Aesthetics March 2018

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CPD: Facial Hyperhidrosis

Ms Natasha Berridge and Mr Mahesh Kumar discuss the management of facial hyperhidrosis

Managing Patient Photographs

Practitioners describe how to create quality patient images

Medium Depth Chemical Peels

Dr Raul Cetto discusses the mechanism of action of medium depth skin peels

Patient Feedback

Operations manager Beverly Moore explains how to collect patient feedback


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Contents • March 2018 07 News

The latest product and industry news

18 Advertorial: SkinCeuticals

Find out the latest innovations in skin restoration with glycolic acid

19 IMCAS 2018

Discover the highlights of the International Master Course on Ageing Science conference

Special Feature Managing Patient Photography Page 25

20 News Special: The Decline in Cosmetic Surgery

Aesthetics investigates the reported drop in cosmetic surgery procedures in 2017 according to the British Association of Aesthetic Plastic Surgeons (BAAPS)

22 ACE Preview: The Elite Training Experience

Discover how you will benefit from this exclusive new training event

CLINICAL PRACTICE 25 Special Feature: Managing Patient Photography

Practitioners detail how to create high-quality images of your patients and store them securely

33 CPD: Facial Hyperhidrosis

Ms Natasha Berridge and Mr Mahesh Kumar discuss the diagnosis and management of facial hyperhidrosis

38 Case Study: Treating a Tear Trough Deformity

Dr Tayyab Bhatti provides a case study of a patient he successfully treated for a tear trough deformity using hyaluronic acid dermal filler

40 Medium Depth Peels

Dr Raul Cetto delivers an overview of medium depth chemical peels and explains their antiageing benefits

47 Case Study: Rejuvenating Menopausal Skin

Dr Charlotte Woodward and Dr Victoria Manning share a case study of a successful skin laxity treatment associated with the menopause

50 Advertorial: DermaGenesis DermaFrac

Find out about how DermaFrac combines microdermabrasion, microneedling, topicals and LED therapy

51 Abstracts

53 Collecting Patient Feedback

Clinic operations manager Beverly Moore discusses how to effectively collect patient feedback and use it to improve your service

57 Sales Recruitment and Retention

Public health and wellbeing professional Nina Fryer considers how clinics can implement positive mental health for employees

67 In Profile: Jackie Partridge

Aesthetic nurse prescriber Jackie Partridge details her various medical roles and her love for the aesthetics specialty

68 The Last Word

Ms Natasha Berridge is a maxillofacial surgeon with a specialist interest in facial aesthetics and surgical dermatology. Ms Berridge has years of experience in treating facial hyperhidrosis and other oro-facial conditions with botulinum toxin. Mr Mahesh Kumar is a maxillofacial and reconstructive surgeon with over 15 years’ experience as a NHS consultant in treating head and neck oncology, surgical dermatology and aesthetic facial surgery. Dr Tayyab Bhatti trained at Sheffield University and completed training in surgical and medical specialities. He works as a GP partner and co-owns aesthetic clinic Cosmedocs Midlands based in Derby with his twin brother Dr Aqib Bhatti. Dr Raul Cetto practises at Clinic 1.6 London, specialising in medical facial aesthetics and skin ageing. He is an honorary researcher and lecturer at Imperial College London, a Teoxane Country Expert and a medical director of Harley Academy.

Dr Victoria Manning is an aesthetic practitioner and GP with more than 22 years’ clinical experience. She is co-founder of River Aesthetics and is a trainer and international speaker at aesthetic conferences, as well as a media contributor.

Aesthetic commercial professionals Sue Thomson and Jean Johnston share advice on avoiding the pitfalls of sales team recruitment and retention

61 Promoting Positive Staff Wellbeing

Clinical Contributors

Dr Charlotte Woodward is a medical aesthetic practitioner with more than 27 years’ experience across both general practice and aesthetics. She is the co-founder of River Aesthetics and specialises in thread lifts and vaginal rejuvenation.

A round-up and summary of useful clinical papers


In Practice Sales Recruitment & Retention Page 57

Dr Nikola Milojevic compares modern medical aesthetics in Croatia and the UK

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S E E U S O N S TA N D 1 4

FRI 27 & 28 APR 2018 / LONDON


Read her lips The Restylane lips range is the secret to soft, naturallooking lips.

Date of preparation: November 2017 RES17-11-0695e

Editor’s letter With the start of spring comes our biggest event of the year – the Aesthetics Conference and Exhibition – which is taking place at the Business Design Centre in Islington on April 27-28. After months of hard work and effort Amanda Cameron from the whole team, we are nearly there Editor and everything is almost finalised! We have included the top expert clinical and business speakers and the most relevant topics for delegates of all backgrounds. If you are a surgeon, doctor, nurse or dentist, you absolutely must check out the Elite Training Experience. This brand new, exclusive agenda gives you a three-hour, CPDverified ‘taste’ of some of the most prestigious training course available. Turn to page 22 to read more about how you can benefit from attending the sessions by Dalvi Humzah Aesthetic Training, Academy 102, Medics Direct Training and RA Academy. So, what articles do we have for your delectation in our March

issue? Well, this month we focus on the patient experience, so we have spoken to practitioners about how to take high-quality before and after photographs, as well as how to effectively and securely store these. Another great read is an article on recruitment (p.57); our choice of staff will affect the patient experience in your clinic so it’s important you get it right! It’s also vital to have happy staff, so Nina Fryer (p.61) takes a look at how to enforce positive mental health and wellbeing – important to us all. Don’t miss our fabulous clinical articles this month – my highlights are the CPD on facial hyperhidrosis by Ms Natasha Berridge and Mr Mahesh Kumar (p.33), an article on treating the tear trough by Dr Tayyab Bhatti (p.38) and a case study on rejuvenating menopausal skin by Dr Charlotte Woodward and Dr Victoria Manning. So, enjoy this issue and let us know what you would like to read more about by tweeting @aestheticsgroup or emailing – we look forward to hearing from you!

Editorial advisory board

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

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

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

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

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

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

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

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

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

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.



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Amanda Cameron • Editor T: 0207 148 1292 | M: 07810 758 401 Chloé Gronow • Deputy Editor & Communications Manager T: 0207 148 1292 | M: 07788 712 615 Kat Cooke • Senior Journalist T: 0207 148 1292 | M: 07741 312 463 Shannon Kilgariff • Senior Journalist T: 0207 148 1292 Megan Close • Journalist T: 0207 148 1292 DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | Chiara Mariani • Designer T: 0203 096 1228 |

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Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Olivia Cole, © Copyright 2018 Aesthetics. All rights reserved. Aesthetics Journal is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


Aesthetics Journal



Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Travel Dr Firas Al-Niaimi @Drfirasalniaimi The next 4 days will be spent in beautiful Siberia, lecturing and training my eager colleagues, before heading to my favourite city, Moscow, to do the same! #DrFiras #London #Dermatology #Health #Beauty #Skincare #IMCAS2018 Michael Krychman @MKrychman @drmayoni_clinic gave excellent speech on Geneveve radio frequency mono polar with surface cooling at @imcascongress – RF for functional and aesthetic issues #Training SabrinaShah-Desai @perfecteyesltd @DrBeatrizMolina advanced training #Galderma #masterclass #RSM #perfecteyesltd

Harley Academy launches new course Aesthetic training company Harley Academy has launched its new Skin Rejuvenation in Aesthetic Medicine course. The course will cover key aspects such as medical topical skincare, mesotherapy, microneedling and skin peels, and will follow a similar structure to Harley Academy’s injectable foundation day and Level 7 qualification. The Skin Rejuvenation course lead will be dental hygienist/therapist Simone Golumb, previous training lead at sk:n and Transform Medical. The company states that this skin rejuvenation qualification aligns with the latest guidelines from the JCCP, CPSA and HEE and is regulated by Ofqual. It is CPD accredited and the awarding body is Industry Qualifications. The course will be available to healthcare professionals and aestheticians with a minimum NVQ Level 3. “We firmly believe that any approach to our patients should start with conservative measures, and only then should we consider medical and surgical treatments,” said Dr Tristan Mehta, CEO Harley Academy. “We anticipate that qualifying in skin rejuvenation, and allowing practitioners to safely deliver transformative skin treatments, will form a new foundation of aesthetics. We have spent over a year developing this qualification and we can’t wait to bring it to life,” he added. Complications

BCAM data sheds light on rate of adverse events

#BreastAugmentation Olivier Branford @OlivierBranford Delighted to have my invited commentary accepted in @ASJrnl “Patients’ & Surgeons’ Perceptions of Social Media’s Role in Decision Making for Primary Aesthetic Breast Augmentation” #breastaugmentation #plasticsurgery #aestheticsurgery @NahaiDr @hunter_alexan #Television Dr Vincent Wong @DrVWong Had the most A-MAZING time on the @tv3elaine panel. Thank you @ElaineCrowley and the fabulous team! #Lips Yvonne Dorrans @yvonnedorrans Had an amazing day doing the lip masterclass with Dr Lee Walker. Feeling very privileged to be part of that workshop yesterday. Huge thanks to my @AgeRefined work family for this opportunity #lovemyjob @btoxclinics

Adverse events from the use of dermal fillers are being reported at three per 1,000 treatments, according to data collected from the British College of Aesthetic Medicine (BCAM). The data comes from the BCAM’s Annual National Audit, which included a pooled survey from 240 of its members from 2017. More than 22,000 dermal filler treatment sessions were reported. Out of these procedures, there were more than 60 individual adverse events recorded. According to BCAM, the vast majority of these were minor, such as bruising or an insufficient aesthetic result. There was a total of six incidents that were described as either vascular occlusions, compression or compromise. Of these, four occurred after lip treatments and the remaining two were related to dermal filler treatment to the nasolabial folds. In each case described, the aesthetic doctor reported full resolution with no long-term adverse outcomes. BCAM board member and clinical lead of the Annual National Audit, Dr Paul Myers, said, “This information is particularly helpful to the BCAM board in terms of future instruction, education and support of members. In terms of prevalence of adverse events, the use of dermal fillers appear to be very safe, with the adverse event rate being reported at only three per 1,000 treatments.” The review also reported on botulinum toxin treatments, stating that more than 24,000 individual sessions were performed by the 240 BCAM respondents in 2017. There were 45 adverse events reported, although this included minor problems such as bruising following the treatment, with the occasional eyelid or brow ptosis or poor aesthetic result. BCAM hopes to discuss its Annual Audit with its members in more detail at its annual conference on September 22 at Church House Westminster, London.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal



3D-lipo to launch new multiplatform machines Aesthetic device manufacturer 3D-lipo is set to introduce a new vaginal rejuvenation device and a hair removal platform at the Aesthetics Conference and Exhibition (ACE) 2018. The 3D-Trilogyice system is 3D-lipo’s latest advancement in laser hair removal. The machine combines three wavelengths, which the company states provides safe and comprehensive hair removal treatments. Also launching is the 3D-Vjuve CO2 device for feminine concerns such as urinary incontinence, vaginal atrophy and dryness. According to the company, the 3D-Vjuve CO2 laser delivers superficial energy to vaginal skin to create tiny white ablated dots of damaged tissue, resulting in a heating response. This works to stimulate new collagen production which, the company explains, improves the thickness of the vaginal lining. Dr Kannan Athreya, 3D-Vjuve brand ambassador said, “In the rapidly evolving market of vaginal rejuvenation, fractional resurfacing using CO2 laser remains the gold standard in treatment choice in terms of safety, patient comfort and efficacy. The remarkable results offered to patients who undergo the quick, clinicbased treatment proves to be rewarding for the practitioner, and life changing for the patient.” Both technologies will launch at ACE 2018, which will take place at the Business Design Centre in London on April 27-28. To register for free, visit

Vital Statistics 15% of companies still have no plan in place to be ready for the new GDPR laws by May 2018 (Direct Marketing Association, January 2018)

In a survey of 2,000 women, 30% said they do not like being reminded of ageing when looking for beauty products (Mintel, 2015)

Over the past 10 years, the average age of a female acne sufferer has increased from 20.5 years old to 26.5 (Emerging Issues in Adult Female Acne, Journal of Clinical and Aesthetic Dermatology, 2017)

By 2024, the global male grooming market is estimated to be worth about $29.14 billion US dollars (Statista, 2018)

Plastic surgery

BAAPS condemns plastic surgery auctioning The British Association of Aesthetic Plastic Surgeons (BAAPS) has released a statement which condemns the recent auctioning of cosmetic surgery as a prize at an annual dinner on January 18. The professional body states that the private clinic in question, has ‘blatantly disregarded General Medical Council (GMC) guidelines to offer cosmetic surgery as an auction prize’. GMC guidance for doctors who offer cosmetic interventions states that services must not be offered as a prize, and that when communicating information about cosmetic procedures, promotional tactics must not encourage illconsidered decisions, or knowingly allow others to misrepresent or offer treatment in ways that would conflict with this guidance. The BAAPS Council issued the following statement, “Offering plastic surgery as a prize is clearly against GMC guidance and, in this case, is both transgressing the guidance for good patient care and bringing the speciality into disrepute in a very public manner. This is unethical and irresponsible advertising practice which therefore contravenes the Committee of Advertising Practice (CAP) guidelines too. By commodifying cosmetic surgery and non-surgical treatment, clinics continue to trivialise the risks and glorify the benefits of procedures.”

Britain is the most obese nation in Western Europe, with 27% of people having a BMI above 30 (Organisation for Economic Co-operation and Development, 2017)

The latest Consumer Price Index showed the cost of living in the UK is now rising at the fastest rate in over three years (+2.7%) (Office for National Statistics, 2018)

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Events diary 1 – 5 March 2018 st


American Academy of Dermatology Annual Meeting, Washington DC

4th – 7th April 2018 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo

27th – 28th April 2018 The Aesthetics Conference and Exhibition 2018, London

15th May 2018 British Association of Sclerotherapists 2018 Conference, Dorney

14th – 16th June 2018 BMLA Laser Skin & Body Conference 2018, Rotterdam

1st December 2018 The Aesthetics Awards 2018, London

Aesthetics Journal



Caroline Gwilliam becomes head of ABC Lasers surgical division Aesthetic sales and business professional Caroline Gwilliam has become ABC Laser’s head of surgical division, UK and Ireland. Gwilliam will bring 18 years of experience in the pharmaceutical and medical device sectors across different specialities. She will help launch FemiLift, a CO2 device for feminine concerns such as stress urinary incontinence, atrophy and recurring infections; LipoLife, a platform for laser-assisted liposuction, skin tightening and fat grafting; and VascuLife, a robotic solution for varicose veins. Gwilliam said, “I am delighted to join the ABC Lasers and ALMA family; an international surgical and aesthetic manufacturer of energy-based solutions in surgery and aesthetics. I’ve recently spent time in Israel being trained in the technology and I am looking forward to successfully launching the product range to our UK practitioners.” ABC Lasers was recently awarded the ALMA Excellence Award for the top sales in Europe. This award was presented to ABC Lasers by ALMA Lasers at its European distributors meeting, which took place during the 20th International Master Course on Aging Science (IMCAS) conference in Paris. Guy Goudsmit, managing director of ABC Lasers said, “This award is extremely well deserved by the UK team and I want to thank them all for an outstanding achievement. I’d like to extend a warm thanks to our loyal clientele who have helped promote Soprano Platinum, Harmony PRO and Accent, making these brands the commodity and success they are today.”


Level 7

SmartMed announces UK launch of Envy Facial Medical systems distributer, SmartMed, a subsidiary of Healthxchange Group, has introduced the Envy Facial to its product portfolio. The Envy Facial is a skin resurfacing treatment that aims to improve skin radiance, visibly reduce fine lines and wrinkles, and stimulate healthy cell renewal. According to the company, the treatment drives serums deep into the epidermal layers at the exact point of exfoliation and extraction to ensure maximum penetration of actives at optimal depths within the skin for enhanced absorption. Steve Joyce, marketing and technology director at Healthxchange Group commented, “We are committed to providing the most effective treatments and products. The launch of Envy Facial fills a gap in the market by providing patented three-in-one technology, which delivers the penetration of active ingredients at optimal skin depths.”

Dental hygienists and paramedics accepted on Level 7 injectable course Industry Qualifications (IQ) has updated the entry criteria for its Level 7 Certificate in Injectables in Aesthetic Medicine to recognise dental hygienists, dental therapists and paramedics. The decision is said to come after extensive consultation within the aesthetics sector. IQ provides qualifications that are approved by UK regulators, including Ofqual and Qualification Wales. It is not, however, the only awarding body to provide a Level 7 certificate in injectables. Chief executive of IQ, Raymond Clarke, said, “We are thrilled to have been part of making such an important change to the aesthetic qualification landscape within the UK. A standard approach to upskilling the competence of aesthetic practitioners from a range of backgrounds can only lead to improvements to patient safety.” The president of the British Association of Cosmetic Dental Professionals (BACDP), Jane Reynolds, said, “The BACDP is very pleased to be accepted by IQ and to be part of standardising training across aesthetic medicine.” She added, “This has been a long time coming. Dental hygienists and therapists have been carrying out injectables in aesthetic medicine since 2009 under the guidance of the General Dental Council.”

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal



Let Go Of The Handbrake to support ACE 2018


Chris Littlejohn, Commercial Director at Schuco International

The author of the Let Go Of The Handbrake book, aesthetic practitioner and dentist Dr Harry Singh, is supporting the Aesthetics Conference and Exhibition (ACE) 2018. Let Go Of The Handbrake has been confirmed as the proud sponsor of the networking event on Friday April 27, as well as a catering sponsor. The networking event allows delegates to unwind and relax after a packed day of learning while giving them the opportunity to meet colleagues, speakers and other delegates in a more informal setting. Dr Singh said, “I am delighted to be sponsoring the Networking Event at ACE 2018 and I am really looking forward to meeting delegates, colleagues as well as old and prospective clients. Delegates can purchase a signed copy of my new book Let Go Of The Handbrake at the event, and I will also be holding competitions for the chance to win a free copy.” Dr Singh will also present an educational Business Track session at 9:50am on Friday April 27. ACE 2018 will take place at the Business Design Centre on April 27 and 28. To register for FREE, and to book an exclusive Elite Training Experience session, visit Energy devices

Lynton partners with DEKA UK-based aesthetic technology manufacturer Lynton has partnered with Italian laser manufacturer DEKA. As part of this new partnership, Lynton will be supporting DEKA, a company within the El.En Group, for the launch of its new alexandrite hair removal laser, the Motus AX. According to Lynton, the Motus AX alexandrite uses DEKA’s FDA-approved ‘Moveo Technology’, which aims to produce faster, painless hair removal treatments, using a 20mm integrated sapphire contact cooling tip. Dr Jonathon Exley, managing director at Lynton said, “At Lynton, we pride ourselves on not only being the UK’s largest laser and IPL manufacturer, but also on the quality of post-purchase support and technical service available to all our customers. I am delighted to announce this new partnership with DEKA lasers as it opens the necessary channels for UK clinics to introduce revolutionary new technology like the Motus AX, but with the added support and reassurance of purchasing with Lynton.” Paolo Salvadeo, general manager of the El:En group, said, “I am delighted that Lynton have agreed to launch the DEKA brand in the UK. We have been seeking a suitable partner in the UK market and to have the opportunity to work with an award-winning company like Lynton is incredibly exciting. We look forward to great success!” The Motus AX is now available in the UK, together with technical service and post-purchase training and support provided by Lynton.

