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w om no 17! ce.c er 0 st 2 en gi CE fer Re A on r fo sc tic he st ae

VOLUME 4/ISSUE 4 - MARCH 2017

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Labia Majora Rejuvenation CPD Dr Dawid Serafin examines rejuvenation of the labia majora with hyaluronic acid filler

Aesthetic Training

Treating the Brow

Developing Trust

Practitioners share advice on how to fully utilise medical aesthetic training courses

Dr Maryam Zamani explains how the brow can be lifted with combination treatments

Dr Rehka Tailor discusses key tips to help gain your patients’ trust


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Contents • March 2017 06 News

The latest product and industry news

14 Conference Report: IMCAS

Aesthetics reports on the highlights of the IMCAS Annual World Congress

16 Advertorial: Galderma Aesthetics Academy Learn more about Galderma’s doctor-led approach to training their trainers 17 News Special: Cosmetic Surgery’s Decline in 2016

A look at BAAPS’ latest cosmetic surgery statistics for last year

18 ACE Preview: A Final Look at ACE 2017

Discover what you can gain from the Aesthetics Conference and Exhibition

Special Feature Aesthetic Training Page 23

CLINICAL PRACTICE 23 Special Feature: Training in Medical Aesthetics

Practitioners share advice on how to successfully learn and develop through training courses in the aesthetics specialty

28 CPD: Labia Majora Rejuvenation Dr Dawid Serafin discusses augmentation and rejuvenation of the labia with

hyaluronic acid

33 Treating the Brow Dr Maryam Zamani discusses lifting the brow using non-surgical treatments 38 Spotlight On: Needle Shaping

Aesthetics explores the use of the needle system that aims to biostimulate the skin

41 Smoking’s Effects on the Skin

Dr Martin Godfrey uncovers how smoking impacts the skin’s health

46 Case Study: Rejuvenating Male Skin Pharmacist prescriber Rukhsana Khan and Dr Rita Poddar present a

chemical peel case study of a male patient

50 Advertorial: SkinCeuticals

Discover the latest innovations in skin restoration A round-up and summary of useful clinical papers

IN PRACTICE 53 How Can You Optimise Your Cosmeceutical Range?

Business strategist Alana Chalmers discusses the factors to consider when stocking cosmeceutical products

56 Understanding Accredited Qualifications

Training provider Sally Durant discusses accredited qualifications in training

60 Tips for Developing Patient Trust

Dr Rekha Tailor discusses her methods for gaining patients’ trust

63 Improving Employee Performance

Clinical Contributors Dr Dawid Serafin is a gynaecologist and one of the first in Poland to specialise in aesthetic gynaecology. He is an instructor in hyaluronic acid filler treatments and writes and lecturers on current topics and techniques in aesthetic gynaecology. Dr Maryam Zamani is a board certified ophthalmologist with experience in ocuplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine, US.

51 Abstracts

In Practice Improving Employee Performance Page 63

Global business executive Reece Tomlinson outlines four core principles to increasing employee performance

Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd. A trained medical practitioner, Dr Godfrey has a wealth of expertise in health and nutritional product marketing. Rukhsana Khan is an independent pharmacist prescriber and aesthetic practitioner based at Surface Clinic in Saltaire, West Yorkshire. She specialises in non-surgical skin rejuvenation treatments such as chemical peels. Dr Rita Poddar is a dental surgeon, multiple clinic owner and an aesthetic practitioner. She has a special interest in non-surgical antiageing, cosmetic dermatology skincare and performing TCA peels.

67 In Profile: Dr Harryono Judodihardjo

Dermatologist Dr Harryono Judodihardjo details his career in aesthetics and his delight at winning an Aesthetics Award in 2016

68 The Last Word

Medical aesthetic analysts Benazir Premji, Lucy Federico and Raghav Tangri argue the potential impacts of topical botulinum toxin on the market

NEXT MONTH • IN FOCUS: Combination Treatments • Brow Ptosis • Treating Scars • Consulting Religious Patients

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Last chance to register for FREE for the Aesthetics Conference and Exhibition on March 31 and April 1! www.aestheticsconference.com

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Editor’s letter Spring is on its way so we know ACE 2017 is fast approaching – in case you have forgotten it will take place on March 31 and April 1. And no, it’s not an April fool! Excitement is running high as we make our final approach, fasten your Amanda Cameron seatbelts and make sure you have registered Editor so you don’t miss out. Let’s all fly high this year on an amazing clinical agenda and a hugely valuable business programme that will bring you the best educational content that you will see in the UK this year! This month we look at training – always topical but maybe more so at the moment with all the debate on who should deliver injectable treatments and what levels of training should be undertaken. In our Special Feature on p.23 we look at various training courses available, their content and how to make the best choices suited to your development needs. As someone who has been in the industry for many years, I am amazed at the number of courses and companies that now offer training, so goodness knows how practitioners new to the industry make their educational choices, hopefully our articles will help.

We have a really strong business section this month with articles on employee performance (p.63), which is an area that should not be ignored, as good employees can drive your business to the next level if managed properly, but unfortunately can have the opposite effect if not! In addition, Dr Rekha Tailor shares advice on how to build your patients’ trust on p.60 and skincare business director Alana Chalmers outlines key questions you should be asking when choosing a cosmeceutical brand on p.53. I also have to mention our Last Word this month which is a fascinating read on what may happen to our market if and when topical botulinum toxin becomes available and its potential implications, please take a look on p.68, it is thought provoking! As always, we love to hear from our readers. Let us know what you learnt from this issue or if you are interested in writing for the journal by emailing editorial@aestheticsjournal.com or tweeting us @aestheticsgroup Finally, don’t forget to visit www.aestheticsconference.com and register for FREE for ACE 2017!

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

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

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

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015.

and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Acquisition

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #LiveTV Dr Tapan Patel @drtapanp Great fun with @Schofe and @hollywills on @thismorning injecting #Juvéderm and #Botox @PHIclinic

#BAAPS Baljit Dheansa @dheansa_plastic One can only hope the decrease in #CosmeticSurgery procedures is because #patients are choosing wisely and avoiding unnecessary treatments #IMCAS2017 Olivier Branford  @OlivierBranford   Great catching up with old friends & making new ones! @danielzliu @ChristineHamori @NahaiDr @JasonEmerMD @ducrest @imcascongress #IMCAS2017 #Lasers Dr Anjali Mahto @DrAnjaliMahto Utterly horrified to see a melanoma in clinic today previously treated by laser in a beauty salon for its removal. #Clinic Marc Pacifico @MarcPacifico A big thank you to all who came to my open evening @McIndoeCentre this evening – great turnout, great atmosphere #plasticsurgery

#Mentoring Harley Academy @HarleyAcademy Fun day training these two doctors #mentoring #HarleyAcademy #botox #fillers

#ProductLaunch S-Thetics @MissBalaratnam Thank you @drbassnyc for your expert advice on @SculpSure yesterday. Great results with #treattocomplete protocol #SculpSure #fatreduction

Allergan acquires ZELTIQ for $2.475 billion Global pharmaceutical company Allergan is set to purchase medical and cooling technology company ZELTIQ Aesthetics for US $56.50 per share. The acquisition will add body contouring to Allergan’s growing portfolio through ZELTIQ’s controlled-cooling technology platform, CoolSculpting.   According to Allergan, the body contouring sector is worth $4 billion on the worldwide market and is increasing. The company hopes that this transaction will significantly benefit their portfolio and client offering. Brent Saunders, chairman and CEO of Allergan, said, “With CoolSculpting, our offerings to plastic surgeons, dermatologists and aesthetic practitioners will now extend to three of the largest and fastest-growing segments of their practices, putting Allergan in a unique position to provide expanded customer service, and help meet the needs of patients.”  Mark Foley, chief executive officer of ZELTIQ said he looks forward to working with Allergan to ensure the success of this transition, “Allergan’s world-class medical aesthetic products, global footprint, history and commitment to developing best-in-class aesthetic treatments makes the company ideally suited to realise the maximum commercial potential of the ZELTIQ controlled-cooling technology platform.” He added, “We look forward to working with Allergan to ensure successful completion of this transaction, and supporting the ongoing success of the CoolSculpting technology in the US and around the world.”    The CoolSculpting System is approved by the US Food and Drug Administration for contouring through lipolysis or reduction of unwanted fat, by cooling targeted fat cells in the body to induce a controlled elimination of fat cells. Injector

TSK launches the  3Dose Unit Dose Injector

Aesthetic needle manufacturer TSK Laboratory has launched a new needle injector aimed at delivering exact measured unit doses. The 3Dose Unit Dose Injector has a ‘clicker system’, which produces audible and tactile feedback per injected dose. It also features a ‘remaining unit indicator’ and unit scale, so practitioners can visualise the injected product and remaining units in the injector. According to TSK, this feedback system aims to ensure that the injected volume is more accurate and more deliberate. The company also claims that practitioners may save up to 20% botulinum toxin per vial. The scale on the plunger is represented in units and a visual unit indicator on top of the injector handle shows the number of remaining units in the injector barrel. 

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Training

Skin Tech and RRS training to take place in April Distribution company AestheticSource will hold training for its medical peeling brand Skin Tech and RRS injectable products in London on April 3. The Skin Tech Pharma Group Symposium will aim to teach delegates how to repair, refill and stimulate skin and hair with peels and mesotherapy for skin lifting and tightening, skin nutrition, management of pigmentation issues and stretch marks, and biostimulation for alopecia. The day will feature a review of combination peels with a focus on hydroxy acids and TCA, as well as deep peels with TCA and phenol; an introduction to the ingredients in RRS; a demonstration of RRS for facial rejuvenation, featuring a comparison of techniques using needling, gun and nappage; a presentation on rejuvenating the eye area; a discussion of alopecia and the launch of the new RRS syringe. In addition, dermatologist Dr Jane Ranneva will speak at the event and share her knowledge of medical aesthetics. Dr Ranneva is an experienced trainer for the use of chemical peels, dermal fillers and botulinum toxin, as well as being the founder of a mesotherapy training course.

THE BUSINESS DESIGN CENTRE / LONDON / 31 MAR & 1 APR 2017

COUNTDOWN TO ACE 2017 EXHIBITION Set over 2,500m2, the free-to-attend ACE 2017 Exhibition Floor is a huge attraction to those looking to discover new products and treatments, while increasing their industry connections. With more than 80 leading manufacturers, suppliers and distributors showcasing their services at ACE, you can find everything from the most innovative and advanced lasers to the latest evidencebased cosmeceuticals to support you in your aesthetic practice. You can also try out some of the fantastic treatments on offer and watch mini live demonstrations to see the impressive results that can be achieved with products being exhibited at ACE 2017. SPEAKER INSIGHT

Skin lesions

New course on increasing awareness of skin lesions Dalvi Humzah Aesthetic Training has launched a new dermatology course that aims to increase awareness of commonly encountered skin lesions. Skin Lesions in Medical Aesthetic Practice will look at benign, pigmented and malignant skin lesions, as well as current clinical guidelines, referral pathways, sun protection and the National Institute for Health and Care Excellence (NICE) guidelines regarding vitamin D. Among those leading the training course will be consultant plastic, reconstructive and aesthetic surgeon, Mr Dalvi Humzah, consultant dermatologist, Dr Stephanie Munn, dermatology nurse specialist, Isabel Lavers and cosmetic and dermatology nurse practitioner, Anna Baker. The interactive session is CPD accredited and will be held on April 21 at Crowne Plaza Birmingham NEC. Aquisition

Hologic set to purchase Cynosure Global healthcare and diagnostics company Hologic is set to acquire aesthetic treatment manufacturer Cynosure for $1.65 billion. Hologic are hoping the acquisition will allow them to capitalise on the medical aesthetics market. Steve MacMillan, Hologic’s chairman, president and CEO, said, “We had identified medical aesthetics as an attractive and complementary growth opportunity through our strategic planning process, and are pleased to have agreed to acquire Cynosure, the best-in-class company in the space. Together, we can strengthen our shared focus on innovation, market-leading products with demonstrated clinical benefits, and strong customer relationships.” Cynosure has a portfolio of more than 20 products across a variety of area in the aesthetics specialty. They will be exhibiting at the Aesthetics Conference and Exhibition (ACE) 2017 on March 31 and April 1 on stand number 20.

Dr Souphiyeh Samizadeh, who will speak on The Basics of Facial Assessment at the Premium Clinical Agenda, said, “Many aesthetic companies choose to launch their new products and treatments at ACE, so I have always found that the Exhibition Floor is an excellent place to find out what’s new and update your clinic offering for the rest of the year. It’s important for practitioners to do our research prior to purchasing any equipment, learn about their risks and benefits, and understand the science behind products. As well as the usual exhibitors, I have noticed that ACE always features new companies in the industry; so attending offers a fantastic opportunity to learn about valuable services you may never have considered before!” WHAT DELEGATES SAY “ACE is so good for networking, sharing experience with peers and seeing the latest treatments and technologies.” AESTHETIC NURSE, WEST SUSSEX

“There is a wealth of experience, knowledge and information available at ACE, allowing delegates to pick and choose which is most relevant to them. It is also an excellent opportunity to network with like-minded professionals and share learning experiences.” AESTHETIC DOCTOR, BUCKINGHAMSHIRE HEADLINE SPONSOR

www.aestheticsconference.com

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Events diary 3rd – 7th March 2017 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

31 March – 1 April 2017 st

st

Aesthetics Conference and Exhibition, London www.aestheticsconference.com

6th – 8th April 2017 15th Aesthetic & Anti-aging Medicine World Congress, Monte Carlo v1.euromedicom.com/amwc-2017

17th – 18th May 2017 BMLA Laser and Aesthetics Conference, Manchester www.bmlaconference.co.uk

15th – 17th June 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting, Helsinki www.bapras.org.uk/

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

PDO threads

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Conference

New Expert Clinic speakers announced for ACE 2017 Leading aesthetic professionals will share their clinical expertise, perform live demonstrations and outline their best practice advice at the Aesthetics Conference and Exhibition (ACE) 2017 Expert Clinic on March 31 and April 1. Delegates can join Dr Fernando Galcerán at his mesoestetic Expert Clinic session on the use of Dermamelan for the treatment of hypermelanosis, in which he will discuss a clinical review of patients and share treatment techniques. They can also attend HA-Derma’s Expert Clinic sessions, where Dr Irfan Mian will outline the use of Profhilo and Aliaxin SR, detailing the results that can be achieved by combining the treatments, while Dr Ravi Jain will argue why he believes that the hybrid technology used in Profhilo is better than other types of hyaluronic acid. Also speaking at an ACE Expert Clinic is Dr Lee Walker, who will speak on behalf of Teoxane UK, as well as product and education specialist Victoria Hiscock, who will present on chemical skin peels at the AlumierMD session. By registering for free, delegates can attend all of the Expert Clinic sessions, choose from 12 Masterclasses and 18 Business Track sessions. Delegates can also choose to upgrade their free registration to a Premium Clinical Agenda pass, where they can attend up to four sessions on treating the face for £109+VAT per session. To find out more and to register visit www.aestheticsconference.com Surgery

4T Medical launches PDO thread training courses Aesthetic product supplier 4T Medical has announced new training courses for 2017 on PDO thread treatments. The courses, which are CPD accredited, include: PDO Thread Introductory Course, PDO Thread Training for Non-surgical Face Lifts, Advanced PDO Thread Training, and PDO Thread Training for the Body. 4T Medical claims that delegates will receive important practical experience from these courses. Once delegates have completed a course, the company will offer ongoing support via telephone, email or follow-up visits. Managing director of 4T Medical, Julien Tordjmann said, “We aim to offer a high standard of training with a good balance of theory and hands-on practical experience so delegates can feel completely confident to carry out PDO thread treatments independently.” The training courses will take place throughout March and April in Cheshire, in collaboration with the Cheshire International School of Cosmetology. 4T Medical will be exhibiting at ACE 2017 on stand 43.

Dr Demosthenous opens hair restoration operating theatre Scotland-based aesthetic practitioner Dr Nestor Demosthenous has opened an operating theatre at his clinic in Edinburgh that specialises in hair restoration procedures. The operating theatre at the Dr Nestor’s Medical Cosmetic Centre provides hair restoration procedures such as follicular unit extraction (FUE) and follicular unit transplantation (FUT). Dr Demosthenous said, “I am delighted to be opening the operating theatre at the Medical Cosmetic Centre, and to be able to offer hair restoration treatments to the people of Edinburgh and beyond. We hold ourselves to the highest standards and it’s incredibly important to us to be able to offer the very best level of care for our patients.” Industry

HA-Derma appoints new BDM Aesthetic distributor HA-Derma has appointed Frank Ward as its new business development manager. Ward has worked in the aesthetics industry since 2002 and, according to HA-Derma, has a vast knowledge of the specialty. The company claims that he is experienced in promoting and educating users on hyaluronic acid (HA) injectable products, and has a strong focus on customer relationship management with aesthetic practitioners and businesses. Ward’s role will include the sales promotion and marketing of the IBSA Farmaceutici Italia range of HA products including Aliaxin, Profhilo, Skinko, Skinko E and Viscoderm. HA-Derma will be exhibiting at ACE 2017 on stand 37.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Distribution

Schuco International to distribute Croma-Pharma aesthetic product ranges

Aesthetics

Vital Statistics

There has been a 109% increase in Britons going abroad for cosmetic surgery in the last two years (Flawless.org, 2017)

UK distributor Schuco International has become the exclusive UK distribution partner of Croma-Pharma GmbH, the pharmaceutical manufacturer of the aesthetic product ranges that include Princess HA Fillers, Princess Lift PDO Threads and Princess Skincare. According to Schuco, the Princess range offers solutions for a wide variety of aesthetic indications. The Princess HA Fillers are monophasic HA fillers cross-linked with BDDE, that are available with or without lidocaine, and aim to deliver safe, long-lasting results with reliable volume effects. The company claims that the Princess Lift PDO Threads, which use completely absorbable, biodegradable threads, deliver high tensile strength and pliability with low resistance to the skin and results that can last up to 18 months. Paul Huttrer, the chief executive of Schuco, said, “We are thrilled to be able to announce that Schuco will now become the exclusive UK distributor for the Princess aesthetics range. Croma-Pharma has a long-established heritage and expertise of manufacturing premium aesthetic products that are used around the world and together we will be working hard to replicate this success within the UK and Ireland.” The full Princess range is immediately available in the UK through Schuco and their appointed pharmacies. Schuco International is the headline sponsor of ACE 2017 and will be displaying the Princess range on stand 24 at the event on March 31 and April 1.

In a survey of 2,000 US women, 91% have made natural/organic skincare purchases in the last 12 months (The Benchmarking Company, 2016)

British men using selftanning products rose from 9% in 2015 to 14% in 2016 (Mintel, 2017)

143,000 Americans aged 65 and older opted to have cosmetic surgery in 2015 (American Society for Aesthetic Plastic Surgery, 2015)

Training

Oculo-facial Aesthetic Academy releases new training dates The Oculo-facial Aesthetic Academy will hold anatomy-based training courses in March, May and June this year. The founder of the Oculo-facial Aesthetic Academy, aesthetic and reconstructive oculoplastic surgeon Mrs Sabrina Shah-Desai will lead the CPD-accredited courses, which cover the prevention and management of dermal filler complications, rejuvenating the periorbital and perioral areas using fillers, and rejuvenating the face with fillers. Taking place at King’s College London, the courses consist of fresh cadaver wet-lab training, with the aim of promoting safe and evidence-based aesthetic practice. Mrs Shah-Desai said, “Our delegates obtain a comprehensive understanding of the facial anatomical layers using fresh cadavers and prosections, enabling them to practice whilst avoiding critical neurovascular anatomy. Courses also include guidance to learn how to avoid complications from poor technique and inappropriate patient selection.”

UV rays account for 80% of skin ageing (Clinical, Cosmetic and Investigational Dermatology, 2013, study of 298 women, aged 30 to 78)

Companies that published more than 16 blog posts per month got 4.5x more leads than companies that published 0-4 monthly posts (HubSpot, 2015, review of more than 13,500 HubSpot users)

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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News in Brief Healthxchange launches recycling service Pharmaceutical supplier Healthxchange Pharmacy has launched a free recycling service for empty cool bags from cold chain orders. The company has partnered with courier service Point to Point, which will collect cool bags that have been used for items such as botulinum toxin at the same time as delivering new products from Healthxchange. “No one likes waste so we are doing what we can to minimise the impact we have on the environment,” said managing director of Healthxchange, Karen Hill. Healthxchange will be exhibiting at ACE 2017 on stand 9. New UK sales manager at Technical Laser Care Aesthetics equipment supplier Technical Laser Care has appointed a new UK sales manager. Nigel Matthews has previously worked for Wigmore Medical, DEKA and Lumenis. He hopes to expand the company’s current sales and find new suppliers to add to its portfolio of products. Matthews has more than 15 years’ sales experience with lasers, IPL and other devices within the aesthetic specialty. SkinMed announces new training dates for peels, acne and rosacea Dermatological distribution company SkinMed has confirmed new training dates for using chemical peels and treating acne and rosacea. The Bespoke Chemical and Physical Remodelling Training and the Acne and Rosacea Training courses will take place in Harrogate on March 21 and May 9; Bristol on April 11; London on March 28, April 25 and May 23; Glasgow on May 3; Manchester on March 7, April 4 and May 11 and in Birmingham on March 14 and May 16. New dermal filler injections resource released  A new textbook on dermal filler injection techniques has been released. ‘Filler Evolution – Volumizing Injections and Advanced Techniques for Facial Rejuvenation’, by Dr Salvatore Piero Fundarò was officially launched at the International Master Course of Aging Science (IMCAS), Paris, in January. It is a practical textbook that aims to inform the reader of hyaluronic acid filler injection techniques. 

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Awards

 

New sponsors announced for Aesthetics Awards 2017

Three new sponsors have been announced for the 2017 Aesthetics Awards on December 2. Cosmedic Pharmacy will sponsor the Award for Best Clinic Midlands and Wales, Enhance Insurance will sponsor Training Initiative of the Year and AlumierMD UK will sponsor the Award for Clinic Reception Team of the Year. Each Award recognises excellence achieved throughout the year and demonstrates the finalists’ commitment to high standards and safety in medical aesthetics. Iain Ashby, superintendent pharmacist at Cosmedic Pharmacy, said, “We sponsored our first award last year and the whole experience of being involved in such a prestigious event encouraged us to return this year. The Awards recognise excellence in our industry and sharing this acts as an inspiration to others. Due to the nomination, voting, ceremony and articles about the winners, it is a great opportunity for us to advertise the Pharmacy almost all year round.” Martin Swann, divisional director at Enhance Insurance, said, We believe that at the heart of every business there should exist good risk management, which is achieved through sound training, processes and procedures. Recognising training initiatives that centre themselves on safe practice is core to helping reduce the risk to the industry in the future, which is why Enhance Insurance has chosen to sponsor the Award again. Last year’s ceremony was very well organised and we look forward to attending again in 2017.” Samantha Summerfield, marketing and events manager at AlumierMD UK, added, “The Best Clinic Reception Team is an Award that is close to our company’s ethos – great people at the heart of our business. An exceptional reception team deserves the accolade as they are responsible for all parts of the patient’s journey and play a huge part in having a successful business.” Visit www.aestheticsawards.com to keep up-to-date with the developments! Sexual wellbeing

Dr Sherif Wakil launches sexual wellbeing association Aesthetic practitioner Dr Sherif Wakil has launched The International Association of Aesthetic Gynaecology and Sexual Wellbeing (IAAGSW). Dr Wakil, president of the association, has formed the group in response to an increase in demand for surgical and non-surgical sexual aesthetic treatments. The group aims to create a transparent platform where professionals from different specialties can join together to share their medical knowledge and experience. Members of the scientific committee include consultant gynaecologist Dr Ahmed Ismail, consultant cosmetic surgeon Mr Paul Banwell and O-shot founder Dr Charles Runels. Dr Wakil said, “Through founding this association, the scientific committee is aiming to create a multi-disciplinary and scientifically-based approach to treatments in this very important, swiftly developing subspecialty, where experts in different medical fields meet to share their knowledge for the greater good of patients.” IAAGSW will be holding its first world congress on Aesthetic Gynaecology and Sexual Wellbeing in London in 2017, as well as regular training dates for delegates.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Training

Aesthetics Skincare

NeoStrata Symposium to be held in May The first NeoStrata European Symposium will be held at The Royal College of Physicians on May 19 and 20. According to UK NeoStrata distributor AestheticSource, the event will feature leading scientists, doctors and aesthetic practitioners from around the globe, who will discuss skin anatomy and physiology, the science behind the brand and how to use the latest ingredients for optimal results. The event will consist of patient specific success stories and review published clinical data for the management of the older patient, acne-prone and oily skin, new approaches to sensitive and rosacea-prone skin, skin of colour and post-inflammatory hyperpigmentation. In addition, the new NeoStrata Retinol Peel will be unveiled. Lorna Bowes, the director of AestheticSource, said, “NeoStrata is a rapidly growing global brand, with its roots in clinical dermatology. With a focus on R&D rather than marketing, there is constant pipeline of innovation and further growth is expected now it is part of the Johnson & Johnson portfolio. The team at AestheticSource is both excited and proud to host the first NeoStrata European Symposium in London in May.” Leigh Ann Catlin, the global marketing manager at NeoStrata, added, “We are thrilled that our UK distributor of five years, the award-winning AestheticSource, is leading the way by launching our very first NeoStrata European Symposium. We hope this to be the first of many dedicated practical and theoretical symposiums and we have no doubt that all delegates will leave fully immersed and inspired.” AestheticSource will be exhibiting at ACE 2017 on March 31 and April 1 on stand number 27.

