four years; if you are not VAT registered and HMRC think you should have been, then they can go back to the first point when, in their opinion, you breached the VAT registration threshold and assess you for VAT from then, no matter how far back that was.6 As a point of interest, this decision by the CJEU does not create a change of law in the UK – rather it highlights a misinterpretation of the law by HMRC. This means that assessments issued by HMRC on their old interpretation could now be challenged, subject to time limits and provided you hold the requisite evidence of the nature of your treatments.

Any competent aesthetic practitioner will keep records for all of their patients which will at least have a signed form from the patient detailing any current medical conditions or treatment, and may also have a note of the clinical assessment of that patient by the aesthetic practitioner. These records are key to defending your decisions on whether or not to exempt your services. Identifying current medical conditions is the starting point, such as migraines, depression, acne or rosacea. Will your proposed treatment improve these conditions?

Have you noted this? Four years from now you will be unlikely to remember your thought processes at the time and contemporaneous notes are very powerful evidence.

Why do you need evidence at all? In simple terms, HMRC have the job of checking that you, the tax payer, are accounting for VAT correctly. They generally do this by organising an on-site visit to your trading premises, where they can meet with you and your staff and inspect your premises. The date for this is usually arranged with you in advance. In the course of that visit they are obliged to test your VAT accounting based on the requirement of the law and the information available to them at the time.7 If you cannot provide evidence to satisfy the exemption treatment then HMRC are required to treat the supply as standard rated and assess you for the VAT they deem due. This is not a personal attack on you, it is what they are required to do under the law and it is up to you to defend your position.

That does not mean that the HMRC officer is always right! Before arriving at your business premises, he will probably have had a look at your website and will have formed opinions about your business and the VAT liability before even leaving his office. If your website does not mention your medical qualifications, or that you offer services which will improve patient health, it is likely that he will have already formed the view that your services are taxable and it will therefore be more difficult to persuade him that your supplies are exempt.

That said, he, like you, has to work within the VAT legislation, although this generally takes the form of compliance with the VAT guidance notices rather than basic legislation. Please bear in mind these notices do not carry any force of law; they are HMRC’s interpretation of the law and, whilst helpful, are not always entirely correct. The VAT legislation clearly says that if you are a medical practitioner or nurse on a statutory register, and you are providing care to a patient, then your supply is exempt.2 What you need to do is make the HMRC officer’s job easier and avoid long drawn out discussions or arguments with him. He still needs to prove that he has tested your VAT treatment and has looked

Aesthetics

Finance VAT

It is essential that your records back up any decision to consider any treatment as exempt from VAT at evidence to back it up, so why not have the relevant evidence ready for him to review?

If your patient assessment forms are the basis for exempting the supply, then he is entitled to see them. By all means anonymise the notes, but they must be made available to HMRC. If the officer is reasonable, these will be sufficient proof for exemption.

Don’t forget that VAT on costs relating to exempt income is normally not recoverable. You must make sure that no VAT is recovered on these costs as this is an easy assessment for HMRC if you overclaim, and you could be liable to penalties.8 Conclusion In summary, you need to consider whether you meet both tests for exemption and whether any of your supplies are exempt. You should then make sure you have sufficient proof to defend that decision. Finally you should look at your remaining taxable turnover, including sale of goods, and check whether it is over the VAT registration threshold, currently £82K per annum.9,10 If it is not then you may want to consider de-registering for VAT. If you are unsure, I strongly recommend that you take the advice of a VAT specialist.

Not all accountants are VAT specialists, so your current accountant may not be able to advise fully, but he should be able to put you in touch with one. Getting it right could save you a lot of money.

Veronica Donnelly is the VAT partner at Campbell Dallas and has been a VAT advisor for 30 years. A chartered tax advisor and associate of the Institute of Indirect Taxation, she speaks regularly at tax conferences for BACN, PIAPA and ASAP. She recently spoke at the ACE conference in London.