This is an exciting time for Schuco – what’s been happening? 2017 was our 60th anniversary, so we’re in the midst of a full year of diamond jubilee celebrations, beginning with a series of exciting product promotions and special offers to celebrate and support both our existing and new customers. We are also working with some fantastic industry leaders on several exciting product launches and industry training events throughout the year. We are very proud that in this dynamic and challenging market, Schuco has stood the test of time since 1957 – we are still a family-run business and are passionate about our core values of delivering personal, prompt service coupled with leading technologies. Tell us more about these new launches? We will soon be unveiling the latest innovation in the Princess® dermal filler range: Volume Plus. This has a higher G prime than the current top five market leaders, and has been specifically designed for mid-face volumising, reshaping and contouring. We have already received outstanding feedback from leading early adopters such as Dr Rita Rakus, and are excited to share more information and expert insights at our Masterclass at ACE. We are also excited about the new worldwide innovations from UniverSkin that we are also planning to launch at ACE – so it’s going to be a very exciting event for us. Schuco has also just signed with a new distribution partner – can you tell us more? We have signed an agreement with Med-fx to exclusively distribute the Princess® Dermal Filler product range. This is very important as it means we can now provide even more safety, support and reassurance for aesthetic clinics and practitioners, as only direct purchases through Schuco and Med-fx can be guaranteed under our strict quality-controlled supply chain. In an industry where there are regular concerns about product counterfeiting and insecure, non-direct distribution, our customers can feel reassured that they are receiving a genuine product which has been properly stored and transported, in line with recommendations. This column is written and supported by

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal



BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

BACN RENEWALS The BACN membership year runs from April 1 to March 31 and we’re encouraging members to renew to Paul Burgess, remain a part of the largest professional CEO of the BACN association for aesthetic nurses in the UK, and welcoming new members into our support network. The BACN has been busy launching new initiatives along with continuing to deliver a wide range of services and support for aesthetic nurses, while working with industry leaders to bring CPD-accredited events with a larger and more nurse focused two-day conference for 2018. Information on how to renew will be sent out to all members throughout March and during this time the BACN will be employing further administration support to ensure that renewals run smoothly! For more information and help, please contact Gareth Lewis, Membership and Marketing Manager at

BACN REGIONAL EVENTS We have our meetings and events calendar live on the BACN website. We have shifted focus to our events and meetings this year and listened to the feedback of our members to ensure these meetings align with members’ learning requirements. We will once again have our wonderful sponsors coming in to showcase the latest in technology, skincare, injectables and more. As well as live demonstrations and educational talks we will also be spending some time in focus groups with a chance to have an open and honest peer-to-peer discussion in an approachable and comfortable environment. All our meetings are tailored to benefit those who have been practising for years and also our newer members. BACN events are CPD-accredited and really are an invaluable learning experience and chance to meet others, so nurses do not feel isolated working in aesthetics. To book your place at one of our events please go to the website and click the events tab – if you have any questions regarding BACN please do not hesitate to contact Tara our Events Manager at 5th March: South Yorkshire Open Day Meeting, Barnsley 12th March: North West Regional Group Meeting, Manchester 19th March: Yorkshire Regional Group Meeting, Leeds 9th April: Scotland Regional Group Meeting, Glasgow 16th April: Wales Regional Group Meeting, Cardiff

This column is written and supported by the BACN

NeoStrata European Symposium dates confirmed Aesthetic distributor AestheticSource has confirmed that this year’s NeoStrata European Symposium will take place at the Royal College of Physicians on May 18 and 19. According to AestheticSource, the symposium will host many world-leading dermatologists and other industry speakers who will present on insightful consumer trends, product innovations, new clinical studies and treatment demonstrations. Delegates will learn more about the new NeoStrata Skin Active product and Tri Therapy Lifting Serum, with new clinical reviews unveiled by leading key opinion leaders. AestheticSource will announce the agenda in the spring. Lorna Bowes, director of AestheticSource said, “Delegates can expect an informative and thorough scientific review of the technologies and formulations that are the backbone of the NeoStrata brand. The latest offering in the continued pipeline of innovation is the amalgamation of 1.25% Aminofil, 8% Gluconolactone and 0.5% LMW HA in the New Tri-Therapy Lifting Serum.” Tattoo removal

Skyncare launches tattoo removal device UK-based aesthetic technology provider Skyncare has added the Biocare-ink tattoo removal device to its product portfolio. According to the company, the Biocare-ink delivers effective removal of dark and coloured tattoo inks through a compact and powerful desktop unit with an advanced Q-Switched laser handpiece. It is a duel 1046 nm and 532 nm wavelength and features an adjustable 1-5mm focusing lens and laser aiming beam. Rob Knowles, biomedical engineer at Skyncare, said, “ It’s unrivalled combination of quality and affordability make the Biocare-ink an easy choice for any clinic that wants to offer effective tattoo removal treatments for clients and a rapid return on investment for the clinic.” Chemical peels

PCA SKIN Perfecting Peel released by Church Pharmacy Exclusive UK distributor of PCA SKIN, Church Pharmacy, has added the PCA SKIN Perfecting Peel to its product offering. The peel is said by the company to be a gentle alpha hydroxyl-acid solution that aims to improve skin surface texture and fine lines, while helping to promote an even skin tone. The product is a multi-faceted skin brightening treatment, which can be used on sensitive skin and higher Fitzpatrick skin types, the company claims. Lizzie Shaw, PCA SKIN account manager at Church Pharmacy said, “We are extremely excited to launch the Perfecting Peel in the UK. There was a gap in the market for a brightening, lightening and tightening peel which could be used alongside other clinical modalities to provide rapid rejuvenation with minimal downtime. Most chemical peels are unsuitable for sensitive skin, however the Perfecting Peel can be used on all skin types, especially those who suffer with sensitivity.”

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal



ABC Lasers to sponsor Medical Aesthetic Practitioner of the Year Distribution company ABC Lasers will sponsor the prestigious category for Medical Aesthetic Practitioner for the Year. The ABC Lasers Award for Medical Aesthetic Practitioner of the Year recognises the aesthetic doctor, dentist, or surgeon who is deemed to have contributed most to the profession and/ or has provided the most outstanding care and treatment to their patients in the last 12 months. Last year, aesthetic practitioner Dr Beatriz Molina won the trophy, with 11 other established practitioners being shortlisted. The 2018 winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole. Guy Goudsmit, managing director of ABC Lasers said, “ABC Lasers has chosen to sponsor this award because it celebrates excellence and achievement in aesthetics. It acknowledges and rewards the practitioner who has truly exceeded in the field of aesthetics and it inspires others to achieve their best. The Aesthetics Awards brings together the best in the industry and helps inspire us all to communicate and collaborate for the good of the industry. The Awards promote a sense of community and unite us in one common goal, to provide the safest and the best treatments for patients.” The esteemed Aesthetics Awards 2018 will take place at the Park Plaza Westminster Bridge Hotel on December 1. With an 800-ticket sell out last year, those wishing to attend in 2018 are encouraged to save the date and secure their tickets early. Hair removal

The Baldan Group launches new hair removal device The Fibra DFA hair removal device has been introduced by Italian aesthetic manufacturer and distributor, The Baldan Group. The Fibre DFA is a fibre coupled 810mm multiple diode which is located inside the body of the machine, as opposed to in the handpiece. It aims to allow the light produced by the multiple diodes to be concentrated in one pulse, and transferred uniformly and directly to the hair through a fibre. Daniela Monai, export manager for The Baldan Group, said, “We are thrilled to launch this new hair removal device. We think practitioners in the UK are really going to like this product as it is a pain-free treatment, is suitable for all phototypes and is extremely precise. For medical professionals, it’s offering something new and totally different from the usual hair removal treatments.”

27 & 28 APR 2018 / LONDON

COUNTDOWN TO ACE 2018 MASTERCLASSES Delegates are invited to attend 12 free Masterclasses across the two days of ACE 2018 on April 27 and 28. The hour-long sessions, worth 1 CPD point each, will be hosted by leading aesthetic companies that include AestheticSource, Beamwave Technologies, Calecim, Galderma, Innoture, Lumenis, Naturastudios,Schuco International and SkinCeuticals. Leading practitioners will outline key considerations to make when adding new products and devices to an aesthetic clinic, while teaching attendees how to get the best results from the products they use, through live demonstrations and interactive discussions. Access restrictions may apply to some Masterclasses, be sure to check what you can attend on the day. SPEAKER INSIGHT Nurse prescriber and Galderma KOL Jackie Partridge will present a Masterclass on Lips Through the Ages. She says, “Lip enhancement treatments have dramatically increased in popularity within the past few years, so I’m looking forward to exploring how the trends have developed over time, while discussing how we can create successful results for patients. Each year I travel down to London from my clinic in Edinburgh to attend ACE. It’s a fantastic event that teaches best practice and new skills, while allowing you to meet suppliers and network with like-minded professionals – all for free!” WHAT DELEGATES SAY “A huge vibrant buzzy event to attend; really enjoyable!” AESTHETIC BUSINESSPERSON, LONDON “There is a wealth of experience, knowledge and information available at ACE, allowing delegates to pick and choose which is most relevant to them.” AESTHETIC DOCTOR, BUCKINGHAMSHIRE ACE HEADLINE SPONSOR

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

@aestheticsgroup Education

Aesthetics Journal



IMCAS Academy releases update to e-learning platform The International Master Course on Aging Science (IMCAS) Academy has updated its e-learning platform, which contains 2,000 video presentations. Aiming to cater for aesthetic practitioners who cannot make the IMCAS congresses or who want to re-watch a lecture, the digital tool provides videos on the latest techniques related to the most popular treatments such as injectables, lasers and light, body shaping, threads and vulvovaginal rejuvenation. Topics also cover cosmeceuticals, nutraceuticals, regenerative medicine and plastic surgery, as well as business advice on digital communication and practice management. In addition, a monthly live webinar aims gives practitioners from around the world the chance to interact directly with the speakers. According to IMCAS, the engagement at its webinars demonstrated that practitioners were hungry for a quick and easy way to communicate amongst themselves and with experts. For this purpose, IMCAS has created IMCAS Alert. This tool, included within IMCAS Academy, is now mobile-friendly and open to all physician subscribers for free. An IMCAS spokesperson explains that through Alert, practitioners can share their complex cases and complications anonymously, illustrated by photos, and get advice and feedback from experts within 24 hours. Since it began, over 100 challenging cases have been submitted, exploring complications such as ‘skin reaction to non-invasive radiofrequency’ and ‘swelling after threads’, and questions like ‘advice on treating keloid with laser’ and ‘filler approach for immunosuppressed patients’ have been answered. Practitioners can find out more by visiting the IMCAS Academy website. Plasma

Plexr Plus to launch this month Aesthetic equipment supplier Naturastudios will officially launch the Plexr Plus device at a workshop at the Royal Society of Medicine on March 23. According to Naturastudios, the device uses plasma through a process called sublimation, which turns solid matter into gas by forming an electrical arc. During treatment, visible smoke is produced as a result of the sublimation process, which is followed by a crusting of the treated skin. This crusting will fall off in a week’s time, leaving no visible bruising or scarring, the company claims. The workshop launch will be run by Naturastudios’ Plexr Plus ambassador, Dr Dev Patel, and will explain the technology behind Plexr Plus and how it works, how practitioners can introduce it into a clinic and how to use it in combination with other treatments. He said, “I am truly passionate about PLEXR and the plethora of conditions it can effectively treat never ceases to amaze me. With so many copycat devices out there, I want to help ensure that appropriately qualified practitioners obtain this device and that they receive the highest standard of training to ensure safe yet effective use of their PLEXR.” There will also be live demonstrations and exclusive discounts on the day. James Anderson, director of Naturastudios Ltd said, “We are extremely excited to be adding the Plexr Plus into our range of aesthetic and medical equipment. After much discussion and meeting with manufacturer, GMV, in Italy, we are confident that our venture together will serve the industry well.”

Murad introduces new products The Retinol Youth Renewal Eye Serum and Night Cream has been added to the portfolio of skincare products by Murad. Both products include Dr Murad’s Retinol Tri-Active Technology, which is made up of three different retinols. These include a fast-acting retinoid that aims to quickly boost cellular turnover; a time released retinol, which the company claims slowly melts onto the skin to deliverer sustained levels of retinol over time; and finally the retinol booster aims to enhance the efficiency of the skin’s receptivity to the retinol benefits. The new Retinol Youth Renewal Eye Serum also contains marine kelp complex and swertia flower, which the company claims improves the signs of ageing around the eyes, firming the skin, brightening dark circles and improving the appearance of crows’ feet. Other ingredients within the Night Cream formula include Red Algae Extract and Swertia Flower, which helps promote a vibrant complexion, visibly minimising lines and wrinkles whilst improving firmness and elasticity, the company states. Industry

Globe AMT launches training clinics UK distributor, Globe Aesthetics and Medical Technologies (Globe AMT), has launched new satellite clinics across the UK for training. The aim of these satellite clinics is to provide a convenient training location for practitioners interested in DEKA lasers, Quantificare LifeViz 3D analysis, Nevisense Mole diagnostics and Cube digital dermoscopy. Globe AMT CEO Lucien Bartram said, “Our concept is to draw specialists together along with best-inclass lasers to create integrated treatment plans producing unique and better results for the benefit of the clients.” The first clinic will launch in Edgbaston, Birmingham, in March, while the Leamington Spa, London Knightsbridge and Brighton satellite clinics will open later in the spring.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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SlimFit Aesthetics announces Dr Rikin Parekh as new KOL Dr Rikin Parekh is the new key opinion leader (KOL) for SlimFit Aesthetics. Dr Parekh is the medical director of two clinics in the Harley Street area and his own training Academy, The Avanti Aesthetics Academy. SlimFit Aesthetics states that Dr Parekh constantly strives to stay at the forefront of nonsurgical treatments, attending conferences in the UK and around the globe. Sophia Hallam, business development manager at SlimFit said, “We are very excited to be partnering with Dr Rikin Parekh and working closely with him to build combination therapy case studies and presenting the outcomes at exhibitions and demonstrating these live. Dr Parekh will be using the SF HIFU Med non-surgical tightening device at the core of his clinic, using this as a base treatment for all of his patients, then recommending procedures to treat patient’s specific concerns and achieve spectacular results.” Dr Parekh said, “SlimFit Aesthetics is a company that supplies a wide range of high-end non-surgical devices, from their SF HIFU Med which provides face and body tightening, to their SF LED skin rejuvenation mask.” He added, “I started working with SlimFit Aesthetics when I purchased their LED mask and HIFU machines after closely looking at all the alternatives in the market. They have proved immensely popular in my clinic, so much so that I had to buy a second LED mask a month after I bought the first due to the demand from patients.” Skincare

Medical Aesthetic Group adds Utopia to portfolio

UK aesthetic product supplier Medical Aesthetic Group (MAG) has added a new silicone-free skincare range to its product portfolio. According to MAG, the Utopia skincare range has been created especially for mature skin and has adaptive technology to suit all skin types. Utopia Skincare is powered by Derma Complex – a combination of eight active ingredients designed to penetrate skin deeply and promote a youthful complexion. The company claims it uses nano-technology to penetrate beyond the surface layers of the skin, delivering effects deep into the epidermis and dermis layers where collagen production takes place and wrinkles start to form. David Gower, managing director of MAG, said, “Utopia delivers the most up-to-date and effective antiageing technology in one range of just six topical products, which properly care for mature skin in a simple and effortless way. Utopia is formulated and manufactured in Britain.”


News in Brief Registration for BCAM Academy to open in April The British College of Aesthetic Medicine (BCAM) Academy will be enrolling new Affiliates from April 3. The Academy aims to raise the bar in professional standards, aesthetic education and patient safety by supporting, mentoring and enabling young aesthetic doctors and dentists to go through their specially planned curriculum over three to four years. Director of BCAM Academy, Dr Chrissy Coffey, said, “BCAM is very excited to be opening its doors to new affiliates and helping to support the next generation of aesthetic doctors and dentists in the UK and Ireland via the Academy.” AestheticSource welcomes new business development manager Aesthetic distributor AestheticSource has hired Sam Leon as its new southeast business development manager (BDM). Through her new role, Leon will be supporting AestheticSource customers to help build their business with their award-winning portfolio of brands, which include NeoStrata, Exuviance, Clinisept+, RRS and SkinTech. Lorna Bowes, director of AestheticSource, said, “Sam brings with her a wealth of experience both in customer support and skincare knowledge and adds yet more expertise to the AestheticSource team.” iMed Aesthetics launches in UK A new medical and aesthetic device company, iMed Aesthetics, has launched in the UK. The company, which is part of Swiss iMed Group International, provides devices for fat reduction, vascular stimulation and cellulite treatment, skin tightening, laser hair removal, lymphatic drainage, and skin resurfacing. Founder John Corbett said, “The UK has an exciting market so we are absolutely thrilled to be launching. Our products will enhance any practice and give instant results for patients.” New sponsors for ACE 2018 New sessions have been added to the free ACE 2018 clinical and business programme. Calecim, a new skincare company which has recently launched in the UK, will sponsor a Masterclass session, along with Innoture Medical Technology. Venus Concept, ThermaVein and Fusion GT are each sponsoring an Expert Clinic session. ACE 2018 will take place at the Business Design Centre on April 27 and 28.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


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Latest Innovations in Skin Restoration with Glycolic Acid SkinCeuticals’ global scientific director Megan Manco answers your questions on the new Glycolic 10 Renew Overnight 1. What is Glycolic 10 Renew Overnight and what sets it apart from other glycolic products on the market? As we know, glycolic acid is a leading anti-ageing ingredient clinically proven to address uneven skin tone, dullness, texture, fine lines and wrinkles. However, its topical efficacy depends on the bioavailable concentration and vehicle used, a detail not commonly considered in many glycolicbased formulations. In fact, integrating glycolic acid in a pH-regulated topical formulation may largely neutralise the acid, attenuating its performance. For example, a concentration of 10% glycolic acid at a pH of 4 has an active level of 40.3%. This means that 40.3% of the 10% is available, equating to a free acid value of only 4.0% glycolic acid. For the first time, SkinCeuticals’ Glycolic 10 Renew Overnight delivers a ‘true’ active level of 10% glycolic acid for the most effective solution to ageing, dull skin. It is formulated at a concentration of 14.6% with a pH of 3.5 to deliver this true 10% active level. Another common drawback of many topical glycolic acid-based creams and lotions is skin irritation and discomfort. To counteract this, Glycolic 10 Renew Overnight has been formulated with a soothing complex Baseline

to form a protective, breathable layer to help lock in hydration and provide comfort.

2. What are the key cosmeceutical ingredients that make Glycolic 10 Renew Overnight a breakthrough product? SkinCeuticals has harnessed 10% free glycolic acid, an optimised level of glycolic acid tolerable for nightly use. 10% glycolic acid is the ideal concentration, efficiently penetrating the epidermis and disrupting cellular cohesion to promote desquamation and increase cellular turnover. Weaker glycolic concentrations (4%) provide minimal exfoliation, whereas stronger concentrations (20%) require administration by a practitioner, and generally cause irritation. Glycolic 10 Renew Overnight has also been synergistically blended with 2% phytic acid which provides comprehensive exfoliation, promoting skin clarity and brightness.

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4. Is the product recommended for a variety of skin types? Yes – Glycolic 10 Renew Overnight is well suited to treating normal, oily, dry, and combination skin types. Due to the effective concentration of glycolic acid, the recommended protocol is to pre-condition skin by limiting initial use to once every other evening to avoid any initial skin sensitivity. After one week, usage may be increased to every evening, or as tolerated, to deliver the best results. As with other glycolic products, a daytime sunscreen should always be used in conjunction to protect from sun damage. For those using a retinol-based product as part of a night time regimen, we recommend alternating between the two products.

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Aesthetics Journal


On the Scene

On the Scene

Botulinum Toxin Training Club networking event, London On January 29, dentist and aesthetic practitioner Dr Harry Singh held a networking event for delegates of the Botulinum Toxin Training Club, to reward them for booking multiple training sessions with the company. The event took place in a private capsule on the London Eye, and delegates were presented with champagne and canapés. Whilst on the London Eye, Dr Harry Singh presented on ‘How to close a sale in 60 seconds’, providing useful marketing tips for delegates, whilst digital consultant Naz Haque spoke about how to improve website search engine optimisation. Dr Singh said, “There were a combination of people in attendance; dentists, doctors, nurses and sales representatives, among others. I hope delegates could take home information to implement in their practice and use tips provided to help build their business.”

1st International Aestheticians Association Meeting, London On January 27, medical aesthetic practitioners gathered at the Thistle Kensington Gardens Hotel for the 1st International Aestheticians Association Meeting: NonSurgical Techniques and Complications, hosted by YouGlo. The aim of the event was to bring like minded doctors who specialise in aesthetics and plastics to improve their injection technique and patient safety. It provided an opportunity to share knowledge and learn from one another, as well as learn about new products. The events featured a range of talks, including PDO threads for body contouring by Dr Lilyanna Marks; periorbital dark circles by Dr Najia Shaikh and mesotherapy, fat injection by Dr Maryam Borumand and aesthetician Bernice Robinson. Dr Borumand, YouGlo conference organiser said, “All delegates agreed there is a need for smaller meetings in the UK where people can learn from each other and share ideas openly.” The 2nd International Aestheticians Association Meeting will take place on 16 February 2019.

20 International Master Course on Aging Science, Paris

further reading into this study.” Dr Molina also presented at IBSA’s two-hour masterclass with aesthetic practitioner Dr Gabriel Siquier Dameto on periocular rejuvenation. She said, “We went Aesthetics reports on the highlights from the 20th through the risks, techniques, International Master Course on Aging Science conference product placement and injection depths. I injected a female model It was another successful year at Paris’s Palais des Congrès for and Dr Siquier Dameto demonstrated on a male patient and we each the 20th International Master Course on Aging Science (IMCAS) used very small amounts of product and got some great results.” UK conference on February 1-3. This year marked 20 years since its aesthetic practitioner Dr Raul Cetto noticed that the conference felt inception, and a record number of 9,245 delegates from all over the bigger than previous years. His highlight was a session by German world met to discuss the latest developments in aesthetic science. aesthetic surgeon Mr Wolfgang Redka Swoboda. He commented, “I Keeping with tradition, the congress began with its full-day Anatomy really enjoyed Dr Redka’s presentation on under-eye dark circles and on Cadaver Workshop. The following three days featured agendas how to treat them with dermal fillers.” This year was the 10th year that dedicated to face, body and breast surgery, while other topics aesthetic practitioner Dr Ravi Jain attended IMCAS, and he said he focussed on all areas within non-surgical aesthetics. This year also valued the scientific session on toxins. He explained, “The botulinum saw the launch of the new IMCAS Academy, a social learning platform toxin debate on Thursday with US dermatologists Dr Mark Nestor for dermatology, plastic surgery and aesthetic science. and Dr Gary Monheit was excellent, with chief scientists from the top Dr Beatriz Molina attended the conference as a delegate and speaker five toxin companies in attendance. It was a great session with useful and said that in general, the conference was ‘a great place to be debate and credible speakers.” Dr Benjamin Ascher, plastic surgeon to meet new colleagues and network’. For her, the highlight was a and IMCAS scientific director, said, “Over the last two decades, talk on injectable complications on Friday. She said, “The speakers IMCAS has been continually expanding and innovating. It started as discussed some really interesting new studies from China and the just a small group of physicians sharing ideas on aesthetic science, US. One in particular was looking at complication rates using different but thanks to our focus on delivering the highest quality teaching, needle sizes. The general consensus that was discussed was that has now grown to welcome more than 9,000 attendees from all the smaller the needle, the less chance of a complication, compared over the world. We are already expecting to welcome over 10,000 to a larger needle. However, they stressed that the anatomy still attendees to benefit from the rich scientific programme at our next matters and how you actually inject. I am really eager now to do some Annual World Congress.”


Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal


The Decline in Cosmetic Surgery – a Healthier Perception or a Struggling Economy?

a healthier and more educated market’. He says that people are also more realistic about how they should look at each stage of life and don’t yearn for drastic changes. “They no longer say, ‘I want to look younger’,” says Mr Cavale, “They want to look their age; they’re more realistic and measured.” He adds, “And that’s a good thing, it shows us that as a society and profession, we are doing the right thing; having healthier conversations and thinking in a better way.” Mr Cavale believes this has led to taking less profound actions, and instead, With the latest BAAPS Annual Audit indicating patients taking up non-surgical treatments. Innovations in the non-surgical specialty over the a drop in the amount of cosmetic surgery past few years will have had some sort of effect procedures taking place in 2017, Aesthetics on the uptake of surgical procedures, according to consultant plastic surgeon Mr Bryan Mayou, and investigates the possible reasons why he believes there has been one big influence in Blepharoplasty, liposuction, and face and brow lifts were just particular that has boosted non-surgical treatments. “A big driver some of the cosmetic surgical procedures that saw a decline for non-surgical treatments is social media, and this has led to more in treatment uptake in 2017, according to data collected by the people seeking these particular types of treatments,” he says, British Association of Aesthetic Plastic Surgeons (BAAPS).1 clarifying that there appears to be more emphasis on non-surgical The annual audit on private aesthetic surgery, which surveys options. Despite BAAPS’s report, The Cadogan Clinic, founded by BAAPS’s 230 (approx.) members, indicated that overall, procedures Mr Mayou, which offers both surgical and non-surgical treatments, for men and women combined were down 7.9% from 2016 actually experienced a rise (6%) in surgical procedures in 2017. (although a few surgeries increased). However, Mr Mayou puts this down to the clinic being in Central According to BAAPS president and consultant plastic surgeon Mr London, and agrees his figures are not reflective of the country as Simon Withey, the small downturn in cosmetic surgery procedures a whole. demonstrates a ‘normalisation’ as the British public are ‘now more aware about the serious impact of surgical procedures’. He Economic uncertainty said, “The slight downwards shift in surgical procedures overall With the UK currently still going through Brexit negotiations that hopefully continues to demonstrate that, at the very least, patients are seemingly less than straight-forward, Mr Mayou believes are realising that cosmetic surgery is not a ‘quick fix’ but a serious the most likely explanation for fewer people opting for cosmetic commitment.” surgery is financial concerns. “I believe the economic situation But whilst it is easy for one to presume this latest reported shift in has played a part; we are all concerned over the future and I surgical treatment uptake is down to a change in perception of the think there is a general loss of confidence in the country at the health and safety risks of surgery, Aesthetics asks if there could be moment.” The state of the economy could also be behind another differing reasons? statistic; BAAPS reported that some surgeries had seen an increase in 2017, and one of these surgeries was breast reduction, A healthier approach which had a rise of 6% for men and women combined. Mr Cavale Consultant plastic surgeon and BAAPS member Mr Naveen explains that this is likely due to the financial strain on the NHS. Cavale believes, like Mr Withey, that the figures reflect ‘a sign of “These days, breast reduction is less readily available on the NHS, due to monetary constraints, something like breast reduction is not getting prioritised for 60,000 funding and it is very difficult to get approved,” he says, explaining that certain criteria must be 50,000 reached to grant a patient breast reduction on the NHS. This includes: expecting more than 40,000 500g of weight to be removed from each breast, proof that if the patient is overweight they have 30,000 brought it down considerably, the patient must be a non-smoker, suffer neck/back ache, and have sores under the breasts and grooves on 20,000 the shoulders from bra straps.2 He adds, “The goal posts are being narrowed more and more, 10,000 meaning more patients are having to go private.” Despite the possibility that more consumers are 0 financially concerned, Mr Cavale believes that 2009 2010 2011 2012 2013 2014 2015 2016 2017 patients are more likely to spend money on this type of private surgery, as it affects their quality Figure 1: Chart shows the amount of aesthetic surgical procedures that took place each year since 2009, according to the BAAPS Annual Audit of life.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

Insider News

Are men really happy with the ‘dad bod’? BAAPS reported that, overall, the 2017 trend was towards women having less facial treatments and more body treatments, and the opposite for men – face/neck lifts were down 44% for women and up 16% for men, while liposuction for men was down 20% in 2017. The BAAPS put this down to men being more comfortable with having a ‘natural appearance body-wise’. Consultant plastic surgeon and former BAAPS president Mr Rajiv Grover, who compiles the audit on an annual basis, said, “For men, the media’s adoption and celebration of the more natural-looking ‘dad bod’ is possibly a driver in this interesting trend, shifting the focus to the face rather than the body. This is a contrast to recent years – a shift that has lessened the pressure to sport a sculpted figure and instead, accept a bit of roundness or softness. Society unfortunately has a history of being more forgiving towards men’s physiques than women’s.” Mr Mayou and Mr Cavale are sceptical of this analysis, with Mr Mayou stating, “Men are very concerned about their bodies, there is no doubt about it.” Mr Cavale adds, “I actually think what has happened is that men are getting more realistic about how they should look at their stage of life, and do not seek unrealistic results.”

Looking ahead With many suggestions as to why there was a shift away from cosmetic surgery in 2017, the question now is whether this will continue to become a trend. Mr Mayou says, “I’m sure there will be other areas in surgery which will start to decline more. For instance, a brow lift has almost gone; it has been so long since we have done one because botulinum toxin treats it so well.” He adds, “You never know what will develop and what will come or go. I’m sure the non-surgical side will continue to make a huge change to what we do.” There will still always be a place for cosmetic surgery, at least in the short term, Mr Mayou believes, explaining, “You can’t beat a surgical facelift. The procedure has improved a lot over time at our clinic; patients are in and out of the clinic within a day and they’re not very bruised. Plus, complication rates are minimal.” And of course, the same can be said for breast augmentation, which continues to rise in popularity; it was up 6% from 2016. Mr Cavale concludes, “We still see a steady increase in breast augmentation. And again, patients are requesting a more natural look and are no longer requesting to be ‘really big’. They are instead requesting to just regain what they may have lost through age and motherhood. Plus, breast augmentation prices have stayed relatively the same over the years, making them now much more affordable.” REFERENCES 1. BAAPS, Cosmetic surgery stats: dad bods and filter jobs, (2018), < press_releases/1535/cosmetic_surgery_stats_dad_bods_and_filter_jobs> 2. NHS, Breast reduction on the NHS, (2018) <>


S E E U S O N S TA N D 5 6

FRI 27 & 28 APR 2018 / LONDON

Thursday 5 April 2018 - 7pm to 9pm

At the Amba Hotel, Charing Cross, Strand, London WC2N 5HX

How would you like to be among the first to get the inside scoop on how to turbo-boost your profits from aesthetics? If you do, sign up for a sneak preview of Dr Harry Singh’s new book, ‘Let go of the handbrake’, at a luxurious, 5-star central London hotel, while enjoying great company, canapés, and Champagne. With the book set for general release in May 2018, you will be one of only 50 people to possess a copy and the insights within, putting you well ahead of the crowd. And that’s not all... Harry will be joined by This Morning’s resident doctor, Ranj Singh, as well as revealing his latest ‘top secret’ project to this select group of people. With only 50 spaces available for this special night, to avoid disappointment, don’t delay!

To secure your place at this exclusive event, please visit... 21


Train with The Elite in London Be mentored by leading aesthetic training providers in the UK at the new Elite Training Experience on April 27-28 It is without a doubt that high-quality education is of upmost importance to medical aesthetic practitioners of today, with training being essential for professional development and revalidation. As there are many training providers in the UK, and certainly throughout the world, often practitioners find it extremely difficult to choose which is best for them. But, what if you had the opportunity to have a ‘taster’ session with a training provider before committing the time and money to their full training course? This is where the Elite Training Experience comes in. This year, at the Aesthetics Conference and Exhibition (ACE) 2018, some of the most renowned training providers and presenters in the UK will showcase their esteemed courses in three-hour CPD-verified sessions, at just a fraction of the usual price. Better still, delegates will receive 10% off a future training course with the provider following their taster session.


Led by award-winning consultant plastic reconstructive and aesthetic surgeon Mr Dalvi Humzah, Dalvi Humzah Aesthetic Training (DHAT) courses are structured to equip both the aesthetic practitioner and trainer to develop, enhance and refine their clinical practice. The DHAT Elite Training Experience will include elements of the various DHAT courses, giving delegates a true taste of what they can hope to gain from booking the full training. This unique session will share practical and interactive injectable

Aesthetics Journal


demonstrations and provide top tips on how to enhance product knowledge and skills using cannulas, while also discussing how to address specific skin and facial areas. On top of this, delegates will also receive a 10% discount voucher for TSK Laboratory, Cosmetic Digital and other companies, to use at ACE following the session. The multidisciplinary international expert faculty will include coaching from Mr Humzah, award-winning cosmetic and dermatology nurse prescriber Anna Baker, US dermatologist Dr Hema Sundaram and German-based general surgeon, Dr Wolfgang Redka-Swoboda. Founder and director of Cosmetic Digital Adam Hampson will also provide his expertise on how practitioners can further develop their business and enhance their position in a competitive market. Mr Humzah said, “DHAT is a multi-award-winning teaching course, and I am absolutely delighted to be able to put together a ‘taster training’ session to run alongside ACE. I have made sure that our three-hour session features the most elite trainers from not just the UK, but from across the world as I feel it is vital that today’s injectors are educated from many different international perspectives.”


Friday April 27: 2pm-5pm Academy 102, led by renowned aesthetic practitioner and multi-award-winning London clinic owner Dr Tapan Patel, is a purpose built aesthetic training provider that is designed to set the bar at a new high for education. With the mantra ‘pursuit of excellence’, its methodology is to ensure that practitioners are fully educated in the latest techniques, product knowledge and complications management. At the Elite Training Experience, Dr Patel will provide an engaging and interactive training session that will give delegates an informed overview of a wide range of injectable procedures. Through live procedure demonstrations and interactive videos from Dr Patel’s new e-MASTR network of high-definition animated videos, delegates will learn expert injection techniques and improve their anatomy knowledge. Dr Patel said, “I believe that unlike many other medical disciplines, the aesthetic practitioner needs to be able to balance a strong scientific background with an eye for artistic beauty. Knowing who to treat, what to treat them with and how to do the treatment safely is the cornerstone of aesthetic practice. Those who attend my Elite Training session will learn all this, and more, to maximise their knowledge of how to provide safe and successful treatments.”


Saturday April 28: 10am-1pm The second day of the Elite Training Experience will feature Medics Direct Training, presented by international speaker and distinguished aesthetic practitioner Dr Kate Goldie. Medics Direct Training is an established medical aesthetic training provider that uses evidence-based techniques and products. It has trained more than 4,000 practitioners since 2007, and prides itself in not only delivering training, but providing support, encouragement and expert advice to help develop and enhance every practitioners’ practice. Dr Goldie will present a lively, dynamic session on the latest techniques in aesthetics at the Elite Training Experience. Dr Goldie will focus on aesthetic artistry – teaching the art of cheek and mid-face enhancements, lip sculpting, combining perioral treatments and

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal


the art of creating the perfect facial profile. After completion of the workshop, delegates will receive a complementary e-learning module with the highlights, technique videos and theory of the session. Dr Goldie said, “I regularly present at conferences and international trainings across the world so I can definitely bring new ideas to practitioners who want to enhance their treatment offerings. My session will include live demonstrations, techniques, facial analysis and evidence-based treatment approaches to boost your confidence, challenge your ideas and grow your practice!”


Saturday April 28: 2pm-5pm The final Elite Training Experience session will be RA Academy, led by award-winning global key opinion leader Dr Raj Acquilla. RA Academy provides a unique approach to dermal filler and botulinum toxin training, offering practitioners with what Dr Acquilla believes to be the latest and most innovative facial rejuvenation techniques from around the globe. With more than 13 years' experience, Dr Acquilla is deemed as an expert in medical aesthetics, facial contouring and volume replacement. In his Elite Training Experience session, Dr Acquilla will be joined by aesthetic nurse prescriber and trainer Jane Wilson, who has spent extensive time on advanced training courses across the world and brings a fresh perspective to RA Academy. Aesthetic practitioner Dr Liesel Holler will also be presenting and demonstrating, showcasing her unique skills in aesthetics. In the three-hour taster session, they will present on facial aesthetic ideals for different genders, facial assessment, treatment planning, anatomy for hyaluronic acid and botulinum toxin injections, as well as risk avoidance and complication management. The session will also feature live demonstrations of Dr Acquilla’s unique full-face approach using injectables. Dr Acquilla said, “This session is not to be missed. My principles are grounded in the promotion of excellence, safety, science, education and not just satisfaction, but also delighting my patients with exceptional results through precise facial mapping and beautification.”

Make the most of the free benefits For a fraction of the usual price, at just £195 +VAT per session, every delegate who books a session within the Elite Training Experience will have an exclusive 10% off any future training with their chosen training provider. As well as this, booking also allows free entry to ACE 2018, which encompasses 47 clinical and business sessions and an exhibition of more than 80 aesthetic companies.

For more information, or to book before places run out, visit

Q: Who can attend the Elite Training Experience? A: Sessions are restricted to doctors, nurses and dentists and may only be booked with a valid GMC, NMC or GDC number. Don’t forget, though, there are so many other amazing CPD-verified sessions on offer at ACE, which are free to attend and open to other aesthetic professionals. Some restrictions do apply to Masterclasses, so it’s best to check the agenda in advance! Q: I have already seen one of these trainers present, what’s new? A: You may have seen some of these renowned trainers present before, but this is the first time where content from their established training courses has been featured at a conference. The trainers will delve into specific training material and share exclusive insights, which would not usually be revealed at typical conference lectures. This is an unmissable opportunity to learn from some of the best providers in aesthetics, whilst gaining CPD points! Q: What’s the difference between the Elite Training Experience and the free sessions at ACE? A: The Elite Training Experience is a separate event which is coinciding with ACE. This is a paid-for agenda and unlike the free sessions at ACE, it is much longer and provides an alternative learning experience as it is based on specific training approaches. Plus, you are guaranteed a seat in a great learning environment! Q: Can I attend ‘taster’ sessions of these training providers elsewhere? A: These three-hour CPD-verified ‘taster’ sessions are exclusive to the Elite Training Experience and the content has been assembled especially. You won’t see this training anywhere else!





27 & 28 APR 2018 / LONDON

Aesthetics journal editor and ACE 2018 programme organiser, Amanda Cameron answers frequently asked questions

Q: I am from abroad, what are the benefits of coming to the UK? A: The UK is leading the way in the aesthetics specialty and we have chosen these Elite Trainers because they are among the best the country has to offer. Also, why not give yourself an excuse to visit the best city in the world – London!

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018




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Aesthetics Journal


five years now. In my opinion, for us to be much more accurate in assessing our results and teaching patients what results are achievable, 3D imaging is a much more powerful medium.” The device can be used to capture 3D face, breast and body images in high-definition resolution.3 Mr Inglefield continues, “We use it not just for documenting treatments, but also for planning Aesthetic practitioners discuss how to take, treatments. We can plan how much volume we’re store and utilise before and after images going to add to a cheek for example, or how much Taking photographs of patients’ aesthetic concerns and the body we can add to a breast that is already asymmetrical, as some subsequent results of treatment is a standard part of all aesthetics of these things aren’t always as evident with a 2D image. It’s the practitioners’ clinical protocol. Not only is doing so essential for same with body contouring procedures; we can be much more documenting accurate medical records, they can be used to train accurate in predicting the outcome of our treatment or procedure if other practitioners and showcase successful results. Yet there is a we use 3D images.” plethora of before and after photographs online that are unclear, For Miss Balaratnam, purchasing an imaging system was one of use bad angles, inconsistent backgrounds and the wrong lighting, the first investments she made when she opened her clinic almost which are unlikely to help practitioners’ marketing efforts and do not three years ago. “I chose to invest in the VISIA complexion analysis portray the aesthetics specialty in the most positive light. Securely system as it acts as a diagnostic tool that allows me to accurately storing images and obtaining the appropriate consent to use patient diagnose my patients’ concerns, so I can treatment plan and track photographs is also a key part of appropriate clinic management. my patients’ journeys over time,” she explains. The device analyses And with penalties for non-compliance to General Data Protection left, right and front facial views, while capturing surface and subRegulations (GDPR) set to come into force on May 26 this year, surface skin conditions to allow practitioners to view data on sun having a thorough process for protecting patients’ data is an damage, porphyrins, spider-veins, hyperpigmentation, rosacea and essential part of any business. acne.4 Miss Balaratnam notes that the device offers standardised Aesthetics spoke to three practitioners on how they take and store lighting, the distance from the patient to the lens is the same and the before and after photographs, as well as Dr Elizabeth Raymond level of accuracy has improved over time. “For me, it’s an excellent Brown, an education specialist and author of Clinical Photography – assessment and diagnostic tool,” she says. Keeping it Legal, Accurate & Consistent,1 for her recommendations on It is important to note, however, that practitioners do not need an photographing aesthetic patients. imaging device to take high-quality before and after photographs. “Choose a good camera,” advises Miss Balaratnam, explaining, Taking photographs “It doesn’t have to be complicated; as long as it’s a good quality camera and you keep the photographs consistent you’ll be fine.” Why should practitioners take before and after photographs of patients? What other points should you consider? Mr Chris Inglefield, a consultant plastic surgeon based at London Bridge Plastic Surgery, says, “Before and after photographs are vital medical records for any intervention that we do on our patients. Photography checklist In our clinic, we have a policy that if a patient refuses to have prePractitioners advise that it is essential the following factors are photographs taken then we won’t operate or treat them as it’s consistent in both the pre- and post-treatment photographs; part of their medical documentation.” Miss Sherina Balaratnam, clinicians should consider these points each time they take a a surgeon with plastic surgery training and founder of S-Thetics photograph: clinic in Beaconsfield, agrees, adding, “From a medicolegal point of view you’re safeguarding yourself, as well as your patient.” This is ✓✓ Lighting: Does the light show skin conditions, lines and supported by the General Medical Council’s (GMC’s) Good Medical wrinkles clearly enough? Are there any distracting shadows Practice guidance, which outlines that recordings made as part of the restricting views of different facial angles? patient’s care form part of the medical record, and should be treated ✓✓ Positioning: Is the patient’s face positioned centrally? Are in the same way as written material in terms of security and decisions they an equal distance from the camera in all photographs? about disclosures.2 Miss Balaratnam also explains that by taking and Have you used a plain background for each image? analysing detailed photographs, practitioners can plan treatment ✓✓ Facial expressions: Is the patient’s skin clear from makeup? accordingly. She says, “We can educate patients about what their Have you taken a variety of static and dynamic photographs areas of concern are and communicate an effective plan with them,” to demonstrate muscle action? adding, “Taking before and after photographs delivers high-quality consultations, which is part of our duty of care to our patients.” Dr Raymond Brown writes in Clinical Photography, “Both a ‘smart’ What devices can you use? technology device (e.g. phone, tablet) and a mid-range compact As well as using digital cameras, there are a number of imaging camera have sufficient image resolution (typically five megapixels) devices on the market that can aid clinical consultations and to record quality images. Smart technologies and compact cameras photograph taking. “I use the VECTRA 3D Imaging Solution for my typically allow the user to select features such as white balance, patients,” says Mr Inglefield, explaining, “I’ve been using it for nearly light metering modes, flash settings, ISO (equivalent to film speed)

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Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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Aesthetics Journal

– so both are an option for easy routine imaging (e.g. facial images) without needing major expense or expertise.”1 She notes, “Bridge cameras and digital single lens reflex cameras (DSLR) offer many additional benefits, such as higher resolution, larger sensor size, better quality lenses, including interchangeable or dedicated lenses such as macro, post-camera processing of images, and a far greater number of user-adjustable settings. But they can need more user involvement to make the most of all the features they offer.” As such, Dr Raymond Brown advises, “Investing in an expensive DSLR is no guarantee of producing quality before and after images if you do not standardise other factors such as lighting, background and patient positioning. It’s better to invest in a simple camera you can use in the right environment, than an expensive, multifunctional camera in a less than ideal setting.”1 Dr Raymond Brown provides detailed advice regarding lighting in Clinical Photography, noting that photographing features you particularly want to see requires practitioners to think critically about the position of the light source(s), the type of lighting and how it falls upon the subject. She explains that a ring flash is a useful tool for practitioners, as it creates a subtle ‘fill’ light as it falls on-axis with the subject. However, Dr Raymond Brown notes that, consequently, it provides even illumination with few shadows, which may not always be ideal for skin and textural images that practitioners may want to capture. “If your camera cannot be fitted with a ring flash, there are several affordable, compact and portable LED lighting units on the market that can significantly improve the quality of clinical photographs,” she says, adding, “Whilst they light a subject very evenly and uniformly, you may need to vary the direction or light output to record skin texture or features such as depressions/wrinkles.”1 Miss Balaratnam says that patients should be free from makeup in all pictures to accurately demonstrate results and investing in a tripod is advisable, in order to keep the height consistent and ensuring your camera doesn’t shake. Dr Raymond Brown adds that using the gridline in the camera viewfinder/display screen is an ideal way to align anatomical landmarks for repeatable images.1 “A floor mat is also beneficial to identify the measurements between the patient and practitioner when taking the photos,” says Miss Balaratnam, while noting that she recommends using a black background. “If you’re using a flash then you’re going to have a harsh refraction of light if the photograph has a white background,” she explains, adding, “Black is also preferred because you see the angles of the face very accurately.” However, Dr Raymond Brown notes that using Before


Figure 1: 41-year-old patient before and after skin conditioning treatments. Photographs taken with the VISIA Complexion Analysis device. Images courtesy of Miss Sherina Balaratnam.


a black background requires skilful lighting to keep the edge of subjects separate from the background. She says, “White or grey are easiest to use in the clinical setting but you may need options for backdrops depending on skin colour and lighting technique.”1 Dr Brian Franks, an aesthetic practitioner based in Harley Street, uses a digital camera and says, “There should be a standard number of photographs you take for each patient depending on their treatment. For example, if you were to administer filler, you would take a full facial photograph, each side of the face, and any other particular angles you want to capture.” He advises that for botulinum toxin procedures, practitioners should take both static and dynamic photographs to capture the lines and wrinkles when they are relaxed, as well as in movement.