On the Scene

New skin rejuvenation treatment launched in the UK Aesthetic distributor Pure Swiss Aesthetics has launched the Vetia Mare Rejuvenescence Activation Treatment aimed at rejuvenating the skin. According to the company, the new treatment is designed as a four-week skin regimen for both men and women, which aims to revitalise and renew the skin, as well as restore firmness and radiance. The active ingredients consist of oceanic elements including dermochlorella, extracted from Chlorella vulgaris, jellyfish collagen, aimed at increasing hydration to improve the skin’s firmness and smoothness, microalgae and macroalgae to stimulate collagen and elastin production, and gorgonian extract that aims to protect the skin with effective anti-oxidant and anti-inflammatory agents to calm sensitive skin. The company claims that the combination of oceanic ingredients helps to stimulate cellular communication and reduce wrinkles, whilst guarding against oxidation-induced ageing.

On the Scene

Meline Workshop, London Aesthetic practitioners were welcomed to an informative workshop at the Royal Society of Medicine in London, to learn about the Meline range that is distributed in the UK by Medical Aesthetic Group (MAG). The Meline range is a treatment that aims to treat pigmentation on all skin types on the face and body. Anne Leonthin, a Meline specialist who demonstrated the application of the range said, “It is a specialised product line which means we have different treatments depending on the prototype of the skin and on the pigmentation of the skin.” She added, “Results from clinical studies have shown 60% reduction of the pigmentation.” Glow Aesthetic Training Academy director, Morag Hague who is working with MAG to educate practitioners through a training course on the Meline pigment treatment said, “The training will be a one-day course that includes theory and practical learning. Attendees will gain confidence in using the products effectively.” MAG will be exhibiting at ACE 2017 on stand 52.

Galderma Global Nurse Faculty meeting, Paris Aesthetic nurses from six different countries gathered at the Mövenpick Hotel Paris Neuilly for the Galderma Global Nurse Faculty meeting on January 28 and 29. The meeting was chaired by aesthetic nurse prescriber and clinical director of Dermal Clinic in Edinburgh, Jackie Partridge, who explained that the aim of the meeting was to identify and discuss the main challenges that aesthetic nurse injectors face and to examine how dermatology company Galderma can best provide support for these challenges. “The Galderma Global Nurse Faculty meeting has been a great coming together of like-minded nurses to share experiences and address key issues and challenges,” said Partridge, adding, “it is fantastic to collaborate with Galderma on this exciting initiative.” There were 12 other participants who attended the meeting from the UK, Sweden, Denmark, Australia, Canada and the US, and they have partnered with Galderma to deliver a series of initiatives and activities in 2017 and beyond. Other attendees from the UK included aesthetic nurse prescribers Lou Sommereux and chair of the British Association of Cosmetic Nurses, Sharon Bennett. Jenny Andersson Colby, global medical affairs manager at Galderma, said of the event, “Nurses play such an important role in aesthetics and this meeting is the first step in an ongoing programme to shape a series of activities together with a core group of nurses.” Galderma will be exhibiting at ACE 2017 on stand 15.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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On the Scene

IBSA’s Annual Marketing Meeting, Paris

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Paul Huttrer, Chief Executive, Schuco International (London) Ltd

More than 27 distributors from around the world attended aesthetic manufacturer IBSA Farmaceutici Italia’s Annual Marketing Meeting at the Hyatt Hotel in Paris on January 24. The meeting included presentations by company manager Tania Pirazzini and international sales manager Leo Magnani, who detailed the latest developments of IBSA’s injectable product range and shared reports on the company’s annual achievements, as well as its future marketing plans. Key topics included presentations on IBSA’s approach to skin ageing and creating the marketing term, ‘multi-level tissue regeneration’. Also in attendance was Professor Hema Sundaram and Professor Daniel Cassuto, who presented scientific data on NAHYCO – the technology that aims to produce the stable hybrid complexes of hyaluronic acid used in Profhilo. Pirazzini closed the meeting with an introduction of the VisionHA project, in which IBSA aim to create a worldwide expert group on hyaluronic acid. IBSA’s UK distributor HA-Derma will be exhibiting at ACE 2017 on stand 37. On the Scene

Cosmetic Courses 1st Annual Conference, Buckinghamshire Aesthetic training provider Cosmetic Courses celebrated its 15th anniversary with a day of learning at its National Training Centre in Buckinghamshire on February 4. Consultant plastic surgeon and clinical director of Cosmetic Courses Mr Adrian Richards opened the event with a welcome talk on the changing face of aesthetic training, before the 70 delegates began a day filled with non-surgical workshops, live demonstrations, and business and marketing seminars. Delegates attended four sessions throughout the day, with two options for each time slot to enable them to tailor their experience to their learning requirements and gain CPD points. On offer were live demonstrations on advanced chemical peeling systems, PDO thread lifting, advanced lower face botulinum toxin treatment and nonsurgical facelifts, and lip augmentations. Seminars covered how to build a successful aesthetic practice, managing patient expectations and potential complications, an introduction to pharmacy service Pharmacyspace, increasing your customer reach, the perfect consultation and online training opportunities. Attendee Dr Shazia Hasan said of the day, “I think there’s been a really good mix between practical demonstrations and factual information. So, for me, I have learnt some new tips about the new thinking in clinical practice. As well as that, I learnt more about the changes in the aesthetic industry so it’s been a really valuable day.”

What sets Schuco apart in the aesthetics industry? With our dermatology and surgical heritage, Schuco are in a unique position to bridge the gap between the medical and aesthetics sectors. From teledermatology for the early detection of skin cancer to personalised cosmeceuticals, we have been pioneering new technologies for 60 years. Innovation is our passion. Our philosophy is to build strong relationships with our customers, promote thorough education and provide clinical support and training. This allows our customers to be well positioned to make decisions based on clinical evidence and to in turn offer the best treatments to their clients. You have recently announced a new partnership to distribute the Princess® range, tell us more. We were extremely excited to be able to announce our new partnership with CromaPharma to become the exclusive distributor for Princess® Fillers, Princess® Lift PDO Threads and Princess® Skincare in the UK and Ireland. Princess® is a well established global brand, offering premium aesthetics products that deliver outstanding and long lasting results. How will the Princess® range complement your existing aesthetics products? The addition of the Princess® products to our range builds on the recent international collaboration between Croma-Pharma and UniverSkin. This means that Schuco is now in a position to offer clinicians a unique synergy between Princess® and UniverSkin, allowing them the opportunity to deliver bespoke combination treatments to their patients. How has Schuco adapted to the changing marketplace? 2017 is our 60th Anniversary so we’ve seen significant change over the years. Now our focus is very much on identifying and embracing the impact of new technology for both clinicians and consumers. With the fast pace of change, this has required us to grow our team in order to have the necessary expertise for evaluating and supporting these new innovations. Our tag line is ‘tomorrow’s skin technology’ and I’m very proud of how hard my team work to do what it says on the tin! This column is written and supported by

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


WIN N E R Best Anti-Ageing Treatment

S TA ND 2 6 3 1 ST M AR - 1 ST AP R 2017, LONDON A E S THE TIC S CONFEREN CE.CO M


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19th International Master Course on Aging Science, Paris Aesthetics reports on the highlights from Paris’ international medical aesthetic conference Taking place between January 26-29, the International Master Course on Aging Science (IMCAS) lived up to its daily paper’s tagline of ‘a lot can happen in four days’. For the 19th year, the varied and diverse educational congress welcomed attendees from around the world at the Palais Des Congrès in Paris, with more than 7,000 delegates in attendance. The exhibition, which was split between two floors, comprised 200 aesthetic manufacturers, distributors and suppliers, all displaying and demonstrating their latest products and treatment protocols. The educational agenda took place in eight different rooms, delivering presentations on a different topic each day, including injectables, clinical dermatology, lasers, genital treatments, cosmeceuticals and regenerative medicine. The agenda included 140 scientific sessions, 250 learning hours and 520 expert speakers. Managing and utilising social media was a big focus on the practice management module, which took place on the opening day of IMCAS. Lectures in the session ‘Managing your online communication: social media and website’ proved to be popular, with talks by UK aesthetic physician Dr Ravi Jain, US aesthetic business consultant Wendy Lewis and UK consultant plastic surgeon Mr Olivier Branford; an avid user of social media with more than 125,000 Twitter followers. Mr Branford stressed the importance of sharing high quality content and emphasised the power of social media, giving advice on blogging and writing articles and how to publicise these through this medium. Lewis said of the sessions, “Social media marketing took centre stage at IMCAS 2017; Instagram and Snapchat are the fastest growing platforms currently, and clinics are struggling to keep up with producing shareable content and the never-ending changes and trends. Emphasis was placed on new ways to create video content and inspiring visuals, how to choose the right hashtags, scheduling content, ideal times for posting, and best practices for managing multiple platforms for a busy clinic.” She continued, “Many speakers underscored the importance of getting the right staff, treating them well, maintaining continuity in the clinic, and investing

Aesthetics Journal

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in the best technology to improve efficiency as essential elements for strong aesthetic clinic growth.” Friday was another busy day at the congress, with many delegates opting to watch presentations on the cosmeceutical agenda. In the morning, a talk on ‘Genetic secrets to youthful looks revealed’ by industry representative David Gunn discussed interesting research from the British Journal of Dermatology, which suggested that although smoking can age the skin by two years, sun damage can age it by four years. In the afternoon, the impact of prebiotics and probiotics on skin health was examined by dermatologist Dr Stefanie Williams, followed by Dr Marita Kosmadaki from Greece who looked at the use of cosmeceuticals on skin ageing. Dr Kosmadaki posed the question to the audience, ‘Can what we eat affect the way our skin looks?’ She discussed the results of a recent study on the severity of wrinkles, which suggested dairy, sugar and meat have a negative influence on skin resulting in more wrinkles. The section was concluded by Canadian dermatologist Dr Sahar Foad Ghannam who spoke about the use of certain foods for photo-protection, which was followed by questions from the audience. One question posed by a delegate, on whether SPF affects the amount of vitamin D absorbed through the skin, brought about much debate from the panel, who had differing views. Dr Foad Ghannam stated there was no direct correlation between vitamin D deficiency and the use of sun protection, whereas Dr Williams disagreed, explaining she had read studies that indicated otherwise. The sponsored symposiums, including talks hosted by IBSA Farmaceutici Italia, Allergan and Teoxane Laboratories, proved very popular with delegates. In the Merz Aesthetics symposium, Dr Simon Ravichandran provided a live demonstration on jaw contouring using hyaluronic acid dermal filler on a male patients in his 50s, and in the Galderma symposium, facial plastic surgeons from the US Professor Jonathon Sykes and Dr Frank Rosengaus performed a live injectable treatment of the mid-face, which was well-received by the audience as 3D imaging was used, enabling delegates to wear 3D glasses to be able to get an in-depth look at the anatomy. Saturday morning began with a court-room style presentation on hand rejuvenation and a debate on whether using just hyaluronic acid is enough; US dermatologist Dr Rhoda Narins acted as the ‘judge’, with ‘cases’ for and against presented by different speakers. Each presented compelling evidence for their respective technique but in the end the judge’s summary sided with the use of multimodal treatments. During the weekend, facial treatments for men and women were presented and chaired by many UK practitioners, including Dr Raj Acquilla, Mrs Sabrina Shah-Desai and Mr Dalvi Humzah. Mr Humzah spoke on cannula versus needle for oval injection in one session, with evidence presented suggesting that cannula is safer when injecting the face. Following this Dr Peter Peng from Taiwan spoke on ‘Recognising and preventing the side effects of neurotoxin injections on the masseter’. He presented a comprehensive review of the potential complications of botulinum toxin in treating the masseter, a topic that, according to Dr Peng, hasn’t been widely discussed. Dr Benjamin Ascher, plastic surgeon and IMCAS scientific director, said, “Each year we strive to bring a richer, more immersive learning experience and our Scientific Committee has worked hard to bring together the best experts and their insights in the aesthetic medical field.”

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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2. Composition Speakers will be poised and have the right gravitas. They will be able to project and engage with the audience, presenting themselves as confident and knowledgeable. 3. Effective communication Presenters will be able to demonstrate the results of products and treatments and discuss them in a way that the audience fully understands. They will be able to communicate the scientific evidence clearly and effectively.

Scientific presentations Many doctors are concerned that when they deliver training as a company representative, they will have to use presentation slides that are littered with marketing jargon and logos, which distracts from the actual content. As such, we’ve approached a group of top doctors from around the world and asked them to create slides that are science-based and doctor led. In order to ensure presentations are as effective and visual as possible, doctors also have access Learn more about Galderma’s doctor-led to an online comprehensive library that they can use to customise their presentations. The library approach to training their trainers contains a wide-range of learning materials Created for doctors, by doctors ranging from the anatomy to the mid-face, upper face, lower face, More and more practitioners around the UK recognise the importance hyaluronic acid fillers, information on injecting and product messages of regular aesthetics training, and in response to this awareness there – it contains everything presenters need to conduct a successful has been an overwhelming abundance of new training courses and clinical demonstration. For example, if a group of doctors are putting providers appearing in the specialty. But can you sign up to a course together a presentation on the mid-face, they can access the library, and feel confident that the person training you is fit to train? go to the Anatomy deck, download a cadaver image and possibly Galderma are not only focused on delivering education, we’re focused even use a 3D video. It is very important that our programmes are on ensuring that our trainers meet the strictest and highest standards, highly individualised. so they can pass on a wealth of knowledge and science to others, who can pass that information to other doctors and, of course, their Invested in local trainers patients. Galderma is one of the only aesthetic companies invested in training The Galderma ‘Train the Trainer’ programme is unique – it’s created for local trainers rather than utilising already existing trainers. We create doctors by doctors – using KOLs in the aesthetics industry to train the local mentors and empower them to work with their local Galderma top level of UK practitioners, so they are able to train others to the best representative and understand the training requirements needed of their ability. in their area. We know there are geographical differences that Over the last couple of years, we’ve created the first global aesthetic influence the demand of different types of treatment, so we ensure curriculum, which comprises, but is not inclusive of, the following: that the trained speaker in each region can work together with the Galderma representative to plan for the training needs in their locality, • Toxin science and create an even more bespoke training event. They can use the • Dermal filler and hyaluronic acid science right information to deliver and fill the training gap in the region. By • Anatomy identifying the local needs, and helping to increase the experience, • Upper, lower and mid-facial assessment skill and technique in that area, our trainers are helping to bring a • Product benefits and messages wider-range of aesthetic practitioner to a high level. • How to talk and present on a podium

Galderma Aesthetics Academy

Invested in you The three key elements Trainers will gain three crucial elements from the course that will help make them a successful aesthetic trainer: 1. The science Practitioners will be able to stand in front of an audience with credibility, demonstrating that they understand all the science behind the products and treatments that they are speaking about.

We are investing heavily in creating trainers of high quality, not just at a national podium level but also trainers who can go into a clinic and train with small groups of people. If anybody is presenting under the name ‘Galderma’, we are confident that they will have the right knowledge of the right science and have the right skill set.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Aesthetics

Cosmetic Surgery’s Decline in 2016 Aesthetics investigates the annual cosmetic surgery data from BAAPS and discusses what it could mean for the growth of the non-surgical specialty In March last year, Aesthetics reported data from The British Association of Aesthetic Plastic Surgeons (BAAPS) that indicated there had been a record-breaking 13% increase in Britons undergoing cosmetic surgery in 2015 compared to 2014.1,2 This year, however, presents a stark difference. In its annual release, BAAPS reported that the number of Britons undergoing cosmetic surgery in 2016 was the lowest in nearly a decade. It suggested that the number of cosmetic operations dropped by 40%, with the total number of procedures below 31,000 – 5% less than those that took place in 2007.3 After almost ten years of relatively consistent growth, the figures may have come as a surprise to many. Why 2016? According to BAAPS, the data is a compilation of private procedures conducted by members, which accounts for approximately 30% of plastic surgeons in the UK. In addition to this data, BAAPS presented research from insight agency Opinium, which partnered with the London School of Economics to survey 3,000 British people on the impact of Brexit on consumer behaviour. It suggests that due to the EU referendum, British people were less likely to ‘engage in any form of economic or social decision’. The report also noted that ‘mentioning the effect of the referendum on virtually anything leads people to answer that they are less likely to engage in activities requiring any level of trust or certainty including life changes, housing decisions, investment and consumption’, which may influence their answers.4 Aesthetic practitioner Dr Kuldeep Minocha, who spoke to Aesthetics last year about the increase in cosmetic surgery and its impact on the non-surgical specialty,1 agrees that Brexit and the presidential election in the US may have had an impact on UK consumer habits. “It reminds me of 2008-2009 when the economy was really shaky and you could tell people were really quite worried about their prospects. I think Brexit has had the same effect; creating the same level of uncertainty,” he says. Thus, it seems that undertaking an invasive cosmetic surgery procedure might

not have been such a feasible option for many in 2016. But, what did this mean for the nonsurgical aesthetic specialty? Most decline Consultant plastic surgeon and former BAAPS president, Mr Rajiv Grover, who compiles the statistics each year, said, “In a climate of global fragility, the public are less likely to spend on significant alterations... opting for less costly non-surgical procedures such as chemical peels and microdermabrasion, rather than committing to more permanent changes.” Anecdotal reports from aesthetic practitioners align to this, with many highlighting an increase in demand for non-surgical procedures. Dr Minocha said, “Year on year I get a rise of between 10-15% of patients. With the focus more on providing a holistic approach to treatment rather than treating just one concern with surgery, we can combine treatments to achieve overall rejuvenation – improving the brightness, texture and tone of the skin, along with correcting patients’ aesthetic concern. Without a doubt, there is an increase in demand for non-surgical treatments.” In addition, it can be argued that the BAAPS statistics indicate a move towards the non-surgical; face/neck lifts, browlifts and fat transfers demonstrated the biggest decrease in procedures taking place in 2016 (53%, 71% and 56%, respectively)2 – all of which are procedures that treat indications that can be addressed very successfully using non-surgical treatments such as botulinum toxin, dermal fillers, lasers, radiofrequency and ultrasound. “With procedures such as facelifts, the downtime is quite significant – it will take the patient a couple of weeks before they feel back to normal,” says Dr Minocha, also highlighting that the scarring that occurs as a result of surgery could put people off having treatment. He adds that patients are now more atuned to this than previous years, especially due to the increased media coverage of celebrities undergoing surgical and non-surgical procedures. In addition, Dr Minocha says the cost associated with cosmetic surgery may have also put people off in a year of potential economic change.

He says, “Non-surgical treatments are very affordable and with such a large number of treatment modalities on offer, patients needed to spend just a few hundred pounds, rather than a few thousand, for really good results.” Least decline The surgical procedures that saw the least decrease in treatments performed in 2016 compared to 2015 amongst both men and women were otoplasty (down 9%) and abdominoplasty (down 6%). Mr Grover suggests that this is likely because there are ‘no-real non-surgical equivalents’ currently on the market. Indeed, for men, abdominoplasty was the only surgical procedure that was performed more in 2016 than in 2015. Despite a 20% decline in procedures last year, breast augmentation remains the most popular cosmetic surgery procedure amongst women with 7,732 procedures performed last year, while rhinoplasty, which saw a 35% decrease, tops the list for most performed procedure amongst men, with 529 procedures performed in 2016.2 The future of cosmetic surgery and nonsurgical aesthetics Looking forward, Dr Minocha and Mr Grover agree that procedures such as breast augmentation and rhinoplasty, for which there are limited or no non-surgical options, are likely to continue to be popular. Dr Minocha notes, “The appearance of breasts and noses play a huge role in patients’ self-esteem and no non-surgical options offer the same results as surgery.” While these types of procedures are likely to remain popular in 2017, procedures such as face and neck lifts, browlifts and fat transfers may not be the first choice for patients. Dr Minocha adds that the growing plethora of evidence-based, non-invasive treatment modalities that can successfully address patients’ aesthetic concerns and offer minimal downtime at a reduced cost suggests that the non-surgical aesthetic market will continue to grow. He concludes, “In my own practice and from what other practitioners report, non-surgical medical aesthetics has never been so busy.” REFERENCES 1. Wales K, Cosmetic Surgery on the Rise (UK: Aesthetics, 2016) https://aestheticsjournal.com/feature/cosmetic-surgery-on-the-rise 2. BAAPS, SUPER CUTS ‘Daddy Makeovers’ and Celeb Confessions: Cosmetic Surgery Procedures Soar in Britain (UK: BAAPS, 2016) http://baaps.org.uk/about-us/press-releases/2202-supercuts-daddymakeovers-and-celeb-confessions-cosmetic-surgeryprocedures-soar-in-britain 3. BAAPS, THE BUST BOOM BUSTS (UK: BAAPS, 2017) http:// baaps.org.uk/about-us/press-releases/2366-the-bust-boom-busts 4. Crouch J, Impact of Brexit on consumer behaviour (UK: Opinium, 2016) http://opinium.co.uk/impact-of-brexit-on-consumerbehaviour/

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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WHAT CAN I SEE AT THE MASTERCLASSES?

A Final Look at ACE 2017 In less than one month, more than 2,000 delegates will gather in London for the Aesthetics Conference and Exhibition 2017. Aesthetics outlines what you will gain from attending this year’s event How can you ensure you remain up-to-date with the latest techniques, treatments, trends and industry developments? Where can you see the UK’s top aesthetic speakers, performing live step-by-step demonstrations and offering fundamental advice on procedures? The Aesthetics Conference and Exhibition (ACE) 2017, taking place on March 31 and April 1, provides all of the above and so much more, allowing aesthetic practitioners and professionals, like you, to be the best they can be in their practice and provide their patients with natural-looking, safe results.

What does FREE registration provide me with? By registering for free for ACE 2017, which takes less than five minutes to do online, you will have complete access to the Expert Clinic sessions, Business Track agenda, Masterclasses, Exhibition Floor and Networking Event.

The Masterclasses are the perfect opportunity to see aesthetic company experts and KOLs perform live treatments; from injectables and energy-based devices to skincare products and PDO threads. Highlights include aesthetic practitioner and KOL Dr Kieren Bong discussing his R+R hand rejuvenation technique using Teosyal Redensity I and Teosyal RHA 2 at the Teoxane UK Masterclass; Dr Uliana Gout leading the Filorga class that focuses on treating the lower face, which will include a live demonstration that outlines how to achieve outstanding results; also presenting will be Dr David Jack who will unveil the latest in combination treatments from Fusion GT – which include Plexr, Needle Shaping, Vibrance and CarboMix systems – for complete skin rejuvenation; and Dr Huw Jones running the Intraline Masterclass, in which he will discuss the beneficial and effective uses of PDO threads, succesful techniques, as well as performing a live treatment. See other sessions from: Galderma SkinCeuticals Lumenis Merz Aesthetics Almirall Ltd

WHAT CAN I SEE AT THE EXPERT CLINIC? There are 17 Expert Clinic sessions to watch at ACE 2017. Presented by leading aesthetic professionals, these sponsored sessions will showcase the latest developments in products and treatments, explore the science behind each, showcase live demonstrations and advise how you can enhance every treatment you perform. Pigmentation can be a challenging skin concern to address, however aesthetic practitioner Dr Fernando Galcerán will explain how topical treatment Dermamelan from mesoestetic, which aims to treat abnormal melanin deposits, could help. Dr Galcerán will discuss a clinical review of patients treated and show the photographic results. An array of skin concerns and treatments will be addressed in the Expert

Clinic, including chemical peel treatments; which will be explained and examined by product and education specialist at AlumierMD UK Victoria Hiscock, as well as skin laxity concerns, where delegates will learn more about the Aesthetics Awardwinning hyaluronic acid injectable Profhilo and how it is used for this concern by Dr Irfan Mian and Dr Ravi Jain, in the HADerma sessions. See other sessions from: AesthetiCare AestheticSource Belle Church Pharmacy Cynosure UK Medical Aesthetic Group

FusionGT Merz Aesthetics Lynton Lasers Naturastudios Rosmetics Teoxane UK

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017

Beamwave Technologies Alumier MD UK Plus more!


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WHAT CAN I SEE AT THE BUSINESS TRACK?

CAN I ATTEND THE NETWORKING EVENT?

