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VOLUME 4/ISSUE 6 - MAY 2017

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Anatomy of the SMAS CPD Mr Dalvi Humzah and Anna Baker detail the superficial musculo-aponeurotic system

Special Feature: The Perioral

Inflammation and Skin

Creating E-newsletters

Practitioners discuss how to successfully rejuvenate the perioral area

Dr Mayoni Gooneratne explains the role that inflammation plays in ageing the skin

Dr Harry Singh discusses how to best engage patients using e-newsletters


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Contents • May 2017 06 News

The latest product and industry news

14 AMWC 2017, Monaco

Aesthetics reports on the AMWC conference in Monaco

16 ACE 2017 in Review

A look at the highlights of the Aesthetics Conference and Exhibition 2017

CLINICAL PRACTICE 23 Special Feature: Treating the Perioral Area

Special Feature The Perioral Area Page 23

A panel of practitioners discuss their treatment protocols for the perioral area and provide their top tips for successful results

29 CPD: Anatomical Concepts of the SMAS

Mr Dalvi Humzah and cosmetic and dermatology nurse practitioner Anna Baker detail the superficial musculo-aponeurotic system

33 Non-surgical Rhinoplasty

Mr Ayad Harb presents his protocol for non-surgical rhinoplasty using hyaluronic acid fillers injected in to three key areas

36 Aesthetics Awards 2017

Details of the Awards categories and entry process

In Practice Creating Effective E-newsletters Page 54

40 Facial Fat Grafting

Mr Anthony Macquillian gives an introduction to fat grafting for facial augmentation

45 The Role of Inflammation in Ageing Skin

Dr Mayoni Gooneratne explains the role that inflammation plays in the skin ageing process and how to treat this effectively

48 Advertorial: Kleresca®

Introducing Kleresca® for acne and skin rejuvenation  

50 Infection Control

Clinical waste technical manager Luke Rutterford details the steps to take to prevent infection

52 Advertorial: Almirall

A combination approach for unwanted female facial hair

53 Abstracts

54 Creating Effective E-newsletters

Dr Harry Singh provides his tips for writing and utilising e-newsletters

59 Rebranding in Aesthetics

Private label cosmeceutical company director Gary Conroy discusses rebranding for long-term business development

63 Utilising Instagram

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Anna Baker is a dermatology and cosmetic nurse practitioner, running nurse-led topical PDT clinics for Galderma UK in conjunction with Ashfield Clinical. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching. Mr Ayad Harb is a surgeon specialising in plastic and reconstructive surgery and is the director of The Bicester Clinic and Qosmetic clinics in London, Oxfordshire and the West Midlands. Luke Rutterford is technical manager for the Initial Medical and Specialist Hygiene divisions of Rentokil Initial in the UK, with responsibility for training, service development, innovation, quality and compliance.

A round-up and summary of useful clinical papers

IN PRACTICE

Clinical Contributors

Digital marketing consultant Gina Hutchings explores marketing with Instagram

Dr Mayoni Gooneratne is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. Dr Gooneratne opened The Clinic by Dr Mayoni in 2016. Mr Anthony Macquillan is a consultant plastic surgeon in the NHS and provides consulting and operating services at his aesthetic and cosmetic surgery practice in Bristol, St Joseph’s Hospital in Newport and the Wellington Hospital in London.

67 In Profile: Dr Carl Thornfelt

Dermatologist and skincare brand founder Dr Carl Thornfeldt shares his successes in the aesthetics specialty

68 The Last Word

Aesthetic nurse prescriber Sharon Bennett debates whether it is appropriate to treat complications caused by other clinicians

NEXT MONTH • IN FOCUS: Lasers • Supplement Ingredients • Hyperpigmentation • Maintaining Happy Patients

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Editor’s letter Time never stands still here at Aesthetics, no sooner have we finished one event and another approaches on the horizon. With ACE 2017 now over, entries for the Aesthetics Awards are now open! Along with many others Amanda Cameron I thought ACE 2017 was a huge success – we Editor had record numbers of attendees and the feedback to date has been extremely positive! I would like to pass on my personal thanks to everyone for making it such a successful event: exhibitors, delegates, the steering committee, our team and especially our wonderful speakers, without whom we could not have maintained the high standard of education. Read our full review on p.16. So on to the Awards! The Aesthetics Awards 2016 saw more than 600 guests celebrate the year in the specialty and this year’s event promises to be even bigger and better! It is now time to start thinking about your entry for 2017 so turn to our Awards Special Focus on p.36 to find out more about the different categories and how you can enter. We continue to assess and improve our processes, having announced new categories, we have also put together a judging panel with some of the most recognised experts in the specialty, and

they will have a keen and critical eye. Entries close on June 30 so get started now and make sure you don’t miss out on your chance to receive a trophy on December 2! It may seem far away, but it will be here sooner than you think! What else is everyone thinking about at the moment – just back from sunny Monaco and the AMWC? Read our coverage from the event on p.14. This month in the journal we focus on the ageing perioral area and on p.23 we have spoken to a panel of practitioners about their approaches for treatment. Inflammation can cause some skin conditions that are difficult to treat; on p.45. Dr Mayoni Gooneratne explains the role inflammation plays in the skin ageing process and how to prevent it. We also have some great business articles this month – don’t miss reading about how to effectively create and send e-newsletters by Dr Harry Singh on p.54. Good luck to those who are entering the Awards, just think of the huge PR opportunities you get from winning or being shortlisted! Be sure to share your feedback on this issue with us on social media: @aestheticsgroup – Twitter theaestheticsjournal – Facebook aestheticsjournaluk – Instagram AestheticsJournal – LinkedIN

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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. Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies. qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments. Dr Tonks has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide. 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. for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

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Dermal filler

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Feedback Mr Dalvi Humzah @mdhtraining A big thank you to Jeanette Haynes at Body BenefitsGalway for such kind words following #ACE2017

#WorkSatisfaction Dr Galyna Selezneva @DrGalyna The sense of satisfaction I get when patients smile – it’s incredibly rewarding #mondaymotivation #bodyconfidence #Interview Mrs Sabrina Shah-Desai @perfecteyesltd Getting interviewed by the Chinese media #aesthetics #trends #Conference Dr Stefanie Williams @DrStefanieW  Finished my 2 lectures at the #AMWC conference in Monte Carlo. I talked on skincare and probiotics. Now time to relax at the gala dinner #Training Fusion GT @FusionGtUk #amazingdoctors #ultimatePlasma #Plexr #training @NuYuLondon @illuminateskins @AbsoluteAesthet @maxmalik @DrShirin_ #Knowledgeispower #ConsentForms Mr Baljit Dheansa @dheansa_plastic  Good example of #innovation is prepared #consent forms with good #patient info to save time, improve consistency & inform pt @InnovationSIG #Celebrity Dr Sach Mohan @SachMohan Thanks to @JamesArthur23 for entrusting @RevereClinics to ensure his #skin remains as good as his #music!

JUVÉDERM VOLLURE XC approved by FDA for severe facial wrinkles Global pharmaceutical company Allergan has confirmed that it has received Food and Drug Administration (FDA) approval to market Juvéderm Vollure XC (known as Juvéderm VOLITE in the UK) for the correction of moderate to severe facial wrinkles and folds in the US. Allergan explained that Juvéderm Vollure XC has been specifically tailored with a balance of gel firmness and low cohesivity to offer a versatile formulation that aims to add subtle volume to treatment areas. In a clinical trial, 59% of subjects saw improvement in moderate to severe nasolabial folds for up to 18 months. In addition, 82% of patients said that they were satisfied at six months and 68% said they were still satisfied at 18 months. Chief research and development officer at Allergan, David Nicholson said, “What’s exciting about Juvéderm Vollure XC is that it was shown to last up to 18 months from the initial or touch-up injection in a majority of subjects, which is the longest lasting result shown in a clinical study in the nasolabial folds.” He continued, “This commitment to ongoing scientific research and development is one of the factors that makes Juvéderm the number one selling collection of dermal filler products.” Skin tightening

Fusion GT launches new carboxytherapy device for cellulite The CarboMix High Performance carboxytherapy system for cellulite and body tightening has been introduced to the UK by aesthetic distributor Fusion GT. According to the company, the device uses carboxytherapy microinjections that combines oxygen and carbon dioxide into one device, aiming to treat a wide range of indications for the body and face, including addressing vein insufficiency in the lower limbs, targeting adipose, lightly lifting ageing skin and reducing the appearance of cellulite. Fusion GT claims it has a higher output and performance time compared to other devices, making the treatment more effective. The company has appointed aesthetic practitioner Dr David Jack as its key opinion leader for this technology, he said, “I am very excited to have been chosen to be a KOL for CarboMix – I have been interested in carboxytherapy for a number of years and am delighted to offer this versatile treatment in my office.” Dr Jack added, “The CarboMix machine was of particular interest to me because of its unique technology that allows regulation of temperature and flow of CO2 to make the treatment more tailored to the individual patient depending on their pain threshold and treatment requirements. In addition, this machine, in particular, also offers the ability to perform an oxygen facial, which, in itself, is a huge bonus to the regeneration and repair of the skin of the patient being treated.”

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Aesthetics Journal

Aesthetics

Awards

New categories and sponsors for Aesthetics Awards 2017

60

John Culbert, CEO of Cambridge Stratum

Entry for the most prestigious Awards ceremony in the specialty is officially open, with eight new categories to choose from. The new categories are Best UK-based Manufacturer, Best Supplier Training Provider, Wholesaler of the Year, Best Clinic Support Partner, Energy Treatment of the Year, Best UK Subsidiary of a Global Manufacturer, Industry Initiative of the Year and the Enhance Insurance Award for Best Independent Training Provider. Also, new sponsors have been confirmed, which are: The AestheticSource Award for Best New Clinic UK and Ireland, The John Bannon Award for Best Clinic Ireland, The Dermalux Award for Best Clinic London, The Profhilo Award for Best Clinic Group UK and Ireland (3 clinics or more), The SkinCeuticals Award for Medical Aesthetic Practitioner of the Year, The Harley Academy Award for Injectable Product of the Year, The iS Clinical Award for Best Clinic South England and The PHI Clinic Award for Industry Initiative of the Year. Continuing their sponsorship from last year are Schuco International, who will once again sponsor the award for Outstanding Achievement in Medical Aesthetics, Healthxchange, who will sponsor Sales Representative of the Year and The Barry Knapp Award for Product Innovation of the Year, supported by Medical Aesthetic Group. Aesthetics journal editor, Amanda Cameron said, “Entering the Aesthetics Awards is an excellent opportunity to celebrate the successes and achievements of your business. It is essential to be able to stand out from the crowd and be recognised as one of the best, so we are encouraging you all to enter to gain your well-deserved recognition!” The Aesthetics Awards will honour Winners, Highly Commended and Commended finalists at the Park Plaza Westminster Bridge Hotel on Saturday December 2. For more information turn to page 36 of the journal and to enter, go to www.aestheticsawards.com. Training

Medira Ltd releases dates for new PRP Masterclass Aesthetic product provider Medira Ltd has released dates for its PRP Masterclass 2017. The course, which will take place in Leeds and Birmingham, aims to guide delegates through the aesthetic application of platelet-rich plasma (PRP) for skin and hair. The training day will cover applied skin anatomy, combining PRP with other aesthetic treatments and a hands-on practical session. Ophthalmic surgeon Mr Ali Hassan will present at the training day. He believes PRP treatments are often misunderstood or taught incorrectly. “If the incorrect technique is used, it’s possible to inject 3ml of PRP and not notice any effect,” said Mr Hassan, adding, “I am pleased to have found a treatment I can guarantee for skin rejuvenation. Around 99% of my patients are happy after a single PRP treatment.” The training days will take place on 7 May in Leeds and 14 May in Birmingham.

Who are Cambridge Stratum? Cambridge Stratum is UK based and was established when I was sourcing equipment for our associate company Cosmex Clinic. It became apparent that there was a need for a broad range distributor that offered unbiased advice and quality equipment that is value for money. Cambridge Stratum provides globally sourced equipment that is tried and tested including approvals, user training and a two-year on-site warranty. We aim to reduce the barriers hindering equipment purchase by providing commercial experience to assist in selecting the right product for each business need. Why is energy-based equipment important to a growing aesthetic business? The market has moved on from simply treating lines and wrinkles and now takes a holistic approach to patient consultation as well as offering combination treatments for optimum results and increased patient satisfaction. The inclusion of both injectable and energy-based treatments increases the revenue per client and protects the business from competition. What to look for when purchasing equipment? The most important aspect for business success is the return on investment (ROI) and by distributing a wide range of technologies we can give genuinely unbiased advice. In order to maximise the ROI the product will need to be effective, in the growth phase of its product life cycle, and be an approved product that is fully supported. Purchase timing is vital and we improve the ability to purchase the product at the right time through a combination of better value pricing, two-year warranty and asset finance. What would you recommend a business to invest in? High intensity focused ultrasound is a technology that produces effective, long-lasting results and a very good ROI. Body contouring/sculpting is a strong growth market but a large investment for an effective machine. There is also a trend globally towards early intervention/preventative treatments and we will be making an exciting announcement related to this area in June 2017. This column is written and supported by

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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

Aesthetics Journal

Aesthetics aestheticsjournal.com

Hair removal

New two-in-one permanent hair removal treatment

BACN LAUNCHES NEW ACTIVITY AREAS FOR 2017/18 BACN Mentoring Programme: bringing together support from experienced members of the BACN to those newer into aesthetics – led by regional leader for Wales, Jane Laferla. An audit and update of the extensive BACN Competence Framework for non-surgical treatments – led by BACN board member Adrian Baker. Facilitating training opportunities for BACN members (cadaver training, business support). More details of these activities will be announced within the Member’s area of the BACN website.

BACN MEMBERSHIP RENEWALS Our renewals period is now open to BACN members for the new membership year. We’re encouraging current members to renew to remain a part of the largest professional association for aesthetic nurses in the UK, and we are welcoming new members to join our support network. For more information, please contact Gareth Lewis, Membership Manager at glewis@bacn.org.uk.