REFERENCES: 1. Gov.uk, VAT Act 1994 (UK: Legislation.gov.uk, 1994) <http://www.legislation.gov.uk/ ukpga/1994/23/schedule/1> (Schedule 1, item 1) 2. Gov.uk, VAT Act 1994 (UK: Legislation.gov.uk, 1994) <http://www.legislation.gov.uk/ ukpga/1994/23/schedule/9> (Schedule 9, group 7, item 1) 3. HM Revenue and Customs, VAT Notice 701/57: health professionals and pharmaceutical products (UK: Gov.uk, 2014) <https://www.gov.uk/government/publications/vat-notice-70157- health-professionals-and-pharmaceutical-products/vat-notice-70157-health-professionals-and- pharmaceutical-products> (para 4.4) 4. Council of the European Union, Sixth Council Directive (77/388/EEC) (EU: European Union,

1977) <http://eur-lex.europa.eu/legal-content/en/ALL/?uri=CELEX:31977L0388> 5. Court of Justice of the European Union, C-91/12 – PFC Clinic (EU: Curia, 2013) < http://curia. europa.eu/juris/liste.jsf?language=en&num=C-91/12> 6. Gov.uk, VAT Act 1994 (UK: Legislation.gov.uk, 1994) <http://www.legislation.gov.uk/

ukpga/1994/23/schedule/1> (Schedule 1, items 1 and 1(6)) 7. Gov.uk, VAT Act 1994 (UK: Legislation.gov.uk, 1994) <http://www.legislation.gov.uk/ ukpga/1994/23/section/73> (Section 73) 8. Gov.uk, Finance Act 2007 (UK: Legislation.go.uk, 2007) <http://www.legislation.gov.uk/ ukpga/2007/11/schedule/24> (Schedule 24) 9. HM Revenue and Customs, HMRC Budget Overview 2015 (UK: Legislation.gov.uk, 2015) <https://www.gov.uk/government/publications/budget-2015-hm-revenue-and- customs-overview/hmrc-overview> (para 6.1) 10. HM Revenue and Customs, Overview of Tax Legislation and Rates (UK: Legislation.gov.uk,

2015) <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418689/

OOTLAR_v8.1.pdf> (para 1.24)

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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The Power of Profiling Julia Kendrick outlines how database mining and a tailored marketing approach can yield valuable results for your business growth With limited time and resources, many clinics are unable to launch a big marketing campaign to boost business. This easy step-by-step guide will help you to grow your business by using tools already at your disposal. By mining your patient database you can identify key patient ‘profiles’ and group these according to certain criteria. These will allow you to maximise your existing marketing approaches, significantly growing your business and optimising patient retention – without a big marketing campaign.

We know there’s a significant thought process and consideration period behind every patient’s decision for treatment. Sometimes, just getting through the door has taken months, if not years, and this is only half of the challenge. Once the first treatment is

complete, a key issue facing practitioners is patient retention – how to keep these patients coming back. Whilst securing new patients is always a plus, the smartest strategy may be to channel resources into reconnecting with existing patients – maximising this base of patients who have already made that ‘big step’ into the clinic.

First, however, you must establish exactly which groups these patients belong to create an organised and clear system.

Maximising the database goldmine Patient profiling: This is where your existing patient database comes in: a potential goldmine of information. If maximised correctly, your database will allow you to reconnect with patients in a targeted way to

Categorising your database 1. FIRST TIMERS: This is where you need to build loyalty to help your business grow. This group has visited once, but are at the highest risk of ‘drop off’ – i.e. not making another appointment. This could be due to a range of factors such as cost, convenience, and satisfaction with treatment results. Ensure you consider what each individual patient’s first type of treatment was when attempting to reconnect with him or her. Those who came in for their first advanced facial or a wrinkle-relaxing treatment may not be ready for some of the more advanced and complex facial or body therapies on offer. Help them along that consideration pathway slowly and steadily.

Some ways to reconnect: • Touch-up reminder – timed to encourage patients to maintain the best effects from their initial treatment type.

• Seasonal theme – discounts on their first treatment type or closely related clinic offers tied in to relevant milestones such as Valentine’s Day, Summer Skin, Bridal, Back to School, etc.

• If you liked X, you’ll love Y – Suggest a linked treatment which they might consider for next time. You could potentially incentivise this treatment with a discount offer.

• Invitation to a clinic ‘behind the scenes’ – an open evening

grow your business. Patient profiling involves reviewing your database and categorising patients based on key criteria. Clinic marketing is then tailored appropriately for each of these groups, maximising the chances for hitting the right ‘consideration spot’ for each patient.