Although many practitioners are extremely skilled and confident in the clinical aspects of medical aesthetics, some may not always have the business knowledge and acumen to make their practice even more successful and profitable. The ACE 2017 Business Track agenda, sponsored by Enhance Insurance, is full of practical tips and advice from leading aesthetic professionals. You can look forward to hearing from medical director of EF Medispa Rudi Fieldgrass, who will provide practical advice on how to successfully grow your practice and create a more profitable and reputable business; experienced accountant Veronica Donnelly, who will tell you all you need to know about business VAT; Naomi Di-Scala of Hamilton Fraser Cosmetic Insurance, who will explain how to handle a complaint against you or your clinic in the most effective way; and PR consultant Julia Kendrick, who will outline how to utilise PR to build your reputation and stand out from competitors. Make sure you also see the following valuable sessions: Skincare - It’s Business! Online Transactions Key Training Priorities Update on Joint Council Training Recommendations Opening a New Clinic Data Collection

Presentation Skills for Trainers Business Building Legal Implications of the GMC Choosing the Right Equipment Patient Selection and Communication Treatment Combinations Insurance Considerations

Yes! All ACE 2017 registrations include a free invitation to attend the esteemed drinks reception, sponsored by 3D-lipo, starting at 5:30pm on Friday March 31. The event will take place near the 3D-lipo stand (Stand 30) and is the perfect opportunity to network with colleagues, clients and peers, and make important connections with key industry leaders; all whilst enjoying a complimentary glass of prosecco! To register visit www.aestheticsconference.com For more information email support@aestheticsjournal.com or call 0203 096 1228 HEADLINE SPONSOR

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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.

Cryolipolysis 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.

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 advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

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HOW DO I BENEFIT BY UPGRADING MY FREE REGISTRATION TO A PREMIUM CLINICAL AGENDA PASS? The free clinical content at ACE 2017 is hugely educational and is delivered by expert speakers, but if you want to enhance your time at the event even further, the Premium Clinical Agenda offers exceptional first class teaching for those looking to enrich their knowledge, skills and expertise on assessing and treating the face. Split into four sessions over two days, three world-renowned aesthetic practitioners will host each symposium. The practitioners will be presented with real patients of different face-types and will each have 20 minutes to analyse the patient’s face, detailing their assessment and discussing their treatment protocol. Each speaker will demonstrate one treatment from their suggested protocol, outlining effective rejuvenation techniques as well as pre- and post-procedure care. With each 3-hour session worth 3 CPD points, you can choose from:

• Saturday AM: The Basics of Facial Assessment – presented by dental surgeon and aesthetic practitioner Dr Souphiyeh Samizadeh, aesthetic nurse prescriber Lorna Bowes and chair of the International Peeling Society aesthetic practitioner Dr Uliana Gout • Saturday PM: The Young Female Face – presented by international speaker Dr Raj Acquilla, chair of the BACN and nurse prescriber Sharon Bennett and aesthetic practitioner Dr Askari Townshend You have the flexibility to choose the sessions you believe will benefit you the most, and for only £109+VAT each, with discounts available when booking multiple sessions, you are guaranteed to get value for money for yourself and your practice.

• Friday AM: The Ageing Female Face – presented by consultant plastic surgeon Mr Dalvi Humzah, aesthetic nurse prescriber Anna Baker and aesthetic practitioner Dr Tapan Patel • Friday PM: The Male Face – presented by aesthetic practitioner Dr Kate Goldie, consultant dermatologist Dr Maria Gonzalez and aesthetic practitioner Dr Beatriz Molina

2017

Make sure you’re there for the most educational and comprehensive event in medical aesthetics. We can’t wait to see you ACE 2017!

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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The Medical Aesthetics Training Process Practitioners share advice on how to be successful through continuous and appropriate training and development The topic of training might, to some, be a rather dry discussion. In most medical professions, such as those who are a doctor, nurse, dentist or surgeon, the training consists of years of study at university, with a specialist qualification awarded upon completion of the degree, after final exams. But for many in the medical aesthetics specialty, the process is somewhat different. Although guidelines for the levels of training needed to perform aesthetic treatments were released by Health Education England (HEE) in November 2015,1 there is currently no regulation with regards to the minimum level of experience that a so-called ‘aesthetic practitioner’ must have to be able to administer non-surgical injectable treatments such as botulinum toxin, dermal filler injections and PDO threads. There is therefore no single route that one must take to become competent in these treatments from a regulation standpoint. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon, as well as the director of Dalvi Humzah Aesthetic Training, winner of the 2016 Enhance Insurance Award for Training Initiative of the Year. He explains, “The problem that we currently have in the UK is that we do not have any specific structured training that says that when you complete this course you are qualified in aesthetic treatments. This means that it is really up to the individual to arrange their own training and make sure that they are competent. That is the difficult thing – it’s not like any other specialty where you can say, at the end of these five years you can do a written exam and be called a specialist. This is something that is sorely missing.”

Aesthetics

medical professional should do to become the safest and most competent practitioner that they can be. Consultant plastic surgeon and clinical director of Cosmetic Courses, Mr Adrian Richards, says, “Ongoing training is essential for any sort of medical professional in any specialty whether you are a surgeon, doctor, nurse or dentist.” He adds, “Aesthetics is no different, in fact, aesthetics is a very fast-growing, changing specialty, so it’s essential that we as practitioners have good training in this area and are up-todate with the latest treatments.” Aesthetic independent nurse prescriber, Rachael Wainwright, who is a trainer for Healthxchange Academy and Allergan, agrees that training in aesthetics is vital, “Safety in the aesthetics industry is a big concern at present, especially in light of the lack of regulation in the industry. Regular training ensures that injectors are keeping up-todate with modern practises and are aware of the safest products and techniques available.” Whether you are an experienced practitioner looking to develop your skills or if you are new to the specialty, the practitioners agree that training is an ongoing process. This process includes careful consideration of what you would like to get out of your training, thorough research and assessment of the types of courses available, how you can make the most out of the information that is provided to you, and how you can continuously build upon and update your skills and knowledge in the aesthetics specialty. Choosing a course The industry is currently inundated with many different training courses, which can pose a challenge to anyone looking to choose their next education session. Dr Sophie Shotter is an aesthetic practitioner who also has experience in training aesthetic practitioners, and says that, “There are so many companies now I think it’s really hard to decide which to go for – when I trained four years ago there really weren’t that many.” Broadly speaking, there are three different types of training course that aesthetic practitioners may consider. These are: • Training courses which may be verified through Continued Professional Development (CPD) bodies, where you can receive CPD points for appraisal or revalidation, which generally include one or two day courses.

“Aesthetics is a very fastgrowing, changing subject, so it’s really essential that we as practitioners have good training in this area and are up-to-date with the latest treatments” Mr Adrian Richards

Importance of training Aesthetic practitioners and trainers interviewed for this article agree that there are certain things that both a new and experienced

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


NEW

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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ deviceapprovalsandclearances/pmaapprovals/ucm439066.htm

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CONTOUR & DEFINE


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• Courses that are conducted through an aesthetic company and may be exclusive to specific products such as a pharmaceutical company or distributor. • Training for a post-graduate accredited qualification by regulatory body Ofqual, which is the Office of Qualifications and Examinations Regulation (may include courses that are inline with HEE recommended guidelines for Level 7).1 So, how do you know what is right for you? Mr Humzah says that it’s all about predetermining your learning outcomes and objectives, “The challenge is to figure out what you will get out of the course – whether it will deliver what you need it to do and that means looking at the course in a lot of detail.” For example, if a practitioner was looking to join the register of aesthetic practitioners administering botulinum toxin treatments that the Joint Council for Cosmetic Practitioners (JCCP) is scheduled to launch later this year,1 then they might consider becoming qualified through a Level 7 course. This is because the JCCP is proposing that only practitioners with this level of training will be able to join the register for this treatment as they are hoping to implement national standards developed through HEE, however this framework has not yet been released so there may be further changes to the requirements of the register.1,2 Mr Richards explains, “Level 7 courses can be for both new and experienced practitioners. If experienced practitioners wish to do a qualification, they can apply for recognition of prior learning so they can use some of their previous practical experience towards the Level 7 modules. If you are new you might want to start with a one or two day foundation course first to see whether aesthetics is for you.” When choosing any course, Wainwright suggests answering the following, “Is it a CPD or Ofqual course? Does it offer practical and theoretical based training? Is it led by industry leading trainers/expert medical professionals? Is the venue purpose built for training courses? How many delegates will be on the course? Small group sizes are best for practical sessions.”

“There are good quality conferences in the UK and abroad so I would definitely advise practitioners to attend these to keep up their knowledge” Dr Raul Cetto

Aesthetics

Dr Shotter also advises to, “Do your research, if you know somebody who is already in the industry ask where they did their training and look the course up. It’s important to note that just because somebody has a ‘flash’ website, it doesn’t mean they are the best around. Look at the reviews as it gives the course independent validation, look at the experience of the trainers and read about the individual courses, what they offer and if they have won any industry awards.” As well as the above considerations, aesthetic practitioner, mentor and trainer at the Harley Academy, Dr Raul Cetto, believes practitioners should, “Choose a course that has a mentoring component – there is great value in attending mentor sessions with people who have been doing this for years. For example, our students who are enrolled in the Level 7 qualification are required to have 10 observed and 10 performed procedures, which is in line with the HEE guidelines, so my role is to mentor them in small groups in my clinic and they observe and perform procedures that are at their level.” Dr Shotter also suggests actively asking for mentorship if the course or trainer does not necessarily offer it, “Ask your trainer or training company for mentorship or ongoing guidance because after a course you tend to go out when you are new and feel very alone. I think your best bet at finding a mentor, if you are new, is on the first training day.” Utilising your training experience Once you have determined which course (or courses) is right for you, there are many ways in which you can ensure that you make the most out of your training opportunity. Dr Cetto explains, “To start with the basics, arrive well rested. The last thing you want to do is arrive to training after a late night or busy week because you are not going to get the best out of it. Also, one of the most important things to do is to read up on all the pre-course material as if you don’t brush up on things like the anatomy you are probably going to be a little bit behind.” Mr Humzah adds that as well as this material, it is a good idea to contact the course provider prior to arriving and tell them what you would like to get out of it, “This allows the training provider to ensure the training is specific to the requirements of the trainee – in our courses we often ask if there is anything that the trainee wants to concentrate on,” he says. Mr Richards believes that for optimum learning outcomes during the training course it is important to, “Take your own notes, ask a lot of questions and be very interactive during the session.” Mr Humzah adds that asking the right questions is key, “Go to the course ready to question what they are teaching you – don’t just accept what is being said, particularly if it is sponsored, as you do need to be aware that there are alternate views. You can ask questions like, ‘how does this technology compare or relate to other technologies?’ Find out before the course what other technologies are available so that you can ask meaningful questions at the course. If you can ask meaningful questions then it will be better for you as you can understand more about the topic and it will help to further your knowledge.” Dr Shotter adds that it might be obvious, but listening is key, “Go to every course with an open mind and just always listen. You might have heard or read loads of it before but if someone switches off and thinks, ‘yes I know a lot of this already’ they will miss out on so many learning opportunities.”

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

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What to do after you have trained Once you have completed a training programme, some may ask, what do I do now? Dr Cetto says putting your new knowledge into practise is a crucial step after the completion of a course to ensure that you make the most out of it, “If you don’t practise and don’t put your new knowledge in place as soon as you have finished training, you will lose the knowledge that you have gained, so there is no point in putting all the time, effort and money into training if you’re not going to do the treatments.” Mr Humzah agrees, “Always try to put your training into practise sooner rather than later – that’s easier said than done – it’s happened to all of us where we have been on various training courses and get all fired up, full of enthusiasm, and then don’t do the procedure for a couple of months!” To help with this, Dr Cetto advises to always line up patients that you can treat after the course is complete. In addition, after the course, Dr Shotter says it is vital to never stand still in regards to your learning, advising, “Take advantage of the opportunities that are open to you – the way I inject now is completely different to how I did it four years ago and that is because I have exposed myself to so many different people’s ideas and techniques. Go to conferences, listen to what other people do and do plenty of reading – I subscribe to every journal I can get my hands on to make sure I am staying up to date. All practitioners interviewed agree that conferences are a great resource for furthering your skills, education and training, Dr Cetto says, “There are good quality conferences in the UK and abroad so I would definitely advise practitioners to attend these to keep up their knowledge.” As well as conferences, Mr Richards also advises practitioners to, “Join the professional organisations, such as the British Association of Cosmetic Nurses and the British College of Aesthetic Medicine, because it provides a support network – aesthetics can sometimes be daunting and lonely especially when you start out, so these associations are great for sharing ideas, networking and helping each other with any issues. Awards evenings are also beneficial to attend for networking opportunities.” Dr Shotter advises that after training, new practitioners should also connect and network with others through social media for added learning, “It’s really important to have a good network around you – there are so many possibilities where you can meet other professionals. One way you can do this is to join Facebook groups where medical practitioners can have conversations on views and experiences, purchasing equipment and complications that people are seeing. You have got hundreds of people in these groups who support each other and also unite together and discuss things like regulation.” When the trainee becomes the trainer For some, the next step of the training journey is to share your skills and knowledge with others through becoming a trainer. “I think you need to have been practising for a few years and have an in-depth knowledge of the field of aesthetics,” explains Dr Cetto, who says that for him, training others is extremely rewarding, “I learn a lot from the people that I mentor and train and you learn things about yourself as well. There is always room for improvement in developing other areas.” However, Wainwright says that moving from an inexperienced practitioner to a trainer is not always a natural progression and is

Aesthetics

“The challenge is to figure out what you will get out of the course – whether it will deliver what you need it to do and that means looking at the course in a lot of detail” Mr Dalvi Humzah

certainly not for everyone, “Not all people are able to train others. Not all people have the ability to support and impart knowledge in a manner that facilitates others to learn and improve their own knowledge and skills. However, experience in the field, managing complications and supporting others through networks in the industry, should facilitate the natural progression to trainer. Showing a continued passion for learning and developing their own skills, will highlight an expert practitioner who is ready to train.” Mr Humzah explains that he believes a good trainer is someone who has the following qualities, “They must have good preparation, understand the needs of the trainee, able to feed back to the trainee and deliver the training with passion, enthusiasm and empathy.” He also believes that a trainer must have the ability to educate in a variety of ways from a one-to-one basis to small groups to large audiences at conferences, “If this does not come naturally to you and you still want to be a trainer, I suggest that you do a trainer course that helps you become a trainer or make sure that, if it is a company that has approached you, they train you thoroughly.” Is education ever complete? According to practitioners, training and education is never complete. Mr Richards says that the training journey is always ongoing and even the best practitioners must continue to learn in order to maintain safe practice and be successful, “Training is never finished for anyone. If you think your training is finished, then you will become a dinosaur and as we know, dinosaurs become extinct! Even as an experienced plastic surgeon I need to stay up to date with the latest techniques – the best practitioners in my experience are the people who focus on continued lifelong learning.” REFERENCES 1. Health Education England, ‘New qualifications unveiled to improve the safety of non-surgical cosmetic procedures,’ HEE, January 2016, <https://hee.nhs.uk/news-events/news/newqualifications-unveiled-improve-safety-non-surgical-cosmetic-procedures> 2. BACN, ‘Joint Council for Cosmetic Practitioners’, 2016, <http://www.bacn.org.uk/JCCP>

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


1 oint

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Labia Majora Rejuvenation Dr Dawid Serafin discusses minimally invasive augmentation and rejuvenation of the labia majora with hyaluronic acid filler The restorative and reconstructive procedures performed to improve the cosmetic appearance, attractiveness and sexual function of female reproductive organs is the focus of aesthetic gynaecology. It is a dynamic and developing subspecialty within aesthetic medicine and I have noticed the popularity increase in recent years. This may be largely attributed to several factors, in particular, the prevalence of womenâ&#x20AC;&#x2122;s body awareness, particularly crossing the barrier of shame when discussing gynaecological problems, and better access to suitably qualified healthcare professionals with the ability to address vaginal aesthetic concerns.1,2 The appearance of the genital area can be affected by traumatic childbirth, previous surgery, frequent body weight changes, intensive physical exercise and age. The postmenopausal period has a significant effect on the female genital area through the plummeting oestrogen levels. However, the look can be improved through surgical and non-surgical treatments. Like in any other surgical subspecialty, the invasive procedures are often abandoned in favour of the minimally-invasive ones, which are associated with less trauma.3,4,5 While there are a number of ways in which the genital area can be rejuvenated non-surgically, this article will focus on the use of hyaluronic acid (HA) filler to treat the labia majora.

Anatomy and function of the labia majora The labia majora are commonly referred to as the outer lips of the vulva, the female external genitalia.6 The female anterior urogenital triangle consists of the external genital organs and their surrounding structures collectively referred to as the vulva. As the most protruding part of the vulva, the major function of the labia majora is the protection of the softer tissues of the vulva. The labia majora are the two longitudinal, adipose tissue-filled cutaneous folds. They are composed of smooth muscle fibres, blood and lymphatic vessels, nerve endings and the dermis, where orifices of numerous glands â&#x20AC;&#x201C; sebaceous, sudoriferous and apocrine â&#x20AC;&#x201C; are located. Its lateral surface is pigmented and contains hair follicles. Labia majora extend from the mons pubis (the rounded mass of fatty tissue over the joint of the pubic bones) to the perianal area (the area surrounding the anus). Anteriorly, they are joined forming the anterior labial commissure, located just under the clitoral hood, and posteriorly they form the posterior labial commissure, located approximately 2cm from the anus. Between them, other structures are situated, such as the labia minora, urethral orifice, clitoris and vaginal vestibulum.6 The main function of the labia majora is to protect other intimate structures from physical, mechanical and chemical damage. Owing to its volume and elasticity it constitutes anti-microbial protection to other vulval structures, additionally preventing the loss of natural microflora and mechanical irritation with underwear or other items of clothing. The labia majora ensures stable temperature and lubrication of other vulval structures, performing a stabilising role during a sexual intercourse.7 For this reason, women presenting with labial (vulvovaginal) atrophy may report dyspareunia, a difficult or painful sexual intercourse.8,9

Rejuvenation of the labia majora using HA Augmentation and rejuvenation of the labia majora involves increasing their fullness through enlargement, as a result of injecting cross-linked HA, which, in my opinion, is a versatile dermal filler. HA is a naturally occurring biopolymer, the molecular structure of which is very similar between living organisms. Its macromolecule is a linear polymer composed of approximately 20,000 repeating disaccharide units with the primary configurations containing D-glucuronic acid and N-acetylD-glucosamine derivatives.10 Cross-linking forms bonds between the individual molecules, preventing their metabolism by a human body, so the filler is slowly biodegraded. The aim of the treatment is to improve the aesthetic appearance of the labia majora, as well as to protect the genitals by reducing irritation, bruising and infections. The HA filler moisturises the skin and the mucous membranes, additionally rejuvenating the treated area by stimulating fibroblasts to produce collagen.11 HA filler injections are recommended in the loss of volume and firmness of the labia majora, caused by a number of factors, including, but not limited to, hypertrophy, atrophy or asymmetry of labia majora, mucocutaneous atrophy and its associated symptoms, such as itching, burning or a feeling of skin tightness. These can develop due to vaginal birth, vulval fibroma, vulvitis or simply ageing and associated excessive vulval and labial skin laxity.12,13,14,15 Additionally, patientreported pain and discomfort during sexual intercourse or sports (especially horse riding and cycling), painful urination and general discomfort when wearing tight underwear or other clothes, may be associated with infections, inflammation, irritation or abrasion. The treatment can be successfully used as a part of perineal repair or after traumatic birth, where the damage often involves the inferior portion of labia majora and can leave deep scars.16 Filling the labia majora with HA aims to restore natural appearance and repair contracture-related aesthetic defects. The use of HA is also recommended in women of low body weight or those after a significant weight loss, who may have lost adipose

Filling the labia majora with HA aims to restore natural appearance and repair contracture-related aesthetic defects

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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tissue in the genital area. There are no uniform guidelines to link body weight with HA augmentation, however, based on clinical experience, I would expect patients with a BMI of 18.5 or below would be more likely to present with atrophy of labia majora, since their bodily content of adipose tissue will generally be low. Another group of good candidates for treatment are women with previously mentioned indications, such as traumatic childbirth, surgery, ageing, rapid weight loss or intensive physical exercise, whose labia majora cannot sufficiently protect other intimate structures. Furthermore, HA-based rejuvenation of the labia majora can be used to correct age-related or menopause-related concerns often associated with the decreased adipocyte volume within the genital area.17 Its efficacy in age-related changes stems from the fact that ageing has the same underlying processes in the entire human body. With ageing, tissue atrophy increases, decreasing the sexual comfort.18,19 As we know, the natural content of HA in the body decreases with age, which results in the skin being poorly moisturised and hydrated, leading to the disruption of collagen and elastin fibre structures.20,21 Many women reporting dyspareunia most likely suffer from tissue dehydration, mucosal dryness and cellular degeneration. Furthermore, decreased oestrogen production during the perimenopausal period reduces fibroblast activity, causing dermis atrophy. With age, human skin (also in the vulvovaginal area) becomes visibly lax, losing its previous volume and shape.22 The loss of firmness and water may promote injuries or infections.23,24 Vulvovaginal dryness is a common complaint reported by perimenopausal women, especially those who do not use hormone replacement therapy. This is another factor, which contributes to labial (vulvovaginal) atrophy. This dryness is directly linked to the loss of subcutaneous adipose tissue and atrophy of the labia majora.13,14 Several factors other than the menopausal period are likely to affect shrinkage of the labia majora, such as hormonal dysfunction, vaginal dryness, imbalanced or a very active lifestyle (horse riding, cycling) as well as some medications.15 HA stimulates fibroblasts to produce collagen, which is a structural protein of human skin. This strengthens the collagen scaffolding of the skin, ensuring its rejuvenation and improving its elasticity.20 Offering long-term effective volume increase and shape correction of the treated structures, HA fillers aim to effectively augment and rejuvenate the labia majora. As a result of treatment, skin firmness and elasticity are restored alongside better vulvovaginal lubrication, reduced risk of bruising or infection, and improved aesthetic appearance affecting patientâ&#x20AC;&#x2122;s self-acceptance, which are reflected Before

Aesthetics

Vulvovaginal dryness is a common complaint reported by perimenopausal women, especially those who do not use hormone replacement therapy by improved sexual satisfaction.25 The loss of elasticity adversely affects womenâ&#x20AC;&#x2122;s body image, as they may start to consider themselves to be less attractive. The decreased self-esteem can impair the sex-related quality of life and trigger complexes which may escalate, manifesting behaviourally as perhaps the inability to get undressed in front of a partner, in a long-term committed consensual relationship.17 Similarly, if a woman is confident with her appearance and her intimate areas, it is likely to positively affect her sexual behaviours. In line with widely publicised standards of beauty promoted by the media, many patients expect their labia majora to cover their labia minora. Therefore, women who are unhappy with the size or appearance of their labia majora make good candidates for HA filler rejuvenation. The injection enlarges the labia majora sufficiently to cover the labia minora, which prevents an invasive labiaplasty procedure in many of the discussed cases.26

Procedure Despite its minimally-invasive nature, the procedure should be preceded by a thorough medical history and consultation, in order to ascertain and exclude potential contraindications. These include: pregnancy (any trimester), breastfeeding, active inflammation at the injection site, malignancy of the vulva/perineum, untreated mental disorder, severe coagulation disorder, autoimmune disorder manifesting within the vulva and a history of allergic response to HA.27, 28 The procedure involves administering HA filler to the subcutaneous tissue of the labia majora in an injection using a small-diameter After

Figure 1: Labia majora hypotrophy correction. Before image shows deep scar after episiotomy. After correction, volume is restored, scar is corrected and labias are closer to each other.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


@aestheticsgroup Before

Before

After

After

Aesthetics Journal

Aesthetics aestheticsjournal.com

Figure 2: Labia majora hypotrophy. The before image shows asymmetry after weight loss and an aesthetic dissatisfaction from the patient. After correction the symmetry and shape is restored.

