Aesthetics march 2014

VOLUME 1/ISSUE 4 - MARCH 2014

Just for you

Don’t miss the UK’s biggest event dedicated to the practice of facial and body aesthetics Register free for ACE 2014, London 8th & 9th March www.ace2014.co.uk

The external skin barrier – CPD Dr Mervyn Patterson on the key role of the epidermis. CPD accredited article

Focus on Injectables Rejuvenation using needles: new approaches, new products, new science

Platelet Rich Plasma Dr Sarah Tonks investigates PRP methods for your practice

Nose reshaping Dr Sotirios Foutsizoglou shares his techniques for non-surgical nose augmentation

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Contents • March 2014 INSIDER 06 The Word Mr Paul Harris on the government response to the Keogh Report 06 News The latest product and industry news 11 On the Scene Out and about in the industry this month 14 News Special: IMCAS We report on the International Master Course on Aging Skin in Paris

CLINICAL PRACTICE The skin barrier Page 24

CLINICAL PRACTICE 19 Special Focus: PRP Dr Sarah Tonks explores the uses of platelet rich plasma in aesthetics 24 CPD Clinical Article Dr Mervyn Patterson discusses the importance of the external skin barrier 28 Techniques Miss Jonquille Chantrey explains the 8-point lift technique for facial rejuvenation 32 Clinical Focus Dr Beatriz Molina on treating lips using Emervel 34 Techniques Dr Askari Townshend on delivering Sculptra using needles 37 Spotlight On We discuss SkinCeuticals’ new Advanced Pigment Corrector 38 Clinical Study An investigation into the use of the 1440nm Wavelength with Sidelaze800 delivery 42 Spotlight On Dr Iryna Stewart explains the mechanisms of the Hyalual Daily DeLux spray 44 Treatment Focus Dr Sotirios Foutsizoglou discusses non-surgical nose reshaping 50 Abstracts The latest clinical studies

IN PRACTICE HR Considerations Page 54

Clinical contributors Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. She practises cosmetic injectables and hormonal based therapies.

Dr Mervyn Patterson is a co-owner of Woodford Medical and has worked in aesthetic medicine over the past fifteen years. He specialises in the latest injectable anti-ageing treatments.

Miss Jonquille Chantrey is a surgeon specialising in aesthetic medical procedures, with a practice in Cheshire. She has been published in peer-reviewed journals and presents at plastic surgery conferences worldwide.

Dr Beatriz Molina practised general medicine for 12 years, before opening her first practice. She now practises as a cosmetic doctor, alongside teaching techniques in botulinum toxin and dermal fillers.

Dr Askari Townshend is an international Sculptra trainer as well as lead UK Sculptra trainer and medical consultant for Sinclair Pharma. His interests include injectables, lasers and peels.

Dr Iryna Stewart is managing director of Rederm and founder of IS clinics. After 15 years in the NHS, she has dedicated the last five to aesthetic medicine, specialising in skin rejuvenation and restoration.

52 Aesthetics Conference and Exhibition Special Focus The latest news from ACE 2014

Dr Sotirios Foutsizoglou is founder and medical director of SFMedica. He has written for numerous UK publications and presented at national and international conferences and expert meetings.

IN PRACTICE 54 Managing staff absence Lawyer Vanessa Di Cuffa on setting rules for employee holiday and sick leave 56 Boosting online presence John Castro outlines simple digital strategies to improve sales 58 Cash Flow Business consultant Kurt Won explains how to maximise your cash flow 60 Call Handling Gilly Dickons discusses the importance of making a good first impression 62 In Profile We speak to Dr Terry Loong, Best New Clinic winner at the Aesthetics Awards 2013 64 The Last Word Aesthetics’ Editorial Advisory Board’s views on the Government response to the Keogh Report NEXT MONTH

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• IN FOCUS: Dermatology • CPD: Cosmeceuticals • Acne scarring • How to read a clinical study

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Editor’s letter Just before we went to press, the government finally published its response to the Keogh report.

The industry response was mixed, ranging from outrage to cautious optimism. We were disappointed, although far from surprised, to see Keogh’s key Leah Hardy recommendation of a compulsory register for Editor aesthetic practitioners being rejected outright and lasers and lights seemingly slipping off the UK regulatory agenda. But what should happen next regarding injectables, which are the focus of this issue of Aesthetics journal? The government response was frustratingly vague about plans to change the law. As Keogh himself has pointed out, it was impossible to classify fillers as prescription-only medicines due to EU legislation. However, we believe the government should be introducing legislation to make fillers prescription-only devices. Unfortunately, even this would not regulate every type of filler until 2018. The EU Medical Devices Directive will reclassify all fillers as medical devices, but manufacturers will then have a three-year grace period to apply for CE marking. Controlling who administers fillers is also complicated; the MHRA states that all medicines may potentially be administered by non-medics under the direction of a prescriber.

However, the prescription model makes the prescriber responsible for the patient, which is where prescribers and regulatory bodies have the opportunity to self-regulate. The major filler companies voluntarily CE mark their products as medical devices, do not sell direct to non-

medics, and indicate on their pack inserts who should administer their products. They regard injectables as medical treatments, are dismayed to see their products in the hands of unqualified injectors and support stronger legislation. If the GMC, GDC and NMC issue strict guidance about selling on, about who is an appropriate person to use prescribed toxins, and about the importance of practitioners only working within their competencies, with firm sanctions against those who breach the rules, then the industry could improve ethics and standards. The Committee of Advertising Practice with the Advertising Standards Authority has independently created codes to meet Keogh’s recommendations and is moving to deal with websites and advertising campaigns that breach them, even unwittingly.

Health Education England is also working on training and standards.

We at Aesthetics strongly support moves within the industry to improve training and education, hence our introduction of CPD accredited content and the strong educational focus of the Aesthetics Conference and Exhibition 2014. While we still need legislation in the industry, for which continued lobbying is vital, regulatory bodies can devise their own codes of conduct supported by the industry itself. We have seen unprecedented cooperation between ethical aesthetics practitioners for European standards and UK training standards. This must continue and develop if we are to create a safer industry for patients. To see more about the government response to Keogh, visit our website www.aestheticsjournal.com.

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s advisory board to help steer the direction of educational, clinical and business content Dr Mike Comins is president and Fellow of the British College

Amanda Cameron is a sales and marketing professional,

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

and was one of the first nurse injector trainers in the UK for dermal fillers. With over 20 years experience in the industry in both the UK and Europe, Amanda has extensive knowledge of medical aesthetics and business development.

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is an aesthetic doctor and previous

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.

maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, who fell in love with the results possible through minimally invasive methods. Now based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

Sharon Bennett is currently vice chair of the British

Dr Nick Lowe is president of the BCDG and a consultant

Association of 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).

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

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The Word

Legal

This month the Government’s response to the Keogh review has left many stakeholders shocked by the lack of implementation of the majority of its recommendations.

Without decisive action from our regulatory authorities, it is more important than ever that surgeons and clinicians share knowledge and expertise in order to benefit patients, and that we work together to eradicate the ‘cowboy’ practitioners, who prey on vulnerable people.

A key component of Keogh’s recommendations was the call to publish outcome data across all providers. The Government appears to have ignored this proposal, missing a vital opportunity to establish greater clarity in the cosmetic sector and, as a consequence, increasing the risks to patients. It is now crucial that we collectively address the data vacuum to ensure that treatments on offer are evidence-based, and that all centres produce freely-available safety results.

We know of the risks, as well as the benefits, of aesthetic treatment and as professionals we invariably agree that these treatments are not appropriate for every would-be patient. However, in a culture where ‘enhanced’ beauty is increasingly popular (the BAAPS 2013 annual audit showed record numbers of patients going under the knife), our shared goal must be to educate the public about the dangers of an unregulated sector, where cheap, unproven and often unsafe aesthetic treatment is sold ‘off the shelf,’ like toothpaste or nail varnish. BAAPS has long been calling for an injection of common sense to remodel the sector, and our collective efforts must ensure that patient care always comes before profit.

Mr Paul Harris Consultant plastic surgeon and council member of the British Association of Aesthetic Plastic Surgeons

RCN indemnity scheme no longer covers aesthetic practice Changes to the Royal College of Nursing (RCN) indemnity scheme means that aesthetic nurses will no longer be covered. At present the RCN indemnity scheme is a contractual arrangement providing members with cover for clinical negligence claims.

Commencing July 1, 2014, all employed RCN members will be excluded from the scheme’s coverage in a bid to stop employers moving the burden of risk onto the RCN. Most self-employed members will still be covered by the scheme, apart from those working in the field of aesthetic medicine. Christopher Cox, director of legal service at the RCN, claimed that the RCN has spent in excess of £1,500,000 on aesthetic claims since 2004. “In the light of the claims history involving aesthetic practitioners, the RCN will in future no longer be able to provide indemnity cover for our members practising in this area,” he said. “This will affect both self-employed members and those working under a contract of employment. Members practising in aesthetics remain protected by the full range of other legal advice and support services available to RCN members, including workplace difficulties, NMC referrals, personal injury accidents and so on. “ The BACN responded, stating, “Those 78% of members (BACN) who are also RCN members will have been shocked to hear the news that the RCN, from July, will exclude aesthetic nursing from their insurance cover.

Whilst we have no expectation that the RCN will change its stance, we will be asking for further information on why and how they reached this momentous decision, which we feel sends out a very negative message without the necessary detail to qualify it.”

Training

Talk Aesthetics #Keogh Tchauhanconsultancy / @tchauhan01 @aestheticsgroup this is a wasted opportunity patient safety clearly not important for gov #advertising ReVamp / @ReVampClinics @aestheticsgroup great piece on POM and advertising... first rule of Botox club...you can’t say Botox #Simple #ACE Dr Johanna Ward / @DrJohannaWard I am presenting a masterclass at @ aestheticsgroup conference on 8 March for anyone interested in the science & art of @ CoolSculptingUK #ACE If you would like to be featured in next month’s letter section, email us at editorial@aestheticsjornal.com, or follow us at Twitter @aestheticsgroup and include #talkaesthetics in your comments.

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Mesotherapy society launches in UK The Society of Mesotherapy of the United Kingdom (SOMUK) has been launched to promote the use of Mesotherapy in the UK. The society provides access to the latest Mesotherapy tools and information for all disciplines including: Facial rejuvenation, Lipolysis, Fat Reduction, Cellulite, MesoSculpting, Mesolift, Mesobotox, Alopecia and Pain Management.

Mesotherapy remains relatively unknown to many aesthetic practitioners in the UK, though a popular aesthetic treatment in France, South America, and Europe. The SOMUK is the exclusive member of the International Society of Mesotherapy (SIM) and works closely with the French Society of Mesotherapy.

SOMUK courses are CPD accredited within the UK. President Dr Philippe Hamida-Pisal said, “The SOMUK teaches the art, science, techniques and procedures of Mesotherapy to licensed practitioners, regardless of their specialty. We provide education and hands-on training within the UK and across the globe.” New member Dr Mohamed Bocus said, “I am a GP in the UK and traditionally we are sceptics about the benefits of alternative medicine. However, with growing interests from patients we need to learn more about what is available.”

Aesthetics | March 2014

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News in Brief

Technology

Dutch company launch new cloud-based patient app

Clinicminds has launched a cloudbased app for patient relationship management. The Dutch software development company has launched the Clinicminds application, which has so far been taken up by two UK clinics, to addresses the full clinical workflow: from appointments to invoicing and client analytics.

The cloud-based nature of the app means that all patient data is stored in a secure and accessible point. Data can be accessed by the practitioner from any location, and from any device with internet access. The app was created by a team of software developers and medical aesthetic physician Toby Makmel. A clinic owner himself,

Makmel was inspired to create the the CRM application because of his desire for a simple and all-encompassing tool for patient management.

“At the time, we were looking for an application covering the full clinical workflow, that was user friendly and also affordable for smaller clinics,” said Makmel.

Tested over the course of a year by medical aesthetics practitioners, the cloud-based app has so far received favourable reviews. Since the software stores patient details, including personal information as well as treatment information, it is also possible to use the app in order to compile patient analytics.

This function allows practitioners to gather data useful for marketing campaigns that target specific kinds of patients, in specific postcodes.

One Dutch client said, “The Clinicminds app allowed us to organize our day-to-day work much more efficiently allowing us more quality time with our patients.”

Accreditation

PaPPS Accreditation launched to improve psychoemotional support The Wright Initiative is launching a new Pre and post Procedure Support Accreditation body. The Wright initiative, which works with practitioners to ensure patients are prepared, mentally and physically, for their treatments, has established the PaPPS Accreditation due to the rise in demand for psychoemotional support in conjunction with surgical and non-surgical treatments. The PaPPS Accreditation follows the PaPPS Initiative, which was shortlisted for Industry Body of the Year at the Aesthetics Awards in December.

The requirements to become PaPPS accredited include holding one or more of the following registrations: NMC, GMC/Specialist register, BACN, BAAPS or BAPRAS. Founder Mr Norman Wright said,”The benefits of being PaPPS Accredited for clinicians involves dedicated PaPPS training and access to the PaPPS support line six days a week.”

The PaPPS Accreditation will go live on Tuesday 2 April 2014.

Medical Aesthetic Group appoints new members Medical Aesthetic Group (MAG) has appointed Simon Bell as special product consultant for hyaluronic acid dermal filler Stylage. His role will include consolidating and increasing sales in the UK, and supporting doctors and clinics that offer the treatment. “HA fillers are perfect tools for the job, but Stylage has the added benefit of shortened recovery time and increased duration of results, which makes it a unique and attractive proposition for doctors,” Bell said. Laurinder Young has been appointed as sales coordinator across all MAG brands, and Pauline Hume will be running training and sales support for topical products including Inno Aesthetics, Mene and Moy and Simildiet.

Venus Concept launch Venus Viva Venus Concept have launched new facial treatment scanner VenusViva, which uses nano fractional smart scan technology to even skin texture, tighten skin, smooth deep lines and wrinkles and reduce appearance of scars. It includes two hand pieces, the Firm FX fractional radio frequency handpiece, and the Firm (MP)2 magnetic pulse hand piece. It has a short downtime of only three to four days, and does not require topical anaesthesia.

Dr Harold Lancer publishes rejuvenation book Renowned Beverly Hills dermatologist Dr Harold Lancer has written a book detailing his 3-step method on rejuvenating skin at home to maintain youthful skin and reverse the ageing process. Younger: The Breakthrough Anti-Aging Method for Radiant Skin details Dr Lancer’s regimen, which involves skin care products and lifestyle choices such as diet, exercise, and stress management, to stimulate the skin’s own healing power. His book is due to be released on March 27.

Chromogenex launches i-Lipo Touch Chromogenex has launched new low level laser diode device i-Lipo Touch for non-invasive fat reduction. The system uses photobiomodulation to stimulate the body’s natural response to fat-burning, targeting areas of excess fat. The lasers trigger a chemical signal in the fat cells, which breaks down stored triglycerides into free fatty acids and glycerol to then be released through channels in the cell membranes. It can be performed on all skin types and body areas with unwanted fat, and the manufacturers claim it can remove four to five inches off the waistline after a course of treatments.

Aesthetics | March 2014

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Laser

New Duetto MT hair removal device uses Mixed Technology to treat dark skin and fine hair A new innovation in laser technology addresses the issue of Fitzpatrick skin type IV with thin hairs, such as those on the face. Long pulsed Nd:YAG (1064 nm) laser and Alexandrite (755 nm) laser is a versatile combination used for gold standard hair removal results. These wavelengths are optimal for hair removal in low and high Fitzpatrick skin types respectively. However, the 755nm wavelength may be too aggressive for some of these skins and the 1064nm just

too gentle for the low melanin content in the hairs.

MT or Mixed Technology, found within the Duetto MT from Lynton Lasers, allows a practitioner to simultaneously deliver a mixture of both Alex (755 nm) and Nd:YAG (1064 nm) in varying proportions. Dr Sam Hills, the Clinical and Training Manager at Lynton says, “Mixing the efficacy of the Alex with the safety of the YAG in this format means these hairs can now be successfully treated. Mixed Technology also has other

Industry

benefits such as increased safety when treating tanned skin and reduced discomfort v’s Nd:YAG alone. The high power and the large spot sizes allow fast treatment at deep skin layers, at fluences sufficient to completely damage the hair follicles in all body areas. The Duetto MT is the only laser in the world with this technological innovation, offering increased clinical efficacy. The Duetto can also emit the two wavelengths independently, simultaneously or sequentially.

This characteristic is particularly important when treating previously sun-exposed skin or skin types higher than Fitzpatrick Skin Type 4. In these cases, the suggested protocol combines a small amount of Alexandrite energy (always less than 12 J/cm2) with a low dose of Nd:YAG laser energy (always less than 25 J/cm2). Using this mixed modality results in more effective, safer and less painful treatments when compared to treatments performed with the Nd:YAG 1064 nm laser alone.”

Appointment

Cosmeceuticals and SkinBrands announce business merge

Dr Red Alinsod joins ThermiAesthetics advisory board

and along with new training programmes for businesses.

David Beesley, managing director at SkinBrands, said, Companies Cosmeceuticals “With the merger, we now have Ltd. and SkinBrands have over a dozen brands to create announced they will be the benefits of a one-stop shop merging to provide the service. Practitioners will be professional market with a able to cherry-pick the best range of skincare brands and products to meet the needs treatments. The new company, of their patients, and it will which will be known as provide a more harmonious SkinBrands @ Cosmeceuticals and easily workable business will have eight full-time business relationship between us and development managers our customers.”

ThermiAesthetics, creator of the ThermiRF temperature controlled radiofrequency system, has announced the appointment of Dr. Red Alinsod, MD, FACOG, FACS as Chairman of its Women’s Health Advisory Clinical Board.

He will help develop strategies and devices to treat specific gynecological conditions.

“We are privileged to have a world renowned urogynecologist, with an outstanding clinical experience in treating women for vaginal laxity, as chairman of our Women’s Healthcare Advisory Board,” said Paul Herchman, Chief Executive Officer of ThermiAesthetics. “ Dr. Alinsod founded “CAVS” (Congress for Aesthetic Vulvovaginal Surgery) in 2005 and is considered one of the pioneers of this evolving field.

Practitioners & their patients feel the difference...

“The favourable safety profile has lead to high patient satisfaction and subsequent recommendations from one patient to another, increasing our practice1” n

Not palpable2 ®

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BEL065/0813/LD Date of Preparation: December 2013

1. Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs Dermatol. 2012 Sep; 11(9):1032-5 2. Data on File: BEL-DOF2_001 Belotero Juvederm Study MRZ 90028_4007

Injectable Product of the Year 2013

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Vital Statistics

Topical

Study shows Galderma’s Mirvaso gel safe and effective Galderma Laboratories, LP, has announced the publication of the long-term efficacy and safety results of a one-year, open-label, noncomparative study of Mirvaso (brimonidine) Topical Gel, 0.33% in patients with moderate to severe facial erythema (redness) of rosacea.

Mirvaso was approved by the U.S. Food and Drug Administration in August 2013 as the first and only topical treatment indicated for the persistent facial erythema of rosacea in adults 18 years of age or older.

The results of this study, in which 276 subjects applied Mirvaso for at least one year, demonstrate that Mirvaso is safe and effective when used once daily for up to 12 months. The study results were published in the January issue of Journal of Drugs in Dermatology.

“The positive results of this long-term study provide additional evidence of the efficacy and safety of Mirvaso for patients with the persistent facial redness of rosacea,” said Humberto Antunes, president and CEO at Galderma Laboratories. “Since we launched Mirvaso commercially in the United States in September 2013, we have seen widespread adoption by dermatologists, underscoring the important need for an effective topical prescription treatment for this most common symptom of rosacea.”

Mirvaso is a topical gel which works by constricting the dilated facial blood vessels to reduce the redness of rosacea. Mirvaso should be applied in a pea-sized amount, once daily to each of the five regions of the face: the forehead, chin, nose and each cheek. The study indicates Mirvaso works quickly to reduce the redness of rosacea from day one of treatment and lasts up to 12 hours before the redness returns.