Firstly, ensure your database is fully updated with patients’ details. This should include a visit log, treatments conducted, whether further treatments were booked and when they were last contacted by clinic marketing. The more detailed the records, the better you’ll be able to appropriately tailor communications that meet patients’ needs. An easy way to categorise the groups is to identify what proportion of your database are ‘first timers’ (i.e. one visit to date), ‘loyal customers’, or ‘lapsed patients’ (not visited clinic for a year or more).

to showcase some of the other services on offer and answer potential patients’ questions. You could also encourage guests to bring a plus one.

• Loyalty programme – maintain their interest with offers, exclusive discounts and priority bookings.

NOTE: Ensure all offers comply with industry guidelines to ensure they are responsible, do not trivialise aesthetic procedures and do not put patients under pressure to buy treatment bundles or act within a limited timeframe to secure a discount.1 2. LOYAL: When assessing this patient group, you need to explore how you can increase value per patient. These patients are your highly valuable repeat clientele, who require consistent great service to ensure their return. They are generally more comfortable with aesthetic treatments and are likely to be more receptive to new therapies on offer. They want the ‘VIP’ approach – to be the first to hear about the latest innovative treatments on the market.

By acting as a trusted source, you will increase their engagement with your clinic. Consider offering exclusive sneak previews of forthcoming treatments, priority booking and bundle offers on the latest treatments alongside their ‘usual’.

Some ways to connect: • VIP birthday gifts for your top 20 clients – let them try another

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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• •

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treatment that gives a great one-off result, but works even better when they undergo a course of treatments.

Newsflash – exclusive sneak preview of a new therapy on offer at the clinic. Give priority booking or discounts to loyal patients.

Hot off the press – share snapshot of the beauty trends / latest treatments unveiled at key congresses that are coming soon to your clinic. Perhaps send email newsletters offering advanced bookings, discounts or bundle offer with their usual treatment.

Invitation to an exclusive taster event – for a new treatment or technique, encourage them to bring a friend.

Refer a friend scheme – provide an incentive for loyal customers who refer a friend.

3. LAPSED – This group represent a huge untapped opportunity to grow your business. You don’t know why they have disconnected – it could be due to cost, fear of side-effects or social pressures – but it’s your job to bring them back with effective marketing messages. Use your clinic team to reconnect with them to find out whether they are likely to come again. Phone calls are preferable to emails as they offer a more personal approach, and I would always recommend developing a Q&A for your staff to use should any negative feedback arise. It could comprise details

The right message for the right group…

When your database is optimised and your patients profiled into clear categories, you can start tailoring your marketing tools to deliver the right messages to these key groups. There are several different channels open to you – emails, post, texts, social media – providing you tailor messages to each group and avoid a ‘blanket’ approach, these can be highly successful communication tools. Whichever ‘channel’ you use, ensure you adhere to some key principles for the content; keep communications short and focused (less words and more pictures to retain attention), make sure the format isn’t too large and is compatible across all electronic devices, ensure the distribution list is hidden in emails and check that your clinic details are clearly visible.

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regarding cost, convenience of service or treatment satisfaction, including adverse event reporting, which would entail informing the manufacturer and the MHRA Yellow Card Scheme of any unexpected or negative side effects described in relation to a product or procedure.2 Once you have established which patients are still keen to return, you can remove patients from your database who are either not suitable, or unwilling to have further treatments.

For the remainder (hopefully the majority) incorporate feedback and address any concerns in your tailored communications.

Some ways to reconnect: • ‘We miss you – come back’ offers – acknowledge the time since their last visit and give an exclusive ‘come back’ offer or discount relating to their previous treatment or to an entry-level therapy.

• Since you’ve been gone – highlight latest treatments/new offerings now available since their last visit and provide an incentive to book again. Potentially tie-in an exclusive event just for lapsed patients.

• Unveiling The ‘New Natural’ Look – highlight latest non-invasive treatments with ‘safety’ oriented messaging to reflect gentle, nonpermanent effects for a refreshed and rejuvenated appearance.

Go one step further…

Additional content options to consider including in your communications could include videos. Directing your patients to your clinic channel for new videos is great for profiling your clinic team, and easily measurable via views. Patient case study testimonials can also be shared via video, or, alternatively, a written format. Testimonials work as a powerful tool to highlight results that can be achieved through certain treatments and emphasise how good the patient feels afterwards. This can reassure those unsure about a procedure. You must ensure, however, that you have full patient consent prior to sharing their image, quotes and videos.

Arguably crucial for marketing are before and after images, which may encourage potential patients to make a firm decision on treatment.

IN PRACTICE: “Having just launched a new clinic in Beaconsfield, most of my database are ‘new’ patients looking for information about my treatments and services.