NEW OPERATIONS MANAGER AT BACN HQ Liz de Pass has left the BACN after four years and we would like to thank her for helping the BACN be what it is today. We are delighted to announce that Sarah Greenan has started as operations manager at our HQ in Bristol. Sarah joins us from the Marriott Group with extensive management experience and innovative ideas to develop the association.

MEET A MEMBER Karen Burgess is an independent nurse prescriber with her own clinic in Derbyshire. Burgess has been working in aesthetics for nine years and is the BACN regional leader for the North West. She likens the BACN to a hospital/trust which provides all round support, education and guidance, and believes that the BACN is vital for aesthetic nurses who often work in isolation. She also regularly attends the annual conference, which she says is a celebration of nurses working in aesthetics and is a big benefit of being a member.

This column is written and supported by the BACN

Aesthetic supplier Clinogen Laboratories has launched a new device aimed at removing hair from the body using static and sound waves. The Epil Sonic treatment utilises two techniques (direct and indirect probes) in one treatment. The direct method uses a needle probe that aims to target and destroy the stem cells in the bulge of the hair to prevent further hair growth, which the company claims is particularly useful on coarse and terminal hair, as well as distorted hair follicles. The indirect probe aims to remove all visible hair. Founder of Clinogen Laboratoties, Sujata Jolly, said an advertisement of a wine glass shattering was the inspiration for Epil Sonic, “If sound waves could shatter glass, then why couldn’t they shatter hair roots? We used this technology to create Epil Sonic, which, via the ‘direct method’, sends sound energy down a probe into the centre of the hair follicle. The sound energy travels until they find something to hit. The first thing they will find is the bulge of the hair, and the soundwave will literally explode, shattering the root and stopping hair regeneration.” According to the company, Epil Sonic is suitable for all skin types, is said to be relatively painless and can be used on sensitive areas of the body including upper lips, underarms, the bikini line and the nipple area. Treatment trends

Non-surgical rhinoplasty on the rise According to new data released by private clinic comparison site WhatClinic.com, non-surgical rhinoplasty has increased by 29% over the past year. The site looked at trends from 5,765 cosmetic surgery and medical aesthetic clinics in the UK listed on WhatClinic.com, as well as website traffic, and discovered that interest in the surgical rhinoplasty had dropped by 5%, with the total number of cosmetic surgery procedures falling by 10%. The data released reflects the recent findings from the British Association of Aesthetic Plastic Surgeons (BAAPS), which found that the number of invasive cosmetic surgery procedures in 2016 was the lowest in almost a decade. According to the data collected by WhatClinic.com, dermal fillers topped the list of non-surgical treatments and internet search traffic grew by 16% in the past year. Commenting on the data trends, Phillip Boyle, head of consumer matters for WhatClinic said, “What we’re seeing on the site is an increase in demand for less invasive, non-surgical treatments that can help patients get the aesthetic change they’re looking for, without the cost or recovery time required of cosmetic surgery. Interest in surgical procedures is still very much there, but there are now more options for patients, especially for those who want to make minor improvements and subtle changes. With more options comes more choice and it’s important that patients read reviews, compare prices, and research medical experts in order to make the best, most informed decision for their treatment needs.”

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Aesthetics

Skincare

5 Squirrels expands Your Signature Range Private label cosmeceutical supplier 5 Squirrels has expanded its series of brandable Your Signature products to include a high-strength premium range and a collection of travel items. Launched three years ago to provide clinics with own branded skincare, Your Signature now includes the premium ‘Your Prestige’ range for existing clients whose patients want to fine-tune their skincare regimen. Also new is ‘Your Cruise’, a collection of travel products designed to help patients maintain their regime while away. The items are packaged in airport security compliance-sized bottles.   “The team have worked really hard over the past 12 months to develop the Your Prestige range, which has been created with the support and advice from other skincare brands who have been extremely successful with their signature range,” said Gary Conroy, co-founder of Five Squirrels. He added, “The Cruise collection allows our brand owners to offer their patients a seamless journey from dressing room table to the first class lounge without disrupting their daily skincare routine. We are delighted to be launching this collection now so that clinics can offer their clients brand continuity without having to spend additional money on duty free mainstream skincare brands.” Included in the Your Prestige range is R+, a high-strength 1% retinol serum; C20, a 20% vitamin C serum; and H2, a luxury intense moisturiser. Your Cruise comprises Prepare, Hydrate, Protect 50 and Recover products in 15ml airless pump bottles.

Vital Statistics

30%

of mobile searches are related to a location (Google, 2016)

Nearly 30% of participants in a poll of 1,000 women in Surrey and the South East cited stress and anxiety as having a detrimental impact on their looks (Health + Aesthetics, 2017)

Infographics are ‘liked’ and shared on social media 3X more than other any other type of content

Resources

New textbook on aesthetic treatments launches A new textbook that encompasses a wide range of topics in aesthetic medicine has been released. Cosmetic Medicine & Surgery, which launched at the 15th Aesthetic & Anti-aging Medicine World Congress (AMWC) on 6-8 April, has more then 70 chapters, 1,200 figures (with many in full colour), and more than 80 tables from an international list of contributors. The book, edited by Dr Pierre Andre, Dr Eckart Haneke, Dr Leonardo Marini and Dr Christopher Rowland Payne, covers five sections; Fundamental aspects, such as the perception of beauty and how to evaluate ageing; Cosmetic aspects, such as cosmetics and cosmeceuticals; Minimally invasive surgery; The aesthetic face lift; and other aspects, such as training in aesthetics and dermatology, marketing and legal considerations. “This is an incredible source for tips and guidelines from experts sharing their knowledge on a discipline, which has an incredibly fast rate of innovative treatment strategies, such as cosmetic and surgical dermatology,” said Dr Marini. He continued, “The hybrid way of sharing knowledge chosen for this book is highly practical and the format options of the book fulfil the requirements of conventional learning as well as e-learning preferences. All aspects of cosmetic and surgical dermatology have been covered in detail with nothing missing.”

(Massplanner, 2016)

Tweets with hashtags get two times more engagement than tweets without (Twitter, 2012)

Rosacea affects 1 in 10 people in the UK (NHS, 2017)

According to statistics from Hamilton Fraser, 2016 saw a 37% increase in surgical and nonsurgical claims from 2015 (Hamilton Fraser, 2017)

Melanoma is twenty times more common in Caucasian Americans than African Americans (AIM at Melanoma Foundation, 2017)

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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

18th May 2017 British Association of Sclerotherapists Annual Meeting, Windsor www.bassclerotherapy.com

26th - 27th May 2017 Association of Scottish Aesthetic Practitioners Conference theasap.co.uk

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

4th - 6th July 2017 British Association of Dermatologists 97th Annual Meeting, Liverpool www.bad.org.uk

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

Hamilton Fraser invests in brand awareness with new website Insurance firm Hamilton Fraser Cosmetic Insurance has launched a new website to showcase its portfolio of products. The company, which provides specialist cover for aesthetic and cosmetic surgery practitioners, has been working on the redesign of the site for a year as part of a wider project to boost awareness of and engagement with its brand. Hamilton Fraser’s CEO Eddie Hooker said, “We are really pleased with the look and feel of our new website, showcasing the vision and core values of our brands. The site is the latest advance in the company’s transformation and will support our future growth and expansion plans.” The website’s features include video, information on Hamilton Fraser’s history and people, and a section containing guides, fact sheets, information and other educational tools for consumers. The website is live now.

Aesthetics Journal

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Clinical trials

Treatment for acne receives positive results Global pharmaceutical company Allergan and biopharmaceutical company Paratek have confirmed that two phase 3 trials of sarecycline met their 12week primary efficacy endpoints. 1.5mg of oral sarecycline was compared with a placebo in subjects with moderate to severe acne based on the Investigators Global Assessment (IGA) scale score and inflammatory lesion counts. Patients were randomised (1:1) into two treatment groups to receive either sarecycline tablets or a placebo once a day for 12 weeks. Sarecycline was statistically significantly (p<0.004) superior to placebo with respect to primary efficacy endpoints. The most common adverse events (>2%) reported in the sarecycline group were nausea (3.2%) nasopharyngitis (2.8%), and headache (2.8%). The rate of discontinuation due to adverse events among sarecycline-treated patients in the two studies combined was 1.4%. “The positive efficacy results observed in the pivotal phase 3 clinical trials indicate that sarecycline can be an effective treatment option for patients with moderate to severe acne,” said David Nicholson, chief global research and development officer at Allergan. He added, “We look forward to submitting a new drug application for sarecycline and bringing to market a potential new option for physicians treating patients with acne.“ Awards

Consentz shows support for Clinic Reception Teams Aesthetic business management software package Consentz will sponsor the award for Best Clinic Reception Team of the Year at this year’s Aesthetics Awards on December 2. This award recognises reception teams that show ongoing outstanding customer services, a continuous training programme, strong practitioner support and effective teamwork that is benefiting the clinic and its patients. “We believe the reception team are truly the heart of every clinic,” said Consentz co-founders Dr Natalie Blakely and Michael Geary. “The reception team play such a fundamental role in both the success of the business as well as the patients’ positive experience, which is why we are delighted to be sponsoring this award.” Consentz is a bespoke software package designed for aesthetic businesses which aims to bring together all the tools needed to build patient relationships, grow revenue, and save practitioners’ time – all within a seamless, compliant and secure system. The Aesthetics Awards will take place at the Park Plaza Westminster Bridge Hotel on December 2. Industry

Acquisition Aesthetics partners with Cosmetic Insure Training academy Acquisition Aesthetics will collaborate with Cosmetic Insure to provide a tailored and discounted insurance package for all of its graduates. Acquisition Aesthetics is a surgeon-led facial aesthetics training academy based at the Royal College of Practitioners in London. According to co-director Dr Priyanka Chadha, the company believes that delegates should be offered comprehensive insurance packages that match their rigorous training in aesthetic treatments, facial anatomy and potential complications. She said, “It is essential that our delegates feel confident in their ability to deliver treatments safely.”

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Skincare

Lynton Lasers expands UK laser and intense pulsed light manufacturer, Lynton Lasers, has announced plans to expand its UK mainland operation and build their presence in the Irish marketplace. According to the company, which won the Aesthetics Award for Equipment Supplier of the Year in 2016, they aim to provide the same high level of customer service, training and post-purchase support experienced by their current UK mainland customers. Dr Jonathon Exley, managing director at Lynton said, “As a British manufacturer who has been predominately focused on the quality of our equipment and the level of customer service we provide, the UK marketplace has been our focus for several years now. As a growing company and brand, we are now looking to expand and increase our resources across Europe, starting with Ireland. We look forward to working directly with clinics across Ireland and helping them succeed using our award-winning aesthetic technology.”

Three-step skincare programme launched by Dr David Jack Aesthetic practitioner Dr David Jack has released a threestep beauty programme and a range of supplements. The Integrative Beauty range includes three targeted topical solutions, four supplement drinks and two capsules available as a package with the tagline ‘beauty from the inside out’. Dr Jack said, “Most modern active skincare products contain high levels of antioxidant molecules but do not address deeper factors affecting the skin from the body within.” He added, “What this range does differently is target the skin from the internal environment in addition to targeting the skin surface with high levels of antioxidants and sun protection.” Products for topical use comprise a vitamin C gel serum for morning application, an SPF 50, a tinted all-day moisturiser and a retinyl palmitate repairing night cream. Also included in the range is a morning matcha tea and an evening superfood tea, along with two supplementary drinks containing a blend of skin-boosting ingredients. A capsule-form supplement for skin, hair and nail health, and one to promote sleep, complete the beauty programme. Dr Jack said, “The Integrative Beauty skincare and nutraceuticals are designed to provide a simple and effective range that cuts out a lot of the unnecessary confusion associated with choosing skincare. These products have been designed with the time-poor, results-driven consumer in mind.”

Symposium

On the Scene

Speakers confirmed for the NeoStrata European Symposium The full agenda and speaker lineup is now available for the NeoStrata European Symposium at The Royal College of Physicians on May 19-20. The two-day educational event aims to provide delegates with all the knowledge and tools to offer first-rate products, regimes and treatments to their patients. Demonstrations and talks will be given by: Professor Beth Briden (US), Professor Mukta Sachdev (India), UK-based dermatologists Dr Sandeep Cliff, Dr Stefanie Williams and Dr Martin Wade, as well as Dr Uliana Gout, and aesthetic nurse prescribers Anna Baker and Lorna Bowes. NeoStrata’s vice president of Clinical Affairs and Technology, Barbara Green will look at skin healing, and the new NeoStrata Retinol Peel will be unveiled on day two by NeoStrata’s Pete Konish, covering the science behind the peel and practical experience using it. Professor Briden, Dr Williams and Baker will relay their own experiences using the peel in their clinics. US aesthetic business consultant Wendy Lewis, supported by an international journalist, will also deliver insight into the consumer view of the aesthetic market, all to help guests understand their clientele better. A buffet lunch is also included on both days for attendees, as well as an evening BBQ on May 19 and a goody bag of products.

Wigmore Medical Open Day, London  Two CPD-certified agendas ran parallel throughout the day at Wigmore Medical’s first exclusive open day for 2017 at the Royal Society of Medicine on April 4. The Merz Aesthetics agenda featured masterclasses on facial assessments and injection techniques with aesthetic practitioner Dr Tahera Bhojani-Lynch, who also provided live demonstrations. Among the sessions on the other agenda was an Invasix session with Neil Wolfenden, managing director of Invasix and InMode on the latest in body contouring technology and a Vaniqa session by director of JVO Consultancy and dermatology educator Julie Van Onselen, who discussed this treatment for facial hair removal. Presentations dedicated to the science and technology behind ZO Skin Health from Rick Woodin, vice president of global research and development took place in the evening. “We were delighted to confirm such a strong itinerary for the day with revered speakers throughout,” said Raffi Eghiayan, director of marketing and business development at Wigmore Medical. He added, “We were honoured to have had Rick Woodin fly over from the US to host an evening with the brand and discuss their latest innovations. It’s set to be an exciting year for Wigmore Medical and it’s always brilliant to see so many in attendance to the Open Days.” 