Consistent results were observed throughout the 12 month study. In addition, no evidence of tachyphylaxis (a sudden decrease in response after drug administration compared to prior usage) was reported. With regard to safety, no new major safety findings were observed in this study as compared to the vehicle-controlled pivotal studies. The most common adverse events (≥4% of subjects) were flushing (10%), erythema (8%), worsening of rosacea (5%), nasopharyngitis (5%), skin burning sensation (4%), increased intraocular pressure (4%) and headache (4%).

Subjects were allowed to use other rosacea therapies (oral and topical) in addition to Mirvaso. Mirvaso is due to launch in the UK in April. It will be a prescription-only medicine.

From the age of

1%

20 we lose

of collagen every year

Murad UK

Last year saw a

41%

rise in liposuction procedures

British Association of Aesthetic Plastic Surgeons

This year

4,500 IMCAS

conference in Paris travelling from

participants attended the

80

International Master Course on Aging Skin

The average person loses

50 to 100 hairs per day American Academy of Dermatology

of South Korean women have undergone plastic surgery to alter their faces

An estimated

20%

International Society of Aesthetic Plastic Surgeons

reduction in hair growth can be expected with each treatment of laser hair removal

ACE

1532 aesthetic practitioners have registered for ACE 2014 At time of printing, 1532 aesthetic practitioners have registered for the Aesthetics Conference and Exhibition 2014, more than twice as many attending CN EXPO last year. 18% of registrants are clinic managers and directors, 17% are dentists, 15% are aesthetic nurses and 15% are cosmetic doctors. Also registered are GPs, surgeons, dermatologists, aestheticians, laser therapists and other aesthetic professionals. Join practitioners from across the country at ACE 2014 on Saturday 8 and Sunday 9 March at the Business Design Centre in London. www.ace2014.co.uk Aesthetics | March 2014

American Academy of Dermatology

19%

would use their partner’s

of men

Fa c e C rea m

Smart Beauty Guide

y Contour Bod in g proceduces for gynaec o mastia rose

24% in

2013

British Association of Aesthetic Plastic Surgeons

9

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Events diary

Research

EternoGen unveils the potential of advanced collagen replenishment portfolio

8th - 9th March 2014 Aesthetics Conference and Exhibition ACE 2014, London www.ace2014.co.uk 3rd - 5th April 2014 Anti-Ageing Medicine World Congress AMWC 2014, Monaco www.euromedicom.com/amwc-2014 20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014, RIBA, 66 Portland Place, London www.bcam.ac.uk 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London www.baaps.meetings.org.uk 3rd October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org

At the IMCAS conference in Paris, EternoGen LLC presented its latest research on its Advanced Collagen Replenishment therapy portfolio for cosmetic use in regenerative dermatology. EternoGen has developed a new type of collagen dermal filler which it claims has overcome issues with previous collagen formulations, such as allergic reactions and short duration of effect.

The innovative EternoGen portfolio comprises Rapid Polymerizing Collagen (RPC) and Gold Nanoparticle Collagen (CG Nanomatrix).

The products have been formulated with integral shielding protection from collagenase degradation. Additionally, they are designed to provide high biocompatibility facilitating natural integration with the skin at a cellular level.

EternoGen says the research presented at IMCAS, “Demonstrates the ability of EternoGen advanced collagen replenishment to overcome the limitations of earlier generations of collagen.”

EternoGen plans to launch its Rapid Polymerizing Collagen (RPC) portfolio in late 2014. Christopher Inglefield, leading UK plastic surgeon, said, “The absence of collagen from the physician’s armamentarium has been felt keenly in recent years. RPC is particularly suited for delicate and challenging treatments in the peri-orbital and peri-oral areas where the risk for lumps and product migration needs to be minimized. A clinical study in the naso-labial folds using RPC is underway and the experience to date is very encouraging.”

Surgical

Training

BAAPS reveal increase in operations on men

ACE 2014 additions

With ACE fast approaching we are delighted to welcome the following exhibitors: Medira, Silhouette Soft, 3D Medic, Statistics from the British Association of Aesthetic Plastic Surgeons (BAAPS) Sedation Solutions, ThermaVein, 5 Squirrels, BioCorrex, have revealed that the number of cosmetic operations in 2013 increased Pay4Later, Society of Mesotherapy UK, Hydropeptide and by 17% since 2012. Figures show that men account for one in 10 aesthetic Lamprobe. Also, joining Dr Tapan Patel and Dr Raj Acquilla at our plastic surgery procedures. Body contouring procedures showed the Free Exhibition Clinical Programme will be Dr Maria Gonzalez, biggest increase amongst men, with an increase of 28% for liposuction, Dr Sach Mohan, Dr Leah Totton, Dr Sarah Tonks, Dr Sotirios and gynaecomastia surgery up by 24%. Former BAAPS president Mr Fazel Foutsizoglou, Mr Adrian Richards, Dr John Ashworth, Mr Simon Fatah said, “Men are becoming more body-image conscious due to men’s Ravichandran, Dr Martyn King, Dr Gabriela Mercik, Dr Britta magazines and the media. Gynaecomastia can occur for no pathological Knoll, Dr Johanna Ward and Lorna Bowes. For details of our full reason, and is a feature in a young person that can affect their confidence.” programme and to book your visit go to www.ace2014.co.uk.

When it comes to evidence you’re safe with Radiesse…

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1. Sadick N, et al A Multicentre, 47 month Study of Safety & Efficacy of Calcium Hydroxylapatite for Soft-Tissue Augmentation of Nasolabial Folds and Other Areas of the Face. Dermatol Surg 2007; 33 (Supp 2): s112-s127. 2. DoF-1-001_01

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Insider On the scene

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Venus Freeze Business Development seminar, London The Venus Freeze Business Development seminar took place on February 10 at the Millennium Hotel Knightsbridge, with the aim of helping attendees promote their businesses and increase sales utilising the Venus Freeze.

Clinical and practice enhancement manager Tracey Mancuso led the seminar alongside guest speaker and international clinical specialist, Anna Olsen. The seminar was attended by clinic, salon and spa owners.

The seminar included short demonstrations using the Venus Concept machines, as well as Mancuso and Olsen talking on ensuring financial success. Venus Freeze delivers treatments for the face and body using magnetic pulses and radio frequency, including cellulite improvement, body contouring, skin tightening and wrinkle reduction, as well as the patented ‘Venus Freeze Facial’.

Michael Dodd, managing director of Venus Concept UK, said, “I was extremely pleased with the turn out for the Venus

Business seminar. Tracey Mancuso provided excellent resources, and up-to-date examples to reinforce tips and concepts on the Venus Freeze. The seminar definitely met my expectations and from the general feedback from our clients it was extremely practical and insightful, with clinical key points.

“I was especially delighted with the comments on the new Venus Viva and Venus Legacy from those who attended. My team and I look forward to hosting the next Venus event,” he said.

3d-lipolite launch, London

The launch of the 3d-lipolite program took place on Jan 27 at the Royal Society of Medicine. The programme – a combination of diet, exercise, motivation and support along with non-surgical treatment – was discussed in length by a panel consisting of Roydon Cowley, Josh Yardley and Dr Martyn King and Sharon King. Dr Martyn King and Sharon King were responsible for developing the weight loss and body-contouring programme. “We have developed this programme exactly how we would want it in our clinic,” said Dr Martyn King. “With this approach, patients get the same service wherever they go, with the same level of professionalism.

Everyone is individual, but as long as this is the core principal then all patients will have a successful programme.” The stages of the programme include a detox phase, which lasts for two weeks, and an active phase, which lasts as long as is required for the patient. The final stage is a maintenance phase, in which the patient remains on a controlled diet. The programme administers sessions of cryolipolysis and fat cavitation, as well as sessions of radiofrequency and vacuum rolling where required.

Dr Johanna Ward, one of the doctors who attended the launch in order to find out more about the programme, said “I like the idea of combining clinician-led guidance with technology. I think it’s exciting that this can be rolled out at a national level with exacting results. We’re thinking of taking it on at our clinic.”

Regency Aesthetics Launch, London The launch of new nonsurgical cosmetic clinic Regency Aesthetics took place on January 23 on Upper Wimpole Street. The event saw 50 clinicians, industry leaders and celebrities attend, and included a champagne and canapés reception, tour of the clinic, and free skin consultation and analysis. The new clinic, run by medical director and facial aesthetics practitioner Dr Rikin Parekh, contains two large treatment rooms and a smaller consultation room, and offers treatments including anti-wrinkle injectables, dermal fillers, and skin rejuvenation treatments such as skin peels, micro-needling, PRP Therapy, mesotherapy hydration

Aesthetics | March 2014

treatments and medical skincare. It also offers machine treatments, including Ultrapulse CO2 laser skin resurfacing, M22 IPL and Nd:YAG laser platforms for treating acne, pigmentation, rosacea, vascular lesions and veins, and the Fractora platform for skin resurfacing, tightening and non-surgical fat reduction.

Additionally, their treatment package includes their own bespoke No-Knife Facelift, and the TiteFX fat reduction treatment for the body.

Alongside Dr Parekh, the team contains four specialist medical professionals. Treatment protocol includes consultation, specialist photography and computerised skin analysis for every patient.

11

Insider On the scene

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I-Lipo Ultra launch, Inverness The launch of laser lipolysis system I-Lipo Ultra from Chromogenex at the SHRINKme clinic marked the first I-Lipo system available to patients in Scotland.

The event took place at the Thistle Hotel in Inverness on January 16, where UK and European Chromogenex product specialist Jo Briggs demonstrated how the treatment works. Clinic owner Iona Urquhart said, “We have been seeing consistently good results, with many of my clients losing in excess of 10 inches before the eight sessions are finished.” I-Lipo can treat calves, knees, thighs, buttocks, stomach, arms and chin, and

targets excess fat without damaging fat cells using low-level laser. “I-Lipo Ultra is supported at the clinic by gentle lymphatic stimulation using the Reviber plate, which accelerates fat out of the body,” Urquhart said. “Using this programme, the client can complete the whole treatment in the clinic, without the need to go home and exercise.” The I-Lipo course includes eight 30-45 minute treatments, taken twice a week at regular intervals. “Watching people shrink substantially in a few short weeks and seeing their self-esteem and confidence grow is hugely rewarding,” Urquhart said.

Inaugural Meeting of the Allergan Medical Institute, Amsterdam Advanced Technical Training: Excellence in Aesthetic Care By Dr Mervyn Patterson On January 24-26, Allergan invited leading aesthetic doctors from all over Europe to share and discuss advanced aesthetic injection techniques. The meeting is part of a major new initiative by Allergan to help improve the delivery of injectables to patients by providing advanced technical training and encouraging a consensus in best practice techniques. The meeting was lead by an international faculty of experts who shared their extensive experience using botulinum toxin and hyaluronic acid fillers. Multiple small group sessions with high quality video technology allowed for a clear, precise demonstration of injection techniques, and the informal atmosphere facilitated a high level of discussion. “There is a clear need for improvement in the delivery of injectable treatments and Allergan are really raising standards by getting together all the leading doctors to improve quality of training,” said Dr David Eccleston, a cosmetic physician from the UK. “This training, by way of detailed cadaveric dissection, reinforces the importance of understanding anatomy to ensure safe treatments.”

Midface augmentation techniques were demonstrated to show an indirect improvement in the infraorbital area, a good choice for less experienced clinicians looking to improve this popular area. Chin augmentation was an additional focus, with treatments designed to project the chin forward and improve the jaw line. Delegates also received advice on how to use fillers in the chin and mental crease area to support the lower lip. Dr Gregor Wahl, a dermatologist from Germany was tasked with leading the presentation on the management of the infraorbital area. “Treating the tear trough with hyaluronic acid fillers can be at times challenging,” he said. “The meeting allowed a discussion of the possibilities and limitations.”

Dr Raina Zarb Adami, a plastic surgeon specialising in non-surgical treatments from London, commented on a demonstration by Dr Boris Sommer, a consultant dermatologist from Germany. “I was impressed with the technique demonstrated by Dr Sommer for volumisation of the lip. This is a different approach with small boluses of filler being placed in the body of the lip to give volume and support, something I will definitely be introducing into my daily practice.” Revitalisation techniques for the hand were discussed in a separate session led by Dr Hervé Raspaldo, an aesthetic surgeon from France. He demonstrated the use of a cannula for delivery of a very even layer of filler just under the skin to significantly improve the look of the ageing 12

hand. Dr Raspaldo, and indeed all of the faculty members, reinforced the need for strict adherence to a sterile technique whilst injecting.

The use of hyaluronic acid fillers in the forehead and temple region is currently of considerable interest and much discussion was given in the meeting to the placement of filler under the eyebrow to give support and lift. Dr Mauricio de Maio, a plastic surgeon from Brazil, skillfully managed the treatment of complex and difficult cases. With clear treatment goals set out, his staged treatments displayed the lifting potential of correctly placed facial filler. Importantly, he gave expert advice on how to prioritise treatment steps to gain maximal improvement within the patient’s budget.The new training format of the Allergan Medical Institute proved to be a success amongst delegates. Dr Tapan Patel, a specialist in facial aesthetics based in the UK, said, “Yet again Allergan raises the standard of training above and beyond what we have had before.” Mr Kambiz Golchin, a plastic surgeon from Ireland, added, “I have great respect for the emphasis placed by Allergan on training and increasing the safety profile of procedures.” Dr John Quinn, a specialist in aesthetic medicine from the UK said, “The conference really reinforced the concept of overall facial volumisation for rejuvenation, and thus treating the patient holistically.”

A spokesperson for Allergan explained that one of the company’s main objectives is to improve patient outcomes by teaching others to be better injectors. He said, “The Allergan Medical Institute was developed to promote excellence in practice and this conference is just one of the steps on the road to achieving our objective.”

Dr Mervyn Patterson has no financial disclosures in the area of dermal fillers.

Aesthetics | March 2014

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ACE Special Focus

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The Aesthetics Conference and Exhibition 2014 1532 registrants 100 exhibitors 57 speakers 59 CPD points to choose from 40 lectures and masterclasses 26 clinical demonstrations 13 business workshops 2 days 1 event Book Now Over 1532 have already registered for their place at ACE 2014.

To book your FREE place today call 01268 754 897 or visit www.ace2014.co.uk

After months of preparation, the Aesthetics Conference and Exhibition 2014 is set to be the largest medical aesthetics event in the UK this year.

Comprising a huge programme of exhibitors, workshops, masterclasses and lectures, ACE provides visitors with the unique opportunity to get up-to-date on the latest product, service and technique innovations and hear from worldrenowned experts on the topics most relevant to the medical aesthetic industry today.

Dr Mike Comins, head of the ACE steering committee, said, “I look forward to the wide selection of CPD accredited education available at the conference.

The masterclasses, lectures, live demonstrations and workshops are vital learning tools for practitioners, which will allow them to progress in their careers and expand their skills and knowledge base.”

ACE programme coordinator Amanda Cameron said, “We have tried to put together an educational and interesting programme so that the audience will not only be entertained but they will leave equipped with new skills to enhance their businesses. The mix of clinical, business and practical sessions is unique and this will create an event that is not to miss.”

“ACE is a huge compendium of learning and development,” said BACN vicechair Sharon Bennett. “I’m really looking forward to the expert clinics with demonstrations and intelligent, innovative presentations from an impressive line up of experts.

“ACE has understood and captured the essence of a rapidly evolving specialty and set a new level for aesthetic excellence and learning,” she said.

Cosmetic dermatologist Dr Raj Acquilla, who is demonstrating at the conference, said, “This will be my third year presenting at ACE, which is a great opportunity for aesthetic practitioners of all levels to come together to learn and share the latest knowledge and techniques in our exciting and rapidly advancing specialty. This year I will be sharing injection strategies from my teaching experience around the world.”

Aesthetics | March 2014

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Clinical Practice Special Focus

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Dr Sarah Tonks discusses what you need to know when selecting a PRP method for your practice

Investigating Platelet Rich Plasma The use of Platelet Rich Plasma (PRP) in aesthetics is relatively recent but has gained considerable publicity due to its adoption by celebrities such as Kim Kardashian and Bar Refaeli, who were both depicted with their faces smeared with whole blood rather than PRP, resulting in a dramatic effect.

However, PRP has been used clinically in humans since the 1970s in opthalmic surgery, orthopaedics and sports medicine.

Much of the interest around PRP has come from the idea that this is an autologous substance and therefore considered to be ‘safer’ than traditional dermal fillers and botulinum toxins. WhatClinic. com reported an increase in enquiries regarding the procedure of 807% over the previous year in 2013. Although PRP is now offered by many clinics and there are numerous systems on the market, some uncertainty remains over its efficacy and proposed mode of action. Some have expressed doubts as to whether this truly represents evidencebased medicine due to the lack of robust clinical trials and outcomes. Indeed a recent Cochrane review in 2012 stated that at the moment there was insufficient evidence to support the use of PRP.1 However, at a microscopic level in a study of PRP treated fibroblasts, the PRP treated groups showed more proliferation and differentiation of fibroblasts into myofibroblasts which are essential for wound healing and increased contraction of the wound during healing time.2 PRP stimulates endothelial cells near their application site and favours the proliferation and formation of new capilliaries.3 Doctors report a high satisfaction and return rate from patients.

What is PRP? Generation of PRP involves centrifugation of autologous blood to separate the plasma and buffy coat portion of the blood, which contains high levels of platelets. Most people have a baseline blood platelet count of 200,000 (+/- 75,000) and although

Before

After

the ideal concentration of PRP is at the moment unclear, most PRP systems produce a substance containing concentrations of growth factors that are threefive times that in normal plasma. A count of 1,000,000/μL or 338% more than the normal total blood platelet count has been proposed as being the ideal4. Studies have shown that PRP with a low platelet concentration does not work and too high concentrations have an inhibitory effect on cell growth. The concentration of PRP for bone regeneration was found to be best around 1,000,000/ μL.5 A separate study found that higher leukocyte content increases inflammation and reduces tissue regeneration so it is important to exclude as many of these cells as possible from the PRP.6 Platelet Poor Plasma (PPP) is blood plasma with a very low number of platelets, usually <10,000. This can be found in the top fraction of the centrifuged blood. PPP is still a useful fraction of blood: it has been shown that both PRP and PPP, when activated with calcium and thrombin, can induce proliferation of dermal fibroblasts.7 The Growth Factors PRP contains high concentrations of growth factors and more than 800 different proteins and it appears that the growth factors work together synergistically.8 Growth factor secretion begins 10 minutes after clotting with more than 95% of pre-synthesised growth factors secreted within an hour, however platelets continue to synthesise growth factors for at least seven days.9 Ideally the PRP must be used on the application site 10 minutes after activation to harness the growth factors. After the death of the platelet, the macrophage takes over wound healing by secreting some of the same growth factors.4 PRGF and TGF- ß1 IMPORTANT COMPONENTS OF PRP • Three isomers of platelet derived growth factors PDGF PDGF-α α, PDGF- α β and PDGF- β β • Vascular endothelial growth factor VEGF • Two of the transforming growth factors TGF- β1, TGF- β2 • Epithelial growth factor EGF

The major effects of PRP are derived from PRGF and TGF- β1, which are concentrated in the alpha granule of the platelet and released during platelet activation. Both PRGF and TGF- β1 stimulate cell proliferation and differentiation resulting in tissue formation.10 Could it be dangerous?

Although no undesirable effects have been reported, hypotheses exist as to the over expression of growth factors and their receptors related to tumour formation and dysplastic tissue. However it is thought that the circumstances leading to neoplasm growth require more continuous doses of growth factors over time than those in PRP, which degrade in seven-ten days.11 Nonetheless, the use of PRP should be avoided in patients with pre-cancerous lesions, in areas of epithelial dysplasia and those with a history of exposure to carcinogens.12 Types of kits Several commercially available methods to obtain PRP are currently used in the clinical setting and there are many kits, centrifuges and vials available. The centrifugation process should be sterile and suited to platelet separation without

© Regen Lab Aesthetics | March 2014

19

Clinical Practice Special Focus

aestheticsjournal.com

lysing or damaging the platelets. Not all systems have been created to produce sufficiently viable platelet and this has led to criticism regarding the efficacy of PRP. When anti-coagulated blood is centrifuged, three layers form due to the differing densities of the blood components; the bottom layer consists of red blood cells, the middle of platelets and white blood cells, and the top plasma layer.3 It is important to reduce platelet fragmentation during centrifugation.