I have therefore profiled them by age and sex, to ensure my marketing communications are as tailored as possible to their needs.”

Miss Sherina Balaratnam, founder of S-Thetics Clinic, Beaconsfield “Being an established clinic, we have focused on ‘lapsed’ patients, using e-mail with a telephone follow up a few days later. An offer of a free skin health assessment encourages patients to come back to see us, and they are then offered the opportunity to sign up to our monthly payment plan, which has been very successful.”

Dr David Eccleston, clinical director of the MediZen Clinic, Birmingham

Unfortunately, image editing is increasing scepticism surrounding photo authenticity.

Make sure your images truly reflect the great results of treatment by using original images, and ensure they are correctly aligned to show the same angles of the area treated, with a plain background. It is also worth highlighting the fact that no image editing has taken place and full patient consent to use the images was obtained. Then, utilise these images through social media marketing. By incorporating these strategies into your clinic and examining your database goldmine, profiling your patients and tailoring your communications, you can truly pave the way to increased business growth and optimised patient retention. By personalising your connection with your patients, you will strengthen loyalty, building trust for long-lasting relationships.

Julia Kendrick has ten years of experience in public relations and communications, and is the founder of new start-up Kendrick PR Consulting, a bespoke strategic consultancy service specialising in medical aesthetics and healthcare PR. REFERENCES 1. Royal College of Surgeons, Professional Standards for

Cosmetic Practice (UK: Royal College of Surgeons, 2013) <https://www.rcseng.ac.uk/publications/docs/professional- standards-for-cosmetic-practice/> 2. Gov.uk, Yellow Card (UK: Gov.uk, 2015) <https://yellowcard.mhra. gov.uk/>

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Aesthetics Journal

Aesthetics

Employment Law for Practitioners Solicitor Shubha Nath addresses the key points that employers need to know about employment law Medical aesthetic practitioners have to undergo extensive training to become skilled in their field, and are bound by professional standards in how they conduct their practices. Many also aim to run and manage their own businesses one day. However, some practitioners may need a little more guidance on the law surrounding employee contracts and dismissal.

Why take advice?

In a culture driven by compensation claims, where large employee pay-outs are publicly advertised in the media, it should be simple for practitioners to avoid the costly and repetitive mistakes made by people who only seek proper legal advice when it is too late.

Due to the highly personal nature and close way of working in an aesthetic clinic, I would advise practice owners to tailor employment standards to each individual clinic. If you consider compliance with the requirements of the Care Quality Commission (CQC),1 the standards are the same across the board but individual practices ensure compliance in the way that fits that particular practice. So it is with employment law: the law is binding, but different approaches may be needed for different practices, depending on the number of staff, the distances people may have to travel to get to work, and dealing with diversity and dignity at work.

Of course, employing staff does come with some risks. Although managers should do everything within their power to avoid upsetting employees, on rare occasions, there may be risks associated with disgruntled employees and claims for unfair dismissal or discrimination. Spending a little time reviewing your employment practices and procedures with a solicitor may help to avoid these circumstances. The expense involved may result in saving time and money in the long run and reducing the chance of dealing with stressful litigation in the future. Being confident in your staff and associate management will also allow you to concentrate on your clinical practice and avoid the risk of being tied up in legal affairs.

A first look Employees have two sources of rights. The first are those set out in their contracts, which may need to be changed from time to time to reflect working practices and current needs of the clinic. The second are employment rights enshrined in law such as protection from unfair dismissal, and prevention of discrimination on any of the prohibited grounds, including age, disability, gender, marital status and race.2 What does it mean to have a contract of employment and why do I need it?

A contract of employment is the body of terms and conditions, which constitute the employment relationship between you and your employees. Although contracts do not need to be in writing,3,4 it is always best to have a written agreement effective from the outset of any relationship in order to give both parties certainty of what they have agreed. If it is envisaged that changes might be made in the course of the employment of staff, they should be easier to effect if there is a flexibility clause, which gives the employer rights to change some conditions of employment, such as relocation or surgery hours.5 It is hugely beneficial to be able to refer back to a contract and eliminate any doubts, should any issues arise in the future. Critically, there should be no ambiguity in the contract about employment status. Furthermore, the contract should establish clearly whether people are employees or, as is the case with many associates, self-employed.