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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News in Brief Merz Pharma to expand production plant in Germany Global pharmaceutical company Merz Pharma is constructing a new production plant to produce dermal fillers at its site in Dessau, Germany. The new plant will allow Merz to hire 25 additional employees, who will consist of scientists, engineers, pharmaceutical technicians and chemical technicians. According to the company, the building will cover approximately 1,200 square metres and is due for completion in the summer of 2018. BAHRS appoints new CEO The British Association of Hair Restoration Surgery has appointed Danny Large as its new, part-time chief executive. Large, from DSL Consulting, aims to help drive the Association forward and build links with the hair loss, hair care and wider aesthetics communities. He said, “I’m very excited to be given this opportunity to work with BAHRS. I look forward to being involved in this part of the industry as well as helping the BAHRS to thrive and become an industry leading organisation.” New pharmaceutical campaign focuses on embarrassment of rosacea Pharmaceutical company Almirall is launching a campaign to raise awareness of the psychological impact of rosacea. The campaign has been timed to coincide with spring, when the skin condition often worsens with temperature changes, more sunlight and greater inclination to be outdoors. The awareness drive is aimed at showing how this chronic dermatological disease of unknown cause can have a significant and detrimental effect on the person’s quality of life. Winners of the Enhance Insurance ACE 2017 competition announced Enhance Insurance has announced the winners of its Aesthetics Conference and Exhibition (ACE) 2017 competition. The first prize – two tickets for the final day of The Goodwood Festival of Speed on July 2 has been won by Ms Ros Bown. The second prize – two tickets for the Moving Motor Show at The Goodwood Festival of Speed has been won by Ms Eva Lewis. Enhance Insurance would like to thank those who took part in the competition.

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On the Scene

A Graceful Jump Beyond Mesotherapy, London Delegates attended the Avanti Aesthetics Academy Training Suites on Harley Street for a day of training on skin treatments on April 6. The training day, held by AestheticSource, was led by Dr Jane Ranneva, a certified trainer. Delegates were taught how to repair, refill and stimulate skin and hair with antiageing treatments, using peels and mesotherapy for skin lifting and tightening, skin nutrition, management of pigmentation issues and stretch marks, and biostimulation for alopecia. “It was great that all attendees left feeling inspired and confident to incorporate Skin Tech peelings and the RRS biorevitalisation range of products into their treatment menus for their patents,” said Lorna Bowes, director of AestheticSource. “Dr Ranneva did a phenomenal job demonstrating the treatment protocols and evidencing the results of the treatments.” She added, “We are all looking forward to the next training day which is on May 30 for Skin Tech.” On the Scene

Epionce Seminar with Dr Carl Thornfeldt, London Aesthetic practitioners from all over the UK gathered at the Royal Society of Medicine for a presentation on the launch of the Epionce Daily Shield Lotion SPF 50 by Epionce founder Dr Carl Thornfeldt. Guests arriving for the early afternoon event were treated to tea, coffee and refreshments and were able to sample the new Daily Shield Lotion prior to the talk. Dr Thornfeldt, a US dermatologist who founded the skincare brand gave a presentation on the Epionce philosophy, explaining that the idea for the products began with the question, “If the epidermis has optimum structure and function, could we help to prevent skin cancer and other skin diseases, and also affect skin ageing?” Dr Thornfeldt then explained the structure of the epidermis, exfoliation, abnormal skin conditions and more, as well as how the Epionce products can help improve a variety of skin conditions. Carly Poore, marketing coordinator at Eden Aesthetics, which distributes Epionce, said, “Our Epionce event with Dr Carl Thornfeldt was a tremendous success with a fantastic turnout. Epionce customers from all over the UK attended for the launch of the new Epionce Daily Shield Lotion Tinted SPF 50. “ She added, “Dr Thornfeldt is a fountain of knowledge.” On the Scene

Future is Fusion event, London Hosted at Chandos House, central London, Harpar Grace International launched the first in a series of exclusive industry ‘Future is Fusion’ events, open to aesthetic practitioners across the UK on April 4.  Blending clinical education, business training, brand engagement and networking, the full-day event presented a showcase of synergistic noncompeting brands. Dermalux, Skinade, Visia, Hydrafacial and iS Clinical contributed to the agenda where they covered a wide range of content including: how to develop depth in your clinic; inflammation, ageing and the exfoliation process; noninvasive hydradermabrasian; and how to transform your business portfolio.  Alana Marie Chalmers, director at Harpar Grace International said, “We have had such positive feedback from both delegates and the brand partners that we will shortly be announcing additional 2017 dates and key UK locations for Fusion events.”

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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AMWC 2017, Monaco A report on the 15th annual Aesthetic and AntiAging Medicine World Congress in Monte Carlo on the 6-8 of April 2017 The warm gleaming sunshine of Monte Carlo was the perfect greeting to the aesthetic professionals who made their way to the Aesthetic and Anti-Aging Medicine World Congress (AMWC) to discover the latest developments in this growing specialty. The congress, which commenced on April 6, was held at the prestigious Grimaldi Forum conference and exhibition centre, where medical professionals from 120 different countries could connect with renowned industry leaders and companies, and partake in expert discussions in the fields of aesthetic dermatology, plastic and aesthetic surgery and multidisciplinary preventative and antiageing medicine. Scientific directors of the congress, Dr Thierry Besins and Dr Claude Dalle introduced this year’s theme as ‘Challenges and Opportunities’ to mark the congress’ 15th anniversary. Dr Besins said, “The theme of AMWC 2017 reflects our long-term commitment to building the advances in research and clinical practice, maximising multidisciplinary approaches to promote, and leaping into the future of aesthetic and antiageing medicine as a whole.”

Sessions covering all aspects of aesthetic medicine took place at the congress. ‘Difficult Zones: Focus on Lower and Upper Eyelid’ was a highlight for delegates, where French surgeon Dr Philippe Kestemont and facial plastic surgeon Miss Cécile Winter discussed the anatomy through videos of cadaver dissections. Dr Kestemont explored the tear trough area, showing a video demonstration on the benefits of stretching the ligament under the eye. He said, “If you only fill the hollow part it’s not enough – you can do a soft movement with the cannula to stretch the ligament and then after you can inject. The benefit is that you use less product and have better results.” In a session discussing regenerative aesthetics, UK practitioner Dr Kate Goldie examined the factors of stem cells in ageing. She said, “We as aesthetic doctors from all over the world have a unique opportunity to be pioneers in regenerative soft tissue medicine.” Delegates attending the ‘Forehead and Eyebrows: A Key Line of Beautification and Rejuvenation’ session saw Spanish practitioner Dr Philippe Deprez provide treatment options for glabellar wrinkles that are resistant to injectable

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treatments, discussing the use of chemical peels in the area instead. He concluded, “You must have the correct post-procedural care with antioxidant creams and sun protection to avoid post-inflammatory hyperpigmentation.” Following this, Dutch practitioner Dr Daria Voropai discussed the importance of the brow and what patients are looking for, “We have a brow obsession, I make brow contact before I make eye contact, that’s a phrase well heard by our patients,” she said. The congress also featured many industry sponsored symposiums, some of which included those from Galderma, Merz Aesthetics, Syneron Candela, Teoxane Laboratories and Allergan. The full-day Allergan symposium, which took place on April 7, was well received by delegates, who watched presentations showcasing Belkyra for submental fullness and the company’s new hyaluronic acid injectable for skin quality, Juvéderm Volite. During the symposium, UK cosmetic surgeon Dr Jonquille Chantrey discussed the importance of skin quality and how skin changes as we age. German dermatologist Dr Patricia Ogilvie followed, discussing Juvéderm Volite in detail. She said, “We have successfully shown that Juvéderm Volite is efficiently able to improve the hydration of skin with only one treatment for up to nine months after a single injection and also improves the texture, smoothness and elasticity of skin.” When discussing the patients’ response to this treatment she added, “Ask your patients ‘how do you feel?’ rather than ‘how you look?’ because this product makes your skin feel different.” Swiss practitioner Dr Marva Safa then performed a live demonstration on how to effectively conduct the treatment. The symposium concluded with an extremely popular hour-long live demonstration of a full facial transformation using Allergan’s MD Codes by Brazilian aesthetic practitioner Dr Mauricio de Maio. His session was awarded a large applause both from inside the auditorium, and from those watching at the Allergan stand on the Exhibition floor. Dr Chantrey said of the congress, “It’s been a great week – I am really happy with the way the symposium went – I feel that we challenged ourselves and took beauty to the next level. Looking at the congress as a whole I hope that the UK and international practitioners will follow suit as patients deserve a higher standard of outcomes.”

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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ACE in Review A look at the highlights of the Aesthetics Conference and Exhibition 2017 With 82 exhibitors, 57 speakers, 51 educational sessions and a record-breaking 2,118 delegates, the Aesthetics Conference and Exhibition (ACE) 2017 was a huge success! On March 31 and April 1, aesthetic professionals met at the Business Design Centre in London for two days packed with learning, innovation and networking at the leading medical aesthetic event in the UK. ACE programme organiser and editor of Aesthetics, Amanda Cameron said, “We are absolutely delighted with the turnout for ACE and how smoothly the whole event ran. It was bigger, better and buzzier than ever before – the feedback has been overwhelmingly positive – we are looking forward to continuing to expand and provide top educational content to practitioners, further cementing our place as the leading medical aesthetic conference in the UK.” As well as being able to explore the 2,500m2 Exhibition Floor, delegates could utilise valuable learning experiences on business development and clinical practice, earning vital CPD points at every session they attended. Comprising four varied and informative agendas, three of which were free to attend, delegates could watch live demonstrations and learn about a wide range of treatment indications, clinical techniques, product innovations and business support from the aesthetic specialty’s most renowned and respected professionals. The event attracted delegates from across the profession, including doctors, nurses, surgeons, dermatologists, dentists, aestheticians and clinic managers. Helen Margaret Bowes, an aesthetic nurse prescriber from Skin Beautiful clinics, said, “I’ve gained a lot of knowledge and things to take back to my clinic at ACE 2017. I was practising for five years before I actually attended ACE and wish I had visited a lot sooner!”

World renowned experts at the Premium Clinical Agenda Taking place in the main auditorium, the Premium Clinical Agenda was split into four sessions dedicated to facial assessment and treatment. Led by the UK’s most renowned aesthetic experts, each session featured live demonstrations and interactive discussions on how to beautify the face using a variety of techniques including injectables and chemical peels. The Ageing Female Face: ACE Steering Committee Chair Mr Dalvi Humzah led the first session on the Premium Clinical Agenda on the Friday morning alongside cosmetic practitioner Dr Tapan Patel, dermatology nurse prescriber Anna Baker and aesthetic practitioner Dr Nestor Demosthenous. Dr Patel began the session by presenting the anatomical changes that occur during the ageing process, with particular emphasis on the changes to the fat compartments, before sharing a film of a successful dermal filler treatment he performed on a 56-year-old patient. In his presentation Dr Patel emphasised, “It’s important to understand what goes on in the ageing process, in particular boney recession and resorption, to provide a strategy for targeted injection.”

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Dr Demosthenous discussed how to offer a successful consultation and take a comprehensive history, as well as how to thoroughly examine the ageing face – considering skin tone, hydration, lines and wrinkles, boney volume loss, asymmetry and dentition. Baker then detailed the cosmetic application of trichloroacetic (TCA) acid for the ageing female face, while detailing relevant facial anatomy and explaining how TCA works in practice. Following her presentation, Baker performed a live TCA peel demonstration, discussing the elastic changes in the patient’s skin, the visibility of pores and the skin’s overall thickness. Mr Humzah also performed a live demonstration of a mid-face dermal filler treatment, which focused on the lower face and the chin, detailing how it ages and advising how to enhance the jawline and balance overall facial appearance. He also engaged the audience in an in-depth discussion of facial anatomy, advising which nerves and vessels to avoid when performing injectable treatments. The Male Face: On the Friday afternoon, consultant dermatologist Dr Maria Gonzalez and aesthetic practitioners Dr Kate Goldie and Dr Beatriz Molina presented the Premium Clinical Agenda session on The Male Face. The practitioners highlighted the variations in anatomical differences between men and women, as well as the difference in skin texture, before showing the audience images of some of the concerns men could present with. Dr Molina explained how she finds that men usually come to her clinic complaining of looking tired and seeking a more youthful, energetic look; while Dr Gonzalez emphasised the need to take consideration of the skin texture, as well as the more obvious lines and wrinkles that men complain about. The practitioners each assessed and treated three models with very different concerns; including how to treat rosacea, how to masculinise a rounder face by creating a squarer jawline, and how to create facial balance. Dr Gonzalez also demonstrated her tips and techniques for using cannulas, which drew great interest from the audience. The Basics of Facial Assessment: Saturday morning began with a session dedicated to those who are newer to the aesthetics specialty – focused on teaching the fundamental skills that are so important to clinical development and mirroring the other sessions of the agenda at a learner level.