Integrity of the membrane can be preserved by the use of acid citrate dextrose type A anticoagulant and low gravity forces during centrifugation.4 Dr Daniel Sister, anti-ageing and hormone specialist at BeautyWorksWest and pioneer of Dracula therapy, speaks on considerations when applying PRP. “The type of harvesting kit, centrifugation methods and time play a crucial role,” he says.

“Plasma is autologous, so most new systems now come without the gel-like separation, because plasma is not totally hermetical and filaments of the gel get mixed with the plasma. All systems must be closed.” “There is also the cost per ml of active plasma to consider,” he says. “The new systems harvest 20cc in one kit and are more efficient, have better ration of growth factors and are cheaper than previous systems.” In the UK the most widely available kits available include Angel, Regen, Tropocells, BTI Technologies, Dracula and Selphyl.

The Angel system is unique amongst the described systems in that the outcome is customisable. The haematocrit level can be adjusted to the desired percentage (usually 2-7% in aesthetics), which will determine the amount of white blood cells in the PRP. In order to activate the platelets the most commercially used method is to add thrombin or calcium to the PRP, although it can be used without activation as in vitro the platelets are activated by contact with collagen.

Addition of calcium replenishes that which was bound by the acid citrate dextrose type A anticoagulant. Previously, bovine thrombin was used as an activator which was associated with the risk of life threatening coagulopathies via immunologic problems and factor V deficiencies; however the adverse reactions

Amount of blood taken Method of taking blood Sterile blood tubes?

Size of tubes Amount of PRP obtained

Concentration of PRP: normal blood Centrifuge time Centrifuge speed Spinning angle of centrifuge

After

© Angel system reported were related to the source and quantity of the thrombin used.13 The addition of calcium is now considered to be a safer option.2 How is it used?

The indications for PRP are numerous. There is evidence for its use to diminish dark circles around the eyes, hair growth and cutaneous regeneration.14,15 PRP is most often performed as a superficial treatment. It can be used intradermally with a 30g needle, in a linear thread, cross-hatching or using the fan technique. It can be used like mesotherapy, in a micro injection or micro papular technique with a 32g needle. Additionally, it is being used supraperiosteally to assist with slowing of bone remodelling and ageing, although at present there is no strong evidence base for this.16 PRP is being used in combination with fat to improve the survival of grafted fat with good results.17

ANGEL

REGEN

SELPHYL

TROPOCELLS

BTI

DRACULA SKIN REJUVENATION

50ml

8ml

18-36ml

10ml or 30 ml

54ml

20ml

Butterfly needle and vacutainer

Closed system

Butterfly set for 10ml blood draw. Needle and syringe could be used for 30ml blood draw

Butterfly cannula with vacutainer vials

Needle and syringe

Yes

Yes

Yes

Yes, endotoxin free

Yes

8ml

10ml

15ml or 50ml

9ml

20ml

4-5ml

9-18 ml

10ml blood draw = 6-2ml depending on platelet conc needed. 30ml blood draw = 18-6ml conc platelets

4-8 x baseline platelet concentration when diluted with PPP

1.8-2.5-fold

+2.2 (yield 74.1%)

17mins

5mins

6mins

First cycle: 3700rpm Second cycle: 2700rpm

3200 rpm

First cycle: 3800 rpm Second cycle (optional): 1800 rpm

Needle and syringe.

Has a specific kit with ACDA anticoagulant No tubes. Uses dedicated sterile hospital quality set

N/A

6-10mls

N/A

45°

Activation substance

None - self activating when injected with small lumen needle

Number of treatments

3 treatments, 4-6 weeks apart and then every 6-18 months

3 treatments every 4 weeks apart and then every 6 months

Method of separating PRP

LED cellular photospectometry and fractionation

Thixotropic gel

20

Before

Calcium gluconate (optional)

24ml dependent on heamocrit

Minimum 6ml

3-5 x above baseline

1-2x volume blood (depends on fraction being used)

3.44 x initial concentration

10mins

8mins

8mins

580g

1800

1500 RCF (or g) Only one cycle

90⁰

90° preferred or 45°

n/a under patent

30°

Calcium Chloride

None, activation in situ

Calcium chloride

Calcium gluconate optional

3 treatments every 6 weeks

3 treatments every 4-6 weeks and then every 6–18 months

3 treatments at 3-4 weeks apart for 3 months, top up every 6-12 months

Twice a year

Cycloaliphatic polymer inert gel, 100% biocompatible

Manually using a plasma transfer device

Mechanical with sodium citrate

Aesthetics | March 2014

Mechanical filter

duction Fat Re

lipomed

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Skin Tighten

A Powerful Three Dimensional Alternative to Liposuction

Cellulite

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise This NEW advanced device is dedicated exclusively to the clinical market

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Why choose 3D-lipomed?

• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required • National PR support campaign • Clinician use only

Cavitation

Complete start up and support package available from under £400 per month

advantages of this technology are high treatment efficacy, no pain

Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss.

Duo Cryolipolysis (New) Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months.

Two areas can now be treated simultaneously.

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology RF (New) The new 3D-lipomed incorporates 3D Dermology RF with the stand alone benefits of automated vacuum skin rolling and radio frequency.

Before

After

“I am so pleased to be given the opportunity to have the first medical version of the award winning 3D Lipo machine in my new clinic. This multi-platform technology offers a powerful non-surgical alternative to lipo suction with the addition of skin tightening and cellulite reduction modalities. I’m so proud to be able to offer my clients the very latest result driven technology.”

Dr Leah Totton - Winner of The Apprentice 2013

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Clinical Practice Special Focus

aestheticsjournal.com

Conclusions Standardisation of PRP preparations is urgently needed to best compare systems. General opinion is that the majority of clinical studies do not have the statistical power to give conclusive results. Human trials do not take into account whether the platelets have been effectively concentrated, whether the PPP is discarded or not, whether early activation occurred or whether there were purification problems. Regarding skin rejuvenation, larger scale studies and randomised controlled trials which would decisively say which methods are most effective have not yet been performed. However, clinical experience suggests that in general, PRP, for skin rejuvenation and other aesthetic indications such as hair loss, can be a useful and attractive treatment.

REFERENCES

Dr Terry Loong, aesthetic doctor, The Skin Energy Clinic Regen PRP system Having used other PRP systems, I love the Regenlab system. It has a red ATS (autologous thrombin serum) which allows thrombin to be extracted from the blood, mixing it with the liquid PRP, activating the coagulation cascade, creating a gel-like substance which provides a matrix when injected, slowly releasing the growth factors. This provides more controlled and targeted delivery. The gel-like matrix acts as a natural alternative to filler, perfect for treatment under the eyes, fine lines and wrinkles, and as skin boosters.

1. Martinez-Zapata M, Marti-Carvajal A, Sola I, et al., ‘Autologous platelet-rich plasma for treating chronic wounds’ (Review), Cochrane Libr (2012), (p. 10).

2. Kushida S, Kakudo N, Suzuki K, Kusumoto K., ‘Effects of plateletrich plasma on proliferation and myofibroblastic differentiation in human dermal fibroblasts’, Ann Plast Surg., 71(2) (2013), pp. 219–24.

3. Eppley BL, Pietrzak WS, Blanton M., ‘Platelet-rich plasma: a review of biology and applications in plastic surgery’, Plast Reconstr Surg., 118(6) (2006), 147e–159e.

4. Marx R., ‘Platelet-rich plasma: evidence to support its use’, J Oral Maxillofac Surg., 62 (2004), pp. 489-96, <http://scholar.google.com/sc holar?hl=en&btnG=Search&q=intitle:Platelet-rich+plasma:+evidence+t o+support+its+use.#0> [Accessed February 10, 2014] 5. Weibrich G, Hansen T, Kleis W, Buch R, Hitzler W, ‘Effect of platelet concentration in platelet-rich plasma on peri-implant bone regeneration’, Bone, 34(4) (2004), pp. 665–71.

6. McCarrel T, Minas T, Fortier L., ‘Optimization of leukocyte concentration in platelet-rich plasma for the treatment of tendinopathy’, J Bone Joint Surg Am, 94(19) (2012) p. 143 (1–8).

7. Kakudo N, Minakata T, Mitsui T, Kushida S, Notodihardjo F, Kusumoto K., ‘Proliferation-promoting effect of platelet-rich plasma on human adipose-derived stem cells and human dermal fibroblasts’, Plast Reconstr Surg., 122(5) (2008), pp. 1352–60.

8. Fortier L, Barker J, Strauss E, Taralyn M, McCarrel D, Cole B., ‘The Role of Growth Factors in Cartilage Repair’, Clin Orthop Relat Res., 469(10) (2011), pp. 2706–2715.

9. Senzel L, Gnatenko D, Bahou W., ‘The Platelet Proteome’, Curr Opin Haematol., 18(6), (2009), pp. 329–333.

10. Marx R, Carlson E, Eichstaedt R, Schimmele S, Strauss J, Georgeff K., ‘Platelet-rich plasma: Growth factor enhancement for bone grafts’, Oral Surgery, Oral Med Oral Pathol Oral Radiol Endod., 85 (1998), pp.

638–46.

11. Albanese A, Licata M, Campisi G., ‘Platelet-rich plasma (PRP) in dental and oral surgery: from the wound healing to bone regeneration’, Immun Ageing., 10:23 (2013) 12. Martinez-Gonzalez J, Cano-Sanchez J, Gonzalo-Lafuente J, Campo-Trapero J, Esparza-Gomez G, Seoane J., ‘Do ambulatory-use Platelet-Rich Plasma (PRP) concentrates present risks?’, Med Oral., 7(5) (2002), pp. 375–90.

13. Martinez-Zapata M, Marti_Carvajal A, Sola I, et al., ‘Efficacy and safety of the use of autologous plasma rich in platelets for tissue regeneration: a systematic review’, Transfusion, 49(1) (2009), pp.

44–56.

14. Amgar G. Gestion, ‘du cerne creux avec les extraits plaquettaires autologues’, Rev AFME, (2009) (Janvier), pp. 12–13.

15. Trink A, Sorbellini E, Bezzola P, et al., ‘A randomized, doubleblind, placebo- and active-controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata’, Br J Dermatol., 169(3) (2013), pp. 690-4.

16. Kutuk N, Bas B, Soylu E, et al., ‘Effect of platelet-rich plasma on fibrocartilage, cartilage, and bone repair in temporomandibular joint’, J Oral Maxillofac Surg., 72(2) (2014), pp. 277–84.

17. Jin R, Zhang L, Zhang Y., ‘Does platelet-rich plasma enhance the survival of grafted fat? An update review’, Int J Clin Exp Med., 6(4) (2013), pp. 252–258.

Dr Rita Rakus, aesthetic doctor, Dr Rita Rakus Clinic Angel PRP system The Angel Lift is a highly effective treatment; it is a two-step procedure that combines PRP with a fractional laser system. Targeting the signs of ageing inside and out, The Angel Lift reduces fine lines, wrinkles and blemishes on the skin surface as well as addressing the structure of the layers beneath to produce visible natural results. With medical grade credentials, the Angel PRP machine offers optimum performance, ensuring it delivers the best possible results.”

Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, who fell in love with the results possible through minimally invasive methods. Now based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

Mr Dennis Wolf, surgeon, The Private Clinic I use the Tropocells kit as it has a few basic components; it is efficient and reliably provides concentrated PRP (four-five times the usual amount from 10ml venous blood). The gel plug separates the PRP from the erythrocyte and granulocyte content, which is thought to have a catabolic effect by releasing metalloproteinases. The filter sleeve prevents any contamination. Depending on what areas the patient would like treated I aspirate 10ml or 20ml venous blood. After centrifugation at 1500g for 10 minutes I can remove some PPP thereby increasing the concentration of the platelets in the remaining plasma. My protocol for facial rejuvenation consists of treating the peri-ocular region, malar region, temple, peri-oral region and nasolabial folds. Peri-ocular and temple region I treat very superficially. The malar region I treat superficial and deep. The peri-oral region I treat superficially and the nasolabial folds deep. For the hands and face I use a 2:1 ratio of fat to PRP. Dr Adam Thorne, cosmetic dentist, Harley Street Dental Group - BTI PRP system We’ve been using PRP techniques at Harley Street Dental Studio for some time now. We use it for faster wound healing, when placing implants or to regenerate bone following tooth extraction, around implants, in bony defects, bone graft placement or after extraction of cysts. A subfamily of TGF is bone morphogenic protein (BMP), which has been shown to induce the formation of new bone. When added to the site with bone substitute particles it allows us to grow bone more predictably and faster than before.

22

Aesthetics | March 2014

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Clinical Practice CPD Clinical Article

one point

aestheticsjournal.com

The External Skin Barrier

Dr Mervyn Patterson discusses the structure, physiological function and mechanisms for repair of the external skin barrier The external skin barrier, the outermost layer of the skin, is comprised of flattened cells separated by thin layers of lipids. The integrity of this barrier is critical to the health of the underlying skin. All skincare professionals who wish to deliver optimal skin health to their clients need to be aware of the importance of the external skin barrier and how to maximise barrier repair mechanisms.

KEY COMPONENTS OF THE EXTERNAL SKIN BARRIER The permeability barrier resides in the stratum corneum and consists of two components; the structural, cellular part and the lipid layer that lies between these cells. A simple analogy is that of slates on a roof kept together and apart by a thin layer of glue, or in this case, lipid. The slates are made of proteinaceous corneocytes filled with keratin. The glue between the slates is made of multiple layers and is predominantly made of three lipids: cholesterol, ceramides and free fatty acids. A point of note is that half of the free fatty acid component must be linoleic acid, an essential acid that cannot be synthesised by the body and must be ingested as an omega-6 fatty acid. When the three key lipids exist in a specific equimolar relationship the barrier is at its optimum. Further research(1, 2) has demonstrated that repair of the barrier is induced by several different, specific ratios of these lipids with very different degrees of repair resulting with each of the ratios. Topical applications of skincare with the 3:1:1 ratio with either cholesterol or ceramide dominating was shown to be the most effective reparative ratio. These lipids have a hydrophilic end that binds water and a hydrophobic end where they join to other lipids. They exist in a weight ratio of 50% ceramide, 30% cholesterol and 20% free fatty acids. This is the equivalent to an equimolar ratio of 1:1:1 in young healthy skin.

To date 11 different ceramides have been described in human skin. The production of these Figure 1: The Epidermis complex molecules is limited by one single enzyme, serine protein transferase. Other enzymes are catabolic and contribute to the anti-inflammatory and hydration effects of ceramides. Sensitive skin and those with eczema are characterised by a marked decrease in ceramide levels and the catabolic enzymes are present in concentrations five times higher than in normal skin.(2, 3) Cholesterol is essential for skin barrier function and is synthesised by the enzyme HMG CoAreductase. Very low cholesterol diets or prolonged high dose lipid-lowering drugs may damage the skin barrier and underscores the importance of taking a good patient history when trying to unravel the cause of a skin complaint. About 20-35% (by weight) of the stratum corneum is composed of water lying between the lipid layers attached to the hydrophilic ends of the three key lipids. The skinâ&#x20AC;&#x2122;s natural moisturising factor is a complex material that is a highly efficient humectant. The balance of moisturising factor, the three key lipids and water affect pliability and flexibility of the skin. The three lipids are reduced in dry skin and aged skin.(3) Moisturisation results Figure 2: 28 day life of an in increased water holding capacity or hydration. It does not necessarily improve the barrier epidermal cell because excessive moisturisation actually reduces barrier function. This factor explains why lipidsoluble corticosteroids applied to treat diseased skin penetrate the skin by up to fifteen times 14 more if the skin is excessively hydrated. This disruption of the stratum corneum and its barrier is 1 Days due to hydration changes throughout the day or with bathing cycles. The epidermis must be in a continuous state of metabolic and differentiation activity to obtain homeostasis.(4) The skin barrier in addition to including corneocytes and their lipid layers also has two other 2 groups of molecules residing in the epidermis. Preformed biological response modifiers include cytokines, growth factors and minerals and anti-inflammatory molecules that specifically bind to 14 pro-inflammatory factors to reduce, prevent or reverse the magnification of the seven inflammatory Days cascades. The purpose of the preformed biological response modifiers is that when injury occurs barrier repair is immediately activated, as is acute inflammation, to rapidly kill microbes, neutralise 3 toxins, irritants and allergens and prevent their penetration.

1 Stratum corneum or External Skin Barrier.

2 Epithelial cells migrate to the surface, change shape, flatten, loose their nucelus and turn into the stratum corneum 3 Cells divide and produce the stratum corneum

24

THE SKINâ&#x20AC;&#x2122;S RESPONSE TO BARRIER DISRUPTION During the first 30 minutes following insult, preformed packets of biological response modifiers including cytokines such as tissue necrosis factor, interleukin-1, growth factors, histamine and nuclear receptors are released along with barrier lipids from lamellar bodies, which are ready prepared storage vesicles of lipids inside the cells. During the next 30 minutes synthesis of cholesterol and free fatty acids are markedly increased to facilitate repair, then ceramide synthesis increases during the next hour. Between two and six hours after injury DNA synthesis and production of fresh lamellar bodies leads to further secretion of the three key lipids into the extracellular space(5). The repair process after injury is dynamic. Basal cells at the base of Aesthetics | March 2014

Clinical Practice CPD Clinical Article

aestheticsjournal.com

the epithelium divide and the new cells migrate to the surface to be eventually shed. This maturation of the keratinocyte takes 28 days, but slows to 35-40 days as we age. In addition to lipid synthesis disruption of the skin barrier by injury leads to reparative epidermal proliferation as evidenced by increased DNA synthesis of basal cell keratinocytes.

ABNORMALITIES OF EPIDERMAL CELLS ARE SEEN IN MANY DISEASE STATES The epidermal cell turnover is markedly increased in many chronic skin diseases, up to three times more in dermatitis and nine times greater in psoriasis. Scaly diseases like ichthyosis vulgaris are due to abnormalities in the keratinocyte maturation process, which are due to abnormal desquamation and have an additional abnormal barrier function.(1, 6) Compromised barrier function is seen in a significant proportion of humans as determined by measuring transepidermal water loss. Upwards of 30% of females complain of sensitive skin with some estimates of sensitivity rising to over 60% in diseases such as rosacea. This is often due to deficiency of total lipid content contributed to by their skincare regimens. Up to 30% of children in the western world are atopic, a condition characterised by a compromised external skin barrier function.

