Aesthetics may 2014

VOLUME 1/ISSUE 6 - MAY 2014

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Lip anatomy CPD Article Sharon King discusses the anatomy and physiology of the lower face for treatment of the lips. CPD accredited article

Combination treatments Leading aesthetic practitioners discuss combination treatments for body contouring

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Data protection

SPF Debate

Dr Natalie Blakely and Mandy Luckman explore the legal and ethical issues with storing patient data

Dr Tiina OrasmaeMeder and Deborah Forsythe on the benefits and limitations of using sunscreen

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Contents • May 2014 INSIDER 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month 17 News Special: Anti-Aging Medicine World Congress We report on the AMWC in Monaco, including the Allergan Medical Institute symposium

18 News Special: American Academy of Dermatology Meeting Dr Nick Lowe and Wendy Lewis share their thoughts on the 72nd

CLINICAL PRACTICE Lip augmentation Page 26

annual AAD meeting in Denver

CLINICAL PRACTICE 20 Special Feature: Combination Treatments A look at the best treatment combinations for body contouring 26 CPD Clinical Article Sharon King discusses the anatomy of the lower face for lip augmentation 32 Treatment Focus Dr Tiina Orasmae-Meder and Deborah Forsythe debate the benefits

and limitations of using SPF sunscreen

38 Clinical Focus

Leading practitioners discuss the best methods for treating pigmentation problems using skincare

44 Techniques

Dr Carolyn Berry shares her experiences in treating caesarean scars and stretch marks

IN PRACTICE Data protection Page 50

46 Spotlight On

We learn more about Eternogen, the new collagen dermal filler portfolio coming to the UK

48 Aesthetics Awards Special Focus

Clinical contributors

The latest news from the upcoming Aesthetics Awards 2014

Dr Nick Lowe is president of the BCDG, professor of dermatology and a consultant dermatologist with over 30 years of experience who practises in London and California

IN PRACTICE 50 Data Protection

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

Dr Natalie Blakely and Mandy Luckman on storing patient data legally and ethically

52 Treatment Portfolio Wendy Lewis explains why body shaping procedures will benefit your clinic

Sharon King is a director and clinical nurse specialist at the Cosmedic Skin Clinic, board member of the British Association of Cosmetic Nurses and member of the Aesthetic Complications Expert Group

56 Marketing John Castro on how using videos effectively can attract potential patients

Dr Tiina Orasmae-Meder is a dermatologist and the founder of Meder Beauty Science, based in Switzerland, who also works at Iris Brand Vigilance to guide cosmetic safety

60 HR John Sellers discusses the importance of nurturing your workforce 62 In Profile

Deborah Forsythe is a medical aesthetic specialist and member of the Allergan faculty responsible for validating practitioners on injection techniques. She specialises in non-surgical dermal facial rejuvenation

We speak to Mr Chris Inglefield about challenging the perception of aesthetic procedures

Dr Carolyn Berry is the founder and medical director of the Firvale Clinic, and also practises as a research fellow and general practitioner

64 The Last Word Dr Darren McKeown promotes collaboration between surgeons and aesthetic professionals

Subscribe to Aesthetics Subscribe to Aesthetics, the UK’s only free-of-charge journal for medical aesthetic professionals.

Visit aestheticsjournal.com or call 01268 754 897

NEXT MONTH • • • •

IN FOCUS: Lower body CPD – Identifying suspicious lesions Special focus: cellulite treatments Treating rosacea

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Editor’s letter I am delighted to be taking over as Editor of Aesthetics journal. Having been intricately involved in medical aesthetics since it first became a professional discipline, I have brought this experience to my work with the Aesthetics Amanda Cameron Conference and Exhibition (ACE) and as part of Editor the journal Editorial Advisory Board. I now look forward to leading the expanding editorial team and working closely with our valued contributors and our Advisory Board, which this month welcomes two new members; Dr Raj Acquilla and Mr Dalvi Humzah.

As the journal continues to move forward as the leading publication for medical aesthetic professionals, we are honoured that two more highly respected and experienced members of the profession have chosen to join this select group. The knowledge, expertise and advice of both, along with our other board members, will be invaluable in continuing our work to create a safer and better industry for patients. In April, we were pleased to be able to attend the Anti-Aging Medicine World Congress in Monaco, where new products and treatments were showcased alongside insightful and educational lectures and presentations from international experts. Our report from this congress is featured on p. 17, along with thoughts from Dr Nick Lowe and Wendy Lewis regarding the American Academy of Dermatology meeting in Denver, which took place in March.

This issue, our focus revolves around ‘The Sun’. For our special feature, we spoke to practitioners about which treatments they use in combination to produce the best bespoke solution for patients seeking body contouring. Dr Carolyn Berry shares her advice on the treatment of scars such as stretch marks and caesarean scars, which are a particular concern to patients during the summer months. We also feature a fascinating debate regarding the use of SPF, with Deborah Forsythe supporting the use of sunscreen profusely, whilst Dr Tiina Orasmae-Meder argues that it can be unnecessary in certain climates and seasons. Aesthetic nurse Sharon King has provided our CPD article for this month, which details the anatomy of the lip and perioral area in relation to lip augmentation procedures. Our business development articles this month include a guide from Wendy Lewis in building a body shaping clinic and key advice from Dr Natalie Blakely and lawyer Mandy Luckman regarding data protection. Our goal for the journal is to support both established products and innovation through medical education.

We aim to provide impartial, credible and evidence based information to support good clinical decisions. This also involves you, and we will work hard to ensure that the journal continues to be a forum for expressing quality opinions and mature debate in order to continue to raise the standards in our industry. If you are interested in contributing to a future edition of Aesthetics journal, or would like to share your thoughts and comments on this issue, contact us on editorial@aestheticsjournal.com

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

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

Dr Mike Comins is president and Fellow of the British

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Sharon Bennett is chair of the British Association of

Mr Dalvi Humzah is a consultant plastic, reconstructive and

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

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

Dr Nick Lowe is president of the BCDG and a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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.

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Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Craig Christie; support@aestheticsjournal.com © Copyright 2013 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240

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.

Insider News

Talk Aesthetics What you’re talking about this month

#AMWC Chytra V Anand / @drchytra At #AMWC2014 the world anti ageing congress @#monaco. My talk on #radiofrequency for #skin tightening... — at Forum Grimaldi.

#Stats Aesthetic Source / @AestheticSource How much do u spend on #skincare?

Women in their Sixties now splash out £235 a year!

#Bestpractice Sharonbennettskin / @sharonbennettuk @JAestheticNurse @aestheticsgroup @ Consulting_Room @CosmedicCoach Who tells their patients which toxin they’re administering? Always.

#Nutrition Dr Nick Lowe / @DrNickLoweSkin If you’re getting fewer than 20 grams of fat a day, your body may not absorb enough vitamin A, which can lead to premature ageing.

#BJNawards Emma Davies / @daviesemma5 @BJNursing @Nurse_A_Baker @BACNurses fantastic night at BJN awards. Congrats Adrian, well deserved winner Aesthetic nurse of the year.

#SPF Dermalogica UK / @DermalogicaUK1 Increases in #pollution levels can cause skin ageing. Use an #SPF with #antioxidants to combat both UV and free radical damage. #dermalogica

#Research Debi@cosmeticsupport / @cosmeticsupport If the NHS does not provide cosmetic surgery, where will reliable scientific evidence come from

#Treatment Dr Sarah Shah / @DrSarahShah #BeautyFact The non-surgical neck rejuvenation is a great alternative to surgery.

Regain your youthful neck with #Botox and dermal fillers.

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

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Editorial board

Mr Dalvi Humzah and Dr Raj Acquilla join the Aesthetics Editorial Board Mr Dalvi Humzah and Dr Raj Acquilla are this month welcomed as official members of the Aesthetics editorial advisory board. Mr Humzah is a consultant plastic, reconstructive and aesthetic surgeon based at the Plastic Dermatological Surgery. A former NHS Consultant Plastic Surgeon, Mr Humzah currently maintains a plastic surgery private practice and is a key opinion leader for Dr Raj Acquilla several aesthetic companies.

Dr Acquilla is a cosmetic dermatologist with over 11 years experience in facial aesthetic medicine. He is UK ambassador, global key opinion leader and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. Of the appointment Dr Acquilla said, “I am delighted to be joining the Aesthetics editorial advisory board at such an exciting time for the journal. Leading Aesthetics forward in its new clinical direction, my role will be to advise Mr Dalvi Humzah and support the publication in order to ensure that we are delivering content of the highest quality and medical authority to our readers.

Aesthetics and its board members are at the forefront of developments within the medical aesthetics industry, and I look forward to being a part of this journey.”

Industry

Sinclair IS Pharma acquires global rights to Ellansé Sinclair IS Pharma announced that the company has entered into agreements to acquire the global rights to Ellansé, a combined dermal filler and collagen stimulator product range. The international speciality pharmaceutical company acquires the global rights to Ellansé through the acquisition of AQTIS Medical BV. The addition of the Ellansé brand will complement Perfectha, Sinclair’s range of hyaluronic acid fillers, acquired in January 2014.

Chris Spooner, Sinclair CEO, commented, “Facial aesthetics is one of the fastest growth segments in dermatology and creating a global presence is a key strategic objective for Sinclair. We expect Ellansé’s innovative product range and emerging market bias, in combination with our existing aesthetics business, to add materially to Sinclair’s overall growth rate and market presence in this exciting field.” This financial year, over one third of Sinclair’s revenues are expected to come from aesthetics. The impact of recent acquisitions including Ellansé means that this is expected to rise to around 50% in the year ending 30 June 2015.

Aesthetics | May 2014

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Acne

New website launched to provide post-acne support A new acne scar resource website has been launched for people suffering with acne scarring. ascarfreeme.ca aims to help people manage the emotional and physical impacts of the aftermath of acne. “Beyond the physical effects, acne scars can impact self-esteem and self-confidence,” said a community manager for the site. “‘A Scar Free Me’

was started to support people, connecting them with a community for advice and help.”

The website offers free online resources, from articles on the latest treatments to blog posts on improving self-esteem. “Millions of people suffer from acne scars every day, often feeling socially isolated and without hope,” said dermatologist Dr. Ruth Tedaldi, member of the

Research

Clinical trial indicates vitamin C makes skin 33% firmer A four-week placebo-controlled clinical trial conducted by Aspen Clinical Research has demonstrated that liposomal vitamin C gel Altrient C significantly improved skin elasticity. The trial included 60 participants with non-firm ageing skin aged between 31 and 65+.

50% took three sachets of Altrient C a day for four weeks and 50% took a placebo. Skin elasticity and firmness were measured at three points throughout the trial.

Results presented that participants using Altrient C showed improvement in skin firmness and elasticity compared to participants taking the placebo. Those who took Altrient C showed an increase in skin firmness of 32.7% after four weeks. Following the four weeks, 100% of participants who consumed Altrient C also reported an overall improvement in their skin, 50% of which noted greater hydration, 43% thought they looked younger and 33% thought their skin appeared more nourished. “This research has demonstrated a clear link between the skin ageing process and vitamin C via dietary

American Academy of Dermatology and a contributor to ascarfreeme.ca. “The first step in treating acne scars is to understand the skin condition, and through ascarfreeme.ca, visitors can quickly get information on how these scars occur, what to expect at your first acne scar consultation and access to many other resources,” she said.

supplements,” said Jonathan Orchard, director of Abundance & Health, distributors of the product. “However, up to 85% of the vitamin C contained in tablets and powders is destroyed in the digestive system. Altrient C vitamin C is encased in a tiny bubble of protective fatty acids. This safeguards the vitamin through the harsh digestive system and the body’s absorption barriers, into the bloodstream, where it is transported through the body.” Danny McCamlie, lead clinical scientist and principal investigator at Aspen Clinical, said, “With an increase of 15.1% and 32.7% in skin firmness, following two and four weeks respectively, Altrient C achieved results that, in our experience, some topically applied creams fail to achieve following eight weeks of use.”

“Formation of free oxygen radicals is widely accepted as a pivotal mechanism leading to skin ageing, and the production of free radicals increases with ageing,” said Dr Sanjay Rajpara, dermatologist and cosmetic skin doctor. “Vitamin C is an important part of the body’s antioxidative defence mechanism. This product has a potential to become one of the first line products for anti-ageing.”

Awards

Sponsors announced for the Aesthetics Awards 2014 The first sponsors for the Aesthetics Awards 2014 categories have been announced. 3D Aesthetics will present the 3D-lipomed Award for Best New Clinic, UK and Ireland; Dermalux will present the award for Best Clinic South England; Church Pharmacy will present the award for Best Clinic North England; Institute Hyalual will present the award for Aesthetic Nurse Practitioner of the Year; Aesthetic Source will present the prestigious Lifetime Achievement award whilst Healthxchange Pharmacy will present The Janeé Parsons Award for Sales Representative of the Year.

Roydon Cowley, managing director of 3D Aesthetics said, “3D-Aesthetics are Aesthetics | May 2014

delighted to sponsor the Aesthetics Awards 2014. We will be thrilled to present the 3D-lipomed Award for Best New Clinic to the deserving winner.” Of The Janeé Parsons Award for Sales Representative of the Year, chairman of Healthxchange Pharmacy Dr John Curran said, “Sales and marketing people are the backbone of any good business; great staff make great businesses work. Janeé was an exceptional example of a colleague who gave her all. Each one of you need recognition and we at the Healthxchange would like to honour the very best amongst you. Good Luck!” Details of how to enter the Awards are found on pages 48 and 49 of the journal.

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White paper

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Industry

National Special Procedures Register proposed in Wales The Welsh government has put forward a proposal for a mandatory register for practitioners offering cosmetic piercing, tattooing, semi-permanent skin colouring, acupuncture and electrolysis. The National Special Procedures Register would require practitioners and businesses in Wales to meet specified standards to obtain registration, and then practice to specific standards to maintain this registration.

Part of the requirements to achieve this would include a standardised pre-and post-consultation with patients and the maintenance of records. Pre- and post-consultation at a minimum would include whether the person receiving treatment had any medical problems that would put them at greater risk resulting from treatment, how the treatment would be carried out, including potential complications, and how to look after any wounds in order to prevent infection occurring.

Other points in the proposal include all practitioners and businesses being required to register in order to practice, practitioners and businesses being required to pay a fee to register and the inclusion of a specified ‘fit and proper’ person test for all practitioners and businesses. There would also be cleanliness standards based on infection control advice and industry best practice. A practitioner or business could also be removed from the register for a specified period of time and would be unable to practice in that time period for offences such as failing to meet cleanliness standards or not following pre-and post-consultation requirements.

A Welsh Government spokesperson said, “Over the last decade, cosmetic procedures such as body piercing and tattooing have become increasingly popular. However, there are known health risks connected to these procedures if they are carried out in an unhygienic fashion. It is therefore important that practitioners have safe working practices, and that good infection control practices are followed at all times, so that customers are protected. Some people taking up these procedures are often more vulnerable than others, which is why we’re proposing to make it compulsory for consultation with customers which would include, for example, a requirement to check whether the person has any health problems that may put them at greater risk as a result of the procedure.” The proposal, released on April 2, was published in a White Paper entitled, ‘Listening to you: Your health matters. Consultation on proposals for a Public Health Bill’. The Welsh Government is currently inviting responses to the proposal, which should be submitted by June 24.

Winner announced for BJN Aesthetic Nurse of the Year Oxfordshire aesthetic nurse Adrian Baker has won Aesthetic Nurse of the Year at the British Journal of Nursing Awards 2014. The awards ceremony, which took place on March 21 in London, was set up to celebrate the contribution of individual nurses to the development of the profession as a whole. Nurses from across the country were in attendance.

Mr Baker, who qualified as a nurse six years ago, became an independent nurse in 2011 and immediately started training to become an aesthetic nurse specialist. He then trained for an independent nurse prescribing qualification and now works as an aesthetic nurse at the MBNS and Qutis Skin clinics in Oxfordshire. “I was incredibly honoured to have been nominated in the first place,” said Mr Baker. “To have won the award was simply breath taking. The best part about this award is that it is demonstrating a recognition of aesthetic nursing as a profession, whilst celebrating excellence within all nursing specialisms.”

Industry

Aesthetics journal team welcomes new contributors The Aesthetics journal is proud to welcome new members to its contributing editorial team. Ruth Donnelly started her writing career on Brand New You, a consumer magazine focused on cosmetic enhancement.

In 2009 she moved to The Cosmetic Surgery and Aesthetics Magazine (later to become The Cosmetic Surgery Guide), before becoming editor in early 2010. More recently, she has been contributing as a health writer for a number of publications. Also joining the team are Suzi Lewis-Barned and David Jacobs. Suzi is a freelance writer, editor, researcher and healthcare journalist with more than 20 years experience. Producing commissioned content across all print and digital media, Suzi’s expertise is also in demand for the fourth year running as a judge at the 2014 Communiqué Awards for Writing Excellence. David is the senior copywriter and a partner at Lewis-Barned & Associates.

A published author and report writer and editor, he also trains others to improve their writing skills.

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

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Vital Statistics

Training

Dr Raj Acquilla launches online training academy Dr Raj Acquilla is set to launch his new online facial injectables training academy, the RA Academy, in May 2014. The website will comprise a series of video masterclasses demonstrating various facial injectable techniques, from common procedures such as frown lines to more advanced strategies, including some of Dr Acquilla’s signature techniques.

The RA Academy has been set up as both a training tool and a reference for practitioners to call upon during their day-to-day practice. As well as the online masterclasses, members will be offered the opportunity to attend an annual live symposium. Dr Acquilla said, “Through continuing to learn and constantly updating our knowledge and technical application we can deliver safe, consistent and exceptional results that will delight our patients and help to grow our practices.”

There are over 4000 aesthetic nurses in the UK 4000+

British Association of Cosmetic Nurses

10%

Over of women surveyed said stretch marks were their biggest skin dislike Syneron-Candela, Censuswide survey

Conference

ACE 2015 is announced

The American Society for Aesthetic Plastic Surgery (ASAPS)

The Aesthetics Conference and Exhibition 2015 will take place on Saturday 7 and Sunday 8 March 2015 at the Business Design Centre, London. This follows the success of ACE 2014, where packed lectures, clinical demonstrations and business workshops provided helpful guidance to practitioners in best practice, new innovations and business development.

Post-event feedback further confirmed the popularity of the conference as a vital learning tool for practitioners. One delegate said, “The event had wonderful lectures aimed at the right level, and a great environment to learn from colleagues.” Another delegate praised the exhibition, saying it was a “great opportunity to meet some truly interesting suppliers who were very helpful.” Based on the feedback, work has already begun on an even larger educational programme, featuring more masterclasses and expert clinic demonstrations. With over 90% of delegates from this year’s event interested in attending again, and key suppliers already requesting exhibition stand space, ACE is set to be the major conference for aesthetic professionals in 2015. Registration will open later this year.

Injectables

TSK Laboratories launch new syringe for botulinum toxin injections TSK Laboratory Europe BV has launched the 3dose syringe, the company’s new instrument for use in botulinum toxin injections. The product was launched at the AMWC 2014 meeting, Monaco, and is expected to be commercially available in May 2014.

The 3dose syringe has an adjustable clicker system, which provides a precise dose injection of 0.025ml, 0.04ml or 0.05ml. TSK claim that this precision means that there is no risk of over- or under-injection, allowing practitioners to administer small doses accurately and consistently. Each syringe comes packed with two 33G 13mm needles, which are 22% thinner than a standard 30G needle and aim to reduce discomfort for patients.

Aesthetics | May 2014

non-surgical cosmetic procedures were carried out in the US in 2013

More than five billion dollars was spent on non-surgical procedures in the US in 2013 The American Society for Aesthetic Plastic Surgery (ASAPS)

One in 20 patients who undergo nonsurgical treatments self-administer Transform Cosmetic Surgery Group, Botox Survey

Over 14% of people surveyed do not want anyone to know they have had line and wrinkle smoothing treatments Transform Cosmetic Surgery Group, UK Wrinkle Smoothing Survey

40% of men have noticeable hair loss by age 35 The Belgravia Centre Non-surgical facial rejuvenation procedures are the fastest growing segment in cosmetics, up almost 6% annually Iovera Beauty, London Beauty Survey

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

Radiofrequency

Syneron’s Sublative technology gains CE mark clearance for stretch marks and acne scars Syneron Medical Ltd has announced that its Sublative technology has received a CE mark, clearing it for the treatment of stretch marks and acne scarring. Promoted as an anti-ageing treatment, Sublative uses fractionated bi-polar radiofrequency to generate deep dermal heating and elicit a woundhealing response, with the aim of tightening and rejuvenating the skin.

With stretch marks affecting an estimated 95% of women and up to 85% of adolescents suffering from acne, the company expects that the new treatment protocols, which will be available on all of the Sublative compatible systems, will expand the appeal of the technology to a wider market.

“We have received very positive physician and patient feedback on the Sublative technology since its introduction in 2009,” said Amit Meridor, CEO of Syneron. “This patented fractional bi-polar radiofrequency technology delivers excellent outcomes with little to no downtime and is a safe and more effective treatment alternative for all skin tones.”

The typical Sublative protocol consists of three to five treatments, spaced four to six weeks apart.

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Injectables

Galderma launches new syringes Galderma has launched two new syringe delivery systems for their Restylane range. Launched at the Anti-Ageing Medicine World Congress in April, the Restylane Filler Syringe and Restylane SkinBoosters Syringe have been designed with the aim of offering greater precision, comfort and control as well as incorporating new safety measures.