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Dental surgeon Dr Souphiyeh Samizadeh, aesthetic practitioner Dr Uliana Gout and aesthetic nurse prescriber Lorna Bowes led this innovative session and presented live demonstrations of their treatment approaches. Dr Gout began by detailing the differences in the male compared to the female face; sharing advice on enhancing skin quality, shape and musculature, before performing a live demonstration of a botulinum toxin treatment and skin peel. Dr Samizadeh then reinforced the need to ‘be safe not sorry’ in her presentation on the complications that can occur as a result of injectable treatment. She shared images of patients with skin necrosis and other complications, while emphasising the importance of understanding facial anatomy and how to safely manage any issues that occur. Dr Samizadeh then performed a live demonstration of mid-face rejuvenation using fillers on an ageing female face, detailing the relevant anatomy to consider and where to inject to achieve full facial rejuvenation. Bowes then took to the stage to present on skin ageing. She emphasised that ‘preventation is better than cure’ and outlined the benefits that can be achieved by taking care of each layer of the skin and the appropriate skincare ingredients to use for enhanced results. Bowes went on to perform a live demonstration of using a peel on a young female face, detailing how it should be applied safely, as well as the importance of pre- and post-procedure care. The Young Female Face: Aesthetic practitioners Dr Askari Townshend, Dr Raj Acquilla and nurse prescriber Sharon Bennett led the final Premium Clinical Agenda session on assessing and treating a female patient showing the first signs of ageing. The experts discussed how to improve general skin quality in younger patients, before Dr Townshend shared advice on managing patients with a limited budget; recommending how practitioners can provide the most effective results with a minimal price tag. He then performed a live demonstration on a 26-year-old patient, before Bennett discussed and demonstrated how to use dermal fillers to improve the skin’s hydration, evening the appearance of the eyes using botulinum toxin and enhancing the lips with fillers. Dr Acquilla gave the final presentation of the day, in which he took an in-depth look at key beauty points in order to lift and rejuvenate the face. He performed targeted injections for full face rejuvenation and shared his expert advice on improving the quality, structure and symmetry of a young female face. Delegate Dr Louise Hallam, who practises in Brighton, said, “I found the Premium Clinical Agenda sessions very interesting. They went through the whole range of treating the face in men and women, which was really useful. It’s unusual to get such an in-depth talk about men so that was good; it was beneficial to learn about the anatomical

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differences and the various treatment methods in men versus women. I will definitely change some of the things that I do in my practice from going to it!”

Key Opinion Leader insights at the Masterclasses The 60-minute ACE Masterclasses gave delegates a fantastic opportunity to hear from highly respected key opinion leaders on how to get the best results from the products and treatments they use. Leading aesthetic companies were able to showcase their latest and most innovative product offerings through interactive presentations and live demonstrations. The first workshop of the weekend was on PDO threads – the engaging session was led by Dr Huw Jones on behalf of Intraline, who discussed the results of a UK-based study on the biological and physical changes, as well as the effect of collagen production following thread treatment. This was followed by a Masterclass on enhancing natural beauty, led by nurse prescriber Jackie Partridge and consultant plastic surgeon Mr Mark Devlin where they outlined the science behind and efficacy of the Restylane portfolio from Galderma in a live demonstration of treatment. The use of peels was a popular topic at ACE with Dr Uliana Gout unveiling the latest trends and techniques for combining peels with cosmeceuticals in a session supported by SkinCeuticals. Next, Dr David Jack showcased how using Plexr, Needle Shaping/Vibrance and CarboMix systems from FusionGT can benefit patients, while performing a live demonstration and discussing the growing use of plasma technology. Lasers for skin rejuvenation can be a valuable addition to an aesthetic clinic, so Dr John Quinn provided profound advice on how to choose the right platform for your practice in a Masterclass supported by Lumenis. Mr Dalvi Humzah and nurse prescriber Helena Collier then drew the first day of ACE to a close with a live demonstration of midface volumisation and lower face contouring with Belotero+ Volume and Radiesse+ from Merz Aesthetics, which included a discussion of anatomy, physiology, facial analysis and injection technique in a special 90-minute session. Saturday’s Masterclasses began with a session led by Dr Maria Gonzalez, who shared her expertise on the use of Almirall’s Vaniqa in combination with lasers for the treatment of female facial hirsutism. Dr Kieren Bong then explained the science behind Teosyal’s Redensity I and Teosyal RHA 2 dermal fillers from Teoxane UK, and demonstrated his technique for hand rejuvenation using these products. Dr Uliana Gout went on to lead her second workshop of the event, this time she presented on using Filorga’s 360-degree combination treatments and advising on best practice, injection technique, anatomy and physiology.

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Harmonising the perioral region was next on the agenda in an engaging session by Dr Emma Ravichandran on defining the lips with Belotero+ at another Merz Aesthetics session. Dr Fab Equizi then looked at the use of the Plasma BT from Beamwave Technologies, discussing with delegates how this can be used to treat eye bags, excess skin and wrinkly eyelids with reduced downtime and risk compared to surgery. The Masterclass agenda concluded with Dr Dev Patel and Victoria Hiscock’s presentation for Alumier MD on the benefits of light and medium-depth peels for both clients and businesses, in which they also performed a live demonstration of a self-neutralising, modified half-Jessner chemical peel.

by Dr Sophie Shotter in AestheticSource’s Expert Clinic session on the use of its RRS range of CE Class III mesotherapy cocktails. Finally, Dr Ravi Jain brought the day to a close with a discussion on Profhilo from HA-Derma, in which he outlined its unique properties and his experience of using the HA technology in practice. The second day of Expert Clinic sessions offered even more variety and valuable learning opportunities across all its sessions. Beginning with a presentation on the use of Dermamelan from Dr Fernando Galcerán on behalf of mesoestetic, delegates were able to learn more about treating hypermelanosis. Miss Sherina Balaratnam then gave an engaging presentation on the SculpSure device from Cynosure, outlining how it can be used to contour the body and reduce stubborn fat in problem areas such as the abdomen. Next, Dr Irfan Mian was introduced to discuss how Profhilo and Aliaxin from HA-Derma can be combined for superior results, followed by a fascinating presentation on volumising and projecting the midface with Belotero+ from Mr Simon Ravichandran, sponsored by Merz Aesthetics. Microneedling was next on the agenda, in a joint presentation from nurse prescriber Natali Kelly and Dr Andrew Christie on the use of the Dermapen from Naturastudios to infuse active substances into the skin for enhanced results. This was followed by Dr Mariya Serheyeva’s engaging presentation on the new biorevitalising PRX-T33 from Medical Aesthetic Group, which aims to protect skin tissues and stimulate both keratinocyte and fibroblast growth factor activity. Dr Rikin Parekh then took to the stage for a second time and concluded the weekend of learning at the Expert Clinic to discuss the modalities of RRS administration from AestheticSource. Bonita Vince, an aesthetic nurse from Birmingham attended the Expert Clinic sessions and said, “The range of talks, the experience and knowledge people have to share was excellent. Seeing different ways people offer treatments is really useful as it gives you advice on how to offer a more of a holistic approach to treatment.”

Live demonstrations at the Expert Clinic

Practice tips at the Business Track

This year saw the introduction of the free, new-look Expert Clinic. The larger space with enhanced sound quality and accessibility offered delegates the chance to attend half-hour sessions on all aspects of clinical practice. The Friday morning began with an engaging talk on using radiofrequency from nurse practitioner Anna Silsby, sponsored by AesthetiCare, which was followed by an injectable presentation from Dr Tahera Bhojani-Lynch on contouring the male face with Radiesse+ from Merz Aesthetics. Dr Rikin Parekh then demonstrated lip augmentation and rejuvenation of the lower face using the Biorivolmetria concept from Regenyal Laboratories’ range of HA fillers, sponsored by Belle, before Dr Shirin Lakhani showcased a nonsurgical blepharoplasty using Plexr, from Fusion GT.

Sponsored by Enhance Insurance, the ACE Business Track delivered 18 dedicated non-clinical sessions to delegates on how to improve business acumen and build a profitable practice. Amongst those speaking was clinic director Rudi Fieldgrass who advised how to grow an aesthetic business and popular ACE speaker and VAT advisor Veronica Donnelly who gave her annual VAT update. The morning also saw private label skincare founder Gary Conroy providing his recommendations on choosing a skincare brand for your clinic, which was followed by Dr Simon Zokaie’s presentation on the influence of online product purchasing and how it could impact an aesthetic clinic. Director of Enhance Insurance Martin Swann then spoke on the importance of risk identification and how General Data Protection Regulation could impact aesthetic practitioners next year. He advised that all practitioners should understand its implications and be prepared for its introduction. This was followed by insurance broker Naomi Di-Scala, who provided an overview of common complaints in the specialty with advice on how to manage them, before Dr Tristan Mehta talked about training options for practitioners and standard development initiatives. Continuing the training theme, consultant plastic surgeon Mr Adrian Richards spoke about the new Joint Council for Cosmetic Practitioners (JCCP), detailing its latest recommendations on regulation and training, which drew an even larger crowd of delegates prepped with questions and comments for discussion. PR consultant Julia Kendrick then shared her expert advice on how to build a brand with PR, before multiple clinic owner Annalouise Kenny concluded the day at the

Following lunch, a live demonstration of the U225 meso injector was performed by Mr Jean-Paul Ben in a session sponsored by Rosmetics, while Church Pharmacy’s speaker, experienced aesthetician Radha Parmar demonstrated how its retinol skincare range, PCA Skin, can enhance patients’ skin. Dr Lee Walker was the next practitioner to take to the stage in a packed session for his lip augmentation demonstration. Sponsored by Teoxane UK, the session discussed the anatomy of the lip, danger zones to be aware of and injection techniques for a perfectly balanced lip. Victoria Hiscock, product and education specialist at AlumierMD then discussed ‘mindful peeling’ emphasising key application and removal techniques to consider when performing a chemical peel. Mesotherapy was the next topic on the agenda, which was covered

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Business Track with advice on opening a new clinic. Saturday at the Business Track began with a valuable presentation on the importance of data collection from enquiry handling and diary management expert Gilly Dickons, before consultant educatalists Hayley Allan and Lisa Hadfield-Law shared top tips on presentation skills for those interested in going into training. Lucy Xu, clinic chain founder, then spoke on how to build a business, before Mr Dalvi Humzah gave his third presentation of ACE 2017 on the legal implications of the General Medical Council reviewing your practice and how you can ensure that you maintain competent standards of practice. Lawyer Alaw Rhys-Owen then shared her perspective on the themes and practices that are commonly seen within aesthetic claims, in a session sponsored by Enhance Insurance, before Dr Rita Rakus shared her advice on choosing the right capital equipment in order to grow your business. Dr Harry Singh was next to the stage to talk about key marketing strategies for the best return on investment, followed by nurse prescriber Lorna Bowes, who closed the agenda with a detailed presentation on how to build a treatment menu which differentiates your delivery and presents a cohesive brand to your patients.

Business connections at the Networking Event After a busy first day of learning and exploring the Exhibition Floor, all delegates were invited to enjoy a complimentary glass of prosecco from the ACE 2017 Networking Sponsor, 3D-lipo. As always, this important part of the day was appreciated by delegates who were able to catch up with friends and colleagues, while also being able to build business connections and liase with conference speakers.

Product launches on the Exhibition Floor With 2,500m2 of floor space and 82 exhibitors on hand to showcase their latest innovations, the ACE 2017 Exhibition Floor showed a busy, hustling scene on both Friday and Saturday. Delegate and aesthetic nurse Judith Gray said, “There’s such a wide variety of things to do on the Exhibition Floor. Not only watching the live demos, but finding out about the latest technology and products that come out was really useful for me!” This year’s headline sponsor was Schuco and on their busy exhibition stand they held live demonstrations from leading practitioners, which each drew large crowds of delegates. Paul Huttrer, CEO of Schuco, said, “As an exhibitor, it’s been a really fun experience, with lots happening over the two days and good footfall throughout the event.” As ACE 2017 drew to close, programme organiser Amanda Cameron reflected, “We are delighted that we’ve been able to attract the best quality speakers and produce content that is both current and educational. We hope everyone had a wonderful time and will join us again next year at ACE 2018!” ACE 2018 will be held on April 27 and 28 at the Business Design Centre in Islington, London. To stay up-to-date with all the latest news and developments join the Aesthetics conference website www.aestheticsjournal.com.

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Follow us on Twitter @aestheticsgroup S-Thetics @MissBalaratnam Big congratulations to the fantastic team @aestheticsgroup & @AmandaCameron11 for hosting a great #ACE2017 conference, see you again soon! Aesthetic Training @GlowTraining Superb couple of days exhibiting @aestheticsgroup #ACE2017 Always great to see existing whilst meeting new clients HUGE TY to all the Team :)

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Treating the Perioral Area Aesthetics speaks to a panel of practitioners who share their top tips for successful rejuvenation of the perioral region Our panel: Dr Jonquille Chantrey (JC) Cosmetic surgeon and skin specialist Jackie Partridge (JP) Independent nurse prescriber Dr Dev Patel (DP) Aesthetic practitioner Dr Emma Ravichandran (ER) Dentist and aesthetic practitioner

JC: My most common demographic is 40-plus, but for young people in the perioral area, I actually perform a lot of corrections. So many people are doing these treatments now and some aren’t doing it very well. Sometimes patients come in with an uneven lip, lumps and a heaviness and over-protrusion, created when the vermilion border is over-injected.

What concerns do your patients often present with in the perioral area? JC: Three things; firstly the associated buccal fat descent that is creating the marionette fold, the second is the perioral lip lines – created mostly in expression when pursing the lips through expression of the orbicularis oris, and the third would be patients wanting gentle enhancement. ER: Most of my patients will complain of an aged, sad look to the perioral area, such as down-turned corners of the mouth, the nasolabial folds, the marionette area; they will also complain of thinning of the lips and barcode lines or smoker’s lines.

How does the perioral area age? ER: There are multiple factors involved: there is the intrinsic ageing that we all go through, leading to loss of collagen, hyaluronic acid (HA) and decreased tone in the skin. The underling muscle, which is predominantly the orbicularis oris, is going to slightly lose its tone and tightness contributing to loss of elasticity in the underlying tissues. You get loss of subcutaneous fat as well; again you lose that plumpness and support to the skin and as people age there is a decrease in the bony support. There are also extrinsic factors, so if people smoke, have a lot of UV exposure or use sunbeds, that really accelerates the ageing of the skin.1,2,3 JP: The perioral area has some of its own issues. The mandible itself is thinning with the ageing process, the density of the bone isn’t what it was in youth and that is going to have an impact on the bony support for the mandibular and perioral area. The bone supporting the teeth is also regressing, the teeth are becoming more unstable and you also may have tooth loss, which means that the structural support is missing. The way I explain ageing to my patients is that if you think of the structural bone support as a table and the skin as a table cloth, the table is getting smaller and the table cloth then doesn’t have the support underneath it to look as nice as it once did.1,2,3

What are the key patient groups seeking treatment for the perioral area? DP: Mainly women who are middle-aged and older – I’d say the 40plus age group and particularly those in their 50s and 60s. For lines around the perioral area it is weighted towards smokers or those who have a history of smoking – but there are also some who have deep static lines in the area and don’t have a history of smoking.