Figure 3: Before image shows labia majora hypotrophy. After correction, volume is restored reducing skin folds.

cannula. Proper instruments are essential, as only a blunt-tip cannula reduces the risk of inadvertently injuring the tissue, blood vessels and helps prevent further complications. It is also essential to determine the location of blood vessels and nerves supplying the vulva prior to treatment. They are located within the lower pole of the labia majora, so caution is advised when the first injection is done at the lower pole.29

The first step involves a thorough decontamination and anaesthetising of the area to be injected. Local anaesthesia is used with approximately 5ml of 2% lidocaine administered along the labia in a single injection. It is repeated in the same manner on both labia. First, a 16G needle is used to access the labia. Then, the 22G cannula is used to administer the filler to the upper pole of the labia. A linear, downward application mode should be followed. To achieve tissue augmentation or labial contour enhancement, a very superficial subcutaneous injection is performed. In order to correct tissue volume, the filler should be administered slightly deeper. The depth of injection plays an important role. I recommend a depth of 5mm, as accessing structures that are too deep may result in administering the filler to the adipose tissue, thus losing its effect. 1-3ml of cross-linked HA is injected on each side. The filler is developed through the highest purity bacterial biosynthesis. Cross-linking increases the duration of filler effect, whereas tissue deposition of HA is up to 1.5 years. Currently, the maximum available concentration of HA fillers intended for female genital augmentation is 28mg, and I would suggest using this for treatment. I would not like to recommend any given brand of HA filler, suggesting instead that practitioners consider the content of HA in a filler because the likelihood of long-term tissue deposition increases with the content of hyaluronic acid.30 Cross-linked HA molecules are biodegradable, which infers the safety and minimally invasive nature of treatment while offering a quick onset of therapeutic effect. The procedure lasts for 15-30 minutes; it does not require a recovery period or sutures â&#x20AC;&#x201C; the patient may commence her normal activity immediately after she leaves the treatment room. After the injection, the patient should be instructed to refrain from sexual activity, sport (especially

Proper instruments are essential, as only a blunt-tip cannula reduces the risk of inadvertently injuring the tissue, blood vessels and helps prevent further complications

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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cycling, horse riding or similar sports) and sitting on a hard surface for seven days. The patient should be advised to drink plenty of water – approximately three litres a day. There is no formal recommendation regarding further management of patients after labia rejuvenation; however, HA is known for its water-binding properties, hence the need to maintain proper hydration for optimum treatment outcomes. In my clinical experience, the HA-based rejuvenation can be repeated after six months at the earliest, however, I would recommend the interval of 12-18 months between the individual procedures. Complications Procedures involving injection of HA fillers are considered safe, can be used in almost all cases without a risk of damage to major organs.31 Possible complications and adverse effects include acute/shortterm consequences such as skin redness around the injection site, hematomas, local inflammation and chronic/long-term consequences, such as fibromas.32 If the filler is administered inappropriately and in excess amounts, hypercorrection may result. Asymmetrical injection may lead to labial asymmetry, and non-compliance to filler dislocation, which destroys treatment effect. However, it is reversible with hyaluronidase.

Conclusion Contemporary aesthetic gynaecology offers surgical approaches along with non-surgical approaches. As discussed, the latter is increasingly more popular among patients and includes HA filler augmentation, which is often opted for due to its minimally-invasive technique, short treatment duration and lack of recovery period. In response to this growing demand, aesthetic medicine can undoubtedly improve patients’ quality of life in aspects related to sexual life and the appearance of external sex organs. Resolving such important problems such as pain during intercourse or sexual dysfunction, which adversely affect both patients’ physical and mental well-being, is important to address. Augmentation of the labia majora using HA filler improves the aesthetic appearance of intimate body parts, offers long-lasting effect of correcting atrophy and restores proper skin hydration. Dr Serafin gratefully acknowledges the assistance of Karolina Kalisz in editing and translating the manuscript. Dr Dawid Serafin is a gynaecologist and one of the first in Poland to specialise in aesthetic gynaecology. He is an instructor in hyaluronic acid filler treatments, a specialist in Intra-Operative Laser Methods for the treatment of vulvo-vaginal disorders and aesthetic corrections and writes and lecturers on current topics and techniques in aesthetic gynaecology.

Aesthetics REFERENCES 1. Lih Mei Liao & Sarah M Creighton, ‘Requests for cosmetic genitoplasty: How should healthcare providers respond?’, British Medical Journal, 2007, 334(7603), pp. 1090-1092. <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC1877941/> 2. Frank Lista, Bhavik D. Mistry, Yashoda Singh, Jamil Ahmad, ‘The safety of aesthetic labiaplasty: a plastic surgery experience’, Aesthet Surg J, 35(2015) pp. 689-695. 3. Dr. Hamori, Labia Majora Reduction, (2016) <http://www.labiaplastyboston.com/labia-majorareduction/index.html> 4. Dr Vitasana, ‘Risks, Side Effects and Complications of Labia Majora Reconstruction’, (2016) <http:// www.drvitasna.com/en/risks-side-effects-and-complications-of-mons-pubis-reconstruction/> 5. David Matlock, ‘Laser Reduction Labiaplasty of the Labia Majora via Vertical Horizontal Elliptical Excision’, (2016) <http://www.drmatlock.com/body-procedures-beverly-hills/labia-majora-laserreduction-labiaplasty-via-vertical-horizontal-elliptical-excision/> 6. Aurora, M, ‘Female Reproductive Organ Anatomy’, Medscape, 2013, <http://emedicine.medscape. com/article/1898919-overview#showall> 7. Inner Body Annatomy Explorer, ‘Labia Majora’, (1999) <http://www.innerbody.com/image_dige04/ repo19.html > 8. Maire B. Mac Bride, Deborah J. Rhodes, & Lynne T. Shuster, ‘Vulvovaginal Atrophy’, Mayo Clin Proc. 85(2010) pp. 87–94, 9. Kristen Levine et al., ‘Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women’, Menopause, 2008, 15(4), pp. 661-666. 10. Bill Widner & Régine Behr et al., ‘Hyaluronic acid production in Bacillus subtilis’, Applied and Environmental Microbiology, 71(2005) pp. 3747-3752. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1168996/> 11. Amir Fakhari & Cory Berkland, ‘Applications and Emerging Trends of Hyaluronic Acid in Tissue Engineering, as a Dermal filler and in Osteoarthritis Treatment’, Acta Biomaterialia, 2016, 9 (7) pp.7081-7092. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3669638/> 12. Origoni M & Climmino C et al.,’Postmenopausal vulvovaginal atrophy (VVA) is positively improved by topical hyaluronic acid application’, European Review for Medical and Pharmacological Sciences, 2016, 20(20), pp.4190-4195. <https://www.ncbi.nlm.nih.gov/pubmed/27831658> 13. Nanette Santoro & Janne Komi, ‘Prevalence and Impact of Vaginal Symptoms among Postmenopausal Women’, J Sex Med, 2009, 6(8), pp. 2133–2142. 14. Rossella E. Nappi & Michele Lachowsky, ‘Menopause and Sexuality: Prevalence of symptoms and impact on quality of life’, Maturitas, 2009, 63(2), pp. 138-41 15. Susan Stevenson & Julie Thornton, ‘Effect of estrogens on skin aging and the potential role of SERMs’, Clin Interv Aging. 2007, 2(3), pp. 283–297 16. Serena Bertozzi & Ambrogio P Londero et al., ‘Impact of episiotomy on pelvic floor disorders and their influence on women’s wellness after the sixth month postpartum: A retrospective study’, BMC Women’s Health, 2011. <http://bmcwomenshealth.biomedcentral.com/ articles/10.1186/1472-6874-11-12> 17. Rossella E. Nappi, et al., ‘Vulvar and vaginal atrophy in four European countries: evidence from the European REVIVE Survey’, Climacteric, 2016, 19(2), pp. 188–197 18. Zbigniew Lew-Starowicz & Monika Szymańska, 45. ‘Sexual disorder and personal problems of women over 45 years of age: Article in Polish’, Przegląd Menopauzalny/Menopausal Review, 2010, 6, pp.381-384. <http://www.termedia.pl/Sexual-disorders-and-personal-problems-of-women-agedover-45,4,15862,1,1.html> 19. Michelle Maciel & Luciana Lagana, ‘Older women’s sexual desire problems: Biopsychosocial factors Impacting them and barriers to their clinical assessment’, BioMed Research International, (2014). <https://www.hindawi.com/journals/bmri/2014/107217/> 20. Paweł Olczyk et al., ‘Hialuronian – struktura, metabolizm, funkcje i rola w procesach gojenia ran’ [Hyaluronan: Structure, metabolism, functions, and role in wound healing. Article in Polish], Postepy Hig. Med. Dosw. 2008, 62, pp.651-659. <http://www.phmd.pl/fulltxt.php?ICID=873381> 21. Raul Fleishmajer et al., ‘Aging of human dermis’, Journal of Investigative Dermatology, 1993, 100, pp.705–709. 22. Frank Wang et al., ‘In Vivo Stimulation of De Novo Collagen Production Caused by Cross – linked Hyaluronic Acid Dermal Filler Injections in Photodamaged Human Skin’, Arch. Dermatol., 2007, 143, pp.155-163. 23. H Murad & Michael P Tabibian, ‘The effect of an oral supplement containing glucosamine, amino acids, minerals, and antioxidants on cutaneous aging: a preliminary study’, J. Dermatolog. Treat., 2001, 12(1), pp.47-51. 24. Ina M. Hadshiew et al., ‘Skin aging and photoaging, the role of DNA damage and repair’, American Journal of Contact Dermatitis, 2000, 11, pp.19-25. 25. Małgorzata Uchman – Musielak, ‘Zastosowanie kwasu hialuronowego w ginekologii estetycznej’ [Application of hyaluronic acid in aesthetic gynaecology = Presentation in Polish], September 10, 2016 <https://e-medycyna.pl/files/manager/file-295422f05120eb3c2ea947fb3bfa129b.pdf> 26. Julie M.L.C.L Dobbeleir & Koenraad Van Landuyt et al., ‘Aesthetic Surgery of the Female Genitalia’, Seminars Plastic Surgery, 2011, 25 (2) pp.130-141. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3312147/> 27. Uwe Wollina & Alberto Goldman, ‘Hyaluronic Acid Dermal Fillers: Safety and Efficacy for the Treatment of Wrinkles, Aging Skin, Body Sculpturing and Medical Conditions’, Clinical Medicine Reviews in Therapeutics, 2011, 3, pp.107–121. 28. Philippe Lafaille & Anthony Benedetto, ‘Fillers: Contraindications, Side Effects and Precautions’, J Cutan Aesthet Surg, 2010, 3(1), pp.16–19. 29. Ronald A. Bergman, Adel K. Afifi, Jean J. Jew & Paul C. Reimann, Anatomy Atlas, (2017), http://www. anatomyatlases.org/HumanAnatomy/6Section/34.shtml > 30. Amir Fakhari & Cory Berkland, ‘Applications and Emerging Trends of Hyaluronic Acid in Tissue Engineering, as a Dermal Filler, and in Osteoarthritis Treatment’, Acta Biomater. 2013, 9(7), pp. 7081–7092. 31. Elena Fasola & Riccardo Gazzola, ‘Labia Majora Augmentation with Hyaluronic Acid Filler: Technique and Results’, Aesthet Surg J, 2016, 36(10), pp. 1155-1163. 32. Edwards PC & Fantasia JE, ‘Review of Long-Term Adverse Effects Associated with the Use of Chemically-Modified Animal and Nonanimal Source Hyaluronic Acid Dermal Fillers’, Clinical Interventions in Aging, 2007, 2(4) pp.509-519. <https://www.ncbi.nlm.nih.gov/pubmed/18225451>

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Botulinum toxin type A free from complexing proteins Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: M-BOC-UK-0046. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients may

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not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with Botulinum neurotoxin products. Upper Facial Lines: very common: Headache. Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent postinjection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: December 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50 units Summary of Product Characteristics (SmPC). March 2016. Available from: https://www.medicines.org.uk/emc/ medicine/23251. 2. Bocouture® 100 units Summary of Product Characteristics (SmPC). September 2016. Available from: https://www.medicines. org.uk/emc/medicine/32426. 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157. Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0040 Date of Preparation November 2016

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Botulinum toxin type A free from complexing proteins


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through the ageing process. These findings are important in assessing eyebrow rejuvenation, particularly as focus and emphasis should be placed on the lateral brow and arch, while avoiding the medial brow.1 Consideration must also be made of volumetric changes to the brow; lateral eyebrow ptosis may be a result of soft tissue atrophy, bone loss and skin changes (loss of elasticity) combined with gravitational effects.11-12 The eyebrow fat, retro-orbicularis oculi fat (ROOF) pad, contributes to youthful periorbital fullness and with its atrophy and the lack of lateral frontalis muscle inserting into the very lateral brow, ptosis of the lateral brow occurs.13 Careful brow repositioning and volumisation of the temporal fossa can provide excellent results in properly chosen patients, as discussed above.14

Treating the Brow Dr Maryam Zamani outlines her combination of non-surgical treatments to lift the brow The periorbita and brow is an area where we often see the first signs of ageing and is a common request for rejuvenation. To understand patientsâ&#x20AC;&#x2122; concerns, we first need to understand how this part of the face ages.

Considerations for eyebrow rejuvenation

Treatments for eyebrow rejuvenation Brow rejuvenation can be categorised into two main groups: surgical and non-surgical. In the last decade, there has been increased demand for non-invasive procedures for rejuvenation15 and a simultaneous explosion of new non-surgical techniques and combinations of such treatments, aimed at improving and rejuvenating the skin around the periorbital and brow area. In treating the brow, there is a vast array of combination treatments that can be implemented. Often, the most successful aesthetic results come from combining different modalities together to create a more unified approach to rejuvenation and improve overall patient satisfaction. According to a study by Beer KR et al, subjects treated with botulinum toxin alone rated the combination treatment more superior at 64% and in my experience the combination of botulinum toxin A and hyaluronic acid (HA) appear to rejuvenate the brow with minimal adverse effects and with higher rate of patient satisfaction.16

The ideal eyebrow was described in 1974 as a lateral arch with the apex terminating above the lateral limbus of the iris and where the medial and lateral ends of the eyebrows were at the same height.1,2 Since then, this ideal has been redefined and studies have indicated that patients and surgeons prefer an eyebrow where the arch is positioned just lateral to the lateral limbus.1,3,4,5 Microfocused ultrasound The focus of eyebrow rejuvenation is based on position, shape, Microfocused ultrasound (MFU) is a non-invasive treatment and symmetry of the eyebrows. There are many factors that modality that uses visualisation to create thermal micro-injuries, contribute to eyebrow shape, including ethnicity, facial shape and also known as thermal coagulation points (TCP), in the dermis cosmetic practices to groom the brows.1 From my experience, and subdermal tissue. Despite its low energy, MFU is capable of criticism of both non-invasive and surgical procedures is generally heating tissue to greater than 60C to a depth of 5mm within the focused on unnatural eyebrow shape, height, and appearance. mid to deep reticular layer of the dermis and subdermis, while In the upper third of the face, the effects of repetitive periorbital sparing the overlying papillary dermal and epidermal layers muscle contractions, decreased skin elasticity and loss of temporal of the skin.17,18 MFU causes collagen fibres in the superficial 6 support to the lateral brow result in brow ptosis. The eyebrows musculoaponeurotic system and deep reticular dermis to contract are maintained by the dynamic balance of the frontalis, corrugator and stimulate de novo collagen.17 The lift is created in the healing of 7 supercilii and the orbicularis oculi muscles. Before Before Overhanging brow with double skin increase Overhanging brow with As we age, studies have indicated that the double skin crease Inability to see position of the eyebrow actually becomes upper eyelid or the eye liner higher, with the medial brow being more elevated than the lateral eyebrow, regardless of ethnicity.8-10 Delyzer et al illustrated in patients younger than 50 that the eyebrow slope decreased due to the After After Elevated eye brow Elevated lateral brow descent of the arch.1 Thereafter, there is an Improved eyelid contour increase in eyebrow slope secondary to Ability to see Improvement more of the in lines and an increase in the arch apex that is likely eyelid and wrinkles eyeliner caused by a reactionary hyperactivity of the frontalis, leading to increased muscle tone at rest.1 The resting tone of the medial depressors keep the medial eyebrow stable or slightly descended consistently Figure 1: Before and after Tri Brow Treatment

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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the TCP resulting in firming, tightening and shrinking of the dermis and subdermal tissues. The efficacies of ultrasound treatments vary on the vector direction of treatment and the total energy supplied. The treatment has a reputation of being painful; however, with proper pre-treatment analgesics, this is well controlled. Pain, oedema, headache, numbness, paresis, post-inflammatory hyperpigmentation (PIH), bruising, and welts are potential risk profiles that need to be discussed with the patient.19 Botulinum toxin Eyebrow ageing is a dynamic process related to differential muscle actions at rest and their relationships to one another. To maintain youthful eyebrows, weakening of the depressor muscles of the eyelid and brow can help restore muscle balance.7 Studies have indicated that in patients younger than 50, paralysing the central frontalis and lateral orbicularis oculi can help correct lateral brow ptosis.1 Botulinum toxin is an effective neuromodulator used to temporarily weaken the orbicularis oculi muscle, a brow depressor that pulls the lateral part of the eyebrow downwards with minimal side effects. As a low risk procedure, botulinum toxin is generally considered a relatively safe treatment.20 In older patients, this frontalis activity may be essential in maintaining brow height and should be treated with caution. Hyaluronic acid fillers HA fillers are playing an even larger role in treating the ageing upper face as a three-dimensional approach to rejuvenation, with particular attention to proportional ideals being sought. In determining which HA product is best to use in the brow, it is essential to look at the viscosity – how the gel flows from the needle, and G prime – gel stiffness of the product. I prefer using products from the Juvéderm Vycross family, particularly Volift, when trying to lift the lateral brow and replace volume loss, because of its lifting capabilities while spreading easily. Volume restoration of the brow must be performed with consideration of the shape of the lateral brow, as well as consideration of the vascular and structural anatomy. HA can be injected into the lateral brow and temples with both deep (pre-periosteal and submuscular) and dermal injections in order to temporarily help improve volume loss. All HA injections in the periorbita carry significant risk (such as vascular compromise, overcorrection) and great care to the underlying anatomy must be taken to minimise potential pitfalls.21 Combination approach: Tri Brow Treatment (TBT) In my practice, I have created a triad of treatments detailed above in a non-surgical protocol called the Tri Brow Treatment (TBT). I have a significant number of patients who present complaining of the appearance of the brow and seek non-surgical treatment options, instead of surgical intervention. The TBT combines botulinum toxin, HA fillers and ultrasound treatment in two sessions 10-14 days apart to treat brow ptosis in younger patients, generally aged 30-55. In the first visit, Ultherapy, a FDA approved ultrasound device is used to treat the brow to promote lifting and tightening of the periorbita. Between 10-14 days after treatment with Ultherapy, patients return for tailored treatment of the lateral brow and temples with HA fillers as well as toxin to the brow depressor and the orbicularis oculi muscle. All patients are advised to wait three to six months before the final improvement can be seen with Ultherapy. It should also be noted that botulinum

Aesthetics

toxin and HA treatments require maintenance as botulinum toxin lasts three to five months and the duration of HA depends on the type of hyaluronic acid used in treatment.

Conclusion In my experience, integrated treatments for the brow cater for the multifaceted changes that occur in the ageing face. These forms of treatment, among other combinations of treatments used for rejuvenation of the brow are of moderately long-lasting efficacy and offer high patient satisfaction. Dr Maryam Zamani is a board certified ophthalmologist with experience in ocuplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine, US, and has worked at Cardiff University in facial aesthetics. REFERENCES 1. DeLyzer Tanya L & Yazdani, Arjang, ‘Characterizing the lateral slope of the aging female eyebrow’, Canadian Journal of Plastic Surgery, 2013, 21 (3) pp. 173-7. <https://www.ncbi.nlm.nih. gov/pubmed/24421649> 2. Westmore M. ‘Facial cosmetics in conjunction with surgery’, Presented at the Aesthetic Plastic Surgical Society Meeting, 1974. 3. Freund RM &Nolan WB, ‘Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females’, Plastic Reconstructive Surgery, 1996, 97 (7) pp.1343-8. <https://www.ncbi.nlm.nih.gov/pubmed/8643716>  4. Scalfani AP & Jung M, ‘Desired position, shape, and dynamic range of normal adult eyebrow’, Archives of Facial Plastic Surgery, 2010, 12 (2) pp. 123-7. <https://www.ncbi.nlm.nih.gov/ pubmed/20231595> 5. Roth JM & Metzinger SE, ‘Quantifying the arch position of the female eyebrow’, Archives of Facial Plastic Surgery, 2003, 5 (3) pp.235-9. <https://www.ncbi.nlm.nih.gov/pubmed/12756117> 6. Manavpreet Kaur & Rakesh K. Garg et al., ‘Analysis of facial soft tissue changes with aging and their effects on facial morphology: A forensic perspective’, Egyptian Journal of Forensic Sciences, 2015, 5, pp.46-56. <http://www.sciencedirect.com/science/article/pii/ S2090536X14000501> 7. Yun S & Son D et al., ‘Changes of eyebrow muscle activity with aging: functional analysis revealed by electromyography’, Plastic Reconstructive Surgery, 2014, 133, pp.455e-63e. <https:// www.ncbi.nlm.nih.gov/pubmed/24378349> 8. Matros E & Garcia JA et al., ‘Changes in eyebrow position and shape with aging’, Plastic Reconstructive Surgery, 2009, 12, pp.1296-301. <https://www.ncbi.nlm.nih.gov/pubmed/19935315> 9. Patil SB & Kale SM et al., ‘Effect of aging on the shape and position of the eyebrow in an Indian population’, Aesthetic Plastic Surgery, 2011, 35, pp.1031-5. <https://www.ncbi.nlm.nih.gov/ pubmed/21538068 > 10. W. A van den Bosch & I. Leenders et al., ‘Topographic anatomy of the eyelids, and the effects of sex and age’, British Journal of Ophthalmology, 1999, 83, pp.347-352. < https://www.ncbi.nlm.nih. gov/pmc/articles/PMC1722965/>   11. Morley, AM & Taban, M et al., ‘Use of Hyaluronic Acid Gel for Upper Eyelid Filling and Countouring’, Ophthal Plastic and Reconstructive Surgery, 2009, 25, pp.440-444. <https://www. ncbi.nlm.nih.gov/pubmed/19935245> 12. Kane MA, ‘Nonsurgical perioribital and brow rejuvenation’, Plastic Reconstructive Surgery, 2015, 135, pp.63-71. <https://www.ncbi.nlm.nih.gov/pubmed/25285684> 13. Myint, SA. ‘Nonsurgical Peri-orbital rejuvenation’ 2014, pp.11. 14. Torres S, ‘Volumetric Eyebrow Lifting with the Aid of a New Hyaluronic Acid Dermal Filler (Intraline) and Upper Surgical Blepharopasty; Enhancing Outcomes’, Journal of Clinical & Experimental Dermatology Research, 2015, 6, p.305. <https://www.omicsonline.org/openaccess/volumetric-eyebrow-lifting-with-the-aid-of-a-new-hyaluronic-acid-dermalfiller-intralineand-upper-surgical-blepharoplasty-enhancing-outcomes-2155-9554-10000305.php?aid=64421> 15. WhatClinic, ‘Enquiries into non-surgical cosmetic treatments rise by more than half (55%) in just six months’, 2015. <http://baaps.org.uk/about-us/press-releases/2039-auto-generate-from-title> 16. Beer KR & Julius H et al., ‘Remodeling of periorbital, temporal, glabellar, and crow's feet areas with hyaluronic acid and botulinum toxin’, Journal of Cosmetic Dermatology, 2014, 13, pp.143-50. <https://www.ncbi.nlm.nih.gov/pubmed/24910278> 17. Fabi SG. Clinical, Cosmetic and Investigational Dermatology. Non invasive skin tightening: focus on new ultrasound techniques. Volume (2015): 8 pp.47-52. 18. Young-sun Kim & Hyunchul Rhim et al., ‘High-intensity focused ultrasound therapy: an overview for radiologists’, Korean Journal Radiology Impact & Description, 2008, 9, pp.291-302. <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2627265/> 19. Hitchcock TM & Dobke MK, ‘Review of the safety profile for microfocused ultrasound with visualization’. Journal of Cosmetic Dermatology, 2014, pp.329-335. 20. Bogdan Orasanu & Sangeeta T. Mahajan, ‘The use of botulinum toxin for the treatment of overactive bladder syndrome’, Indian Journal of Urology, 2013, 29, pp. 2-11. <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC3649594/> 21. Lafaille, P., Benedetto A. ‘Fillers: Contraindications, Side Effects and Precautions’, Journal of Cutaneous and Aesthetic Surgery, 2010 Jan-Apr: 3(1) 16-19. <https://www.ncbi.nlm.nih.gov/ pubmed/25399626>

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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.

The Ageing Female Face The Male Face

Cryolipolysis 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.

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

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

advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

What the experts say... ‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients.