Figure 2: Photographs taken with the VECTRA 3D Imaging System. Images courtesy of Surface Imaging Solutions and Canfield Scientific, Inc.

“When taking post-treatment images, have the pre-treatment images available to remind yourself of the views you captured,” adds Dr Raymond Brown, stating that video recording is also beneficial; “A short video clip will illustrate muscle action far more effectively than a series of static images… recording in HD video also allows extraction of good quality still images using readily-available software.” If practitioners are monitoring individual lesions through their photography, then Dr Raymond Brown advises that the use of scales are valuable. “Take a series of photographs showing; overview, regional area, regional view with additional marking,” she advises.1 The practitioners interviewed recommend that clinicians should take into account that there is a risk that, by taking such high-quality photographs, patients may be more critical of their concerns and the treatment results. “After you perform an aesthetic treatment, the patient looks at absolutely everything,” says Dr Franks, highlighting that they may look at their post-treatment photographs and still see areas of concern. Miss Balaratnam agrees, emphasising that it is essential that practitioners are explaining to patients that aesthetic treatments are not quick fixes so their expectations are managed effectively. “However, sometimes, treatments don’t go according to plan,” she says, advising, “It’s important for us as medical practitioners to appreciate that, take it on board and say ‘OK, how can we optimise this?’ When it doesn’t go right, which is the minority of the time, we can still jump in and change the patient’s regime. In terms of skincare especially, having high-quality images of the patient’s progression helps identify whether your treatment plan is working.”

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


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Aesthetics Journal

Obtaining consent Types of consent The practitioners interviewed advise that consent forms for the use of photographs should cover four key purposes: • Medical records: having before and after photographs is essential for keeping track of patients’ progression and to use as evidence if questions or complaints arise • Patient education: images can be used to show future patients the potential results that can be achieved with the treatments on offer • Training: photographs are beneficial for aesthetic trainers to use to educate other practitioners on their techniques and strategy approaches for successful results • Marketing: before and after images can showcase results to potential patients across both digital and print promotional material

The GMC outlines specific guidance for aesthetic practitioners on obtaining consent from patients, in Guidance for doctors who offer cosmetic interventions.5 It says, ‘Before accepting a patient’s consent, you must consider whether they have been given the information they want or need, and how well they understand the details and implications of what is proposed. This is more important than how their consent is expressed or recorded’. In accordance with GDPR, practitioners should also ensure that the request for consent is given in an ‘intelligible and easily-accessible form, with the purpose for data processing attached to that consent’. The regulations also state that, ‘Consent must be clear and distinguishable from other matters… using clear and plain language’ and that it must be as easy to withdraw consent as it is to give it.6 The practitioners interviewed emphasise that this doesn’t just apply to consenting to the procedure itself, but also for the use of photographs taken. “We consent for their use both inside the clinic and outside,” says Miss Balaratnam, noting that she has a detailed consent form specific to photography; “We have a separate consent form for showcasing our photographs in studies to one that enables patients to choose which media context their photography will be used in; be that on Facebook or on the website. In this day and age when there are multi-platforms of media interaction, we have to be as accurate as possible to give our patients the choice.” Mr Inglefield points out that care should be taken to describe exactly why and how a patient’s photographs will be used. “Some patients who have body contouring treatments will request not to show their face or any identifying marks such as tattoos,” he explains. For facial photographs, many practitioners will redact the patients’ eyes so they can’t be identified. “Always discuss how you will present the photos, so the patients are prepared for this,” advises Mr Inglefield. Dr Franks uses patient management system Consentz to take and store notes during the consultation, as well as using its consent form software. The tablet-based system has tick-box options for the different types of consent, which practitioners can tailor to their clinic’s preferences. Dr Franks explains, “I use photographs because I teach and train, as well as for marketing, so I have separate consent options for each of those. When you give the patient the device to sign, they cannot move out of their records because it has a security code that I have to put in to be able to move to the next stage. So


even if I left the patient alone with the device – which I of course wouldn’t do – they could not access anybody else’s records.” Miss Balaratnam obtains consent for the use of photographs during the initial consultation, however she notes that her team members state their use once more in follow-up calls. “During these calls we mention to patients again that they have consented for the use of their photos; giving them the opportunity to re-consent or remove their consent to ensure they are comfortable with us sharing their results,” she explains.

Securely storing photographs Maintaining patients’ confidentiality is a significant part of any medical procedure. The GMC states, ‘Confidentiality is central to trust between doctors and patients. Without assurances about confidentiality, patients may be reluctant to seek medical attention or to give doctors the information they need in order to provide good care’.7 However, it adds that appropriate information sharing is, ‘Essential to the efficient provision of safe, effective care, both for the individual patient and for the wider community of patients’,7 which aligns with necessity of using patients’ before and after photographs for the reasons discussed previously; primarily, to educate future patients and to teach other practitioners. In 2013, the GMC released guidance on Making and using visual and audio recordings of patients which states, ‘The increasing use of technologies such as video and picture messaging has made it considerably easier to record, copy and transmit recordings of patients. Doctors may be interested in using new technologies to aid rapid diagnosis and consultation and therefore improve patient care. Doctors need to bear in mind that when used for clinical purposes, such recordings form part of the patient’s medical record and the same standards of confidentiality, and the same requirements for consent to disclosure, apply’.8 As with all medical records, practitioners need to ensure they are storing photographs of patients securely. Just last year, Mr Inglefield’s clinic experienced a data breach after a cyber attack. “We were the victims of an attack last year, which was a massive problem for us,” he says, explaining, “They did get a very small number of photos – probably less than 30 – but it’s difficult to tell whether those photos were obtained from an email which we sent to patients with their photos in, or accessed through our system.” Data breaches have become an increasing problem in the digital age,9 which has resulted in the development of GDPR. Launched in 2016, the regulations replace the Data Protection Directive 95/46/EC and have been designed to harmonise data privacy laws across Europe. Following a two-year grace period since 2016, from May 26 this year, businesses can be fined up to 4% of their global annual turnover if they breach GDPR. It is now mandatory for businesses to notify the Information Commissioners’ Office (ICO) of a data breach within 72 hours of finding out it has occurred, where a data breach is likely to ‘result in a risk for the rights and freedoms of individuals’. Business owners also have to notify customers ‘without undue delay’ as soon as they are aware of the data breach.6 What can practitioners do to improve data security? All practitioners should ensure they are encrypting data advises Mr Inglefield, explaining that all his patient photographs and other medical records are uploaded onto a secure cloud-based server. He says, “You should password protect all files you send and access should only be given to designated staff. This is one of the key things in our

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

S E E U S O N S TA N D 4 6

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Aesthetics Journal

“If a photograph is worth taking in the first place, it is surely worth taking a meaningful and accurate one Dr Elizabeth Raymond Brown

The GMC’s Good medical practice guidance makes clear that patients have a right to expect that their personal information will be held in confidence by their doctors. The advice in this guidance is underpinned by the following eight principles:2 1. Use the minimum necessary personal information. Use anonymised information if it is practicable to do so and if it will serve the purpose. 2. Manage and protect information. Make sure any personal information you hold or control is effectively protected at all times against improper access, disclosure or loss. 3. Be aware of your responsibilities. Develop and maintain an understanding of information governance that is appropriate to your role. 4. Comply with the law. Be satisfied that you are handling personal information lawfully. 5. Share relevant information for direct care in line with the principles in this guidance unless the patient has objected. 6. Ask for explicit consent to disclose identifiable information about patients for purposes other than their care or local clinical audit, unless the disclosure is required by law or can be justified in the public interest. 7. Tell patients about disclosures of personal information you make that they would not reasonably expect, or check they have received information about such disclosures, unless that is not practicable or would undermine the purpose of the disclosure. Keep a record of your decisions to disclose, or not to disclose, information. 8. Support patients to access their information. Respect, and help patients exercise, their legal rights to be informed about how their information will be used and to have access to, or copies of, their health records.


by other patients, unauthorised healthcare staff, or the public’. It says, ‘You should not abuse your access privileges and must limit your access to information you have a legitimate reason to view’. For practitioners who are responsible for the management of patient records or other patient information, the guidance states, ‘You should make sure that they are held securely and that any staff you manage are trained and understand their responsibilities’. It also recommends making use of professional expertise when selecting and developing systems to record, access and send electronic data, and make sure that administrative information, such as names and addresses, can be accessed separately from clinical information, so that sensitive information is not displayed automatically.2 Miss Balaratnam says, “My patients’ photographs are stored in the VISIA device itself, which is password protected and stored in a locked room.” She adds that her team members need to sign a disclosure agreement when they come on board with the clinic to ensure patient confidentiality. For Dr Franks, his patients’ data is stored in his patient management system. “It’s certified with the International Information Security Management Standard and is a G-cloud approved supplier for the UK government’s digital marketplace,” he explains, adding that its security is also regularly checked with a global third-party security organisation.10 “I’ve got the comfort of knowing it’s fully GDPRcompliant and all regulations are in place,” says Dr Franks.

Summary Clinics across the UK have become more confident in using photographic tools and social media platforms to showcase their results, while the internet and social media have made it increasingly easy for the public to investigate a practitioner’s success stories before booking an appointment for aesthetic treatment. As a result, care should be taken to ensure photographs are accurate, clear and consistent, while appropriate consent must be obtained to hold any images, with clearly identifiable purposes, and all images should be stored securely with only necessary access authority permitted. As Dr Raymond Brown writes in Clinical Photography, “If a photograph is worth taking in the first place, it is surely worth taking a meaningful and accurate one.” Miss Balaratnam concludes, “Data protection and patient confidentiality is key.” REFERENCES 1. Elizabeth Raymond Brown, ‘Clinical Photography – Keeping it Legal, Accurate & Consistent’, Laser Education Limited, 2017. 2. General Medical Council, Good medical practice (UK: GMC, 2013) good_medical_practice.asp 3. Surface Imaging Solutions, VECTRA (UK: Surface Imaging Solutions, 2018) 4. Surface Imaging Solutions, VISIA (UK: Surface Imaging Solutions, 2018) 5. General Medical Council, Guidance for doctors who offer cosmetic interventions (UK: GMC, 201X) < interventions_080416.pdf> 6. EU, GDPR: Key Changes (EU: )<> 7. General Medical Council, Confidentiality: good practice in handling patient information (UK: GMC, 2017) <> 8. General Medical Council, Making and using visual and audio recordings of patients (UK: GMC, 2013) < recordings_of_patients.pdf> 9. Digital Guardian, History of Data Breaches (US: Digital Guardian, 201X) blog/history-data-breaches 10. Consentz, Our Partnerships and Accreditations (UK: Consentz, 2018) <>

clinic; only individuals who need access to patients’ photographs and other medical records will have a password. You don’t let any and everybody get access to them.” This is in line with the GMC’s Good medical practice guidance, which states, ‘You should not share passwords or leave patients’ records, either on paper or on screen, unattended or where they can be seen

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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1 oint


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Facial Hyperhidrosis Ms Natasha Berridge and Mr Mahesh Kumar discuss the recognition, diagnosis and management of facial hyperhidrosis Facial hyperhidrosis is a localised variant of hyperhidrosis, a common condition of exaggerated sweat production from the eccrine sweat glands. The condition exists in two variants. Commonly, there is no medical cause identified (nor is it a side effect of medication); hence, it is of primary idiopathic origin. Secondary hyperhidrosis occurs due to an underlying medical cause such as Frey’s syndrome or as a side effect of medication.1-4 Understandably, excessive facial sweating can impact significantly upon the psychosocial wellbeing of the affected individual and directly affect quality of life.5,6 Aesthetic practitioners tend to have little experience in treating facial hyperhidrosis, unlike more common forms such as axillary and palmoplantar hyperhidrosis. In this article, we will discuss facial hyperhidrosis and review the most up-to-date treatment options available to manage this debilitating condition.

About hyperhidrosis Hyperhidrosis is a common distressing complaint, affecting approximately 1% of the population in the UK.1,4 It is characterised by excessive sweat production from the eccrine sweat glands, which are distributed over nearly the entirety of the body. Eccrine sweat glands are most densely populated in the axillae, forehead, palms of the hands and soles of the feet.7,8 Conversely, apocrine sweat glands are less numerous and are limited in distribution to the axilla and groin. Eccrine sweat glands open directly onto the skin surface, whereas apocrine sweat glands open onto the hair follicle within the dermis of the skin.2,8 For the majority of people, sweating is a normal physiological process that is essential to regulate ‘normal’ body temperature, otherwise known as ‘thermoregulation’. Thermoregulation is controlled by the sympathetic nervous system within the thoracic region, but is also responsive to emotional and gustatory stimuli.2,8 In hyperhidrosis, the amount of sweat produced is far greater than that required for normal body temperature regulation. It is widely postulated in the literature7,9,10 that this is a consequence of dysfunction of both the sympathetic and parasympathetic nervous systems, rather than actual pathology of the gland itself. Hyperhidrosis may lead to dehydration, electrolyte disturbances, blurred vision (profuse sweating of the face) and recurrent skin infections if not appropriately treated.6 Primary idiopathic hyperhidrosis, otherwise known as ‘focal’ hyperhidrosis, occurs in very specific body areas such as the axilla, palmoplantar and craniofacial regions. Typically, it occurs symmetrically and often begins in childhood or early adolescence.1,2 Ro and colleagues report an autosomal dominant positive family history in up to 65% of cases11 and genome studies report a possible association with chromosome 14q.12 Distinction must be made from ‘generalised’ hyperhidrosis that affects the whole body and tends to occur in adulthood. Unlike primary hyperhidrosis, sufferers experience sweating whilst sleeping overnight.1,2,10 Secondary hyperhidrosis can be related to medication (e.g. antidepressants), infection, endocrine disorders (e.g. hyperthyroidism, hyperpituitarism, acromegaly, menopause and pregnancy) and malignancy (e.g. carcinoid syndrome, pheochromocytoma, Hodgkin’s

disease).1,2 Special forms of ‘focal’ hyperhidrosis results from central or peripheral neuronal damage. Frey’s syndrome is a classic example of secondary focal hyperhidrosis and almost exclusively occurs in those who have surgery or, less commonly, trauma to the parotid gland.1 Frey’s syndrome causes ‘gustatory sweating and/or facial flushing’ in the cheek and mandibular regions during mastication, particularly with hot foods types. Authors are yet to fully elucidate the exact pathophysiology, but it is believed that Frey’s syndrome occurs due to aberrant re-innervation of postganglionic parasympathetic neurons to denervated sweat glands and cutaneous blood vessels.13-16 Gustatory sweating may also be seen in families, known as hereditary gustatory sweating, or can simply occur as part of a compensatory mechanism, causing excess sweating in diabetic patients.1,2,17 Excessive facial sweating is undoubtedly a distressing problematic disorder that has the potential to interfere with leading a normal lifestyle. Various well documented studies2,6,18 have used validated subjective assessment tools such as the Hyperhidrosis Impact Questionnaire (HHIQ) to demonstrate that quality of life can be greatly affected.19 A 2016 multi-centre study by Bahar et al. using patient-based health questionnaires reported that there is an increased prevalence of anxiety and depression in those patients with hyperhidrosis.18

Diagnosis A diagnosis of hyperhidrosis is often made clinically and usually no further investigations are required for those who give a classic history of primary or secondary focal hyperhidrosis.9,20 However, it is important to pay particular attention to the distribution of excessive sweating, as a suspected diagnosis of generalised hyperhidrosis warrants medical investigations to exclude an underlying cause such as medication or disease. Routinely in our clinical practice, we use the well-established Minor’s Starch Iodine test, a useful diagnostic test to objectively evaluate the exact location of excess sweat production in the facial region.4,10,14 We apply a coating of aqueous povidoneiodine solution to the facial skin, allow it to dry for 10 minutes, then uniformly powder a layer of corn starch over the iodine. To stimulate sweating, our patients are either placed in a warm room or given a strong gustatory stimulus (such as lemon drops) depending on whether primary focal hyperhidrosis or Frey’s syndrome is suspected, respectively. After approximately 10-15 minutes, the onset of sweating is highlighted by a blue/violet discolouration as a result of the interaction between iodine and starch (Figure 1). Other quantitative tests are available, such as sudometry and gravimetry which are commonly used as part of research or clinical trials to determine the exact amount of sweat produced in a defined period of time (e.g. mg/mL).6,10 Additionally, there are numerous patient-based assessment scales used to quantify the severity of symptoms.2 Specifically, Solish and colleagues demonstrated that the Hyperhidrosis Disease Severity Scale (HDSS) is a quick and easy method of grading disease severity the into mild, moderate and severe based upon how sweating interferes with activities of daily living (Table 1).21

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Treatment Options There are a number of treatment options currently available that are clinically effective in reducing the amount of sweat produced Figure 1: Minor’s Starch Iodine Test performed on a in hyperhidrosis. In patient following parotid surgery. It demonstrates addition to lifestyle gustatory sweating after eating citrus flavoured boiled sweets. The photograph clearly demonstrates modifications, the area of the face affected by excess sweat treatments are production. This area has turned blue/violet as a typically categorised result of the interaction between starch and iodine. into non-surgical (topical agents, iontophoresis, oral medications, botulinum toxin A injections) and surgical techniques (such as endoscopic thoracic sympathectomy and surgical excision of eccrine sweat glands). 3,4,7,9,10,13,14,16,22-25 All of these interventions vary in their effect (temporary versus permanent), associated risks and clinical efficacy dependent upon body site treated. In this article, we will specifically review nonsurgical and minimally invasive treatments which are commonly used for facial hyperhidrosis, while an extended online version of this article will also discuss the surgical interventions. Non-surgical options Topicals In a recent literature review, authors documented that topical antiperspirants, which contain aluminium salts (usually 20% aluminium chloride in absolute anhydrous ethyl alcohol) are often first-line treatment in the management of hyperhidrosis because of the ease of use, cost-effectiveness and good safety profile.8 A small study of 15 patients with axillary hyperhidrosis treated with topical antiperspirants demonstrated that long-term use leads to obstruction of the distal eccrine sweat gland ducts, causing structural and functional damage, with an overall reduction in sweat production.26 Most patients achieve satisfactory results with antiperspirant therapy for axillary hyperhidrosis, although the effects are short-lived and temporary.9,10 Patient compliance is imperative for maintenance of long-term success, although in the facial area this may be challenging. Adverse events are limited, but irritation to the skin or eyes and/or allergic hypersensitivity to the aluminium salts is commonly reported.2,4,9,22 Various studies have demonstrated that topical anti-cholinergic ointments such as glycopyrrolate and oxybutynin are highly effective agents used in the treatment of facial hyperhidrosis.24,27 These agents reduce excessive facial sweating by competitively binding to postsynaptic acetylcholine receptors near eccrine sweat glands.2,9,28 In a 2008 study by Wo et al., of 25 patients treated with 2% topical glycopyrrolate for facial hyperhidrosis at least 96% were satisfied with its therapeutic effect.27 We commence treatment with 0.5% topical glycopyrrolate, dose titrating to a maximum of 2%, dependent upon symptom control. Patients are advised to apply the ointment to the affected facial area at night and warned to avoid inadvertent application to the mucous membranes of the mouth, nose or eyes. Inappropriate absorption of glycopyrrolate can lead to problematic dry eyes, blurred vision and dry mouth.9,27 Systemics Anticholinergic agents, such as glycopyrrolate, may also be used systemically in the treatment of hyperhidrosis. In a 2017 literature

Aesthetics Journal


review, the authors conclude that oral anticholinergics are an effective potential treatment alternative for hyperhidrosis.9 Unfortunately, their use in most patients is limited by their intolerable systemic side effects which include dizziness, blurred vision, dry mouth/eyes, constipation and heart rhythm disturbances.2,9,10 Botulinum toxin A injections Iontophoresis has been shown to be an effective treatment for focal hyperhidrosis, particularly of the palms and soles if regularly used.29 The exact mechanism of action by which iontophoresis reduces sweat production is not fully elucidated, although it’s postulated that ionised particles either physically block or prevent sympathetic mediated regulation of the eccrine sweat glands.9,4,28 In facial hyperhidrosis, iontophoresis is delivered via the patient wearing a well-fitting mask Hyperhidrosis disease severity scale

How would you rate your hyperhidrosis?