In your opinion, what are the key considerations that must be made when assessing and treating the perioral area? JC: Do a proper assessment and anatomical diagnosis. Practitioners need to be aware of the dental profile and arcade, the relationship of the teeth, the lips to the nose, and the chin. They need to be looking at the patient from both the frontal and profile view. JP: Less is more! I think doing smaller treatment modalities but more of them is going to give a better and safer aesthetic outcome. You will have less risk of vascular compression if you aren’t using so much product. DP: Don’t just look at the perioral area – see it as part of the whole face as, often, particularly in this area, it has become such a focus in the patient’s eyes that it is easy to zoom in and focus on this with them. We have a lot of options for this area, find a nice treatment combination, which is appropriate for that person, based on their wishes and what their expectations are.

How do you approach patients with the following indications? Loss of volume in the lips JP: The lips thin as we age. Patients often report that their top lip completely disappears when they do a big smile, so to address this, it is important that we don’t lose symmetry; the top lip to bottom lip should be a 1:1:6 ratio. I would use Restylane Kysse, as it’s a cohesive product but also has projection. JC: It depends on what the patient is trying to achieve, their own perceptions of their proportions and their profile. I look at the

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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patient in expression – kissing, smiling. If they need an increase in their lip height then I’ll consider treating the vermilion border; if they have a flatter cupid’s bow, then I’d inject that; and if it’s just a general lip fullness that they request then I would inject the pink body of the lip. I’d use Juvéderm Ultra Smile or Volbella in the perioral area because they are very cohesive. ER: You are assessing the relationship of the mandible and the maxilla – consider the symmetry and proportions of the lip with respect to the face and be cautious of the patient’s profile. To replace the loss of true volume within the vermilion, I will use Belotero Intense and a 25G 1.5 inch cannula and will insert the product in the subcutaneous plain, which is the safest way of injecting the product subcutaneously with regards to the risk of injecting the superior labial artery. Lines and wrinkles or ‘smoker’s lines’ around the mouth ER: You need to know what has caused the lines and make a proper diagnosis to determine whether they have just genetically inherited the lines, whether they smoked or continue to smoke, use vapourisers, or are real sun worshippers, which will all encourage perioral lines to form. If they currently do, they are not good candidates for treatment. JC: It depends on the underlying diagnosis, some patients need support around the vermilion border to get good results; I’d do a small injection into the vermilion border to support that. If it’s just early lines, I’d get the patients to express and purse their lips and do micro injections into the line itself with Juvéderm Ultra 2 or Volbella. DP: There are lots of options depending on the severity. If it’s very early and there are a lot of dynamic lines then botulinum toxin A may prevent them forming. I also might use the Needle Shaping/ Vibrance device, which triggers collagenases and production of elastic fibres and will give subtle improvement to those early lines. Once they have static lines, if they want a quick fix, I’d use the blanching technique with Belotero Soft. Skin resurfacing by remodeling the skin would give them longer improvement and the type would depend on the patient. My options are fractional ablative laser, I use iPixel; vertical microneedling such as Dermapen, or peels – I use Enerpeel MA because they have a specific peel for the perioral area. Soft surgery is also an option – Plexr is good for working on the deep static lines that are already there, you use it by treating the area immediately adjacent to the line and one or two treatments will give you really good results. Nasolabial folds JP: We are moving more away from treating the individual nasolabial folds and instead we are augmenting areas to give you lift in the mid-face, which again will correct areas of volume loss further down the face without adding weight to the lower face. ER: You need to know what’s caused the nasolabial fold – the nasolabial fat compartment is probably the last fat compartment to lose fat in the face and most of the descent comes from loss of the mid and lateral cheek fat compartments so they need to be addressed first. We also get widening of the nasal aperture as we age, loss of bone, a widening of the nose and deepening in the alar triangle. Often, it’s the shadow in the triangle that gives the impression that the nasolabial line is bigger than it is. If we lift and push that triangle forward with a bolus of filler we reduce the shadow, impacting on that depth or the apparent depth of the nasolabial fold.

Aesthetics Before

Before

After

After

Figure 1: Patient before and immediately after 1ml of Belotero Balance, 1ml of Volume and 1ml of Intense, treated at ACE 2017. Images courtesy of Dr Emma Ravichandran.

The marionette area JC: Most patients presenting with a marionette fold usually have some degree of descent in the mid-face – so assess the mid-face and see if it needs treating, adopting an indirect approach to treatment. If the patient wants a direct approach, I tell them the results won’t be as good, but I will treat the marionette fold directly. DP: My approach would be to use a simple HA filler – Belotero Volume or Intense – and I would put it in and around the problem areas and follow the principals of not just filling a line, and certainly not just filling a fold, but replacing the support around the area giving them a lift. ER: It’s important to have adequate support for the lower and upper lip and ensure that there is a nice blend from the cheek into the chin area – you don’t want to overfill. Choose the right product that has the right level elasticity, plasticity and cohesiveness so that it doesn’t migrate and will move on animation. You want to place it subcutaneously using a cannula to minimise the risk of bruising – it’s about pushing the marionette area forward so there is a nice colour refraction. Improving skin texture and overall appearance at the clinic JC: It starts with a diagnosis and medical history, followed by an assessment. Is the skin dehydrated, oily, rough and dull? Is there increased pore size? In office, I love Juvéderm Volite because we can improve skin texture, elasticity and hydration with a single session. I also use different strengths of TCA chemical peels for skin texture improvement. I find that they offer an enhanced smoothness that is difficult to achieve with other modalities. JP: I might consider a laser peel for rejuvenating the skin to stimulate collagen production and tightening pore size; it’s important that we utilise different modalities for treatment because there are so many treatment options which work in harmony to give the best outcome. You can also consider Restylane Skin Boosters to add hydration in the area of concern for patients, to give an improvement around the perioral area, especially for acne

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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scarring as we know the chin especially can be affected. DP: I find chemical peel and fractional ablative laser treatments give very minimal downtime of two to three days. They have really fantastic results, addressing skin texture, pigmentation and even some of the vascular changes you get with ageing and sun damage.

Aesthetics Journal

Before

After

Permanent makeup for enhancing the lip

The application of pigment into the skin can also enhance the natural Before After appearance of the lip. Laura Kay, a semi-permanent makeup specialist who runs her own training academy, says, “As people Figure 3: Two different patients before and after permanent makeup get older, unfortunately, the natural lip line tends to age and fade and they lose the definition and fullness here. Semi-permanent makeup gives you definition in the lip line, which can create the appearance of more volume.” When performing the treatment, Kay says, “I like to stay on the natural lip line and I like to do a lip blush, which is a lip line that is blended into the lips so you look like you have a wash of colour as well as definition. I personally don’t like doing the lip line on its own as I think it looks quite false.” If a patient wants more volume in the lip itself, she says dermal filler can be used in combination, “I have relationships with quite a few practitioners that either inject the lips first and then wait six weeks for it to settle and then I will do the permanent makeup, or I will do the permanent makeup first – so it can work hand-in-hand together quite well.”

Improving overall appearance using home care ER: Before other treatments like IPL, laser or peels, I would get the patient onto a good skin health programme for about two to four weeks. We would then introduce maybe a combination of either a hydroquinone product, a non-hydroquinone product or a retinol product, in order to even the texture and to try to improve any pigmentation. DP: Skincare at home is important. My top ingredients, especially if the patient has lines, are retinol, vitamin C and epidermal growth factor (EGF) – retinol is in the vitamin A family and has been proven to increase fibroblast activation leading to collagen production. We have three key brands in clinic: Tebiskin, Image Skincare and AlumierMD, which I have recently introduced as there is some really advanced science in their range. Before

Aesthetics

After

Figure 2: Patient before and two weeks after 1ml of Belotero Intense. Images courtesy of Dr Emma Ravichandran.

JP: I would bring a patient into the clinic for a Visia scan to analyse their skin quality and I would likely get them on to vitamin A to stimulate cell renewal and to bring the life back to dull skin – we use Environ because it allows for a step-up process with different levels of vitamin A. It’s also important to educate our patients on the importance of SPF usage because the SPF prevents more pigmentation issues which are going to give a further ageing effect. JC: Prescribed skincare is my go-to for long-term maintenance. I use the ZO range extensively in my clinic and I advocate the use of exfoliators, salicylic acid pads, vitamin C and retinol as the cornerstones for textural-related concerns.

What are some of the risks practitioners need to be aware of in the perioral area and how can you reduce these? ER: It’s an incredibly vascular area so there is a high risk of haemostasis, bruising, and swelling. It’s important to minimise the trauma to the tissues during product placement. The other risks are vascular occlusions, risk of product being placed into the superior labial or inferior labial artery, which can have catastrophic consequences for patients, so using a cannula is going to minimise the risk of intravascular injections.

JC: Knowledge of vascular compromise is very important, the superior and the inferior labial arteries; be very mindful what layer you are injecting in and I think you should always check with aspiration. JP: Bruising and swelling are two things that are common in the perioral area as it’s very vascular. It is really important to explain the risks of vascular occlusion and necrosis. All risks need to be discussed with the patient before they can give an informed consent to treatment. There is also risk of hyper- and hypo-pigmentation when resurfacing with lasers. DP: You need to be aware of the potential variations of anatomy from human to human – there are some good studies that suggest that there is quite a lot of variation in the area so you may think ‘there is an artery here’ but actually, it’s somewhere else.

What are your final words of advice? DP: Really try and identify the patient’s expectations and give them the real picture of the results that can be achieved. The most common request I get asked when treating the lips is to get rid of the deep lines – I tell patients that you’re not going to get rid of them, you’re going to soften them, and it’s important that they understand that. JC Don’t inject large amounts inappropriately – there is a lot of over injecting going on and that damages our specialty because it makes people think that it’s what the lips should look like. ER: Make sure the function of the lips are kept – coming from a dental background, I am very concerned with maintaining the integrity and functionality of the lips – there seems to be a real desire to make lips look sexy by having a space in the middle, but they are designed to close the mouth and to keep the teeth healthy. REFERENCES 1. AL-DREES, AM, ‘Oral and perioral physiological changes with ageing’. Pakistan Oral & Dental Journal, 2010, 30(1) p.26-30. 2. Bodic F, et al, ‘Bone loss and teeth’. Joint Bone Spine, 2005, 72(3) p.215-221. 3. Sveikata KI, Balciuniene, & J Tutkuviene, ‘Factors influencing face aging. Literature review’, Stomatologija, 2011, 13(4) p.113-6.

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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

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

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Anatomical Concepts of the SMAS Mr Dalvi Humzah and cosmetic and dermatology nurse practitioner Anna Baker detail the anatomical significance of the superficial musculo-aponeurotic system Abstract The anatomy and significance of the superficial musculo-aponeurotic system (SMAS) is well described, with cadaveric studies continuing to emerge to further enhance clinical awareness. Whilst the context of this plane is acknowledged in the surgical literature, this layer represents important boundaries to the non-surgical clinician, at defined anatomical regions. This paper captures the salient anatomical descriptions and considerations, and summarises some of the key findings from current literature.

1 1

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2

2

Introduction

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The third anatomical layer of the face forms one continuous plane, encompassing each facial region, although for descriptive purposes, different names are given to certain parts, often according to the superficial muscle contained within the anatomical region.1 It is named the galea over the scalp, the superficial temporal fascia over the temple, (nomenclature describing the temporal fascia is inconsistent within the literature),2 the orbicularis fascia in the periorbital region, the superficial musculo-aponeurotic system (SMAS) over the mid and lower face, and platysma in the neck.3,4 Whilst the focus of this paper is to explore the anatomy, it is key to understand its context and characteristics in different anatomical regions, to ensure treatments are performed appropriately and safely.