Here the greatest reduction is in ceramide levels but with a reduction in all three key lipids as well as reduced levels of urea, filaggrin and small protein-rich proteins. This genetic abnormality is linked to asthma, hay fever and food allergies with gastrointestinal symptoms.(2, 7)

SEVERAL ENVIRONMENTAL INSULTS COMPROMISE THE EXTERNAL SKIN BARRIER • • • •

UVA, UVB and X radiation Humidity and temperature extremes Microdermabrasion and chemical peels Excessive hydration, especially hot water

• • • •

Excessive use of humectants Prolonged use of cold creams Certain skincare ingredients Physical and emotional stress

During the summer our skin is exposed to the sun for a longer period resulting in increased UV disruption.(8) Humidity and temperature changes are known to compromise barrier function. In the winter, after two to four days in freezing or below freezing conditions, the low ambient humidity results in dehydrated skin, scaling, itching or burning with water or moisture application and higher sensitivity to the elements.(8, 4) Prolonged visits to polar regions where the protective troposphere is deficient allows for significant increased exposure to UV damage. Microdermabrasion treatments and chemical peels may make the skin more vulnerable to sun damage, particularly if exposure occurs before the external skin barrier has had time to repair. Sunscreen with a high sun protection factor must be regularly applied, especially during times of increased sebum Figure 3: External skin barrier production because the sunscreen breaks down with sun exposure and is diluted as it mixes with the acids in the skin barrier. Repeated or excessive hydration, particularly having hot baths, usually disrupts the skin barrier. Despite moisturisers being regularly used by women, the incidence of facial dermatitis has been steadily increasing over the past few decades. One contributing factor is over hydration of the skin with excessive water and humectants, which Lipids that m actually decrease the protective function of the skin barrier by separating the spaces between The external skin barrier is barrier are in the lipid layers. The converse to this is prolonged use of cold creams as cleansers. These composed of the top 12 to 15 skin cells and the lipids that lie between products are devoid of water and dehydrate the skin to less than 10%, which causes abnormal them. These keratinocytes and corneocyte desquamation, producing visible skin scaling, decreased skin pliability and stratum lipids provide protection to the (4, 7) corneum fracturing. Harsh ingredients in skincare products, especially soaps and cleansers underlying layers. damage the stratum corneum by various methods. Sodium lauryl sulphate is still commonly found in skincare products and actually destroys the lipid layers and corneocytes.(9, 10) Figure 4: Electron Other chemicals known to cause damage to the skin barrier include propylene glycol, retinoic microscope image of the acid, formaldehyde, urushiol, quaternium 15 and certain hydroxy-acids, including lactic acid. stratum corneum and Whilst intermittent exposure to these products causes acute inflammation, prolonged use transitional layer leads to activation of chronic inflammation which in turn produces upregulation of matrix metalloproteinase enzymes. These go on to reabsorb and remodel collagen and elastin fibres to produce micro scarring and wrinkling.(8, 11) A reduced quantity of the three key lipids in our diet also contributes to a compromise in the quality of barrier function. Inadequate consumption of 2 anti-inflammatories and antioxidants impinge on the skin’s ability to mount a protective acute 1 inflammatory response. Also chronic use of lipid lowering agents, fish oil and Niacin, as well as anti-inflammatories such as ibuprofen and aspirin, contribute to abnormal stratum corneum 3 and epidermal function. Radiation therapy carries a high risk of inducing itchy, difficult to treat dermatitis due to barrier disruption, inhibition of lipid synthesis, slow epidermal proliferation and reduced sebum production. Lipid variations resulting in barrier function abnormalities occur in peri- and post-menopausal women due to the fall in oestrogen and relative rise of testosterone which are known to compromise the permeability barrier. The production of all three key lipids 1 Stratum Corneum and particularly cholesterol is reduced in this group. Medication that depletes water such as 2 Stratum Corneum cells separated by diuretics and those that reduce sebum production, including isotretinoin, retinoids, niacin and a thin layer of lipids tetracyclines, all have an impact on barrier repair.

3 Transitional Layer

REPAIRING THE BARRIER, RESTORING THE DEFENSIVE SHIELD

Epithelial cells make a transition into the flat, hardened stratum corneum cells

In young adults, after injury to the stratum corneum barrier, a rapid recovery phase occurs during Aesthetics | March 2014

25

Clinical Practice CPD Clinical Article

aestheticsjournal.com

the first 12 hours which produces 50-60% recovery, with full recovery taking up to three days. In older people this may take up to a week or longer. Reaccumulating skin lipids becomes the most critical factor in restoring barrier function. As stated before, normal skin contains an equimolar ratio of cholesterol, ceramide and free fatty acids of which 50% is the essential acid, linoleic acid. Work by Dr Carl Thornfeldt and other researchers(11, 12) has shown that barrier recovery is markedly accelerated by changing the proportion of the key lipids to a 3:1:1 ratio with ceramide or cholesterol dominance. In one study this ratio produced a 75% barrier recovery within four hours compared to only 35% with the equimolar ratio 1:1:1. Work has shown that formulas containing just ceramide or cholesterol or fatty acids have either no significant barrier repair properties or adversely affect barrier function. Certain non-physiological lipids such as petrolatum, glycerin, lanolin, bees wax, and squalene provide some barrier repair. 100% petrolatum is known to markedly improve barrier function by 43% in 45 minutes. The other non-physiological lipids work by different mechanisms and also improve barrier function, but at different time points and to various degrees. Thornfeldt and others developed skincare technology that combined the best ratio of the three key barrier repair lipids with low therapeutic concentrations of these non-physiological lipids. The EpiB complex, which forms a key component of the platform technology within Epionce skincare, has been shown to produce an 89.6% repair of the skin barrier with complete normalisation after two hours.(6) For extrinsic ageing the ideal repair ratio of the physiological lipids is a 3:1:1 ratio with cholesterol as dominant combined with petrolatum and glycerin between 3-15% concentrations of each. When used regularly, barrier-repairing moisturisers not only help to produce and maintain remission of many inflammatory skin diseases but they also help reverse and prevent the activation of extrinsic ageing. An independent, split face, double blind, prospective controlled clinical study using this barrier repair formulation showed a highly statistically significant

Figure 5: Healthy lipid ratio is key to a healthy barrier

improvement in tactile roughness, clarity and reduction in fine lines and wrinkles after 12 weeks of use.(13) Many of the very light moisturising products are actually very destructive to the external skin barrier because they are deficient in the total amount of lipid needed and often negatively affect the normal skin lipid ratio, thus damaging barrier integrity.

SUMMARY • An intact skin barrier is the first line of defence against harmful environmental insults • The integrity of the stratum corneum regulates DNA synthesis of the epidermis • Many skin diseases and ageing are characterised by external skin barrier abnormalities • A disrupted external skin barrier is a primary driver for unwanted chronic inflammation • After exfoliating procedures, the barrier must be rapidly regenerated, otherwise the benefits of the procedure are reduced • Rapid closure of the external skin barrier postprocedure is achieved with appropriately formulated combinations of physiological and nonphysiological lipids • Practitioners now have available barrier-repair moisturisers proven in clinical studies to treat the signs of ageing skin

Figure 6: Lipid layer made of three lipids, ceramide, cholesterol and free fatty acids

fatty acid (Stearic Acid)

Lipids that make up the external skin

Ageing, skin disease and poor skin repairbarrier are in a ratio of 1:1:1 lead to a deterioration of the skin barrier and Lipids that make up the the normal ratio of healthy lipids changes. external skin barrier are in a ratio of 1:1:1 Epionce is formulated to restore a healthy lipid ratio and external skin barrier.

REFERENCES

cholesterol

Lipids that make up the external skin barrier are in a ratio of 1:1:1

Lipids that make up the external ski As a co-owner of Woodford Medical, Mervyn Patterson is a highly barrier are inDr a ratio ofdoctor 1:1:1 experienced aesthetic providing

1) A.W. Johnson, ‘Cosmeceuticals: function and the skin barrier’, in Cosmeceuticals 2nd ed, ed. by Z.D. Draelos (Philadelphia: Saunders-Elsevier, 2009), pp. 7-14.

2) G. Dell’Acqua, ‘Sensitive Skin and Skin Barrier’, Cosmetics & Toiletries, 123:12 (2008), 71-75.

3) J.A. Bouwstra, G. Pilgram and M. Ponec, ‘Structure of the Skin Barrier’, in Skin Barrier, ed. by Peter M. Elias and Kenneth R. Feingold (New York: Taylor Francis, 2006), 65-96.

4) J.Q. DelRosso, ‘Moisturizers: Function and Clinical Applications’, in Cosmeceuticals 2nd ed, ed. by Z.D. Draelos, (Philadelphia: Saunders/Elsevier, 2009), pp. 97-103.

5) Kenneth R Feingold, ‘The role of epidermal lipids in cutaneous permeability barrier homeostasis’, Journal of Lipid Research (2007), 48: 2531–2546.

6) Medical Barrier Cream Superior in Cutaneous Healing (2014) <http:// www.epionce.com/wp-content/uploads/2011/09/10_ClinicalStudy_ EpionceSuperiorinCutaneousHealing.pdf 7) Z.D. Draelos, ‘Noxious sensory perceptions in patients with mild to moderate rosacea treated with azelaic acid 15% gel’, Cutis, 74(4) (2004), 257-60.

8) Peter M. Elias, ‘Defensive functions of the Stratum Corneum: Integrative Aspects’, in Skin Barrier, ed. by Peter M. Elias and Kenneth R. Feingold (New York: Taylor Francis, 2006), pp. 5-14.

9) CIR publication (1983), “Final Report on the Safety Assessment of Sodium Lauryl Sulfate and Ammonium Lauryl Sulfate”, International Journal of Toxicology 2 (7): 127–181.

26

ceramides

a wide range of non-surgical treatments.

Financial disclosures: Medical director at Eden Aesthetics.

Distributors of Epionce / Agera skincare, and Colorescience mineral makeup.

Dermagenesis microdermabrasion and Dermafrac microneedling @drmervpatterson

10) Marrakchi S, Maibach HI (2006). “Sodium lauryl sulfate-induced irritation in the human face: regional and age-related differences”. Skin Pharmacol Physiol 19 (3): 177–80.

11) Peter M. Elias and Kenneth R. Feingold, ‘Does the tail wag the dog?’, Archives of Dermatology, 137 (2001), 1079-81.

12) C.R. Thornfeldt, M. MaoQing, Peter M. Elias et al, ‘Optimisation of physiological lipid mixtures for barrier repair’, J Invest Dermatol, (1996), 1090-1101.

13) Renewal Facial Cream Reduces Signs of Photoaging (2014) <http://www.epionce. com/wp-content/uploads/2011/09/2_ClinicalStudy_RenewalPhotoaging.pdf >

Aesthetics | March 2014

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Clinical Practice Techniques

aestheticsjournal.com

8-point lift: achieving the liquid face lift Miss Jonquille Chantrey on the benefits of Allergan’s new 8-point lift technique in achieving a comprehensive, whole-face approach to facial rejuvenation Miss Jonquille Chantrey is a highlyexperienced surgeon and well-respected figure in cosmetic medicine and minimally invasive cosmetic surgery.

She regularly presents at plastic surgery conferences throughout the world and has published scientific articles in peer-reviewed journals, including The Lancet. Miss Chantrey has her own practice in Cheshire.

As an industry, we are continuing to move away from ‘chasing the wrinkle’ and more towards treatments and techniques that incorporate a whole-face approach, with increasing prominence given to flexible and well-considered strategies.

Facial volume loss contributes significantly to facial ageing, typically occurring in the malar region, temples, infra-orbital and mandibular areas, resulting in dark shadows that give the face a tired and drawn appearance. Over the past five years we have primarily treated the midface, both supporting the peri-orbital region and lifting the perioral region, 28

to treat the changes in the facial fat compartments. In doing so, there have been many techniques whereby large boluses of products have been placed in the anterior malar and zygomatic areas. This can create inappropriate projection and volume, resulting in an unnatural-looking result, both in repose and animation, when patients speak and smile. Other side effects of large bolus techniques may also include the formation of biofilms.

For some time, many practitioners have been considering and utilising techniques in which we can use minimal amount of product – with specific placements in certain areas – in order to achieve the maximum amount of lift for the patient with a more natural outcome. This has now been stratified into eight points: the key lifting areas of the face.

The 8-point lift was originally devised by Dr Mauricio De Maio, a plastic surgeon from Brazil, and I was one of the first physicians in the UK to be trained by him on this signature technique. Small adjustments are made Aesthetics | March 2014

in eight areas of the face to achieve an overall lifting effect, with the ethos being to treat minimally and precisely, looking beyond individual zones of concern to the definitive causes of the signs of ageing, which is often fat and bone resorption in predictable parts of the face.

The technique utilises the Juvéderm Vycross collection of non-permanent HA dermal fillers. These hyaluronic acid dermal fillers each work in specific ways to volumise and give structure to the face: Juvéderm Voluma is injected deeply, lifting and restoring volume; Juvéderm Volbella has a water-like consistency and is suitable for the delicate peri-orbital area, as well as the area around the lip; Juvéderm Volift works to treat mediumdeep depressions.

My personal preference with my patients is to use both needle and cannula for a full-face treatment. The aim of the 8-point lift is to support the infra-orbital areas, lift the mid-face, nasolabial fold, oral commissure and help to improve the jawline. It also helps to give more contour and appropriate fullness through the malar, parotid and buccal areas.

In terms of patient selection, the 8-point approach has a lot of versatility. It is a technique appropriate for the young patient, perhaps in his or her 30s, who might do a lot of physical training or who has had large weight fluctuations due to dieting, and has experienced significant fat loss shifts to their superficial fat compartments. Other indications may be post-pregnancy facial changes or illness.

This technique addresses the variations that can give the face a tired appearance, despite a relatively young age of patient.

The technique is also appropriate for patients 10 to 20 years older. These patients will notice further signs of facial ageing and descent within the face, accompanied by a development of the pre-jowl sulcus and an early loss of the mandibular line.

I have successfully used the 8-point lift technique to treat patients in their 70s and 80s, who have advanced volumetric changes and descent, with excellent results showing a pleasing lift.

This approach is effective for both male and female patients. Needless to say, the proportions of a male face are very different to the proportions of a female face. As long as that is respected then the 8-point lift is absolutely appropriate for both genders.

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Clinical Practice Techniques

aestheticsjournal.com The positions of the 8-point lift are as follows:

1

3

2 8

4

7 5 6

THE NO-GO AREAS

Images © Dr Mauricio De Maio before

after

before

after

Patient images © Miss Jonquille Chantrey

• The first point is the junction between the cheek and the temple. It is a very specific point and treated with a deep placement of Juvederm Voluma onto the zygomatic bone, usually 0.1-0.2mL. This can help to lift the zygomatic area and restore it’s youthful curve, whilst also correcting the lid-cheek junction.

• Point number two is a beautification point, positioned over the anterior aspect of the zygomatic bone. Here I would use a further 0.1-0.2mL. This also helps to support the outer aspect of the infra-orbital region and lift the mid face.

• Point number three is a point in the anterior malar area, within the cheek. The deep malar fat is injected in this position, so that it acts as an anchor point to fix the face superiorly. Placement of 0.3mL of Juvederm Voluma or Volift in this position helps to support the tear trough, correct the palpebral-malar groove and can lift the nasolabial fold.

• For point number four, I would switch to a lighter product such as Volift in order to minimise any external vascular compression and inject a small amount of this into the canine fossa. Between 0.2-0.3mL may be sufficient to lift the rest of the nasolabial fold.

• Point number five is the oral commissure. Here, I would also use 0.1mL Volift intradermally, which helps to give the oral commissure a more supported horizontal position.

• Point number six is the pre-jowl sulcus. This is the area that female patients in particular can experience early mandibular recession and is also important for patients who exhibit retrognathia. Treating this point delivers more support to the chin, and gives better definition. This is a point where I use a cannula to simultaneously support the prejowl sulcus, marionette line and deeper element of the oral commisure. My product of choice is commonly Voluma and 0.5mL can produce excellent contouring.

• Point number seven varies between a male and a female. In a male, this is the definition of the mandibular angle, resulting in a square appearance to the jaw. In a woman, it may be desirable to give gentle mandibular definition, but certainly not overly project it, as this can masculinise a female face. The position where I tend to put point number seven is higher than the mandibular angle, usually approximately 2cm above, which gives a nice lift to the posterior aspect of the face. The important point to note about this point is that it needs to be very superficial in its placement. If injected deep in this area then risks could include a parotid cyst or facial nerve injury. Juvederm Voluma or Volift can be used in this area; product volume varies from 0.05mL to 0.3mL for enhanced definition.

• Finally, I like to think of point number eight as a superficial zone. This tends to run from the pre-auricular area, across the parotid and then into the sub-malar and buccal areas. By treating this zone, not only can volume deficit and hollowing be treated appropriately, but a subtle lift of the buccal or jowl fat can be achieved. I always use a cannula here, gently in the subdermal plane, above the parotid fascia. This helps to minimise the risk of facial nerve, facial artery and parotid duct damage. Quantities used for this zone may be approximately 0.3mL to 0.6mL. In patients that have significant solar elastosis or weakness to the skin I would use Volift not Voluma. This area then requires massage immediately post-treatment.

In points one to five I use a needle to administer the treatment, but it is important to note that you can also achieve additional improvements by using cannulas in these points, by revisiting points two and three. I return to these areas and treat them superficially with vectoring. I generally use a many vectoring techniques in my cannula work and so I incorporate this into the 8-point lift.

I don’t use all eight points in every patient. In many patients, for instance if they’re young or they have very good preservation of their facial fat compartments, then I may only treat point one and point two. Similarly, I may only use points one, two and three in a patient whose face has a tired expression. With other patients who might be financially limited we can use points one, two and eight to give a lifting effect. This technique is about precise and specific positioning and placing of the product, focusing on the cause of the descent, rather than just treating the effects of it.

Communication is an essential part of the 8-Point Lift. Patients 30

must understand that if small initial quantities are used, then they may require several appointments to achieve the desired result. In the initial one-hour assessment, I consult the patient to understand what they’re trying to achieve and also discuss in detail the causes of the changes in their face. We then agree a strategy as to how quickly or slowly they want to progress.

One of the advantages of this method is that the result is buildable, depending upon the expectations of the patient.

In my experience, this approach results in a very high patient satisfaction rate and predictable, beautiful outcomes.

Aesthetics | March 2014

Advertorial Boston Medical Group (BMG) Ltd

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Revanesse and Redexis HA dermal fillers: the practitioners’ choice Boston Medical Group (BMG) Ltd. presents Prollenium Medical Technologies, Canada and explains why more clinicians are opting for their products Established in 2007 with the goal of providing exceptional aesthetic products within the UK and Ireland, Boston Medical Group (BMG) distributes mainly to aesthetic practices. BMG prides itself on only selecting the most effective product ranges, research-based with proven results and keeping up-to-date with advances in the aesthetic world with their top quality training programmes. BMG’s extensive product range includes Revanesse and Redexis dermal fillers, and Dermal Roller SR - all manufactured by Prollenium Medical Technologies. In addition to this, they also offer SR Serum for skin rejuvenation and cellulite, HL serum for hair loss, Viscoderm hyaluronic acid, Phiderma cosmeceuticals and CNC equipment. The Revanesse range is composed of six hyaluronic acid (HA) dermal fillers, all of which suit a different purpose whether it be for treating deep lines and wrinkles, achieving fuller lips, volumetric filling or improving hydration. The great thing about HAbased fillers such as Revanesse is that they are biodegradable and non-animal based, therefore safe for all skin types.

Both Revanesse and Redexis incorporate a unique formula and patented Thixofix cross-linking technology, which maximises the effectiveness of the cross-linked HA chains in the gel and makes the product safe and long-lasting. As a result, a homogenous highly viscous gel with smaller, uniform particles is created, allowing it to be easily injected through a fine gauge needle without causing degradation to the modified HA particles - setting it apart from other HA-based fillers.

The manufacturer of the Revanesse range, Prollenium Medical Technologies based in Ontario, is the first and only manufacturer of dermal fillers in Canada. The company undertake the whole formulation process in-house including syringe-

filling, sterilisation, testing and packaging. Their on-site R&D department means they are constantly researching new advances in aesthetics to improve their range and stay ahead of their competitors. With integrity and trust at the heart of what they do, Prollenium’s in-house nature lends transparency to the brand and distributors can see exactly where the products come from – a welcome idea following recent events in the industry such as the PIP scandal. This traceability is one of the reasons many practitioners have opted to use the range. Malti O’Mahony, medical director at popular London clinic Harley Street Treatments Ltd., said, “The products are an ideal choice for me due to the safety and easy traceability to the manufacturer in Canada.”

The Revanesse range is becoming increasingly popular with medical practitioners across the UK and Ireland, receiving high acclaim due to its variety and quality. Dentist Dr. I. Mian at Chinbrook Medical Ltd., said, “Revanesse seems to tick all the boxes. The portfolio range can be used for different depths and indications and you do not need to overcorrect. While the filler slowly degrades over time, it does not result in complete loss of volume, and tends to maintain its integrity whilst it degrades.” Others have noticed the numerous benefits in comparison to other dermal fillers on the market. “I have incorporated Revanesse into my every day practice as it offers advantages in ease of injection, volume enhancement and smoothness of results,” said nurse practitioner Elena Korshunova. “I have also found it to be very good for use in the lips, as it is soft, does not cause more severe or prolonged swelling than other HA products and once it is settled, the results look very natural, rather than the persistent ‘rubberiness’ seen with other longer-lasting HA fillers. Patient satisfaction is high.”