The new Restylane Filler Syringe has been designed in consultation with practitioners and has a new grip and thumb rest to provide greater comfort. Safety measures include a new tamper-proof seal and a Luer lock. The Restylane SkinBoosters Syringe uses the SmartClick system to provide built-in dosage control, dispensing ~10 μL microdroplets.

The idea is to allow practitioners to focus on technique, rather than the amount being injected. The feature can also be turned off if required. The Restylane SkinBoosters Syringe also incorporates the same safety precautions as the Restylane Filler Syringe. Both syringes are compatible with thin walled needles and pix’L flexible microcannulas.

Hair removal

Soprano ICE introduces diode laser alexandrite technology The Soprano ICE hair removal system has now expanded its usage to offer removal for fine hair that aims to be pain-free, using a diode laser based on an alexandrite wavelength.

The system, created by ABC Lasers, incorporates a wavelength of 755nm, to provide better energy absorption by the melanin chromophore. Soprano ICE cools the skin with an encircled sapphire tip, preventing surface burns while maintaining heat within the dermis. This high fluency delivery system aims to provide a comfortable and fast treatment with improved results for light-coloured and thin hair.

Soprano ICE now also has a lighter and improved ergonomic design, meaning it can be used to treat smaller and difficult-to-target areas such as the eyebrows, nose and ears.

This provides a more comfortable treatment experience for the practitioner, as well as the patient.

The manufacturers claim that the new, more powerful energy absorption Aesthetics | May 2014

combined with contact cooling, treatment coverage, comfort and low maintenance of the solid-state laser provides a solution for a wide range of hair types and colours using one platform.

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Skin tightening

Zeltiq launches new CoolSmooth head Zeltiq Aesthetics Inc has launched its CoolSmooth applicator for noninvasive fat reduction on the outer thighs. The latest addition to the CoolSculpting range of applicators, CoolSmooth is to be used in conjunction with the CoolFit applicator, designed to treat the inner thigh, now allowing practitioners to treat the entire thigh area.

“The introduction of the CoolSmooth applicator provides a new solution to individuals who struggle to reduce fat in the thigh area, a difficult-to-treat part of the body,” said Mark Foley, president and chief executive officer of Zeltiq.

“Through our newest applicator, we are excited by the opportunity to expand our current offerings to physicians and, ultimately, the individuals who may benefit from our unique technology. Results achieved with CoolSmooth add to the growing body of evidence demonstrating the safety, efficacy and long-lasting results of the CoolSculpting procedure.”

Study demonstrates single treatment tightening effect with ThermiAesthetics device Temperature controlled radiofrequency system ThermiRF has demonstrated effective skin tightening in a single treatment, according to a study published in the Journal of Drugs in Dermatology. The 18-person study, which was carried out by board-certified dermatologist Dr Douglas Key, showed statistically significant results in reducing skin laxity on the face and neck after just one treatment.

Patients reported no pain during or after the ThermiTight procedure, and any redness or swelling subsided within a few hours. No pigmentary alterations or scarring occurred during the trial.

“This is the future of skin tightening,” said Dr. Key. “Previous radiofrequency devices have required multiple treatments and offered unpredictable results. ThermiRF delivers radiofrequency heat energy in conjunction with Thermal Image Monitoring. This advanced infrared

imaging allows medical professionals to see and direct heat at all three layers of the skin, achieving optimal skin tightening results in a single treatment.”

As a safety measure, the ThermiRF device contains an auto shut off feature that is triggered when temperatures rise above predetermined levels. A number of further studies are planned and underway to demonstrate the use of ThermiRF for conditions such as axillary hyperhidrosis, cellulite, snoring and postchild-bearing vaginal laxity.

Botulinum toxin

Johnson & Johnson to terminate neurotoxin programme Pharma giant Johnson & Johnson has revealed that it will discontinue developments of PurTox, a neurotoxin widely referred to as a potential rival for Allergan’s Botox.

Johnson & Johnson acquired PurTox in 2009, following the acquisition of breast implant maker, Mentor. The company has now expressed a desire to focus on its core breast

surgery business. The termination of the PurTox programme will lead to a small number of job losses in the US. “We are winding down the neurotoxin program in a responsible manner,” said Tom Sanford, vice president of communications at Johnson & Johnson.

“Regrettably, this involves the elimination of a small number of positions in the United States. Mentor has long been a leader in the

breast surgery market, both in augmentation and reconstruction, and we are committed to maintaining our leadership,” he said.

“Focusing on our core breast surgery business will allow us to expand successful programs, as well as increase our investments to develop additional new products to meet the needs of patients and the surgeons who care for them.”

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News in Brief

Radiofrequency

PelleFirm receives FDA clearance for tissue heating and cellulite reduction The new PelleFirm RF body treatment system has received FDA 510(K) clearance for tissue heating and for temporary reduction in the appearance of cellulite. Its distributor Ellman International, Inc. has also received FDA clearance to market the system. The PelleFirm is CE marked for body skin tightening and cellulite reduction. The system is a non-invasive radiofrequency treatment for the body, which aims to produce firmer skin and impermanent reduction in the appearance of cellulite. PelleFirm has two large diameter handpieces, which elevate tissue temperature up to 45°C, and mechanical massage heads to treat areas with cellulite, and particularly focuses on problem zones such as the abdomen, arms, thighs and buttocks.

“We have been working with physicians around the world to develop PelleFirm and are excited to bring this innovative RF body treatment system to market,” said Ellman International CEO and president Frank D’Amelio. “It addresses the need for an effective, non-invasive body solution. With two different sized handpieces, PelleFirm can address almost every area of the body.” Dermatologist Josephine Hernandez said, “Many of my patients request treatment for sagging skin in their arms, hands, abdomen, thighs and gluteal area. The results with the PelleFirm system are outstanding and superior to any of the many body contouring or skin tightening devices we have used in our practice. I have seen PelleFirm results in as little as a few treatments. We are very satisfied users.”

Research

C-Tetra found to be effective against photo-ageing An independent study carried out by researchers at Prefectural Hiroshima University, Japan, has established that Tetrahexadecyl Ascorbate, otherwise known as C-Tetra, is more effective at preventing photo-ageing than standard vitamin C. C-Tetra, a vitamin C derivative used in the Medik8 cosmeceutical range, was also found to increase collagen synthesis.

It was found that by administering 10-50 microM of Tetrahexadecyl Ascorbate to human fibroblasts and then irradiating them with UVA, the cells were protected from UV damage. The tests used several markers to evaluate the performance of C-Tetra, including the successful repression of MMPs and the repression of p53 gene expression, a hallmark of UVinduced damage.

Pharmacologist and Medik8 founder Elliot Isaacs, said, “We are extremely satisfied with the conclusions of this respected Japanese scientific group whose findings corroborate and in fact exceed our own research data into the activity of Tetrahexadecyl Ascorbate.”

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Aesthetics | May 2014

Murad reveal new Essential-C Sun Balm This month Murad will launch its portable sun stick, Essential-C Balm Broad Spectrum SPF 35 PA+++.

The balm provides protection against UVA and UVB rays and incorporates the use of the branded MuraSol Antioxidant Defence: a blend of antioxidants designed to penetrate the skin to create a protective barrier of encapsulated free radical neutralisers.

Dr Carl Thornfeldt to present Epionce workshop Dr Carl Thornfeldt, CEO and founder of Episciences Inc., will present a workshop at this year’s FACE conference. He will explain the science behind the Epionce line, offer practical demonstrations and launch the Epionce MelanoLyte Pigment Perfecting Serum to the European market. “I am pleased to have the opportunity to share some pearls from my years of clinical practice and research with the attendees,” said Dr Thornfeldt. The workshop will take place on June 21.

Aneva Nutraceuticals introduce new antiageing skin drink Aneva Nutraceuticals have launched new skin health drink Aneva Derma. The product’s formula includes bio absorbable collagen and hyaluronic acids, promoting collagen synthesis and skin health. Dr Diane Keith, based in Harley Street said, “Aneva Derma differs from other collagen drinks by addressing crosslinking problems with antioxidants. It also provides exceptional collagen and hydration skin support due to the high level of hyaluronic acid and hydrolysed collagen peptides.”

Cambridge Biotech Ltd launch Uma Jeunesse Ultra Cambridge Medical Aesthetics/Cambridge Biotech Ltd have announced the launch of Uma Jeunesse Ultra, the latest addition to the Uma Jeunesse range of dermal fillers. Uma Jeunesse dermal fillers are monophasic, hyaluronic acid (HA)based and cross-linked with butanediol diglycidyl ether (BDDE). Uma Jeunesse Ultra also contains lidocaine, which aims to make the procedure more comfortable for patients without the need for topical anaesthesia.

Medik8 launch new skin ageing kit Medik8 has launched a new Skin Ageing Essential Kit, aimed at women and men aged 40+. The kit is suitable for normal to dry skin and contains both Vitamin C and Vitamin A skin serums and moisturisers for day and night. The edited collection treats skin ageing concerns including lines and wrinkles, dull complexion, uneven skin tone and sun damage.

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Insider On the Scene

Enerjet demonstration, London

Dr Tapan Patel played host to an intimate presentation on Enerjet on Monday March 24 at 102 Harley Street, speaking to an audience of doctors and aesthetic practitioners, including Apprentice winner Dr Leah Totton. A dermal remodelling system that pneumatically introduces a jet of Hyaluronic Acid (HA), Enerjet works to remodel skin, repair scars and lift facial tissue. Described as a non-surgical facelift using HA, Enerjet is a skin remodelling treatment in which strong, controlled volumetric injury induces collagen regeneration. As the first practitioner to introduce this treatment to the UK, Dr Patel shared his experience of the system before performing live demonstrations. This saw Dr Patel administer powerful pneumatic injections into the model’s skin in order to create intentional wounds, triggering a natural healing process that generates production of new collagen, skin thickening and tightening.

ARTAS Workshop, Manchester

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The Future of Harley Street, London A live debate on the future of the famous medical destination Harley Street took place on March 27, at the Royal Society of Medicine.

The event was host to over 200 attendees, including Harley Street doctors and surgeons, practice managers, property owners and advisors, patients and health journalists, and was opened by Keith Pollard, managing director of harleystreet.com.

The debate, chaired by medical journalist and former ITV News medical correspondent Sue Saville, allowed attendees to vote on a number of issues. The results of the votes included that 75% believe there is additional potential in the Harley Street brand that is yet to be exploited, whilst 50% believe that Harley Street is the place to go for the best doctors, dentists and healthcare professionals. Other issues discussed included the lack of representation of the UK and Harley Street at international medical tourism events, and lack of central marketing support promoting UK clinics to those overseas who wish to visit the UK for aesthetic treatment. Pollard said, “As a result of Thursday’s events, we already have a number of people interested in joining a steering committee, who will look at forming a formal Harley Street Partnership, to maximise the Harley Street brand both in this country and overseas.”

Attendee Darren Rowe, managing director at Harley Street Cancer Concierge, said, “I was keen to attend this event as I felt it was important to support what I consider to be a very worthwhile initiative. We’ve known for some time that Harley Street as a brand isn’t keeping up with other parts of the world and the data presented at the meeting highlighted this,” he said. “The fragmented nature of Harley Street can make it quite difficult for patients, and with no cohesive marketing plan, our voice on the international stage is drowned out. I was encouraged that the survey indicated a desire to do something collectively. I hope we can maintain momentum and start to work towards a common goal of increasing patient volumes and providing an outstanding level of customer service to go with the outstanding level of patient care.”

Sculptra Open Day, London

Europe’s only live robotic hair transplant surgery workshop took place at the Farjo Hair Institute on Friday 28 and Saturday 29 March.

Each day included a morning seminar followed by a live demonstration of new technology, the ARTAS Robotic System.

The system uses a robotic arm to identify follicles for harvest and extract the donor hairs and surrounding tissue. Performing up to 1,000 follicular extractions per hour, the ARTAS Robotic System uses advanced imaging technology to locate the densest areas of donor hair before harvesting an evenly distributed selection of donor grafts.

A Sculptra open day was held at The Cadogan Clinic in London on March 27, to demonstrate the effectiveness of the CanuSculpt technique to guests. As part of the open day, consultant oculoplastic and aesthetic specialist, Dr Maryam Zamani, completed a full facial analysis on a model and treated half her face with Sculptra using the cannula technique.

Dr Maryam illustrated how this procedure leaves minimal or no marks, makes the procedure more comfortable for the patient and decreases the risk of bruising.

Sculptra aesthetic account manager Claire Williams said, “This type of exclusive open event with a small group of clients is a very effective way to demonstrate the benefits of Sculptra using the cannula technique. It was a great success with a high level of interest from all the guests.”

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Aesthetics | May 2014

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12th Anti-Aging Medicine World Congress On the 3 -5 April the annual AMWC meeting was held in Monaco.

We look back on the event and report on the Allergan Medical Institute eye symposium With delegates attending from over 120 countries, the 12th Anti-Aging Medicine World Congress was an opportunity for international peers and colleagues to learn from experts in their field and see the vast number of new products available. This year, the emphasis was on looking forward, with the congress’s overall concept labelled, ‘Be ready for the future’. Dr Chytra V Anand, a cosmetic dermatologist based in India, presented several sessions during the three days. She said of the event, “As faculty, what I love is that not only do I get to share my knowledge but I am also able to learn from other masters, which is very important in order to stay updated.”

The importance of expert collaboration to enhance learning was also highlighted by Dr Ravi Jain, who said, “I was privileged to be part of the Galderma symposium on achieving patient satisfaction, using optimised injection strategies with Dr Philip Levy and Dr Colette Carmansch from Switzerland.”

Dr Anand also emphasised the independent nature of the presentations as a key draw for practitioners looking for information on best practice, new products and clinical excellence; she said,, “I enjoy lecturing at this event as the organisers are keen on keeping the lectures devoid of commercialisation, and ask speakers to be open with their disclosures.” With more than 250 companies exhibiting over four floors, there was plenty of opportunity for delegates to speak to suppliers and distributors and find out more about exciting products and treatments being showcased. “I spent my time mainly looking at a few new machines as I am currently expanding my clinics”, said Dr Johanna Ward “I spoke with several leading dermatologists in France who use the Tri Wings LED system and they highly recommended it for the kind of dermatology work that I do.”

Delegates at the congress were provided with a comprehensive educational programme and a vast range of exhibitors, reflecting the congress’ focus on preparing practitioners to meet with and embrace the challenges of the ever-changing world of anti-ageing medicine. “It’s a good opportunity to understand what is currently trending in the rest of Europe and liaise with our European colleagues,” said chair of the British Association of Cosmetic Nurses Sharon Bennett. “I was particularly interested in the workshops on periorbital and perioral areas as this is so relevant to the type of patients I see in my clinic on a day-to-day basis, and who are always wanting to know what’s new.”

Editor Amanda Cameron reports on the Allergan symposium: “An eye for detail: a progressive approach to periorbital revitalisation” The Allergan Medical Institute symposium at AMWC, designed to both educate and entertain, comprised a full day programme with a mixture of talks, live demonstrations and debates, focused on the periorbital region. A panel of experts were in attendance to cover the topics of relevant anatomy, patient assessment, new clinical data and recommended injection technique.

Dr Koenraad De Boulle, chairing the day with Dr Lakhdar Belhaouari, introduced the symposium with insightful photography, demonstrating the role that the periorbital region has in conveying emotions and communicating feelings. This presentation highlighted the complexity of the area and thus its treatment.

The first formal session of the day saw plastic surgeon Mauricio De Maio emphasising the importance of patient assessment. Thorough consultation and assessment, he reminded us, allows the practitioner to make an informed decision as to the most appropriate treatment, or combination, for each patient. He advised that the strategy for periorbital treatment should be dependent on the analysis of a number of key anatomical issues including: skin excess; muscle laxity; cheek ptosis; skin laxity; volume loss and excess fat.

Dr De Maio then spoke in detail on patient perception and expectation, stating that patients will not be satisfied with just filling lines, as often the impact of these outcomes are too minor in terms of what observers (partners, friends) will notice.

His discussion also included an explanation of the stark differences between how a patient perceives their own face, and how a practitioner views the patient’s face.

Patients, he explained, tend to view their face in units (small areas) whereas the practitioner will consider the face in its entirety and get the ‘full picture’. His recommendation was for practitioners to discuss the patient’s face with them in facial thirds, either horizontally or vertically, as it is easier to take sections and look at minor details of the patient without the distraction of the full face.

Professor Hee-Jin Kim continued with an informative session on anatomy, focusing particularly on the need to study the anatomy of the nerves and vessels, highlighting the delicate nature of the skin around the eye and its anatomical complexity. In his presentation on treating the tear trough, Dr Hervé Raspaldo concurred with this, emphasising that in his opinion, the tear trough is an area for experienced injectors only, and that it took him 20 years before he felt confident enough to inject in that region. Delegates were then shown the new app from the Allergan Medical Institute, which allows practitioners to analyse exactly where they are injecting whilst performing a procedure. This technology further underlined the importance of a firm and detailed grasp of anatomy when performing aesthetic treatments, a recurrent theme of the symposium, along with the role that technology can play in assisting practitioners to achieve increasingly precise and aesthetically pleasing results. The symposium provided a wealth of learning for attendees, and not only demonstrated advanced injection techniques in the periorbital area but also provided delegates with expert and useful advice that could be easily applied elsewhere in medical aesthetic practice.

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American Academy of Dermatology Annual Meeting Dr Nick Lowe, Aesthetics editorial advisory board member, professor of dermatology and president of British Cosmetic Dermatology Group, discusses the highlights of the recent AAD meeting With more than 350 sessions and attracting over 16,000 delegates and exhibitors, the 72nd Annual Meeting of the American Academy of Dermatology, which was held in Denver Colorado between March 21 and 25, is the largest and most prestigious dermatology conference in the world.

This was the 30th consecutive AAD meeting I have attended. This year, I was invited by the Academy to be guest presenter at two sessions on injectables and facial rejuvenation.

The protocol I described and demonstrated was the use of different volumising fillers and neurotoxins for synergistic improvement of the facial lines and ageing.

This is achieved by using hyaluronic fillers such as Voluma or SubQ as lifting and filling injections, administered to the zygomatic area and mid-face.

To correct volume loss caused by age, weight loss or post-acne scarring, Sculptra can be administered to the mid face following these hyaluronic filler injections.

Combining Sculptra with hyaluronic fillers creates the optimum lifting and filling effect, and one that improves over time and with subsequent Sculptra treatments.

Some patients also benefit from injection of botulinum toxin to the depressor angulae oris, the jawline and platysma, with small doses of neurotoxins. During the live demonstrations, a simultaneous cadaver dissection showed the relevant anatomy, and key areas to avoid or be cautious with, such as the periocular nasal and lower facial areas, because of their vascularity.

Serious complications of injecting filler into the blood vessels and causing blindness or skin necrosis when treating these areas with fillers were discussed at length. The consensus view of the dermatologists was that injections into these areas should be classed as high risk interventional procedures and should only be administered by specialist physicians with additional training. If signs of ischemia appear, such as pain or blanching, we can immediately inject Hyalase to dissolve the filler, apply nitroglycerin paste to the affected area and consider other treatments to increase vascularity, such as oral niacinamide. Any visual disturbances should be treated as an ophthalmologic emergency.

There were interesting sessions on body contouring. Systems such as Venus Freeze, Venus Legacy and ThermiRF administer radiofrequency plus magnetic Dr Nick Lowe is president of the BCDG, professor of dermatology and a consultant dermatologist with over 30 years of experience who practises in London and California

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Aesthetics | May 2014

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resonance and can achieve a steady state deep tissue temperature of 48-50°C, providing collagen tightening, and refining body contour. For cryolipolysis, the Zeltiq system was considered at present the most reliable and fully tested system. Fat necrosis has been described with other systems. The key to success for all body contouring treatments is to be realistic in patient selection and evaluation. For example, it may be necessary to suggest weight loss before treatment, and patients with significant excess skin should be referred for abdominoplasty if they desire. Cynosure’s new Nd:YAG vascular laser presented an alternative treatment for facial redness. Unlike pulsed dye lasers, it did not result in several days of bruising, and patchy, irregular improvement.

There were interesting presentations on combination scar treatments, showing how needle-driven RF systems such as Intracel or fractional CO2 lasers deliver microscopic channels into hypertrophic or keloid scars, reducing vascular supply and scar density. Megapotent cortisone creams can then be applied, which penetrate deeper into the scar tissue, reducing scar thickness. Patients can also apply Haelan tape overnight to the scars. Any scar erythema can then be reduced with vascular lasers. Several treatment sessions may be required depending on scar size and density. Recent topical treatments were also discussed for rosacea; in addition to Galderma’s recent Mirvaso (Brimonidine gel) for facial redness, which has been available in the USA for several months, there was an interesting new treatment of rosacea papules and pustules with Ivermectin (a drug used to treat headlice) delivered as a gel. The mechanism of action is not known but may involve a reduction in dermadex population in rosacea lesions.

One of the most exciting products discussed at the meeting was a new biologic drug developed for adult atopic eczema. Patients treated with Dupilumab, an antibody drug targeting the cytokine interleukin 4, saw disease activity decline significantly. About 85% of patients treated with Dupilumab had at least 50% improvement in Eczema Activity and Severity Index (EASI-50) after 12 weeks, compared with 35% of the placebo-treated patients. We have several active biologic drugs for psoriasis but Dupilumab is a first to be active in atopic eczema.