SMAS background The innovative and renowned plastic surgeon, Mr Tord Skoog (19151977), introduced pivotal changes in surgical face lifting techniques, spurning a shift in thinking by questioning the underlying change in the ‘loose’ appearance of skin seen in ageing, as well as laxity, believing that the reason lay in the fibrous support layer beneath the skin. At the time this was known as the superficial fascia and was deemed a radical concept when first presented in 1969.5 Two years later, a defining article appeared in Plastic and Reconstructive Surgery, co-authored by French surgeons, Mr Vladimir Mitz and Mr Martine Peyronie, in which a new name was introduced for Skoog’s superficial fascia – the ‘superficial musculo-aponeurotic system,’ commonly known by the acronym SMAS. This changed aesthetic plastic surgery indefinitely.3 Facial ligaments were later described by plastic surgeon, Mr David Furnas in 1989, who observed a stronger adherence of the superficial fascia, to the outer surface of the SMAS than in other areas. Through systematic cadaver dissection, Mr Furnas was able to describe a new element of facial anatomy.6

Anatomical context It is important to appreciate the basic five-layer structure of the superficial soft tissues over the facial skeleton, to understand the contextual relevance of the SMAS. This ‘layer’ concept is well established historically, and consistently described within the literature:3,7,8

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Figure 1: SMAS Layers 1-5. Image shows the anatomy over the skeleton and bony cavities.20

Layer 1: Skin Layer 2: Subcutaneous tissue, including the fibrous retinacular cutis Layer 3: Frontalis (upper face), SMAS (mid-face), platysma (lower face and neck) Layer 4: Together these outer three layers form a composite anatomical unit, which is fixed in areas through ligaments in the subSMAS. Layer 5: Investing layer of deep fascia on the muscles of mastication or the periosteum, where the skeleton may not be concealed by these muscles. Variations within the five-layer composition over the face and different aspects of the cheek, are described within the surgical literature.8 Most of the variations of the basic five-layer soft tissue composition occurs over the orbit and oral regions, whereby the soft tissues continue beyond the skeletal apertures to form the eyelids, central cheek and the lips.9 Within the cheek, separating the lateral from the anterior cheek is the vertically-situated line of masseteric retaining ligaments near the medial border of masseter.10 Consistent with the arrangement over the orbit, the superficial layers pass medially to this boundary to overlie the deeper soft tissues of the central cheek as well as the buccal fat.11 The region-specific anatomy of the SMAS is described in the forehead, parotid, zygomatic, and infraorbital regions, as well as the nasolabial fold, and the lower lip.12 The SMAS forms one continuous, organised fibrous envelope, comprising collagen fibres, elastic fibres, fat cells and muscle fibre, and connects the facial muscles with the dermis.1 The subcutaneous fat of the body is segmented from the muscle compartment by an investing layer of fascia encasing all muscles of the body.13 In the face, the muscles have connections to the skin in order to enable the mimetic activity of facial animation to take place. Muscles of facial expression are distinctly different from skeletal muscles beneath the deep fascia, as they are situated within the superficial fascia and move the soft tissues for which they are part of.3 All

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muscles of facial expression have either their entire or the majority of their components within Layer 3 of the face, predominantly located over and around the orbital and oral cavities.7 Within Layer 3, the facial muscles have a layered configuration, with the broad, flat muscles forming the superficial layer that covers the anterior aspect of the face. The frontalis covers the upper, orbicularis oculi, the middle and lower thirds, as well as the platysma.14 The muscles within this layer have minimal direct attachment to the bone, stabilised to the skeleton at their periphery. Facial retaining ligaments are an area of anatomy which are gaining increasing interest and recognition in the context of ageing and aesthetic corrective treatments. In relation to the SMAS layer, the zygomatic ligament is one of the major ligaments supporting the facial soft tissues, but develops negligible laxity between its origin and connection to the SMAS.15 Conversely, other ligaments, such as the masseteric ligaments below the oral commissure, significantly weaken and stretch with age.6 Aesthetically, this may manifest as a dimple or pocket, with which overlying soft tissues anchor and appear to fold over, and may contribute to the worsening appearance of the jowl.

Current literature A number of pivotal anatomical studies are emerging, which are deepening understanding of the anatomy of fascia in the face. Of particular interest to aesthetic practitioners are the recent findings of Pessa9 who undertook a detailed literature review and clinical dissection to explore the concept of bilaminar SMAS fusion zones, suggesting that the boundaries of these zones equip the clinician with valuable, practical information. The authors illustrate this concept in context of the course of branches of the facial nerve travelling as deeply as possible until reaching the edges of the muscles which they innervate, where at this point they transition from the deep to the superficial fascia. Pessa suggests that to minimise the risk of injury, nerves transition as close to muscle as possible, for example, the buccal branch of the facial nerve can be injured at the superior border of the zygomaticus major muscle, which is described as a transition point along a SMAS fusion zone within this study. Furthermore, Pessa proposes that the frontal branch of the facial nerve is most often injured at the inferior border of the frontalis muscles (along a temporal SMAS fusion zone), with injury to the marginal mandibular nerve and zygomatic branch occurring in the same manner. Based upon these clinical findings, Pessa argues that if a clinician is aware of the location of the SMAS fusion zones, the course of the facial nerve branches, from the deep to the superficial fascia, could potentially be anticipated and thus, avoided during cosmetic procedures.9 Kang et al.16 describe findings from their cadaveric study comprising 40 hemi-faces (unembalmed tissue) to analyse if the superficial fascia (Layer 3) was bilayered at specific anatomical regions. The authors reported that the superficial fascia, (including the SMAS and the superficial temporal fascia), comprised two layers from the temporal area to the lower face, with the SMAS consisting of a superficial layer and a deep layer, separated by areolar tissue. Equally, these findings demonstrated that the temporal branch of the superficial temporal artery ran within the superficial temporal fascia, with the frontal branch entering and extending to the superficial component of the deep temporal fascia, approximately 2-4cm lateral to the eyebrow. The authors state that the platysma was not continuous with the superficial layer of the SMAS, and describe the remnant portion of the orbicularis oculi, zygomaticus major and minor, and the platysma

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as being invested by the deep layer of the SMAS. Furthermore, they were able to demonstrate that the SMAS was separable into two layers, and that the deep layer covered the levator labii superioris and levator anguli oris, but propose that these two structures (the deep SMAS and deep fascia), represent the same layer, which is coplanar with the platysma. Kang et al. demonstrate findings to conclude that the superficial facial fascia comprises two layers throughout the face, temple, and forehead.16

Non-surgical considerations Optimal outcomes for non-surgical interventions can be obtained by ensuring treatment protocols are aligned to the anatomical and temporal changes of ageing. With the description of the SMAS, surgical techniques were developed to reposition the SMAS and overlying tissues and, hence, offer ‘SMAS-Lift Procedures’. The limited SMAS lift approach, has been modified and extended. Currently the modified technique is popularised as the S-lift or miniSMAS technique; they address the lateral part of the face but not the central area.17 The surgical procedures had a potential downside – as the dissections proceed medially to correct the mid-face changes, there is a danger of facial nerve damage as the branches of the facial nerve transition from Layer Four/Five into Layer Two through the SMAS.7 The other problem was that these SMAS elevation procedures often left patients with facial disproportion and the ‘windswept’ look as many surgeons excised the redundant SMAS.18 The issue here is that the volumetric changes in the face due to ageing were not addressed. This has led to techniques of reusing the redundant SMAS with methods such as imbrication and foldover procedures (autologous volumisation), ultimately leading to the ‘deep plane’ approach of dissection under SMAS, which was popularised by Sam Hamra.18 An important outcome of this was the understanding of the SMAS, its relation to the facial ligaments and the underlying facial sub-SMAS spaces. To get optimal results, three things need to be addressed: 1. SMAS tightening 2. Facial ligament retightening to reposition the SMAS 3. Revolumisation of the facial disproportion When this is looked at in the context of non-surgical interventions, there are possible combinations that allow us to address these concepts. Targeting the SMAS It has been shown that using a diathermy directly on the SMAS causes areas of thermal damage and contraction of SMAS.19 It is now possible to use focused ultrasound energy to target the SMAS under visualisation to produce contraction of the SMAS. The targeted thermal energy causes the SMAS to contract and repeated application will result in tightening of this area.19 It is important to deliver the energy directly into the SMAS and not into the superficial subcutaneous tissues or into the deeper areas as the treatment will compromise deeper structures. Some improvement is often seen when using deeper or superficial settings, which may be the result of thermal energy indirectly working on the facial ligaments.20 Other energy delivery such as radiofrequency will also indirectly work on these areas but lack the specific focus to directly target

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the SMAS. The lack of a focused target results in a lack of longevity and repeated treatments are required for maintenance. Being able to target the SMAS and cause contraction of this particular layer results in an improvement of the overlying skin tone by fascial retightening.20 Facial ligament retightening The true facial ligaments run from the deep layers of the face (periosteum) to the cutaneous tissues and due to stretching, laxity of the SMAS and resorption of bone, this allows the overlying skin to droop, bulge and wrinkle. The analogy used by Mendelson is to imagine a room under SMAS: the walls being the ligaments, forming columns running from the deep layers through the SMAS to attach to the superficial layers. The floor being Layer Five and the roof being the SMAS (Layer Three).5,7,8,11,23 The first such space described by Mendelson was the prezygomatic space over the cheek, and being able to treat the cheek using dermal filler in this area gives a natural and anatomically-based outcome. Using an appropriate procedure to enter this prezygomatic space (with a cannula) will allow the injection of an appropriate product amount into this space and for a safe treatment.22 This is of particular importance as the ‘ceiling’ of the prezygomatic space is composed of the suborbicularis oculi fat or ‘SOOF’. This structure is implicated in the aetiology of malar oedema and, as such, should not be injected into directly. Filling the prezygomatic space achieves two things. Firstly, it inflates the ‘room’ and tightens the retaining ligaments – this transmits the tightening and lifting to the superficial parts of the ligament pulling the skin and tightening the overlying SMAS. Secondly, it also provides further lifting to the superficial tissues as it corrects the underlying deep tissue loss (see below).15,21,23 Revolumising facial disproportion Ageing of the facial skeleton results in loss of bony support in areas of the face.24 Going back to the room analogy, as the bony support reduces, (the floor/foundations deteriorate) this results in a collapse of the overlying structures causing the overlying cutaneous and subcutaneous tissues to droop and wrinkle. The ability to correct and augment the area within the room provides a firm foundation for the overlying SMAS, which lifts and repositions the subcutaneous fat pads. The ‘triple area’ procedure is a suitable technique, but beyond the scope of this article. It aims to address the mid-face and tear trough area. In youth, in the area where the alar meets the cheek, there is a fullness created by the underlying maxillary bone and the deep medial cheek fat pad. With age, there is bone resorption and loss of the deep medial cheek fat pad from this compartment, which has been termed ‘Ristow’s Space’.21 Being able to strategically inject into this space results in mid-facial rejuvenation and allows an indirect approach to treating the tear trough.21 This injection technique introduces either dermal filler or fat transplants into this facial space to reshape the overlying maxillary fullness in facial rejuvenation. Use of an appropriate product (with g high G’) will allow correction of the drooping and will provide fullness by transmitting the tissue turgor through the overlying SMAS. These procedures allow for an indirect and direct approach to treating the SMAS through non-surgical cosmetic interventions. Techniques using superficial placement of dermal fillers are based on superficial revolumisation and do not address the SMAS–associated changes.

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Conclusion It is widely accepted that the safest and most effective treatment outcomes arise, in part, from a thorough and detailed facial analysis, which include an appreciation of the facial anatomical planes, to ensure product is placed appropriately and safely to yield the desired result. The continual emergence of new anatomical concepts reaffirms the importance of maintaining an accurate and critical awareness of published literature, as studies increasingly move away from formalin specimens and larger cohort numbers, to reflect more pivotal conclusions as methodology becomes more robust. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Mr Humzah worked as a consultant plastic surgeon in the NHS for 10 years and teaches nationally and internationally. Anna Baker is a dermatology and cosmetic nurse practitioner, running nurse-led topical PDT clinics for Galderma UK in conjunction with Ashfield Clinical. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a post-graduate certificate in applied clinical anatomy, specialising in head and neck anatomy. REFERENCES 1. Gossain A.K., Yousif N.J., Madiedo G., Larson D.L., Matloub H.S., Sanger J.R., ‘Surgical anatomy of the SMAS: a reinvestigation’, Plast Reconstr Surg 92 (1993), pp.1254-1263. 2. Baker A, ‘Temporal fossa anatomy: a review of the literature and safe planes of augmentation’, Journal of Aesthetic Nursing 4(9) (2015), pp.372-379. 3. Mitz V, Peyronie M., ‘The superficial musculo­aponeurotic system (SMAS) in the parotid and cheek area’, Plast Reconstr Surg (1976), pp.58:80. 4. Stuzin J.M., Baker T.J., Gordon H.L., ‘The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging’, Plast Reconstr Surg 89 (3) (1992), pp.441-449. 5. Mendelson B, In Your Face: The hidden history of plastic surgery and why looks matter, Hardie Grant Books, 2013. 6. Furnas D.W., ‘The retaining ligaments of the cheek’, Plast Reconstr Surg, (1) (1989), pp.11-16. 7. Mendelson B.C., Jacobson S.R., ‘Surgical anatomy of the mid-cheek; facial layers, spaces and midcheek segments’, Clin Plast Surg, 35 (2008), pp.395-404. 8. Mendelson B., Wong C.H., ‘Commentary on: SMAS Fusion Zones Determine the Subfacial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging’, Aesthetic Surgery Journal, 36(5) (2016), pp.529-532. 9. Pessa J.E., ‘SMAS Fusion Zones Determine the Subfascial and Subcutaneous Anatomy of the Human Face: Fascial Spaces, Fat Compartments, and Models of Facial Aging’, Aesthetic Surgery Journal, 36(5) (2016) pp.515-526. 10. Thaller S.R., Kim S., Patterson H., Wildman M., Daniller A., ‘The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation’, Plast Reconstr Surg, (1990). 11. Mendelson B.C., Muzzaffar A.R., Adams W.P. Jr., ‘Surgical anatomy of the midcheek and malar mounds’, Plast Reconstr Surg, 110 (3) (2002), pp.885-896. 12. Ghassemi A., Prescher A., Riediger D., Axer H., ‘Anatomy of the SMAS Revisited’, Aesthetic Plastic Surgery, 27 (2003), pp.258-264. 13. Har-Shai Y., Bodner S.R., Egozy-Golan D., Lindenbaum E.S., Ben-Izhak O., Mitz V., Hirshowitz B., ‘Mechanical properties and microstructure of the superficial musculoaponeurotic system’, Plast Reconstr Surg, 98 (1996), pp.59-70. 14. Matros E., Garcia J.A., Yaremchuk M.J., ‘Changes in eyebrow position and shape with ageing’, 124(4) (2009), pp.1296-1301. 15. Humzah D., Baker A, ‘Mid-face Rejuvenation’, Aesthetics Journal, 3(5), (2016). 16. Kang H.G., Youn K.H., Kim I.B., Nam Y.S., ‘Bilayered Structure of the Superficial Facial Fascia’, Aesthetic Surgery Journal, DOI: 10.1093/asj/sjx001 (2017). 17. Tonnard Patrick, Verpaele Alexis, Monstrey Stan et al., ‘Minimal Access Cranial Suspension Lift: A Modified S-Lift’, Plast Reconstr Surg, (2002). 18. Lemmon, M.L. , Hamra S.T (1980) Skog rhytidectomy: A 5-year experience with 577 patients. Plastic and Reconstructive Surgery 65(3) :283-297 19. Pritzker R.N., Hamilton H.K., Dover J.S., ‘Comparison of different technologies for noninvasive skin tightening’, J Cosmet Dermatol, 13(4) (2014) pp.315-323 20. Fabi S.G, ‘Noninvasive skin tightening: focus on new ultrasound techniques’, Clin Cosmet Investig Dermatol, 2015, 5(8) pp.47-52. 21. Rohrich R., Pessa J.E., Ristow B., (2008) The Youthful cheek and the deep medial fat compartment. Plastic & Reconstructive Surgery 121(6):2107-2112. 22. Van Loghem J.A.J., Humzah D., Kerscher M, ‘Cannula Versus Sharp Needle for Placement of Soft Tissue Fillers: An Observational Cadaver Study’, Aesthetic Surgery Journal, 2016. 23. Mendelson B & Chin-Ho W, ‘Anatomy of the Ageing Face’, Aesthetic Surgery of the Face, 2013, p.83. 24. Shaw R.B., Katzel E.B., Koltz P.F., Yaremchuk M.J., Kahn D.M., Langstein H.N., (2011) Ageing of the facial skeleton: aesthetic implications and rejuvenation strategies. Plastic and Reconstructive Surgery 127(1): 374 -384