Malti O’Mahony agrees that the product range has produced high patient satisfaction and little swelling. “The product is extremely well-tolerated by my patients,” she said. “I am especially pleased with Revanesse Kiss due to its ease of application, minimal swelling and longevity. The Revanesse range is extremely well-tolerated and is now the most popular choice amongst my patients.”

Dr. Khan, medical director at the London-based Beauty Spot Ltd., added, “I have recently been introduced to the Revanesse range, and I am very happy with the results. I will continue to use this product range.”

Recent additions to BMG’s growing product range include the Lidocaine range, Revanesse Contour for facial volumising and chemical peels – the perfect solution for medical practitioners who want to purchase their products from one reputable and well-tested source. Prollenium may be a relatively small company compared to well-known industry brands, but with a strong research and development department that is always at the cutting edge of aesthetic advances, they are fast establishing themselves as a name to trust.

Want to learn more about any of the products from the Prollenium range?

BMG offers free product training in their purpose-built premises in London’s Bayswater area. Visit the Boston Medical Group at stand 5 at this year’s Aesthetics Conference and Exhibition (ACE) 2014 and see Revanesse Ultra, Revanesse Ultra Lidocaine and Revanesse Contour in use at their ‘Facial Volumising and Shaping’ workshop on Sunday March 9 at 2pm.

Boston Medical Group Ltd - Tel: +44 (0) 207 727 1110 info@boston-medical-group.co.uk - www.boston-medical-group.co.uk Aesthetics | March 2014

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Clinical Practice Clinical Focus

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Why Emervel Lips?

Dr Beatriz Molina shares her technique when using Emervel to treat the lip and perioral area Lip treatments are a particular favourite of mine.

Treatments of this area can have a big impact, and make a substantial difference to patient selfconfidence. My choice of product when treating the lip and peri-oral area is Emervel Lips hyaluronic acid (HA) dermal filler. The Emervel Range offers an optimal balance between cross-linking and gel calibration, creating four degrees of cross-linking (resistance to deformation) and three degrees of calibration (lifting capacity). This optimal balance therefore provides (1) the broadest spectrum of distinctive soft textures and (2) the optimal match to the tissue type at each injection site. In a recent FRESH study, 85.7–100% of patients injected with products from the Emervel range for lips, upper lip lines, nasolabial folds and marionette lines, said they would like to be injected with the same product again. Scores ranged from 85.7% for Emervel Lips to 100% for Emervel Classic (upper lip lines). The versatility of Emervel Lips allows practitioners to treat vermillion border, body of the lip and upper lip lines with only one syringe.

TECHNIQUES: When treating the lip I divide treatments, depending on which areas my patient and I have agreed to treat. I look specifically at the following factors: amount of volume loss or enhancement for lip, symmetry and treating only vermillion border and/or also perioral area. All of this will influence treatment technique (layering, crosshatching, linear threading) depth of injections, and tools (sharp needle or blunt needle (cannula). For quick lip volumising treatments, or just for lip definition, I use needles. The needle is versatile, and creates great definition within the vermillion border and volumes the body of the lip well. Emervel Lips has 0.3ml lidocaine and injects easily through a 30G needle so comfort for the patient is optimised. However, if I am treating the peri-oral area as a whole I prefer using a 25G cannula, as I feel it is less traumatic for patients and can treat a wider expanse. I believe that when treating the lips it is essential to take the whole perioral area into account and to assess patients’ balance and asymmetry, not only face-on, but also from in profile. Normally I begin with two small injections of lidocaine in the chosen access point, which will vary depending on the area of treatment. I then use the 23G needle to puncture the skin to allow easy penetration of my 25G cannula. It can be challenging when a patient has a 32

Needle treatment using Emervel Lips:

Cannula treatment using Emervel Lips:

1

First 2 small injections of lidocaine 2%.

2

Second do your access point with a 23G needle.

Third I would normally use a 25G 2” cannula (you may also use a 27G) and do a fanning retrograde technique which allows me to treat upper and lower perioral lines as vermillion border and commisures of the mouth from one access point. You may even want to treat nasolabial folds and marionette if indicated from the same access point.

3

noticeable amount of volume loss in mid-face, presenting heavy jowls and deep naso-labials creating deep mouth commissure lines, but only wants a lip treatment with one syringe of product. In these cases I will limit my treatment to just the lip and upper lip lines. The versatility of Emervel Lips means that you can provide an impactful treatment with noticeable improvement. However, I would always recommend a full treatment to the mid-face first, making the overall result much more balanced.

Another challenge is uneven lips and uneven smile. Always ensure you take a range of patient photos at rest, smile and profile. Uneven smiles will normally require a combination of botulinum toxin (BontA) and filler. I prefer to treat with BontA first two to four weeks prior to balance the smile before defining with Emervel Lips filler.

In summary, the key to a successful treatment is: • The initial assessment • A technique that suits you • Keeping facial features in balance and in keeping with age • Making small tweaks and improvements to create a huge difference Assessing the face as a whole is the most effective approach and will always deliver best results. You have one opportunity; if a patient is not impressed on their first visit, it is likely that the initial assessment and consultation of needs was incorrect.

Dr Beatriz Molina is a member of the British College of Aesthetic Medicine (BCAM). She practised general medicine in Somerset for 12 years, before opening her first practice, the Medikas MediSpa Clinic. She now practises full time as a cosmetic doctor whilst also teaching beginners and advanced techniques in botulinum toxin and dermal fillers.

FURTHER READING: 1) Cartier, H., et al., ‘Perioral rejuvenation with a range of customized hyaluronic acid fillers: efficacy and safety over six months with a specific focus on the lips’, J Drugs Dermatol, 11(2012) (1 Suppl), 17-26 2) Kestemont, P., et al., ‘Sustained efficacy and high patient satisfaction after cheek enhancement with a new hyaluronic acid dermal filler’, J Drugs Dermatol, 11(2012)(1 Suppl), 9-16 3) Rzany, B., et al., ‘Correction of tear troughs and periorbital lines with a range of customized hyaluronic acid fillers’, J Drugs Dermatol, 11(2012) (1 Suppl), 27-34 4) Segura, S. et al., ‘A complete range of hyaluronic acid filler with distinctive physical properties specifically designed for optimal tissue adaptations’ J Drugs Dermatol, 11 (2012) (1 Suppl), 5-8

Aesthetics | March 2014

Distinctive Technology - Optimal Balance TechnologyTM offers a variety of calibration and cross-linking levels around a fixed HA concentration of 20mg/ml for safety and longevity Long Lasting - 92.1% of participants remained improved at month 6 vs. baseline1 High Patient Satisfaction - Across the range, 92%* of patients would like to have Emervel again2

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Proven - Clinical studies demonstrate great efficacy and patient comfort with Emervel1,2,3

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EME/021/1013 Date of prep: October 2013

References 1. Rzany B et al, Dermatol Surg 2012;38: 1153â&#x20AC;&#x201C;1161 2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26 (*Results taken from a mean value across all treatments performed in study) 3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93

Clinical Practice Techniques

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Dr Askari Townshend explains the technique of using needles to deliver Sculptra

Using Sculptra with needles In last month’s issue, the benefits of using cannulae by means of a new technique were discussed.

In this article, I explain the advantages and mechanisms of the needle technique to deliver Sculptra.

stay still to avoid traumatising surrounding structures. Immediate post-injection massage is also essential to ensure good spread of the product and an even aesthetic result.

PREPARATION Sculptra is a powder that must be carefully reconstituted with water (I use 7mls) at least 24 hours before use though I strongly recommend no less than three days. Injection of clumps of product risks nodule formation and blockage of your needle. 2mls of 2% lidocaine is added just before treatment, which provides patient comfort during the treatment (some practitioners also like to apply topical anaesthetic beforehand). Ensure that you have a sterile field for your equipment including a plastic reservoir for chlorhexidine. Use it to clean the face thoroughly before you start and before every injection.

TREATMENT AREAS Sculptra should not be used in boney areas with little fatty covering e.g. forehead and nose. The lip vermillion, top lip and modiolus (just under 1cm inferiolateral from the oral commissure) should also be avoided. As with fillers, always start with the most superior area and work your way inferiorly as the volumisation up high will change the requirements of the areas lower down.

EQUIPMENT AND TECHNIQUE Cannulae are useful for fanning under large areas of skin minimising the number of needle punctures and reducing the chance of bruising. However, for those of you not familiar with cannulae, needles are cheaper, easier to use and still achieve great results.

Many use brown 26G x 0.5inch Terumo needles (Microlance seem to block more often) but you should also consider the orange 25G x 1.5inch size (of either brand). This much longer needle allows fanning (similar to a cannula) in the sub-dermal plane.

Most use a 1ml luer lock syringe but I prefer to use a 2.5/3ml slip lock syringe. If you are pushing so hard that the needle comes away, take this as a warning that if you feel resistance to your injection, then stop. Never inject against great resistance. Excellent aspiration technique is important for all aesthetic facial injections, regardless of the treatment, but is essential with Sculptra as the volumes injected in depots are larger. Ensure that the needle tip is not moved during aspiration and that it maintains the same position when injecting. Attention to detail in this will also be important if your needle becomes blocked. When pulling the plunger to and fro, the needle tip should 34

TEMPLE Often, only two depot injections are required of up to 1.5mls each. These should be near perpendicular to the skin and pass through both layers of fascia to the periosteum.

Know your anatomy and avoid the superficial temporal artery and its branches as well as any visible superficial veins.

1

2

3

1. Before 2. After first session 3. After month 7 from first injection

ZYGOMATIC ARCH This can be treated in two ways – over the top of the arch with the 1.5inch needle via a deep retrograde injection (as you might do with a heavy filler), or by a series of deep injections just underneath it. A total of 2mls can be used here, which provides volume from deep within, helping lift the skin of the lower face.

MID-CHEEK My personal feeling is that the area most commonly needing volumisation is over the infra-orbital foramen. Be respectful of the neurovascular bundle that exits here though it is deep and has a fibrous covering. I use one finger to push up fat from lower down to create a buffer and ensure that my needle doesn’t reach the periosteum. If you are anxious about damaging the bundle, aim a little lateral.

I place boli of up to 1.5mls from medial to lateral without removing my needle completely. Only change the direction of your needle once you have withdrawn almost all of it.

Aesthetics | March 2014

aestheticsjournal.com ALAR TRIANGLE This single 45° injection, 5mm from the nasal alar pointing medially, is sensitive but very straightforward. Pull the nose anterially as you enter to move the angular artery out of the way and deposit up to 1ml.

PAROTID AND BUCCAL AREAS If hollow, filling this area can make the masseter less prominent and improve the jawline and jowls. Beware those with masseter hypertrophy and/or round faces: this is where the longer 1.5inch needle is ideal. Stay above the parotid fascia and don’t stray towards the superficial temporal artery. Fan the area and consider using gentle aterograde injection. Hydrodissection is the idea; I’m uncertain how much of a difference this makes but in my opinion it won’t do any harm. You can easily use 2mls here.

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MARIONETTE AND CHIN Marionette areas are treated with a vertical injection from the underside of the chin keeping deep and parallel with the ramus of the mandible. Like the mid-cheek, place more than one bolus, only moving the angle of injection once you have withdrawn the needle almost fully. The mental crease can be treated with a deep retrograde injection.

SKIN TEXTURE IMPROVEMENT As long as you keep to the rules set out above, you can fan almost any area of skin that needs improvement such as thin, crepey, sun-damaged skin or acne scarring. Ensure that you do not leave any boli here; leave a thin lake of Sculptra across the whole area and massage well.

AFTER CARE Although you will have massaged after every injection, perform a thorough massage at the end of the treatment. One big difference with Sculptra treatment is that the patient must massage the treated areas at home. The European consensus is for five minutes twice a day for one week. There are benefits to facial massage and so I ask my clients to massage until they see me next, usually six weeks later. You cannot massage too much, but you can certainly do it too little.

In summary, needles can be used to deliver Sculptra to various treatment areas allowing for a diverse alternative to cannulae.

Whilst cannulae reduce the number of needle punctures and chance of bruising, needles are cheaper, quicker and easier to use with different lengths and styles available to target different problem areas.

Dr Askari Townshend qualified as a doctor in 2002 and was awarded MRCS in 2006. Already with several years of injectable experience, Dr Askari opened his own clinic in 2008. Having been approached by sk:n in 2010, he sold the clinic and held the position of Director of Medical Services there until 2013. His interests include injectables, lasers, and peels. Dr Askari is an international Sculptra trainer as well as lead UK Sculptra trainer for Sinclair Pharma. In addition, he is the UK medical consultant providing support for Sculptra practitioners.

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Clinical Practice Spotlight On

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Pigmentation is the new wrinkle We discuss SkinCeuticals’ newest addition to its skincare line, Advanced Pigment Corrector Today, over half of women aged between 35 and 59 cite discolouration and uneven skin tone as a more significant skin concern than loss of firmness. Dermatologist Dr Patricia Ogilvie has gone so far as to say that “Pigmentation is the new wrinkle.” While pigment problems can occur for hormonal reasons, due to post-inflammatory hyper-pigmentation, and because of environmental inflammation, UV exposure is the primary cause. Many women experienced excessive UV exposure in a time before high SPF creams were widely available, or indeed, before there was any popular understanding of the long-term risks of tanning. As they age, these women are now seeing unwanted pigmentation appear and are increasingly seeking out treatment from aesthetic doctors and dermatologists for the problem. Advanced Pigment Corrector is now offered as a new topical treatment.

THE SCIENCE OF SKIN TONE Jim Krol, SkinCeuticals head of Scientific Affairs, explains that the concept behind Advanced Pigment Corrector was to take a cocktail approach to address pigmentation in all layers of the skin. “No other treatment does this,” he says. This meant it had to interrupt melanin stimulation of the melanocytes, block production of melanin, and prevent transfer to keratinocytes, plus it would help exfoliate existing dark marks from the skin surface. And the aim was to achieve this with a topical cream that was pleasant to use, would fit into a simple skincare routine and would be non-irritating.

Research presented at the World Congress of Dermatology in Seoul, Korea, found that photoaged fibroblasts produce melanogenic growth factors that promote excess pigment production, leading to both new and recurring pigmentation.

By strengthening fibroblasts, the expression of these growth factors are downregulated, making skin more resistant to pigmentation.

Skinceuticals’ Advanced Pigment Corrector contains 5% yeast extract, which strengthens the dermal fibroblasts to enhance skin resistance to newly forming pigment, and contains ellagic acid to inhibit the production of melanin,

stimulating tyrosinase in the melanocytes at the basal layer. Ellagic acid has been shown to be as effective as 4% hydroquinone at reducing the appearance of dark spots and hyperpigmentation. It also contains hydroxyphenoxy propionic acid, a non-toxic derivative of hydroquinone, to reduce melanin transfer to skin cells in all the layers of the skin. Hydroxyphenoxy propionic acid has been shown to be as effective as 2% kojic acid at reducing discolouration. The formula also includes 0.3% salicylic acid to enhance exfoliation of dark spots at the skin surface and enhance penetration of the active ingredients.

As they age, these women are now seeing unwanted pigmentation appear and are increasingly seeking out treatment from aesthetic doctors and dermatologists for the problem RESULTS In a 12-week, multi-ethnic clinical trial, Advanced Pigment Corrector was found to improve hyperpigmentation by an average of 15%, dark spots by nearly 20%, and radiance by 20%.

Jim Krol says, “No patients failed to respond and there was up to a 90% improvement in some cases. Indeed, the results matched those of the gold standard treatment of 4% hydroquinone plus 0.025% tretinoin, with the treatment performing better on skin tone clarity, radiance and evenness.” Cosmetic doctor Dr Tapan Patel says, “Tretinoin, though invaluable to dermatologists, can be too irritating for some patients, and we do not recommend it for daytime use. Advanced Pigment Corrector can be used day and night.

Hydroquinone may also be problematic. It can cause irritation, plus it can bleach skin to a lighter colour than the natural skin tone, which is impossible with the ingredients in Advanced Pigment Corrector.” Krol adds, “We saw no side effects in our studies. No subject discontinued the study because of redness or peeling and we had 95% compliance in the study.” The treatment can safely be combined with other skincare products and medical treatments, such as laser and IPL. Study participants used Advanced Pigment Corrector alone, with only Skinceuticals Gentle Cleanser and SkinCeuticals Physical UV Defense SPF30, which offered visible results, but these may be boosted further by adding an anti-oxidant serum before applying Advanced Pigment corrector by day, and, for severe discolouration, adding retinol 0.3% at night. As with all treatments for pigmentation, a broadspectrum sunscreen is essential to achieve and maintain results.

Krol says, “We launched Advanced Pigment Corrector in the US in September where it was very successful. It has addressed a huge unmet need for an effective product that is easy to use. The new big trend in aesthetic dermatology is to offer home care with in-office treatments. We believe this can help build patient loyalty and compliance. When patients see the results and are invested in them, they are more likely to stick with their treatment programme and to try new treatments. When they see results, they want to achieve more.”

Aesthetics | March 2014

37

Clinical Practice Clinical Study

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Clinical Experience using the 1440nm Wavelength with SideLaze800 Delivery System for Facial Contouring Gordon H. Sasaki, MD, FACS Professor, Loma Linda Medical University Center Private Practice: Pasadena, California USA Introduction The purpose of this white paper is to report the early experience with the 1440nm wavelength in combination with the SideLaze800 delivery system, including a side-firing fibre for facial contouring, primarily to the lower third of the mid-face and neck.

The recent implementation of the 1440nm Neodymium YAG wavelength laser (Cynosure, Inc., Westford, MA), provides tissue rejuvenation in areas such as the face.1-3 The longer 1440nm wavelength provides increased and localised photothermal and photomechanical (microbubbling) effects on fatty tissue and collagen fibres (water), achieving 20 times more absorption in adipose tissue than the 1064nm/1320nm—and 40 times more absorption than 924nm/980nm wavelengths.4 Laser Delivery System The SideLaze800 delivery system allows for use of a 1440nm wavelength through a fibre protruding 2mm from the tip of a 2mm microcannula, delivering energy in a bidirectional manner. In this report, the 1440nm wavelength was selected for laser lipolysis and shallow heating of collagen fibres (water) within the dermis and septae. An accelerometer (SmartSense), a motion-sensing device, was attached to the laser handpiece. This prevents excessive thermal deposition by regulating uniform energy delivery to the treated tissues. To control tissue heating, two additional systems were employed alongside SmartSense to monitor and regulate realtime temperatures during bilayered treatments. First, the Before

After

ThermaGuide system recorded subdermal temperature changes with a temperature sensor located at the tip of the cannula. It was set to an alarm temperature of 47°C, which reflected a superficial skin temperature of between 40-42°C, optimal for collagen denaturation. It also later delayed tissue tightening.1-3 When the local temperature reading exceeded the limit, the laser system would stop, resuming again when the temperature decreased below 47°C, or when the laser fibre was moved to cooler temperature areas. Second, an infrared thermal camera (FLIR ThermCAM E45, Niceville, Florida) was used to obtain continuous skin temperatures between 40-42°C and ensure a uniform, realtime delivery of heat via a depiction of a confluent orange-red colouration within each treatment site.