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• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Contouring • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required

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EXHIBITION

The Basics of Facial Assessment

3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

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Spotlight On: Needle Shaping Aesthetics explores the use of a new needle system that aims to biostimulate the skin What is Needle Shaping? Invented by Italian Professor Giorgio Fippi in 2012, Needle Shaping is a non-invasive technique that aims to create new tissue in the skin, increase collagen and elastin fibres and provide a lifting effect. With the use of acupuncture needles and an electrical current, this technique is different to other skin-stimulating aesthetic treatments currently available. “Needle Shaping describes the technique of inserting acupuncture needles into the skin and then applying a mixed galvanic current to the needles,”1 explains aesthetic practitioner Dr Dev Patel, who offers this treatment in his clinic. “Once the current is applied, it shifts the water in the skin away from the needle tip, which effectively dehydrates the tissue. This then allows each needle (which you turn with your hand once placed) to pick up elastin and collagen fibres and form a natural ‘thread’. In actual fact, I refer to the treatment on my website as the ‘natural thread lift’ as effectively, that is what it is.” Once the ‘thread’ is formed, traction is then applied to the needle, which results in an autologous microtransplantation of tissue, in other words, a transplantation of the patient’s own tissue. Ultimately, this aims to result in a lifting and volumising effect in the treatment area.2 “It’s not as aggressive as actual threads,” claims Dr Patel, adding, “and although you do need multiple treatments, four on average, the cost of a course of this treatment is less than one thread treatment.” As well as the autologous microtransplantation of tissue, the process is said by Fusion GT – the distributors of the treatment – to trigger a production of collagen and elastin, which will happen over a couple of weeks post treatment.2

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give patients a brow lift; with patients I have seen with asymmetric brows, I have worked on the lower brow and within one to two treatments the brow is back to where it originally was. Advanced users can also use this treatment for lip volumising and in combination with other devices.” In addition, Dr Patel says that the treatment can be used anywhere on the body, including lifting the breasts and buttocks,3 although he does not have experience in this area. “I have seen one buttock lift where the practitioner only used a radiofrequency treatment and then Needle Shaping; you do need to put in a lot of needles when treating a larger area such as this, which is very time intensive, and the same can be said for the breast lift – it does give a good result but it needs four to six treatments. Smaller areas, such as the face and neck, provide fantastic results in just three to four sessions.” Method For the treatment, acupuncture needles are placed superficially in the dermis, with just the tip of the needle in the skin. The number of needles used will vary on the area being treated and the severity of the ageing skin. Once the needles are in place, a galvanic current, which is programmed with basic parameters (pulse width and pulse repetition rate), is passed through the needles.2 The treatment comes with recommended user settings and treatment protocols,2 but Dr Patel claims it is very user dependent. “Since I’ve been using this treatment the results get better and better as I have developed my own protocols. The way you place the needles, the way they point, where to strategically place your needles; it is very much something you get a feel for.” Dr Patel adds, “On some occasions, we have used just one acupuncture needle on the whole of the face, and in this circumstance you would put the current on a lower setting, as the energy is consistently carried along the whole needle.” A minimum of four treatments, two weeks apart, is needed to get the best result in most areas, and if the patient has advanced ageing or skin laxity, then it may be worthwhile doing up to eight treatments to gain the most from it. “A good time to sit down and have a review with the patient is after the fourth treatment. If they decide to stop there, then I always encourage them to come back for maintenance treatments, but it is very much budget-dependent for the patient. I always say to them that if they can come in twice a year, then that’s great, but if they can come in up to four times, even better!”

Treatment areas Dr Patel explains that the treatment can be used on any area of skin that has wrinkles, laxity and lack of volume, and you can even use it to treat concave scars. “The most common areas I treat are the neck and lower face, although I have also used it to

Results Dr Patel explains that by the second visit, half of the patients will say that they have felt a small amount of tightening and can see a slight result, and by the third visit, the majority of patients will report moderate skin tightening Before After and a lifting effect. He says, “To date, all my patients have said they have noticed an improvement in the quality of their skin and by the end of the treatment, they all have that ‘glow’.” Dr Patel adds, “The first patient I treated and took before and after photographs of, I only did four treatments of Needle Shaping, plus four fat dissolving treatments using a different piece of electro-current Figure 1: Before and after images of a 54-year-old patient after four needle shaping treatments, two weeks apart equipment. The patient said that she

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had seen a great improvement and that she didn’t need to see the before and after photos again because all her friends had told her how nice her skin was looking. So you do get skin rejuvenation as well as lifting and tightening.” Dr Patel has also noted that in some patients there has been an enhancement effect in the cheeks, “You can see some lifting and when placing the needles in the cheeks I have seen the equivalent of what could have been 1ml of filler in each cheek after four Needle Shaping treatments. You can’t guarantee it, but you can say to patients ‘between volumising, lifting and skin rejuvenation, you’re going to get a really nice improvement’.” Dr Patel explains there are no stipulations for the treatment, but patients that present with severe skin laxity and ageing would be recommended to have an alternative treatment. “For severe ageing I would recommend something a bit more hard-hitting, such as a fractional laser skin resurfacing treatment, and then maybe discuss dermal fillers. However, sometimes there are patients who don’t want the alternatives, so if they really want to go ahead with Needle Shaping then I let them know we might not get the same results and that results are cumulative over a period of time.” He adds, “This treatment is not for the patient with unrealistic, high expectations or one who wants quick results.” Complications and side effects are said to be minimal to none, according to Dr Patel, “The only side effects I have personally witnessed are brusing and swelling from the needles. Due to the nature of the treatment, I don’t believe there are any other risks,” he says.

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Conclusion The non-invasive nature of this treatment and the subsequent positive results it has attained has made this a highly requested treatment at Dr Patel’s clinic, and he believes it is unique, “This is the only technique I am aware of that works in this way – the microtransplantation of the patient's own material with biostimulation.” He concludes, “Although there are, of course, lots of devices out there that result in biostimulation of the skin, this treatment is quick, relatively painless and as low risk as one could hope for with an aesthetic treatment.” REFERENCES 1. Fusion GT, Needle Shaping, (2017) <http://www.fusiongt.co.uk/products/soft-surgery/ vibrance-2/> 2. Fusion GT, Needle Shaping guide, PDF on file 3. A, Marcou, International Aesthetic Medicine and Soft Surgery Conference, Breast lift with non-invasive techniques p.31(2015) <http://www.softsurgeryconference.com/images/Book_of_ abstracts.pdf>

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Smoking’s Effects on the Skin Dr Martin Godfrey considers the impact smoking has on the skin’s health It was Sir Walter Raleigh that was said to have brought tobacco to England for the first time in 1586. Yet, back then, tobacco was seen as ‘good for your health’ and was suggested to relieve toothache and used for the treatment of worms, halitosis, lockjaw and even cancer.10 However, as we well now know, tobacco (or more specifically the toxic substances it releases when burned) is detrimental to health. Cigarette smoking is linked to fifteen types of cancer (lung, lip, pharynx, larynx, mouth, nasal cavity and nasal sinus, oesophagus, pancreas, stomach, liver, kidney, cervix, bladder, myeloid leukaemia),11 as well as coronary heart disease, stroke, chronic obstructive lung disease, peripheral vascular disease, stillbirth, low birth weight, sudden infant death, infant mortality, congenital abnormalities and miscarriage.12 Many smokers know this, however, in my experience, relatively few of these smokers are aware of the evidence that smoking prematurely ages the skin.

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wrinkling was carried out in California by researchers from the Department of Veterans Affairs, the University of California, and the Kaiser Permanente Medical Group.3 After adjusting for age, average sun exposure and body mass, the risk of moderate or severe facial skin wrinkling was more than twice as high for men who smoked than those who had never smoked and three times higher for female smokers.3 These results have been broadly replicated in many more recent studies.4,13,14 The relative risk for moderate-to-severe wrinkling for current smokers compared to that of life-long non-smokers has been indicated to be 2.57 with a confidence interval of 1.83-3.06 and a P<0.0005.5 Wrinkle scores were three times greater in smokers than in non-smokers, with a significant increase in the risk of wrinkles after 10 pack-years.6 Pack-years are calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 10 pack-years would define both as smoking one pack a day for 10 years, or two packs a day for five years.6 So what exactly are the underlying causes of smoking damage on skin?

Smoking and skin damage One of the primary effects of smoking is a decrease in capillary blood flow to the skin caused by vasoconstriction. Nicotine causes these tiny vessels to narrow, which, in turn, creates oxygen and nutrient deprivation in the cutaneous tissues.7 This damage to the blood supply makes affected skin 12 times more likely to slough off during surgery (e.g. cosmetic surgery) for a smoker than a nonsmoker.7 Smoking also releases an abundance of free radicals into the skin tissues. These first reduce the production of new collagen and then increase the concentration of the enzyme matrix metalloproteinase-1, which degrades the existing collagen.15 There is also an increase in ‘elastosis’ (degenerative change in the elastic tissue of the skin).8 These effects break down the skin’s vital scaffold leading to the development of fine lines and deep wrinkles. Ultimately, those who smoke have fewer collagen and elastin fibres in the dermis, which causes the skin to become slack, hardened and have less elasticity.16 Another effect of smoking is to increase keratinocyte dysplasia and decrease keratinocyte migration, which leads to increased skin roughness. Smoking also decreases the production of erythrocytes, which are red blood cells.17 When the number of red

Smoking and ageing Healthcare professionals have known about the effect of tobacco smoke on the skin for a long time. In the early 1970s, a study of 1,104 smokers carried out in California noted an association between cigarette smoking and skin wrinkling that was striking in both sexes.1 Smokers were observed to have as many wrinkles as non-smokers who were 20 years older. Further research was needed from this initial study, and many labs began to look into the effects of smoking on the skin. At the beginning of the 1990s, researchers from the University of Utah assessed and compared the degree of facial wrinkling in 132 smokers and non-smokers.2 They concluded that cigarette smoking was a risk factor for the development of skin wrinkles and ‘crow’s feet’ and smoking acted as a risk factor independent of age and sun exposure. Furthermore, premature skin wrinkling increased with the amount smoked and the duration of smoking.2 In the mid-1990s, a 156-person study of smoking status and facial

Ultimately, those who smoke have fewer collagen and elastin fibres in the dermis, which causes the skin to become slack, hardened and have less elasticity

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blood cells are decreased, it’s similar to developing anaemia and the complexion becomes paler; in some skin tones (particularly light skinned people with fewer melanocytes) this can make the skin (especially of the face due to it being very vascular and on show) appear a very unattractive, yellow and/or grey colour. The actual texture, smoothness and glow of the smoker’s skin degrades, especially in the exposed upper lip and chin area where those ‘cigarette lines’ appear. Smoking also leads to an increase in the development of telangiectasia – small star-shaped superficial vessel complexes that look unsightly on the cheeks and nose.9

Peripheral vascular diseases As mentioned, nicotine causes vasoconstriction as well as hypercoagulability, increasing the chance of blood clots occluding blood vessels. Smoking can therefore aggravate or initiate:25 • Chilblains • Frost-bite • Primary or secondary Raynaud’s disease • Ulceration, in patients with systemic sclerosis • Buerger’s disease

Due to these effects, the smoker’s face typically looks as follows:18 • Dry, coarse skin • Blotchy, sallow, yellowy-grey colouring with prominent telangectasiae • Facial wrinkles and furrows, e.g. crow’s feet at lateral canthus, vertical ear crease, smoker’s lines around lips • Baggy eyelids and slack jawline

Summary

Once the damage has been done, it’s very difficult to reverse. Hormone-replacement therapy has been demonstrated to prevent further wrinkling and reduce wrinkle depth in post-menopausal women.5 However, in long-time smokers their skin does not appear to respond.5 Similarly, those smokers who try moisturisers, vitamins and hydration techniques to fight their poor complexions also find they make little headway. For them, treatments such as microdermabrasion, skin peels and lasers may be the only answer. Beyond the cosmetic, smoking can have many other serious effects on skin, which include the following. Wound healing Smoking delays wound healing, including skin injuries and surgical wounds. It increases the risk of wound infection, graft or flap failure, death of tissue and blood clot formation.19 The reasons for this are unclear, but involve those previously described: lack of oxygen reaching skin cells, delayed migration of keratinocytes, decreased collagen synthesis and also delayed growth of new blood vessels within the wound.19 Ulcers Smoking contributes to the development and persistence of leg ulcers, particularly arterial ulcers, diabetic foot ulcers and calciphylaxis. This is because smoking reduces blood flow and thus increases the likelihood of skin breakdown in areas that already have poor perfusion such as in the lower leg in smokers.20 Skin cancer Smoking cigarettes doubles the risk of developing squamous cell carcinoma, compared to non-smokers.21 There is also an increased risk of oral leukoplakia (pre-cancer) and oral cancer; 75% of cases of oral cancer and lip cancer occur in smokers.22  Psoriasis Research has suggested that smokers tend to have more extensive and severe psoriasis than those that do not.23 Patients with chronic plaque psoriasis appear to smoke more than patients without psoriasis (although this is possibly linked to the stress associated with the disease).24

In summary, smoking is a threat to the skin and many of the body’s organs and key structures. As aesthetic and cosmetic professionals we should make it our business to support the actions of all other medical professionals in helping to encourage patients to quit smoking for good. Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd. A trained medical practitioner, Dr Godfrey has a wealth of expertise in health and nutritional product marketing. His main responsibilities are gaining scientific verification for Minerva’s products through overseeing clinical trials and obtaining the support of medical professionals. REFERENCES: 1. Daniell HW, ‘Smoker’s wrinkles: A study in the epidemiology of “crow’s feet”’, Annals of Internal Medicine, 75(1971) pp.873-880. 2. Kadunce DP, Burr R, Gress R, et al, ‘Cigarette smoking: risk factor for premature facial wrinkling’, Annals of Internal Medicine 114(1991) pp.840-844. 3. Ernster VL, Grady D, Miike R, et al, ‘Facial wrinkling in men and women, by smoking status’, Am J Public Health 85(1995) pp.78-82. 4. Koh JS, Kang H, Choi SW, et al, ‘Cigarette smoking associated with premature facial wrinkling: image analysis of facial skin replicas’, International Journal of Dermatology, 41(2002) pp.21-27 5. Castelo-Branco, C.,Figueras, F.,Martinez de Osaba, M.J.&Varnell, J.A, ‘Facial wrinkling in postmenopausal women. Effects of smoking status and hormone replacement therapy’,Maturitas,29(1998)pp.75–86. 6. Peto, J, ‘That the effects of smoking should be measured in pack-years: misconceptions’, Br J Cancer, 103(2012) pp. 406–407. 7. Rees TD, Liverett DM, Guy CL, ‘The effect of cigarette smoking on skin-flap survival in the face lift patient’, Plastic and Reconstructive Surgery, 73(1984) pp.911-915. 8. Boyd AS, Stasko T, King LE, et al, ‘Cigarette smoking-associated elastotic changes in the skin’, J Am Acad Dermatol, 41(1999) pp.23-26 9. Leow, Y.H.andMaibach, H.I, ‘Cigarette smoking, cutaneous vasculature, and tissue oxygen’,Clin Dermatol,16(1998) pp.579–584. 10. Ben Johnson, Introduction of Tobacco to England, Historic UK, (2017) <http://www.historic-uk.com/ HistoryUK/HistoryofEngland/Introduction-of-Tobacco-to-England/> 11. U.S. Department of Health and Human Services,The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. Atlanta, (2014) <http://www.quitshisha.com/blog/ cancer/15-types-of-cancer-caused-by-smoking/> 12. Oncken C, McKee S, Krishnan-Sarin S, O’Malley S, Mazure C, ‘Knowledge and perceived risk of smoking-related conditions: a survey of cigarette smokers Prev Med, (2005) pp.779-84. 13. Adeline Petitjean, Sophie Mac-Mary, Jean-Marie Sainthillier, Patrice Muret, Brigitte Closs, Philippe Humbert, ‘Effects of cigarette smoking on the skin of women’, Journal of Dermatological Science, 42(2006) pp.259–261. 14. Fengju Song, Abrar A Qureshi, Xiang Gao, Tricia Li & Jiali Han, ‘Smoking and risk of skin cancer: a prospective analysis and a meta-analysis’, Int J Epidemiol, (2012) pp. 1694–1705 15. Ingrid Emerit, ‘Free radicals and aging of the skin’, Free Radicals and Ageing, 62(1992) pp. 328-341 . 16. Ruta Ganceviciene, Aikaterini I. Liakou, Athanasios Theodoridis, Evgenia Makrantonaki, Christos C. Zouboulis, ‘Skin anti-aging strategies’, Dermatoendocrinol, 4(2012) pp.308–319. 17. Lawrence S. Rubenstein, M.S , ‘The Effects of Age, Sex, and Smoking on Erythrocytes and Leukocytes Norman Helman’, J Clin Pathol ,(632016) pp.35-44. 18. Susan Stevenson and Julie Thornton, ‘Effect of estrogens on skin aging and the potential role of SERMs’, Clin Interv Aging, (2007) pp.283–297. 19. Jørn E. Siana, Sven Rex & Finn Gottrup, ‘The effect of cigarette smoking on wound healing’, Scandinavian Journal of Plastic and Reconstructive Surgery, 23(1989). 20. Sharon Muzerengi and Indrajit Gupta, Leg Ulcers in Older People: A Review of Management Adeyemi Adeyi, BJMP 2(200):pp.21-28 21. Hertog SA, Wensveen CA, Bastiaens MT, Kielich CJ, Berkhout MJ, Westendorp RG, Vermeer BJ, Bouwes Bavinck JN, ‘Relation between smoking and skin cancer,’ J Clin Oncol, 19(2001) pp.231-8. 22. Sayed M. Mirbod, M.Sc.Stephen I. Ahing, ‘Tobacco Associated Lesions of the Oral Cavity: Part I Nonmalignant Lesions’, J Can Dent Assoc, 66(2000) pp.252-6. 23. Wolk, Katarina; Mallbris, et al, ‘Smoking and Pathogenesis of Psoriasis A Review of Oxidative, Inflammatory and Genetic Mechanisms’, The British Journal of Dermatology, 89(2009), pp. 492497(6). 24. Jens Trap-Jensen, ‘Correspondence information about the author M.D. Jens Trap-Jensen, American Heart Journal, 115(1988) pp.263–267 25. Robert L. Rubin, Tracee M. Hermanson, et al, ‘Effect of Cigarette Smoke on Autoimmunity in Murine and Human Systemic Lupus’, TOXICOLOGICAL SCIENCES 87(1), 86–96 (2005) .

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Case Study: Rejuvenating Male Skin Pharmacist prescriber Rukhsana Khan and Dr Rita Poddar present a case study on male skin resurfacing using a chemical peel Chemical peels are a popular treatment used for skin rejuvenation and can offer successful results for a range of aesthetic concerns. In this article we detail the treatment of a 49-year-old male patient (Patient A), who presented to our clinic with a 20-year history of acute and chronic rosacea, extensive acne scarring since his teenage years, uneven skin tone, fine lines and wrinkles, and thread veins (Figures 1, 2 & 3). To achieve an overall improvement to Patient A’s skin, a deep trichloroacetic (TCA) chemical peel treatment was used. The patient never had any dermal fillers or botulinum toxin procedures performed before, during or after the treatment.

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Treatment selection The patient’s clinical indications justified the use of a deep chemical peel to correct his skin concerns. The acne scarring and textural damage involved both the epidermis and dermis, so to correct this a peeling agent with the ability to reach the intermediate reticular dermis was required. A 26% TCA controlled depth peel was recommended and, as detailed above, Patient A was thoroughly informed of what the treatment would entail. The use of a TCA-based chemical peel is well documented as an effective and controllable peel solution, and is self neutralising.9 When applied to the skin, TCA causes localised cell destruction, leading to exfoliation of the damaged layers of skin cells.10 TCA has the benefit to be used as a stand alone or combination peel solution with other chemical peel solutions including lactic, glycolic and citric acid. TCA can further be used to perform very superficial peels using a 5% solution, while a peel to the stratum spinosum can be achieved using a 10% TCA solution. The papillary dermis is reached through using a 15% or 20% TCA solution, while the upper reticular and intermediate reticular dermis can be reached with a 26% or 30% TCA solution. Applying multiple layers of each of these percentage TCA solutions further increases penetration. This characteristic and particular properties of TCA allows for the solution to be absorbed and self-neutralised and further penetration of the solution is inhibited. Applying additional layers will allow the solution to then penetrate to the following layers, making it possible for the clinician to control the solution penetration to a required layer in the epidermis and dermis.9,10

The consultation At the first consultation Patient A was examined using a standardised skin classification system,11 observing colour of the skin, sebum/oil/ sebaceous gland activity, skin thickness, skin elasticity and fragility, and epidermis and dermal skin health. In addition, we performed a clinical examination of Patient A’s acne scarring, thread veins and pore appearance, before discussing with him the treatment options available at our clinic, which included both chemical peels and laser treatment. We then advised Patient A of what each procedure entails, the cost, the results that might be achieved, as well as the side effects and potential complications involved in both. Ensuring that the patient has a thorough understanding of their treatment options helps them decide which they will be most comfortable with and reduces the chance of dissatisfaction following treatment, which is beneficial to both the patient and the practitioner. As recommended by the General Medical Council, it is important to give the patient a cooling-off period before they undergo any nonsurgical or surgical procedure, so Patient A was advised to carefully consider the options before treatment begun and consent forms were signed.14 Before

After

Figure 1: Patient A before treatment presenting with acne scarring, enlarged pores, rosacea, poor texture and uneven skin tone and after treatment with TCA peel for skin resurfacing. Images courtesy of Rukhsana Khan.

TCA has the benefit to be used as a stand alone or combination peel solution with other chemical peel solutions including lactic, glycolic and citric acid Skin preparation To prepare the skin for the deep peel, Patient A was instructed to follow a 12-week skincare routine prior to treatment. The aim of adopting this routine was to optimise basal layer stem cell turnover (mitosis) to ensure the successful repair of the skin after the peel procedure,4 to promote dermal collagen formation5 and to prevent the occurrence of post-inflammatory hyperpigmentation (PIH) following the chemical peel.6 Home skincare routine: • An exfoliating wash twice daily • Exfoliating scrub treatment on alternate days • Oil reduction and prevention treatment once daily • Glycolic and lactic acid complex exfoliator twice daily • A skin bleaching and pigment correcting cream containing 4% hydroquinone

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manufacturer’s instructions and in compliance with optimal training in procedure technique for a safe treatment.9 As mentioned, TCA is self-neutralised so the peel does not have to be washed off or neutralised. The peel aimed to reach the intermediate reticular dermis in specific areas of concern to optimise clinical outcome, by activating dermal fibroblast reaction to induce active collagen and elastin production to tighten the skin and correct deep acne scars.3,6,7 Side effects and potential complications All resurfacing treatments, including ablative, non-ablative and deep chemical peels are associated with substantial downtime of five to 11 days for the epidermis to recover.9,10,11 In this case the recovery time was nine days. Complications associated with chemical peels can include post-inflammatory hyper and hypopigmentation, infection and, rarely, scarring (only if the deep dermal layers were involved).13

After

Before

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Figure 2: Patient A before treatment presenting with thin epidermis/dermis, wrinkles and lines. Six weeks after TCA peel treatment, patient displays epidermal/dermal correction and wrinkle line reduction. Images courtesy of Rukhsana Khan.

• Additional skin lightening and blending cream containing 4% hydroquinone to be used with tretinoin twice daily • Tretinoin 0.1% to optimise mitosis and skin cell turnover twice daily • A sunscreen and primer with SPF 30 in the morning • An at-home peel cream can be applied during the skin preparation period to escalate exfoliation • A calming and hydrating treatment cream to use during the day when the skin feels very dry or when required Our chosen skincare range was the ZO Skin Health and MD products, however other products that have similar properties can be used instead. We would advise that whichever products a practitioner chooses to use, they get thorough training in their properties, mechanism of action and use to ensure that they offer the safest and most successful treatments to patients. During the 12-week preparation period, clinical signs of redness, dry and exfoliating skin are an eminent part of the skin rejuvenation process, with the increased cell turnover and effects of the tretinoin taking place.8 Patient A was consulted every four weeks in clinic and images were taken to monitor his progress and ensure optimal preparation of his skin before the peel was achieved. The patient noted that while the preparation phase was, at first, time consuming and took commitment, it soon became an easy morning and evening routine.

Treatment The skin preparation phase was stopped five days prior to the procedure to allow the epidermal barrier function and layers of skin cells optimal health and function. Local anaesthetic facial nerve blocks were used to ensure a fairly comfortable experience for Patient A, who explained that he experienced an intense heat sensation with very little pain and discomfort. A 26% TCA controlled depth chemical peel was performed, observing specific clinical depth signs during the procedure to ensure a successful outcome post procedure. The peel was applied following the

Figure 3: Patient A before and six weeks after treatment. Images courtesy of Rukhsana Khan.