AAD also named its contact allergens of the year, which are causing frequent contact dermatitis. This year one was benzophenone-3, the sunscreen ingredient better known as Oxybenzone. The other key allergen discussed was methylisothiazolinone (MI), a widely used preservative in shampoos; particularly when used every day, it can be a significant contributor to facial and neck dermatitis. Attending and listening to the presentations reminded me of the vital role dermatologists and skin specialists hold as ‘dermatology detective’; identifying causative factors in skin diseases and being the specialist for all diseases and treatments of skin, hair and nails, as well as having the optimum knowledge for aesthetic

treatments. This was an excellent conference from which delegates learned much new information and I brought back to the UK many ideas to refine our dermatology and aesthetic practices at the Cranley Clinic.

Wendy Lewis discusses the role of professional skin care at the American Academy of Dermatology Conference According to the IMCAS Tribune, the global market for cosmeceuticals (referred to by the French as cosmeceutiques or cosmetique active) is valued at $1.05 billion for 2014 and is projected to grow to $1.38 billion by 2018 (imcas.org). This represents an average annual growth rate of +7.4%. Unsurprisingly, the principal zones, in descending order, were the US, Asia, Latin America, and Europe. Nowhere was this trend more apparent than at the 72nd annual American Academy of Dermatology Conference where, although the anti-ageing category captured the lion’s share of attention, acne, scars, stretchmarks, sensitive skin, sun protection, and pigmentation solutions all had a strong presence.

Elizabeth Arden entered the physician channel with the Elizabeth Arden Rx collection featuring Triple Protection Factor Broad Spectrum Sunscreen SPF 50+, based on a combination of of three protective and restorative ingredients - DNA Enzyme Complex, Antioxidant Complex and broad-spectrum SPF 50+ sun protection in a moisturising base. Another new launch into the physician distributed skincare arena was GMC Medical, from G.M.Collin, a 25-year-old Montreal based spa brand. This comprehensive line of a dozen products addresses acne, skin ageing, sun damage, and pre- and post-medical aesthetic procedures. L’Oreal put forth new entries from some of its active cosmetics brands, while SkinCeuticals captured attention by featuring an impressive total of 13 scientific publications, and the debut of Resveratrol B E Antioxidant Night Concentrate. La Roche Posay showcased the new Anthelios 60 Ultra Light Lotion Spray with Cell-OX Shield, which boasts new micro shield technology to protect skin during intense UV conditions and in water. Also launched at the meeting was NeoStrata’s new Skin Active Triple Firming Neck Cream, which targets the neck and décolleté areas with Swiss Apple Stem Cell Extract and an array of proprietary ingredients. Exuviance Age Reverse HydraFirm, a luxurious cream that targets the visible signs of ageing and replenishes optimal hydration levels, was on display boasting a triple firming complex of patented Bionic, NeoGlucosamine and Matrixyl Peptides to plump and fill skin. The Canadian giant Valeant Pharmaceuticals International presented its new Neotensil daily under eye reshaping procedure, available through Obagi Medical and sold in clinics.

Finally, pigmentation problems always take centre stage at the AAD and this year was no different. ZO Skin Health, Inc., from Dr. Zein Obagi, introduced two new GSR Systems, comprehensive home care kits designed for normal to dry and normal to oily skin types, as well as two new specialised pigmentation treatment programs, ZO Multi-Therapy Hydroquinone System and ZO Non-Hydroquinone Hyperpigmentation System.

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

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Suzi Lewis-Barned speaks to medical practitioners regarding the fat loss and skin tightening treatments they use in combination at their clinics

Body contouring for the summer -choosing the winning combination Body contouring is an increasingly popular market among a wide group of male and female patients seeking treatment for a variety of conditions, including those resistant to exercise and diet regimens.

Although as Esther Fieldgrass, founder and CEO at EF Medispa explains, treatments typically appeal to women aged 25 to 65, the male market is also now reported to be growing; gynaecomastia treatment increased by 24% and male liposuction was up 28% last year, according to the British Association of Aesthetic Plastic Surgeons’ (BAAPS) annual audit for 2013.

Partly driven by the visible success of treatment, Dr Andrew Weber, medical director at Bodyvie Clinics, feels the popularity of this market is likely to be due to the pressure many women feel after browsing the content of popular magazines.

“People see pictures of other women and they feel they must have that look – there’s a sense that it’s easily achievable for them too. Of course, some of the time, it isn’t,” he says. Jill Zander, owner of the Jill Zander Skin Rejuvenation Clinic, has also noticed considerable growth in the market, as well as the increasing availability of new devices to serve this demand. She explains, “Demand is increasing tremendously and will continue to grow – we are investing more than ever in new devices and, without doubt, everyone who offers fat loss treatments should also offer skin tightening, either through a different device or in combination devices.”

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People visit cosmetic clinics for treatments that target a range of problems: loose skin that needs tightening or firming; ‘stubborn’ areas of fat including around the abdomen; ‘bingo wings’; fat thighs and/or buttocks.

And, according to Jill Zander, a key patient group is younger women looking for anticellulite treatment.

What treatments are combined?

According to Dr Grant Hamlet, founder and director at You by Design cosmetic surgery, combination therapies are showing “true promise” although different combinations need to be used depending on the nature of the problem. Esther Fieldgrass of EF Medispa explains, “We put specific treatments together because they will enhance the texture of the skin as well as the performance of the treatment. As an example, after Vaser LipoSelection we will use manual lymphatic drainage to help with the healing process of the body by using the massage to stimulate any particular fatty areas that we want to get rid of. If there is a deep pocket of fat we may use carboxytherapy (carbon dioxide therapy) to pump blood and oxygen into that area to remove any fatty deposits.”

Dr Martyn King, co-owner at the Cosmedic Skin Clinic and medical director of the 3D-lipolite program, uses the 3D-lipo machine, a multi-platform device, to combine a range of treatments that will vary according to the client’s expectations, gender and areas of concern. He explains, “For slimmer clients who are just concerned about a Aesthetics | May 2014

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particular area (such as ‘muffin top’, inner thighs, or upper arms) then cryolipolysis works well. For all over body contouring we tend to use a combination of all treatments over several sessions and cellulite is often treated by a combination of radiofrequency and dermology.” He adds, “For patients who are most interested in total weight loss, we would combine weekly treatments with a whole diet, exercise and wellbeing programme (3D-lipolite) using meal replacement supplements and biometric monitoring.” These treatments are normally offered over a course of eight sessions, starting with cavitation, which normally gives quick results, and combined with radiofrequency during weekly sessions.

There may also be one or two treatments with cryolipolysis on specific areas and most courses are completed with dermology.

Dr King has noticed good early results using cavitation, including improved body measurements, with the results of cryolipolysis tending to show after about eight weeks.

Zander says her clinic often combines treatments for cellulite, such as Lipotripsy acoustic wave followed by Ballancer treatment for lymphatic drainage. Lipotripsy works as cellulite calcified deposits form around fat cells, which prevent fat being released; the acoustic wave shatters the fat cells so the fat can escape. As an alternative, her clinic might use the FDA approved, non-invasive, Cynosure SmoothShapes system, which combines laser (915nm) and light (650nm) energy with a vacuum and mechanical massage rollers, which allow the expressed fat and fluids to be filtered out of the body via the lymphatic system.

Additionally, Zander uses BTL’s Vanquish,

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BTL Vanquish - Before treatment

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BTL Vanquish - After treatment

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the other is less intensive, which has implications for the clinic and staff.”

Treatment protocols

BTL Vanquish

which she says is particularly effective for treatment of the abdomen. “Vanquish seems to be a forerunner in the field,” she says. “The technology is very new and powerful, and you have to be careful when monitoring the temperature the patient’s skin reaches, which must not exceed 42°C.” Dr Ravi Jain, medical director and founder of Riverbanks Clinic, says that for about three years his clinic has used Med Contour. He explains, “This system combines ultrasound, lymphatic drainage and massage in one system. We’ve had very good results: fat reduction on the tummy and waistline, and cellulite improvement on the thighs. We offer this treatment once a week for six treatments.

Alongside Accent radiofrequency, Dr Weber uses the Endermolab endymology system, mesotherapy and injectable lipolysis, Aqualyx, in his clinic. “Endymology is a system of vacuum and rollers used for treating cellulite,” he says. “It also provides lymphatic drainage, which will speed up absorption of fat. The Aqualyx, the injectable that dissolves fat, also helps to speed up the absorption of fat, produce more skin tightening and tones the skin, and can also be used as a standalone. Mesotherapy can be used for creating volume.”

Dr Tracy Mountford, founder and medical director of the Cosmetic Skin Clinic deploys CoolSculpting in combination with Thermage CPT radiofrequency skin tightening. She stresses that before adopting any new treatments she waits to check how they have been performing in the market and also waits until they have been FDA approved as meeting safety and efficacy measures; “It’s great to have ‘new’, but as I have always maintained, ‘new’ does not always mean better,” she says.

Med Contour

22

For his patients, Dr Grant Hamlet uses VASER lipo, in conjunction with VelaShape, which combines bi-polar radiofrequency (RF) and infrared light energy with a vacuum and mechanical massage. VASER lipo targets unwanted fat using ultrasonic technology whilst preserving important tissues such as nerves, blood vessels and collagen and helps with particularly stubborn areas that will not shift through diet or exercise and can improve overall shape.

What are the benefits of combining treatments?

Many practitioners are confident in the use of combination therapy to achieve optimum results; Dr King says, “I would certainly recommend a combination approach to achieve the best results,” and Dr Hamlet explains, “For example, VelaShape may improve cellulite from a little to a lot, but adding other technologies and techniques, or even a surgical procedure, is definitely going to improve your final result. We are finding that combination treatments also increase the longevity of results.”

The reported overall success rates of combination treatments tend to be higher with women because they effectively reduce their peripheral fat, whereas men are more likely to have problems with visceral fat, which cannot be treated, even with combined therapies. As Dr King explains, “One size does not fit all; clients are different and treatment areas cannot all be treated with the same technology,” an approach endorsed by other practitioners who confirmed the need to ‘mix and match’.

Esther Fieldgrass adds that ensuring patient comfort whilst achieving the best possible end result is key when conducting combination treatments; “We want something that creates the best effects with little down time,” she says.

The practical considerations are also important as Dr Claire Oliver, medical director at Air Aesthetics Clinic, explains; “The Exilis treatment can be used to target areas of fat that another applicator may not be able to fit,” she says. “Furthermore, one treatment is resource intensive whilst Aesthetics | May 2014

For Esther Fieldgrass, the key is to see how a patient is responding to treatment and to adjust the protocol accordingly to achieve the optimal result. As she explains, “Body contouring is an art and practice is required to see where [practitioners] are going to get the best results.” Dr Hamlet stresses the importance of careful patient consultation and monitoring to this effect.

“We treat what needs to be treated,” he says. This approach is also adopted at Dr Weber’s clinic, as he explains, “Some people respond better than others to specific treatments; it’s a question of finding a treatment, or combination of treatments, that are effective on that particular person.

As a rule of thumb you can assume a treatment is going to work in 95% of patients but the other 5% are not going to respond very well – so then it’s a question of having something as an alternative.”

Jill Zander suggests six to 10 Lipotripsy treatments followed by Ballancer, then mixing in SmoothShapes but, as she explains, it’s never a case of ‘one size fits all’. “What we try to do is to individualise and personalise packages,” she says.

“We also offer packages at different price points – this is a great way to encourage clients to commit to completing a full course of treatment.” Dr King’s experience has led him to believe that radiofrequency treatment is best for skin tightening, especially of the lower abdomen postpregnancy. He explains that cavitation works best for larger areas of fatty tissue, and reaches greater depths than radiofrequency while cryolipolysis can destroy 25-30% of fat cells, although the results do not appear quickly. This is why his treatment protocol often begins with cavitation, for which the results are more or less instantaneous.

What are the difficulties and limitations of combination therapies?

Dr King suggests that whilst most patients are suitable for combination treatments, the normal exceptions apply, including: those with unrealistic expectations (for example liposuction-style results), people in poor health, pregnant women and those breastfeeding, patients fitted with a pacemaker and those with uncontrolled diabetes and taking immunosuppressants.

Dr Oliver adds that she will not offer

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treatment to people who are more than two stone above their ideal body weight.

Although there may be a number of risks associated with using treatments in combination, Dr Ravi Jain advises that the main consideration is to check for sensation; “A lot of these treatments can cause temporary altered sensation to the skin so we need to know a patient has normal sensation in the skin before we do any treatment, let alone mix treatments,” he says. “If they can’t feel pain, you may be doing them harm; if there is bruising from treatment you don’t want to do another treatment until that has settled. CoolTech is a very effective treatment, but if you try to repeat it too soon before the full effects of the first treatment have taken effect you could end up with over-correction. It’s important to make sure you do not overtreat people.”

CoolTech

Advice for practitioners wishing to invest in body contouring devices Dr Ravi Jain highlights the importance of auditing results

Aesthetics Journal

on patient satisfaction to help improve the services you offer.

“Each practice, no matter what technology they have, needs to audit their results and be able to communicate satisfaction levels to their patients,” he says.

“If satisfaction levels are low, use a different type of technology to change that, we need to be above 80%. You have to think about the patient’s point of view before the clinic’s; if you get that right your business will be taken care of quite nicely.” Dr Claire Oliver agrees that understanding your patients’ needs is the key to success, as well as being aware of financial investments that you are making. “Understand and identify what your clients require and choose your system from there,” she says.

“Be mindful that investment in technologies requires a commitment to marketing to ensure the targeted payback of the system is achieved.”

Dr Weber also agrees that practitioners should be conscious of the investments they make in devices. “Investing in devices is a big financial commitment; with lasers you’re looking at close to £100,000 with some. Endymology is still running at about £30,000 and radiofrequency is around £50,000. You need to get the most out of it and make certain that the device is going

Device selection With no shortage of choice within the body contouring device market, our contributors were invited to highlight the main factors they had considered when selecting devices for their clinics.

Esther Fieldgrass’s decision factors included: published research results; the existence of good back-up support for any equipment procured; high quality continuous training for the clinic’s therapists; and actual clinical results from an in-clinic two-month trial period.

Dr Martyn King took patient conversion rates into account when it became apparent that a combination approach was far more popular with his patients.

Dr Tracy Mountford spoke to colleagues in the profession that she felt she could trust, as well as checking the device was FDA approved.

Dr Grant Hamlet considered whether or not a device would complement the other treatments already offered in his practice and whether any future modifications were planned that would help his patients, (e.g. a larger handpiece for the VelaShape III that can be used to treat cellulite).

Dr Claire Oliver highlighted the significance of ‘no downtime’, as well as the need to select a proven technology that was safe, effective, approved and that could be profitably deployed.

Dr Andrew Weber placed greater reliance on the objective feedback from colleagues and the results of clinical studies than on the pitch of device sales staff.

He also took account of the nature of the treatment and whether it was likely to be pleasant and well tolerated by his patients.

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to stand the test of time, so try to do your research.” He explains that trialling products and gathering feedback from other users is a good way to test the effectiveness of devices before making an investment. Dr Jain adds that it’s important to keep up-todate with technological advancements; “If a clinic’s technology is over four or five years old, the chances are they need to improve it,” he says.

In terms of what technology to opt for, practitioners have differing opinions. “I feel the combination of radiofrequency and ultrasound will be the future of body contouring,” says Jill Zander. However, Dr Ravi Jain believes everyone should be looking into cryo technology. “A good cryo system means no treatment should be required more than once every three months or once every two months,” he explains. “We’ve found it to be a one-off treatment in most of our patients.”

He also finds benefits in designing your treatment package specifically for each patient. “When we have sold courses of three treatments, patients have had treatment in different areas, as there was no need to repeat in the same area,” Dr Jain explains. “So now, depending on how big the patient is, we adjust our package offers. If they have two fistfuls of fat, we are confident that they will only need one treatment. If they have a whole tummy [of fat] they may need two hours, which is two sessions.” He also explains that you should design your treatment packages to achieve optimum efficiency; “Don’t combine one weekly treatment with another weekly treatment as the patient will be with you forever; instead, combine a weekly, perhaps with a one-off treatment.” It is clear that there are multiple different combinations of treatments available on the market that appear effective and choosing the right combination requires careful analysis against a range of selection criteria determined by your clinic’s particular priorities. Ultimately, success will be about choosing the right combination for your patient group that provides them with the optimum results.

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Lip Augmentation: an art and a science Sharon King discusses the anatomy and physiology of the lower face in relation to lips

INTRODUCTION Lips are viewed by many as the most beautiful feature of the face.

Aesthetically, they provide a focal point of beauty and, functionally, they are part of the apparatus of speech in addition to providing a visual display of varied human emotions. Patients often have a clear idea of what look they want before seeking treatment of the lips with dermal fillers, although this may not always be ideal. Patients who want to look like a favourite celebrity or those asking to look significantly younger pose a challenge to any practitioner as the shape of the lip alters with age and lip volume naturally decreases. Critical changes in the perioral area can include vertical rhytids, increased prominence of nasolabial folds (the crease that runs from nose to the corner of the mouth), ptosis of the oral commissures (sagging of lines from the corners of the mouth), thinning of the lips, and flattening of the upper lip with less definition of the Cupid’s bow.1 Rejuvenation of the lips is a commonly requested and frequently performed procedure with numerous strategies available to practitioners. Common approaches include adding volume to the body of the lips or accentuating the vermillion border (lipline) usually through the injection of dermal fillers or enhancement of the lip line using semipermanent makeup. Volume is added to create a more protruding and pouty lip, based on the fundamental belief that volume loss is a significant part of the ageing process.

ASSESSMENT AND MEASUREMENT Figure 1 Before proceeding with lip enhancement there are a few basic rules that should be considered. The Ancient Greeks are accredited with applying the ‘Golden Ratio’, with canons dictating that the lower lip should be 1.614 times as thick as the upper lip and (Figure 1) Copyright that the upper lip should protrude 2mm Cosmedic Skin Clinic 2014 further than the lower lip. We should observe these rules when looking at aesthetic enhancement to maintain a natural look and balance for the face.2 • In general the distance between both oral commissures should be equal to the distance between both mid pupil points if the four points were linked to form a square5 (Figure 1) • In Caucasians the proportion of the upper lip in relation to the lower lip should be 1 to 1.618mm (other ethnicities may have dimensions approaching 1 to 1).

• The height/volume of the upper lip should be between 0.65-0.85 that of the lower lip. Although men have relatively thinner upper lips than women, the ratio in both genders is similar.

• A well-shaped cupid’s bow with full philtral columns is the ideal.3 Several other methods have been used for evaluating lip position and its influence on facial profile. Among the most popularly referenced are Rickett’s ‘E’ line, Steiner’s ‘S’ line, Holdaway’s ‘H’ line, Burstone’s 26

‘B’ line and Sushner’s tissue nasion-chin line ‘S2’. (Figures 2-6) Naidu, while studying the consistency of the five reference lines, found that the S2 line, the E line and the B line had the smallest variation and therefore provided the best reference lines in judging the horizontal position of the lips in profile.4 Rickett’s line (Figure 2) shows the relationship of the lips in relation to the nose and chin. Although the upper lip should protrude slightly more than the lower lip in the vertical plane (1-3mm), for aesthetics there should be a 4mm space and 2mm space between the maximum protuberance of the upper and lower lips respectively. Burstone’s B line (Figure 5) joins the soft tissue sub nasally and the skin pogonion (with the mid point of the chin as its lower point of reference).

Sushner’s line (Figure 4) is drawn from the soft tissue nasion (the bridge of the nose) to the soft tissue pogonion. Holdaway’s line (Figure 6) is a line drawn from the soft tissue pogonion to the upper lip.5 Figure 2 Rickett’s E line

Figure 3 Steiner’s S line

Figure 5 Burstone’s B line

Figure 4 Sushner’s S2 line

Figure 6 Holdaway’s H line

The height of the upper face, mid face and lower face should be approximately equal to maintain symmetry. The lower face can be split into thirds, with the upper third being the sub nasal point to the mouth (ideally 1.1cm) and the lower two thirds, the mouth to the chin.

On projection the upper lip should project 1-2 mm forward from the lower lip.2 Some common errors that tend to lead to poor aesthetic results include: 1. Treating the vermillion border only, particularly in older patients 2. Placing too much product in the centre of the lips 3. Failing to achieve balance by over injecting the upper lip versus the lower lip or vice versa 4. Placing product throughout the lips without paying attention to defining features creating shapeless lips 5. Injecting too much dermal filler in general 6. Not retaining balance with the surrounding structures in the perioral area or the face in general.2 For example over projection of the lips, giving the all too familiar ‘trout pout’

Aesthetics | May 2014

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PHYSIOLOGY Before performing a lip augmentation using dermal fillers, it is essential to understand the anatomy. An unqualified or inexperienced injector is more likely to inject into the wrong tissue plane resulting in an unsatisfactory treatment or cause complications by injecting dermal filler into muscle or a

Aesthetics Journal

Aesthetics

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A good understanding of the anatomy of the lip and lower face, and the application of the fundamental rules of measurement, will also enable the practitioner to achieve a result that is aesthetically pleasing with less risk of the errors around 1.5cm inferior to the oral commissure. The facial artery then carries on to the nasolabial groove as the angular artery forming branches to the alar and anastomosing with the dorsal nasal artery.