38

Before

After

Clinical Protocol Patients with isolated accumulation of fat to the lower third of the face and neck and mild to moderate tissue laxity were selected for laser lipolysis and tissue tightening1-3 with the 1440nm wavelength, utilising the SideLaze800 delivery system. The procedure was recommended in patients without strong and apparent vertical platysmal bands. Patient exclusion criteria included pregnancy, uncontrolled diabetes mellitus, collagen disorders, significant cardiovascular diseases, bleeding disorders, smokers, and those having previous surgical procedures to the current treatment sites within a year. All subjects were consented for their office procedures under local anaesthesia treatments. Subjective aesthetic assessments included the Global Aesthetic Improvement Scale and a patient satisfaction questionnaire at the third and sixth month follow-up period. After pre-operative, standardised digital photography, treatment sites were marked into one 5x5cm square, lateral to each marionette line, and into three 5x5cm squares across the entire neck. Subjects received oral premedication and skin preparation with povidineiodine (Betadine) washes. Tumescent solution, consisting of 500mg lidocaine, 1mg epinephrine, and 20ml 8.4% sodium bicarbonate per litre of normal saline, was infiltrated into the deep and superficial subcutaneous fat layers. Lasing began about 20 minutes later to allow for diffusion of tumescent infiltrate and maximum vasoconstriction through two incisions, ‹1cm postlobular and ‹1cm submental. Laser energy was delivered within the deep subcutaneous fat in each square. Then, liposuction with a 1.2mm cannula to the lower third of the face or with a 3.2mm flat cannula to the neck removed the liquefied fat and tissue debris under a vacuum pressure of 450500mm Hg. Thirdly, shallow subdermal treatment distributed laser energy in each square, achieving the targeted skin temperature of between 40-42°C. Temporary quarter inch penrose drains were inserted into each post-lobule incision site and removed within 24 hours. Compression garments with sponge inserts were applied for 7-10 days, after which a series of weekly external ultrasound treatments were administered to reduce irregularities and swelling.

Results Between September 2010 and May 2011, 12 consecutive patients (two men, ten women; 41-74 years old, mean age 53.3) were indicated for laser lipolysis and improvement in fat contour and tissue tightening at jowl and neck regions.1-3. The mean pretreatment weight was 78.8 kg (range 46.6-103.6 kg) with a mean body mass index of 29.5 (range 20.5-36.9). At the third and sixth-month evaluation period, there was no significant change in the baseline weights and body mass indices. An average of 200ml of tumescent solution (range 125-280) was infiltrated into the deep and superficial subcutaneous layers within the lower third of the face and the entire neck. This total volume was equal to about 3050ml within each 5x5cm square. Within the deep subcutaneous fat in each square, the delivered energy ranged from 6-10 watts at

Aesthetics | March 2014

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Clinical Practice Clinical Study

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25 Hz, averaging 695 joules per 5x5cm square (range 500-1044 joules per 5x5 cm square). The endpoints of treatment were determined when: (1) the average number of joules was between 500-700 per square, (2) the ThermaGuide temperature consistently measured around 47°C whereas skin temperatures measured between 38-42°C, and (3) there was increased ease of passing the firing laser fibre through the tissues. Depending on preoperative findings, liposuction removed between 50-125ml aspirate, of which about 55% per volume consisted of fat. Shallow subdermal heating distributed an average of 285 joules per 5x5cm square (range 250-400 joules per 5x5cm square) at 1-5mm below the dermis. The total average joules (deep and superficial) delivered per patient was roughly 5565 joules, which translated to about 1030 joules per 5x5 cm square.

Because elevated skin temperatures returned to baseline levels within two to five minutes after termination of shallow lasing, the skin was re-challenged with additional lasing to temperatures between 38-42°C for possible increased tissue tightening through tissue coagulation1-3, based on clinical findings. The quarter inch penrose drains were removed within 24 hours to facilitate drainage of residual fluids. The surgical time averaged about one hour (range 45-75 minutes), with postoperative recovery less than an hour. Compression garments were worn for another 10 days to prevent any incidence of seroma formation.

Conclusion The incorporation of the 1440nm wavelength delivered through a side-firing fibre, SideLaze800, achieved effective laser lipolysis and tissue tightening through coagulation for facial contouring in 12 patients who presented fat accumulation in the lower third of the face and neck. Most of these patients exhibited moderate degrees of tissue laxity and sagging. Photographic analyses and positive responses from Global Aesthetic Improvement Scale indicated that the 1440nm wavelength achieved high thermal absorption within fat and collagen (water), which led to laser-assisted lipolysis and collagen denaturation, and progressive tissue tightening* by three to six months. The combination of the 1440 nm wavelength, SideLaze800 side-firing fibre, and the thermal-control systems provided a safer and more effective means for facial contouring. Further studies are needed to validate these initial findings.

Outcomes And Side Effects Patients were very satisfied with their results, especially regarding the definition of their mandibular-neck outlines with reduction of the pre-jowls and submental fullness. The incidence of bruising and swelling was low and resolved completely within two weeks. No patients developed hematomas, sensory or motor nerve injuries, striations, blisters or dyschromias after dual layers of treatment. Three patients developed small fibrous nodules within the subcutaneous fat in the neck, which resolved within six weeks with post-operative ultrasound treatments.

Post-operative discomfort was mild to moderate, with patients using analgesic products such as extra-strength acetaminophen or lowest doses of hydrocodone/ acetaminophen. Most patients were able to resume their levels of pre-surgical activities within two weeks. There were no unanticipated significant adverse events. Patients experienced about an 80% improvement by three months, with progressive tissue tightening* and contouring thereafter until six months.

Patients were asked to evaluate their overall satisfaction at three and six months after treatment on a five-point scale (0, worse; 1, no change; 2, mild; 3, moderate; 4, excellent). The mean score at three months was 2.5 with improvements in fat reduction and tissue laxity. The mean score at six months increased to 3.5 with continued progressive definition through tissue tightening. Ultrasound imaging and measurements from one patient taken pre and three months post SideLaze800 treatment, represented intensity change of the dermis with enhanced collagen depositions from 1.40mm pre to 1.81mm three months posttreatment. This represents an increase in skin thickness of 29%. All patients said they would recommend the procedure to others.

REFERENCES

Discussion Using the side-firing 1440nm wavelength produces selective fat destruction and collagen denaturation in septal and dermal structures for eventual tightening through coagulation.5 A Monte Carlo simulation study6 with three different wavelengths (1064nm, 1320nm, and 1440nm) demonstrated that the 1440nm wavelength produced the highest fat and dermal tissue ablation efficiency, with minimal localisation of heat over depth. A recent study5 on the acute and delayed histological changes after 1440nm, 1320nm and 1064nm wavelength exposures in the deep and superficial layers in human abdominal tissue, confirmed the Monte Carlo simulation observations. The present clinical experience demonstrated persistence of clinical benefits at six months in all patients by objective and subjective analyses. Adverse events were limited to transient swelling and bruising, the severity of which was mild and completely resolved by two to three weeks. Treatment burns were not observed because the internal and skin temperatures were monitored in real time.

40

Aesthetics | March 2014

1. Gordon H. Sasaki and Ana Tevez, ‘Laser-Assisted Liposuction for Facial and Body Contouring and Tissue Tightening: a 2 Year Experience with 75 Consecutive Patients’, Seminars in Cutaneous Medicine and Surgery, 28(4) (2009), 226-235.

2. Gordon H. Sasaki, ‘Quantification of Human Abdominal Skin Tightening and After Component Treatments with 1064nm/1320nm Laser-Assisted Lipolysis: Clinical Implications’, Aesthetic Surgery Journal/The American Society for Aesthetic Plastic Surgery, 30(2) (2010), 239-245.

3. Gordon H. Sasaki, ‘The Significance of Shallow Thermal Effects from 1064/1320nm Laser on Collagenous Fibrous Septae and Reticular Dermis: Implications for Remodeling and Skin Tightening’ (unpublished White Paper, Loma Linda Medical University Center Private Practice, 2009) 4. Francis A. Duck, Physical Properties of Tissue (San Diego: Academic Press, 1990), pp. 320 -328.

5. Gordon H. Sasaki, Ana Tevez and Marcella Gonzales, ‘Histological Changes after 1440nm, 1320nm and 1064nm Wavelength Exposures in the Deep and Superficial Layers of Human Abdominal Tissue: Acute and Delayed Findings’ (unpublished White Paper, Loma Linda Medical University Center Private Practice, 2010) 6. J. I. Youn, ‘Ablation Efficiency Measurements for LaserAssisted Lipolysis Using Optical Coherence Tomography’ (unpublished White Paper, Lutronic Corporation, 2009)

Gordon H. Sasaki, MD, FACS Professor, Loma Linda Medical University Center Private Practice: Pasadena, California USA Ana Tevez, Surgical RN Pasadena, CA. USA Connie Ha, LVN Pasadena, CA. USA Erica Lopez Ulloa, CST Pasadena, CA. USA Chelsea Knutson, CST Pasadena, CA. USA Margaret Gaston, Computer Analyst Pasadena, CA. USA

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Clinical Practice Spotlight On

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Hyalual Daily DeLux Dr Iryna Stewart explains the mechanisms and benefits of the new anti-ageing and postprocedural restorative care spray

Most cosmetic procedures are associated with primary damage to the epidermis and sometimes dermis, and this damage to the integrity of the skin causes an inflammatory response. Procedures in aesthetic medicine most commonly associated with epidermis damage include chemical peels, microdermabrasion, laser resurfacing, electrosurgical and laser excisions, cryotherapy, electrical and laser hair removal and injection techniques (redermalisation, mesotherapy and biorevitalisation).

Hyalual Daily DeLux spray aids skin restoration post-procedure by forming a membrane on the skin surface. The spray contains a combination of 0.014% hyaluronic acid (HA), 0.071% succinic acid (SA) and water, and has no conservatives or preservatives. Both active ingredients are already contained in body tissue and do not cause allergies or complications.

The HA in Hyalual retains epidermal moisture by forming a microfilm on the skin surface, keeping moisture within the epithelium. This aids restoration after traumatic procedures, where transepidermal moisture loss occurs. The resulting hydration of the HA film increases the antioxidant and metabolic effects of SA. SA neutralises free radicals, which are formed during skin traumatisation and attack cells. SA also has an anti-bacterial and anti-inflammatory effect, providing cell mitochondria with more energy to fight bacteria. This optimises cell metabolism and improves cell recovery.

Any anti-ageing or moisturising face cream will have no effect as soon as water evaporates from the skin. The use of Hyalual Daily DeLux spray builds a membrane on the dermis, which prevents water from evaporating and enables the effect of face creams to be prolonged by extending their absorption time into the skin. It can therefore be recommended to patients for daily rejuvenation. Other benefits of Hyalual include no contraindications, no staining on clothes and no effect on make up. Additionally the spray applicator provides a touch-free alternative for your patients; the spray dries after one to three minutes and there is no need to wipe, minimising the risk of infection. The product can be used post-procedure with any major treatment, such as laser procedures, dermal and chemical peels, Dermaroller, microneedling and botulinum toxin injections. Spray for three seconds continuously one minute after treatment, then repeat one to three times, each time after the evaporation of the water fraction and the formation of the HA microfilm.

The patient should then be advised to use the spray twice daily for up to a week after the procedure, in the morning and evening. The hydrophilic ingredients shorten recovery period and reduce appearance of erythema and oedema. It can also be used on patients post-acne and with burns. The spray can be used pre-procedure as a replacement for cling film when using Emla numbing cream or Lidocaine. Ten minutes after application of the anaesthetic cream, spray Hyalual for three seconds continuously in a parallel plane to provide uniform deposition and absorption. Spray again after three minutes to improve the effect: the SA attracts Emla into the layer of the epidermis. A clinical trial investigating the effectiveness 42

Aesthetics | March 2014

of the spray included 20 patients aged 26-52 years.1 After a redermalisation procedure, Daily DeLux Hyalual spray was used at the final stage to reduce intensity of pain, severity of oedema and erythema.

A control group of 20 patients aged 28-52 years did not receive post-treatment. Results showed that 30 minutes after procedure and spray application, the decrease in intensity of hyperaemia was 31%, intensity of oedema reduced by 45% and severity of pain, due to potentiation of anaesthetic cream, decreased by 46%. Three days after application, there was no pain or swelling recorded. Results of the control

before

before

after

Patient A Patient in the control group before the procedure (T0) and after 30 minutes redermalisation (T30)

after

Patient B Patients were sprayed with Daily DeLux before the procedure (T0) and after 30 minutes redermalisation (T30)

group showed that there was a slower decline in the severity of symptoms, and pain persisted after 30 minutes and after the procedure. The average score of hyperaemia 30 minutes after procedure was 1.1, oedema was 0.9 and pain was 0.9, compared to 0.5, 0.5 and 0.7 with use of the spray. On average, 80% of treated patients reported low pain level, whilst only 55% of untreated patients reported low pain. Figures A and B compare pre- and post-treatment photos of patients in the control group (A) with patients who used Daily Delux (B). Hyalual Daily DeLux is a product only available for aesthetic specialists and their patients. It reduces patient recovery time and pain, by decreasing severity of inflammation and contributing to potentiation of anaesthetic creams.

This helps to restore the surface of the lipid mantle, accelerate healing and increase patient comfort, which enhances their clinic experience and improves efficiency and quality of treatment.

REFERENCES 1. E.A. Bardova, â&#x20AC;&#x2DC;Justification of applying the Daily DeLux spray after invasive cosmetic proceduresâ&#x20AC;&#x2122; (unpublished clinical trial, National Academy for Postgraduate Education, Department of Dermatovenerology, Ukraine, 2013), p. 5.

Dr Iryna Stewart is managing director of Rederm and founder of IS clinics.

After graduating in 1998, she worked for 15 years in NHS, and has spent the last five years dedicated to aesthetic medicine. She specialises in skin rejuvenation and restoration.

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Clinical Practice Techniques

aestheticsjournal.com

A growing area in aesthetics is reshaping the nose without surgery.

Dr Sotirios Foutsizoglou discusses

Non-Surgical Nose Reshaping Despite the fact that rhinoplasty is the most common facial operation in aesthetic plastic surgery - among both men and women, and overall the third most common - it is one of the most technically difficult surgical procedures and is quite often associated with complications and poor aesthetic results. Over the last few years non-surgical nose reshaping using dermal fillers seems to be gaining popularity due to its safety profile, almost instant results and high patient satisfaction for well selected individuals.

Patients seeking surgical or non-surgical nose reshaping often have dimensional abnormalities such as the following.

• Excessive or inadequate nasal length • Excessive or inadequate nasal tip projection • Excessive or inadequate radix projection • Congenital or acquired deformities (e.g. “saddle nose” or previous over

reduction of the bony dorsum, the so-called “ski slope” appearance).

The excessive dimensions need a surgical rhinoplasty whereas patients with inadequate nasal dimensions or minor deficits in the nasal skeleton would potentially be very good candidates for dermal fillers. The use of silicone and other permanent graft materials in the nose is generally not advocated. These tend to be unreliable and the rate of extrusion and other complications is too high to make such grafts a viable and safe option.

My experience with non-absorbable fillers such as Aquamid or Artecoll is limited and therefore I cannot advise for or against these. Fat grafting by the Coleman method can give good and predictable results when used to disguise visible irregularities of the underlying cartilage and bone and enlarge the nasal tip with virtually no complications or serious side effects. However autologous fat transfer will inevitably prolong the procedure and make it more costly for the patient.

Injectable hyaluronic acid or CaHA fillers are by far the most commonly used filler materials worldwide for non surgical nose reshaping. They are suitable for Advantages and disadvantages of dermal fillers in nasal augmentation.

ADVANTAGES • Ideal for those who do not want surgery for whatever reason or may have contraindications to general anaesthesia

• Minimally invasive

• Can be used in both congenital and acquired nasal defects

• Potential for reversibility

• Satisfactory cosmetic enhancement • Can be used in conjunction with rhinoplasty surgery

• Less expensive • Safer • Less complications • Minimal downtime

• Quick treatment • Almost instant results • Only topical anaesthesia required

DISADVANTAGES • Non permanent • Limited range of application • Skin necrosis or thinning

44

• Cannot correct nasal functional problems • Cannot be used when nasal reduction is required

Aesthetics | March 2014

augmentation of the dorsum, definition of the tip and correction of minor defects such as retracted columella, slight asymmetry, saddle nose or pollybeak deformity. Fillers offer a safe alternative to both primary and revision rhinoplasty when there is a small area to be filled out. Although great results can be achieved with dermal filllers, they are not comparable with those obtained by surgical rhinoplasties, and this is an important issue to discuss with the prospective patient. In addition, the patient should be made aware of the fact that repeat injections are likely to be necessary to maintain the result.

Nasal Aesthetics The nose is the most prominent facial feature, particularly, on a profile view. A three dimensional assessment (caudal, profile, frontal view) of the nasal osteo-cartilaginous skeleton is of paramount importance. Optimal results can only be achieved following a thorough evaluation of all the factors that are associated with the nasal appearance.

For instance, missing frontal teeth causing inversion of the lips and accentuation of the smoker’s lines or a retracted chin will keep distracting from facial balance even after a well corrected nasal dorsal asymmetry.

Other facial features affecting nasal appearance ▪ Nasal skin You can achieve a better definition in a thin skinned nose but a thick skin is more forgiving to potential mistakes (e.g. poor injection technique, overcorrection), lumps and bumps formed following injection of a filler, etc.

▪ Subnasale The point at which the nasal septum merges, in the midsagittal plane, with the upper lip.

▪ Chin projection When viewed in profile, an underprojected chin may magnify the perceived size of the nose.

▪ Contour of lips and philtrum Full lips and a well defined philtrum improve the nasolabial angle.

▪ Malar contour Enhancement of the malar/mid-face volume makes the nose appear smaller.

Below are some measurements that can help the inexperienced injector familiarize themselves with the “ideal” nasal dimensions.

S

E

EATMEN T TR

20 MILLIO

STYLAN RE E

20

N

RLDW WO ID

Heritage – Over 16 year’s experience in aesthetic treatments Superior Lifting – Firmness that gives shape and definition 1 Lasting Effect – Clinical studies demonstrate duration up to 36 months with just two maintenance treatments 2,3

COME AND SEE US AT STAND 58

Galderma (UK) Ltd, Meridien House, 69-71 Clarendon Road, Watford, Hertfordshire WD17 1DS Galderma Switchboard: 01923 208950 Email: info.uk@galderma.com For more information visit www.galderma-alliance.co.uk

RES/031/1113a Date of prep: Feb 2014

References: 1 – Edsman K et al. Dermatol Surg 2012;38:1170-1179.

2 – Narins RS et al. Dermatol Surg 2008;34(Suppl 1)S2-8.

3 – Narins RS et al. Dermatol Surg 2011;37(5):644-650.

Clinical Practice Techniques

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Nasal Anatomy The supporting skeleton of the nose is composed of bone and hyaline cartilage (Fig. 1). The bony part of the nose consists of nasal bones, frontal processes of maxillae and nasal part of the frontal bone and its nasal spine. The cartilaginous part consists of five main cartilages: two lateral cartilages, two greater alar (or lower lateral) cartilages and a septal cartilage. The bony part is covered with periosteum, which is continous with the perichondrium over the cartilaginous part. Please note that the angular branch (A) of the facial artery (F) runs along the nasolabial fold, branching off the superior labial artery (SL). The alar branch is a terminal branch of the angular artery, which is the main feeding blood vessel for the nasal ala. The superior labial artery and the dorsal branch (D) of the supratrochlear artery (ST) communicate with the alar branch around the nasal tip (Fig. 2). Fig. 3 shows the course of the angular artery and vein across the side of the nose as they approach the medial canthus. Bearing this image in mind can help practitioners to avoid injecting into these important blood vessels.

Fig. 1

Fig. 2

Injection technique For correcting humps, augmenting the bridge or defining the dorsum of the nose I prefer using either Radiesse or HA filler such as Juvederm Ultra 4.

VOLUMA can also be used when greater volumes are required such as in cases of westernisation of a depressed bridge in an Asian nose (Fig 4). By using a 27G x 0.5inch sterile hypodermic needle (0.4x13mm) I usually start near the nasion where I deposit, on average, anything between 0.2-0.5ml over the bridge of the nose depending on the degree of the augmentation I want to achieve. I use the same size needle to inject both the nasal dorsum and tip. Moving caudally, in a straight line Before

After

Frontal View • Symmetry • Tip Defining Points • Alar width - Equals Intercanthal distance - Half of Interpupillary distance - 70% of Nasal length • Nasal length - 1/3 of the face Profile View • Dorsal Humps • Nasal Length • Naso-Frontal Angle (NFA) • Naso-Facial Angle (NFcA) • Nasolabial Angle (NLA) Caudal View • Equilateral Triangle • Columella:Lobule = 2:1 • Ala (A):Lobule (L) = 1:1 • Columellar Show = 2 - 4mm

Fig. 3

TERMINOLOGY Glabella is the smooth, slightly depressed area on the frontal bone between the superciliary arches.