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Non-surgical Rhinoplasty Mr Ayad Harb presents his protocol for non-surgical rhinoplasty using hyaluronic acid fillers injected at three key areas Non-surgical rhinoplasty has remained within the domain of advanced aesthetic practitioners due to the perceived narrow margin for error and low potential risks.1 The procedure is not intended to replace a surgical procedure, much like a thread lift or liquid facelift is not intended as an equal alternative to a surgical facelift. However, the non-surgical rhinoplasty can correct minor deformities such as saddle nose, prominent humps and issues with proportions, and can be useful as an adjunct to a surgical procedure. There are numerous described techniques that can achieve excellent results in experienced hands.2,3 However, one must always be mindful of the limitations and contraindications of these techniques as well as the potential risks and pitfalls. Mullen and Hunter, in their two-part article published in the Aesthetics journal, gave an excellent overview of the non-surgical rhinoplasty and the nasal anatomy relevant to the procedure and its inherent risks.4 This article will describe my protocol, the trademarked 3-point Rhino, a rationalised and standardised three-point method for performing a non-surgical rhinoplasty using hyaluronic acid (HA) fillers. This technique name has been trademarked, meaning that I have found this procedure to be safe, reliable and effective whilst also reducing the risks of swelling, scarring and inconsistent results.

The 3-point Rhino The 3-point Rhino offers a rationalised approach of systematically addressing the most common anatomical traits in patients presenting for rhinoplasty – low radix, dorsal hump, and inadequate tip projection.5 Other less common complaints can be treated as required, but I have found that for the majority of patients the above concerns are more common. Through my experience and technique refinement, it has been possible to rationalise and simplify the nonsurgical rhinoplasty into a fundamental three-point method, which is suitable for the majority of nose patients. To date, the 3-point Rhino has been employed in 148 patients with consistent, reliable and satisfactory results. Non-surgical rhinoplasty is beneficial for both the patient and the practitioner. From the patient’s perspective, this is a 15-minute, office-based procedure, which is generally painless and carries minimal risk. The patient is usually pleased to hear that no anesthetic is required, the procedure should leave no scars and the result is immediate with no downtime. There is also a subset of patients who cannot have surgery for medical or personal reasons; in these instances non-surgical rhinoplasty can be an excellent way of achieving the nasal correction that they desire. Furthermore, the procedure can be used on patients who are considering a surgical rhinoplasty and wish to see how a ‘new nose’ might look, before embarking on potentially risky and costly surgery.

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From a practitioner’s perspective, this is a relatively easy three-step corrective procedure that enables the practitioner to rationalise their assessment and subsequent treatment of the nose deformity. This obviates the need for excessive injections and serial refinements, as can be the case with other non-systematic or ‘inject-as-you-go’ techniques, which can lead to inaccuracies and swelling, as well as lengthy procedures and added discomfort to the patient. The 3-point Rhino method offers a reliable template for treating the most common nose complaints, by addressing the critical anatomical sites, with consistently satisfactory results. This rationalised 3-point Rhino method would be a good template for novice nasal injectors to follow and can later be adapted to treat more complex cases of nasal deformity.

Technique Following appropriate consultation and consent, the patient is prepared in the treatment suite. The three anatomical points and injection areas are marked (Figure 1) at the radix, either side of the dorsal hump and the tip. Topical anaesthesia creams may be used; however, be aware that there is a slightly higher incidence of swelling, irritation and bleeding at the site, which could obscure the subtle contours needing treatment.6 To avoid the need for additional anaesthetic pre-injections, which can distort and mask the fine nasal discrepancies, a HA with integral lidocaine is selected. The ideal filler should be a viscous, cross-linked hyaluronic acid that offers increased longevity and volumising capability. The injection is performed in the least traumatic way possible with the minimum number of penetrations – ideally only three. As the 3-point technique refers to the three critical anatomical points on the nose that are addressed with this procedure, not the number of injections made, occasionally it may be necessary to re-inject at the same site if the correction is insufficient. In non-surgical rhinoplasty, as with surgical techniques, the principle should be to inflict the least amount of damage to the soft tissues, thereby reducing pain, swelling and scarring. The preference therefore is to use a needle, directly injecting at discrete points (Figures 2, 3 & 4). An inert HA filler, which triggers minimum tissue reaction and has a low swelling profile should be used. Non-HA collagen stimulators or other bioactive semi-permanent fillers that could provoke increased collagen formation or scarring should be avoided in the nose.7 For this technique in particular, I always perform with a needle for direct injection at the critical points; there are other instances when cannula is necessary such as correction of a deviation. Overzealous cannula techniques should be avoided to reduce the amount of repetitive burrowing under the skin and minimise the amount of trauma and potential scarring to the soft tissues of the nasal dorsum. One should be mindful to Figure 1: The three anatomical points minimise interference with and injection areas market on the the normal nasal anatomy in patient

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Figure 2: The first injection point at the radix. This elevates the lift-off point of the nose, giving it more aesthetic balance and blends in an hour-glass curve with the medial eyebrows.

Figure 3: The second injection point at the dorsum. This helps to mask any prominent dorsal hump or depression.

order to ensure that swelling and recovery time are reduced and that the result is natural. Factors that may contribute to excessive tissue oedema and bruising, thereby making the fine tuning of the procedure more difficult and less predictable, are the use of multiple injection points and repetitive refinement, crude injection technique and injection of low quality HA fillers.8,9 It is also imperative to reduce scarring, by minimising the amount of local tissue trauma, particularly in patients who may, in future, wish to consider surgical rhinoplasty as the disrupted tissue planes and additional scarring may make the operation more challenging.10 Among other similar techniques, the 3-point Rhino overcomes these barriers and simplifies the technique to just three critical points of injection, which yield aesthetically pleasing results for the majority of patients. Injection point 1 is the radix The HA filler is injected at the radix and bony dorsum and massaged into a fan shape, narrowing caudally towards the dorsal hump. The purpose of this point is to raise the level of the radix to the upper lash line for a better proportioned nose and reduce the appearance of a curved bottom-heavy nose. The fan shape also helps to accentuate the gentle hourglass curvature from the brow into the nose. A slightly more caudal injection at this point can be used if there is a very prominent dorsal hump that would require smoothing. Injection point 2 is the dorsum HA filler is injected as a small bolus immediately cephalad and caudal to the dorsal hump prominence. The HA bolus is massaged cautiously to reduce the prominence of the dorsal hump and smooth Before

After

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Before

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Figure 4: The third injection point at the tip of the nose. This aims to enhance the light reflection points at the tip and give the appearance of greater lift.

any contour irregularities on the nasal dorsum, leading gently into the lower third of the nose. Injection point 3 is the tip Finally, a small volume of HA is injected at the two light reflection points of the tip. This volume is highly variable, typically 0.05-0.1ml, and depends on the shape of the tip and the response of the soft tissues to the filler injection. These injections help to raise the tip slightly giving a very mild supratip break, which is more aesthetically pleasing than a perfectly straight profile, particularly in female patients.11 The tip injections also give the appearance of a chiselled nasal tip and improves the nasolabial angle. In my experience, I have found that this injection point addresses the nasal tip shape adequately and seldom is there a need to use additional columellar injections for correction of the nasolabial angle.

The ideal patient The 3-point Rhino is extremely versatile and can be used to treat a wide array of patients. The ideal patient should have realistic expectations of the results that can be achieved following a nonsurgical procedure. A typical nose with a gentle dorsal convexity or hump, low radix and deficient tip projection is the ideal candidate for treatment with non-surgical correction techniques such as the described 3-point Rhino method. It is important to make the patient understand that by adding volume to what they might already perceive as their â&#x20AC;&#x2DC;big noseâ&#x20AC;&#x2122;, it will naturally become bigger, though this will not be obvious. The improved balance and proportion, and the straightened profile and lifted tip, are much more noticeable and will make the nose more attractive and in harmony with the rest of the face. After

Before

Figure 5: Different patients before and after non-surgical rhinoplasty using the 3-point Rhino technique

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The risk of blindness following non-surgical rhinoplasty, despite its exceptional rarity, remains an important material risk to the patient and should always be included in the consent process What results to expect The results from this technique are extremely reliable and repeatable if the patients are selected appropriately, the rules of minimal interference with the normal anatomy are respected and small volumes of a good quality HA filler are used. The typical volume required is 0.6-1.0ml. The result longevity depends on the type of filler that is used and other patient-related factors, such as physical activity and metabolic rate.12 One would expect the results of the 3-point Rhino and other non-surgical rhinoplasty techniques, using an appropriate HA filler, to last nine to 12 months.

Contraindications Difficulties can arise in certain noses. Patients who have very large noses or prominent dorsal humps that clearly require surgery should be advised accordingly. Previous surgery and trauma, thin skin and high-demand patients with unrealistic expectations are all potential pitfalls for the uninitiated practitioner. The practitioner should recognise these issues and should never be afraid of refusing to treat a patient. The 3-point Rhino template is not suitable for treating severely deviated noses, septal problems, functional nose complaints and other unilateral asymmetries, which should be treated with meticulous assessment and bespoke injection techniques or surgery.

Side effects and complications As with any procedure, there are potential side effects and complications. These include compromised circulation if the filler is not injected sympathetically or if the skin is placed under excessive tension; abnormal nasal contours and boluses of large volumes of filler can be visible or palpable if extensive changes are attempted in a patient who would have been better treated with a rhinoplasty.1,2 Generally, visibility and palpability of filler can be improved with gentle massage or with hyaluronidase injections if necessary. The fact that you can treat complications with hyaluronidase is another reason for choosing a reversible HA filler over non-HA alternatives. The risk of blindness following non-surgical rhinoplasty, despite its exceptional rarity, remains an important material risk to the patient

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and should always be included in the consent process.13,14 This risk is minimised by deep injection onto bone, minimum number of injections, slow injection technique and an intimate knowledge of the local anatomy. Other general risks of injection include bleeding, bruising, pain and infection. These can be minimised by employing sterile injection technique, maintaining a sound knowledge of the facial and nasal vascular anatomy and applying firm pressure to bleeding points to reduce the risk of bruising.13,14

Contraindications The usual contraindications to any dermal filler also apply to non-surgical rhinoplasty, including acute or chronic skin disease, pregnancy, breastfeeding, allergies or intolerances to dermal filler materials.2,3 Caution should be exercised in patients who have had previous nasal surgery or trauma as the normal arterial anatomy can be altered and the viability of the skin may be more sensitive to tension.15,16

Conclusion The 3-point Rhino is a procedure that offers a simplified and rationalised method of addressing the most common anatomical traits in patients presenting for rhinoplasty – low radix, dorsal hump, and inadequate tip projection. This method has demonstrated consistency and reliability for producing aesthetically pleasing results, whilst avoiding undue trauma to the natural anatomy and reducing the risks of swelling and scarring. Mr Ayad Harb specialises in plastic and reconstructive surgery and is the director of The Bicester Clinic and Qosmetic clinics in London, Oxfordshire and the West Midlands. Mr Harb founded The Qosmetic Academy in 2015 and has developed a number of signature treatments including the 3-point Rhino and the Collagen Ladder. He also practices in the NHS as Senior Clinical Fellow in Plastic Reconstructive Surgery. REFERENCES 1. McKeown DJ, ‘The risk of blindness following ‘non-surgical rhinoplasty’,Journal of Plastic, Reconstructive & Aesthetic Surgery, 2013, 66. <https://www.ncbi.nlm.nih.gov/pubmed/23631867> 2. Beer KR, ‘Nasal reconstruction using 20 mg/ml cross-linked hyaluronic acid’, Journal of Drugs in Dermatology, 2006, 5, pp.465-6. <https://www.ncbi.nlm.nih.gov/labs/articles/16703786/> 3. Alexander Rivkin & Kontis TC, ‘The history of injectable facial fillers’, Facial Plastic Surgery, 2009, 25, pp.67–72. <https://www.ncbi.nlm.nih.gov/pubmed/19415573> 4. Mullen, G & Hunter B, ‘Non-surgical Rhinoplasty’, Aesthetics, 2016, pp.34-36. <https:// aestheticsjournal.com/feature/non-surgical-rhinoplasty> 5. Constantian MB, ‘Rhinoplasty: craft and magic, St Louis: Quality Medical’, CRC Press; 1 Har/DVD edition (22 July 2009) 6. Product Information, Emla Cream (lidocaine-prilocaine), Astra-Zeneca Pharmaceuticals, Wayne, PA. 7. Van Loghem J & AlexandrovnaY et al., ‘Calcium Hydroxylapatite: Over a Decade of Clinical Experience’, Journal of Clinical Aesthetic Dermatology, 2015, 8, pp.38-49. <https://www.ncbi.nlm. nih.gov/pubmed/25610523> 8. Philippe Lafaille & Benedetto A, ‘Fillers: Contraindications, Side Effects and Precautions’ Journal of Cutaneous Aesthetic Surgery, 2010, 3, pp.16-19. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2890129/> 9. Zielke H & Wobler L et al., ‘Risk Profiles of Different Injectable Fillers: Results from the Injectable Filler Safety Study (IFS Study)’, Dermatologic Surgery, 2008, 34, pp.326–335. < https://www.ncbi. nlm.nih.gov/pubmed/18177399 > 10. Guyuron B & Kinney B, ‘Aesthetic Plastic Surgery Video Atlas’, Elversier, 2011, pp.170-172. 11. McArdle A & Young R et al., ‘Preferences for the white female nasal supratip break’ Annals of Plastic Surgery, 2012, 68, pp.366-8. <https://www.ncbi.nlm.nih.gov/pubmed/22421480> 12. De Boulle K & Glogau R et al, ‘A Review of the Metabolism of 1,4-Butanediol Diglycidyl Ether– Crosslinked Hyaluronic Acid Dermal Fillers’, Dermatolic Surgery, 2013, 39, pp.1758-1766. <https:// www.ncbi.nlm.nih.gov/pubmed/23941624> 13. Nandasoma U, ‘A question of consent’, MDU Journal, 2015. <https://mdujournal.themdu.com/issuearchive/issue-1/a-question-of-consent> 14. GMC, Consent guidance: Part 2: Making decisions about investigations and treatment’, 2017, pp.28-36. < http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_part2_making_ decisions_about_investigations_and_treatment.asp > FURTHER READING: 15. Constantian MB, Rhinoplasty: craft and magic, St Louis: Quality Medical, CRC Press; 1 Har/DVD edition (2009). 16. Rohrich R, Adams P, Dallas Rhinoplasty: Nasal Surgery by The Masters, CRC Press; 3 edition (2014),