(Figure 7) Š 2008 Encyclopedia Britannica, Inc.

neurovascular vessel. A good understanding of the anatomy of the lip and lower face, and the application of the fundamental rules of measurement, will also enable the practitioner to achieve a result that is aesthetically pleasing with less risk of the errors referred to above, thus providing a safer outcome and more effective treatment. If we were to dissect the tissue of the human lip, we would find that from superficial to deep, the layers of the upper and lower lips include the epidermis, subcutaneous tissue, orbicularis oris muscle fibres and mucosa. In cross section, the inferior and superior labial arteries run their course between orbicularis oris muscle fibres and the mucosa. Minor salivary glands are present within the lip itself but are absent from the vermillion border.

BLOOD SUPPLY Blood is supplied to both lips from the external carotid artery, which ascends from the facial artery in the neck over the middle of the mandible. The facial artery runs deep in the platysma, risorius and zygomaticus major and minor muscles and superficial to the buccinator and levator anguli oris where it branches into the inferior and superior labial arteries. The superior labial artery is located around 1cm above the oral commissure and the inferior labial artery (Figure 8) Copyright medicalartwork.co.uk

NERVE SUPPLY Motor nerve supply is provided via the seventh cranial nerve (Facial Nerve), whilst sensory function of the perioral region is provided via the maxillary and mandibular branches of the fifth cranial nerve (Trigeminal Nerve). The infraorbital nerve is a terminal branch of the maxillary nerve and exits via the infraorbital foramen, which is situated below the infraorbital rim. This usually lies in the mid-pupilliary line and it runs beneath the levator labii superiosis and superficial to the levator anguli oris to supply the lateral nasal sidewall, alar, columella, mid cheek and upper lip. The lower lip and the chin receive their sensory supply from branches of the mandibular nerve. A further branch of the mandibular nerve, the alveolar nerve travels through the body of the mandible and exits via the mental foramen, this is located below the apex of the second premolar with a variance of 6-10mm laterally. The nerve is located in the mucosa as it exits the foramen and can often be visible in the mucosa. Having taken in to consideration the nervous and venous supply to the lips and lower face, next we give consideration to the muscles of the lower face. A better understanding of the function of each of the various muscle groups and their intersection points in relation to the lips will give a more aesthetically pleasing result from the treatment.

MUSCLES Precise movement of the lips is essential for respiration, ingestion, phonation and facial expression. Thus, there are numerous muscles working together to produce the appropriate function. In order to describe the muscles acting on the lip, they have been divided below into three groups - Group I are muscles acting on the angle of the mouth at the modiolus, Group II attaching above the lip (elevators) and Group III acting on the lower lip (depressors).

Muscle Group I The modiolus is the area at each commissure, which serves as an attachment for several of the muscles of the lower and upper lip.

Within this group are the orbicularis oris, buccinator, levator anguli oris, depressor anguli oris, zygomaticus major and risorius muscles.

Orbicularis oris is a sphincter muscle, which causes the lips to purse and presses them against the teeth when contracted. Further muscle fibres of other muscles insert superficially in to orbicularis

28

Aesthetics | May 2014

oris. In cross section orbicularis oris is seen as a long vertical segment that curls out at the superior and inferior margins. Motor movement is provided by the buccal and marginal mandibular nerves. In the upper lip the fibres of orbicularis oris are few, sparing the central region, this gives rise to the philtral column, which is devoid of dermal attachment, and thus this gives rise to a concave depression or cupids bow.

Buccinator arises from the posterior alveolar process of the maxilla (Pterygomandibular raphe), a ligamentous band of the buccopharyngeal fascia and the body of the mandible it inserts into the modiolus. Its function is to press the cheek and lips against the teeth. Motor movement is supplied via the buccal branches of the facial nerve. The parotid duct joins the buccinator at the edge of the masseter muscle.

Levator anguli oris arises from the canine fossa of the maxilla beneath the infraorbital foreman and descends vertically and inserts in the modiolus with the function of elevating the oral commissure. The buccal and zygomatic branches of the facial nerve innervate this muscle and the facial artery and infraorbital nerve travel superficially on the surface of the muscle.

Depressor anguli oris (DAO) lies on the mandible below the canine and first premolar and inserts in to the modiolus. The marginal mandibular branch of the facial nerve supplies the DOA and enters the muscle deep. The DAO’s function is to depress the oral commissure, this brings the smile line down, a feature often associated with negative perceptions.

Risorius arises in the fascia over the parotid gland and passes horizontally forward superficial to the platysma and inserts into the skin at the angle of the mouth, drawing the commissure laterally to help produce a pleasing smile. The buccal branch of the facial nerve enters the muscle deep. This muscle helps to produce the smile that is unique to human emotions.

Zygomaticus Major originates in the cheek area of the zygomatic arch just anterior to the zygomaticotemporal suture line, passing over the buccintor and inserting into the modiolus.

Superiorly its fibres are deep and inferior and run superficially to the facial vessels and facial nerve. The zygomatic and buccal branches of the facial nerve supply zygomatic major and upon contraction, the corners of the mouth are lifted obliquely upwards and laterally, lifting in the corners of the mouth, resulting in a smile.

Muscle Group II A further group of muscles insert in to the upper lip. These are levator labii superioris, levator labii superioris alaeque nasi (Otto’s muscle) and zygomaticus minor.

Levator labii superioris is a quadrilateral muscle arising from the inferior orbital rim under orbicularis oculi and attached to the maxilla above the infraorbital foramen. Muscle fibres insert into the dermis of the upper lip skin and into the orbicularis oris muscle. The buccal branch of the facial nerve innervates this muscle and its action is to elevate the upper lip.

Levator labii superioris alaeque nasi, this muscle has the longest name of any muscle in the human body. It is sometimes referred to as ‘Otto’s muscle’ after an anatomist who argued that its anatomical name was too long. It is not to be confused with levator labii superioris; this completely separate muscle arises from the frontal process of the maxilla. Its interior fibres insert on to the lateral alar cartilage and the dermis of the upper lip and orbicularis oris. Again nerve innervation is provided by the

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buccal branch of the facial nerve and, upon contraction, levator labii superioris alaeque nasi dilates the nostril and elevates the upper lip into a snarl.

Zygomaticus Minor originates from the zygoma, seated below orbicularis oculi and laterally to the zygomaticomaxilliary suture.

Fibres pass downward and inferiorly insert into orbicularis oris.

Innervation is supplied by the buccal branch of the facial nerve and blood supply via the labial branch of the facial artery. Upon contraction, zygomaticus minor elevates and pulls the commissure laterally, contributing to the smile but also the formation of the nasolabial fold.

Muscle Group III Depressor Labii inferioris originates from the anterolateral mandible and medial to the insertion of the depressor anguli oris and lying deeper than the depressor anguli oris. Its fibres pass in a fan like distribution into the lower lip dermis and orbicularis oris muscle, depressing the lower lip and pulling it slightly laterally.

Mentalis, a paired central muscle of the lower lip, arises from the anterior midline of the mandible and inserts into the dermis. It pulls down on the margin of inferior orbicularis oris and everts the central portion of the lower lip. In conjunction with orbicularis oris contraction, the mentalis muscle allows the lips to ‘pout’. Externally, mentalis contraction causes wrinkling of the chin skin (a dimpled chin), as used in expressions of doubt or displeasure.

Platysma is a broad thin sheet of paired muscle made up of fibrous bands arising from the fascia covering the upper part of the pectoral and deltoid muscles, passing upwards over the clavicle, the fibres proceed upwards and insert into the inferior border of the anterior mandible. The fibres cross superiorly just before reaching the edge of the mandible border and attach to the bone of the lower jaw and also have insertions into the skin

(Figure 9) Removal of granulomatous material lower lip unknown HA. Copyright Cosmedic Skin Clinic 2014

(Figure 10) Removal of granulomatous material lower lip unknown HA. Copyright Cosmedic Skin Clinic 2014

and subcutaneous tissue of the lower face. Many of the fibres of platysma blend with muscle fibres of neighbouring muscles around the angle of the mouth and lower face. The cranial branch of the facial nerve provides innervation and predominant blood supply via the submental branch of the facial artery.6,7,8 TREATMENT TECHNIQUE AND MINIMISING RISK Starting with the vermillion border, and working from lateral to medial, slowly inject the filler (retrograde technique) and aspirate, or draw back, prior to injection to minimise the risk of intra-vascular injection. Volume can be created by injecting into the wet/dry border at mid-depth. Complications or unwanted side effects can occur with the injection of any dermal filler no less so than when injecting the lips, hence the importance of seeking training in this specific technique from an experienced trainer. The first step to avoiding complications is to ensure an appropriate product for the indication is used. Adverse events, however, can still 30

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occur and may be immediate or delayed in onset. Complications might include injection site reactions, infection, sensitivity and allergy, bruising and trauma from poor injection technique. After a thorough consultation and medical history the practitioner should consider herpes prophylaxis if indicated before treating with dermal fillers (Aciclovir 200mg 5 times a day for 5 days).9 There is no evidence-based data to support the belief that fillers play a triggering role in recurrent herpes infection and thus there is no rationale in using an antiherpes prophylaxis regimen with every patient. However, patients who have had an history of developing cold sores after a filler injection may benefit from it.10 Filler injections should not be performed if there is an adjacent site of infection e.g. intraoral, mucosal or dental infection or herpes labialis for lip injections. Stopping anti inflammatory drugs and refraining from alcohol for two to three days prior to injection can help to minimise the risk of bruising. Practitioners should discuss with the patient the treatment fully including expected results and potential complications. Any pre-existing asymmetry or skin conditions should be highlighted and of course good pre- and post-treatment photographs are essential.

Products which are placed too superficially may result in nodules or the presence of a bluish tinge known as the Tyndall phenomenon. This can also be a result of hemosiderin caused by intradermal bleeding.11 Nodules formed of hyaluronic acid (HA) in the lip can sometimes be punctured and their contents expressed.

(Figures 9 and 10) Consider injections at the lip angles to offer extra support and injection of the philtral column if needed for optimum aesthetic results.

CONCLUSION When treating the lips and perioral region it is important to create and maintain an overall plan. Understanding the anatomy of the region as well as taking into consideration the age, gender and ethnicity of the patient will ultimately give a more favourable and aesthetically pleasing result. Assessment using well-defined scales is helpful and taking into account additional factors such as volume and movement will create a more natural appearance.

Sharon King RN, NIP is a director and clinical nurse specialist at Cosmedic Skin Clinic, board member of The British Association of Cosmetic Nurses, member of the Aesthetic Complications Expert Group and Aesthetic Nurse Practitioner of the Year (Aesthetics Awards 2013-14). She has worked as a clinical trainer for some of the leading suppliers to the aesthetics industry during her 10 years in aesthetic practice.

REFERENCES 1. Chisholm BB, ‘Facial implants: Facial augmentation and volume restoration.’ Oral &

Maxillofacial Surgery Clinics of North America, 17(1), (2005), pp.77-84.

2. Goodman,G Duckless, ‘Lips: How to Rejuvenate the Older Lip Naturally and Appropriately’ Cosmetic

Dermatology, Vol 25 No 6 (June 2012) 3. Swift A, Remington K, ‘BeautiPHIcation: a global approach to facial beauty.’ Clinical Plastic Surgery., 38

(2011), pp. 347-377 4. Naidu D, ‘Comparisons of the Consistency and Sensitivity of Five Reference Lines of the Horizontal

Position of the Upper and Lower Lip to Lateral Facial Harmony’ The Orthodontic Cyber

Journal, (2010) http://orthocj.com/2010/11/comparisons-of-the-consistency-and-sensitivity-of- five-reference-lines-of-the-horizontal-position-of-the-upper-and-lower-lip-to-lateral-facial-harmony/ 5. Hoefflin SM, The beautiful face: The First Mathematical Definition, Classification and Creation of True

Facial Beauty (California, Steven M. Hoefflin, M.D, 2002) 6. Nelson DW, Gingrass RP, ‘Anatomy of the mandibular branches of the facial nerve.’ Plastic

Reconstructive Surgery, 64(4), (1979), pp.479-82 7. Gray H, Grays Anatomy The Classical Collector’s Edition, (Crown Publishing, 1977) 8. Pinar Y A, Bilge, O,Govsa F, ‘Anatomic study of the blood supply of perioral region.’, Clin Anat., 18(5),

(Jul 2005), pp.330-9 9. British National Formulary (BMJ Group London, 2013) 10. Duffy DM, ‘Complications of fillers: Overview’ Dermatol Surg, 31 (2005), pp. 1626-33 11. Bergeret-Galley C, Latouche X, Illouz YG, ‘The value of a new filler material in corrective and cosmetic

surgery: DermaLive and DermaDeep’, Aesthetic Plast Surg, 25 (2001), pp. 249-55

Aesthetics | May 2014

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.

5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: March 2014

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Aesthetics Journal

The SPF debate: benefits and limitations It’s vital to use SPF profusely, says aesthetic specialist Deborah Forsythe Deborah Forsythe is a medical aesthetic specialist and member of the Allergan faculty responsible for validating practitioners on injection techniques. She specialises in nonsurgical dermal facial rejuvenation.

There is a dark side to the sun. The US government has officially identified ultraviolet radiation (UVR) both from the sun and from tanning machines as a known cause of cancer in humans.1 UVR produces DNA changes that may lead to mutations in genes involved in the development of skin cancer.1 The US Environmental Protection agency (EPA) estimates that the sun causes 90% of all non-melanoma skin cancers2 and other research links it to 65% of all melanomas.2 Therefore, along with other sun safety strategies, sunscreens that absorb or block UVR serve an important protective function. Sun Protection Factor

(SPF) is a concept that was first described by chemist Franz Greiter in 1962. Coincidentally, Greiter is also one of four people variously credited with bringing to market the first sun protection products in the 1930s and 40s. Recent changes to both the Food and Drug Administration (FDA) SPF rules and the European Cosmetic Regulation 1223/2009 have underlined the need for ‘broad spectrum SPF’3.

To understand the SPF debate, we need to be clear about the difference between SPF and ‘broad spectrum SPF’, and for this we need to understand what we are using them for. Ultraviolet Radiation (UVR) is produced by the sun and measured by wavelength, from 100 to 400. (Fig 1) Even when the weather is cloudy, over 80% of UV rays penetrate the cloud layer, and other factors can increase UV exposure. For example, sand will increase UV exposure by

Figure 1

32

Wavelength

From

To

Notes

UVA

100

290

Not filtered by glass Penetrates dermis Intensity consistent all day, all year

UVB

290

320

Unable to penetrate glass Affects epidermis, causes sunburn Most intense in summer - 70% of annual exposure Vitamin D synthesis

UVC

320

400

Absorbed by ozone layer No effect on skin

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up to 20% due to reflection of the rays, and snow will do the same but with up to an 80% increase in exposure. Within UVR, UVA and UVB are not present in similar quantities they are split as 95% UVA and just 5% UVB. However the different wavelengths are responsible for different concerns, concisely described by the European Commission, document IP/06/571 04/05/20064 as, “UVB radiation is the cause for ‘sun-burn’. UVA radiation causes premature skin ageing, interferes with the human immune system, and is an important contributor to the skincancer risk.”

UVR affects skin both acutely and in the longer term. Immediate effects are sunburn, immunosuppression and DNA damage. As reported by Green et al5 sunburn is due to UVB radiation, and is an inflammatory response known as apoptosis, which breaks down damaged keratinocytes in a sort of cell-suicide whereby severely damaged cells are killed in an attempt to prevent them becoming cancerous.

Sunburn is also associated with an increased risk of melanoma, particularly before the age of 20.6 Long-term UVR effects are caused by both UVA and UVB damage. Fisher GJ et al7 reported that UVA reaches the dermis and is absorbed by fibroblasts and stimulates matrix metalloproteinases (MMPs), causing a reduction in collagens I, III and VII, a reduction in fibrillin and an increase in elastotic material It is these changes that lead to the visible signs of ageing – skin laxity, facial volume loss, fine lines and wrinkles. Chronic sun exposure is associated with an increase in risk of squamous cell carcinoma (SCC)6 as UVA and UVB radiation creates free radicals (unstable oxygen molecules that have lost one of their two electrons) which damage cell function and can alter RNA and DNA. Basal cell carcinoma (BCC) is the most common skin cancer, and is also due to long-term sun exposure. SPFs are mostly combinations of physical and chemical ingredients; zinc and titanium oxides are the most frequently used physical screens, and work by scattering the light and blocking it from the skin; avobenzone, benzophenones, dibenzoylmethanes, ecamsule, octocrylene, octyl methoxycinnamate, PABA, phenylbenzimidazole sulfonic acid and salicylates are among the more common chemical sunscreens, and they work purely by absorbing UV light.8 The EU document IP/06/571 goes on to state, “However, the so-called SPF only

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protects against sunburn (UVB radiation).”4 This led to changes in EU legislation including the need for a UVA logo or seal to inform consumers that a given product has ‘broad spectrum SPF’ (i.e. includes protection against UVA), a ban on the terms ‘sun-block’ and ‘total protection’, and improved labelling with standardised verbal descriptors.

In the US, SPF is measured when product is applied to the skin at a uniform thickness of 2mg/cm2. If it takes 10 minutes to burn without a sunscreen and 100 minutes to burn with a sunscreen, then the SPF of that sunscreen is 10 (100/10). 2mg/cm2 equates to approximately 30ml to cover the body, and approximately 1.2g to adequately cover the face. In Europe, The European Commission guidelines recommend a higher level of 35g to cover the body, equivalent to six teaspoons of cream. Guidelines from

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Cancer Council Australia are clear: “Apply sunscreen liberally – at least a teaspoon for each limb, front and back of the body and half a teaspoon for the face, neck and ears. Most people don’t apply enough sunscreen resulting in only 50-80% of the protection stated on the product.”9 SPF15 provides greater than 93% protection against UVB. Protection against UVB increases to 97% with SPF of 30+. Therefore the difference between a SPF 15 and a SPF 30 sunscreen may not have a noticeable difference in actual use as the effectiveness of a sunscreen has more to do with how much of it is applied, how often it is applied, whether the person is sweating heavily or being exposed to water. EU Commissioner Markos Kyprianou, responsible for health and consumer protection says, “Consumers must be made fully aware that no sunscreen product can provide 100% protection against hazardous UV-radiation. There are serious health risks, such as skin cancer, linked to insufficient protection from the sun. EU citizens need to be fully informed about what sunscreens will and will not do for them.”4 There is a vast body of evidence of the damage that UVR can cause, from the

The deficit of UV stimulation is virtually as dangerous as its surplus, argues Dr Tiina Orasmae-Meder Generally speaking, the advice given by cosmetic dermatologists to patients regarding sunscreen is to insist that it should be worn during all seasons, anywhere and by everyone, suggesting to their patients, “There is no safe tan.” Indeed, the damaging effect of ultraviolet (UV) has been researched thoroughly. It’s been confirmed many times that the skin damage caused by UV radiation is a major risk factor for all types of skin cancer, including melanoma and basalioma1.

Degradation of dermal amorphous substance, increased activity of free radicals resulting in enhanced lipid peroxidation, activated metalloproteinase and direct activation of transcription factors, Dr Tiina Orasmae-Meder is a dermatologist and founder of Meder Beauty Science, based in Switzerland, and also works at Iris Brand Vigilance to guide cosmetic safety

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immediate pain of ‘sun-burn’ through to cosmetic and health implications of long term exposure.

Protection against photo damage is critical.

Many procedures carried out by aesthetic practioners increase the risk of damage associated with exposure to UV radiation.

For maximum protection against the damage of UVA and UVB a broad spectrum SPF is essential.10 However the manner of application of the SPF is vital to ensure not only protection against ever present UV damage, but continued support for the epidermal and dermal structures to prevent premature ageing.

REFERENCES 1. World Health Organisation (WHO), Environmental Health Criteria (EHC) 160: Ultraviolet radiation, United Nations Environment Programme, World Health Organization, International Commission on Non-Ionizing Radiation Protection (Geneva: WHO, 1994)<http:// www.who.int/uv/publications/EHC160/en/> 2. United States Environmental Protection Agency, Sunscreen: the Burning Facts (EPA, 2006) < http://www.epa.gov/sunwise/doc/ sunscreen.pdf> 3. Regulation (EC) No 1223/2009 of the European Parliament and of the Council of 30 November 2009 on cosmetic products’, Official Journal of the European Union (2009) <http://eur-lex.europa.eu/ LexUriServ/LexUriServ.do?uri=OJ:L:2009:342:0059:0209:en:PDF> 4. Council Directive of 27 July 1976 on the approximation of the laws of the Member States relating to cosmetic products, (European Commission, 2010) <http://eur-lex.europa.eu/LexUriServ/LexUriServ. do?uri=CONSLEG:1976L0768:20100301:en:PDF> 5. Green A, Williams G Logan V, Strutton G, ‘Reduced melanoma after regular sunscreen use: randomized trial follow up’, J Clin Oncol, 29(3) (2011), pp. 257–63.

6. Bowes L., ‘Understanding the dermal effects of heightened exposure to the sun’, Journal of Aesthetic Nursing, 1(1) (2011), pp.

25-31.

7. Fisher G.J., Datta S.C., Talwar H.S. et al, ‘Molecular basis of sun induced premature skin aging and retinoid antagonism’, Nature, 379 (6563) (1996), pp. 335–9.