Nasion is the intersection of the frontonasal and internasal sutures.

Nasal Root or Radix is a point on the midline nasal dorsum at the level of the supratarsal folds.

If a supratarsal fold is not present, then the root of the nose can be reliably measured in the midline 6mm above the inner canthus.

Tip is the midline point found at the level of the dome-projecting points of the lower lateral cartilages.

connecting the glabella to the supratip, and by using a linear threading technique I deposit threads of about 0.1-0.2ml per injection until the desired dorsal definition and augmentation has been achieved. Please note that by increasing the height of the dorsum, the nasofacial angle will decrease. This will lead to an apparent decrease in nasal tip projection. This is why I tend, almost always, to refine the tip with every nose reshaping procedure. My favourite form of topical anaesthesia for a non-surgical nose reshaping is application of cold packs around the injection site which, in addition to instant pain relief, will also produce vasoconstriction minimising any swelling or bleeding. In the case of dorsal hump(s) I would apply the same technique as above with the only difference being that I would inject only anteriorly and posteriorly to the hump(s) trying to even out the height of the dorsum when looked at from the side.

Before

After

Fig. 4 Non-surgical nose augmentation

Nasal dorsal augmentation with Radiesse

46

Aesthetics | March 2014

Fig. 5 Linear threading over nasal dorsum

Clinical Practice Techniques

aestheticsjournal.com

Dermal fillers can also help in the case of a significant nasal asymmetry such as deviated septum or nasal bone deformity. Fig 6 shows the example of a 42-year-old lady whom I treated quite recently. The patient has had two surgical rhinoplasties following an assault 10 years ago. She was left with a deviated septum, a C-shaped nasal dorsum and a bulbous tip. I injected 0.7ml of Juvederm Grade 4 across the dorsum as described above and 0.3ml in order to redefine the tip. That has resulted in the illusion of a straighter and better defined dorsum and slightly more projected tip.

Fig. 6 Before and right After correction of nasal asymmetry and tip projection

Sculpturing the nasal tip The nasal tip, on lateral view, influences the refinement, inclination, length, and width of the nose. Changing the nasal tip contour will change both the apparent nasal length and dorsal height.

INDICATIONS FOR NASAL TIP REFINEMENT

METHOD

Nasal tip volume reduction

Surgical

Interdomal distance reduction

Surgical

Cranial rotation

Surgical

Increasing tip projection Decreasing tip projection

Non-surgical / Surgical

Surgical

Sound knowledge of the blood supply to the tip will allow practitioners to inject safely in this area. The superior labial artery supplies the nostril sill and the base of the columella. The columellar artery of the superior labial artery, which is a substantial branch, ascends in the columella just superficial to the medial crura (Fig. 7). My experience in redefining the tip lies mainly with hyaluronic acid fillers and therefore I cannot recommend or reject any alternative non-HA filler.

Dermal filler injections in the tip can be used instead of • a spreader graft to restore the vault shape support between the upper lateral cartilage and the septum • a columellar graft in order to reinforce the medial crus and increase the nasal tip projection • a tip graft for tip projection and to correct the proportion between the nostril and the nasal tip thus avoiding any potential risks and complications associated with nasal tip surgery and general anaesthesia.

Fig. 7 Nasal tip technique I insert my needle through the columella and caudal aspect of the septal cartilage approximately 3-5mm below the tip defining points near the infratip break in a superoanterior direction. Bearing in mind the columellar arteries I inject boluses of 0.2-0.3ml between and over the domes as far as the suspensory ligament of the tip. The dome is formed by the junction between the middle and lateral crura of the greater alar cartilage - some rhinoplasty surgeons also call it lower later cartilage. Ideally the projected tip of the nose should have a triangular appearance with its superior apex lying approximately 2 mm above the dorsum and this is what we try to recreate by injecting fillers in the dome area. This is a relatively safe area to inject as there are no end arteries other than anastomoses as shown in figure 7. Finally I apply a lightweight aluminium external nasal splint for 24 hours which molds to any shape of nose and can be trimmed easily to adjust size, but remains rigid once applied (Fig. 9). The splint provides protection for the nose against trauma as well as preventing excessive soft tissue swelling which may precipitate filler migration altering the Fig. 9 Nasal splint desired shape and size.

48

Aesthetics | March 2014

Fig. 8 The needle is inserted through the infratip lobule

Summary Non-surgical nose reshaping has increasingly become a very popular alternative to the traditional surgical rhinoplasty due to its safety, quick results and high patient satisfaction when used for the appropriate indications. A thorough three dimensional examination of the nose and application of nasal aesthetics can guide you to a very satisfactory outcome. Remember that documented evaluation of all parameters that contribute to the appearance of the nose such as the thickness of the nasal skin must also be made. No matter how well defined the underlying osteo-carilaginous nasal skeleton may be, you may not be able to achieve optimal definition of the dorsum or projection of the tip in the thick skinned nose. In a future article I will share my experience in using intradermal 10mg/1ml steroid injections for the thick nasal skin. Finally, you can always complement a non-surgical nose enhancement by injecting a few units of BTX-A (i.e.

2 units per side) in the alaeque nasi for the bunny lines, in the nasalis and levator alae nasi for the flaring of nostrils, and in the depressor septi nasi for the plunging tip.

REFERENCES Foutsizoglou S and Leontsinis T. Augmentation Rhinoplasty: A Unique technique using autograft rib shavings enveloped in bovine pericardium for a more natural and predictable result. Body Language Journal.

Issue 46; p. 60-62. 2011 Brown DL. Borschel GH. Michigan Manual of Plastic Surgery. Lippincott Williams & Wilkins, 2004.

Dr Sotirios Foutsizoglou is the founder and medical director of SFMedica. He has written for numerous UK publications and presented at national and international conferences and expert meetings. He is also the senior lecturer in Facial Anatomy and trainer in nonsurgical procedures with KT Medical Aesthetics Training Group.

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In Practice Abstracts

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A summary of the latest clinical studies Title: Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause.

Authors: Nappi RE, Palacios S. Published: Climacteric, 2014 Feb Keywords: Vulvovaginal, postmenopausal women, VVA Abstract: Vulvovaginal atrophy (VVA) or atrophic vaginitis is a medical challenge because it is under-reported by women, underrecognized by health-care providers and, therefore, under-treated.

More or less 50% of postmenopausal women experience vaginal discomfort attributable to VVA. Very recent surveys suggest healthcare providers should be proactive in order to help their patients to disclose the symptoms related to VVA and to seek adequate treatment when vaginal discomfort is clinically relevant. Women are poorly aware that VVA is a chronic condition with a significant impact on sexual health and quality of life and that effective and safe treatments may be available. Indeed, female sexual dysfunction and genitourinary conditions are more prevalent in women with VVA. That being so, it is very important to include VVA in the menopause agenda, by encouraging an open conversation on the topic of intimacy and performing a gynaecological pelvic examination, if indicated. According to very recent guidelines for the appropriate management of VVA in clinical practice, it is essential to overcome the vaginal ‘taboo’ in order to optimize elderly women’s health care.

Title: Recent trend in the choice of fillers and injection techniques in Asia: a questionnaire study based on expert opinion.

Authors: Lee SK, Kim HS. Published: The Journal of Drugs in Dermatology, 2014 Jan Keywords: Filler injection, Asia, questionnaire Abstract: A panel of dermatologists, who are recognized as filler experts and key speakers in Korea were asked to fill out an in-depth questionnaire on fillers in 2012. The results of the 2012 questionnaire are presented and compared with the questionnaire results of the exact same group of doctors in 2011. Those who participated in the questionnaire study practiced fillers for an average of 10.6 years with an average of 32.8 filler cases per week. Common indications for filler injection were midface augmentation and nose augmentation. Indications that most drastically increased between 2011 and 2012 were midface and forehead augmentation. For the nasolabial folds, the most preferred choice of filler product, needle, injection technique and injection depth was Radiesse, 27G short needle, layering technique and the upper subcutaneous fat layer. For filler rhinoplasty, the preferred choices were Radiesse, 27G short needle,linear threading technique and the mid-deep fatty layer. For dark circles, the favoured choices were Esthelis Basic, 30G short needle, vertical technique and the SOOF (suborbicularis oculi fat) layer. For forehead augmentation, the most favoured choices were Juvederm Voluma, 23G cannula, linear threading technique and fanning and the supraperiosteal layer.

Title: Bacterial biofilm formation and treatment in soft tissue fillers Authors: Alhede M, Er O, Eickhardt S, Kragh K, Alhede M, Christensen LD, Poulsen SS, Givskov M, Christensen LH, Høiby N, Tvede M, Bjarnsholt T. 50

Published: Pathogens and Disease. 2014 Jan Keywords: Biofilm, soft tissue fillers, bacteria Abstract: Injection of soft tissue fillers plays an important role in facial reconstruction and aesthetic treatments such as cosmetic surgery for lip augmentation and wrinkle smoothening.

Adverse events are an increasing problem and recently it has been suggested that bacteria are the cause of a vast fraction of these. A novel mouse model was developed and hyaluronic acid gel, calcium hydroxylapatite microspheres and polyacrylamide hydrogel were evaluated for their potential for sustaining bacterial infections and their possible treatments. The authors were able to culture Pseudomonas aeruginosa, Staphylococcus epidermidis and Probionibacterium acnes in all three gels. When contaminated gels were left for 7 days in a mouse model, the authors found sustainment of bacterial infection with the permanent gel, less with the semipermanent gel and no growth within the temporary gel. Evaluation of treatment strategies showed that once the bacteria had settled (into biofilms) within the gels, even successive treatments with high concentrations of relevant antibiotics were not effective. The data substantiates bacteria as a cause of adverse reactions reported when using tissue fillers, and the sustainability of these infections appears to depend on longevity of the gel. Most importantly, the infections are resistant to antibiotics once established but can be prevented using prophylactic antibiotics.

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ACE Special Focus

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Question Time is now free to all Aesthetics Conference and Exhibition attendees.

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Another reason to register FREE for ACE 2014 Over 1532 medical aesthetic practitioners have already registered to attend ACE 2014, taking place at the Business Design Centre on March 8-9.

Now, in addition to an exhibition of over 100 premium aesthetic suppliers and access to a huge programme of complimentary business workshops, clinical demonstrations and masterclasses, attendees will receive FREE entry to the evening Question Time. Our thanks to Question Time sponsors 3D-lipo and their 3D-lipolite programme for making this possible.

What is Question Time?

Following a drinks networking reception, delegates will have the opportunity to observe and participate with a panel of industry figures, and discuss important topics affecting the medical aesthetic profession. Professional press will also attend this important event.

Want to ask a question?

Audience members can submit their questions online now; so If you would like to know what the implications of the Keogh report will be, how the CEN standard will affect you, or you have another important question you would like to ask the panel, submit your question today.

Visit www.ace2014.co.uk

The Question Time Panel Peter Sissons - Chair

Dr Andrew Vallance-Owen

Formerly a news presenter for ITN and BBC News, Mr Sissons was a broadcast journalist for 45 years before retiring from the BBC in 2009.

Dr Andrew Vallance-Owen is the former medical director of Bupa and a member of Sir Bruce Keoghâ&#x20AC;&#x2122;s Cosmetic Interventions Review team.

Dr Leah Totton

Dr Mike Comins

After completing her Bachelor of Medicine and Bachelor of Surgery, Dr Totton went on to win the 9th series of The Apprentice in July 2013.

Dr Comins is president and fellow of the British College of Aesthetic Medicine and head of the ACE steering committee.

Dr Tracy Mountford

Sharon Bennett

Dr Mountford is the founder and medical director of The Cosmetic Skin Clinic with clinics in both Buckinghamshire and London Harley Street.

Sharon is currently vice chair of the British Association of Cosmetic Nurses (BACN) and also the UK lead on the BSI/CEN Committee.

Mr Dalvi Humzah

Dr Martyn King

Mr Humzah was a consultant plastic surgeon in the NHS for 15 years and has maintained a plastic surgery private practice for over 10 years.

Dr Martyn King is the owner and director of Cosmedic Skin Clinic and medical director of Cosmedic Pharmacy.

Book Now The Aesthetics Conference and Exhibition 2014 is just weeks away but you can still register for your FREE place today. Call 01268 754 897 or visit the website www.ace2014.co.uk

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Aesthetics | March 2014

In Practice HR

aestheticsjournal.com Other parts of the handbook will not be contractual and will consist of employment policies, which may be subject to change in order to comply with legal updates and general business changes.

Although it is never easy to predict the range of issues you, as a business owner, will face, it is almost a certainty that if you employ people, you will be required to deal with absence and questions about holiday entitlement and allowances.

Managing staff absence Employment law specialist Vanessa Di Cuffa explains the importance of setting out rules for holiday and sick leave entitlement for employees Managing employees and staff is arguably one of the hardest aspects of running a business. And if you are a small business owner, you are unlikely to have a dedicated resource to deal with employee issues. Certain rules are essential in any business because they ensure compliance with the various laws that we are all bound by, as well as providing clarity and certainty for managers and employees on how to deal with routine scenarios that might occur. By always following the same set of rules that have been clearly outlined to staff, you provide consistency of approach, which will help to safeguard your business against being sued.

The policies that are most vital are in relation to discipline and grievance processes. The ACAS Code of Practice provides basic practical guidelines for employers and employees to ensure policies on disciplinary and grievance in the workplace are outlined effectively. Acting promptly and consistently with all employees at the time of any issue is vital in maintaining relationships within the business. Employers must be seen to carry out necessary investigations on any issues that arise in order to establish the facts and make informed actions. It is important to note that failing to comply with the Code does not, in itself, make a person or organisation liable to proceedings. However, employment tribunals do take the Code into consideration when assessing cases. Despite this, both parties should always seek to resolve disciplinary and grievance issues within the workplace by encouraging an open communication culture and following the appropriate policies and guidance from an expert.

As your business grows, your bank of policies will most likely expand. Regular policies I might recommend include: health and safety, company car use, expenses, study leave, flexible working, maternity, paternity and adoption leave, stress at work, equal opportunities, bullying and harassment and whistle blowing, but this is by no means an exhaustive list.

Some businesses choose to place these rules or at least a summary of them in a staff handbook, parts of which may be deemed to be contractual. Detail in the handbook may expand on the rights set out in employment contracts.

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Aesthetics | March 2014

Since there are a range of laws in the UK which provide protection and rights for various sections of society in relation to different types of absences (pregnancy related absence, sickness absence, holidays etc) it is crucial that you have a process in place which enables your business to maintain consistency in the management of absence and also offers the opportunity to establish the reasons for absence in each individual case. Employers can request â&#x20AC;&#x2DC;fit notesâ&#x20AC;&#x2122; from an employeeâ&#x20AC;&#x2122;s doctor if they have been continually off sick for seven days or more. On the occasion where a fit note states an employee may actually be fit for work, employers may need to discuss wider occupational health issues with the employee. Changes to working hours or level of responsibility held by an employee could be amended to encourage an employee to return to work. These changes should be discussed with the employee in detail to ensure a suitable solution can be made. In the event that an employee is unable to return to work or do their job or any other job on account of illness, a capability process may need to be implemented.

If an employee is unable to do the job they are employed to do and/or there are no alternatives, an employer may have to manage the employee out of the business through a capability process.

Legal advice should be taken in respect of how this could be done.

Pinpointing the reason for absence is critical in determining the process that may follow.

For example, you need to ask if the absence is related to sickness, a child being sick, an emergency, bereavement, or is it not attributable to anything and therefore unauthorised? The law affords different levels of protection depending on what the reason for absence is. Managing the absence correctly is important to reduce the risk to the business if an individual challenges the process and threatens to sue. The rights afforded to individuals who are deemed disabled, in the legal sense of the word, are complex: the management of a disabled employee requires proper consideration and an element of flexibility on the part of an employer, in order to assist and help the employee to feel at ease to work.

When an employee books a holiday, a clear set

In Practice HR

aestheticsjournal.com of rules outlining the process from their employer means that difficult conversations can sometimes be averted because the matters are set out in a policy. Your business may have peak periods and you would be entitled to set out in a policy whether there are periods or days that holiday cannot be taken. It may specify whether there is a limit on the time you take and a limit on the number of people who can be off at one time.

Holiday entitlement and working bank and public holidays always creates confusion and emotion. If your business works bank holidays, this must be clear in the contract and policy.

If you want to shut your entire business down for a specific period each year, for example, at Christmas or during a particularly quiet period, then set it out in a policy. According to Gov.uk, holiday entitlement for those who work a five-day week is 28 days paid annual leave. However, self-employed workers, which are common amongst the small business community, aren’t entitled to annual leave at all. Whether employees are full-time or part-time, and whether they have irregular or flexible working hours will determine the level of leave eligible to individuals, but it is important to ensure all employees on the same contracts are offered the same holiday entitlement in order to avoid employee unrest in the workplace.

It really is not advisable to have the full range of ‘A-Z’ of possible policies. You simply need what is relevant to your business and the complexity of the policy will be dependent on

the nature of what you do and the type of people you employ.

Look on the ACAS website for guidance but generally it is always best to consult a lawyer or HR professional.

Remember the more policies you have, the more you have to keep up-to-date. Having a policy does not rule out the ability to exercise discretion and make exceptions but in the key areas, such as absence and holiday, it is always sensible for you and your staff to have clear rules and to follow them. This will reduce the risk of allegations against owners and managers of discrimination based on sensitive and difficult issues. Sound, professional advice can establish quickly what will and what won’t be appropriate for your business, and experience and exposure to the issues you may face will ensure that you get the appropriate policies to suit your business.

Vanessa Di Cuffa Is an employment partner specialising in employment law and HR at the Birmingham office of law firm Shakespeares. Vanessa advises on all aspects of employment law and HR across sectors including medical, ranging from small SMEs to large corporate organisations. She is commercially focused, providing you with real solutions.

REFERENCES 1) http://www.acas.org.uk/\ 2) https://www.gov.uk/holiday-entitlement-rights

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In Practice Digital Strategy

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5 Ways to boost your online presence John Castro explains how employing simple online strategies can grow your business The world has changed. The way consumers spend money, access information, build trust; the way they do just about everything has changed. Why? The digital economy. The emergence and huge growth of social networks and mobile devices has allowed us to access anything, anywhere, anytime we want it and all with our smart phones. Recent research even suggests that 2014 is the year we will see 50% of internet search originating from mobile devices. It is clear there is a wealth of information available, with new technologies and social networks launching every day. However, using these platforms can be a confusing arena, especially for someone for whom this is a new experience. Here, I’ve outlined five simple strategies to improve your online presence and thus boost your sales.

1. FIND TIME You may already feel as though there aren’t enough hours in the day to accomplish all that you need to, but if you’re not willing to dedicate some time each week then you will struggle to boost your online presence. Consistency is key. Set up a schedule and stick to it; two to three hours a week will be sufficient. Putting this time aside regularly to help increase enquires and appointments for your clinic is truly a must for an effective digital strategy.

2. CONTENT IS KING, BUT CONTEXT IS GOD Frequent content additions to your website such as blogging and news letters are certainly the easiest way to engage visitors and send out new information regularly. However, be sure to be selective and relevant.. Your content should be something of interest to your readers and potential patients, the last thing they will want is just more junk email.

Quick tip: Write about more than one new treatment including ones you don’t even provide. This may seem counter-intuitive but will gain trust and ensures your readers that you genuinely care for their wellbeing and that you are not only concerned with sales.

3. SOCIAL MEDIA You may feel that you have heard this before but that’s because it is of paramount importance to the success of your online presence and thus potential sales. However, social media can be daunting.