My sweating is never noticeable and never interferes with my daily activities


My sweating is tolerable and sometimes interferes with my daily activities


My sweating is barely tolerable and frequently interferes with my daily activities


My sweating is intolerable and always interferes with my daily activities

Table 1: The Hyperhidrosis Disease Severity Scale (HDSS) as recommended for use by the International Hyperhidrosis Society.2 A score of 1 or 2 indicates mild or moderate hyperhidrosis. A score of 3 or 4 indicates severe hyperhidrosis. This validated patient-based questionnaire may also prove useful to assess clinical effectiveness before and after treatment.21

which is soaked most commonly in tap water (although other solutions have been tried such as glycopyrrolate) to allow ionised particles to cross the normal skin barrier.30 Treatment regimes vary upon body site (axilla versus face), however, initially it occurs every few days, lasting up to 30 minutes per session until the desired effect is achieved. Thereafter, to maintain results, ‘top-up’ treatment sessions should occur once weekly. Iontophoresis is a relatively safe procedure. However, it has been associated with adverse reactions such as skin erythema, a burning sensation and skin vesicles.9,10,31 Despite its well documented use and license in the UK for axillary hyperhidrosis, botulinum toxin A (BoNT-A) has also been used to treat hyperhidrosis in other body regions such as the face.1,2,4,7,9,10,21,23,24 It is also the treatment of choice for patients with extensive gustatory sweating.13-17,25 BoNT-A is a neurotoxin derived from the anaerobic bacterium Clostridium botulinum and it specifically targets cholinergic nerve endings, which regulate eccrine sweat gland activity in sweat production. This causes a temporary and reversible local chemodenervation by the blockade of acetylcholine release, leading to the desired clinical effect of reduced sweat production at the site of injection. Over time, the formation of new receptors lead to the production of sweat, and hence the ‘wearing off’ effect of BonT-A.22,23 Over the years, BoNT-A has become one of the mainstay treatments for facial hyperhidrosis as it is considered extremely effective and safe when performed by an appropriately skilled clinician. One study demonstrated that BoNT-A for the treatment of primary focal

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal


hyperhidrosis of the axilla, palms and forehead is associated with high levels of patient satisfaction, as evidenced by the modified Dermatology Life Figure 2: Following identification of the affected Quality Index scale.32 facial skin with Minor’s Starch Iodine Test, the area Additionally, BoNT-A is bordered and divided into 1x1cm squares to aid provides effective intradermal injection of toxin. relief of symptoms for up to four to six months as demonstrated in numerous published studies.24,32,33 In our clinical practice, we use onabotulinum toxin A 100IU, which is reconstituted with 4mL of normal saline yielding a solution concentration of 2.5IU/0.1mL. Patients are treated in the outpatient setting. Following identification of the affected facial skin with Minor’s Starch Iodine test, the skin is bordered and divided into 1x1cm squares with a waterproof marking pen (Figure 2). We administer 2.5IU/0.1mL of toxin into each square, ensuring even superficial intradermal distribution of the toxin diffusion in order to minimise the potential for adverse effects. In our experience, results can usually be observed within one week and last for almost six months, therefore we typically follow-up our patients at two weeks and four months post-injection. Documented complications are rare, however, injection site pain and post procedural bruising are common. In our experience, topical anaesthesia or a nerve block injection, dependent upon the area of facial skin affected, may minimise discomfort during treatment. Furthermore, inadequate injection technique and local over-dosage may result in unwanted, aesthetic less satisfactory paralysis of the treated mimetic muscles (especially if

treatment is performed in the central area of the face). We therefore recommend that hyperhidrosis treatment of central facial areas only be performed by experienced aesthetic practitioners.

REFERENCES 1. Hyperhidrosis (excessive sweating). Primary Care Dermatological Society website. 2017. <http://www.> 2. International Hyperhidrosis Society. 2017 <> 3. Schlereth T and Dieterich M. Hyperhidrosis: Causes and Treatment of Enhanced Sweating. Dtsch Arztebl Int. 2009; (106) 3: 32-37. 4. Jack D. Palmoplantar Hyperhidrosis. Aesthetics Journal. Feb 2017. 5. Amir M, Arish A et al. Impairment in quality of life among patients seeking surgery for hyperhidrosis (excessive sweating): preliminary results. Isr J Psychiatry Relat Sci. 2000; 37 (1): 25–31. 6. Muthusamy A, Gajendran R et al. A Study on the Impact of Hyperhidrosis on the Quality of Life among College Students. Journal of Clinical and Diagnostic Research: JCDR. 2016; 10 (6): CC08-CC10. 7. Thomas I, Brown J et al. Palmoplantar Hyperhidrosis: A Therapeutic Challenge. Am Fam Physician. 2004; 69 (5): 1117-1121. 8. Eccleston D. Hyperhidrosis. Aesthetics journal. October 2014. 9. Grabell DA and Hebert AA. Current and emerging medical therapies for primary hyperhidrosis. Dermatol Ther (Heidelb) 2017: 7 (1): 25-36 10. Stashak AB & Brewer JD. Management of Hyperhidrosis. Clin Cosmet Investig Dermatol. 2014: 7: 285-299. 11. Ro KM, Cantor RM et al. Palmar hyperhidrosis: evidence of genetic transmission. J Vasc Surg. 2002; 35 (2): 382–386. 12. Higashimoto I, Yoshiura K et al. Primary palmar hyperhidrosis locus maps to 14q11.2-q13. Am J Med Genet A. 2006; 140 (6): 567–572. 13. Bonanno PC, Palaia D, et al. Prophylaxis against Frey’s syndrome in parotid surgery. Ann Plast Surg. 2000; 44 (5): 498. 14. Eckardt A & Kuettner C. Treatment of Gustatory Sweating (Frey’s Syndrome) with Botulinum Toxin A. Head & Neck. 2003 25 (8): 624-8. 15. Laskawi R et al. Up-to-date report of botulinum toxin type A treatment in patients with gustatory sweating (Freys’s syndrome). Laryngoscope. 1998. 108 (3) 381-4. 16. Clayman MA, Clayman SM et al. A review of the surgical and medical treatment of Frey syndrome. Ann Plas Surg. 2006: 57 (5): 581-4. 17. Mailander MC. Hereditary Gustatory Sweating. JAMA. 1967; 201 (3) 204-204. 18. Bahar R, Zhou P et al. The prevalence of anxiety and depression in patients with or without hyperhidrosis (HH). J Am Acad Dermatol 75:6 (2016): 1126-1133. 19. International Hyperhidrosis Society. The Effects on Patients’ Lives: Quality-of-life surveys. 2017. https:// 20. Hornberger J, Grimes K et al. Recognition, diagnosis, and treatment of primary focal hyperhidrosis. J Am Acad Dermatol. 2004; 51 (2): 274–286. 21. Solish N, Bertucci V et al. A Comprehensive Approach to the Recognition, Diagnosis, and SeverityBased Treatment of Focal Hyperhidrosis: Recommendations of the Canadian Hyperhidrosis Advisory Committee. 2007; 33: 908-923

22. Eisenach JH, Atkinson JLD et al. Hyperhidrosis: Evolving Therapies for a Well-Established Phenomenon. Mayo Clinic Proceedings. 2005, 80 (5): 657-666. 23. Kreyden OP & Burg G. Hyperhidrosis and Botulinum Toxin in Dermatology. Curr Probl Dermatol. Basel, Karger 2002; (30): 1-9. 24. Nicholas R, Quddas A et al. Treatment of Primary Craniofacial Hyperhidrosis: A Systemic Review. Am J Clin Dermatol. 2015: 16 (5): 361-70. 25. Chamisa I. Frey’s syndrome - unusually long delayed clinical onset post-parotidectomy: a case report. Pan Afr Med J. 2010; 5: 1. 26. Holzle E & Braun-Falco O. Structural changes in axillary eccrine glands following long-term treatment with aluminium chloride hexahydrate solution. 1984; 110 (4): 399-403. 27. Kim WO, Kil HK et al. Topical glycopryloate for patients with facial hyperhidrosis. Br J Dermatol. 2008: 158 (5) 1094-7. 28. Patient Information Leaflet. Hyperhidrosis. <> 29. Karakoc Y, Aydemir EH et al. Safe control of palmoplantar hyperhidrosis with direct electrical current. Int J Dermatol. 2002; 41 (9): 602-605. 30. How Iontophoresis Removes Excessive Sweating of the Head. 2018. <> 31. Stolman LP. Treatment of excess sweating of the palms by iontophoresis. Arch Dermatol. 1987; 123 (7): 893–896. 32. Tan SR & Solish N. Long-term efficacy and quality of life in the treatment of focal hyperhidrosis with botulinum toxin A. Dermatol Surg. 2002; 28: 495–9. 33. Campanati, A, Penna, et al. Quality-of-life assessment in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study. Clin Ther. 2003; 25: 298-308. 34. Cina CS & Clase CM. Endoscopic thoracic sympathectomy for hyperhidrosis. Technique and results. J Minim Access Surg, 2007 3 (4): 132-140. 35. Glaser DA, Hebert AA et al. Facial Hyperhidrosis: Best practice recommendations and special considerations. Cutis. 2007. 79 (suppl 5); 29-32. 36. NICE Interventional Procedures Guidance. Endoscopic thoracic sympathectomy for primary blushing. <> Feb 2014. 37. Atkinson, JLD & Fealey, RD. Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis. Mayo Clin Proc. 2003; 78: 167-172. 38. Lin TS, Kuo SJ et al. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery. 2002; 51(5 suppl): 84-87.

Summary Facial hyperhidrosis (including Frey’s syndrome) is not as common as other forms of hyperhidrosis (axillary, palmoplantar). Without doubt, it can be socially debilitating, severely impacting upon activities of daily living and overall quality of life. Many sufferers will attempt to modify their lifestyle to camouflage or live with the condition, often seeking medical advice and/or treatment long after the onset of symptoms. Our article highlights the current available treatment options that have achieved clinical success and patient acceptance. In our opinion, BoNT-A has revolutionised the management of facial hyperhidrosis. We feel it is important to raise awareness so that aesthetic practitioners are able to recognise and potentially treat facial hyperhidrosis in their clinical practice. Acknowledgements: We would like to thank consultant maxillofacial surgeon Mr Michael Amin, for providing the clinical photographs used in this article. Ms Natasha Berridge is a maxillofacial surgeon with a specialist interest in facial aesthetics and surgical dermatology. A fellow of the Royal College of Surgeons and member of the Faculty of Dental Surgery, Ms Berridge has years of experience in treating facial hyperhidrosis and other maxillofacial conditions with botulinum toxin. Mr Mahesh Kumar is a maxillofacial and reconstructive surgeon with more than 15 years’ experience as a NHS consultant in treating head and neck oncology, surgical dermatology and aesthetic facial surgery.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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Treating a Tear Trough Deformity

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linked and non-cross-linked HA chains, giving unique viscoelastic properties, allowing it to integrate into the tissues evenly.5 I only ever use a maximum of 1ml at any one sitting for both eyes. I find that RD2 does not cause a huge amount of swelling, which is great when treating this delicate area.

Dr Tayyab Bhatti details how he successfully treated a patient for a tear trough deformity using hyaluronic acid dermal filler ‘Catching someone’s eye’ is often the first form of non-verbal communication, but it can also tell you a lot about a person. It acts as an indicator of their chronological age, general wellbeing and physical attractiveness. Dark circles and deep lines around the eyes are not deemed as an attractive feature. A prominent tear trough (TT) deformity is the sunken appearance of the lower eyelid region which casts a shadow that is resistant to cosmetic concealment.1 This can make an individual appear tired, despite adequate resting, and can make them look aged beyond their years. The causes of TT deformity include ethnicity, volume loss with age, laxity and changes in skin thickness, hyperpigmentation and the prominent pooling of venous superficial vessels contributing to the illusion of depth. An attractive lower lid region should display a relatively smooth transition between the preseptal and orbital portions of the orbicularis oculi (OO) muscle and continue into the upper malar region without a definable transition point.2

Classification of the TT deformity The most recent classification is by Hirmand,3 which grades the deformity from I to III: mild, moderate or severe (Figure 1). It is important to highlight the severity of the deformity to patients using picture examples and explain the possible expectations of outcome with treatment at this stage. Although a Grade 3 severe TT can be improved, it is unlikely to be fully restored to how it appeared when the patient was younger without the need for multiple treatments or surgery.

Treatment options There are multiple treatment options available in aesthetic clinics for TTs, including topical cosmeceuticals, platelet rich plasma (PRP), microneedling and hyaluronic acid (HA) dermal fillers. In my practice, I solely use Teosyal Redensity II (RD2) for all TT treatments. It is the first filler specifically developed to provide a solution for the tear trough and, if injected correctly, is less likely to migrate and form lumps like some other fillers.4 RD2 contains a mixture of crossClass

Clinical description


Patients have loss of volume, limited medically to the tear trough. These patients can also have mild flattening extending to the central cheek


Patients exhibit loss of volume in the lateral orbital area in addition to the medial orbit, and they may have moderate deficiency of volume in the medial cheek and flattening of the central upper cheek


Patients present with a full depression circumferentially along the orbital rim, medical to lateral

Figure 1: Tear trough classification by Hirmand3

Needle vs. cannula In younger patients with good skin tone and little laxity, I prefer to use serial point injecting (multiple, evenly spaced small boluses of HA using a 30G needle). For older patients, over the age of 50, to reduce the risk of bruising, I like to use a 27G or 25G cannula; 38mm is long enough for most treatments. The risk of intravascular injury is rare in this area as long as you avoid the terminal branch of the facial artery called the angular artery.6 This runs alongside the nose towards the inner canthus supplying blood to the upper and lower eyelids as well as the nose; an appreciation of the anatomy here is essential. Be aware that anatomical variations of vessels can occur.7 Although the incidence of ocular blindness is a very rare occurrence following TT injections, patients must be warned about this risk.8

Case study A 28-year-old female patient visited my clinic complaining of a dark line under the eyes that she felt was making her look tired; this was her first TT treatment. Once she was counselled and consented, the area around the TT region was cleaned with Clinisept+. I like to have my patients sitting at a 45-degree angle, as lying flat can obliterate the deformity and hence make targeted injections difficult. I ask patients to keep their eyes open whilst looking upwards. This stops them from squeezing their eyes tighter if their eyes were closed, which in turn leads to them raising their cheeks during injecting, which can obscure the TT. I always inject the deeper TT deformity first. The needle was inserted perpendicular to the skin at the most lateral part of the TT. The bevel of the needle should be pointed away from the eye. Aspiration remains controversial; however, some practitioners may prefer to do this. As this is a delicate area to inject I avoid unnecessary movement and inject slowly. Approximately 0.05-0.1ml of HA was deposited above the bone, but below the OO muscle. There is the temptation to inject superficial to the OO muscle, which does give the immediate gratification of observable filling; however, be warned this can lead to filler migration as the orbicularis muscle squeezes and can push the filler medially. The needle was removed and gentle pressure was applied immediately. At this stage, it is tempting for the injector to see if there is any bleeding but removing pressure too quickly may cause unwanted bruising. After gentle pressure was applied, the next point of injection was more medial and was placed in a similar manner, and I continued moving more medially. This serial point method is excellent to treat mild to moderate deformities. I stopped injecting the first side before I had used more than 0.5ml. Gentle massaging along the TT helps the product to integrate smoothly. This is a good opportunity to show patients the difference between the treated and untreated side whilst they are sat up. I then continued the same method on the other side; stopping to ask about any symptoms such as pain or visual problems. Practitioners should stop injecting immediately if there are any concerns. I used a total of 1ml of product in total. If I was to have used a cannula, I would make my entry point with the anchor needle just lateral and below to where the TT ends. I would need to make sure there was sufficient length for the cannula to get close to the canthus region. Once the cannula is inserted, before starting

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

Clinical Practice News to inject, I try to tent the cannula to determine its depth. If you can clearly see the cannula shaft tenting the skin, After the depth is too superficial and you are above the OO muscle. Withdraw and advance again with a deeper angle. If you are Figure 1: Patient before and after treatment for a below the OO, you TT deformity will see no tenting. Whilst slowly withdrawing the cannula, I would deposit small beads of filler in the TT line with small gaps between each bleb. This allows for expansion of the filler during hydration and reduces the risk of overfilling. Once treatment was finished, I gave general post-dermal filler advice such as the avoidance of sun beds/saunas, avoiding alcohol for the rest for the day, and trying to stay upright for the next four hours, but strongly emphasised the need to avoid strenuous activity for 48-72 hours, as a small vessel can start to bleed and cause bruising if not noticed. Swelling post procedure was minimal; however, if noticed, I advocate using antihistamines to reduce the duration and severity of symptoms. Before

Results After four weeks, the patient returned for a follow up. She had not suffered any significant swelling or bruising. The dark lines had improved and a more vibrant and youthful look was achieved. The patient had noticed the skin around her eyes had become lighter; she was very happy with the results. At this stage, further filler could be injected, however, it was not needed in this case. HA lasts between six and nine months in this area, however, if its injected deep to the orbicularis muscle I find HA breakdown is slower and lasts closer to 12-15 months. As this is an advanced technique, it is advised for injectors wishing to use RD2 to attend organised workshops by the product manufacturer to become competent in this technique and have an in-depth knowledge of the anatomy and managing complications should they arise. Dr Tayyab Bhatti trained at Sheffield University and completed training in surgical and medical specialities. He works as a GP partner and co-owns aesthetic clinic Cosmedocs Midlands based in Derby with his twin brother Dr Aqib Bhatti. They provide non-surgical aesthetics as well as laser treatments and private general practice. REFERENCES 1. Jaishree Sharad, Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes, J Cutan Aesthet Surg, (2012) <https://www.ncbi.nlm.nih. gov/pmc/articles/PMC3560162/> 2. Glaser DA, Patel U. Enhancing the eyes: Use of minimally invasive techniques for periorbital rejuvenation. J Drugs Dermatol. 2010;9:S118–283. 3. Anatomy and nonsurgical correction of the tear trough deformity. Hirmand H Plast Reconstr Surg. 2010 Feb; 125(2):699-708. 4. Grosse_2017_FillerGuide_CosmMed – pdf on file. 5. Teoxane UK, Teosyal Specifics, (2018) <> 6. Dr John Quinn, Filler complications (2014) <> 7. Cardinot, TM, Vasconcellos, HA, Vasconcellos, PHB, Oliveira, JR, Siqueira, PB and Aragão, AHBM, Anatomic variation of the facial artery and its implications for facial surgery: a case report (2014) <> 8. Kim, Young Jun, et al., ‘Ocular ischemia with hypotony after injection of hyaluronic acid gel’, Ophthalmic Plastic & Reconstructive Surgery, 27.6 (2011), e152-e155


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reach the epidermis, whereas a 45% TCA solution will likely penetrate to the upper reticular dermis.7 Multiple applications should considered as an alternative to a higher Dr Raul Cetto discusses the mechanisms of action be concentration, for example several applications of 20% TCA in six week intervals can produce and antiageing benefits of chemical peels the same effects as one application at 45%. Chemical peeling is the application of a chemical agent of a Higher concentrations or multiples applications of TCA are better defined strength, resulting in predictable accelerated exfoliation tolerated by patients with thick, seborrheic skin, rather than those and skin damage. The release of cytokines and inflammatory with smooth thin skin. A period of pre-treatment of the skin with mediators following this damage results in thickening of the retinoid or hydroquinone (available on prescription only) will epidermis, and an increase in dermal volume through deposition of improve the penetration, as will proper skin degreasing with an collagen, producing the appearance of rejuvenated skin.1 alcohol preparation solution.3 Augmentation of the TCA should There are generally three depths of chemical peels: superficial, also be considered, for example an application of 0.025-0.05% medium and deep (Figure 1). This article will focus on medium as retinoic acid just before TCA application enhances penetration a discussion on superficial and deep will each warrant an entirely and may provide better results.3 The best results for patients with separate article. A medium-depth peel aims to reach the papillary photoageing are obtained in patients with phototype II, although and upper reticular dermis at a depth of approximately 0.45mm. it is also effective in type III and IV phototype patients. TCA is not In general terms, medium depth peels use a trichloroacetic acid systemically absorbed and therefore can be used safely in patients (TCA) concentration of 35-50%. TCA is an analogue of acetic acid, with cardiac, hepatic and renal morbidities.3 which was first used by German dermatologist Dr Paul Gerson Unna as a chemical peel – this was documented in 1882.2 Its medical 35% TCA augmented with Jessner’s solution and cosmetic applications continued to be studied throughout Jessner’s solution consists of resorcinol, salicylic acid, lactic acid the early 20th century and was found to improve the appearance at 85%, and ethanol at 95%. This was first described by American of scars, blemishes and wrinkles in a 50% solution. However, dermatologist Dr Gary Monheit in 1989.8 Jessner’s solution destroys complications such as hyperpigmentation and scarring were high at the epidermal barrier function by breaking the intercellular bridges this concentration. By the 1950s, dermatologists had found several between keratinocytes allowing a TCA solution (35% is typically new ingredients to produce mixtures with a lower solution of TCA to used) to better penetrate the epidermis.8 This combination clinically 3 reduce the risk and produce a more predictable outcome. improves the appearance of photoaeing skin, actinic keratoses, and rhytides.8

Medium Depth Peels

Medium-depth peel agents and mechanisms of action Several chemical agents are commonly used in medium-depth peels to produce a predictable and controlled exfoliation of the skin –discussed below. 35-50% TCA TCA at 35-50% can be used in the treatment of photoageing, particularly actinic keratosis, pigmentation, fine facial rhytides and moderate perioral wrinkles.3 It is not appropriate for the treatment of lax skin or deep rhytides caused by movement of the muscles of facial expression, which would be better treated using a deeper acting peel.5 TCA causes protein to denature leading to keratocoagulation and keratinocyte death. As the skin then re-epithelialises, collagenesis is observed and the previously present abnormal keratinocytes are replaced by healthy new cells.6 The concentration of TCA will also determine the depth of action. For example, a 15-20% TCA concentration will only

1. Superficial peels: exfoliate the epidermal layers without going beyond the basal layer 2. Medium peels: penetrate the upper reticular dermis 3. Deep peels: penetrate the lower reticular dermis Figure 1: The penetration of a superficial, medium and deep peels.