8. Skin Cancer Foundation < http://www.skincancer.org> 9. Cancer Council of Australia <http://www.cancer.org.au> 10. National Institute for Health and Care Excellence, Skin cancer prevention: information, resources and environmental changes (PH32) (NICE, 2011) <www.nice.org.uk/guidance/PH32> FURTHER READING Armstrong B.K., Kricker A., ‘How much melanoma is caused by sun exposure?’, Melanoma Res, 3(6) (1993), pp. 395-401.

such as the activator protein 1 (AP-1) and nuclear factor kappalight-chain-enhancer of activated B cells, NF-kB are known effects that UV radiation has on human skin. It is without doubt that ultraviolet rays, especially UVB-type, cause degradation of the skin’s main structures. However, lack of consideration of the UV spectrum as a factor affecting human organisms is unfavorable.

One of the basic vitamins, liposoluble vitamin D, is synthesised only if activated by skin exposure to UV radiation. Therefore the absence of such stimulation may result in vitamin D deficiency, and the development of hypovitaminosis. Insolation deficiency in individuals who for various reasons have only limited sun exposure (for example prisoners, Arctic dwellers and people with disabilities that make it hard or impossible to spend time outdoors) is known to enhance the development of osteoarticular disorders (such as decrease in bone tissue density, pain syndrome, undesired changes in ligament elasticity, stiffness and dystrophic degeneration of joints) and characteristic changes of skin2. Furthermore, vitamin D deficiency is linked to a higher risk of certain types of cancer, cardiovascular pathologies, and decrease

Aesthetics | May 2014

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Here are just some of the reasons why 3D-skintech will become the brand of choice in 2013 • Complete treatment portfolio for anti-ageing, pigmentation and acne • 4 technologies ensure a prescriptive & total approach to your clients needs • Used in conjunction with medical peel and cosmeceutical skin care line • Unsurpassed results ensures maximum client loyalty • Highly profitable with a multitude of services to offer • Provides you with a competitive edge in your area • Free product starter pack • Affordable finance packages available

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‘To compliment our core injectable business the 3D-skintech has added an array of new result driven facial services to our clinic’s menu as well as the combination services for our more curative patients. We recognized that this device offered the stand alone quality of each technology in a unique machine that will ensure that we both deliver the results but equally can make money from the start due its affordability. As a clinician too many times in the past we have invested huge sums of money in a single concept that has proven difficult to profit from. In my opinion this type of system represents the future in our industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic

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in immunity system function.3 From an aesthetic point of view, both insufficient and excess exposure to UV radiation causes rather similar skin changes.

Excess UV is a risk factor for skin tumours and accumulative pigmentation disorders (hyperpigmentation, mostly of chloasma or melasma type). However, if we look at the potential acceleration of ageing as a process of structural proteins’ degradation, then the deficit of UV stimulation is virtually as dangerous as its surplus.

To establish a safe time frame for insolation, it is crucial to remember that there are different levels of UV radiation. The intensity of its impact depends on several factors: the number of rays penetrating the atmosphere, their angle to the Earth, and the presence or absence of barriers (dust in the air, clouds, high levels of ozone).

In Saint Petersburg, Oslo, Stockholm and some other cities the level of UV radiation is so low that it can be disregarded. The UV index 1 is considered a negligibly low level of UV radiation and in the course of the northern winter the UV index may equal 0 for significantly long periods of time. At this time, I would advise that using sunscreen is not necessary because there is no damaging impact to protect the skin from.

A noticeable damaging effect (i.e. with visible results on unprotected skin after 20 minutes exposure to the sun) is caused by sun radiation with UV index 5 or higher. In England the season of intense UV (around UV index 7) lasts for no more than two weeks, usually at the end of June. The UV index in England virtually never goes higher than 8, a level that borders between “high risk” and “very high risk”. In England, the average UV index from the end of October until the beginning of April rarely exceeds 3. The intensity and characteristics of the vitamin D synthesis varies and is individual. For some people, several minutes of exposure to the sun is sufficient to activate the synthesis completely, whilst others need more time. According to a large survey held in the USA in 2001-2006, around 8% of the population are in the vitamin D deficiency risk group, and another 24% face the risk of insufficient intake. Together these two groups make up almost a third of the country’s population3.

Various research shows that some vitamin D deficiency, at least half-related to insufficient insolation, is diagnosed in over a billion people over the world3.

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In Saint Petersburg, Oslo, Stockholm and some other cities the level of UV radiation is so low that it can be disregarded.

The UV index 1 is considered a negligibly low level of UV radiation and in the course of the northern winter the UV index may equal 0 for significantly long periods of time.

Of course, a lot depends on the laboratory data that researchers rely on, specifically the level of 25-hydroxycholecalciferol (25(HO) D) that is considered borderline. Today most researchers agree that the level of 25(HO)D < 30 nMol/L corresponds to a vitamin D deficiency risk, and level 30 to 49 nMol/L signifies insufficient intake. Level 50 nMol/L and higher allows us to call the intake sufficient4.

The nutrition available to an average person does not cover the need for vitamin D due to low amounts of it in staple foods and high caloric value of the food that contains calcifierol5. According to research data, people living between the 37th and 50th parallels (most European countries and a large part of North America) do not receive the amount of insolation necessary for independent vitamin D synthesis in winter time5, and for those who live north of the 50th parallel (Scandinavian countries and most of Russia) the level of UV radiation is not high enough for complete synthesis all year round6.

I absolutely concur with the consensus that it is completely necessary to use sunscreens when open body parts are exposed to the sun with UV index higher than 5. It is important to remember that even with the low UV index its impact can be doubled in the mountains or by the sea due to the light reflecting from snow or water. But for city dwellers, in the days when UV index is not higher than 4 and especially when the solar activity is minimal and UV index equals 1–2 or less, I believe there is no objective need to protect the skin from the sun.

Moreover, excessive use of sunscreen may lead to the development of vitamin D deficiency and related problems, like the acceleration of the natural skin ageing process, early wrinkles and loss of skin tone. The guidelines for using skin protection against the sun are too general and based on an assumption that ultraviolet radiation in any form has a solely damaging effect.

REFERENCES 1. Marija Buljan et al, ‘The Role of UV Radiation in the Development of Basal Cell Carcinoma’, Coll antropol., 32 (2008) <http://www.ncbi.nlm.nih.gov/pubmed/19138022>, Suppl. 2, pp. 167-170.

2. M. Nathaniel Mead, ‘Benefits of Sublight: A Bright Spot for Human Health’, Environ Health Perspect., 116(4) (2008) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2290997/>, pp. 160-167.

3. Holick MF, ‘Sunlight and vitamin D for bone health and prevention of autoimmune diseases, cancers, and cardiovascular disease’, American Journal Clinical Nutrition, 80(6 Suppl) (2004), pp. 1678S-88S 4. Wolpowitz D1, Gilchrest BA, ‘The vitamin D questions: how much do you need and how should you get it?’, Journal of the American Academy of Dermatology, 54(2) (2006), pp. 301-17 5. Ross AC, Taylor CL, Yaktine AL, Del Valle HB, Dietary Reference Intakes for Calcium and Vitamin D, (Washington (DC): National Academies Press, 2011) 6. Harinarayan CV, Joshi SR, ‘Vitamin D status in India — Its implications and Remedial Measures’, Journal of the Association of Physicians of India, 57 (2009), pp. 40–48

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Pigmentation: a topical issue Ruth Donnelly speaks to leading aesthetic practitioners regarding their recommendations for treating pigmentation problems using skincare The treatment of pigmentation is a rapidly emerging market in aesthetics. “Dark patches, irregular skin tone, sun spots on the hands, face, chest, neck and red faces are some of the most ageing conditions on the skin,” says esteemed consultant dermatologist Dr Nick Lowe. Many practitioners treat the condition with laser and light-based treatments, using skincare as a complementary resource. However, with a recent influx of cosmeceutical products designed specifically for the purpose, some experts in the field assert that topical treatment should be every practitioner’s front line when it comes to pigmentation.

A 2012 study conducted by Dr Lowe showed that a combination cream programme can be as effective as treating pigmentation with Intense Pulsed Light. An independent double blind study was carried out on 24 randomly selected subjects with mild to moderate pigmentation, who received either the cream treatment (12 subjects) or IPL (12 subjects). Results showed that when measured with the complexion analysis computer, 10 of 12 subjects (83%) of those treated using the cream treatment programme showed improvement, as did those treated with IPL (10 of 12 subjects/83%).1 “This study clearly shows that a daily combination of the right creams can be highly effective for redness and pigmentation,” says Dr Lowe.

With the number of ways to treat pigmentation evidently on the rise, approaches vary. However, most leading practitioners agree that skin preparation is key. “People with colouration need to be medically blended as best they can before they go on to further treatment,” 38

says Beverly-Hills based dermatologist Dr Harold Lancer. “So the protocol in my clinic is that everyone is evaluated by me then at the end of that consultation a treatment plan is created to include lightening, exfoliating and epidermal and dermal rebuilding agents; topical medical treatments are used for at least a two to four week period before any instrumentation is considered.”

Dr Mervyn Patterson agrees that skin needs to be fully prepped before the commencement of any treatment, be it laser, IPL or topical. “It’s important to control all aspects of the pigmentation process whilst at the same time controlling inflammation, without disrupting the external skin barrier,” he says. “Tackling pigmentation without first repairing the skin barrier and dampening chronic inflammation would be like repainting the walls of a building without first fixing the roof.”

Key patient groups Although commonly thought of as an age- or ethnicity-related issue, people of all ethnic groups, ages and both genders experience pigmentation problems.

However, the way you treat the problem will differ depending on many factors, foremost of which, according to Dr Lancer, is the patient’s ancestry. “Pigmentation concerns are the most difficult arena in cosmetic dermatology,” he says. “Because the lighter the ancestry – not just the clinical presentation of the patient, but the geographical origin of their greatgrandparents and grandparents – the chances are, the better result from treatment. So if you have a pigmentary problem in a person from a Swedish origin then chances are you will get a Aesthetics | May 2014

better result than in someone with a fairer complexion but who is from a Moroccan or Italian ancestry.” Founder of Pharmaclinix Advanced Cosmeceuticals and chemist, Shashi Gossain agrees that pigmentation is a complex issue. “Types of skins and types of melasma are very different,” she says.

“Some people have very light patches, and some patches are very deep due to long exposure to sun damage, so you have to be careful and specific on what and how you treat. You absolutely cannot use lasers to treat hyperpigmentation on skin types III to V, because of the risk of postinflammatory hyperpigmentation, which is a lot more common in the darker skin tones.”

Hydroquinone – the gold standard?

Hydroquinone has been deemed to be the gold standard for the treatment of pigmentation for over 50 years2.

However, it has been reported that 80% of patients can develop a resistance to hydroquinone if used for more than a few months3, and the ingredient has also been shown to cause ochronosis, a skin condition presenting as severe, irreversible darkening and coarsening of the skin, in darker Fitzpatrick skin types.4 Although hydroquinone can still be found in most of the major prescription-only skincare lines, some doctors prefer not to use the ingredient, for reasons of both safety and efficacy. “I reject hydroquinone or hydroquinone/retinoid combinations because of the irritation rates and risk of profound rebound of pigmentation once the bleaching agents are withdrawn,” Dr Mervyn Patterson explains. Dr Lowe takes a different approach, combining agents to achieve optimal results. “It’s key when treating pigmentation to use a combination of numerous safe lightening agents to work

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EME/021/1013 Date of prep: October 2013

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

Clinical Practice Clinical Focus

Active Ingredients Lorna Bowes lists some of the key ingredients that she would recommend when choosing a skincare line to treat pigmentation Fruit and lactic acids – exfoliate to reduce superficial hyperpigmentation Vitamin C – reduces melanin production Neoglucosamine – reduces tyrosinase and exfoliates Tertahydrocurcumin (THC) – inhibits tyrosinase production; antioxidant properties Oligopeptide 34 – reduces tyrosinase and melanin production; antiinflammatory properties Kojic acid – chelates copper and inhibits tyrosinase production (although many manufacturers have chosen to withdraw products containing kojic acid due to concerns of dermatitis and toxicity)

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on different aspects of melanin production.

This is a preferable approach to only using prescription hydroquinone products.” Other practitioners claim that the ingredient can be used safely if clinicians are cautious: Dr Lancer says, “We use hydroquinone treatment under tremendous clinical observation; we don’t use prescription level hydroquinone, our chemists make it to our specification. Depending on how it’s manufactured and what it’s blended with, it works differently; discolouration from hydroquinone can occur only if it’s used in a misguided fashion.” The shift away from the use of hydroquinone has led cosmeceutical companies to conduct significant research into what other ingredients can be used to treat pigmentation problems. Lorna Bowes, aesthetic nurse and director of AestheticSource.com, UK distributor of NeoStrata, says, “There are multiple plant extracts known to resurface, reducing superficial hyperpigmentation, and inhibit tyrosinase, which is a key enzyme in the production of melanin.”

Topical versus light-based treatments Although proven to effectively treat pigmentation, lasers and light sources do have their limitations. “There are many things that will not respond [to lightbased treatment], even in the most ideal circumstance,” Dr Lancer explains. “There are certain hormonal situations such as oestrogen imbalance that can cause a high risk rate or non-response rate to lasers and light sources.”

Dr Marc Ronert, president and medical director of Image Skincare, claims that the new Iluma line from Image yields similar results to laser treatment. He adds that, “The active ingredients in the Iluma line have also been clinically proven to block melanin production, which is not possible with a laser.” These ingredients include Belides (bellis perennis (daisy flower)) and Indian Kudzu Pueraria tuberosa leaf cell extract, claimed by the company to limit melanogenesis.

Many clinicians clearly agree that it is possible to receive effective results from the use of skincare products alone; however, patient education is key to yielding those results.

Patients before and after treatment with cream1

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Educating your patients to increase positive outcomes Dr Nick Lowe explains that the efficacy of a skincare range depends on the user’s commitment to the regime. “The biggest Aesthetics | May 2014

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problem with treating pigmentation with skincare is patient compliance, especially regarding sun protection,” he says. “The secret of success is through compliance in the use of lightening products, and year-round sunscreen use is absolutely essential. The skin must always be protected with a day cream containing anti-oxidants and broad-spectrum UVB and UVA protection. Without this, any benefits from creams or IPL will be undone as sun exposure is one of the primary causes of pigmentation and contributes to redness.

“Patient education about this is very important. There is a myth that patients need not apply their skin lightening creams if they are on a sunny holiday. This is absolute nonsense. In fact this is when they need it most.”

Dr Stefanie Williams agrees; “Whether a prescription or non-prescription option is chosen, the patient must use a broadspectrum sun protection with SPF 45 or 50, every single day, whether sunny or not,” she says. “However, it’s not only sun protection, but also sun avoidance that is crucial. One day of excess sun can undo months of treatments.” The clinician’s job is therefore to ensure that patients understand the importance of sticking to the prescribed treatment programme.

Another key factor in patient education is managing expectations. Although the overall results from a skincare regime can be extremely effective, it will take longer for those results to appear than with a course of laser treatments, and patients need to be aware of that. “It’s important to tell the patient that any improvements are gradual,” Dr Williams explains. “The best result can take as long as six months.”

However, topical skincare for the correction of pigmentation can be combined with inclinic treatments, such as chemical peels, for maximum effect. Dr Lowe claims that the combination of skincare with Dermasweep can prove particularly effective.

“Dermasweep uses a vacuum action to lift the skin as the particle-free dermabrasion brushes sweep away dead skin cells,” he explains. “This disturbs the skin barrier just enough to enable the infusion of an antioxidant skin lightening complex. There was a good presentation on brush-delivered systems at the recent American Academy of Dermatology conference. This system can also be used with laser or intense pulsed light treatments to improve results.”

ELEGANT • FULFILLED • MY TIME

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site.

Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming.

Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection.

Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or

rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013.

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

1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1139/BOC/NOV/2013/LD Date of preparation: March 2014

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The ones to watch

Super Light Skin Tone Perfector by Dr Nick Lowe Iluma by Image Skincare

Super Light Skin Tone Perfector by Dr Nick Lowe Dr Lowe’s most powerful skin lightening cream yet, the cream contains an increased number of skin lightening active ingredients, from three to nine. Octadecenedioic acid and liquorice root extract limit melanin production in the skin cells that produce pigment, niacinamide and azalaic derivative lightens skin, whilst ferulic acid provides natural antioxidant protection against pigmentation. Preliminary studies showed that 71% of subjects showed a visible reduction in the appearance of pigmentation spots, 77% of subjects reported a more even skin tone and 82% of subjects reported a more radiant complexion after just four weeks of use. “The key is to use products with proven active ingredients, such as niacinamide, liquorice extract and anti-oxidants,” says Dr Lowe.

Iluma by Image Skincare “What really makes Iluma unique is the use of a revolutionary new delivery system called Vectorize Technology,” says Dr Ronert. The company claims that the Vectorize delivery system creates non-ionic vesicles that penetrate the deeper layers of the skin, releasing active ingredients for a prolonged time. With active ingredients including green tea extract, Dipeptide-16, Vitamin C and Coenzyme Q10, the Iluma range aims not only to correct pigmentation problems but to prevent their recurrence.

Epionce MelanoLyte Pigment Perfecting Serum and Melanolyte Tx

Medik8 White Balance Click

NeoStrata Enlighten

REFERENCES 1. Hassan, H. Lowe, NJ. Barlow, R. Harris, D., ‘Four

methods of evaluation of facial erythema and pigment

treated with intense pulsed light or cream’, Journal of

Cosmetic and Laser Therapy 14 (2012), pp. 200-206 2. Halder R. M. and Richards G.M., ‘Topical Agents

Used in the Management of Hyperpigmentation’, Skin

Therapy Letter, 9(6) (2004) <http://www.medscape. com/viewarticle/482649_2> 3. Hill, Rosalind, ‘Zein Obagi: ZO Skin Health’, PRIME Journal, (2012) <https://www.prime-journal.com/zein- obagi-zo-skin-health/> 4. Phillips, James, ‘Ochronosis in Black South Africans Who Used Skin Lighteners’, American Journal of Dermatopathology, 8(1) (1986) <http://journals.lww.com/ amjdermatopathology/Abstract/1986/02000Ochronosis_in_ Black_South_Africans_Who_Used_Skin.3.aspx> 5. Epionce, Melano Corrective System vs. Obagi® Nu Derm for Hyperpigmentation (Episciences, Inc.: www.epionce. com, 2011) <https://www.epionce.com/wp-content/ uploads/2011/09/5_ClinicalStudy_EpionceMCSvObagi.pdf>

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Epionce MelanoLyte Pigment Perfecting Serum and Melanolyte Tx “An independent clinical study showed that Epionce MelanoLyte Pigment Brightening Lotion and Pigment Perfecting Serum are as effective as hydroquinone/retinoid combinations without the irritation5,” says Dr Patterson. “Epionce Pigment products contain a wide blend of proven botanical ingredients that are effective at controlling all the steps in the pigmentation process and at reducing inflammation.” Active ingredients include turmeric, paper mulberry, bamboo and apple, and the promotional pack claims that, if used together, the two products address all the steps leading to irregular pigmentation.

Medik8 White Balance Click A brightening serum containing kojic acid, niacinamide, alpha-arbutin and linoleic acid, Medik8 White Balance Click claims to combat seven signs of hyperpigmentation, including sun damage, age spots, dark spots, melasma, uneven skin tone and blotchiness. “We use the Medik8 White Balance Click in our clinic because it contains a good concentration of a number of effective over-the-counter anti-pigmentation ingredients,” says Dr Williams.

NeoStrata Enlighten NeoStrata Enlighten is a three-product regimen containing NeoGlucosamine, THC, Vitamin C, Oligopeptide 34 and selected plant extracts. “In a study presented at the European Academy of Dermatology meeting in 2012, NeoStrata Enlighten demonstrated efficacy when used alone to lighten hyperpigmented areas, as well as providing all over brightening of skin tone,” says Lorna Bowes. “A group of 30 ethnically diverse women used the Enlighten three product regimen for 16 weeks; clinical grading, chronometer measurement, photography and self-assessment were used to establish efficacy and 93% of patients showed clinical improvement within four weeks.”

The future is bright With technology and products improving all the time experts agree that treatment for pigmentation can only get more effective in years to come. “The topical chemistry of products we use is reinvented every six to 18 months,” Dr Lancer says. “So chemistry and technology is always improving.” As consumers become ever more aware of the ageing effect of dark spots and uneven skin tone, clinics will need to have more tools at their disposal to treat a diverse range of patients, and it seems that skincare could play a pivotal role, as both a post-procedure regimen and a stand-alone treatment.

Disclaimer: Please refer to the European Commission directive 1223/2009 Scientific Committee on Consumer Safety for opinions on certain ingredients

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Clinical Practice Techniques

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Scar Treatment

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understand this, and it almost seems trivial to even consider such unimportant issues as overhang and stretch marks – they are often considered our battle scars to be worn with pride.

For me, treatment for the caesarian section overhang happened by accident. I had acquired a CoolSculpting machine and one of my patients requested I treat her caesarian section overhang. There was sufficient mobility of the fat to treat with CoolSculpting and the results were very encouraging. Unfortunately, many women do not realise that there is such an effective, non-invasive treatment for this fat bulge, and still believe the only treatment is invasive liposuction.