Here are some tips to get you started Be consistent. If you are going to build attention on social media make sure you are regularly distributing content. But remember quality information and content, no rubbish or you may find that your audience dwindles.

Be patient. Social media is a marathon not a sprint. Your goal is to build an audience by providing quality content and information that captures attention so that when you post your services and start to sell to them, they trust you and are more likely to book an appointment.

Be personable. Do not be afraid to be you when posting and sharing; do not follow the crowd. People buy people and you are not going to attract everyone. Your ideal clients are those who you genuinely engage with. It is those who become patients forever, and it those who recommend you to others, thus expanding your customer base.

Be organised. You should plan your social media activity in advance each week. This will save you time and help you to keep your posts 56

regular. However, don’t forget the importance of being personal and relevant. You should make sure you also post in response to current affairs and reply to others’ comments.

4. UPDATE YOUR WEBSITE If you had your website designed over three years ago, it is more than likely already dated and not mobile responsive. The goal of most websites is to get visitors to the content they seek as quickly as possible. A simple, intuitive design is the best way to accomplish that and fewer page elements are key to this. Keep focus on the ultimate outcome, whether it’s a phone call, email enquiry, or sale.

Work with a web designer to clean up your site and make sure they know and understand your intended client base. It is your design and user interface that will help your home page generate more enquires for you.

Quick tip: Replication is the easiest way to get results fast. This does not mean copy, it means finding out what design techniques others use to generate enquires and utilising these. Doing your research and using a web agency that understands this is key.

5. GOOGLE, GET INVOLVED I strongly encourage you to make use of Google’s free marketing tools, such as Google Local and Google Plus (their social network).

Set yourself up a Google Plus profile and a Google Plus Business Page and work it like you do other social networks. The more you are active with Google products and platforms, the more Google will value your website as an authority and therefore the higher you are likely to rank in a search.

These five simple tips will help you to boost your online presence.

If you are consistent, patient and get on board with this evergrowing digital economy then you will soon see the returns in both new enquiries and a loyal and engaged customer base.

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Aesthetics | March 2014

John Castro is the founder and director of Websites For Cosmetics, the only web agency that solely and exclusively works with the medical aesthetic and cosmetic surgery industry.

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In Practice Finance

aestheticsjournal.com

Maximising your cash flow Kurt Won explains the importance of close control and understanding your business’ finances The Common Myth: “If I’m a great practitioner, my business is guaranteed to be a success,” Being a fantastic practitioner certainly helps to attract new patients and retain existing ones.

However, it does not guarantee the financial sustainability of your business. The future of your business depends on your ability as the business owner to manage cash flow, and essentially increase revenue and reduce expenses. Many people shy away from taking responsibility for their finances: they stick their head in the sand and wait for their accountant to tell them the state of their finances at month-end or quarter-end. Having a bookkeeper and an accountant on your team is of course vital, but it is even more important for you to be comfortable looking at the numbers. Numbers don’t lie and having a clear idea of the timing of cash coming in and going out will help you make better business decisions.

I’ve set out some simple but effective ways to help you take better control of your cash flow: 1) Ask your bookkeeper or accountant to prepare a weekly cash flow projection, which will use the following formula: Step 1: Note down your bank balance at the start of the week (W) Step 2: Calculate how much money is due to come into your business that week (X) Step 3: Work out what expenses (including payroll) are due to be paid out of the account (Y) Step 4: Calculate your projected bank balance using this formula: Beginning week bank balance + Projected revenues – Projected Expenses = End of Week Cash Balance W + X – Y = Z Being aware of your projected end of week balance will help you to make decisions quicker.

For example, deciding how many products or consumables you can order from your supplier. If the end of week balance was projected to be negative, you have advanced warning of how many more products or treatments you or your staff need to sell to cover the deficit. If you have a contingency fund, you will be aware of when to transfer money into your current account. The worst position to be in is being caught unaware of a potential negative balance and being charged for returned direct debit 58

payments, or going into unauthorised overdraft limits. For example, one of my clients discovered that a particular month-end was going to end in a large deficit, so we focused their team on generating new sales and collecting outstanding payments from their clients, which saved my client hundreds of pounds in bank and overdraft charges.

2) Manage your accounts receivable and accounts payable In your aesthetics business, there should not be a great deal of accounts receivable (patients who owe you money) but patients may be paying for treatments in instalments. Make a conscious effort to keep track of these clearly and to chase your patients for those remaining payments.

Accounts payable is the money you owe to suppliers. If your supplier has kindly given you terms on your invoice, e.g. ‘30 days to pay’, ensure you schedule the date of the payment into your cash flow projection report so that you pay it on time. Paying on time will help build trust and a good credit score with your supplier, which will help if you need to negotiate for extended payment terms. Successfully extending payment terms to 60 or 90 days will benefit your business considerably. Failing to make payments on time could mean payment terms or credit lines being revoked: avoid this at all costs.

3) Get into the habit of putting money away It’s important to strategically re-invest money into the business. Have subaccounts where you can divert a percentage of your money coming in every week or month. Your bank can easily create a long-term savings account if you are thinking of investing in new equipment, premises or even staff. It’s also advisable to create sub-accounts for tax and payroll. Speak to your accountant about how much you can and should be putting away every week or month to meet your future obligations. Your ultimate target as a good business owner should be to get the business to a position which operates on 70-75% of the money that comes into its bank account, so the remaining 25-30% goes into a contingency or long-term investment account. Don’t worry if you can’t put 25% of your money away straight away.

4) Prepare and review monthly management reports At a minimum, ask your accountant or bookkeeper to prepare detailed, monthly profit and loss statements for you to review with them or with a business advisor.

Don’t be afraid to ask them to explain what the numbers in your financial statements and management reports mean. It helps to see each month’s revenues and expenses in one spreadsheet, so that you can spot trends or anomalies in how your money is being made and spent. The more frequently you review your numbers, the quicker you can make decisions and adjustments in your business and the more empowered you will feel as a business owner.

Kurt Won is the CEO and co-founder of SalesPartners UK (www.salespartnersuk.com), a multi-award winning business consultancy that has helped over 850 business owners and entrepreneurs in the past four years to make and keep more money by driving sales, increasing profitability and building championship business teams. He has spoken at various aesthetic and beauty conferences.

Aesthetics | March 2014

READY • AUTHENTIC • MY BUSINESS

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin.

Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution.

4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis),vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin.

Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May

result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany.

Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 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. 1134/BOC/NOV/2013/LD Date of preparation: November 2013

In Practice Patient Experience

aestheticsjournal.com

Gilly Dickons explains the importance of call-handling in increasing patient retention in your clinic

Is your practice making an exceptional first impression?

In the highly competitive sector of aesthetics it is very important that you regularly review the quality of your customer service, especially your call handling. ideally you should take this action every three months. The aesthetic client is making an emotional and important decision in terms of having treatment, as well as deciding where to go to receive it, and this requires both a professional and personal initial response. If you have a receptionist, whether part time or full time, it is essential that they are thoroughly trained. After all, they are responsible for creating the first impression that your patient will receive of your practice.

Equally, if you are an independent practitioner who handles your own calls, the following will still apply. With great initial call handling your practice will grow, enabling you to garner the right support.

I am convinced that hospitality is the one of the most important aspects of your business, and suggest that you set time aside to take a look at the various skills your front of house staff require, in order to ensure you are optimising any new opportunities. If you do not employ staff, these are skills you either need yourself, or should look to acquire via outsourcing to a specialist service. The consensus of opinion is that the current industry gold standard of converting a new enquiry to appointment is 60%. With great training and focus on the following areas this could be 75-85%, which could make a big impact on your revenue.

Any front line member of staff will benefit from call handling training; after all, they are in a sale’s role, albeit a soft one. The person who answers your phone requires exceptional customer service skills, in the same way that you need to be a skilled treatment provider. As a starting point for a review of this aspect of your business, whether for staff or to critique yourself, I would recommend that you consider the following tips as a brief guide to the essential skills your staff require: · Tone of voice Your staff must sound warm, inviting and interested. There is nothing worse than rushing your caller, sounding distracted or having an abrupt manner. · Calls need to be picked up within a few rings Not left to go to answer machine. When a first time caller gets through to an answer machine they may be very reluctant to leave a message. A caller who has waited for more than 10 rings may become agitated and may question the service you are providing. · Knowledge about the clinic A thorough understanding of the clinic and what makes it special is essential.

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· Knowledge about you Your employees must be able to credential you and let prospective clients know why you are the person that they should choose to administer their treatment. · Knowledge about the procedures you offer A general understanding of the treatments that you offer is essential. Whilst you will give clients the technical information, your staff must be confident in discussing the various treatments you provide at a conversational level. · Ability to ask the client questions Asking questions enables the patient to open up, and when they do your staff need to sound interested and engaged. Questions should be gently probing and focused towards the reason for the call. For example, ‘Have you been considering this treatment for a while?’ This leads to the next point… · Ability to listen Listening is the key skill in building relationships. To use as a guide, here are ten commandments of active listening: 1) Stop talking: you cannot listen if you are talking.

2) Concentrate: always be prepared to listen before the need arises; stay focused.

3) Acknowledge and empathise: prove that you are listening and interested by using encouraging noises and showing empathy where appropriate.

4) Be objective: keep an open mind and do not make hasty judgements of your clients. Everyone is different and everyone’s reaction to a given situation is different. Never assume and always treat each client as if they are your most important one.

5) Ask questions so that you can listen to answers: questions demand answers and help to build understanding and relationships.

6) Reflect, confirm, clarify, summarise: it is important to do this as we cannot see the person we are talking to. We need to check our understanding to maintain control of the call, for example, “So you would like to book xyz – is that correct?”

7) Be patient: allow the patient his or her say and do not interrupt them. Simply wait until they finish what they are saying. Listen to understand, rather than to reply.

8) Take notes: get the key points of the conversation down so that you can refer back to them.

9) Listen between the lines: listen for feelings and ideas behind the words. Often it is the way something is said, not what is said, that is important.

10) Stop talking: this is the first and the last commandment, as all the others depend on this action.

Aesthetics | March 2014

In Practice Patient Experience

aestheticsjournal.com

· Understanding key motivators/indicators Clients always have a reason or a ‘trigger’ for their call. For example, an event such as a wedding or a holiday. It’s important to understand this as it helps to build a strong relationship right from the outset. · Overcoming objections There will always be objections, most frequently regarding the cost of a treatment. Equip your staff to handle these effectively right from the start. Objections provide another highly effective way to build the relationship, so see them as positive. Objections may include price, appointment times, recovery time, how ‘painful’ the treatment is perceived to be, lack of support from their partner etc. · Need versus want Patients often ask for one thing, even though they may require something completely different. Asking questions and listening carefully will highlight any inconsistency. For example, a new caller often wants a ‘quick fix’ treatment, but what they really need is the very best solution for the issue they are concerned about. It is important to identify the need using gentle questions, and by building a relationship on the phone.

making an initial enquiry or are simply shopping around. Ideally you will have implemented the above and there will only be 1525% of enquiries who don’t book. Ensure that you have gathered adequate information to enable you to send patients your next newsletter and other relevant material as some of them will book at a later date.

You may have identified at this stage that some of these points refer to natural skills and abilities, such as tone of voice and warmth, whilst others require training from you, such as product knowledge, for example. If you are not in a position to employ staff you can look to employ a remote enquiry management and appointment booking service to take care of your phones for you. As you seek to grow your practice, don’t overlook this area or take it for granted; the time and investment you make in your call handling will make a huge impact on your success. These essential front line skills will not only impact your conversion of new enquiries into consultations, but will also enhance your existing patient’s experience, contributing to increased patient retention, which in turn will increase your revenue.

· Effective data capture The minimum on any call needs to be a name and number, as well as where the patient heard about you. Some patients are only

Gilly Dickons is the founder of Aesthetic Response, a unique, expert enquiry management service to the UK’s aesthetic and cosmetic sector. AR’s team of patient advisors manage calls and diaries on behalf of a variety of practices, using exceptional customer service skills to convert valuable enquiries into consultations.

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In Practice In Profile

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Owning your own clinic is very different to renting a room Dr Terry Loong, owner of The Skin Energy Clinic and winner of Best New Clinic at the Aesthetics Awards 2013, explains her route into the industry and provides insight on setting up your own practice After qualifying in 2002, working as an anatomy demonstrator, and undergoing surgical training for four years, Dr Terry was inspired by her late mother to change direction in 2007. “She suffered from terrible acne, psoriasis, eczema, varicose veins and stretch marks,” says Dr Terry of her mother. “She inspired me to help as many women as I could.” Dr Loong began aesthetic training taking courses in botulinum toxin and fillers, then started out by treating patients at a friend’s beauty salon in Kent, whilst working as an associate to a clinic in Knightsbridge. “I was an ex-surgeon, so the eye-hand coordination and artistry of aesthetics came naturally to me,” she says. In 2010, she started her own business, at first just renting a room on Harley Street a few days a week. “I was reluctant to open my own clinic, as I saw many doctors who owned clinics working constantly with no work-life balance, which scared me,” she says.

She expanded her skill-base by studying nutrition, hormonal rebalancing and functional medicine in the US in 2011, focussing on preventative and holistic anti-ageing. Now with more experience and confidence, in 2012 she invested in her first practice, The Skin Energy Clinic, based on South Molton Street. “Owning your own clinic is very different to renting a room,” she says. “As well as being a

ADVICE ON SETTING UP YOUR OWN CLINIC ■ If you can, go into partnership You’ll find it easier to pay the overheads and will have a better work-life balance, rather than going it alone and hiring a manager, who will require a high salary.

■ Don’t get too emotionally attached Running your own clinic is not easy; you will have good and bad days.

Remember that it’s just business, don’t take things personally and don’t make enemies.

■ Do present yourself publicly Being a social butterfly by networking and using social media will help your business grow - there’s nothing better than word-of-mouth marketing. Take opportunities to talk: I spoke at The Anti-Ageing and Beauty Show last year. It’s about meeting new clients, retaining them, exceeding their expectations and getting referrals.

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■ Do be realistic I was overly optimistic about having 100% capacity in my clinic at the start – optimism will help you move forward, but being unrealistic can be stressful. If you halve the expected capacity figure in your business plan, you’ll exceed it, which is much better than trying to catch up.

■ Do retain your personality My aesthetic mentor advised me to build my clinic the way I want and not to change who I am. You will attract your own type of patients, and there are enough patients for every practitioner. My patients tell me I’m like a friend; they feel comfortable telling me things, and I am honest with them when I don’t know the answer. Doctors are trained not to show weakness, but patients love to know you still have skin breakouts, you’re worried about your wrinkles and that you’re human.

Aesthetics | March 2014

good practitioner, you have to develop as an ethical business person, and learn about finances, human resources, sales, team building, marketing, patient retention, practitioner motivation and administration.

The big learning curve was working with a range of personalities in my team, whilst serving patients,” she says. Dr Terry attended multiple workshops on business, marketing and public speaking, and even hired her fiancée, a business consultant, as her business coach. She worked with online marketing and video coaches, and when she found her premises, commissioned an interior designer to create a stylish interior. However, the set up wasn’t a seamless process. “If I was to do it again, I would spend less money on decorating the clinic and more on PR and marketing to promote the business,” she admits. Now, to keep in touch with patients, she sends out weekly newsletters. “They’re inspirational, educational and remind patients that you’re there for them,” she says. “I don’t like pushing treatments. The lack of consumer education in this industry concerns me, so I want to put information in the public domain.” The Skin Energy Clinic offers injectables, PRP, chemical peels, microneedling, mesotherapy and hormonal rebalancing. “PRP is my favourite aesthetic treatment, because of the preventative anti-ageing qualities,” she says. “It’s not just for now, but for the future.” For her own future, Dr Terry is partnering with a pharmacy. “This will make dispensing a lot easier for my patients,” she says.

She also wants to create a training school, and focus on her educational Dr Terry TV YouTube channel.

At the root of her plans is the aim of creating happy patients and practitioners. “My biggest goal is to create a clinical environment where patients love coming to see us and feel looked after, but which also promotes a positive work-life balance, so that practitioners enjoy coming to work.” she says. “I’m getting married at the end of this year and want to start a family, so that’s really important to me.” But crucially, she wants her patients to feel confident.

“The irony of aesthetics is that, if everybody was confident in their appearance, the industry would not make any money,” she says. “I want to take a different approach: I want my patients to feel they want, rather than need, aesthetic treatment.”

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In Practice The Last Word

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With the long-awaited government response to the Keogh report published this month, we asked members of our editorial board to share their reactions

Government response to the Keogh report on cosmetic interventions Mr Adrian Richards Plastic and cosmetic surgeon “The government response to Keogh lacked firmness regarding regulations and who can do what. As an industry I think we were hoping that dermal fillers would be made prescription-only medicines. What the response said was that individuals need to be trained before administering fillers – however it didn’t give details on what kind of training, or who would be able to administer them. This was disappointing. In the UK there are many different competing bodies within this industry that naturally have different interests, so it’s understandable that it’s difficult for the government to get consensus. Hopefully this response can be marked as progress, in terms of assessing regulation and in the execution of an implant registry, but it seems that real change will take a long time.”

Dr Nick Lowe Consultant dermatologist and president of the BCDG “I hope the details of the response today will be influential as far as this is feasible. I am currently involved in proposing ideas to Health Education England (HEE), the body which has been chosen by the government to work with stakeholders to approve training for practitioners. I believe that an appropriate body such as the British Association of Dermatologists working with the HEE and with royal colleges would be ideally placed to organise training programmes for practitioners. Today’s response was very much an overview of what’s been discussed previously. Now it’s down to individual bodies to put this into effect. It’s a move in the right direction, but I would have liked it to have regulatory teeth.”

Sharon Bennett Vice chair of the BACN “I welcome any review leading to tighter regulation in the aesthetic industry.

Following the government report there may be concern that it does not go far enough to regulate an industry in need. Loopholes are in need of tightening surrounding cosmetic injectables. The HEE will require support and guidance from us all at this time and I am confident that their committee, made up of industry experts including the BACN, will produce a framework of education and training with defined minimum standards to ensure patient safety is met. Support from the professional bodies will make a real difference to the practitioners who work in this area.”

Dr Sarah Tonks Aesthetic doctor “The recommendations specifically around non-surgical providers are shockingly lax – what on earth is an appropriately trained person? Unless there are prescriptive guidelines set out around who can inject what and where then I don’t see how this can be in the patient’s best interests. I disagree with the statement that we do not need our own register, because registration and training as a unified body for all non-surgical providers doctors, dentists and nurses is essential to ensure that we are all moving together, maintaining a 64

high standard of practice across the board. Each practitioner must practice according to their abilities but with knowledge of all the available treatment options. At the moment we are all separate, practicing alone and often with no professional support. It’s time to take aesthetic medicine into the medical professional arena and make it a serious specialty with our own governing body.”

Amanda Cameron Sales and marketing professional “Whilst the government has gone some way to protect consumers, I feel they have missed a great opportunity to fully regulate the industry. They appear to be encouraging double standards with the qualified providers being held to account, whilst unqualified individuals are still free to practice with no accountability. I read the report several times in the hope of finding some concrete actions but they are sadly lacking. I am disappointed but not surprised, as reports on our industry have been produced before with recommendations developed only to be ignored. It appears this one is no exception and patient safety does not feature on the government’s list of priorities.”

Dr Mike Comins President and fellow of BCAM “I was disappointed by the fact that there wasn’t any immediate action on making dermal fillers a prescription-only device. I think that this was a missed opportunity and would have changed the whole industry. I welcome most of the other points raised, particularly the need for standardisation and training in non-surgical aesthetics. I know that BCAM are working with Heath Education England regarding this. Whilst I support the idea that surgeons need to be on the specialist register to perform cosmetic surgery, I do feel that minor surgical procedures such as fat reduction treatments and hair transplants, which are performed under local anaesthetic and which fall under the definition of aesthetic medicine, need to be addressed. There’s still some confusion around this area and I’m hoping BCAM can work with the GMC to resolve this.”

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