As an employer, you must be aware of the terms of the Employment Rights Act 1996.1 Although you are not legally required to create a contract that must be signed by the employee, the law requires you to set out a written statement of the principal terms and conditions applicable to your staff within two months of them joining you.6 Failure to do so may attract additional compensation in the event of a finding of unfair dismissal. A properly drafted contract should ideally include:3 · · · · · · · · ·

The names of the employer and employee The date when the employment began If the employee was doing a job for you previously, then the date on which the period of continuous employment began A description of the employee’s job How much the employee will get paid and what are the pay intervals The employee’s place of work The notice period Terms and conditions relating to holidays, sickness and pensions Grievance and disciplinary procedures

The terms need not be set out in one document, but if an issue arises, it is far more efficient for the job offer to be reflected in the contract. It is good practice to provide more detailed provisions in an employee handbook, the employee’s guide to ‘how

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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things workâ&#x20AC;&#x2122;; and what should be done in the event of, for example, sickness, holidays, maternity leave and flexible working requests.

If your practice is small, you can safely rely on the procedures and guidance offered by the Advisory, Conciliation and Arbitration Service (ACAS). Ensuring the critical terms of the contract are in writing is essential, but there is an unwritten term which reinforces all contracts of employment: the law implies a term of mutual trust and confidence, which underpins the requirement that the employer must act in a reasonable manner towards an employee.7 How can I make changes to the contract of employment?

By using a flexibility clause, a contract of employment allows the employer to make some changes to contractual terms. However, it is good practice to give the employee the same period of impending change as is reflected in the notice provisions of the contract. 8 Simply imposing new terms may be an invitation to a tribunal claim for constructive dismissal. A series of minor changes, such as changes to the job scope, benefits or working hours, if not agreed with the employee, may amount to a cumulative breach of the implied term of mutual trust and confidence between employer and employee.

The best practical advice is that unless the contract clearly allows you to make changes (assuming these do not undermine the implied term of trust and confidence) you should seek consent wherever possible. If the employee refuses, that will be grounds for terminating their employment.

If changes are imposed without formal acceptance by the employee, but the employee simply carries on working, they will be deemed to have accepted. If they continue to work but under protest, a tribunal would be likely to find that they have accepted the change. However, they may decide to resign and claim constructive dismissal, which is when an employee feels they have been unfairly forced into leaving their position due to employer conduct. It makes sense to seek legal advice before implementing changes which could be fundamental to the employment relationship.

Disciplinary and Grievance Procedures It is a statutory requirement that employers inform employees of disciplinary rules applicable to them;9 in the majority of organisations these can be found in the employee handbook. For aesthetic clinics, these could include rules on personal appearance, timekeeping, following instructions, use of clinic telephones and IT equipment and using social media in working hours.

ACAS has a Code of Practice for employment, which can be found on their website.10 It is useful for small businesses as it sets out the requirements for a fair procedure. Importantly, the Employment Tribunals also refer to the Code of Practice.3 However, a tailormade handbook is one to which staff will have access and is to be recommended, if resources permit. Many clinics are small businesses and may not have the resources for independent investigation, hearing of a grievance or a disciplinary procedure and the separate hearing of an appeal. The Employee Handbook should set out how these basic procedures will be followed, if invoked.

How not to dismiss unfairly The Employment Rights Act 1996 sets out the potentially fair reasons for dismissal, including conduct, capability and redundancy.11 Case law differentiates between misconduct and gross misconduct. Gross misconduct is conduct so serious as to amount to a fundamental breach of contract on the part of the employee and, subject to the safeguards of the employer having a genuine belief in the misconduct,

Aesthetics Journal

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supported by a reasonable investigation, may justify dismissal without prior warning. Misconduct includes things such as persistent lateness or unauthorised absence from work, and should be correctly assessed and handled in the appropriate manner, such as arranging a meeting with the employee and issuing a warning. Some actual examples of gross misconduct are: throwing a laptop at a manager; watching inappropriate online videos during office hours; defrauding the employer through setting up and diverting company funds to private accounts; and defrauding the employer by using company frequentflyer rewards for personal use.

It is important that whatever the disciplinary issue the correct procedures are followed, to ensure that you, as the employer, have acted fairly at all times. These could include writing to inform the employee of the impending action, or holding a meeting with the employee and deciding on the appropriate course of action.