Recovery Peeling following TCA treatment generally takes nine to 11 days for this specific peel solution as per the manufacturer’s advice3,9,11 and patients can expect extensive peeling over the first three to seven days after the peel, with some mild redness, pain and discomfort experienced in the first three days. As long as preparation of the skin was well executed, according to the guidelines prescribed for this particular peel, the procedure has a low complication and risk profile due to the fact that the stratum basale cell turnover has been optimised using tretinoin.14 The preparation before the procedure aims to minimise redness, optimise quick skin recovery and prevent rebound pigmentation risks. It is important that aftercare is structured and followed through by the patient, under supervision of the practitioner. Patient A’s aftercare advice included the continued use of post-procedure skincare products for six weeks. The patient started a standardised maintenance skincare programme after this period. Results Patient A’s results were immediately visible with significant and visible improvement to his concerns. Specific improvement of acne scarring, rosacea, textural damage, enlarged pores, lines and wrinkles were documented (Figures 1, 2 & 3). To further optimise results, an ablative or non-ablative laser resurfacing procedure can be performed directly after applying the last coating of this specific TCA-based peel. In addition, the clinical results achieved in this case could be further enhanced by a repeat of the same TCA peel or similar after 9-12 months.8

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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Conclusion This case study supports the findings of similar studies that TCA as a peeling solution can be effective for the treatment of extensive acne scarring, rosacea, structural epidermal and dermal skin damage, large pores and to improve general skin health and aesthetic appearance.3,7-10 The use of a trusted skin classification system and skin conditioning creams for a specific period of time is essential to reduce any possible complications associated with chemical peel procedures.10,12,13 In line with the Health Education England (HEE) recommendations for practitioners to perform aesthetic treatments in a safe, professional and accountable way, we advise that practitioners have Level 6 and 7 qualifications and receive certification to perform advanced skin rejuvenation treatments using TCA peels.1,2 Rukhsana Khan an aesthetic practitioner based at Surface Clinic in Saltaire West Yorkshire. She is an independent pharmacist prescriber and specialises in non-surgical skin rejuvenation treatments such as chemical peels. Dr Rita Poddar is a dental surgeon, multiple clinic owner and an aesthetic practitioner. She has a special interest in non-surgical antiageing, cosmetic dermatology skincare and performing TCA peels.

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REFERENCES: 1. Department of Health, ‘Expert group on the regulation of cosmetic surgery: Report to the Chief Medical Officer’, <https://www.bipsolutions.com/docstore/pdf/9422.pdf> 2. Health Education England, ‘Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery Part 1&2,’ (2015) <https:// www.hee.nhs.uk/sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20 one%20update%20v1%20final%20version.pdf> 3. Obagi Zein, Obagi Suzan, Alaiti Samer, ‘TCA Based Blue Peel: A Standardized Procedure with Depth Control’, Dermatologic Surgery, 25(10), 1999, pp.773 – 780. 4. Shao Y, He T, Fisher GJ, Voorhees JJ, Quan T, ‘Molecular basis of retinol anti-ageing properties in naturally aged human skin in vivo’, Int J Cosmet Sci, (2016) 5. Griffiths CE, Russman AN, Majmudar G, Singer RS, Hamilton TA, Voorhees JJ, ‘Restoration of collagen formation in photodamaged human skin by tretinoin (retinoic acid)’, N Engl J Med, 329(1993) pp.530-5. 6. Rendon M, Dryer L, ‘Investigator-Blinded, Single-Center Study to Evaluate the Efficacy and Tolerability of a 4% Hydroquinone Skin Care System Plus 0.02% Tretinoin Cream in Mild-toModerate Melasma and Photodamage’, J Drugs Dermatol, 15(2016) pp.466-75. 7. Fulton JE, Plast Reconstr Surg, ‘Simultaneous face lifting and skin resurfacing’, 102(1998) pp.2480-9. 8. Pharmazie. 2006 May;61(5):453-6. Epidermal effects of tretinoin and isotretinoin: influence of isomerism. Tadini KA1, Gaspar LR, Maia Campos PM. Dermatol Surg. 1999 Oct;25(10):773-80. 9. Obagi S, Alaiti S, Stevens MB.TCA-based blue peel: a standardized procedure with depth control. Obagi ZE1, 10. Khunger N1; IADVL Task Force, Indian J Dermatol Venereol Leprol. 2008 Jan;74 Suppl:S5-12. Standard guidelines of care for chemical peels. 11. Obagi Zein, The Art of Skin Health – Second Edition, CRC Press, 2015, System of Skin Classification. P. 81. 12. Obagi Zein, Kiripolski M, The Art of Skin Health – Second Edition, CRC Press, 2015, Topical Agents for Skin Health Restoration. P. 45 13. Brown M, Cutis. 2016 Aug;98(2):E27-8. Preventing, identifying, and managing cosmetic procedure complications, part 2: lasers and chemical peels. 14. GMC, Give patients time to think before cosmetic procedures, doctors told, 2015 <http://www. gmc-uk.org/news/26550.asp>

PHI CLINIC I S E X PA N D I N G ! We are looking to recruit practitioners to join our team and have positions available for aesthetic nurses, aestheticians and doctors. This is a unique opportunity to work alongside Dr Tapan Patel and the award-winning team at PHI! Ideally you will have experience of working with aesthetic medical devices and lasers. This opportunity offers an excellent remuneration package and the potential for developing a truly rewarding career. For more information contact Gudiya Patel Gudiya@phiclinic.com

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


Advertorial H.A. Intensifier

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H.A. Intensifier – Expert Q&A with Megan Manco Latest Innovations in Skin Restoration with a Corrective Serum that Amplifies Hyaluronic Acid Levels 1. HA breakdown in skin is a key factor in the ageing process which starts in our 20s and accelerates over time: why is it so challenging to tackle this effectively with topical skincare? Topical penetration of hyaluronic acid into skin is limited by its low permeability. The challenging characteristic of hyaluronic acid in the use of topically applied preparations has been that its molecules are large in diameter. This makes it difficult for HA to penetrate into deep layers of the skin, like the epidermis and dermis. 2. What is H.A. Intensifier and how does it address these challenges? H.A. Intensifier is a revolutionary topical serum that amplifies hyaluronic acid levels to help support the skin’s matrix. Rather than focusing on the penetration of hyaluronic acid in the skin, we developed a high-concentration multi-modal technology that works to synthesise natural hyaluronic acid and inhibit hyaluronic acid breakdown in the skin. 3. How can H.A. Intensifier complement injectable aesthetic treatments? H.A. Intensifier has been designed to work either as a standalone topical solution, or as a complement to dermal filler treatments. Dermal fillers provide a degree of structural lift (locally to the area injected) and direct HA replacement. H.A. Intensifier is a complementary at-home maintenance topical regime, applied globally to the face, to enhance and maintain results of dermal fillers by acting directly upon the HA synthesis and degradation processes in skin. 4. What about tackling the early signs of ageing? We know that HA production begins to decline from the age of 20, resulting in minor shadows, fine lines and dullness. Therefore, there is a clinical need to support younger skin with a HA replenishment regime, rather than waiting until the cumulative and rapid decline and degradation of hyaluronic acid, requiring dermal fillers. 5. What makes H.A. Intensifier so different from the other topical HA products on the market? Many HA products on the market claim to penetrate the skin, however, there is limited evidence to validate this claim, even when the HA is included in its fragmented form. SkinCeuticals took a different approach: we developed a multi-modal facial serum that is proven to address hyaluronic acid levels in skin. The H.A. Intensifier formula we developed contains a combination of fragmented, whole, and encapsulated HA demonstrated to have immediate and sustained hydration, Proxylane, which has been shown to stimulate hyaluronic acid synthesis, and purple rice extract and dipotassium glycyrrhizate, which have been demonstrated to inhibit the breakdown of HA. As with all SkinCeuticals products, H.A. Intensifier has undergone rigorous in vivo clinical testing to demonstrate significant results in skin – including: • A 30% increase in skin HA content after just 4 weeks1 • Statistically significant increases in HAS2 (70%) and COL1A1 (50%) biomarkers at 12 weeks2 • Statistically significant improvements (p<0.05) in key markers of firmness, plumpness and texture in a 12-week independent clinical trial3 H.A. Intensifier is a true game changer and the culmination of four years of research. I believe it will become a valuable addition in aesthetic clinical practice, both in-clinic, and as part of a comprehensive homecare regimen. 50

Aesthetics | March 2017

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Megan Manco SkinCeuticals DMI – Director of Scientific Communications Megan is currently the Director of Scientific Communications for SkinCeuticals overseeing global clinical research and scientific affairs. She is responsible for providing technical support to the global markets, developing a global scientific communication strategy, and ensuring scientific integrity of content. Megan previously worked as a Senior Scientist for L’Oréal’s Early Clinical, Advanced Research team, where she was responsible for spearheading the evaluation of new concepts, technology, and formulae. Megan graduated from the Fashion Institute of Technology with a Masters of Professional Studies degree in Cosmetic and Fragrance Marketing Management. She graduated with a Master of Science degree in Microbiology from Wagner College. She earned her Bachelor’s degree in Psychology with a concentration in Pre-Medicine from the College of the Holy Cross.

H.A. Intensifier from SkinCeuticals Available Now Retail size – 30ml – Trade Price £34.56 For more information, please visit www.skinceuticals.co.uk or connect with us on Twitter: @SkinCeuticalsUK REFERENCES 1. SkinCeuticals Data on File. Protocol: A 4-week study on 12 females, ages 45-65. Hyaluronic acid localization was visualized using a biotinylated hyaluronic acid binding protein and streptaviden-conjugated horse radish peroxidase. 2. SkinCeuticals Data on File. In a 12-week clinical study, 3mm punch biopsies were collected on the face at baseline and week 12. Quantitative RT-PCR was used to determine the mRNA abundance in 11 skin biopsy samples for several gene markers. 3. SkinCeuticals Data on File. Protocol: A 12-week, single-centre clinical study was conducted on 59 females, ages 40 -60, with mild to moderate facial sagging and loss of firmness, rough skin texture, nasolabial fold wrinkles, marionette wrinkles, and presence of fine lines/wrinkles in the crow’s feet area. H.A. Intensifier was used twice daily in conjunction with Gentle Cleanser and a sunscreen. Efficacy and tolerability evaluations were conducted at baseline and at weeks 4, 8, and 12.


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A summary of the latest clinical studies Title: Mechanical Performance of Poly Implant Prosthesis (PIP) Breast Implants: A Comparative Study Authors: Ramião NA, Martins PA, Barroso MD, Santos DC et al Published: Aesthetic Plastic Surgery, January 2017 Keywords: Poly Implant Prosthesis (PIP) breast implant; implant thickness; mechanical behaviour Abstract: There is societal concern regarding potential health problems associated with breast implants. Much of this distrust climate was a reaction to the Poly Implant Prosthesis (PIP) scandal. Studying the mechanisms of implant rupture is an important step for their improvement. The mechanical behaviour of breast implant shells was studied on explanted and virgin implants. Implants from both PIP and another brand (brand X), currently in the market, were considered. To study the mechanical behaviour of the shell, a total of 940 samples from 11 explants and 5 control implants were analysed. Pearson correlation analysis and the multi-factor ANOVA statistical tests were performed using mechanical test data. Both PIP control and explants had significant variations of stress (P = 0.0001) and shell thickness (P = 0.000) throughout the implant. The stress was directly related to shell thickness. Shell thickness varied significantly for PIP implants, exceeding the manufacturer’s specifications. Regarding the other brand, thickness variation was within manufacturer’s specifications. The heterogeneous nature of PIP implants was confirmed. The implant shell thickness should be considered as a relevant parameter during the manufacturing process, for quality control purposes. These results may contribute to dispel mistrust and doubt surrounding breast implants, among the medical community and patients. Title: Comparative Study Using Autologous Fat Grafts Plus PlateletRich Plasma With or Without Fractional CO2 Laser Resurfacing in Treatment of Acne Scars Authors: Tenna S, Cogliandro A, Barone M, Panasiti V et al. Published: Aesthetic Plastic Surgery, January 2017 Keywords: Acne; fat graft; laser; lipofilling; nano fat; Abstract: The aim of this study was to evaluate the efficacy of nanofat and platelet-rich plasma (PRP) infiltration alone and combined with fractional CO2 laser resurfacing to improve atrophic scars of the face. From March 2014 to June 2015, 30 patients with atrophic acne scars on the cheeks were selected for this study. Patients were evaluated pre- and postoperatively by physical examination, photographs and ultrasound with a 22-MHz probe to measure subcutaneous tissue thickness. All patients were treated with infiltration of nanofat plus PRP. In 15 randomly chosen patients, a fractional CO2 laser resurfacing at 15 W was also performed right after the infiltration. An Italian version of the FACE-Q postoperative module was administered to analyze each patient’s satisfaction and aesthetic perception of the result. The average preoperative thickness of subcutaneous tissue of patients from group A was 0.532 cm, while the average preoperative thickness of subcutaneous tissue of patients from group B was 0.737 cm. The average postoperative thickness of subcutaneous tissue was 1.201 cm in group A and 1.367 cm in group B. The improvement of thickness of subcutaneous tissue was

0.668 cm in group A and 0.63 cm in group B. We applied a T test on unpaired data, comparing the difference in thickness obtained with the treatment in both group A and in group B, with a p value =0.7289 (not significant). All patients in both groups had a treatment benefit, confirmed with FACE-Q postoperative module, but without a significant difference between the two groups. Subcutaneous infiltration with nanofat and PRP seems to be effective to improve atrophic scars, either alone or combined with fractional CO2 laser resurfacing. Title: Early use of CO2 lasers and silicone gel on surgical scars: Prospective study Authors: Alberti LR, Vicari EF, De Souza Jardim , et al. Published: Lasers in Surgery and Medicine, January 2017 Keywords: Factional CO2 laser; scar; silicone gel Abstract: The aim of this randomised, double-blinded clinical trial was to compare the aesthetic quality of the scar from a group of patients submitted to super-pulsed fractional CO2 laser applications (10,600 nm fractional CO2, set at a density of 20% and an energy of 10 mJ, a scanner of 03 × 03 mm, and a pulse repetition time of 0.3 seconds) in contrast with the other group that used only the silicone gel on the scar after plastic surgery. A prospective study was conducted by analyzing 42 patients with recent scars of up to three weeks in patients with a I-IV Fitzpatrick skin type. The scars were evaluated aesthetically in the second and sixth months by applying the Vancouver scale. At two months of treatment, the statistical data showed a discrete superiority in the laser group’s treatment, as compared to that of the silicone group, in both percentage and significance concerning flexibility (P = 0.05) and pigmentation (P = 0.01). Laser group presented better results in the sixth month (P = 0,03). The early use of the fractional CO2 laser contributed to improving the aesthetic quality of scars from elective surgeries in the second and in the 6th months. Title: Tranexamic acid in treatment of melasma: A comprehensive review of clinical studies Authors: Taraz M, Niknam S, Ehsani AH. Published: Dermatologic Therapy, January 2017 Keywords: Hyperpigmentation; melasma; tranexamic acid Abstract: Melasma is a human melanogenesis dysfunction that results in localized, chronic acquired hyperpigmentation of the skin. Tranexamic acid (TA) is a plasmin inhibitor used to prevent abnormal fibrinolysis to reduce blood loss and exerts its effect by reversibly blocking lysine-binding sites on plasminogen molecules, thus inhibiting plasminogen activator (PA) from converting plasminogen to plasmin. As plasminogen also exists in human epidermal basal cells and cultured human keratinocyte are known to produce PA, there is basic rationale that TA will affect keratinocyte function and interaction. A thorough literature review indicates that while TA is used through various routes of administration including oral, topical, and intradermal injection and as adjutant therapy with laser to treat melasma, its efficacy is not established adequately. Further studies are needed to clarify the role of TA in treatment of melasma.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


Make a consultation more than words with API-100 Skin Analyser The lightweight API-100 skin analyser is a handheld, portable device that can be used in-clinic or easily transported for trade shows and events. It allows you as a practitioner to give your patients a truly visual experience and guide them through their bespoke treatment plan as well as recommend suitable products. The API-100 uses 3 types of light (polarised, flash light and UV). This allows it to measure a variety of parameters including: Moisture / Sebum / Pore / Melanin / Acne / Wrinkle / Sensitivity

STAND 11 31 S T M A R - 1 S T A P R 2 0 1 7, LO N D O N A E S T H E T I C S CO N F E R E N C E .CO M

The results can be viewed on your own device, whether desktop, iPad or smartphone via Wi-Fi image streaming. These can then be shared with the client as well as used for on-going analysis of skin improvements using the on-screen comparison tool. API-100 is compatible with Windows, Android and iOS giving you full flexibility on how you communicate the results.

API-100

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● Immediate, visible results ● X30 Magnification ● Portable and comfortable grip

● Personalise treatment solutions based on results ● Versatile – Can be used on other areas such as arms and back ● Record of skin improvements between treatments ● Compare before and after results on screen.

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2. Are you getting results that your staff and patients are delighted with? Whilst the level to which the clinic may be invested in evaluating patients’ results may vary, and photographic and technological methods of feedback may not always be employed; reactions, downtime, complaints, returns, repeat visits and repeat purchase are all meaningful feedback mechanisms of results of your chosen skincare. Every clinic will also have regular insight to the verbal feedback from its staff and patients. If your team is not excited and confident to use the products themselves and are not enthusiastic to sell it to patients, then it could be that there is something that may be amiss with your selection. Sit down and reevaluate your choice. If you come to the conclusion that you have the correct selection, consider providing more training for your staff, as they may not be confident in selling the product if they don’t have the correct knowledge of the ingredients, mechanism of action, and application.

Are You Optimising Your Cosmeceutical Range? Business strategist Alana Chalmers poses 10 questions every clinic should ask themselves about the cosmeceutical line they stock Cosmeceuticals have become an integral element of the aesthetic clinic business. However, the importance of evaluating if you have the right offering in place and, equally, if it is working well for you is underestimated, yet it is a useful exercise for anyone wishing to grow their clinic revenue in 2017. Making your cosmeceutical offering ‘work harder’ across all facets of your business to optimise resources, improve customer satisfaction, increase turnover and unlock new revenue streams begins with these 10 key questions:

1. What is your current turnover of cosmeceuticals sales per month? Stock should be moving fluidly and represent an exciting and very influential part of your day-to-day running of the clinic. Clinics can generate anything from £1,000 to £10,000 or more on a monthly basis from skincare sales alone. Many clinics fail to unlock this revenue potential and, with it, the benefits of cash flow and patient satisfaction. In order to optimise your cosmeceutical turnover, consider not offering too many different brands, as this can prove counter productive. Instead make sure that the brand/s you do stock have a comprehensive offering to meet the wide array of your patients’ needs and that you have a clear strategy in place for all stages of your patients’ journey, which will be explored in this article.

3. Does your brand of choice create its own demand? Life is made a lot easier where pre-existing awareness and demand exists for a brand you offer. Equally, if the brand provider is demonstrating continual efforts to drive this awareness and demand into your clinic and generate appointments for and with you, even better. That’s not to say stocking a line that is less well-known is not recommended – often clinics choose an unknown brand as they don’t want what everyone else has and it allows them to stand out. But bear in mind that you may have to work harder to establish a brand presence before you have even sold a single unit. Most importantly, select a brand that has evidence-based results in the clinical and consumer sector and has good clinical ingredients.

4. How many patients don’t currently buy skincare from you? How many regular patients do you have that are not on full regimes with you? If they are not buying from you then they are likely buying from someone else. Most clinics rely on their practitioners or perhaps the receptionist to make recommendations to their patients and sometimes there is little incentive, time and the correct offering in place to enable them to do so effectively. Patients’ understanding and education of advanced skincare is key to laying the foundations for their purchasing decision and this education should be threaded through their treatment journey with you. Ensure team members understand the importance of cosmeceuticals in patients’ treatment plans and educate them in how to effectively make recommendations for their patients’ skin type, needs and conditions. Incentives to support this training could include giving a percentage of their sales back to them in either products or a bonus, or what can be very effective is defining a reward of their choice at the start of a period and motivating them to achieve it through their sales.

5. Is it producing your best return on investment (ROI) in your clinic? Of course, high value treatments within a clinic can provide a fantastic ROI as they carry the highest margins. However, cosmeceuticals, if leveraged strategically, have the potential to be one of the most flexible, low investment, hardworking assets you have. Stock on your shelves is a perfect place to start and the power of retailing is demonstrated when we strip things back to basics: just one therapist a day targeted to sell one serum each day could equal £17,000 a year (based on selling five per week at £70 RRP) and that sale may only take a few minutes per day. Equally, selling a cleanser

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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and serum could equate to creating the same level of turnover from a two-minute sale of a homecare regime as you could from an advanced facial treatment, which has possibly taken one hour of your practitioner’s time, as well as room capacity. Cosmeceutical sales require little time and give patients ongoing results and a reason to return in-between treatments.

6. Is your cosmeceutical offering integrated at each stage of the patient journey? Every aspect of the patient journey has the potential to be transformed into a new sales opportunity. Review your current journey – from the moment they contact your practice to the moment they leave and assess how and if your cosmeceuticals play a role in the patient experience:

CONSULTATION

CRM

Patient journey touchpoints where cosmeceutical sales can be optimised

TREATMENT

HOMECARE

Stage 1: Consultation What are you doing to prepare and optimise the patient’s skin pretreatment? This stage can be used to initiate the patient’s journey with you and embark on their first steps to improving skin health with cosmeceuticals straight away. This could be where you introduce a ‘prep kit’ prior to a resurfacing or ablative treatment, recommend skincare treatments that will be of benefit to the patients and also discuss their current regime. It will create loyalty and show patients that you are committed to achieving their results. At the very least, the consultation should cover the importance of combining the treatment with a long-term homecare maintenance plan. Stage 2: Treatment This stage offers a multitude of opportunities to increase sales. Many will see integration into current protocols as additional expense, but it’s an opportunity to build the patient’s relationship with the brand and results it offers. For every treatment you offer there is the potential to sell anything from a simple cleanser to an advanced homecare regime, potentially generating additional retail sales in cross-selling your cosmeceuticals.

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Stage 3: Home Before the patient leaves the clinic is usually when the majority of sales are generated – but the level of these sales is entirely dependant on your strategy and processes implemented to ensure this is maximised. Cumulative improvements in skin health as well as maintaining results achieved in clinic are a natural selling point at this stage; stress the importance of ensuring their treatment results last between appointments. If your patient has had an ablative treatment, consider what products can be used and prescribed to help with recovery. Your patients will truly value and will pay for recovery solutions, especially where scarring or discomfort is a possibility, so explain to them the benefits of using cosmeceuticals to help the skin recover and manage potential scarring. Stage 4: CRM Customer relationship management (CRM) may not be an avenue fully explored by some clinics, yet the stage at which the patients are away from the clinic and potentially not even planning a return visit, can represent a valuable source of retail sales. Look at every aspect of your business and evaluate where you can add value and create an edge to your customer experience. Your patient journey is paramount and your messaging needs to be clear, cohesive and consistent with follow-up procedures in place to make any meaningful changes to patient purchasing patterns. Know your customers, their buying patterns, their skin concerns and offer products to meet their needs continually. Remind them what you offer regularly and enlist creative ways to engage with them and make your offering relevant and appealing to them. It helps to have a CRM system in place to implement this, however, it is not essential if budget is a constraint. CRM can be easily improved with some careful client segmenting, record keeping and an electronic mailing facility.

7. Do you offer a flagship treatment from your cosmeceutical brand? Having a flagship treatment is critical for cementing the brand’s place within your clinic. A flagship treatment is one that encapsulates your best-known skillsets and approach and often would feature something that is bespoke or unique to you or the clinic. It is the treatment that you would use for press opportunities and promote with confidence. Additional news, treatment events, offers and revenue can be generated as a result of offering a flagship treatment alongside your general portfolio. This can provide further revenue for your clinic, as patients will come to you specifically for this and it will set you apart from competitors.

8. Are you utilising your cosmeceutical provider? Consider: • Cross-selling: e.g. recommending complementing homecare lines to address ongoing patient needs alongside their treatment plan, or pairing a course of treatments with a homecare kit to cement a 12-week results plan. • Upselling: e.g. encouraging your patients to support their injectable plan with the addition of an eye-maintenance formula. • Repackaging: e.g. marketing an existing treatment as a men’s/ bride’s/pregnancy package with homecare built in. • Re-invigorating: e.g. re-positioning your treatments and corresponding retail lines for key skin conditions, such as rosacea or dry skin and seasons to engage patients. • Re-inventing: e.g. creating a new treatment combination, such as a laser treatment with a ‘hero’ retail product.

Ideas and materials ranging from videos, case studies, testimonies, flyers and social media assets should be supplied in abundance from your cosmeceutical provider – after all, they have the most experience in the brand. Sampling tools are often overlooked as a key tool but used correctly they can be very effective in initialising sales that may not have otherwise occurred. Sampling should be tailored to generating a response in the skin relevant to the patients’ needs and ideally given prior to the treatment; giving out random free samples without a thought to what the patient’s skin needs won’t be constructive and won’t allow patients to see the full potential of the products. Everyone that leaves your clinic without homecare or samples to trial with mechanisms in place to follow up and make a transaction with them is a wasted opportunity. Use these opportunities to build loyalty and ensure patients return to you for all of their skin health needs.