However, if clinicians increasingly focus their attention on treating both striae distensae and the caesarean overhang, our patients will as a consequence feel that they don’t have to just “put up “ with the sequelae of pregnancy.

Dr Carolyn Berry shares her experiences in treating caesarean scars and stretch marks There has been an interesting evolution of ‘body awareness’ in aesthetic practice. In the past, we have been primarily concerned with rejuvenating the face, but certainly in my practice, there has evolved an increasing emphasis on improving body concerns. This is particularly noticeable at this time of year, as our patients prepare for their summer holidays. Interest in body image increases year on year and I anticipate it will continue to do so. As practitioners, we need to be appropriately skilled in order to address our patients’ concerns and provide them with the best possible results. Whilst we are seeing a growing male population in our practices, the majority is still made up of women. A large proportion of these women have children and very few women go through pregnancy without any sequelae.

Stretch marks are a very common problem, particularly on the lower abdomen. The caesarean section scar itself is rarely a significant worry because it now lies very low, however the ‘overhang’ affects virtually 100% of women post caesarian section, even the very thin. This is due to the reflection of the abdominal fat of the rectus muscles of the anterior abdominal wall.

Caesarean section overhang Most women aspire to wearing a bikini post childbirth. It is a marker of body attractiveness because it is unforgiving and shows every bulge and imperfection, and even those without abdominal stretch marks struggle with the ‘fatty pouch’ or overhang following caesarian section.

Because of this I am increasingly asked to provide correction. Many of these women are not existing patients, and are not already having aesthetic treatments. However, successful treatment of this area often leads to further interest in other aesthetic procedures.

As a doctor I have been pre-occupied with the caesarean overhang for many years, having first noted it when I worked in general practice.

What fascinated me was that it did not just occur with heavier women, but also with very slim women with a flat abdomen. Even these women experienced a little bulge, tending to sit just above the bikini bottoms.

Unfortunately there is very little in medical literature about this phenomenon, and it appears thus far to have been largely ignored by doctors. The overriding consensus would appear to be: baby well, mother well, scar clean and healed, job well done. One can fully 44

Dr Berry uses CoolSculpting to treat caesarian section overhang

Striae distensae Unlike the overhang, there is thankfully some helpful information on stretch marks. Striae distensae (stretch marks) are an extremely common, therapeutically challenging form of dermal scarring.1 Aetiology remains somewhat of a mystery with various possible causes cited including hormones, physical stretch and structural alterations to the integument. Genetics would also appear to be an important factor in determining susceptibility of connective tissue.2 Various treatments have been trialled over the years. However, few high-level randomised controlled trials evaluating treatments for striae distensae exist. The histology of stretch marks is that of a scar and the development likened to that of wound healing.3 In the early stages there are inflammatory changes with recent striae distensae showing superficial perivascular lymphocytic infiltrate around the venules.4 In the later stages there is thinning of the epidermis due to flattening of the rete ridges and loss of collagen and elastin.5 Many therapies have been tried over the years, including topical agents, and these have had limited success. Vitamin E creams may have some effect on prevention of stretch marks6 and Tretinoin was found to have better results in striae rubra but even this was limited.7 As our patients’ expectations have evolved they now expect significant change and good results, and are increasingly unhappy with minor improvements, which means we as practitioners are under pressure to deliver.

Treatment With the knowledge that we are dealing with scar tissue, it is reasonable that we treat striae distensae in a similar manner to a scar. Scar tissue needs to be damaged and stimulated to initiate

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Clinical Practice Techniques

reconstructive surgery showed a substantially beneficial effect of PRP for several indications, including better wound healing rate, an increased survival rate of fat grafts and an enhancement of bone graft regeneration.14 Platelets contain a number of bioactive factors that contribute to the process of wound healing, such as platelet derived growth factor and transforming growth factor.15

Technique

I had already observed that PRP has really revolutionised my treatment of scar tissue in general, and therefore predicted similarly positive results when treating striae distensae. repair mechanisms and so the more invasive treatments will yield better results. Having researched the literature and various treatment modalities it became apparent to me that lasers presently appear to give the best results.8 Various lasers improve the appearance of striae distensae: the pulse dye improves immature striae rubra,9 and the Nd:Yag laser gave satisfactory results in treatment of striae distensae in a study of 20 patients.10 The most encouraging results to date have been with fractional but unfortunately the studies with fractional laser available are few and limited. A 2007 Brazilian clinical study showed that Fraxel improved texture and appearance of mature, white striae distensae in skin type I to IV. The study demonstrated an early new indication for stretch mark treatment with Fraxel.11 This certainly looks promising and from reviewing the literature, it would seem that fractional is the laser currently giving the best results in treating striae distensae.

However mention should also be made of radiofrequency. Of note is a study evaluating the effectiveness of a radiofrequency device in combination with a pulsed dye laser, in which 89% of the patients showed good to very good overall improvement. This is of particular interest because the study population was Asian and only one developed hyperpigmentation, which then improved in three months.12 So where does this leave treatment of striae distensae? I for one want more efficiency and whilst the studies show improvement, we want reproducible and excellent results. How therefore can I improve upon the results of fractional laser, and maximise stimulation of the repair mechanisms?

The answer would appear to be with platelet rich plasma. I had already observed that PRP has really revolutionised my treatment of scar tissue in general, and therefore predicted similarly positive results when treating striae distensae. General studies encouraged this thought and good results have been achieved by adding PRP treatment to fractional radiofrequency. Objective assessment in one study showed 71.9% of participants reported “good” or “very good” overall improvement.13 A review study of PRP in plastic and

As previously mentioned, I apply my scar treatment to stretch marks and caesarian section scars. If the patient has loose skin, which they often have as the abdominal skin has lost elasticity due to the striae distensae, I will start them on a course of radiofrequency with weekly treatments. Not only will this tighten the skin but it also causes visible improvement in the striae distensae without further treatment. Usually after three treatments, the patient has CO2 fractional resurfacing and immediately afterwards, I inject their PRP under the treated skin, paying particular attention to the worst striae distensaes and to the caesarian scar. I mainly use a mesotherapy technique, or inject the length of the striae distensae. The settings for the CO2 laser will depend on assessment of the patient’s skin and apparent depth and severity of the lesions. The first treatment is usually milder to allow me to assess what they will tolerate and how long their healing time is. When healed, the patient will return to their radiofrequency for a further three treatments after which I will repeat the process. I only treat skin types I to IV with this method as studies have shown treatment of IV to VI can cause side effects, including hyperpigmentation.16 In darker skins I use radiofrequency and skin needling with PRP injections.

Dr Carolyn Berry was brought up and trained in Belfast.

Practicing as both a research fellow and GP, she founded the Firvale Clinic in 2008. Her aim is to bring excellence in Aesthetics medicine, through treatments and research of new techniques. Firvale Clinic is now one of the most technically advanced clinics in the UK, offering a wide range of treatments to its patients.

REFERENCES 1. Al-Himdani et al. Striae distensae: a comprehensive review and evidence based evaluation

of prophylaxis and treatment. British Journal of Dermatology, 170, (2014), pp. 527-547.

2. Burrows NP, Lowell CR, ‘Disorders of Connective Tissue’. Textbook of Dermatology

(Blackwell Science, 2004), pp. 46-47.

3. Atwal GS, Manku LK, Griffiths CM et al. ‘Striae gravidarum in primiparae’, Br J Dermatology,

155 (2006), pp. 965-9.

4. Arem AJ, Kischer CW. ‘Analysis of Striae’, Plast Reconstr Surg,65 (1980), pp. 22-9.

5. Pierard GE, Nizet Jl, Adant JP et al. ‘Tensile properties of relaxed excised skin exhibiting stria

distensae’, J. Med Engl Technol, 23 (1999), pp. 69-72.

6. Wierrani F, Kozak W, Schramm L N et al. ‘Attempt of preventative treatment of strie

gravidarum using preventative massage ointment administration’, Wiener klinische Wochenschrift, 104 (1992), pp. 42-4.

7. Kangs, Kim KJ, Griffith CE et al. ‘Topical tretinoin (retinoic acid) improves early stretch marks’,

Arch Dermatol, 132 (1996), pp. 519-26.

8. Elsaie ML, Baumann LS, Elsaaiee LT. ‘Striae distensae (stretch marks) and different

modalities of therapy: an update’, Dermatol Surg Vol 35 (2009), pp. 563-573.

9. Karsai S, Roos S, Hammes S, et al. ‘Pulsed dye laser: what’s new in non-vascular lesions’,

JEAD, 21(2007), pp. 877-90.

10. Goldman A, Rossato F, Pratti C. ‘Stretch marks: treatment using the 1,064 nm Nd:YAG laser’,

Dermatol Surg, 34(2008), pp. 1-7.

11. Macedo OR, Macedo O, Bussade M et al. ‘Fractional photothermolysis for the treatment of

striae distensae’, JAAD, 56 (2007), p. 204.

12. Ho D, Moskowitz K, Sum R, Dee J, Rudolph A,Burch C, Pebley W and Orser C. ‘Wound

Healing Properties of Reconstituted Freeze-Dried Platelets’, Wound Repair and Regeneration, 13 (2005), pp. 1067-1927.

13. Suh DH, Chang KY, Son HC et al. ‘Radiofrequency and 585 nm pulsed dye laser treatment

of striae distensae: a report of 37 Asian patients’, Dermatol Surg 33 (2007), pp. 29-34.

14. Suh DH, Lee SJ, Lee JH, Kim HJ, Shin MK, Sang KY. J. Cosmet Laser Ther, 14 (2012), pp. 272-6.

15. Sommeling CE, Heyeman A, Hoeksematt, Verbelen J, Stillaert FP, Monstrey S, J. Plast

Reconstr Aesthetic Surg, 66 (2013), pp. 301-11 16. Nouri K, Romagosa R, Chartier T, Bowes L and Spencer JM. ‘Comparison of the 585nm

Pulse Dye Laser and the Short Pulsed CO2 Laser in the Treatment of Striae Distensae in

Skin Types 4 and 6’, Dermatologic Surgery 25(1999), pp. 368-370.

Aesthetics | May 2014

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Rapid Polymerising Collagen: Tissue in a Syringe Collagen could be returning to the UK aesthetics market with the development of a new collagen dermal filler portfolio. But what benefits does collagen have to offer the modern practitioner?

Collagen was the original dermal filler; it rapidly became so synonymous with volumising that it is still often used as a popular term for all fillers, particularly in the lips. Introduced in the 1980s, it was skin-friendly, safe, soft and natural. However, there was a small risk of allergic reaction to bovine collagen, so patients required a skin test, and the product lasted as little as two to four months post-injection.

The emergence of safe, long-lasting and reversible hyaluronic acid fillers decreased the demand for collagen. A durable, cross-linked, porcine collagen product, Evolence, was launched in 2004 but was withdrawn again in 2009 for business reasons. However, whilst HA fillers are now incredibly sophisticated, some doctors are still nostalgic for the unique properties of porcine collagen, particularly for fine, delicate skin indications.

At IMCAS, at the beginning of 2014, EternoGen attracted a great deal of interest as the company unveiled a new collagen portfolio comprising Rapid Polymerising Collagen (RPC) and Gold Nanoparticle Collagen (CG Nanomatrix). Charles Weatherstone, EternoGen’s marketing director, announced that, “Both have been formulated with unique integral shielding protection from collagenase degradation to offer long-lasting, natural-looking treatment results.”

“They are also designed to provide high biocompatibility, facilitating natural integration with the skin at a cellular level, which minimises the risk of inflammatory reactions and post-treatment problems,” says Weatherstone. “A lidocaine combination has also been developed to ease discomfort on injection of RPC.” Given the sheer number of hyaluronic acid fillers, we might question why the aesthetics market needs a new collagen filler. Weatherstone explains, “Skin is 80% collagen, and collagen is lost with age. Injected hyaluronic acids hold the skin up well, but they stay as a bolus, and don’t integrate with the skin. On the other hand, RPC is a liquid that trickles through the dermis.

After a few minutes, it polymerises to form a mesh of tissue that won’t migrate or change shape.”

“In our studies, just two weeks after injection, blood vessels started to grow into the injected collagen,” he says. “After 53 days, you could look at the injection site under a microscope and the collagen was completely integrated into the dermis. It all became one tissue, which is why we call it ‘tissue in a syringe’. It also improves skin smoothness and radiance.” EternoGen has conducted investigations into conjugating collagen with gold nanoparticles to provide additional benefits and enhanced duration. The research, carried out at University of Missouri, demonstrates that Gold Nanoparticle Collagen (CG Nanomatrix) has the potential to further increase resistance to degradation with treatment results lasting for up to two years. The addition of gold nanoparticles also provides antioxidant benefits. “This has the potential to reduce possible inflammatory reactions, such as swelling,” Weatherstone says. “The product will also not need a skin test before use, and it will be long-lasting and easy to use.”

Christopher Inglefield, plastic surgeon and medical director of London 46

Figure 1 Histology of RPC vs HA one month post-injection

Rapid Polymerising Collagen resembles host tissue’s cellular and vascular structure

Hyaluronic Acid remains as a distinct blue bolus

Bridge Plastic Surgery, has recently been conducting human trials using the new collagen portfolio. He says, “The RPC collagen is a clear liquid which injects very smoothly through a 30 or 32G needle, having the lowest extrusion force for fillers. It is associated with mild to moderate discomfort on injection. We are in the middle of a human safety study and all is proceeding well. “RPC is unique in replacing the skin’s lost collagen,” he says. “Therefore it is suitable for rebuilding the skin, where lines or wrinkles are a concern, or for example, for treating acne scars and post-surgical scars.” He continues that RPC’s unique ability to integrate with human skin is its key strength compared to other fillers. “RPC collagen can be used in a mesotherapy treatment or as a volumising produce because of the in-situ polymerisation,” he says. “This remains stable with no risk of product migration.”

Some doctors remain wary because of previous cases of patients experiencing reactions; However, Mr Inglefield says, “There will always be concerns about the use of porcine collagen despite numerous safety studies and hundreds of thousands of patients who have benefited from porcine products.

“The producers of EternoGen are being scientific and ethical in the development of the product to ensure that they launch a highly developed and researched product,” he says. “Collagen started the revolution in non-surgical aesthetic medicine; HAs have provided a very beneficial tool in restoring lost volume, but collagen is the gold standard in providing true rejuvenation of the skin.

“I firmly believe there is a clear need for a skin friendly collagenbased filler to provide safe, natural-looking results and the skin health benefits that both consumers and physicians seek today,” says Mr Inglefield. “RPC is particularly suited for delicate and challenging treatments in the peri-orbital and peri-oral areas where the risk of lumps and product migration needs to be minimised.”

Whilst hyaluronic acid fillers produce long-lasting, safe results, recent developments of RPC, enabling it to integrate completely into the dermis, and the potential of Gold Nanoparticle Collagen to last for up to two years, mean that there could soon be an increased demand for collagen in the aesthetics market.

Aesthetics | May 2014

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Awards Special Focus

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The Aesthetics Awards bring together the very best in medical aesthetics and leaders in the industry to celebrate the achievements of the past year. For 2014, twenty-one prestigious awards categories have been designed to recognise the finalists and winners for their services to the profession and industry. Awards are presented to those who have worked hard to represent the highest standards and have truly excelled in the field of aesthetic medicine, from clinics and individual practitioners to manufacturers and suppliers.

Following the success of last yearâ&#x20AC;&#x2122;s awards, the 2014 event will be bigger and more glamorous than ever. To be held on Saturday 6th December at the luxurious Park Plaza Hotel in Westminster, the evening will play host to 500 guests, new award categories and exciting entertainment. Aesthetics is delighted to announce Changing Faces as the official charity of the awards once again.

Entries will be open from 12th May until the end of June, whereby a shortlist of finalists will be selected based on the key category criteria. Finalists will be announced in September and online voting and judging will commence until the end of October. The award winners, and those who have been highly commended and commended in their categories, will be announced at the awards presentation evening in December and winners will be invited on to the stage to receive their award in front of an audience of their peers, colleagues and friends.

The categories for The Aesthetics Awards 2014 are as follows: The Pinnell Award for Product Innovation This award recognises the most innovative and dynamic products on the market. To be eligible for nomination, products must have been launched into the UK market in the 12 months before the 2014 Awards entries opened.

Entrants should demonstrate how their product provides a new and original treatment, leading to a better patient experience.

Cosmeceutical Range/Product of the Year This award will go to the best cosmeceutical range or product. This can be any professional use product range but must be retailed in UK medical aesthetics clinics. The winner should demonstrate support from practitioners and strong safety and efficacy evidence.

Injectable Product of the Year This award will go to the manufacturer or UK distributor of the injectable product deemed to be the best available in the UK. Entrants will be required to explain the potential and realistic outcomes of treatment along with good evidence of safety and efficacy.

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Treatment of the Year This award will be given to the manufacturer or supplier with the best medical aesthetic treatment as voted for by Aesthetics journal readers. The winner should show how this treatment is a valuable addition to the UK market for patients and practitioners.

Equipment Supplier of the Year Taking into account customer service, support for practitioners and product range, this award will be presented to the company voted as the best equipment supplier in the UK.

The JaneĂŠ Parsons Award for Sales Representative of the Year, supported

by Healthxchange Pharmacy This award, given in memory of Obagi territory manager JaneĂŠ Parsons, will be presented to the UK industry sales representative who is deemed to have provided the best service to his or her company, customers and ultimately patients.

Aesthetics | May 2014

Best Customer Service by a Manufacturer/Supplier This award acknowledges the manufacturer or supplier that voters believe has offered the best service in terms of practitioner support, customer training and client relations.

Distributor of the Year This award acknowledges the vital role played by UK distributors who bring new, international products and treatments to the UK market. The winner will be voted for on the basis of their customer service, product range and services to the industry.

Training Initiative of the Year This award will be presented to the training provider or individual trainer who is considered to have advanced the education of aesthetic medical professionals most effectively during 2014 through their course. Judges will take into consideration the dynamic method of delivery, attendee reviews and outcomes for participants.

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Best Clinic Awards For 2014, Best Clinic Awards will be awarded regionally. Clinics will be judged on their customer service, commitment to patient care and safety and demonstration of continuous clinical excellence. Clinics can nominate themselves in the following regions –

Best Clinic Scotland The Church Pharmacy Award for Best Clinic North England

The Dermalux Award for Best Clinic South England

Best Clinic London

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efforts of an aesthetic nurse who has provided exceptional care and treatment to their patients. The winner will be judged based on evidence provided by the entrant about him or herself, along with patient testimonials.

Aesthetic Medical Practitioner of the Year This award goes to the cosmetic doctor, dermatologist or surgeon who has excelled in his or her field this year. The winner will be judged based on evidence provided by the entrant about him or herself, along with patient testimonials.

Clinic Reception Team of the Year This award will go to a front of house team that has provided outstanding customer service, along with strong practitioner support for the benefit of both the clinic and patients.

Association/Industry Body of the Year

Best Clinic Wales Best Clinic Ireland The 3D-lipomed Award for Best New Clinic, UK and Ireland This award will recognise the recently launched clinics in the UK. Entrants will need to show how they have provided an excellent standard of care to patients along with details of initiatives used to grow their business during 2014. The clinic must have been established within the 12 months prior to nominations opening.

The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year This award will recognise the achievements and

This award will be presented to the association who is deemed by voters to have achieved the most, both for their members and aesthetic medicine as an industry and profession in 2014.

The Aesthetic Source Award for Lifetime Achievement This award recognises the achievements of an individual who has had a long career within aesthetic medicine and honours their significant contribution to the industry. Previous winners include Mr Chris Inglefield and Dr Patrick Bowler.

Awards Special Focus

How will winners be selected?

Our judging panel will select a list of finalists for each category, which will be announced in September. A process of voting will take place to select the winners. Aesthetics journal readers will be able to vote online to select the winner in the following categories: • Cosmeceutical Range/ Product of the Year • Injectable Product of the Year • Treatment of the Year • Equipment Supplier of the Year • The Janeé Parsons Award for Sales Representative of the Year, supported

by Healthxchange Pharmacy • Best Customer Service by a Manufacturer/Supplier • Distributor of the Year • Association/Industry Body of the Year An expert judging panel selected by Aesthetics will vote for the winners in the following categories: • The Pinnell Award for Product Innovation • Training Initiative of the Year • The 3D-lipomed Award for Best New Clinic, UK and Ireland • Best Clinic Scotland • The Church Pharmacy Award for Best Clinic North England • The Dermalux Award for Best Clinic South England • Best Clinic London • Best Clinic Wales • Best Clinic Ireland • The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year • Aesthetic Medical Practitioner of the Year • Clinic Reception Team of the Year The winner of the Aesthetic Source Award for Lifetime Achievement will be selected by Aesthetics Journal and will be announced on the night.

How to enter All entries must be made via the Aesthetics Awards website, www.aestheticsawards.com. You can enter in as many categories as you wish but you may only enter yourself, a company you work for, or an employee who works for your company.

Nominations made on behalf of a third party will not be accepted.

You should only enter once. Multiple entry forms for the same clinic, company, individual, treatment or product will be

disregarded. All entries must be accompanied by the supporting evidence requested in the entry form. This information will be used to create the list of finalists and by the judges when voting on a winner.

The list of finalists will be announced in the September issue of Aesthetics Journal, after which the voting process will begin.

Voting Readers of Aesthetics journal will be able to vote for their favorite finalist in each of the appropriate categories from September. Each reader can vote for one finalist in each category.