35% TCA augmented with solid CO2 In 1986, Brody and Hailey reported positive results to treat actinic degeneration, acne scarring, rhytids, and pigmentary aberrations with the application of solid carbon dioxide to ‘ice’ the skin, to enhance the penetration of a 35% TCA solution used.9 The histological specimens studied by Brody and Hailey showed an expanded papillary dermis with neocollagen formation in the sub-epidermal region of the dermis and a mid-reticular dermal band consisting of elastic fibres and collagen. This technique was reported to penetrate to the upper reticular dermis and to be more effective than Jessner’s solution plus 35% TCA in the treatment of acne scarring;9 however, it has been reported that it can destroy melanocytes not confined to the epidermis and therefore result in hypopigmentation, particularly in darker skins.10 It was also noted that the depth of penetration is difficult to control and somewhat unpredictable, yielding variable results and complication, because the depth of action of the solid CO2 is dependent on how hard the operator applied the block to the skin, which is a difficult measure to standardise.9,10 35% TCA augmented with 30-70% glycolic acid Glycolic acid peels penetrate the skin easily and have anti-inflammatory, keratolytic, and antioxidant effects.11 The glycolic acid peel is applied prior to the TCA. Different concentrations of glycolic acid can be used (30%-70%) to adjust the intensity of the peel.11 Glycolic peels are usually better tolerated by patients compared to Jessner’s solution because it produces less visible exfoliation post procedure.12

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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Complications Chemical peels can potentially cause several complications, some of which can be treated easily. In general, medium-depth peels produce fewer complications, and with less frequency than deep peels as their penetration is more superficial, so the damage to the skin is more limited. There is no risk of systemic complication when using a medium-depth peel. Pigmentary changes Reactive hyperpigmentation can occur after any depth of chemical peel. Usually, lighter complexions have lower risk of hyperpigmentation.1 Priming the skin by using a combination of hydroquinone and retinol creams for several weeks before a mediumdepth peel, can reduce the rate of hyperpigmentation.1 Demarcation lines, a harsh line between treated and untreated areas, can be softened if the boundary of the peeling area is hidden under the mandibular line and feathered gradually to the normal skin.13 Hypopigmentation is associated with darker skin types and increased post-peel sun exposure.6 Infection Bacterial and fungal complications in chemical peels are rare.1,14 Patients with positive history of herpes simplex infection should be treated prophylactically with antiviral medications acyclovir or valacyclovir during peeling, until full re-epithelisation is achieved, as all peels can reactivate the virus. Toxic shock syndrome has also been reported after chemical peels, and patients should be warned of the symptoms for this reason.3,14 Scarring The contributing factors to the likelihood of post-peel scarring are not well understood yet. However, delayed healing and persistent redness may precede scarring. A topical steroid should be used to treat such scarring as soon as a diagnosis is made, but this may still not prevent unsightly scars from forming.1 The most common location of post-peel scars is in the lower part of the face, and this may be due to more aggressive treatment in this area or possibly due to eating and speaking during the healing process, which moves these tissues.3,7 Milia These are inclusion cysts, which appear as a part of the healing process in up to 20% of patients after chemical peels, usually eight to 16 weeks’ post procedure and can be long-lasting or even permanent. They are more likely to occur in patients who have had a deep peel rather than a medium. If they do not resolve spontaneously, patients can be treated with mild epidermabrasion following re-epithelialisation, gentle extraction or electrodissection.1 Acneiform dermatitis Acneiform eruption after chemical peels can appear immediately after re-epithelialisation and is not a rare complication. It can be related to exacerbation of previously existing acne or may be due to overuse of oily preparations on the new skin. Short-term systemic antibiotics, together with discontinuation of any oily products will usually provide relief.1

Discussion In the patient’s consultation, various contraindications should be discussed to ascertain whether the patient is a good candidate for the proposed intervention. Absolute contraindications are active and recent bacterial, viral, fungal or herpetic infection, open wounds, a history of the

Aesthetics Journal


use of medication with photosensitising potential, such as exogenous oestrogen, an oral contraceptive pill or isotretinoin use in the preceding 12 months, inflammatory dermatoses (psoriasis, atopic dermatitis, pemphigus) and facial skin melanoma. In addition, most would call a non-compliant patient an absolute contraindication to this treatment as pre-peel treatments and post-peel sun exposure limitation relies entirely on patient compliance, and non-compliance will likely produce an undesirable outcome. The patient must be motivated enough to adhere to a daily regimen for a few weeks before and after the procedure. If a patient has a history of abnormal scarring, then a medium depth or deep peel would not be recommended. Sun-damaged skin shows epidermal changes, elastosis, and collagen distortion in the mid-reticular dermis and, to eradicate this, a deep peel would be required. More superficial peels, even when performed in repetition, do not reach the affected histological level and therefore have a minimal effect on photodamaged skin.10 Practitioners should advise patients to stop smoking. The dynamic action of puffing can create or worsen perioral rhytides. The smoke can cause squinting, increasing wrinkling around the eyes and nose, and furthermore, the chemicals in the smoke can cause enzymatic reactions that can cause wrinkling around the mouth and eyes.10 Patients should be carefully counselled about the downtime of five to 10 days following a medium depth peel.4 Patients who are overly self-conscious may not be prepared for their aesthetic appearance immediately following the peel. Particularly, patients with unrealistic expectations or suspected body dysmorphic disorder should be excluded from these treatments, and counselled in line with General Medical Council (GMC) guidance on these matters.15 All discussion and steps in the counselling process should ideally be fully documented, as recommended by the GMC.16

Conclusion The type of peel that will be best for any patient will be dependent on their skin type, their medical history, their cosmetic concerns and their expectations. Thorough counselling is absolutely necessary to ensure that the best possible results are achieved. Patient selection is key with regards to medium depth peel application. Dr Raul Cetto practises at Clinic 1.6 London, specialising in medical facial aesthetics and skin ageing. He is an honorary researcher and lecturer at Imperial College London, a Teoxane Country Expert and a medical director of Harley Academy. Dr Cetto holds a diploma in Otolaryngology and Head and Neck Surgery, and membership with the Royal College of Surgeons. REFERENCES 1. Nikalji, N., Godse, K., Sakhiya, J., Patil, S. & Nadkarni, N. Complications of medium depth and deep chemical peels. J. Cutan. Aesthet. Surg. 5, 254–60 (2012). 2. Brody, H., Monheit, G., Resnik, S. & Alt, T. A history of chemical peeling. Dermatol. Dermatol Surg. 26, 2000;26:405–9 (2000). 3. Camacho, F. M. Medium-depth and deep chemical peels. J. Cosmet. Dermatol. 4, 117–28 (2005). 4. Fischer, T. C., Perosino, E., Poli, F., Viera, M. S. & Dreno, B. Chemical peels in aesthetic dermatology: An update 2009. J. Eur. Acad. Dermatology Venereol. 24, 281–292 (2010). 5. Jackson, A. Chemical peels. Facial Plast. Surg. 30, 26–34 (2014). 6. Roenigk, H. H. Treatment of the aging face. Dermatol. Ther. 13, 141–153 (2000). 7. Brody, H. J. Variations and comparisons in medium-depth chemical peeling. J. Dermatol. Surg. Oncol. 15, 953–963 (1989). 8. Monheit G. The Jessner’s TCA peel: a medium depth chemical peel. J Dermatol Surg Oncol. 1989;15:945-952. J. Dermatol. Surg. Oncol. 15, 945–952 (1989). 9. Brody, H. J. & Hailey, C. W. Medium-depth chemical peeling of the skin: A variation of superficial chemosurgery. J. Dermatol. Surg. Oncol. 12, 1268–1275 (1986). 10. Obagi, Z. The Art of Skin Health Restoration and Rejuvenation: The scoience of clinical practice. (CRC Press, 2015). 11. Sharad, J. Glycolic acid peel therapy - A current review. Clin. Cosmet. Investig. Dermatol. 6, 281–288 (2013). 12. Kim, S. W., Moon, S. E., Kim, J. A. & Eun, H. C. Glycolic Acid versus Jessner’s Solution: Which Is Better for Facial Acne Patients? Dermatologic Surg. 25, 270–273 (1999). 13. Litton, C. & Trinidad, G. Complications of chemical face peeling as evaluated by a questionnaire. Plast. Reconstr. Surg. 67, 738–744 (1981). 14. Holm, C. & Mühlbauer, W. Toxic shock syndrome in plastic surgery patients: case report and review of the literature. Aesthetic Plast. Surg. 22, 180–4 (1998). 15. GMC. Guidance for all doctors who offer cosmetic interventions. Bdj 220, 449–449 (2016). 16. General Medical Council. Good medical practice. GMC Med. Guid. 18–24 (2013).

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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Aesthetics Journal


was prescribed by her gynaecologist, but she continued to feel the menopause was causing her skin to age rapidly.4 We discussed the different treatment options with her to address her jowls, which included hyaluronic acid (HA) fillers, radiofrequency skin tightening, high intensityfocused ultrasound (HIFU) skin tightening, nonsurgical thread lifts and polycaprolactone (PCL) biostimulatory fillers. Threads could have lifted and volumised, but the treatment has more downtime then the other modalities, and radiofrequency could tighten the skin but not volumise it. We agreed on the PCL-based filler, Ellansé, as we felt this would improve her skin texture, restore her volume loss and elasticity, as well as improve moisture with minimal downtime, that would be long lasting. Although HA fillers would have provided the volume, the PCL filler maintains volume better over time.5 From experience, HA fillers tend to last no more than one year, whereas PCL-based filler lasts in excess of two years. We often recommend a combination treatment Dr Charlotte Woodward and Dr Victoria Manning and discuss this with our patients. One possible combination we have seen success with for share a case study of a successful skin laxity treatment indications such as this, is to start with treatment associated with the menopause radiofrequency for skin tightening, followed by a dermal filler, followed with a thread lift for optimal We all know that the skin ages as we grow older, but this can lifting and volumisation. This is especially effective in our older patients. be accelerated for women around the time of the menopause For this patient, we deemed it wasn’t necessary. by approximately 6%.1 Most aesthetic practitioners will see a large number of menopausal women who are trying to delay this acceleration and keep their youthful appearance natural, without Polycaprolactone looking like they have had anything ‘done’. PCL is totally resorbable and non-toxic, and biodegrades to hydroxycaproic acid and water, which is subsequently Ageing is multifactorial, as described below: completely excreted from the body.9 When injected, there is a foreign body response to the 1. Bone resorption and remodelling leads to volume loss and product. This starts within two hours with the initial inflammatory changes the overlying soft tissue and skin. phase, followed by the production of macrophages, which in 2. Fat loss and redistribution causes volume loss and changes the turn stimulate fibroblasts to form type III collagen (scar tissue). contours of the face. Deeper fat ‘thins out’ and slides, blocked by Within two weeks, the microparticles are encapsulated by retaining ligaments, leading to deep creases and contour defects. fibroblasts that produce type I collagen around the particles. 3. Muscles become atrophic and contract, causing fat displacement This response varies on the patient’s age and health and and sagging. also on the particle shape and size. Particles less than 10 4. The dermis thins due to collagen loss, which causes a reduction micrometres (μm) are phagocytosed by macrophages and in skin elasticity and moisture. Subsequently, ageing skin is eliminated from the body. Particles between 25-50μm, which thinner, dryer and more prone to wrinkles, sagging and increased are spherical in shape, produce the most fibrosis and new pigmentation. collagen. Particles greater than 50μm produce a prolonged 5. A drop in oestrogen levels, associated with the menopause, inflammatory reaction producing only type III collagen.9 2,3 causes a loss of elasticity, which worsens already sagging skin. The PCL microspheres are totally smooth, spherical shaped and 25-50μm, for the best possible biostimulation to produce Case study type I collagen. The CMC gel carrier is gradually phagocytosed A 49-year-old woman presented to clinic who had previously only by macrophages over a period of six weeks. During this time, been treated with botulinum toxin. She had been treated with toxin the PCL microspheres stimulate neocollagenesis to replace in the upper face in the glabella, forehead and around the eyes the volume of the resorbed carrier. PCL microspheres are not for dynamic lines. She had also had toxin in the lower face for phagocytosed because of their size, they are encapsulated, masseter hypertrophy. as mentioned previously. Neocollagenesis leads to a collagen The patient said that she always had full cheeks, but felt that they scaffold anchoring the microspheres in place and preventing had dropped, especially since she started the menopause in her migration. The PCL is safe and metabolises completely over mid-40s, which had subsequently caused her to develop jowls. The time to CO2 and water.9 patient had started taking hormone replacement therapy (HRT), which

Case Study: Rejuvenating Menopausal Skin

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018






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Aesthetics Journal



Results At her three-month review, the patient was extremely happy with the result and felt she looked ten years younger. There was restoration of the volume to her mid-face and the product had lifted her jowls as you can see from her photographs. Most patients need reviewing once a year to evaluate whether any further treatment is needed. We try and review our patients annually, if not sooner. A lot of patients attend for regular toxin treatments so we can monitor them then, to see if more threads or dermal filler are needed. There is a potential risk for bruising and swelling, especially with biostimualtion, and we always warn patients of this, but the patient experienced no side effects.


Figure 1: Case study patient before and after treatment with a PCL-based filler

Product Treatment with PCL-based collagen stimulatory fillers allows an immediate correction, but also volumisation through biostimulation and neocollagenesis.6 The formation of new collagen helps to regain elasticity and moisture, which has been affected by the patient’s lowering oestrogen levels. The biostimulation improves volume in

The filler improved skin laxity and texture via neocollagensis, both superficially and at a deeper level the hypodermal fat layer, by collagen stimulation, which improves dermal thickness and elasticity, similar to hyaluronic skin boosters, but with results lasting in excess of two years.7 The filler is 70% aqueous carboxymethylcellulose (CMC) gel carrier and 30% synthetic PCL. This allows immediate filling from the CMC, followed by stimulation of the body’s own collagen; neocollagenesis by PCL. The carrier is not cross-linked, which we believe makes it easier to inject and creates a smooth extrusion force.8 Treatment Using a 25g cannula, 2ml of the PCL-based filler was injected into the lateral mid-face region, 1ml per side. The product was placed sub-dermally in retrograde linear threads with a fan technique. This area was treated to allow volumisation of the mid-face, and to lift the lower face. The patient was advised that instantly after treatment, she would see about 85% of the final result. This would reduce slightly at about two to four weeks post treatment, and then, as the CMC carrier gel is resorbed, the PCL would stimulate neocollagenesis to replace this over the following weeks. She was advised that we would review her at three months, when the neocollagenesis would be complete and 100% of the overall result would be visible.

Conclusion In the case of this particular patient, we achieved the desired result of lifting her jowls and volumising her mid-face, similar to her pre-menoopausal appearance. The PCL-based fillers used are safe, effective and long-lasting, and can be used for biostimulation as well as volumisation. For this patient, the filler improved skin laxity and texture via neocollagensis, both superficially and at a deeper level. The patient had restored shape and redefined contours. This treatment is a good option to be able to offer your patients as an alternative to standard HA fillers. Dr Charlotte Woodward is a medical aesthetic practitioner with more than 27 years’ experience across both general practice and aesthetics. She is the cofounder of River Aesthetics, which has clinics in the New Forest, Sandbanks and at Grace, Belgravia in London. She specialises in thread lifts and vaginal rejuvenation. Dr Victoria Manning is an aesthetic practitioner and GP with more than 22 years’ clinical experience. She is co-founder of River Aesthetics and specialises in thread lifting and vaginal rejuvenation. Dr Manning is a trainer and international speaker at aesthetic conferences, as well as a media contributor. REFERENCES 1. Morgan E. Levine, Ake T. Lu, Brian H. Chen et al. Menopause accelerates biological aging, PNAS, (2016) <> 2. Vleggaar D, Fitzgerald R. Dermatological implications of skeletal ageing: a focus on supraperiosteal volumization for perioral rejuvenation. J Drugs Dermatol. 2008; 7: 209-220. 3. Murphy MR, Johnson CM Jr, Azizzadeh B. The ageing face consultation. In: Master Techniques in Facial Rejuvenation. Elsevier; 2006: 1–16. 4. Susan Stevenson and Julie Thornton, Effect of estrogens on skin aging and the potential role of SERMs, (2007) <> 5. Dr Siew, Ellansé – Everything you Need to Know About The Collagen Stimulating Filler, (2016) https:// 6. Nicolau PJ, Long lasting and permanent fillers: biomaterial influence over host tissue response. NICOLAU P. J. Plast. Reconstr. Surg. 119 (7), 2271-86, 2007. 7. Russo PR, Fundarò SP,The Invisible Facelift—Manual of Clinical Practice. 2nd edn. O cina Editoriale Oltrarno, Florence Iozzo I (2016) Combined use of suspension threads and polycaprolactone ller. Chapter 12: Use of combined techniques for the mid-lower face with suspension threads, ller and botulinum toxin. 8. CE mark- Technical dossier (Whitepaper W113.05) 9. Woodward, S.C., Brewer, P.S., Moatamed, F., Schindler, A., Pitt,C.G. The Intracellular degradation of poly(ε-caprolactone). J. Biomed. Mat. Res. 19, 437-444, 1985.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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A summary of the latest clinical studies Title: An innovative method to quantitate tissue integration of hyaluronic acid-based dermal fillers Authors: Dugaret AS, Bertino B, Gauthier B et al. Published: Skin Research and Technology, February 2018 Keywords: Hyaluronic acid, Dermal filler, Biointegration Abstract: Following intradermal injection, hyaluronic acid (HA)based fillers tend to spread within the reticular dermis and to distribute between the dermal fibers. This biointegration is commonly measured qualitatively using histological methods. We developed a “toolbox” consisting of a visual scoring and a semi-automatic image analysis method using an internal developed algorithm to quantitate the biointegration of Restylane® in histological sections. Restylane® was injected intradermally in the abdominal skin of 10 healthy human subjects scheduled for abdominoplasty. The injections were performed either in vivo before surgery or ex vivo on samples taken post-surgery at different time points. The samples were processed for histology by visual scoring and image analysis using algorithms developed in Definiens to assess biointegration. The image analysis segmentation was accurate with <5% manual changes. Furthermore, the results calculated with the semi-automatic method were consistent with the visual scores obtained on injected human skin samples by means of a 5-grade photographic scale. The results obtained in this study confirmed the known intermediate biointegration properties of Restylane®, thus validating these innovative methods. Title: A Qualitative Investigation of the Impact of Acne on HealthRelated Quality of Life (HRQL): Development of a Conceptual Model Authors: Fabbrocini G, Cacciapuoti S, Monfrecola G Published: Dermatology and Therapy Journal, February 2018 Keywords: Acne vulgaris, Qualitative, Topical treatment Abstract: The negative impact of acne on aspects of health-related quality of life (HRQL) has been demonstrated in many quantitative studies; however, there has been relatively little qualitative research exploring the impact of acne and the use of topical treatment. The study aimed to explore the impact of moderate-severe acne on HRQL in adolescents and adults with inflammatory and non-inflammatory lesions. In addition, the study aimed to identify the attributes of topical acne treatments that are most important for patients. Thirtyfour adolescents and 16 adults with moderate-severe acne who were currently/recently prescribed topical treatment were recruited in this cross-sectional qualitative study in the UK, Italy, and Germany. In-depth, semi-structured telephone interviews explored patients’ experiences of acne and the impact it has on their HRQL, and their experience of topical treatments for acne. Data were analyzed using thematic analysis and a conceptual model was developed. The analysis identified seven main areas of HRQL that are affected by acne: emotional functioning, social functioning, relationships, leisure activities, daily activities, sleep, and school/work. Also common throughout the interviews was the perception and reaction to acne from others. The conceptual model illustrates the impact on HRQL and the links between HRQL domains. For both adolescents and adults, it was most important for acne treatments to be fast-acting, non-irritating, and non-bleaching. The results of this qualitative study demonstrate that moderate-severe acne has an extensive impact on

adolescents’ and adults’ HRQL. The conceptual model illustrates the many areas of HRQL that are affected and draws attention to the importance of effective treatments for acne. The study also highlights topical acne treatment attributes that are most important for patients. Title: A novel cosmetic and clinically practicable laser immunotherapy for facial verruca plana: intense pulsed light combined with BCG-PSN Authors: Zhang F, Shi L, Liu P et al. Published: Photodiagnosis and Phototherapy Journal, February 2018 Keywords: Facial verruca plana, Flat warts, Laser immunotherapy Abstract: There is no alternative method to remove facial verruca plana and achieve better cosmetic effects. The present study is the first study to use intense pulsed light (IPL) as photothermal therapy (PTT) combined with intra-gluteal injection of bacillus calmetteguerin polysaccharide nucleic acid (BCG-PSN), which function as immunotherapy, contracting a new type of clinically available laser immunotherapy for the treatment of facial verruca plana. The aim of this study was to evaluate the efficacy, cosmetic outcome, and adverse reactions of IPL combined with BCG-PSN for facial verruca plana. Twenty-three patients with facial verruca plana were treated with IPL (590-nm filter, 12-16 J/cm2) and all patients were given intragluteal injections of BCG-PSN twice a week for 8 weeks combined with IPL once a month in two times. A complete and excellent response was noted in 17 patients (74%). Of the 676 treated warts, 548 were eradicated and the overall clearance rate was 81%. Only four recurrences were observed during the 20-week follow-up. No obvious adverse reactions were observed. Almost all patients showed an improvement in skin texture after IPL treatment. We conclude that a novel LIT based on BCG-PSN and IPL for the treatment of facial verruca plana proved to be a well-tolerated and effective treatment modality. This novel LIT can clear skin lesions and achieve a very good cosmetic effect. Title: Atopic Dermatitis in Diverse Racial and Ethnic Groups Authors: Kaufman BP, Guttman-Yassky E, Alexis AF Published: Experimental Dermatology, February 2018 Keywords: Minority Groups, Skin Diseases, Eczema Abstract: Atopic dermatitis (AD) is a chronic inflammatory skin condition that affects diverse ethnic groups with varying prevalence. Despite a predominance of studies in individuals of European ancestry, AD has been found to occur more frequently in Asian and black individuals than whites. Therefore, an understanding of the unique clinical features of AD in diverse ethnic groups, as well as the differences in genetic polymorphisms that influence susceptibility to AD and response to current therapies, is paramount for management of an increasingly diverse patient population. In this article, we review key nuances in the epidemiology, pathophysiology, clinical presentation, and treatment of AD in non-white ethnic groups, which are largely under-appreciated in the literature. We highlight the need for studies evaluating the tissue molecular and cellular phenotypes of AD in non-white patients, as well as greater inclusion of minority groups in clinical trials, in order to develop targeted treatments for a multi-ethnic population.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018




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Collecting Patient Feedback Clinic operations manager Beverly Moore discusses how to effectively collect patient feedback and use it to improve your service Happy patients are key to a well-run, successful clinic. Regardless of how skilled the practitioners who work in the clinic are, the reputation of your business depends on how your patients review your services. If patients are satisfied with their treatment, not only will they come back, but they will recommend you to others. By listening to our patients’ feedback, whether positive or negative, we can aim to improve upon the service we offer, keep patients happy and maintain a successful clinic. But unless you have an effective way to collect and monitor feedback, it is impossible to get a proper picture of how they feel about the service they have received and know where you need to make improvements. Documenting and evaluating their feedback gives us a better understanding of their expectations, as well as their likes and dislikes about our service. Sometimes these reports can be rather unexpected – a patient who seemed to be happy with everything, may reveal that they were less than satisfied with some aspect of the service. The reverse also occurs – a patient who grumbles about everything can give the most glowing report. Feedback like this gives us valuable insight to help improve the service and care we offer. In this article, I shall look at the different ways feedback can be received and how to record and monitor it appropriately.