Reproduced from Aesthetics | Volume 4/Issue 4 - March 2017


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9. Are you using your cosmeceutical brand to grow your social media engagement and profile? Social media is critical in engaging with current and prospective patients. Your chosen cosmeceutical brand should have the profile, news and tools to support you in your social media strategy. It should echo your core values and marry with your intended perception within the market – so it should be interwoven throughout your social media activity in order to build the relationship with your target market. In addition, proactive PR support from your brand is also important in you maximising your success as a clinic. Celebrities, reputable key opinion leaders and influential journalists/bloggers provide a way to further engage with the aspirations of your target market and your cosmeceutical brand could provide a cost-effective valuable toolbox in support of your efforts in doing this. Case studies demonstrating successful results with before and after photographs are also a natural choice for inclusion across your social platforms, so you should use a constant stream of these from your clinic and those supplied to you from the brand owners.

10. Is your distributor your business partner? The answer to this question is more than likely evident at this stage following an assessment of the above points. Your chosen distributor should be working to proactively help you address each and every one of these points, no matter how small your clinic is or how new you are to the industry. Select a partner who truly cares about your success and thoroughly supports you in achieving the most from their brand in your business.

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Summary A credible and well-supported cosmeceutical brand should be capable of being leveraged to achieve success in every one of the mentioned areas. If this is not the case, it may be a result of lack of strategic vision and subsequent inactivity of the team from not being truly inspired by what you are offering. Alternatively, it may be that you are simply working with the wrong brand for your business needs. Brand replacement needs to be well thought out and can instil apprehension amongst clinic staff, but managed well it can represent a re-energised and commercial strategy to benefit both profits and indeed patients. Clinic managers and owners need to look at each aspect carefully and make an objective assessment as to what refinements need to be implemented to get their brand of choice working harder for them, than ever before. Disclosure: Alana Chalmers is the director of Harpar Grace International, which distributes the cosmeceutical range iS Clinical. Alana Chalmers is a branding and business strategy specialist with a background in the management of global brands across the luxury health and beauty sector. Having founded luxury distribution and consultancy outfit Harpar Grace International, Chalmers specialises in working with clinics and practitioners in the UK aesthetics industry to enhance clinic propositions, grow revenue and fast track profitability.

Marketing Masterclass in Facial Aesthetics SATURDAY 29TH APRIL 2017 - LONDON

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A Guide to Understanding Qualifications Training provider Sally Durant discusses the different kinds of training and how to determine if your chosen course has an accredited qualification The Joint Council for Cosmetic Practitioners (JCCP) and the Clinical Practice Standards Authority (CPSA),8 are well underway to developing new standards for qualification and practice standards to provide an accredited education and training framework for the aesthetics industry. This framework, which is due to be launched later this year, is currently being designed by the JCCP’s Working Party on Education, Training and Accreditation, which is a multidiscipline focus group of the JCCP. Qualifications from Levels 4 to 7 are thus being developed in line with the HEE recommendations for each treatment modality.1-3 The JCCP will provide information on this work once it has been completed

The Ofqual process The process of getting a course recognised by Ofqual is complex. Each required element of study or indicative content must be meticulously specified and documented; every learning outcome, or area of the syllabus, must be mapped against the National Occupational Standards or the regulations and guidelines of professional statutory bodies, such as the General Medical Council (GMC), Nursing and Midwifery Council (NMC) or General Dental Council (GDC).4,5 Furthermore, how this learning will be delivered, the course structure, how competency will be assessed and measured and where the achievement of the learning outcome will be evidenced, must be detailed.6 Courses are submitted to Ofqual for accreditation by the registered Awarding Bodies, not by individual training providers. The preparation of a course submission to Ofqual is a lengthy process of documentation owing to the meticulous nature of curriculum design. Submissions are dealt with by Ofqual within a calendar month, after which the course will either be accepted or returned for amendment. Once a course is accredited by Ofqual, individual training providers can apply to the Awarding Body to offer the course and will need to develop their course resources, delivery methods and assessment schedules to fit against the accredited course framework. The individual provider will then need to apply for their own accreditation to offer the course – i.e. the Awarding Body will need to validate that their course design is compliant with the standards and required format.

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and validated. When it comes to education and training, some practitioners may be confused about the true nature of an ‘accredited’ qualification and how this differs from other education and training courses. In order to clarify what you should look for in a training course, and also, vitally, in the individual or company providing it, this article will discuss the difference between a qualification and other forms of learning programmes such as CPD validated courses, while also exploring what makes one qualification different from another, the Ofqual levelling system and who actually provides the accreditation.

Accredited qualification According to its strictest educational definition, the term ‘accredited’ means that the course has either been recognised by a government-registered qualification awarding body or by a university.21 Furthermore, in the former instance, such qualifications will be regulated and registered by the Regulated Qualifications Framework (RQF).6-19 Therefore accredited or regulated qualifications are only available through a university or offered through one of the Ofqual Awarding Bodies such as Edexcel, Industry Qualifications. For beauty therapists the Awarding Bodies are City and Guilds, CIBTAC or VTCT. Ofqual stands for ‘The Office of Qualifications and Examinations Regulation’. It regulates qualifications, examinations and assessments in England and reports directly to parliament. Ofqual maintains education standards in GCSEs, A Levels, AS Levels and vocational qualifications.4,5 To establish whether a course you are looking to enroll on is recognised by Ofqual or by a university, you simply need to visit the Ofqual website or The Universities and Colleges Admissions Service website.6,7 You may need to get the course reference code from the training provider, but usually you will find the course you are looking for by searching its title. If the course is not visible on either of these registers then it is either unaccredited or it may offer a customised qualification,15 which is unique to the training provider. In this case you must contact the Ofqual Awarding Body itself to check the credentials of the course. Accredited qualification titles, types and levels Many people get confused about qualifications in respect of their title or type of certification – is the course you are looking at an Award, a Certificate, a Diploma or a Degree? Principally, this comes down to the size of the course, which will be measured in unit credits according to the requirements of the Qualification Credit Framework.8 Unit credits will be given in two ways. Firstly it will be measured according to the number of Guided Learning Hours i.e. the time spent in teaching or training activities. Secondly, the credits given for the Total Qualification Time will indicate the additional activities involved within a course by way of private study, research work, assignments, case studies etc. The unit credits of a qualification determine whether it is an Award, a Certificate, a Diploma or a Degree and each unit of credit represents 10 hours of learning time. • Award: 1-12 credits or 10-120 hours • Certificate: 13-36 credits or 130-360 hours • Diploma: more than 37 credits or 370 hours of study Degrees are slightly different in that they are accredited by a university rather than an Ofqual Awarding Body and there are a

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HEE Qualification Levels TREATMENT MODALITY

LEVEL 4

LEVEL 5

LEVEL 6

LEVEL 7

Chemical Peels

Very superficial to stratum corneum only

Mid-epidermal level

Down to the grenz zone (dermal/epidermal junction)

Microneedling

Up to 0.5mm with a manual device

Up to 1mm with a manual device

• Up to 1.5mm manual device on the face & body • Up to 1mm with a mechanised device

Laser / IPL / LED

• Hair removal • Non-ablative skin rejuvenation and treatment of benign sun-related hyperpigmentation • LED for acne

• Tattoo removal • Benign vascular lesions

• Generalised and discrete benign pigmented lesions. • Ablative fraction laser treatments

• Fully ablative skin treatments (non-fractional resurfacing) • Laser treatments within the periorbital rim

Mesotherapy

Mesotherapy with or without homeopathic topical agents

Injectable mesotherapy with pharmaceutical topical agents Injection lipolysis

Botulinum Toxin

Administration of botulinum toxins to upper face

Administration of botulinum toxins

Dermal Fillers

Administration of temporary/ reversible fillers for lines and folds (precluding complex zones)

Deliver temporary/ semipermanent dermal fillers

Non-surgical Hair Restoration

Full face phenol peels

Perform hair restoration surgery

Figure 1: Shading at Levels 6 & 7 indicate the requirement for oversight by a prescribing or clinical practitioner. Further treatment modalities are currently under review for inclusion in this framework by the JCCP Working Party for Education, Training and Accreditation.1,2

number of different types or levels; beginning with a Foundation, Undergraduate or Bachelor’s Degree and upwards to a Master’s Degree and Doctorate or PhD. Whether an individual chooses to complete an Award, Certificate, Diploma or Degree will really depend on the extent of the study they wish to undertake. Ofqual and the RQF define different levels of learning that reflect an upward sliding scale in the advancement of the complexity and depth of the knowledge or skill being learned, the teaching and learning styles employed and modalities of assessment.5,6,8 In respect of the HEE guidelines, the qualification levelling for cosmetic interventions also factors in the degree of risk for each treatment modality and the extent of invasion. Who can provide accredited qualifications? Accredited qualifications are provided by education establishments that are working under an Ofqual Awarding Body or university which will recognise their credentials and facilities to be fit to deliver and assess the accredited qualifications in question. The teaching and assessing staff of these organisations will be required to have not only professional qualifications in the area of work or subject matter they are delivering, but also teaching and assessing qualifications. This system provides quality assurance for the aesthetics sector in respect of both the clinical and educational provision. For information on the requirements of teaching and assessing personnel for any particular qualification you should refer to the specific Awarding Body that holds the accredited course. As a potential student, this information on those who will be teaching you, and indeed their certification, should be freely available.

Endorsed short courses and validated CPD Certified short courses, Continued Professional Development (CPD) programmes or supplier-driven training all have a very important place in our sector but do not constitute as ‘qualifications’. They can vary extensively in their quality, educational rigor and the measurement of achievement. That being said, CPD of any kind is vital for keeping knowledge and skills updated, and for the ongoing learning required for professional revalidation.

The JCCP will establish a separate register of training organisations and individual trainers who provide these courses

You may have come across the term ‘CPD accredited’ for short courses and also courses ‘accredited’ by industry insurers, trade publications or representative organisations. However it is important to note that in this context, the term ‘CPD accredited’ does not mean that is has been recognised through a governmentregistered education body, but that it has been recommended by a professional body in that it has been ‘endorsed’ or ‘validated’. For this reason, I will refer to it as CPD validation to avoid confusion in the below. Either way, CPD courses and short courses endorsed by non-governmental organisations are not ‘qualifications’, but have been verified through a CPD accreditor, which is a common misconception.20 CPD can be validated or non-validated. If the course materials have been inspected and assessed by a CPD certifying organisation such at CPD Healthcare, the CPD Certification Service, the CPD Standards Office or the International Academy for CPD Accreditation, the delegate or learner might receive a certificate bearing a registration code, which verifies it as a genuinely validated CPD course.12,13 CPD may also be validated by a Professional

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Statutory Body such as the GMC, NMC or GDC, or by industry bodies such as the British College of Aesthetic Medicine, the British Association of Cosmetic Nurses, or by insurance companies. CPD validated learning is not confined to formal training provision but may also include seminars, webinars, e-learning programmes, workshops and conferences. Individual presenters or speakers may also gain validation for their work. It is important to note that to gain CPD validation, its content must be impartial.

that the teaching is provided to the required standard by qualified and experienced educators and clinicians. This registration in itself will help potential students sift out which training organisations offer appropriate qualifications qualifications aligned to the qualification framework and practice standards developed by the JCCP and the CPSA. The detail of how the Register of Training Providers will be formatted and the requirements for such registration is under current debate and development by the JCCP.

APL and RPL

Conclusion

The Accreditation of Prior Learning (APL) and the Recognition of Prior Learning (RPL) are standard practices in education.14 In principle the process of accrediting or recognising prior learning requires the gathering and cross-referencing of documented evidence of the learning and the assessment of knowledge and competency. In the aesthetics sector this is very difficult to do due to the lack of formally measured or evidenced education and training provision in the past and, equally, it can be a very arduous and expensive process. An example of this difficulty arises commonly when any form of short course has been undertaken where formal assessment or evidence of learning is not completed. Course notes are not enough to accredit the individual with having completed a programme of learning or achieved a level of knowledge or skill mapped against a formal syllabus. In the case of accredited qualifications, a certificate of attendance cannot be used for APL because the syllabus for that course may not be formally set out and mapped against the accredited curriculum framework. Equally, the measurement of knowledge and practical skill will not have been carried out under formal assessment conditions and with detailed documentation of portfolio evidence and thus cannot be automatically verified.14 Individual training organisations will set their own protocols for the assessment of prior learning which may involve formal testing of the applicant or the compilation of a portfolio to demonstrate the knowledge and/or practical competency of the individual. This can be an arduous process depending on the complexity and size of the curriculum and the responsibility for proving prior learning will usually fall with the student. For the aesthetics sector, the issue of APL and how it may be measured against the new qualification standards is currently under debate by the JCCP.

With the JCCP qualification standards soon to launch, it is important that you understand what you are going to get out of a course that you have chosen to take, whether it be an accredited qualification or validated CPD certificate. You should also remember that education and training of any kind should be a worthwhile and rewarding experience. It is forever ongoing and whatever your training learning objective is, the quality of the course provision, and the qualification and credibility of those who will teach you, must be ascertained.

Role of JCCP The JCCP will establish a separate register of training organisations and individual trainers who provide these courses. This is to provide clear assurance that an education provision is robust and

CPD validated learning is not confined to formal training provision but may also include seminars, webinars, e-learning programmes, workshops and conferences

Sally Durant has 36 years’ experience in aesthetics and the management of skin health, together with a commitment to establish recognised standards of training and practice. Durant specialises in the development of advanced post-graduate training programmes for all types of skincare therapists and clinical practitioners. REFERENCES 1. HEE, Part One: PART ONE: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015 <https://hee.nhs.uk/sites/ default/files/documents/HEE%20Cosmetic%20publication%20part%20one%20update%20v1%20 final%20version.pdf> 2. HEE, PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery, 2015, <https://hee.nhs.uk/sites/ default/files/documents/HEE%20Cosmetic%20publication%20part%20two%20update%20v1%20 final%20version.pdf> 3. Bruce Keogh, Review of the Regulation of Cosmetic Interventions, Department of Health, 2013, <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_ the_Regulation_of_Cosmetic_Interventions.pdf> 4. Ofqual: The Register, 2017, to <http://register.ofqual.gov.uk/> 5. Ofqual: What we do, (2017) <https://www.gov.uk/government/organisations/ofqual 6. Bloom’s Taxonomy, <http://www.bloomstaxonomy.org/Blooms%20Taxonomy%20questions.pdf> 7. UCAS, 2017, <https://www.ucas.com/> 8. Qualifications and Credit Framework, 2012, <http://www.accreditedqualifications.org.uk/qualifications-and-credit-framework-qcf.html> 9. UK Government, ‘What qualification levels mean,’ 2016, <http://www.gov.uk/what-different-qualification-levels-mean/list-of-qualfification-levels> 10. BACN, Joint Council of Cosmetic Practitioners (JCCP), 2016, <https://www.bacn.org.uk/documents/ jccp/JointCouncilforCosmeticPractitionersJCCP-CSAGenericPresentationV1.pdf> 11. The Joint Council for Cosmetic Practitioners journey so far, Hamilton Fraser Cosmetic Insurance, 2016 <http://www.cosmetic-insurance.com/blog/business/joint-council-cosmetic-practitionersjourney-far/> 12. What is CPD, The CPD Standards Office, (2017) <https://www.cpdstandards.com/what-is-cpd/> 13. The CPD Certification Service, Welcome to The CPD Certification Service, (2017) <https://cpduk. co.uk/> 14. UCAS, ‘APL’ (2017) <https://www.ucas.com/search/site/type/article/type/structure_ content?keywords=APL> 15. Industry Qualifications, ‘IQ Customised Qualifications’, (2017) <http://www.industryqualifications.org. uk/qualifications/developing-a-qualification-with-us> 16. Jeremy Benson, ‘Speech: Reforming Regulation of Vocational Qualifications’, 2015, <https://www. gov.uk/government/speeches/reforming-regulation-of-vocational-qualifications> 17. Gov.UK, ‘Find a regulated qualification’, 2016 <https://www.gov.uk/find-a-regulated-qualification> 18. Ofqual, ‘Guidance to the General Conditions of Recognition’, 2016 <https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/538339/guidance-to-the-general-conditions-ofrecognition-July_2016.pdf> 19. Ofqual, ‘Qualification and Component Levels: Requirements and Guidance for All Awarding Organisations and All Qualifications, 2015, <https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/461637/qualification-and-component-levels.pdf> 20. The CPD Cirtification Service, ‘CPD Explained’, 2017 <https://cpduk.co.uk/explained> 21. Accredited Qualifications, 2012, <http://www.accreditedqualifications.org.uk/>

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S TAND 36 3 1 S T M A R - 1 S T A PR 2 017, LO N D O N AE S THE TICS CONFE R E NCE .CO M

PRESENTS

Educational Opportunities

April 3rd London Skin Tech Pharma Group’s Dr Jane Ranneva will be presenting A Graceful Jump beyond Mesotherapy An interactive workshop covering the RRS range and introducing the new syringe presentation plus Skin Tech’s world famous peels including NEW Easy TCA Pain Control.

May 19th & 20th NeoStrata European Symposium RCP London

Beauty Booster Redensity [I] takes a new step up in beauty boosting: acting from the dermis up to the skin’s surface with natural, visible and scientifically

A panel of global leaders will gather at the Royal College of Physicians to share their experience with all things NeoStrata. Professor Beth Briden, Dr Sandeep Cliff, Dr Stefanie Williams, Dr Martin Wade, Anna Baker and others will be joined by members of the US NeoStrata scientific and marketing teams to discuss the science behind the brand, and practical hints and tips to develop SkinFitnessTM within your aesthetic practice.

proven results. Its exclusive patented formula, a unique mix of non-crosslinked hyaluronic acid and essential nutrients, rejuvenates and hydrates the skin to make it beautiful and radiant. For skin redensification or in prevention of the signs of ageing, Redensity [I] is a deep boost of confidence for all patients.

For more information contact Teoxane UK

Tel: 01793 784459

TEOSYAL® Redensity [I] is a product of the TEOSYAL® PureSense range, (medical devices, class III, CE mark), for medical professional use only. Please refer to the instructions for use.

Build Your Business With Us For further information on how to reserve your place please call us on:

01234 313130 info@aestheticsource.com www.aestheticsource.com


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Tips for Developing Patient Trust Dr Rekha Tailor discusses best ways to gain patients’ trust As aesthetic practitioners, patients come to see us because they are seeking improvement of their skin, face or body, and may be anxious or embarrassed. For many patients, making the first appointment will have taken a great deal of courage and careful consideration. It is therefore important to earn each patient’s trust to guide them smoothly through the consultation and treatment process, with the aim of retaining their business and referrals in the long term. Trust allows the patient to openly and effectively discuss the issues that concern them so that the practitioner can advise them of the most appropriate treatment options. When patients develop this level of trust, I have found that they are also more likely to comply with the practitioner’s recommendations and the overall treatment plan, and hence achieve better results. In order to gain trust, there are three main areas that you should focus on, which include how to present yourself prior to the consultation, the first meeting and your follow-up communications.

1. Gain trust before you meet your patient Online reputation Often, the first point of contact for patients is your website. It is therefore important to make a site that accurately reflects your brand, is user-friendly and informative. This includes being mobile optimised, as many people will use their phones to conduct an internet search, so you need to ensure your website is easy to navigate on all platforms. According to a survey carried out in 2015 by global information and measurement company, Nielsen, which surveyed 30,000 internet respondents in 60 countries, data indicated 70% of people trusted branded websites.1 This reinforces the importance of making your branding obvious to your patients by clearly displaying who you are and the services that you offer on your website. Your unique selling point, your treatment specialities as well as your location should also be obvious. It is also very important to make patients feel comfortable when they are attending the clinic for the first time and to take away any uncertainty if possible. Images and videos of the clinic that can be viewed online before

According to Nielsen’s survey, 66% trust other people’s opinions that have been posted online1

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they visit, such as the reception area, waiting room and treatment rooms, often help patients to feel comfortable and at ease as they will recognise surroundings. Many patients will also identify with what existing customers think about the practitioner, staff and the clinic. Word-of-mouth, independent reviews and social media can have a positive impact on a practitioner’s and a clinic’s reputation. I have found that many patients trust testimonials and want to get another patient’s candid opinion. According to Nielsen’s survey, 66% trust other people’s opinions that have been posted online.1 Hence, it is important to clearly display independent reviews on your website. As well as this, data by Nielsen’s survey further indicates that 83% trust recommendations from friends and family above all other forms of advertising.1 It is therefore important to remember that if your patients are happy, they will recommend you to their friends and family. Credentials Professional qualifications, membership of professional bodies, experience, recognition within the industry and industry awards enhance the practitioner’s credibility. Patients often check the practitioner’s credentials, experience and reputation by researching online. Ensure that you have the sufficient credentials for your treatment offerings and that they are easily accessible to perspective patients via your website. This will make patients feel comfortable and confident in your skills and hence develop trust in you and your clinic. It is important to keep up to date by regularly attending conferences and training events and it can be beneficial to mention this attendance on your website, which can further promote you as a reputable practitioner. Membership of an appropriate college, such as the British College of Aesthetic Medicine, is also valuable as it demonstrates that you are part of a recognised industry body. Winning industry awards, or even becoming a finalist, also significantly demonstrates industry recognition and competence within your specialty, which will be visible to patients when they research online.

2. Meeting the patient for the first time When a patient enters your clinic, they are likely to instantly form an opinion based on their first experience of it, such as your professional environment, staff and equipment. Some of the questions worth considering to help develop patient trust include:

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Offer the patient knowledge and guidance so that they are empowered to make an informed decision • Is the reception and waiting room warm, welcoming and comfortable? • Is the clinic professional looking, with neat, tidy products and equipment? • Is the receptionist welcoming, friendly and knowledgeable? • Is the team dressed professionally and behaving in a professional manner? • Are the staff enthusiastic and knowledgeable? In-depth consultation process As they say, there is no second chance to make a first impression. Hence, it is essential to deliver an exceptional level of care and service from the very beginning. The below will help patients develop trust during the consultation: Communication Effective communication is essential to developing a mutual understanding between the patient and the practitioner. Communication encompasses speech, visual aids, clinic environment, how patients are greeted and much more. Getting to know your patient on a personal level by spending adequate time with them and learning about and understanding their personal situation helps build rapport and enables trust to develop. Time during consultation It is essential to allow patients plenty of time to discuss their concerns, especially during the first consultation.2 Patients should not feel rushed and should have the opportunity to discuss all the issues that concern them and know that they have been taken seriously.2 Give the patient your full and undivided attention and time. Offer the patient knowledge and guidance so that they are empowered to make an informed decision. I believe more educated patients are more satisfied patients. Speak honestly Always speak to patients honestly. Most patients will appreciate your candour. It is

essential to make sure that your patients’ expectations are realistic and that they are aware of the costs, limitations of treatment, possible complications and likely outcome. Shared decision making Develop personalised treatment plans with costs, which are written down for them to take home and consider. Give additional information regarding the procedure, including recovery time and potential side effects. Check that the patient understands the procedure and process and feels comfortable going ahead with treatment. Patients will feel more confident if they are involved in the decision making process.3,4,5 Patients are putting their trust in the practitioner and clinic, so want to feel that their treatment is safe and will help them achieve excellent results. Cooling-off period It is important to give patients a coolingoff period and provide the opportunity for them to return and ask more questions. The cooling-off period depends upon several factors such as the invasiveness, complexity and permanence of the procedure and the risks involved. Patients need to be able to make informed decisions in their own time. This is a GMC requirement for doctors but, in my opinion, should be followed by all aesthetic practitioners.6

3. Future communication Contacting patients after an initial consultation or a procedure makes the patient feel that you care. This is ideally done with a telephone call made by a member of the team, such as reception staff or therapists, the next day and then a follow-up appointment with the practitioner who performed the procedure. This is to make sure that the treatment went to plan and to address any concerns that the patient may have. It is also important to have visual proof in the form of before and after photographs or videos that patients can refer to, to illustrate

the results achieved with treatment. It is important to find out how a patient would like to receive communication after their procedure – via phone calls, emails, text, newsletters etc. They can state their preferred methods on their initial consultation form. Ensure you listen to your patients’ requests as they will not want to be bombarded with information that is irrelevant to them. As well as electronic communication, information evenings are an excellent way to provide knowledge to patients and potential patients regarding the clinic and specific treatments. It is vital to allow patients to give feedback post procedure and express any concerns or positive thoughts that they may have. Patients value the fact that you listen to what they have to say and if you ensure that they feel that their opinion matters, this enables trust to develop. It also allows the clinic to address what is working and not working, thus enabling the clinic to grow.