Multiple votes from the same email address, name and IP address will be discounted from the final result.

Aesthetics | May 2014

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In Practice Data Protection

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Data Protection: what every practitioner needs to know Dr Natalie Blakely and specialist lawyer Mandy Luckman answer key questions about the ethical and legal issues involved in storing patient data Protecting your patientâ&#x20AC;&#x2122;s details isnâ&#x20AC;&#x2122;t just crucial for your business but also for your reputation. If you record, handle and store medical information, then you are liable under the Data Protection Act 1998 to protect that information. The Act states you should only collect the information you need, keep it secure, ensure it is up-to-date, only hold as much as you need and for as long as you need it and allow the patient to see it on request. With data protection breaches for unauthorised disclosure and for lost and stolen paperwork higher in healthcare than in other sectors, collecting good quality data and storing it securely demonstrates good practice and could help to protect you against litigation.

Is it legal to transport paper medical records around?

Clinical records must be kept confidential at all times, including during transfer between sites. It is legal to transport medical records if necessary but stringent security measures must be put in place to avoid security breaches. There are many reported examples of data protection breaches occurring. One such case involved a lawyer who was transporting patient records by hand to a court hearing. Unfortunately she was involved in a RTA and the records were dispersed around the site of the accident.

Clearly, although the circumstances are very unfortunate, this had the potential of allowing very sensitive patient information to be accessed by unauthorised persons. This resulted in stringent measures being put in place to avoid the scenario recurring. For 50

example, records should only be transported when absolutely necessary and if so, they are stored in locked cases.

What must we do to ensure patient data protection when transporting medical records?

Security measures will include physical, organisational and technological measures, such as use of secure portable equipment and ensuring administrative and strategic processes are in place to guarantee that the documentation is secure at all times.

The movement and location of records should be controlled so that a record can be easily retrieved at any time, any outstanding issues can be dealt with, and there is an auditable trail of record transactions.

Is it legal to store patient photos on phones and/or a personal cloud?

The Data Protection Act 1998 controls how data is used by organisations, businesses and public authorities (part 1 (1) (e) Data Protection Act 1998) 1. A key principle of the Act stipulates that information must be kept safe and secure.

There is a stronger legal protection for more sensitive information such as information related to health. It is therefore not advisable to store confidential data on mobile phones which can easily be lost or stolen, or on a personal cloud which disseminates to other devices around the house.

What security features should you look for in a digital system?

Cloud-based storage systems encrypt data Aesthetics | May 2014

and back it up on several servers: this is called redundancy and means that, should a server fail, your data is unaffected.

It is worth checking with your cloud provider that their server is based within the EU. Right now the EU provides strong protection for personal data. If data belonging to EU businesses or citizens is stored outside the EU, the transfer of that data needs to be secure with data protection requirements at the other end, at least as strong as those in the EU. What happens to patient records if you terminate the contract with a digital provider?

EU data law states that cloud providers must allow a person or business to move data from one cloud provider to another.

Itâ&#x20AC;&#x2122;s also worth checking that, should you request it, your data will be returned to you in a usable format, such as a PDF. Where should patient photos be stored?

Appropriate technical and organisational measures should be taken against accidental loss. Therefore it is advisable to store confidential data in a safe secure environment or electronically where appropriate security protections are in place. The Data Protection Act advises that you should have security that is appropriate to the nature of the information in question and the harm that might result from its improper use, or from its accidental loss or destruction.2 Since photographs pertaining to medical treatment may be particularly sensitive there will be a greater

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requirement for security.

Guidance given by the Information Commissioner’s Office states that physical and technological security is likely to be essential as well as management and organisational security measures3. Physical security includes considering the quality of doors and locks, and whether premises are protected by alarms, security lighting or CCTV. It also includes how you control access to premises, supervise visitors, dispose of paper waste, and keep portable equipment secure. Technological security involves use of secure servers, firewalls and encryption.

How long must we keep patient medical records for?

The Data Protection Act stipulates that records should only be retained for as long as necessary.4 There is no definition of ‘necessary’ in the Act; however, the Department of Health states that the maximum period of retention of NHS records should be thirty years.5 The NHS code of practice states that records should be retained for at least eight years for adults and 25 years for children.6 GP records must be kept for ten years after a patient dies or leaves the country.7 This also applies to private records in accordance with the Private and Voluntary Health Care (England) Regulations 2001.8 The Medical Defence Union advises that, if possible, records should be kept for beyond the prescribed periods, as claims do sometimes arise after these timescales, and it may prove difficult to successfully defend a claim without the records.9 Ideally, all records should be reviewed before they are destroyed, and it is sensible to keep any patient records where there has been an adverse incident or complaint.

Disposal should be carried out in such a way that protects patient confidentiality, for example, by shredding paper records.

Computer-held records may be difficult to delete entirely from a hard drive and it is

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The movement and location of records should be controlled so that a record can be easily retrieved at any time, any outstanding issues can be dealt with, and there is an auditable trail of record transactions. advisable to seek appropriate advice from a specialist IT company. The Information Commissioner’s Office advised that data retention and review schedules should be in place for categories of personal data to help practitioners comply with this principle.

After a set period of time the data should be reviewed, and destroyed when it no longer needs to be retained.10 When paper records are no longer required, their placement in a designated secondary storage area may be a more economical and efficient form of storage. There are several accredited documentary storage facilities, which are able to securely store NHS, medical and pharmaceutical records.

Who do the records belong to?

Legally, although the patient owns the information contained within the medical records, the healthcare provider owns the paperwork that contains this information.

The records should therefore be retained by the treating clinician, though patients have a legal right to access their medical records under the Data Protection Act 1998.11 This means that any individual is able to obtain a copy of their own medical records upon request, subject to paying reasonable copying charges up to a cost of £50.12 What does the new EU directive on information governance for 2015 mean for practitioners and clinics?

Under current law, the Information Commissioner’s Office can issue a maximum penalty of up to £500,000 for the most serious breaches of the Data Protection Act.13 Moreover the Information Commissioning Officer can decide to apply fines or not at their own discretion based on the severity of the consequences of

Other key changes in the new EU directive include: • • • • • • •

In Practice Data Protection

Higher standard of consent (Articles 4(8) and 7) Data minimisation (Article 5) New and strengthened rights for data subjects (Articles 12, 17 and 18) Breach notification within 24 hours (Article 31) Data protection impact assessments prior to risky processing operations (Article 33) Obligation to appoint a data protection officer (Articles 35-37) Imposition of large fines for failure to comply (Article 79)

Aesthetics | May 2014

such breaches. Fines have been imposed in the past for incidents such as transfer of personal data using unencrypted memory sticks and loss of electronic devices containing personal data.14 The draft proposal introduces a requirement for supervisory authorities to impose prescribed fines of up to €1 million (£0.9 million) or 2% of a company’s annual global turnover in the event of a violation of the Regulation (Article 79), regardless of the harm caused.

More serious breaches are likely to involve deliberate misuse of data leading to substantial damage or substantial distress.15 Dr Natalie Blakely is medical director of the Light Touch Clinic in Surrey and founder of the Consentz patient record app. While developing Consentz she became fascinated by the legal issues surrounding consent and how practitioners can improve their consenting processes, helping to protect both themselves and their patients.

Mandy Luckman is a partner in the Medical Law & Patients Rights team at Irwin Mitchell in Birmingham. Mandy leads a team that acts exclusively for claimants in clinical negligence cases and is regularly contacted by the media to quote on developments and regulation within the field of cosmetic surgery.

REFERENCES 1. Data Protection Act 1998, Schedule 1 <http://www.legislation. gov.uk/ukpga/1998/29/contents> 2. Data Protection Act 1998, Schedule 1, Part II, Principle 7(9) <http://www.legislation.gov.uk/ukpga/1998/29/contents> 3. Information Commissioner’s Office <ico.org.uk> 4. Data Protection Act, Schedule 1, Part I, Principle 5 <http://www. legislation.gov.uk/ukpga/1998/29/contents> 5. Records Management: NHS Code of Practice, Part One (2006)

and Part Two (2009) < https://www.gov.uk/government/ publications/records-management-nhs-code-of-practice> 6. Records Management: NHS Code of Practice, Part One (2006)

and Part Two (2009) < https://www.gov.uk/government/ publications/records-management-nhs-code-of-practice> 7. Records Management: NHS Code of Practice, Part One (2006)

and Part Two (2009) < https://www.gov.uk/government/ publications/records-management-nhs-code-of-practice> 8. The Private and Voluntary Health Care (England) Regulations

2001, Schedule 3, Part 1 < http://www.legislation.gov.uk/ uksi/2001/3968/contents/made> 9. MDU <www.themdu.com> 10. Information Commissioner’s Office <ico.org.uk> 11. The Data Protection Act, Part II, Section 7 <http://www. legislation.gov.uk/ukpga/1998/29/contents> 12. The Data Protection (Subject Access) (Fees and Miscellaneous

Provisions) Regulations 2000, Regulation 6 < http://www. legislation.gov.uk/uksi/2000/191/made> 13. The Data Protection Act, Sections 55A and 55B <http://www. legislation.gov.uk/ukpga/1998/29/contents> 14. Information Commissioner’s Office <ico.org.uk> 15. The Data Protection Act, Sections 55A and 55B <http://www. legislation.gov.uk/ukpga/1998/29/contents>

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In Practice Treatment Portfolio

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Building a body shaping clinic Wendy Lewis explains why now is the perfect time to consider expanding your offering from the face to the body The emerging market segments of body shaping and skin tightening have shown unprecedented growth in recent years. Body shaping and skin tightening devices have demonstrated aggressive expansion and have shown explosive growth: the British Association of Aesthetic Plastic Surgeons (BAAPS) audit for 2013 showed a 41% rise in liposuction procedures, a 16% rise in abdominoplasty procedures and a 24% increase in male gynaecomastia body contouring procedures.1 The emergence of energy-based systems and innovative technologies has paved the way for more companies to enter the sector, offering more options for practitioners as well as consumers. The time has never been better to consider adding body-shaping procedures to your clinic offering.

Body shaping encompasses a wide range of procedures that target weight reduction, as well as toning, firming and cellulite reduction. Skin-tightening procedures address wrinkles and skin laxity on the face and body.

For the quickest and most dramatic results, more invasive body-shaping surgery may be the preferred option. However, there has been a sea change in the mindset and goals of consumers since 2008, resulting in flat levels of growth in the surgical category. Because consumers tend to associate surgical procedures with longer recovery times, possible risks, higher costs, an anaesthetic, a hospital stay and visible scars, they are very open to investigating alternative options. Although non-surgical or minimally invasive treatments may not be the right fit for obese patients or patients with excessive skin laxity, a large percentage of consumers are willing to accept a lesser result from a lesser procedure.

Today, there are effective forms of cosmetic enhancement procedures to target every part of the body, which may require some improvement.

SURGICAL PROCEDURES Whether their ultimate goal is to look great in clothes, fit into a smaller size or look good naked, patients have a lot of options to consider. The fact remains that there are some body issues that cannot be significantly altered through diet and exercise alone. The category of surgery for the body has greatly expanded to include numerous variations in ways to address excess fat, skin sagging and contouring defects. There is a global trend of more and newer procedures making up each of 52

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the major segments of cosmetic surgery for the body.

For example, to address the mid-section, surgeons may now offer a standard abdominoplasty, modified or mini abdominoplasty, abdominal etching, liposuction, fat grafting or a combination procedure. This may also be combined with a lower body lift, thigh lift, buttock lift and/or fat grafting, as well as an upper body lift consisting of breast augmentation, mastopexy or reduction mammoplasty or gynaecomastia, brachioplasty, liposuction and so on. According to the American Society for Aesthetic Plastic Surgery (ASAPS), 2013 marked a record upward trend in both labiaplasty and buttock augmentation surgeries.

Labiaplasty procedures increased by 44% over the course of the year, and buttock augmentation procedures rose by 58%.2 The rise in vaginal rejuvenation is often credited to the explosion of pornography online, while the increasing interest in buttock sculpting procedures has been at least partially driven by an overwhelming desire to have a firm, smooth, round bottom like many celebrities.

Cosmetic Surgery of the Body • • • • • • • • • • • • • • •

Abdominoplasty Body lift Brachioplasty Breast enhancement Breast lift or reduction Buttock enhancement Buttock lift Calf implants Fat grafting Gynaecomastia Laser lipolysis Liposuction Pectoral implants Thigh lift Vaginal rejuvenation

If you are not a trained surgeon, but are seeing patients who are candidates for surgery and who have the means to have it done, consider recruiting a BAAPS plastic surgeon to your clinic a few days per month to expand your service offering. This way you may be able to keep those patients in your clinic rather than risk losing them to another clinic that is not likely to refer them back to you for nonsurgical treatments.

NON-SURGICAL BODY CONTOURING More clinics in the UK are expanding their treatment menu as new and effective options for fat reduction, cellulite treatment, skin tightening, hair removal and décolletage and hand rejuvenation evolve. The emerging range of laser and light treatments and non-surgical services can now effectively address every conceivable aesthetic concern. Advanced technologies enable many wavelengths and energies

Introducing the NEW

One Treatment NEW FDA Clearance Ultimate Body Platform More Power Innovative Design

www.syneron-candela.co.uk | info@syneron-candela.co.uk Tel. 0845 5210698

This is not intended for the U.S. market. Š2013. All rights reserved. Syneron and the Syneron logo are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. Candela is a registered trademark of the Candela Corporation. UltraSculpt and UltraShape are registered trademarks of UltraShape. PB82801EN

In Practice Treatment Portfolio

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Body Shaping – the three basic categories and most popular treatment areas 1.

2.

3.

Skin tightening – tummy, arms, thighs, knees Fat reduction – tummy, hips, thighs, knees, back, arms, chest (men) Cellulite reduction – thighs, buttocks, knees

to be used on all skin types and skin colours.

Skin tightening can be accomplished with a variety of energies including radiofrequency, ultrasound, heat-based energy or a combination of wavelengths.

Fat reduction is used to target localised fat deposits without injections, anaesthetic or visiting the hospital. The energies used to fight fat range from heat (radiofrequency) to cold, ultrasound and lasers. Actual fat loss in centimetres varies from person to person and the downside is that results may not be immediate and usually multiple treatment sessions are needed. Ideal candidates are at a good weight with only small bulges.

Each system comes with its own limitations based on the energy used and the configuration of handpieces. For example, some systems use handpieces that are too large for small body areas like upper arms, under the chin and knees. It is important to know before you buy exactly what the system will treat when you are purchasing it, not just what is planned for the future.

Most non-invasive systems just reduce fat cells and are not intended for serious skin tightening, so you may need more than one device to treat a wider range of patients.

Consider which areas patients are most interested in treating, and what fees they may be willing to pay, based on your location and the demographics of your current clientele. It is not wise to bring on a new device with the sole purpose of attracting a brand new segment of patients, unless you have a huge marketing budget: you should have enough existing patients in your clinic to target first, and then build up additional clientele over time.

Cellulite reduction has proven very difficult historically, with past treatments focusing on surface remedies; however, new therapies are changing the way practitioners approach cellulite. It has been said that 90% of woman have cellulite, which accounts for a vast number of patients who have a potential interest in 54

this service. Cellulite patients come in all shapes and sizes; even thin women can have lumps and dimples, which tend to get worse with age. There is some overlap when it comes to the body contouring and cellulite reduction categories, which is why it is important not only to research and trial several systems, but also to have more than one method to offer patients. Each patient represents a unique set of circumstances, which makes the task of consulting with patients even more important. Some systems may simultaneously sculpt specific areas of the body and target cellulite, or it might take a combination of different approaches to deliver good results.

With regards to cellulite, it is critical to be honest with patients. Every woman has heard about the miracle cures and most have a healthy degree of scepticism about new treatments. Let patients know up front what they can expect and how many treatments they really need, and build a maintenance programme into the treatments from the beginning. Offer advice on diet, exercise, lifestyle, and have them come back for additional treatment sessions as necessary.

Cellulite is like everything else you treat: it is chronic, it often gets worse with age, and it requires a multifactorial approach to keep it under control.

OFF-FACE APPLICATIONS FOR ENERGYBASED SYSTEMS If you find that patients are asking about services that you do not yet offer, and that you are referring them to colleagues and/ or competitors, it is time to take a look at how best to step it up.

A good place to start is to analyse what you already have in your clinic that may currently be underutilised. For example, if you are the proud owner of a multi-platform device that targets brown spots, hair, sun damage and acne, you already have the ability to do off-face treatments without incurring additional costs. The first areas Aesthetics | May 2014

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to expand laser therapies to would be the chest or décolleté and the hands. If you are currently doing full face IPL or skin tightening, try using the same treatment for other areas where patients may have discolouration, crepey skin texture and other signs of sun damage and ageing skin.

Patients are not only conscious of the skin quality of their face; they are also interested in improving brown spots on their chest, arms and legs, and are interested in laser hair removal literally from their hairline to their toes. If you are an expert peeler, consider launching a body peel programme, with peeling solutions, microdermabrasion, dermal infusion systems and body products for home use.

Hand rejuvenation using dermal fillers as well as neurotoxins, fat grafting and a series of glycolic or TCA peels, as well as energy-based treatments, is a popular category, which offers patients a whole new reason to come back to your clinic regularly. If you deal with reputable manufacturers or distributors that stand behind their products, you should enquire about having the clinic staff retrained to expand the uses of the systems you now own. Alternatively, consider trading up. If you have limited space, look into additional handpieces, or upgrading your current system(s) for newer models that work better, faster and do more.

In the near future, many practitioners focusing predominantly on facial injectables and skin-rejuvenation treatments will need to incorporate other services into their treatment portfolio to remain competitive and ensure clinic growth; looking into opportunities to do so will help expand your clinic, increase patient retention and encourage new patients to choose you over your competitors.

Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on antiageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications.

REFERENCES 1. The British Association of Aesthetic Plastic Surgeons, Britain sucks (2014) <http://baaps.org.uk/about-us/press-releases/1833- britain-sucks> 2. Plastic Surgery Practice, ASAPS: Below-the-belt procedures

on the rise (2014) <http://www.plasticsurgerypractice. com/2014/02/asaps-belt-procedures-rise/>

In Practice Marketing

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than any TV network. This age group may not be your exact target demographic for treatments, however these statistics prove how easy it is to reach people directly through the use of video.

John Castro, owner of Websites for Cosmetics, explains how the power of video can be harnessed to increase footfall to your clinic

Getting in front of the camera: using video to increase enquiries The way we absorb information is still not fully understood, despite extensive research into the field. However, it does seem fairly certain that humans absorb information much better with a visual aid, which is why video as a medium is a highly powerful tool, and one which you should employ in your marketing strategy.

Why video?

Video allows you to really engage and interact with users, and deliver your message easily, quickly and clearly. The medical aesthetic industry is very much driven by gaining trust from potential clients and the immediacy of video will help you gain that trust quicker. We have all heard the saying, ‘people buy people’, so put yourself in front of the camera, deliver your message and watch your enquiries increase. An example of good video utilisation comes from Clinetix, a

medical aesthetic clinic based in Glasgow, and one of our clients. Clinetix host a highly effective video on the homepage of their website, introducing their clinic.

Our tracking shows that aside from the treatments tab, the video is the second most clicked-on item on their home page.

This proves that when easily accessible, videos entice browsers, which in turn will increase the rate of conversion of website visitors into enquiries. Video also helps to gain the trust of potential clients before they’ve even picked up the phone, as it conveys personality. With the amount of information online today, being personal has never been so important.

The growth in accessing video online has increased in recent years and continues to do so. Today, 100 hours of video content is uploaded to YouTube per minute and the site reaches more 25 to 35-year-olds

Two key tips for recording video: 1. Audio Make sure you use an external microphone. Audio is key to any video recording and testing shows that bad audio will result in people changing their mind and clicking onto something else. A £20 lapel microphone is sufficient.

2. Lighting Lighting can lift a video from looking amateur to looking like professional media footage.

Natural sunlight is great but if you can, purchase some professional ‘soft box studio lights’ as they will make a big difference to the look and feel of your recording. Studio lighting is not expensive either. For less than £60 you should be able to pick up two soft box studio lights online.

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It is this growth that has changed how consumers want to receive information, especially marketing messages.

Consumers today are increasingly savvy, and the use of video provides a dynamic, interactive experience for website visitors.

This medium enables you to introduce your company more effectively and highlight promotions, as well as provide treatment descriptions.

Below are the two most common reasons clients give for avoiding the use of videos, along with some advice to help you when creating and posting your videos online.

“I don’t know how to record good videos” This is the most common objection, as everyone naturally wants to look professional. However, today video can be recorded using a smart phone as long as it supports recording in HD. There are some limitations to this, but the truth is that many smart phones record video that is of a good enough quality to get a message out there. If you are, however, thinking of investing in some equipment, a good quality HD camera will not cost more than £200.

“Video is too expensive” Video does not need to cost thousands of pounds. However, if video is to become a focal part of your marketing strategy, then I would suggest investing a couple of hundred pounds in purchasing your HD camera, lighting and lapel microphone.

Spending a portion of your marketing money on producing videos should not be considered a burden but an investment.

Even if you buy a higher-end camera, some lights and a high-end microphone, the total cost should not exceed £1,000.

Video has become so effective that once you have invested that money and started shooting and sharing videos, I am convinced that you will see an increase in enquiries. You could even make videos on treatment aftercare and hand them out to patients, which will inevitably increase client loyalty as it demonstrates to your customers that their wellbeing is important to you, and not just when they are in your treatment room.