Surveys At my clinic, we ask all patients to complete a patient satisfaction survey immediately after their first consultation (Figure 1). Even if they decide not to proceed for treatment or it is deemed not suitable for them, it’s important for us to understand how they feel they have been treated. Apart from providing us with constructive feedback, the survey gives the patient a platform to tell us if something hasn’t been as good as they expected. This gives us the opportunity to respond immediately. Patients are invariably very happy to complete a survey. They usually complete a paper form at the clinic immediately after their consultation. We ask patients to rate every step of their experience, from making the initial phone call – ‘How easy was it to get through to the clinic on the phone?’ to ‘How would you rate the success of your procedure?’ Most questions require the patient to give a score between 1 (poor) and 5 (excellent). It’s important to make sure the questions are pertinent to the group of patients you are treating and that the data you are collecting is meaningful, so we adapt the form according to the potential treatment. The questions should also reflect the Care Quality Commission’s (CQC) key lines of enquiry (KLOE),1 showing that you are safe, effective, caring, Tips for managing the patient experience To increase the likelihood of receiving positive patient feedback, simple steps can be taken to make the patient’s experience smooth and hassle-free: • Ensure all patient details are up to date and accurate prior to the consultation • Make sure that all consent procedures are followed and paperwork is signed and scanned/stored into the patient’s record • Follow the clinic’s policy regarding the ‘cooling-off’ period and follow industry guidance.1 This ensures the patient has had time to reflect on the consultation and to make a decision about whether it is right for them without feeling pressured • Document accurately what was discussed and recommended during a consultation • Take before and after photos so there is a visual record • Make sure you offer a follow-up consultation after treatment

responsive to patient’s needs and well-led/ managed. The CQC are expecting your clinic to demonstrate that you are meeting the highest level of service, and this is to protect both the patient and the provider. As part of the survey, we ask patients to comment on their overall experience and whether we can share their review with others, anonymously if they prefer. Potential patients tell us they find these personal reviews useful as they can relate to another patient’s experience. We also receive many unsolicited testimonials in the form of thank you emails and cards. These are always shared with all members of the team and then added to the patient satisfaction report (discussed further down). If we use these for marketing we always ask permission from the patient first.

Word-of-mouth feedback New patients are always asked how they heard about us and most frequently it is because of a recommendation from a friend or acquaintance. These wordof-mouth endorsements provide great feedback, demonstrating the highest level of satisfaction, as the patient is confident in recommending the clinic to others. Make sure you monitor how many recommendations you get as, if numbers start to drop, there may be a reason for it. While it could be any number of things, such as competitor activity, fewer recommendations may also be a sign that your patients are not ‘singing your praises’ quite so much. Staff feedback All staff play a vital part in the patient satisfaction process, from the practitioner to the receptionist. The cliché about first impressions is so true and a welcoming smile and offer of a drink can set the tone for the patient’s entire visit. Don’t forget that your front-of-house team is also the clinic’s eyes and ears – they hear and see everything. Listen to your staff and the feedback they receive; a casual remark from a patient while chatting to a receptionist is invaluable. Our receptionists report patient comments at staff meetings and will alert their line manager to any negative comments immediately.

Social media Social media is where many patients engage with us. From an Institute of Customer Service survey, of consumers and customer service executives, it was found that 12% of consumers viewed

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018




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Patient complaints We have all experienced dealing with patients who are less than happy with their patient journey – be it as trivial as not liking the décor of the waiting room or something more serious, such as not getting the results they expected from their treatment. The aesthetic patient can be particularly challenging. They usually have a personal vision of what they want to look like and have high expectations of how the treatment will improve their appearance. Emotions can run very high if their expectations are not met. Many may find it hard to articulate exactly why they are not happy with their treatment and choose something less personal as the focus of their dissatisfaction – such as the clinic’s wallpaper, for example. However hard you try, a patient complaint is inevitable and it’s the hardest way of receiving patient feedback. It can also be demoralising for the team – no one wants to feel they haven’t managed a patient’s expectations. I always try to manage complaints on an informal basis to begin with, as most patients just want to be listened to. If it does escalate into a more formal complaint then I follow our complaint management policy and ensure that I document every interaction with the patient. It’s important to acknowledge any failing on the part of the clinic and work with the patient to put things right. Use the experience as a tool to improve in the future and see it as an opportunity to show the patient how important their satisfaction is to you.

Patient satisfaction survey (excerpt)

How welcoming were the reception staff upon your arrival? 1=Poor 5=Excellent

1 2 3 4 5

Did you go in on time to your appointment?

Which doctor/practitioner did you see?




Did you receive and understand all information given on your treatment?

Yes No

Did your doctor/practitioner discuss all treatment options?



Do you feel all your concerns and questions were adequately answered? Yes


Were you given a fully priced treatment plan?



Figure 1: Example of questions from a patient satisfaction survey

Twitter and Facebook as the perfect vehicle to escalate complaints and 39% of consumers actively provided feedback to organisations online.4 With this in mind, you must ensure to regularly check your social media channels. The comments we receive via Facebook and Instagram are extremely useful, showing what interests our patients and what is important to them. Especially monitor your star rating on your Facebook business page, as many patients will rate your business out of five and provide useful commentary. Research shows that more than half of consumers would be influenced to think more positively about a business after seeing praise on social media.3 Ensure to respond to all feedback online if you can, as potential patients like to see that a clinic is listening and responding. If you receive

any negative reviews via social media channels then I suggest that you respond by saying that you will contact the patient privately and then do so immediately.

Patient satisfaction report Each month we pull together patient feedback from all the various sources to compile a patient satisfaction report, which is shared with clinicians and staff. The majority of the data comes from the survey, but we supplement this with patient correspondence, comments on social media, feedback from staff and numbers of recommendations. The report allows us to see if there are any areas where our service may not be meeting patients’ expectations. It may be as simple as patients reporting that they were not offered a cup of tea or coffee on

arrival or more seriously, a patient feeling they wern’t given enough information at the initial consultation. These issues would be immediately addressed with the appropriate members of the team and we would be looking for immediate improvement in the next patient satisfaction report.

Conclusion The only way to truly know if your patients are happy with the service they have received is to listen to them. As you can’t have your eyes and ears everywhere, you need to make sure you give plenty of opportunities for patients to speak their mind. And more importantly, you need to ensure you have a system in place to log this feedback and action anything that is causing dissatisfaction. Documenting patient satisfaction also provides evidence to other providers, healthcare regulators, and new and existing patients about your performance and commitment to patient care. And last but not least, reviewing positive feedback from patients is highly motivational for all members of the team, reassuring them that they work in a happy, professional environment with patients who appreciate their skills, care and compassion. The comments from satisfied patients are a morale boost for the entire team and help to remind us all why we have chosen to work in healthcare. Beverly Moore is the operations manager of Cooden Medical Group. She has worked in the medical industry for 40 years, and was formerly a nurse before moving into management. Moore’s career includes 11 years with BUPA, where one of her roles involved handling patient complaints. Since 2005, she has focused on setting up and running private clinics for oncology, orthopaedic and aesthetic services. REFERENCES 1. CQC, Key lines of enquiry, prompts and ratings characteristics for healthcare services files/20171020-healthcare-services-kloes-prompts-andcharacteristics-final.pdf 2. GMC, Guidance for all doctors who offer cosmetic interventions, a public consultation on out draft guidance (2015) https://www. interventions__consultation_220515_FINAL.pdf_61261996.pdf 3. Small businesses don’t think social media is important, consumers think otherwise (2015) <https://www. small-businesses-dont-think-social-media-importantconsumers> 4. Jo Causon, Customer complaints made via social media on the rise, (2015) < may/21/customer-complaints-social-media-rise>

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018




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Aesthetics Journal


required for that specific role and incorporate these into the search. The member of staff may be exceptional on a spreadsheet or with procedures, but do they represent your new company values? Can they communicate with your patients in the most effective way? This will help ensure that all communications and internal discussions centre around this vital component which is key to attracting the correct candidates, and will save valuable time sifting through inappropriate CVs, or interviewing candidates who do not meet the set criteria.

Sales Recruitment and Retention or trying to recruit a new team member. Before embarking on the recruitment process, you should always ask: • ‘Is this role essential to our organisation’s strategy for success?’ and, if yes, • ‘Does the current structure of the role fully support the business’s needs?’

For example, your posting for a member of the front-of-house team could attract three shortlisted candidates: • A hairdresser who, although they have years of excellent customer service experience, has never worked in the aesthetics specialty • A beautician who has exceptional testimonials for ‘hands-on’ treatments but has never been responsible for booking appointments or initial patient contacts • A receptionist with seven years’ experience in another clinic.

Whilst this may sound like an obvious first step, it is surprising how often organisations that are faced with a vacancy feel the need to immediately fill this void, without assessing whether the role truly supported the business. Consider, instead, viewing this situation as an opportunity to review your current business structure with a fresh and up-to-date perspective. Once these questions have been answered, the next priority is to pinpoint the essential skillsets

So how, then, is it possible to compare these candidates? The answer is to build a logical and robust recruitment process which provides an environment designed to allow an individual’s skills and personality to shine through. By focusing on the essential skills identified in step one, this process would allow for fair comparisons, highlight transferrable skills and help shine a light on less obvious ways that candidates can add value to your team and business. There are

Aesthetic commercial professionals Sue Thomson and Jean Johnston share advice on avoiding the pitfalls of sales team recruitment and retention Effective sales teams are the lifeblood of successful clinics, manufacturers and distributors. As a clinic, it’s easy to forget that all customer-facing staff are, essentially, sales people and need to have the requisite skillsets. Whether ‘selling’ an idea, a product or even the availability of an appointment – sales professionals, front-of-house staff or reception staff are the face of your organisation and are critical to your business success. However, many employers struggle not just to recruit the right individuals, but to retain those individuals and create high-functioning teams. Recruitment can be an expensive task, and failure to attract and retain quality candidates has a significant impact on sales and company growth. In this article, we provide an overview of the most common recruitment pitfalls and give our top tips for how to ensure success in finding – and keeping – the best candidates for your team. 1: Missing the opportunity to take a strategic view Steven Covey, an acclaimed leadership author advises that, “To begin with the end in mind means to start with a clear understanding of your destination… so that the steps you take are always in the right direction.”1 This is never more relevant than when an organisation is building a team

2: Failing to create a solid process The aesthetics specialty in the UK is very diverse, and still relatively young, so many organisations find that great candidates come to them from a wide range of backgrounds and disciplines.

It is surprising how often organisations that are faced with a vacancy feel the need to immediately fill this void

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018




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many evaluation tools including psychometric testing, presentations, role plays and group activities, however each organisation is unique and must consider culture, values and aspirations to develop an assessment protocol specific to those needs. If in doubt, consult with an expert who can, through in-depth discussion and outlining available options, advise and assist you. 3: Advertising EVERYWHERE The aesthetics specialty is exciting and lucrative, yet still quite shiny and new. It is also a unique blend of commerce and medicine which requires a specific skillset for success. Although advertising your role far and wide will ensure maximum exposure, the draw of the aesthetics specialty does not always attract the right calibre of candidate. Similarly, selecting candidates for an aesthetics sales specialist role is not as simple as adding some skills to an algorithm containing a job description and finding which CVs fit. Choose your recruitment specialist well and, if you carry out the whole process yourself, select quality industry-specific publications and websites to advertise your vacant role to ensure it is being viewed by an appropriate candidate. 4: Selecting the most qualified candidate This sounds counter-intuitive! Why would an organisation, after going through the rigours of recruitment, select a lessqualified candidate? Although it is vital to ensure all employees have the necessary qualifications to meet any regulatory standards for their role, it is a mistake to base the recruitment process solely on qualifications alone. As mentioned, your business is unique in its culture and its people, therefore organisational fit is every bit as fundamental to the successful placement of a new employee as qualifications or experience. When looking for new team members, it is good

Aesthetics Journal


business practice to look at the existing team first. Finding a candidate who acts and thinks exactly like the rest of the team does not always make for a winning dynamic. Although certain core values are requirements for all team members, diversity really can revitalise a team by adding ideas from a different perspective or bringing experience gained in different sectors. Failing to consider team culture, personalities and organisational fit will, at best, result in stagnation and lower team energy. At worst, it will result in a completely dysfunctional team. Remember that high performing teams have many star players – the role requires more than a list of skills and qualifications, it needs a personality. 5: Not offering a development programme Getting the right candidate in the door is just the start. Sales people are, by nature, competitive, driven and goal-oriented. If you bring them into a role where they have no clear pathway for progression or development, they can quickly become disconnected from your business and seek these opportunities elsewhere. High staff turnover can cost the company more than just recruitment and training fees. Offering short term initiatives for the whole team, or individual training tailored to an individual staff member’s specific interests may help build company loyalty and make staff feel valued. High-performing teams need high-performing leaders who can motivate and mentor the entire group and provide each team member with a personal development pathway. This does not mean you need to create layers of job titles or complex bonus structures. Progression and development could be as simple as upskilling a team member within their existing role or demonstrating that the company values the individual. Clear roles, tasks and expectations, together with regular opportunities for one-to-one support and the sharing of ideas, will

By ensuring you have clear internal processes and specialised support, you will be more likely to identify the right candidate and reduce attrition

provide direction, strengthen team bonds and re-energise your team. Remember that front-of-house and reception staff see all types of customers, from the deal and voucher chasers to your loyal patients who return year after year – encourage them to share their insights and ideas to allow them to be part of your success. The danger of neglecting team development is that your star player may take their discipline and hard work elsewhere, leaving you back where you started with a vacant position and the lost opportunity costs that may bring. Summary Successful recruitment is about so much more than CV selection. By ensuring you have clear internal processes and specialised support, you will be more likely to identify the right candidate and reduce attrition. By offering specifically-designed training and mentoring programmes, you can remove the barriers to success – making your business more attractive to candidates and more likely to keep great people on a long-term basis. We believe that every business is only as good as its employees and that building successful high-performing sales teams is the cornerstone of commercial success. By developing a robust recruitment and training framework, the dynamics of a high performing all-star team is well within your grasp. Disclosure: Sue Thomson and Jean Johnson are the founders and directors of SJ Partnership, a new aesthetic sales optimisation and recruitment consultancy. Sue Thomson is an international sales leader whose career has spanned pharmaceutical and medical device businesses within the public and private sectors. In these positions Thomson has also supported her clients in achieving award-winning status in new product development, achieving commercial goals, while building and leading successful sales teams. Jean Johnston’s career has spanned FMCG, pharmaceuticals and the medical aesthetics industries. Building and leading teams, she has supported some of the biggest brands worldwide including Coca Cola. She has also developed a sales training model which has been used to train many medical aesthetics manufacturer and distributor sales teams on sales techniques and effectiveness. REFERENCES 1. Dr Stephen R Covey, “The 7 Habits of Highly Effective People” Free Press 1989

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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productivity due to presenteeism, where an employee with mental ill-health remains in the workplace but works less productively, and staff turnover. Staff turnover is a key consequence of the impact of mental illhealth on workplaces, which has a cost for both the employee and the employer. For the employer, losing valuable employee expertise often follows a period of extended employee absence, which may put a strain on other employees. For the employee, there are a range of negative health consequences which may spill over into their home life, including but not limited to, anxiety, depression and the financial consequences of being out of work.7

Employer responsibilities

Promoting Positive Staff Wellbeing Public health and wellbeing professional Nina Fryer advises how clinics can implement positive mental health for employees Most adults spend a large proportion of their lives in the workplace,1 so it is important that employees have a good experience. Employers and managers should also be attuned to recognising when a staff member is having a negative experience, and do what they can to promote positive mental health and wellbeing for their staff. In 2008 The Black review was published to look into the health and wellbeing of the working age population.2 This, along with the subsequent government response,3 highlighted the need to change attitudes to health and work, promote wellbeing in the workplace and help more people get into work. The Institute of Directors, an organisation that represents and sets standards for business leaders nationwide, supports the view that having a healthy workforce is good for both the employee and the employer. This includes better attraction and retention of talent, higher staff engagement, reduced levels of absenteeism, reduced staffing costs in terms of turnover, higher levels of productivity, and the reputational benefits that come with being recognised as a ‘good’ employer.1 However, despite this increased awareness,

evidence shows that mental ill-health is still one of the largest causes of absence from work.4 The recent Farmer/Stevenson 2017 review into mental health in the UK workplace highlighted that this topic is becoming an important agenda.4 The review found that although there is increasing awareness of the importance of supporting good mental health at work, the reality is that people with mental ill-health find it much more difficult to stay in the workplace. Additionally, the review found that around 15% of people at work have symptoms of mental ill-health. Figures from mental health charities such as Mind, suggest that this may be higher, affecting as many as one in four people over the course of their lifespan.5 This article will look at why aesthetic clinic owners and managers should focus on their employees’ mental health. It will also provide tips for how to ensure that aesthetic clinics have a positive environment to promote positive staff mental health and wellbeing.

Consequences of mental ill-health Mental ill-health is estimated to cost employers between £33-42 billion.6 This is linked to sickness absence, the lost

Legally, all employers have a duty of care to their employees,8 so they should take reasonable action to support their employees’ health and wellbeing – this includes mental health. Irrespective of whether the cause of mental ill-health is work related, employers have a responsibility to ensure that their work environment does not have a negative effect on their employees’ mental health. This is embedded with the Health and Safety Executives Stress Management Standards,4 which provide guidance to employers on the key causes of work-related stress and offer suggestions, case studies and toolkits to help identify and address issues that arise. The Farmer/Stevenson Review9 makes a compelling argument to revise practice around mental health at an organisation level. It proposes a set of mental health core standards to provide a practical framework for employers which, the authors believe, will reduce mental ill-health in the workplace. The standards suggest six key actions that can be taken by employers, which are described below. I have also presented some practical suggestions for implementing these, drawing upon my own experience and evidence from across a range of workplaces.

1. Produce, implement and communicate a mental health at work plan Improving the culture and practice around mental health at work often begins with an employee taking initiative and instigating interventions and activities. However, whilst such interventions can be effective in the short-term, long-term cultural change is more likely if you have senior level support. Gaining support from senior parties has been shown to be effective in reducing the stigma of mental ill-health,10 and in creating the leverage needed for wellbeing action

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


within an organisation.11 If done effectively, this creates the ability to dedicate staff and time resources towards a positive mental health agenda. With senior level support, consider setting up a working group with relevant members from across the organisation who are passionate about achieving change and that can leverage financial and human resources. In an aesthetic clinic, this might involve the clinic manager along with line managers, or even the owner if they have the time. If possible, try to include somebody with communications expertise, such as your communications manager, to ensure that messages around mental health are presented in a way that colleagues can understand and support. This working group can then be the driver around the creation of a mental health at work plan, drawing on supporting toolkits such as the Business in the Community Mental Health Toolkit for Employers,12 or the Mind Wellness Action Plan toolkit.13 Planning activities to coincide with national events, such as ‘Time to Talk Day’ in February,14 or Mental Health Awareness Week in May,15 can be a cost-effective way to ensure broader supporting resources are utilised. These events mean employers can request resources such as printed materials, and some charities also offer employer visits to coincide with these national events.

2. Develop mental health awareness among employees

Mental health awareness is the ability to recognise signs of mental ill-health in both oneself and others. There is increasing evidence that interventions such as mindfulness training can be useful tools for enhancing personal mental health awareness.16 Mindfulness training is loosely based on a form of meditation that teaches you to notice your emotional reactions as they are happening, and to acknowledge that this influences how you feel and behave. By raising levels of awareness, the potential for your emotions to hijack your behaviour and to cause anxiety is reduced.17 Mental health first aid (MHFA) training is also effective at developing understanding of signs and symptoms in others. MHFA training teaches employees at all levels to spot the symptoms of mental health issues and how to offer initial help in terms of signposting that person to available support. This training does not teach employees to be therapists, but it does enable them to identify signs of mental ill-health and teaches skills for listening and responding.18

Aesthetics Journal


For managers, being aware of the nature, scope and size of your staff’s job roles to ensure that it is achievable in the time available is an important way to create and manage realistic workloads If these initiatives are accompanied with clear signposting to sources of support for mental ill-health, for instance in staff handbooks, posters/leaflets in staff communal areas, and as part of annual appraisal and staff development discussions, then you will be better equipped to create a supportive mental health culture. Ensure that promotional materials relate directly to your employees. For example, there is evidence that men engage less in mental health discussions than women.12 Therefore, if you have male employees within your clinic, ensuring that they are represented in materials is especially important. 3. Encourage open conversations about mental health and the support available when employees are struggling One natural consequence of raising awareness of mental ill-health, and challenging the culture of silence around mental ill-health, is likely to be an increase in the number of conversations about mental health. The BITC Mental Health Toolkit for employers suggests that supportive conversations include finding a place to speak which will be uninterrupted, both by people and by mobiles/emails.19 Questions could include ‘How are you doing at the moment?’, or ‘You’ve seemed a bit withdrawn lately, is anything the matter?’ Giving colleagues time to answer and listening carefully is important. If the conversation is between a manager and their staff member, agreeing to a plan of action and setting a follow-up meeting can give structure to the support. Finally, recommending appropriate internal or external support is helpful at this point.19 For example, if you find that your clinic staff member is struggling, you can signpost them to see a trained counsellor.