Suspension may be appropriate where there are concerns about patient safety or the reputation of the practice. In the case of poor performance then it is important that the employer can show that he or she has carried out a careful appraisal of the employeeâ&#x20AC;&#x2122;s performance, has warned the employee of the potential outcome, and has given the employee an opportunity to improve prior to dismissal.

Getting it right Taking the preventive approach yields dividends. A good understanding of the legal requirements to the way you run your practice will not prevent employees putting in employment tribunal claims, but it will reduce their chances of winning if their claim is not correct. To ensure you are in the best position, check the contract of employment, check your employee handbook for what it says regarding the particular issue in hand and read the ACAS guide on the correct procedures.

Shubha Nath is a solicitor and the managing director of Nath Solicitors Limited; she has spent more than 20 years practising partnership and company law and learning first-hand about partnership agreements and setting up and running of companies.

REFERENCES 1. Care Quality Commission, Regulations for service providers and managers (UK: Care Quality

Commission, 2014) <http://www.cqc.org.uk/content/regulations-service-providers-and-managers> 2. Citizens Advice, Basic rights at work (UK: Citizens Advice, 2015) <https://www.citizensadvice.org.uk/ work/rights-at-work/basic-rights-at-work/> 3. Gov.uk, Equality Act 2010 (UK: Legislation.gov.uk, 2015) <http://www.legislation.gov.uk/ ukpga/2010/15/contents> 4. Gov.uk, Employment Rights Act 1996 (UK: Legislation.gov.uk, 2015) <http://www.legislation.gov.uk/ ukpga/1996/18/contents> 5. Gov.uk, Changing an employment contract (UK: Gov.uk, 2015) <https://www.gov.uk/your- employment-contract-how-it-can-be-changed/making-changes> 6. Gov.uk, Employment contracts; Written statement of employment particulars (UK: Gov.uk, 2015) <https://www.gov.uk/employment-contracts-and-conditions/written-statement-of-employment- particulars> 7. Gov.uk, Employment contracts; Contract terms (UK: Gov.uk, 2015) <https://www.gov.uk/employment- contracts-and-conditions/contract-terms> 8. The Advisory, Conciliation and Arbitration Service, Varying a contract of employment (UK: The

Advisory, Conciliation and Arbitration Service, 2012) <http://www.acas.org.uk/media/pdf/8/6/Varying- a-contract-of-employment-accessible-version.pdf> 9. Gov.uk, Section 1, Employment Rights Act 1996 (UK: Legislation.gov.uk, 2015) <http://www.legislation. gov.uk/ukpga/1996/18/section/1> 10. The Advisory, Conciliation and Arbitration Service, Homepage (UK: The Advisory, Conciliation and

Arbitration Service, 2015) <www.acas.org.uk> 11. Gov.uk, Section 98, Employment Rights Acts 1996 (UK: Legislation.gov.uk, 2015) <http://www. legislation.gov.uk/ukpga/1996/18/section/98>

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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Aesthetics Journal

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“There’s just so much I want to do and learn” From mental health nurse to aesthetic nurse prescriber, Lou Sommereux reflects on her varied medical career “I had no ambition to be a nurse,” admits Lou Sommereux, who went on to win the accolade for Aesthetic Nurse Practitioner of the Year at the 2014 Aesthetics Awards. Growing up in Cambridge, she explains, “I’m sadly of a generation where careers advice for women wasn’t very good. My options were limited to secretary, teacher, mother or nurse.”

Sommereux chose the latter route. “I completed my training at the Middlesex Hospital in 1978,” she explains, “before moving back to Cambridge and working at Addenbrooke’s Hospital before spending five years working at Fulbourn Psychiatric Hospital.”

In 2001, however, Sommereux heard that models were required for botulinum toxin treatment. She volunteered and, after a successful treatment, proceeded to research the aesthetic specialty. In 2002 she attended IMCAS in Paris, and explains her aesthetic career spiralled from there.

After completing her training, Sommereux practised aesthetics in 11 beauty salons across Cambridgeshire. In 2002 she set up a clinic base in rented premises, before opening Cosmex Clinic. She explains that she was lucky to receive informal additional training from one of the three plastic surgeons offering non-surgical procedures in Cambridge.

At the time, she says that she was the only nurse practising aesthetics in the area. “Consultant plastic and reconstructive surgeon Mr Per Hall was very supportive and mentored me at the beginning, when I really needed it,” she says. “I think every one should ‘buddy-up’ with likeminded practitioners to develop your own support network within your aesthetic community.”