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In Practice Marketing

@aestheticsgroup

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Creating the right kind of videos The type of video you record will depend on what message or end goal you are trying to achieve.

Below are four types of videos you should record and their purpose:

1. THE INTRODUCTORY VIDEO

3. THE TREATMENT VIDEO

This video is for your website home page. It is an introduction to either you or your clinic, and probably both. Ideally this should be led by the clinic manager, clinical director or owner. It is vital in any small business to be personal and inviting. Use this video to introduce who you are and your specialist treatments. It should be no longer than two minutes, ideally about 90 seconds.

This type of video is perfect for describing and explaining your treatments. When consumers want to undergo a medical aesthetic treatment they will have several questions; this video can answer those questions and help to alleviate some of their concerns. A short, informative video about the treatments you offer could be the difference between a patient booking a consultation with you or your competitor – and this kind of video does not always have to be produced by you. Most large aesthetic brands today can supply access to their library of videos, meaning that you can easily share this ready-made material on your own digital platform, aiding potential patients’ understanding of what a particular treatment involves. However, filming a treatment video yourself at your clinic can be much more effective as it

2. THE CLIENT-IN-THE-CLINIC VIDEO Nothing builds trust more than recommendations. It is the lifeblood of many businesses today, but many do not think outside the box and rely on clients recommending within their own social circle.

By producing a video with your patients in your clinic discussing their experience, you will build trust with potential new clients.

instantly personalises the user’s viewing experience.

4. THE PERSONAL EVERYDAY VIDEO In my opinion this video is the most effective video strategy if used properly, and over time. One of my 10 Online Marketing Commandments is ‘Be Personal, Not Promotional’ and today this is more important than ever. Due to the amount of generic information thrown at people everyday, your patient is now looking for a personal touch in their purchasing experience. A personal, everyday video is spontaneous. It could be about a new treatment that you plan on introducing, or it may be that you are at an event and want to post a video of your experience. This should not be professional or structured, just you in front of your camera sharing yourself.

Where to share Sharing your videos is crucial. It is vital that people actually click the play button, and in our experience, there are three places where video creates an effective impact: YouTube, Facebook and your own website.

YOUTUBE This is where you should host your videos. Upload them here first and then embed and share the YouTube video on other platforms. This is important firstly because of Google’s recent implemented change in how they rank websites. This change has resulted in a dramatic increase in the appearance of videos on the first page of Google. Search Engine Optimisation is complex and just uploading a video to YouTube does not mean you will be page one of Google, but every little helps. Secondly, hosting your videos on YouTube as a primary base is important because if you upload video directly to your website it could create speed problems when loading, as video files are usually fairly large. You certainly do not want someone clicking off your website because they are waiting for it to load.

YouTube is a great platform for hosting purposes and embedding a YouTube video on your website is much more effective than uploading it directly.

FACEBOOK Facebook is the most effective social media platform to share video. It’s a space where videos are shared and watched daily as the user can easily watch without having to leave the site. We have found that sharing video on Facebook business pages is extremely effective.

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On average, our written Facebook posts reach around 100 people each time according to page analytics. However, when we post videos the number of people the post reaches exceeds around 500 each time.

YOUR WEBSITE It is a must to put your videos on your website. Make sure you create a section on your website just for your video content. We recently did this with a client of ours, Dr Anil Budh-Raja. It has been very effective and now users can access a selection of videos directly on his website, including videos about the doctor and his most popular treatments.

As well as having a ‘Videos’ section, uploading videos in a blog is also very effective. If you write a blog, complement it with a video about what you have written. We now know that having a visual aid to any piece of writing engages users better, and that patient engagement is crucial to boosting enquiry conversion rates. The personal nature of video encourages users to spend more time on your website, which in turn will increase interest in your clinic, services or company.

Aesthetics | May 2014

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

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In Practice HR

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John Sellers explains how to acquire and keep hold of staff who will prove an asset to your businesses

Nurturing your work force The medical aesthetics industry is extremely competitive. Most clinics are using similar technology and offering the same treatments, so how can your business stand out?

Though your clinic may have a similar offering to your competitors, the service you provide can differ significantly.

Making your customers feel respected, cared for, and safe in your hands does not stem from the reputation of the principal medical professional alone, it is acquired from the contact your customer has with every single member of staff involved in their treatment journey. Your people make your business.

Advertising to attract the best industry professionals Making a hiring mistake can be very costly, when you take into account the potential damage to your reputation, loss of revenue, and training costs. Hiring the right employees is fundamental to the continued success of your company. People are an investment, not a cost. Define your specifications carefully. List the requirements of the job and the personal qualities of the ideal candidate. Define what skills and attributes are necessary to the role, and be realistic: don’t look for something that does not exist. You should think about the company as a whole, for example, think about the personality that would gel successfully with your existing staff members, and one which your customers would appreciate. Write a clear and honest job advert. Include the expectations of the role, the responsibilities, the salary and benefits, the hours worked, and make each detail as accurate as possible. If the details are too vague or are subject to change, this might deter serious jobseekers, or might cause you to waste time interviewing candidates who simply cannot meet your needs.

Advertise only via appropriate channels. Make sure you pick a relevant job board for your vacancy. If job boards don’t work for you, then industry-specific recruitment companies will utilise all of the appropriate advertising avenues for you, and proactively headhunt ideal candidates. Don’t forget that referrals are also often a good method to find candidates. Ask people you trust in the sector to recommend staff to you.

CVs and interviews: identify the right candidates Don’t judge someone purely on their CV, but do filter out the weakest applications. Beware CVs that have short stints 60

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in employment or gaps between jobs. It may show a lack of loyalty, or an inability to hit targets, though this may not be the employee’s fault every time, so there is a balance to be struck.

Skills can be taught and knowledge can be instilled in someone who has the right attitude to fit into your organisation. A CV doesn’t tell you about an individual’s personality, emotional intelligence or social skills. Would you rather hire someone with the right experience but the wrong attitude, or someone with not quite enough experience but the right attitude?

Conducting a thorough interview is one of the best ways to get a deeper sense of a person’s character and mindset. Think about your interview questions carefully. It’s also important to remember that an interview is a two-way process. The best candidates will be interviewing you, too, as they will get their pick of employers.

When you find a great candidate, don’t hang around, as the best candidates will be quickly snapped up.

Induction and retention: lay solid foundations and stay in touch A good induction process will help your new employee feel comfortable, and will reassure them that they have made the right decision joining your company. Employees are happier in their jobs when they fully understand what is expected of them. Set out the company values and goals, and individual expectations and targets, but don’t ignore the basics, as these also help to form solid foundations. Tell your employee who they report to, how they book holiday, and even where they can eat their lunch.

Make staffing policies clear. An ‘unwritten rule’ should be formalised in writing if it is a regulation that you all tend to follow. For example, if you want employees to give you a month’s notice before booking holiday, include it in induction documents, don’t just tell them when the instance arises.

Consider training opportunities for all employees, even if they are very experienced, as this will show that you are willing to invest in every staff member, and help them with training that can complement and develop their role. Be fair; don’t make employees work every weekend or too many late evenings. Make sure you tell them when they are doing well in their role. You will be amazed at how well they’ll respond to praise. If you are in any doubt about how satisfied your employees are, organise regular catch-ups so they can give you their feedback. Create opportunities for progression and development. If your company can accommodate internal promotion, create a structure where this is possible. Otherwise, think about ways that employees can increase their responsibilities or benefits. If your company is doing well financially, share the success in the form of a bonus scheme.

If funds are tight, an extra day of holiday for loyal employees will remind them that their hard work is valued.

Take some time out together as a company. You don’t have to book an expensive away-day, sometimes just treating your team to some cakes and having a chat during your tea break can raise a smile after a difficult working week.

John Sellers is the managing director and owner of ARC Aesthetic Professionals, a recruitment consultancy specialising in the aesthetic medicine and cosmetic surgery sector. Since 2008, John and his team have helped numerous organisations within the industry grow their businesses by hiring the most talented aesthetic professionals in the UK.

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In Practice In Profile

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“Seeing happy patients is why I do what I do” Mr Christopher Inglefield, esteemed surgeon and medical director of the London Bridge Plastic Surgery and Aesthetic Clinic, explains his route into plastic surgery and challenges common cosmetic misconceptions After completing his medical degree in 1985, it was postgraduate training that ignited Mr Inglefield’s love for plastic surgery. “I loved the challenge and the variety in fixing problems for patients that nobody else could fix,” he explains.

His career journey began in Canada, where he studied a BSc (Hons) in Biochemistry and Microbiology in Waterloo, Ontario, before moving back to his birthplace, Trinidad, The West Indies, to pursue medicine. He went on to work in general surgery, orthopaedics and intensive care anaesthetics, before moving to the UK in 1988 to undertake surgical postgraduate training.

Mr Inglefield attained his Fellowship of the Royal College of Surgeons (FRCS) in 1990, and was then awarded the FRCS Plastic Surgery in 1998. He went on to work as a paediatric reconstructive plastic surgeon and as a consultant plastic surgeon in the NHS until 2006, when he decided to devote his time to setting up his own private practice at London Bridge Hospital. “I was splitting my time between the NHS and private work; I realised my service to my patients and my own quality of life would be better if they could have me around 24/7 for follow-up care and personal contact,” he explains. In 2010, he moved his practice to Wimpole Street, where it is currently based.

Throughout his extensive career, he says that he’s seen much change in the private medical industry. “There’s been a big increase in ensuring the private sector provides a very high standard of medical care, and a huge increase in the standard of products and treatments available to patients, for example, implants.” He says that this improvement in technology has lead to the growth of non-surgical treatments, which has opened the doors of cosmetic medicine to a much wider segment of the population. “Only 5% of the population would have surgery, whereas 80% would have non-surgical treatment,” he says. “Where cosmetic treatment used to be restricted to celebrities, now practitioners treat everyone from teachers to bus drivers to chief executives. Whoever the patient is, from cleaners to lords and ladies, they all get treated the same in my clinic.”

Whilst the patient demographic has widened, he explains that criticism of those who have cosmetic treatment still exists. “We live in a very judgemental society,” he says. “It is a quality of life issue, not a necessity, to reconstruct a skier’s anterior cruciate ligament so that they can ski again next season. They are not judged, but the person who has a large nose and wants to improve it to increase their self-esteem, is stigmatised and considered to be superficial. In reality, what is the difference? Any procedure done for the right reasons in the right patient, which improves their quality of life, is a good thing.”

He also challenges the controversy behind certain cosmetic procedures, such as vaginal reshaping, which is carried out at his own clinic. “Labial surgery is sometimes criticised and associated with female genital mutilation (FGM), which has received a lot of attention recently,” he explains. “This comparison is absurd and belittles FGM. I see several patients suffering from the condition every year, and it is assault of the worst possible kind. The majority of patients come to me requesting reduction because of physical symptoms due to an enlarged labia; aesthetic improvement is a secondary benefit.”

For the industry to move forward and simultaneously raise standards, he advises that an overall non-judgemental and supportive attitude is key. “I will listen to a patient, understand who they are and why they have a desire to change something and help them understand what is possible and whether it is good for them or not,” he says.

“Seeing happy patients is why I do what I do.”

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What’s been the biggest lesson of your career?

To be humble, no matter how good or experienced you think you are, and to focus on providing the highest standard of care I possibly can for my patients.

What advice would you offer others?

Always put your patients first and do what’s best for them. Additionally, challenge the accepted; always ask why procedures are done a certain way, and look into the evidence and science behind what you do. Finally, embrace technological change to offer your patients the best solutions.

What’s the best advice you’ve received?

Aim to be well trained and to have enough experience to deal with the difficult problems – don’t settle for the easy job, but at the same time don’t stretch yourself beyond reality.

What is currently your favourite treatment?

Endymed 3-Deep radiofrequency (RF) skin tightening. It’s state-of-the-art technology in nonsurgical rejuvenation and when patients finish a course, they want to come back for another. It’s a multi-phased RF device, which provides more effective heating of the collagen than bi-polar RF. What gives you the greatest satisfaction in your career?

Seeing my patients happy. Watching them come back after a treatment or surgery smiling and confident is why I exist.

What is the future for aesthetics?

Cellular therapy, using stem cells, fat cells and fibroblasts, is advancing fast and will be used for everything from skin rejuvenation to rebuilding cartilage and noses. The use of ultrasound for treating fat will become more commonplace, but I feel radiofrequency devices will still be the number one choice.

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In Practice The Last Word

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Aesthetics Journal

The last word Collaboration between surgeons and aesthetic doctors would provide patients with the best treatment solutions, argues Dr Darren McKeown The last two decades have seen significant growth in cosmetic practice both in the UK and worldwide. This explosion in cosmetic interventions has been largely characterised by newer, less invasive surgical procedures and the emergence of a whole new field of non-surgical procedures.

As the cosmetic interventions market has grown, more and more practitioners from a wide range of backgrounds have fought for a slice of the pie, territories have been marked out and fierce competition has emerged between rival factions. There has developed a ferocious battle between surgical and nonsurgical practitioners, with the former claiming their surgical results are more durable and longer lasting whilst the latter camp argues that their procedures have less down time and less risk.

There are a few surgical practitioners who will make the argument that they are qualified to offer both surgical and non-surgical solutions and therefore they alone are best placed to fully assess patientsâ&#x20AC;&#x2122; needs and offer the most appropriate treatment. But in my opinion this argument does not really cut it.

As with all things in medicine, and indeed life in general, the more experienced you are at one particular procedure, the better your outcomes will be. A general plastic surgeon who does 10 rhinoplasty operations per year is highly unlikely to achieve the same level of results as a rhinoplasty specialist who does 10 rhinoplasty operations per week.

Likewise, a plastic surgeon who does the occasional injection of Botox will not achieve the same results as a doctor who specialises 64

in the procedure day-in, day-out carrying out thousands of procedures per year.

Indeed, this sort of cavalier attitude towards non-surgical procedures fails to realise the significant benefits that can be achieved or the degree of skill required to achieve them.

Whilst it may be easy for anyone to pick up a syringe and inject, doing it in such a way as to make a face look genuinely more attractive is far from easy and requires a great degree of skill, knowledge and experience.

I believe that this attitude extends both ways, and there are non-surgical practitioners attempting increasingly complex surgical procedures, which, in some cases, may be beyond their level of competence. In this situation, patients might be offered the surgical procedure the doctor can do, rather than the one that might be best for them.

But is the competition and rivalry between surgical and non-surgical practitioners justified? The cosmetic market is already a substantial size and growing every year; there is plenty of opportunity for good practitioners to grow a large and successful practice, without fear of competition from other specialists. At the heart of our practice should always be finding the right procedure, for the right patient, with delivery by the right practitioner. This is good medical practice across the board, and should equally be applied to cosmetic practice. What is required is closer collaboration between surgical and non-surgical practitioners, with the focus on the needs of each individual patient.

There are many clear overlaps between surgical and non-surgical practice. One Aesthetics | May 2014

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aestheticsjournal.com

classic example encountered every day in the non-surgical clinic is the patient with heavy upper eyelids who presents requesting treatment to improve them. The non-surgical solution is to carry out botulinum toxin treatment using a pattern of injections designed to elevate the eyebrows. Whilst this does solve the problem of the heavy upper lids, it does so at the expense of creating a whole new problem of over-elevated eyebrows that inadvertently age the face and create an unnatural appearance. The proper solution in this situation is usually to recommend an upper blepharoplasty to remove the excess skin followed by a course of botulinum toxin treatment and filler injections to improve the remaining rhytids.

By combining the two, it is possible to create an optimal cosmetic result.

Whilst it is true that some patients simply do not want surgery, that is an informed decision that they need to make themselves after having a thorough consultation and explanation of the options available. It is not a decision that should be dictated based upon the availability of local skills and services.

Last year I teamed up with a surgical colleague to offer joint consultations in my non-surgical practice. The objective of the collaboration was to offer our patients a more comprehensive assessment that truly put their needs at the heart of the process.

Patients are assessed from both a surgical and non-surgical perspective and the options are discussed in detail until we arrive at the most appropriate treatment package for each individual. By combining the skills of surgical and non-surgical practitioners, a synergy is achieved where the result of combining skill sets achieves better results than either practitioner acting independently. The overall result is happier patients, with optimised outcomes and rapid growth in practice. In recent years, multi-disciplinary teamwork has dominated the management of most areas of medicine, although until now this has largely evaded cosmetic practice. Perhaps now is the time to re-think this position. Rather than viewing other specialists as a threat, we should look to each other as allies and work together for the benefit of everyone, not least for all our patients.

Dr Darren McKeown specialises in facial aesthetics and is medical director of the Dr Darren McKeown Aesthetic Medicine Institute clinic chain, based in Glasgow and on Harley Street. He previously trained as a plastic surgeon and is a member of the Royal College of Surgeons.

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Silhouette Soft Contact: Denise Daddario +442089730518 www.juvin-essence.com

Lumenis UK Ltd Contact: Nigel Matthews or Mark Stevens 020 8736 4110 UKAesthetics@lumenis.com delivering the promise www.lumenis.com Contact: Jane Myerson

Skin Geeks Ltd +44 01865 338046 info@skingeeks.co.uk www.skingeeks.co.uk

Contact: Ashaki Vidale Ellipse Technical Support T: 0208 741 1111 T: 0208 741 1111 T: 0208 741 1111 E: sales@ellipseipl.co.uk Beautylight Technical E: sales@ellipseipl.co.uk E: ashaki@ellipseipl.co.uk W: www.ellipseipl.co.uk W: www.venusconceptuk.co.uk Services Ltd W: www.technicalsupport.ellipseipl.co.uk/ Services: UK distributor of IPL & Laser Services: UK distributor of Venus Services: OnsiteAshaki service & repairs of systems, IPL & Laser training courses Contact: Vidale Freeze and Swan Radio Frequency (RF) aesthetic systems. UK agent for Ellipse and technical support & Magnetic Pulse (MP) systems IPL & Venus Radio741 Frequency +44 0208 1111systems ashaki@ellipseipl.co.uk technicalsupport.ellipseipl.co.uk Services: Onsite service&repairs Lynton of aesthetic systems. Ellipse IPL& 01477 536975 Venus Radio Frequency systems info@lynton.co.uk www.lynton.co.uk

b

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Bioptica Laser Aesthetics Contact: Mike Regan +44 07917 573466 mike.regan@bla-online.co.uk www.bla-online.co.uk Services: Core of Knowledge Training and Laser Protection Adviser (LPA) Services

Sound Surgical (UK) LTD Contact: Raj Jain +44 7971 686114 rjain@soundsurgical.com www.SoundSurgical.co.uk

t

m

Boston Medical Group Ltd Contact: Iveta Vinklerova +44 0207 727 1110 info@boston-medical-group.co.uk www.boston-medical-group.co.uk

Energist Medical Group Contact: Eddie Campbell-Adams +44 01792 798 768 info@energistgroup.com www.energistgroup.com

g

MACOM Contact: James Haldane +44 02073510488 james@macom-medical.com www.macom-medical.com TECHNICAL SUPPORT Beautylight Technical Services Ltd

c Candela UK Ltd Contact: Michaela Barker +44 0845 521 0698 michaelaB@syneron-candela.co.uk www.syneron-candela.co.uk

Galderma Aesthetic & Corrective Division +44 01923 208950 info.uk@galderma.com www.galderma-alliance.co.uk

h

Contact: Ashaki Vidale T: 0208 741 1111

E: ashaki@ellipseipl.co.uk

W: www.technicalsupport.ellipseipl.co.uk/

Med-fx Contact: Faye Price +44 01376 532800 sales@medfx.co.uk www.medfx.co.uk

Services: Onsite service & repairs of aesthetic systems. UK agent for Ellipse IPL & Venus Radio Frequency systems

ThermaVein Catherine Fuente 0161 826 3404 info@thermavein.com www.thermavein.com

v

Intense Pulse Light (I2PL) & Laser Systems Contact: Jane Myerson

delivering the promise Contact: Jane Myerson

Venus Freeze T: 0208 741 1111 E: sales@ellipseipl.co.uk Contact: Jane Myerson W: www.venusconceptuk.co.uk +44 0208 741 1111 Services: UK distributor of Venus Freeze and Swan Radio Frequency (RF) sales@ellipseipl.co.uk & Magnetic Pulse (MP) systems www.venusconceptuk.co.uk Services: Venus Freeze and Swan Radio Frequency (RF) & Magnetic Pulse (MP)2 systems

T: 0208 741 1111 E: sales@ellipseipl.co.uk W: www.ellipseipl.co.uk Services: UK distributor of IPL & Laser systems, IPL & Laser training courses and technical support

2

z Carleton Medical Ltd Contact: Nick Fitrzyk +44 01633 838 081 nf@carletonmedical.co.uk www.carletonmedical.co.uk Services: Asclepion Lasers

66

Hamilton Fraser Contact: Wai Chan +44 0845 3106 300 cosmetic@hamiltonfraser.co.uk www.hamiltonfraser.co.uk

Medical Aesthetic Group Contact: David Gower +44 02380 676733 info@magroup.co.uk www.magroup.co.uk

Aesthetics | May 2014

Zanco Models Contact: Ricky Zanco +44 08453076191 info@zancomodels.co.uk www.zancomodels.co.uk

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RES/013/0414 Date of Preparation April 2014