Summary By considering the above five points, you will be well on your way to developing patient trust in your abilities and your clinic. However always bear in mind that the best way of developing long-term happy and loyal practitioner-patient relationships is on a foundation of trust and by taking care of our patients. Dr Rekha Tailor is the founder of health + aesthetics. She has been a qualified medical practitioner for more than 27 years and an aesthetic practitioner for more than 10. Dr Tailor is a full member of BCAM and of the RCGP. REFERENCES 1. Nielsen, Global Trust in advertising survey. Winning strategies for an evolving media landscape, 2015. <http://www.nielsen. com/content/dam/nielsenglobal/apac/docs/reports/2015/ nielsen-global-trust-in-advertising-report-september-2015.pdf> 2. Freeman GK, Lavoisier CJ, Afonso NM, et al, ‘Evolving general practice consultation in Britain: issues of length and context’, BMJ, 2002, pp.880–2. <http://www.bmj.com/ content/324/7342/880> 3. Ommen OT & Holger SP et al., ‘The relationship between social support, shared decision-making and patient’s trust in doctors: a cross-sectional survey of 2197 inpatients using the Cologne patient questionnaire,’ International Journal of Public Health, 2011, 56, pp.319–27.<https://www.ncbi.nlm.nih.gov/ pubmed/21076932> 4. Cohen D & Longo MF et al., ‘Resource effects of training general practitioners in risk communication skills and shared decision making competences’, Journal Evaluation Clinical Practice Impact, 2004, 10, pp.439–45. <https://www.ncbi.nlm.nih. gov/pubmed/15304144> 5. Edwards A & Elwyn G, ‘Involving patients in decision making and communicating risk: a longitudinal evaluation of doctors’ attitudes, and confidence during a randomized trial’, Journal Evaluation Clinical Practice Impact, 2004, 10, pp.431–7. <https:// www.ncbi.nlm.nih.gov/pubmed/15304143> 6. General Medical Council, Guidance for doctors who offer cosmetic intervention’s 2016, pp.24-27. <http://www. gmcuk.org/Guidance_for_doctors_who_offer_cosmetic_ interventions_210316.pdf_65254111.pdf>

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and effective. I strongly suggest that the clinic reviews this from a cost/benefit perspective and analyses the cost of providing and, equally as importantly, not providing a ‘tool’ in order to ensure the potential expected benefit is fully understood. When combining this very simple premise with the concept of performance measurement, it equates to a situation where employees can be held to a higher performance standard.

2. Performance measurement and incentives

Improving Employee Performance In the first of a three-part series on ‘How to Maximise Clinic Performance’, global business executive Reece Tomlinson outlines four core principles to increasing employee performance It goes without saying that when a company hires a new employee, they are always looking for the hardest workers, the most intelligent and the most talented people; those with a wealth of industry knowledge and experience. We aim to hire those who we believe are the best people for the role, who should, in theory, provide the best results for the business. Unfortunately, for some managers and companies, the employee who was thought to be that highly sought after great performer (and hired accordingly) can end up performing at an average level. So why does this happen and how can we prevent it in the future? The answer, in my opinion, is that some companies fail to provide the basic foundation that any employee (regardless of performance level), would require to do their job to the best of their abilities. Whether or not a clinic has two employees, or hundreds, the notion of increasing individual employee performance will always have a large-scale positive effect. An employee who is, for example, generating more sales, making fewer mistakes, and focusing on things that will positively impact the strategy of the clinic; is much more valuable from a financial perspective than employees who aren’t. It’s simple mathematics and even marginal gains in employee

performance can tremendously benefit the clinic, or any business. From my experience of leading employees in a variety of businesses and industries, I have found that at its most basic level, increasing employee performance is based on four simple core principles that must exist in the business, or area, that the employee works within.

1. The right tools Providing the right tools is essential to maximising employee performance. This means making sure the employee can operate efficiently, is comfortable, understands the requirements to do their job and is otherwise set up for success. Whether it is making sure that an employee has a computer that can keep up to the demands of their work pace, a customer relationship management (CRM) system that can speed up calling customers, extra training when required or better treatment chairs and procedure room lighting; there will be things that can be provided for every employee which will help make them more efficient

Increasing employee performance must be closely tied to what the clinic is measuring. The quote, ‘What you measure is what you get’, by H. Thomas Johnson, the creator of Six Sigma1 – a data-driven approach and methodology for eliminating defects in any process – is from my experience, very true and highly relevant in business. What the clinic measures employee performance upon and then what it carefully communicates to its employees, will largely correlate to gains in those specific, measured areas. Simply put, when it comes to employee performance, you will get more of what is measured and less of what is not. As Simon Sinek, the author of Leaders Eat Last states, ‘Give us something specific to set our sights on, something we can measure our progress toward, and we are more likely to achieve it’.2 For example, if the clinic’s objective is to grow sales, then employees should have their individual performance in this area measured, as well as the growth of the team that they belong to. Employees need to know exactly what they are working towards, where they currently stand, how they can improve their performance, and how they will be rewarded and recognised if/when they do this.

Performance Measurement & Incentives

The Right Tools

Core Principles of Increasing Employee Performance

Appreciation

Transparent Communication

Figure 1: Core principles of increasing employee performance

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Example of employees who may be measured against KPI

KPI

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Example of how to measure KPI

Sales growth

Anyone impacting sales / entire company

Desired % of Sales Growth Over Prior Period (month, quarter, year) expressed in percentages.

Profit

Depends on the clinic, however certainly managers should be measured against the degree to which the clinic can generate profits

A desired profit margin for the period (month, quarter or year) expressed in GBP or percentages.

Cash generated from operations

Sales Manager, General Manager, Operations Manager etc.

Desired cash flow generated from operations for the period (month, quarter or year). Typically expressed in GBP.

Customer retention rate

Anyone impacting sales / entire company

Desired percentage of customers that are returning for repeat treatments in a given period (month, quarter or year).

Add-on sales as a percentage of sales

Practitioners, customer services, receptionists

Desired additional sales in addition to the booked treatment in a given period. Can be expressed as a percentage or in GBP.

Customer or treatment quality related complaints

Practitioners, customer services, receptionists

Allowable number of complaints in a given period (month, quarter or year). Should be expressed in individual complaints.

Average number of patient treatments

Anyone impacting sales / entire company / customer service

Desired number of average patient treatments per year. Should be expressed in treatments.

Number of new customers

Anyone impacting sales / customer service / entire company

Desired number of new customers in a given period (week, month, quarter or year). Expressed in number of customers.

Number of inbound and outbound sales calls per day

Customer service

Desired number of inbound and outbound calls made per day. Expressed in number of calls and can be tracked daily, weekly and monthly.

Figure 2: List of KPIs and employees who may be measured

KPI Key Performance Indicators (KPI) are generally referred to as the critical qualitative or quantitative information that is being measured by the company, needed to explain a company’s progress towards its stated goals and strategy.3 Every clinic has a number of KPIs that could be routinely measured to gauge individual, team and overall clinic performance. Some examples of KPIs to which employee performance can be measured against can be seen in Figure 2. Although there is not a set of rules regarding how often a clinic should calculate KPI data I would suggest utilising monthly or bi-weekly KPI reports. Similar to checking the gauges in your car to determine how fast you are going and how much longer you can go before you need to fill up with petrol, KPIs are crucial to determining whether or not you are on track to perform as a company and whether your employees are meeting, exceeding or falling short of expectations. The more regular and consistent the KPI reports; the quicker the clinic can alter individual and company performance to ensure objectives are being met. Measuring performance When reading this, you may ask yourself, why does an employee need specific performance criteria in order to improve their own performance? This question is even more relevant in larger clinics where the correlation between the employee and the performance of the clinic is less direct and perhaps less obvious. Fortunately, the answer is simple. Let’s consider the situation expressed above where increasing clinic

sales are the main objective of the clinic. Therefore, if the clinic manager believes that a clinic’s employee(s) can directly impact the clinic’s ability to generate sales (which one could argue that almost every employee of the clinic can), then the degree to which sales grow versus expectations can become a performance indicator to which the employee’s own individual performance can be measured against. Realistically one performance indicator may not be enough to accurately measure performance. This becomes more apparent when one considers the various roles within the clinic. Although each employee may have a direct or indirect correlation to the sales growth of the clinic itself, they may also have additional performance measures which are critical to individual or functional performance. For example, if the clinic has a customer service team (such as front desk staff), performance measurement may not only be limited to sales but also to their ability to generate ‘add-on’ sales in addition to the original – such as consumable products, new treatments and booking return appointments. Another example could be measuring complaints from patients. For many reasons, measuring the number of complaints within the clinic, and subsequent complaints against each individual employee or set of employees is very important data against which employee performance can be measured. Patients who have complaints, whether legitimate or not, have the ability to decrease your profits, hurt your reputation and create potential costly legal issues. Minimising complaints is of best interest to the clinic, and could be something

to be considered a KPI used to assist in measuring employee performance. Performance-based incentives Using KPIs and measuring performance is very useful in assessing employee performance, but how you choose this data can be even more important. Providing performance-based incentives such as bonuses based, cash and non-cash rewards as well incentives such as trips, days off and etc; can help to ensure that employees have additional motivation to achieve specified results that correlate to the clinic’s strategy and by doing so, increases relative employee performance.

3. Transparent and regular communication Maximising employee performance requires consistent and effective communication from management. A recent survey of 1,562 US workers by the American Psychological Association indicates that 25% of employees don’t trust their employer.4 Transparency is essential in building a relationship of trust between the clinic and its employees. This is particularly important when it comes to individual employee and team performance. Using KPIs, along with other management tools such as one-on-one meetings, quarterly or semi-annual performance reviews, regular candid discussions regarding how the employee is doing, asking them what they are having challenges with and what they need from management to excel; are all paramount for maximising employee performance. At the company I lead, we have a mandate for monthly one-to-one

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meetings between managers and their direct reports â&#x20AC;&#x201C; regardless of position, for every employee in the company. These one-to-one meetings help the manager and the employee openly communicate how to address issues impacting performance, where challenges may lay, any questions the employee may have, issues of concern for both the employee and the manager, as well as potential personal issues that may be impacting performance. Regular and transparent communication combined with performance measurement metrics such as KPIs, create an environment where employees can generate, and be held to, higher levels of performance.

Aesthetics Journal

Aesthetics

It is an incredibly simple premise with major implications, and it can cost nothing. Appreciation can come in many forms. Be sincere, be honest and make it known how the employeeâ&#x20AC;&#x2122;s performance is noted and is impacting the clinic. Send thank you notes, publicly praise employees, surprise your team with a treat for a job well done and go out of your way to acknowledge that what they do and the hard work they put into the clinic matters. From experience, the outcome of sincere appreciation is that employees are even more willing to step up, which translates to individual as well as company performance increases.

Conclusion 4. Sincere appreciation I cannot stress this enough, if the intent is for employees to push themselves to higher levels of performance and by doing so improve the performance of the clinic; appreciation is critical. In fact, a recent study by Bersin and Associates indicates that companies that excel at employee recognition, are on average 12 times more likely to generate strong results.5

To summarise, increasing employee performance should be a priority for all clinics and clinic managers. Each and every employee has the potential to be a higher performer, and can be more engaged and more present at work. Even marginal gains in employee performance can have a large impact on the clinic from a financial, efficiency and cultural perspective. The principles contained within this article are

only one of many requirements to truly create an environment conducive to increasing employee performance, however they can be implemented easily and quickly, which will translate into results. Reece Tomlinson is the global CEO of Intraline Medical Aesthetics Ltd. He holds an MBA, is a chartered professional accountant and has completed extensive executive education. His areas of expertise include: executive leadership, strategy development and execution, corporate finance and M&A. He spends his time between Kelowna, BC and London. REFERENCES: 1. Six Sigma, What You Measure Is What You Get (2017) <https:// www.isixsigma.com/community/blogs/what-you-measure-whatyou-get/> 2. Simon Sinek, Leaders Eat Last, Penguin Group Publishing, New York, New York, (2014) 3. David Parmenter, Key Performance Indicators (KPI): Developing, Implementing, and Using Winning KPIs, John Wiley and Sons Inc., Hoboken, New Jersey, (2010) 4. Entrepreneur.com, 4 Reasons You Need to Embrace Transparency in the Workplace (2015) <https://www. entrepreneur.com/article/245461> 5. Chad Brookes, Employee Recognition Linked to Better Business Performance, Business News Daily, (2012) <http:// www.businessnewsdaily.com/3387-employee-recognitionlinked-to-better-business-performance.html#sthash.L7ObEDrj..>

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“I love being able to offer my patients the complete service” Dermatologist Dr Harryono Judodihardjo details his pioneering career in aesthetics and his delight at winning Best Clinic Wales at the Aesthetics Awards 2016 “Starting a clinic is very, very difficult,” says Dr Harryono Judodihardjo, who founded Cellite Clinic in Cardiff 18 years ago. “We were losing money initially and it took about 18 months to break even,” he explains. Now, however, Cellite Clinic is a thriving medical aesthetic business based in the centre of the Welsh capital; offering everything from injectables to body contouring treatments and hair transplants. The success of the clinic has also led to it being recognised as Best Clinic Wales at the Aesthetics Awards 2016. Dr Judodihardjo started his career as a dermatologist after completing a postgraduate in Education in Dermatology, a Master’s and a PhD at the University of Wales College of Medicine, before working as a clinical lecturer. He then began to develop an interest in medical aesthetics, explaining, “I was learning about it at conferences in America, but at that time not many dermatologists were practising aesthetic medicine.” As a result, Dr Judodihardjo decided to further his knowledge, approaching experts in various fields, such as botulinum toxin and hair transplantation, to learn their trades. “When I’d go to conferences and see someone present, I would approach that person and try to learn from them how things are done,” he explains. Without the training courses that are available today, Dr Judodihardjo says this was painstaking work, but worth the effort as he is now considered one of the pioneers in the specialty. For those just starting out, Dr Judodihardjo advises, “Start with the most common procedures first, such as toxins and fillers to build your patient database. Then ensure you can do these procedures really well; practise them hundreds of times so you build your skill. Aesthetics can be a very unforgiving specialty – if you make a mistake you can lose a patient or potentially face litigation – when you have built your confidence

only then should you start to introduce new treatments to your patients.” Coming from a dermatological background has been a great advantage to his aesthetic career says Dr Judodihardjo, explaining, “I know the skin really well, not just from the disease point of view, but also the histology, which enables me to offer additional services to my patients and thoroughly understand how a treatment will react on the skin.” For Dr Judodihardjo, his favourite aspects of clinical practice are the use of botulinum toxin and dermal fillers, however he notes that he enjoys performing all types of procedures and helping patients achieve their goals. “Not everything can be treated with toxin and filler so I love being able to offer my patients the complete service and take an interest in the person as a whole,” he says. Appealing to such a wide range of patients is not easy though, he notes, emphasising that practitioners shouldn’t simply rely on traditional marketing activities. “There can still be a lot of mistrust in aesthetic medicine, but over the years I’ve managed to win the trust of my patients and they have told their friends and family members about the clinic. Word-of-mouth referrals are so valuable,” he says. That trust ultimately led to Cellite Clinic becoming an award-winning practice in 2016. “Winning the Aesthetics Award for Best Clinic Wales was a very pleasant surprise for me,” Dr Judodihardjo says, explaining, “We were just enjoying our dinner and catching up with friends before our name was called – it was a really great feeling!” Dr Judodihardjo says he would encourage everyone to enter the Awards, “It does take some time to fill in the form, but it’s a good time to celebrate your strengths and reflect on your weaknesses so you can improve for the following year. Give it a go, it’s a fun and very glamorous night!” With a successful career behind him, Dr Judodihardjo is now working towards his

next big project – opening a clinic in London. “I’ve wanted to do it for a long time, but my children were young,” he explains, adding, “They are old enough to look after themselves now so I can dedicate more time to this project.” While he acknowledges that it won’t be easy, with the experience and knowledge of running an award-winning clinic in Wales, Dr Judodihardjo says he is confident in his abilities and excited to get started! What treatment do you enjoy giving the most? At the moment, I’m really excited by the skin rejuvenation results that can be achieved with the new Tixel device. It’s a machine I can switch on all day and treat almost everyone who walks into my clinic, as there is hardly any downtime and it can treat all skin types safely. What’s your industry pet hate? My industry pet hate is actually the word ‘industry’ – it drives me nuts! I hope that before I die we will refer to aesthetic medicine as a ‘specialty’. ‘Industry’ just seems too focused on money and getting rich quickly, and I really don’t like that. Do you have a motto or ethos that you follow? The motto I have for myself is one that is used by all doctors – ‘do no harm’. What aspects of medical aesthetics do you enjoy the most? How happy I can make patients. When I was working in the NHS, we could only spend 10-15 minutes with patients, whereas I now spend 45 minutes with a patient. We listen to them properly and offer them results that can be life changing!

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which resulted in the decision to discontinue the development plan for RT001 and focus only on the injectable BoNT-A version RT002.6 While it is not clear when this may come to market, Anterios is developing a ready-to-use topical BoNT-A gel and has successfully completed phase II clinical trials.7 We expect to see more companies adding topical BoNT-A to their pipelines; in particular; we predict that global biotechnology specialty care group Ipsen may get involved, due to the leading status of its product Dysport and soon-to-be-launched liquid formulation, Dysport Next Generation (DNG).8 If Anterios’ topical BoNT-A clinical trials are successful and should this product come to market, it will expand Allergan’s product portfolio and, in our opinion, serve to distinguish the company from its competitors.

The Last Word Medical aesthetic analysts Benazir Premji, Lucy Federico and Raghav Tangri argue how topical botulinum toxin may impact the medical aesthetics market In recent years, some pharmaceutical companies have been making efforts to launch topical botulinum toxin A (BoNT-A).1 In comparison to the current methods of administering BoNT-A via needle injections, topical BoNT-A gel would be applied by hand to the surface of the skin with the aim of decreasing wrinkles and reversing the signs of ageing.2 However, the development and success of topical BoNT-A faces several challenges including the biological mechanism of action, the regulatory environment governing its use, possible contraindications, and its pricing strategies. Should topical BoNT-A surpass these challenges and become available, in our professional opinion, the treatment could have the potential to significantly disrupt the facial injectable market as we know it. Industry efforts of producing topical BoNT-A Fear of needle injections and the pain associated with the needle piercing the skin may present a significant barrier for some patients who are considering undergoing traditional BoNT-A injections. Given its needle-free nature, a topical BoNT-A gel could offer an attractive alternative to both patients and practitioners. As such, some pharmaceutical companies have made efforts to launch topical BoNT-A products to capitalise on this potentially lucrative market. Two companies – Allergan’s subsidiary Anterios, and Revance Therapeutics – have been working on the production of topical BoNT-A gels for more than seven years. Until recently, Revance Therapeutics was pursuing the development of RT001, a topical BoNT-A gel indicated for smoothing wrinkles on the facial skin.3 The clinical success of RT001 in preliminary phase I and II trials showed promise and garnered a lot of industry attention.4 However, the company failed to meet clinical endpoints during their phase III clinical trials (they have not explicitly stated why),5

Challenges However, developing a topical product with an effective mechanism of action presents a large challenge for companies. One difficulty was finding a mechanism to shuttle the neurotoxic molecule to the specific nerve receptors in a muscle, due to the fact that BoNT-A molecule’s large size hinders it from passing through the skin on its own.9 Therefore, aesthetic companies are using a nanotechnology approach, which is a peptidebased delivery system, to circumvent this issue.10 In this way, the neurotoxin can ‘piggyback’ on the peptide to the target muscle, enhancing muscle specific targeting, which in turn means facial wrinkles can be more precisely smoothed out.10 Additionally, given the topical nature of the product, the concentration of neurotoxin will need to be strong enough to penetrate into the deeper layers of the muscle. Clinical trials at present focus on thinner skin areas, such as the wrinkles adjacent to the eye.11 Furthermore, if the concentration of botulinum neurotoxin in the topical BoNT-A is higher than in traditional BoNT-A (which is typically sold in 100ml vials) topical BoNT-A may experience an inflated average selling price. Increased prices may deter practitioners and patients from adopting this product. The impact that this type of product might have on BoNT-A administration regulation should also be considered. As we know, there is limited regulation surrounding the administration of BoNT-A injections in some countries. For example, here in the UK, non-healthcare professionals are allowed to inject it if their patient has been prescribed the product through a medically trained practitioner with a prescribing license.12 If topical BoNT-A was to come to market, although it is likely that it will still need a prescription, given that it is in a format that is much easier to apply, it could mean that more inexperienced practitioners could start offering the treatment, potentially resulting in increased complications due to misapplication such as ptosis or expressive facial asymmetry.10 To our knowledge, there is also no legislation or guidance set up for topical BoNT-A at the present time, so this would also need to be considered. In addition to the regulations surrounding topical BoNT-A administration, possible contraindications for topical BoNT-A need to be taken into consideration. For example, studies have been published indicating that needle-injected BoNT-A can spread to neighbouring facial muscles when injected into the target muscle, causing unintended side effects, such as drooping eyelids.13 This risk would also be present in the topical use of BoNT-A so, to ensure the safety of patients and to facilitate practitioner comfort and trust in the product, more robust research and clinical trials

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would need to be conducted. This would include the completion of the current trials being conducted and on top of that, further clinical trials to convince practitioners and patients that the products are safe and efficacious. Summary Overall, the impact of a topical BoNT-A product depends on how similar it is in terms of safety, efficacy, longevity and price to traditional BoNT-A products, which will influence its success amongst practitioners and patients. However, the fundamental advantage of topical BoNT-A, namely, its needle-free nature, has the power to truly shake up the developing aesthetics neurotoxin market. Benazir Premji is an analyst on the medical device insights team at Decision Resources Group. Her main areas of focus are the facial injectable and aesthetic energy-based device markets. Benazir holds a B.Sc. in life sciences from McGill University. Lucy Federico is an analyst on the medical device Insights team at Decision Resources Group. Her main areas of focus are the global breast implant, facial injectable, and cosmetic thread markets. Lucy holds a B.Sc. in biological sciences from McGill University.

Aesthetics REFERENCES 1. Mooney, Paula, ‘Beauty Trends For 2016: Botox Creams, Pressed Serums And Fillers’, The Inquisitr News, (2016) <http://www.inquisitr.com/2716892/beauty-trends-for-2016-botox-creams-pressedserums-and-fillers/> 2. Prweb, ‘Is Topical Botox the Next Big Thing?’, (2017) <http://www.prweb.com/releases/2015/02/ prweb12547220.htm> 3. Revance, ‘Revance Therapeutics Initiates Phase 3 Clinical Trial of Botulinum Toxin Type A Topical Gel to Treat Lateral Canthal Lines’ (2015) <http://investors.revance.com/releasedetail. cfm?ReleaseID=933474> 4. ClinicalTrials.gov, ‘Safety Study of Two Repeat Doses of RT001 for the Treatment of Moderate to Severe Lateral Canthal Lines in Adults’, (2013) <https://clinicaltrials.gov/ct2/show/NCT01124565?term= Rt001&rank=1&submit_fld_opt=> 5. Revance, ‘Revance Reports Results for RT001 Topical Phase 3 Trial for Lateral Canthal Lines’, (2016) <http://investors.revance.com/releasedetail.cfm?releaseid=975537> 6. Revance, ‘Revance Announces Completion of Pre-Phase 3 Meeting with FDA for RT002 Injectable to Treat Glabellar Lines’, (2016) <http://investors.revance.com/releasedetail.cfm?releaseid=979658> 7. ClinicalTrials.gov, Clinical Trial To Evaluate ANT-1207 In Subjects With Crow’s Feet, (2012), <https:// clinicaltrials.gov/ct2/show/NCT01358695> 8. Businesswire.com, ‘Ipsen announces clinical results of Dysport® Next Generation (DNG) and its intent to file the first ready-to-use liquid toxin A in Europe and ROW’, (2014) < http://www.businesswire.com/ news/home/20140204006849/en/Ipsen-announces-clinical-results-> 9. Deprez, Philippe, ‘Textbook of Chemical Peels: Superficial, Medium and Deep Peels in Cosmetic Practice, 2(2017) 10. Journal of Clinical and Aesthetic Dermatology, ‘Topical Botulinum Toxin’, (2010) <https://www.ncbi.nlm. nih.gov/pmc/articles/PMC2921740/> 11. ClinicalTrials.gov, ‘Dose Finding Study In Subjects With Crow’s Feet’, (2014) <https://clinicaltrials.gov/ ct2/show/NCT01951742?term=anterios&rank=2> 12. Department of Health, ‘Review of the Regulation of Cosmetic Interventions’, (2013) P.14 <https:// www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_ Regulation_of_Cosmetic_Interventions.pdf> 13. Indian Journal of Dermatology, ‘Botulinum Toxin’, (2010) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2856357/>

Raghav Tangri is an analyst on the medical devices insights team at Decision Resources Group. His main area of focus is aesthetics in the Asia Pacific region. Raghav holds a masters degree in biological sciences from Imperial College London.

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With Juvéderm® VOLITE you can improve your patients’ skin quality attributes — increasing smoothness,§ hydration and elasticity — for up to 6 months with just one treatment.2,†,‡,||

Utilising patented VYCROSS® technology,3 Juvéderm® VOLITE is injected intradermally and can be used for areas such as the face, neck, décolletage and hands.4

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

December 2016 UK/0869/2016

Aesthetics March 2017  

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