This notion is clearly something Sommereux carries very dear, demonstrated through her active involvement with the British Association of Cosmetic Nurses (BACN). Having been a member of the Royal College of Nurses’ (RCN) aesthetic forum, which she describes as the “forerunner” to the BACN, Sommereux says she was delighted to be asked to join the BACN’s board at its conception in 2009. She went on to become vice chairperson, and regional lead for East Anglia. “I thought, what an amazing opportunity to be involved in driving aesthetics forward and making it a recognised nursing specialty,” she explains. Due to her clinic commitments, Sommereux has very recently stepped down as vice chairperson, but will continue her role as a regional lead. She says, “I still feel very passionate about the BACN – if you cut me in half, I’d have BACN and aesthetics written right through me!”

One of Sommereux’s biggest achievements stems from her involvement with the BACN. In 2013, the RCN published and accredited the BACN’s Integrated Career and Competency Framework for Nurses in Aesthetic Medicine, which was updated and re-accredited in 2014. Sommereux co-wrote these competencies along with other BACN members, offering guidance and advice to beginner, proficient and expert aesthetic practitioners. “They’re the first and only competencies, which are accessed both nationally and internationally,” she explains. “And while they will need continuous updates when new treatment modalities are introduced, writing

them has been a huge achievement for me, both personally and professionally. I think the BACN has put the rubber stamp on bringing nurses together.”

Sommereux credits winning an Aesthetics Award last year with having a hugely positive influence on both her marketing potential and her professional reputation. “Patients are telling me they’re privileged to come to my clinic, which is such an honour,” she explains. “It’s been wonderful to be recognised by my peers and colleagues, and I think it has made me stand head and shoulders above other clinics in the area. This year, I’d like to put my clinic forward for best reception team as my winning has been a very positive experience for us.”

Although she has spent most of her aesthetic career offering injectable treatments, Sommereux’s desire to learn about new treatment modalities is ongoing. “I’m 58 this year and people ask if I’m going to retire, but no, that word’s not in my vocabulary. There’s just so much I want to do and learn.” And with a loyal, ever-expanding patient-base, as well as a passion for progression, it seems unlikely that Sommereux, who started out with no solid ambition to be a nurse, has any intention of slowing down.

What treatment do you enjoy giving the most?

Dermal fillers. I love using my artistry and knowledge to achieve the best results for patients.

What technological tool best compliments your work as a practitioner?

Medical needling, as you can use it to treat a range of indications and it has a wonderful rejuvenation effect on the skin.

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

Fellow aesthetic nurses Fiona Collins and Marie Duckett said to me once, “Don’t shy away from anything adverse.” If something goes wrong, or someone’s unhappy with their treatment, they advised me to action it straight away. I’ve carried those pearls of wisdom with me throughout my career.

Do you have an industry ‘pet hate’?

I don’t like it when people over exaggerate their competency. I think that there’s nothing wrong in being humble. Practitioners should be encouraged to ask for advice, help and support.

What aspects of aesthetics do you enjoy the most?

I love being part of a community – I’ve met so many amazing people and made such fantastic friendships. There are some very dedicated people out there, trying to make aesthetics safer and to raise standards, and I love that. I love that I’m part of leaving a legacy for aesthetic nurses, I think that’s what the BACN does and I’m very proud of that.

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Aesthetics Journal

The Last Word Dr Ahmed Al-Qahtani addresses the misrepresentation of stem cell skincare products and advises practitioners on how to avoid unsupported advertising claims Since the 1980s, results of research into the efficacy of stem cell treatment has emerged as a major topic of debate.1 Until recently, stem cells have acquired a largely negative reputation due to a misinformed public. Many people have automatically affiliated stem cells with embryonic stem cells, where a potential human or animal life is lost.1 Embryonic stem cells are grown from cells found in the embryo when it is just a few days old.2 They have been used by scientists to research a range of medical conditions, including the formation of cancer, and aid the understanding of how cells respond to certain drugs.2 This, however, means the embryo has to be destroyed, which has invited a significant amount of debate from those who argue an embryo should be regarded as a human or animal life.1 From my experience, however, it seems that many people hadn’t realised until recently that, as well as embryonic, there are also such things as plant stem cells and stem cells found within us.