Providing training for your managers on how to initiate conversations about mental health within both normal working conversations, and, as part of leadership and review discussions, will enhance their confidence and the confidence of other staff in the organisation’s ability to support positive mental health. 4. Provide employees with good working conditions and ensure they have a healthy work-life balance and opportunities for development We know that physical activity can be effective at reducing mental ill-health.20 Physical activity can be promoted through things such as organising team sports events, provision of subsidised gym membership, and supporting active transport.21 For example, you can support the staff who cycle to your clinic by providing changing and storage facilities, or subsidised bike purchase schemes. It can also be modelling healthy behaviours such as taking a lunch break away from your desk, or, where appropriate, practically challenging unhealthy working cultures, such as long-hours, by encouraging staff to not work out of their normal working hours. Where this is necessary for the business and has been discussed and negotiated with the team member, consider ensuring that this is not just extending your employee’s workload by allowing flexible working time to accommodate for this. For example, in some clinics it may be necessary from time to time to treat patients, for example celebrities, outside of the normal working hours. For managers, being aware of the nature, scope and size of your staff’s job roles to ensure that it is achievable in the time available is an important way to create and manage realistic workloads. Initiate

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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There is increasing evidence that interventions such as mindfulness training can be useful tools for enhancing personal mental health awareness conversations about workloads as part of staff review and appraisal processes. 5. Promote effective people management through line managers and supervisors For many leaders and managers, the biggest barrier to supporting colleagues with mental ill-health is personal confidence in their own skills and knowledge about how to do this effectively. One tip for addressing this at the start of an employee’s journey is embedding mental health into line managers’ job descriptions, to make explicit the responsibility that line managers have for their staff. We also know that one major cause of work-related mental ill-health is when employees experience problems with working relationships.22 Enhancing line management expertise can help to reduce this, because all too often, staff are promoted because they are good at their current job, without considering whether they have any development needs related to managing others. Therefore, as part of promotion discussions, you could identify any training needs that the staff member has relating to line-management, or proactively embed this by offering training for all managers with line management responsibility. 6. Routinely monitor employee mental health and wellbeing Sickness absence recording can provide data for further analysis of your staff’s wellbeing and health. Creating a positive culture around mental health and mental ill-health support should mean that staff do not feel concerned if they disclose mental ill-health as the cause of their sickness absence, as they know they will be appropriately supported. Improving your sickness absence data also means that you can initiate conversations with staff who are taking time off work with mental ill-health, to reduce the possibility of recurrences. Many employers routinely conduct staff surveys to gather information on issues that are within the workplace. The opportunity to include questions about mental wellbeing should not be missed here, as it will give a

clear indication of organisational areas that may need further attention. The ‘Time To Change’ mini health check for employers23 suggests some questions that could be asked in staff surveys that concern individual mental health status, organisational culture, and management practice around mental health. I have used these questions in evaluations of mental health stigma reduction interventions to great effect.10 Examples include: • Have you experienced stress, low mood or mental health problems while in employment? • In your opinion, how well does your organisation support employees who experience mental health problems? • How confident do you feel in supporting people you line manage with mental wellbeing at work? It is crucial that before asking these questions, a plan on timescales and resources for responding to issues raised, is drawn up.

Summary Changing the cultures around mental health in your clinic, challenging stigmas of mental ill-health and creating positive work environments do not always need large scale, expensive interventions. It can begin with just one champion and it has the potential to make both immediate and longerterm improvements to working environments, benefiting employees and employers alike. With the new Farmer/Stevenson Review published, the challenge now is to for employers to engage positively with these standards and translate them into actions and policies in the workplace. Nina Fryer is a public health professional with an academic background in organisational health and wellbeing, health promotion and evaluation of interventions. Fryer gained her MSc in Public Health from Leeds Metropolitan University in 2002 and has worked for 16 years as a senior lecturer and health and wellbeing manager.

REFERENCES 1. Fair C, & Wright H, Wellbeing and the importance of workplace culture (Great Place To Work, London, Dec 2016), <http://www. culture_final_011216.pdf> 2. Black C, Working for a Healthier Tomorrow – a review of the health of the working age population, (Department for Work and Pensions, London, 2008), < publications/working-for-a-healthier-tomorrow-work-and-healthin-britain> 3. DoH, DWP, 2008, Improving health and work – changing lives, (Department for Work and Pensions, London, 2008), <https://> 4. Stevenson D & Farmer, P, Thriving at Work: The Stevenson/ Farmer independent review of mental health and employers, (UK, 2017), < uploads/attachment_data/file/658145/thriving-at-workstevenson-farmer-review.pdf> 5. Mind, Mental Health Facts and Statistics, (UK, Mind, 2017), <> 6. Deloitte, 2017, Mental Health and Employers: The case for investment. Supporting study for the Independent Review, (UK,, 2017), < public-sector/articles/mental-health-employers-review.html> 7. Rajgopal T, ‘Mental wellbeing at the workplace’, Indian Journal of Occupational and Environmental Medicine, 14 (3), (2010), 63-65 8. ACAS, Defining an employer’s duty of care, (UK, ACAS, 2012), <> 9. Health and Safety Executive, Stress Management Standards: What are the Management Standards?, (UK, 2017), <http://www.> 10. Fryer, N and Kenvyn, I, ‘Evaluating the effect and impact of Mindful Employer Interventions in two organisations: The results of a ten month study, (commissioned report, Leeds Trinity University, February 2017), 38p 11. Quinlan N & Tideswell G, ‘Organisational Wellbeing – a continuing journey’, Chapter 14 IN Wellbeing, Productivity & Happiness at Work, ed. by Robertson IT & Cooper C, (UK, Palgrave MacMillan, 2011) 12. BITC, Mental Health Toolkit for Employers, (Business in the Community, 2016, London), < default/files/mental_health_toolkit_for_employers_-_small.pdf> 13. Mind, Guide to Wellness Action Plans, (Mind, 2013), <https://> 14. Time to Change, Mental Health Calendar, (Time to Change, 2018), <> 15. Mental Health Foundation, Mental Health Awareness Week, (Mental Health Foundation, 2018), <https://www.mentalhealth.> 16. Lomas, Tim; Medina, Juan Carlos; Ivtzan, Itai, ‘The impact of mindfulness on well-being and performance in the workplace: an inclusive systematic review of the empirical literature’ European Journal of Work and Organizational Psychology, 6 (4), (2017), 492-513 17. NHS, Welcome to the moodzone : Mindfulness, (NHS, Jan 2016, Crown Copyright, London), < stress-anxiety-depression/mindfulness/> 18. Mental Health First Aid, Training for a healthy oragnisation, (MHFA, Aug 2018, England), < organisations/workplace/> 19. Mens Health Forum, Best Practice: Mental Health Promotion: How to make mental health services work for men, (London, Mens Health, 2017) <https://www.menshealthforum.> 20. NHS Choices, Get active for mental wellbeing, (NHS, Jan 2016, Crown Copyright), <> 21. Department of Transport, Cycle to Work Scheme Implementation Guidance, (Department for Transport, 2011, Crown Copyright), < system/uploads/attachment_data/file/11305/cycle-to-workguidance.pdf> 22. Health and Safety Executive, Causes of Stress at Work: The HSE Stress Management Standards, (Health and Safety Executive, no date, Crown Copyright), < stress/causes.htm> 23. Time to Change, Time to Change Mini Healthcheck for Employers, (Time To Change, no date), < Mini%20Healthcheck%20for%20Employers_2.pdf>

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

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“Keep pushing yourself to be the best that you can be” Aesthetic nurse prescriber Jackie Partridge details the various medical roles she has undertaken and her love for aesthetics Academic Record 1994: Registered General Nurse (RGN) Lothian College of Nursing and Midwifery, Edinburgh 2008: Independent Prescriber V300 (NIP) Stirling University 2014: BSc (Derm), Stirling University 2017: PgCert (Distinction) Non-Surgical Aesthetic Practice, Northumbria University Current: PgDip in Non-Surgical Aesthetic Practice, Northumbria University (TBC)

Aesthetic nurse prescriber Jackie Partridge began her nursing career caring for premature babies in the Neonatal Unit at Simpson Memorial Maternity Pavilion in Edinburgh. It was a difficult and emotionallydraining job, dealing with lots of deaths and working late nights. “I wanted to work with babies, and ideally wanted to be a midwife,” says Partridge, adding, “But there were no spaces available on the midwifery course once I had qualified as a nurse, so I got a job working with premature babies, which was the next best thing. However, it was very challenging and I soon realised there was more to life than working nights and weekends!” Partridge decided to take on a very different role and went into medical sales at Convatec (Woundcare) medical device company and then Molnlycke Healthcare, and won many awards for her sales ability. Here, she gave advice to hospitals on wound care products. This was before landing a sales job in 2007 with ColBar Lifescience, where she finally discovered aesthetics. “With ColBar I was selling collagen dermal filler Evolence to aesthetic practitioners. Within six weeks of joining that company, I was doing incredibly well and achieving all my sales targets. I got a company car and was earning good money, and it was at that point that I turned around and said to my husband, ‘I want to set up my own business’,” she says. Through selling Evolence, Partridge met doctors and nurses who had their own businesses in aesthetics; suddenly, she realised that she had the skillset to do what they were doing. “I knew I had a head for

business, a passion for sales and a love for caring for people. So, for me, it was a bit of no-brainer,” she explains. Partridge left ColBar, completed her ‘return to practice’ to regain her nursing licence and began building a business. In a short space of time, Partridge was running a peripatetic service out of 60 different locations across Scotland, providing injectable treatment. “I was running around everywhere; covering three locations a day, just to meet the demand,” she remembers. Partridge worked like this for three years, but knew the business couldn’t grow without a premises of its own. “My husband, who was a national sales manager, joined me and we found a place to rent in Edinburgh that had three treatment rooms and a consultation room. But we soon grew out of it, and in 2014, we decided to purchase our own clinic. We now have seven treatment rooms, a minor operations room and 17 people working there,” Partridge explains. As well as running a busy clinic, Partridge has key roles with the British Association of Cosmetic Nurses (BACN) and pharmaceutical company Galderma. She sits on the programme board for Healthcare Improvement Scotland (HIS) and the Scottish Government, representing the BACN. Partridge explains, “There are a lot of regulatory changes happening in Scotland and it is taking a lot of work and time to try and put forward the best possible solutions we can. I felt that some form of regulation was very important as we previously never had the Care Quality Commission (CQC) in Scotland, and it was completely unregulated. But to now be in a position to have another body we are accountable to I think is really important.” Partridge’s work with HIS led to the Secretary of Health thanking her for her passion and enthusiasm. Partridge has especially enjoyed her role with Galderma, explaining that she got involved with them when they invited her in 2009 to attend anatomy training in Nice. “Galderma really took me under their wing; I ended up going through their country mentor training programme, which was an intensive

three to four days of learning speaking and presentation skills, and, from there, I was asked to be part of the global nurse faculty.” She adds, “It has really allowed me to establish myself as a speaker and presenter.” The most important thing to be aware of as a practitioner today, Partridge explains, is ensuring a thorough consultation. She says, “If a patient is determined they want a treatment, they will actually be quite deceptive in the consultation process. I think it is down to us to be very inquisitive, to probe and to ask more questions, or ask them in different ways. It is important to make sure there isn’t some form of body dysmorphia underlining their desire to have treatment.” When asked what career advice she would pass onto others, she says, “Never stop learning. I haven’t, and I don’t think a year has gone by where I have stopped learning.” She adds, “You’ve got to keep pushing yourself to be the best that you can be. You owe it to yourself.” Which treatment do you enjoy giving the most? I love injectables! I really enjoy doing botulinum toxin and dermal fillers – you get such a buzz out of doing it and getting hugs from your patients because they are so pleased with the results. Do you have an industry pet hate? Unqualified, uncaring practitioners who are just in it for the money. Also, medical colleagues who prescribe for non-medics. What do you enjoy the most? I think we have many amazing colleagues in aesthetics. It is an ever-changing, dynamic industry, and there are always new things coming. What do you predict will be the next big thing? Plasma technology. I think it will develop further as it is minimally-invasive and people want results without risks and downtime. I also think we will see an increase in male patients.

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018


Aesthetics Journal


is as low as 15%, I have noticed that Croatian men are catching up with their UK counterparts and treatment requests are rising. Unsurprisingly, there are great similarities between the two countries in the most popular procedures. Just like in the UK,5 non-surgical aesthetic procedures such as botulinum toxin (BoNT) and hyaluronic acid (HA) dermal fillers are overtaking surgical procedures.6 Similarly to the UK, I have found that the main reason for this is the ease of having these procedures with little risk and downtime, along with lower prices when compared to the surgical procedures. This is especially appealing to patients in Croatia as the minimum wage is much lower than the UK – €5,548 vs €16,812 per year.7,8 However, interestingly, dermal filler treatments in Croatia are much more popular than BoNT treatments, which is unlike the UK. In my experience, BoNT is deemed as a ‘poison’ to patients in Croatia, as they feel HA is something more ‘natural’. Whereas in the UK, BoNT is still frequently requested in my clinic, with the trend moving to lower ‘baby Botox’ doses.9 Of course, I try to educate my patients in both countries that the two modalities of rejuvenation have their specific indications and that they work even better in combination. I also explain that of course, is not a poison, but an organic protein. Dr Nikola Milojevic compares modern medical BoNT, Interestingly, in Croatia we only have one brand of BoNT aesthetics in Croatia and the UK available as no other toxin brands have been approved for aesthetic use by the Croatian version of the US Food Being the owner of two aesthetics clinics, one in Zagreb, Croatia and Drug Administration, the Croatian Agency for Medications (Drugs) and one in London, I can compare two very different countries and And Medical Products (HALMED),10 so practitioners are very restricted approaches to aesthetic medicine. with product choice. I split my time between the two countries, which I think has made me In both countries, there has been a big move towards skin a better doctor and a better aesthetic practitioner. I also believe that rejuvenation treatments such as dermal rollers, platelet rich plasma, by learning how medical aesthetics is practised in a country such as laser rejuvenation and vaginal rejuvenation. In my experience, body Croatia, aesthetic practitioners in the UK can learn a great deal. shaping procedures are becoming more popular in general yet, while liposuction surgeries are popular in both countries, I have found that History fat freezing procedures are more prevalent in the UK.11 In Croatia, The history of private aesthetic clinics in Croatia dates back to 1967, culturally, ‘freezing of the fat’ is not really understood, with ultrasound when my father Professor Bosko Milojevic opened the first private and radiofrequency procedures being more popular for body clinic for aesthetic plastic surgery in Zagreb.1,2 It was among the first contouring. In fact, as far as I am aware, my clinic in Croatia is among such clinic in Southeastern Europe. In the UK at the time, there were the only one in the country to have purchased a fat freezing machine. no private aesthetic clinics. With the subsequent development of Again, this could be due to the greater skepticism to new technologies cosmetic surgery in the UK over the following 15 years, the British in Croatia, and a lesser tendency to ‘jump on the bandwagon’, which Association of Aesthetic Plastic Surgery was formed in 1979 and many I notice more amongst UK-based aesthetic practitioners. In the UK, private practices opened.3 I find that we have a better support from our distributors in terms of Although Croatia was first to enter the surgical aesthetic field,4 the UK marketing, which might also have an effect on the understanding and was first to undergo the ‘non-surgical’ boom. In Croatia, the rise of non- popularity of treatments. surgical treatments has only really occurred within the last six years. I believe this could have been because many surgeons were not as The interesting thing about Croatia, and something we can learn open to non-surgical options as those in the UK, as well as the fact that from, is that I find that aesthetic practitioners are often a little bit more a larger variety of practitioners are permitted to perform the treatments skeptical about new procedures. The bureaucracy is also generally in the UK, which is discussed in more detail below. much more complex. For example, opening a clinic is much harder in Croatia as it needs approval from the Ministry of Health. In the UK, the Types of procedures Care Quality Commission is very stringent, but it is not a requirement In terms of patient requests, in the two countries, the ‘less is more’ for many clinics offering aesthetic treatments to be registered with the attitude is prevalent, with most patients preferring more natural CQC and be open to inspection.12 treatments and results. In comparison, in the neighbouring Serbia, and indeed in the US, the ‘done’ look is still generally popular. Regulation Additionally, in the UK, 35% of my patients are now men, especially Perhaps the biggest difference between the two countries is the for the treatment of tear troughs. Even though in Croatia this number regulation of our specialty. While we struggle to stop the dangerous

The Last Word

Reproduced from Aesthetics | Volume 5/Issue 4 - March 2018

practice of untrained and unqualified individuals from injecting BoNT and fillers in the UK, Croatia is perhaps on the other end of the spectrum. Only surgeons, doctors and dentists are allowed to practise medical aesthetics, while beauticians, other non-medics and even nurses are not allowed to practise. There is a very strict view in Croatia from both those working within the aesthetic profession and the public, that they should not because they are deemed to not have enough training through their studies. Authorities and the public alike feel that nurses do not have training that involves enough anatomy, physiology, biochemistry, and not enough clinical experience in diagnosis and examination of the patient, as medical training for doctors is much longer and more thorough. Summary In medicine, and in life in general, we can always learn from others, even when we may think that we know better. With practitioners travelling from all over Europe to share information at conferences and other events, and to the great credit of the Aesthetics journal and similar publications, I believe there has been a standardisation of aesthetic practice. This has occurred throughout Europe, with similar standards of treatments, patient education and high levels of practitioner knowledge and experience. I believe that the regulation in Croatia, in regards to who can practice, is a little too strict. However, in my opinion, the patient in Croatia is safer with better quality control and more skilled practitioners guaranteed. In the UK, despite thousands of highly professional and skilled aesthetic doctors, dentists and nurses, many patients are still confused with who they should turn to for treatment. In the UK’s unscrupulous, price-driven market, many may still visit the cheapest practice for their injectable treatments, where there in an increased risk of being treated by an under-qualified person. Dr Nikola Milojevic is the owner of Milo Clinic in Harley Street and Polyclinic Milojevic in Zagreb. He has more than 14 years’ experience in medical aesthetics and with over 40,000 dermal filler and botulinum toxin procedures and 6,000 tear trough procedures performed. REFERENCES 1. Milo Clinic, ‘Prof. dr Boško Milojević’, 2017. <> 2. Jurica Körbler, Jutarnji List, 2017, <> 3. British Association of Aesthetic Plastic Surgeons, ‘History of BAAPS’, 2017 < about/history_of_baaps.aspx> 4. Večernji List, Velika proslava povodom 50 godina estetske medicine 2017. <https://www.vecernji. hr/lifestyle/velika-proslava-povodom-50-godina-estetske-medicine-1176050> 5. Gronow C, ‘Aesthetic Surgery’s decline in 2016’, Aesthetics journal, March 2016, <https://> 6. ZENA.HR, ‘Sve veći broj Hrvatica odlučuje se na estetsko-kozmetičke zahvate’. 2014, <https:// zahvate/10996> 7., UK National Minimum Wage 2018. <> 8., Croatia National Minimum Wage 2018. national-minimum-wage/croatia 9. Tracy Ramsden, ‘What is Baby Botox and why are more young women than ever having it done?’, Marie Claire, 2018. <> 10. HALMED, ‘About HALMED’, 2018. translate?hl=en&sl=auto&tl=en& 11. Charlotte McDonagh, Mums are FREEZING their fat to get post-baby bodies like the stars, Daily Star, 2014. <> 12. CQC, The scope of registration (UK: Care Quality Commission, 2015) < sites/ default/files/20150428_scope_of_registration_independent_medical_practitioners_ working_in_ private_practice.pdf>


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Just Celine Preserve the identity of your patients with natural-looking results.1 Azzalure® is indicated for the temporary improvement in the appearance of moderate to severe glabellar lines (vertical lines between the eyebrows) seen at frown and/or lateral canthal lines (crow’s feet lines) seen at smile lines, in adult patients under 65 years, when the severity of these lines has an important psychological impact on the patient.2 References: 1. Molina B et al. J Eur Acad Dermatol Venereol 2015;29(7):1382-1388 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary. Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe: • Glabellar lines seen at maximum frown, and/or • lateral canthal lines (crow’s feet lines) seen at maximum smile in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Glabellar lines: recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,; 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. Lateral canthal lines: recommended dose per side is 30 Speywood units (60 Speywood units for both sides, 0.30 ml of reconstituted solution) divided into 3 injection sites; 10 Speywood units (0.05 ml of reconstituted solution) administered intramuscularly into each injection point. All injection points should be at the external part of the orbicularis oculi muscle and sufficiently far from the orbital rim (approximately 1 - 2 cm); (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. The efficacy and safety of repeat injections of Azzalure has been evaluated in Glabellar lines up to 24 months and up to 8 repeat treatment cycles and for Lateral Canthal lines up to 12 months and up to 5 repeat treatment cycles. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or amyotrophic lateral sclerosis. Special warnings and precautions for use: Care should be taken to ensure that Azzalure is not injected into a blood vessel. Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any Adverse events should be reported. For the UK, Reporting forms and information can be found at For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website:; E-mail: Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Nestlé Skin Health S.A. AZZ17-05-0026a Date of preparation: May 2017

alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy, Lactation & Fertility: Not to be used during pregnancy or lactation. There are no clinical data from the use of Azzalure on fertility. There is no evidence of direct effect of Azzalure on fertility in animal studies Side Effects: Most frequently occurring related reactions are headache and injection site reactions for glabellar lines and; headache, injection site reactions and eyelid oedema for lateral canthal lines.. Generally treatment/injection technique related reactions occur within first week following injection and are transient. Undesirable effects may be related to the active substance, the injection procedure, or a combination of both. For glabellar lines: Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and haematoma). Common (≥ 1/100 to < 1/10): Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites, predominantly describes brow paresis), Asthenopia, Eyelid ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual impairment, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. For lateral canthal lines: Common (≥ 1/100 to < 1/10): Headache, Temporary facial paresis (due to temporary paresis of facial muscles proximal to injection sites), Eyelid ptosis, Eyelid oedema and Injection site disorders (e.g. haematoma, pruritus and oedema). Adverse reactions resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: January 2017

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