There has been an abundant amount of ‘adult stem cells’ found within tissues like bone marrow, fat, muscle, and skin.3,4 In the past decade, there have been huge advances in the field of adult stem cell research and therapy. From orthopedics and neurology, to autoimmunity and of course aesthetics and plastic surgery, these advances are revolutionary.4,5 Skin stem cells have been used to grow new skin in a laboratory for burn patients,5 which has of course invited an interest into other potential skin rejuvenating properties of stem cells.

Stem cells and skincare Most of the hype is evolved from a desire to reverse the signs of ageing by growing

new, healthier skin. The stem cell era acted as a beacon of hope, delivering promises, solutions and infinite cures to many skincare battles. As a result of the advances, the term ‘stem cell’ has become unduly misused within the field of cosmetics and aesthetics. From the ‘stem cell face lift’, to the ‘stem cell face cream’, medical practitioners and cosmetic manufacturers alike are cashing in on this buzzword. It truly is an effective marketing strategy to claim that their ingredients are either derived from stem cells or stimulate the growth of stem cells. But in reality, many don’t contain stem cells at all.

Unsubstantiated marketing claims It seems that opportunistic skincare marketing departments have caught on to the now positive associations with stem cells and mis-advertise their products with unsubstantiated and misinformed assertions.

Despite the marketing jargon and faulty claims, some of these products that claim to contain ‘stem cell conditioned media’ or ‘stem cell extract’ do not have proven studies or data to support them. It seems unfair to me that a significant proportion of the skincare market comprises false advertisements, especially those that claim ‘scientific breakthrough’, whilst there are some honest, genuine, hardworking companies formulating and inventing new ingredients that have been proven to battle premature ageing skin.

Sourcing trustworthy products and treatments Unfortunately, these reliable companies are hard to find for our patients and, often, their

Aesthetics aestheticsjournal.com

scientifically-based products are not sold in major stores and retailers. So naturally, where does everyone turn to for answers?

The internet. The sad thing about this approach is many fail to recognise the power of marketing companies that strategically buy high search rankings on Google. Thus, potentially leaving our patients with another underperforming skin care product. So, when looking to incorporate a new stem cell derived skincare line into your clinic, how can you decide what is worth trying?

Important factors to look out for: · Look for ingredients that are scientifically proven to improve skin and prevent premature ageing. Pubmed.com is a free site that publishes numerous studies that have researched ingredients and products, which could help practitioners discover the efficacy of some ingredients. · Research the company, paying close attention to its history and involvement in scientific research. · Find out if it’s available in other aesthetic practices or pharmacies and talk to those practitioners that stock it. They may be able to advise you of their patients’ responses to the product and how successful it has been for them. · Be aware of the words ‘organic,’ ‘natural,’ ‘rare plants,’ or ‘holistic.’ Those words can often be simply jargon. Look instead for references to clinical studies that have enrolled plenty of impartial participants.

Finally, don’t be afraid to talk to colleagues and ask them for their advise on stem cell skincare brands. Many will be well educated on what is effective, and unlike many cosmetic companies, will not have an underlying sales agenda.

Dr Ahmed Al-Qahtani is an assistant professor at the College of Medicine and Health Sciences at the United Arab Emirates University, and the president and founder of AQ Skin Solutions.

REFERENCES 1. Embryonic stem cell research: an ethical dilemma (Europe:

EuroStemCell, 2011) <http://www.eurostemcell.org/factsheet/ embyronic-stem-cell-research-ethical-dilemma> 2. Embryonic stem cells: where do they come from and what can

they do? (Europe: EuroStemCell, 2015) <http://www. eurostemcell.org/factsheet/embryonic-stem-cells-where-do- they-come-and-what-can-they-do> 3. Adult Stem Cells 101, Where do we get adult stem cells? (Boston:

Boston Children’s Hospital, 2015) <http://stemcell. childrenshospital.org/about-stem-cells/adult-somatic-stem- cells-101/where-do-we-get-adult-stem-cells/> 4. Stem Cell Information (Maryland: National Institutes of Health,

2009) <http://stemcells.nih.gov/info/scireport/pages/execSum. aspx> 5. Stem cell research & therapy: types of stem cells and their

current uses (Europe: EuroStemCell, 2012) <http://www. eurostemcell.org/factsheet/stem-cell-research-therapy-types- stem-cells-and-their-current-uses> 6. Regenerative Medicine (US: National Institutes of Health, 2013) <http://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=62>

Reproduced from Aesthetics | Volume 2/Issue 7 - June 2015

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