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CATEGORIES COMPANY AWARDS The winners of these categories will be decided by a combination of votes and scores from an expert judging panel, selected by Aesthetics. DISTRIBUTOR OF THE YEAR  Have you brought new, international, ground-breaking treatments to the aesthetics market? This award recognises the vital role played by UK distribution companies, and finalists will be selected on the basis of their customer service, product range and services to the industry.

Enter now for the Aesthetics Awards 2017! Entry is now open for the most prestigious awards event in medical aesthetics –find out how you can be recognised amongst the best in the specialty! Never before has recognition for excellence in medical aesthetics been so important – the Aesthetics Awards aims to acknowledge and reward those who ensure best practice, deliver outstanding customer service, offer innovative products, uphold strong ethics and show clinical excellence. To be held on Saturday 2 December 2017 at the Park Plaza Westminster Bridge Hotel in central London, the Aesthetics Awards will recognise the winners and finalists of 26 categories, including some exciting new ones for 2017. Around 700 guests will celebrate their fantastic achievements at a lively networking and drinks reception, where there will be a delicious three-course meal and entertainment from a top comedian, as well as the Awards presentation itself. After the final award is presented, guests will then be able enjoy music and dancing late into the night.

GET THE RECOGNITION YOU DESERVE Entering the Aesthetics Awards is an excellent opportunity to celebrate the successes and achievements of your business. In an ever-growing and increasingly competitive market, it is essential to be able to stand out from the crowd and be recognised as one of the best in your field. By entering the Aesthetics Awards you could be shortlisted as a finalist in one or more of the categories, giving you the chance to receive a Commendation, High Commendation or, of course, be crowned the Winner. These achievements offer valuable marketing opportunities, allowing you to prove to patients and clients why they should work with you or visit your clinic. Entry is open now and will close on June 30, with finalists announced on September 1 on the Aesthetics Awards website and in the September issue of the Aesthetics journal.

WHOLESALER OF THE YEAR (NEW) If you sell a range of products at competitive prices and provide your customers with an outstanding service, then enter this category. New to 2017, this award acknowledges the crucial role of wholesalers that provide a one-stop shop in the aesthetic market. BEST UK-BASED MANUFACTURER (NEW)  Exceptional customer service, initiatives aimed at improving and maintaining it, as well as consistent supply and aftersales support make up some of the criteria that the Aesthetics team will look for in this awards entry. If your company is based in the UK and meets these benchmarks then you could be accepted as a finalist within this category. BEST UK SUBSIDIARY OF A GLOBAL MANUFACTURER (NEW)  This year, Aesthetics will also be recognising the excellent service provided to clients by global manufacturers. Original ingenuities aimed at refining and upholding top service are essential in distinguishing you from your competitors and this award will recognise the stand-out companies. BEST CLINIC SUPPORT PARTNER (NEW)  There are many ways in which different business services and products support your clinic to remain prosperous. If you are a business that supports clinics through products and services such as clinic software, CRM systems, insurance, PR support or any other service that demonstrates how your support has maintained a clinic’s standards and profitability, then enter this exciting new award. THE HEALTHXCHANGE AWARD FOR SALES REPRESENTATIVE OF THE YEAR  Sales reps play a fundamental role in the aesthetics specialty; through ensuring that products provide the best possible results for patients and supporting clinic staff in how to most effectively utilise products in order to maximise sales, this award distinguishes the most successful and supportive representatives in aesthetics.

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PRODUCT AWARDS

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TRAINING PROVIDER AWARDS

The winners of the product awards will be decided by a combination of votes and scores from an expert judging panel, selected by Aesthetics, with the exception of The Barry Knapp Award for Product Innovation of the Year, supported by Medical Aesthetic Group, which will be decided purely on judges’ scores.

The awards for best training provider will be decided by scores from an expert judging panel and reader votes. THE ENHANCE INSURANCE AWARD FOR BEST INDEPENDENT TRAINING Enhance Insurance Advice Support PROVIDER This award will acknowledge those who provide an exceptional independent training service. With an array of training providers and academies available and consistently increasing, this Award ensures that those who independently provide training which promotes safety, good ethics and best practice will not go unrecognised. |

COSMECEUTICAL TREATMENT OF THE YEAR The manufacturer or UK distributor of the best cosmeceutical range or skin treatment retailed in UK medical aesthetic clinics will be awarded the trophy for this category. Finalists will be selected for detailing the efficacy of their products, their safety and demonstrating the excellent results that can be achieved. THE HARLEY ACADEMY AWARD FOR INJECTABLE PRODUCT OF THE YEAR  To be recognised as the best injectable product of the year, entrants must demonstrate that their product or treatment is effective, can be used in a wide-range of indications and is safe for patients. The award will be given to the manufacturer or UK distributor of the product(s) that meets all the above criteria and beyond. ENERGY TREATMENT OF THE YEAR (NEW)  With a huge surge of energy-based treatments reaching the market over the past few years, the Aesthetics Awards will now recognise these for the first time in their own category. Do you manufacture or distribute an energy-based device that achieves outstanding results for patients, without the sacrifice of painful treatment or extended downtime? If the answer is yes, then enter for the chance to be recognised. THE BARRY KNAPP AWARD FOR PRODUCT INNOVATION OF THE YEAR, SUPPORTED BY MEDICAL AESTHETIC GROUP The most innovative and dynamic product to the UK aesthetics market in 2017 will be given the accolade of product innovation of the year. In order to be considered as a finalist, the product must have been launched into the specialty after 1 January 2016. Judges will be looking for genuine revolution or product enhancement that has led to treatment for new indications, enhancement of current ones or quicker and safer treatments, all supported by solid scientific evidence.

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BEST SUPPLIER TRAINING PROVIDER (NEW) Many suppliers provide first-rate training programmes to clients and the Aesthetics Awards will reward those who go the extra mile to provide comprehensive and practical training as finalists. Enter this brand new category if you believe your company delivers unrivaled training.

REGIONAL CLINIC AWARDS Awards for best clinic are granted regionally and are awarded to any clinic in the UK and Ireland that has been open for 12 months or more. The finalists will be whittled down by the judging panel, who will be looking at the clinic’s commitment to excellence in customer service, patient care and safety, and evidence of positive feedback from patients and clients.

THE COSMEDIC PHARMACY AWARD FOR BEST CLINIC MIDLANDS & WALES

THE JOHN BANNON AWARD FOR BEST CLINIC IRELAND

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THE ALUMIER LABS AWARDS FOR BEST CLINIC GROUP UK & IRELAND (10 CLINICS OR MORE) THE DERMALUX AWARD FOR BEST CLINIC LONDON

THE IS CLINCAL AWARD FOR BEST CLINIC SOUTH ENGLAND BEST CLINIC NORTH ENGLAND BEST CLINIC SCOTLAND

THE CONSENTZ AWARD FOR CLINIC RECEPTION TEAM OF THE YEAR The clinic reception team is often at the heart of the clinical practice and the Aesthetics Awards recognises the hard work clinic teams put in to ensuring a profitable and successful reputation. Reception teams of any size can enter in the UK and Ireland and judges will be looking for evidence of outstanding customer service, continuous training and effective team work.

OTHER CLINIC AWARDS THE AESTHETICSOURCE AWARD FOR BEST NEW CLINIC UK & IRELAND If your clinic was established after 1 January 2016 then you will be eligible to enter the award for Best New Clinic UK & Ireland. Judges will look closely at the initiatives designed to promote growth, evidence of commitment to customer service, patient care, patient safety and fantastic feedback from patients and clients. The below are open to any clinic group in the UK and Ireland with either more than three clinics (but less than 10) or 10 clinics or more. The group will be judged as a whole on their obligation to excellence in the service they provide, patient care and safety, and exceptional feedback. THE PROFHILO AWARD FOR BEST CLINIC GROUP UK & IRELAND (3 CLINICS OR MORE)

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CLINIC, COMPANY OR ORGANISATION THE PHI CLINIC AWARD FOR INDUSTRY INITIATIVE OF THE YEAR (NEW) This award recognises the important role that both patient-focused and professional campaigns play in promoting consumer education and patient safety. It is open to associations, companies and individuals. In selecting finalists, the Aesthetics team will look for evidence of activity designed to benefit the industry as a whole and tangible outcomes.

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THE SCHUCO INTERNATIONAL AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICAL AESTHETICS The outstanding achievements and significant contribution to the profession by an individual with a distinguished career in medical aesthetics will be recognised with the trophy for Outstanding Achievement in Medical Aesthetics. This category will be announced on the night of the Awards and will not be open to entries.

HOW TO ENTER

INDIVIDUAL PRACTITIONER AWARDS These prestigious and most-sought after categories recognise individuals in the aesthetics specialty who go above and beyond in their commitment to their patients and their profession. THE INSTITUTE HYALUAL AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR The outstanding contribution made by nurses does not go unrecognised and the Aesthetics Awards acknowledges those who have contributed the most to their profession, as well as providing excellent care and treatment to his or her patients in the past 12 months. Entrants must demonstate clinical expertise and and the positive difference they have made to their patients and profession. THE SKINCEUTICALS AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR This accolade will be given to a doctor, dentist or surgeon who has proven that they have contributed the most to the profession and enhancing the lives of their patients through first-class treatments. Judges will be looking for those who demonstrate their clinical expertise, continuous professional development and the difference they have made to their patients, clinics and profession as a whole.

All entries must be made via the Aesthetics Awards website. You can enter in as many categories as you wish but you may only enter yourself, a company you work for, an employee who works for your company or a product made or distributed by your company. Entries made on behalf of a third party will not be accepted. You may only enter each category 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. The information provided will be used to choose the lists of finalists and by the judges when voting on a winner.

Entering the Aesthetics Awards is an excellent opportunity to celebrate the successes and achievements of your business

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Due to the fact that capillary ingrowth takes a few days following graft placement, the cells have to rely on diffusion of oxygen and nutrients from surrounding tissue fluid. This means that only cells near the surface of the block of tissue will be nourished and survive. If the fat particles are very small and have a large surface-to-volume ratio then the whole particle will survive. Large particle size, however, means that the inner cells will not achieve re-establishment of blood flow in time to prevent cellular death. This is why small particle grafting is essential. Fat graft systems that are able to produce small graft particle size will therefore have better rates of graft take.5

Using fat grafting for augmentation

Facial Fat Grafting Mr Anthony Macquillian provides an introduction to fat grafting for facial augmentation Fat grafting to the face has often been limited to lipodermal structural grafts and in the past has perhaps been used as more of a reconstructive procedure rather than an aesthetic one.1 There has been an increasingly better understanding of fat harvesting and injection techniques, which has produced a more reliable level of graft take and reduced the risk of lumpiness in the recipient sites, making its use a far more attractive proposition for both patients and practitioners. Fat grafts are stable, autologous, and part of the normal tissue composition at the recipient site. They appear to have the potential ability (although it is not yet fully understood) to rejuvenate the tissues into which they are injected, through the stem cells contained in the vascular stromal fraction of the lipoaspirate.2 Although the treatment is unlikely to replace hyaluronic acid dermal fillers as the mainstay product for soft tissue remodelling, as the modality requires a degree of surgical training, it presents a compelling alternative to those able to offer the technique to their patients. It is also beneficial that practitioners who are not qualified to conduct these treatments understand the treatment process so that they are able to explain it to their patients should they ask. This article will outline the basics of fat harvest and transfer for the face as well as provide an overview of indications and contraindications.

Fat grafting is increasingly being used for rejuvenation or augmentation of several areas of the body, the most common being the breast,6 hands7 and face.8,9 It has the benefit of being fully autologous (no risk of hypersensitivity reactions), and once vascularised (capillary ingrowth has been completed) there is an extremely low risk for infection. It responds to touch exactly like normal tissue and can be used as a bed into which further fat can be injected if desired in the future. In my opinion, this has the makings of the ultimate injectable revolumising material. Several forms of fat graft application to the face have been described, such as lipodermal grafts, micro grafts and nano fat transfer. Recently the introduction of micro-straining techniques to filter, purify and reduce particle size (one of the original descriptions being emulsification) has resulted in the development of â&#x20AC;&#x2DC;nano fatâ&#x20AC;&#x2122;.2 Nano fat grafting is the use of very small particles, or almost liquidised fat, which has been used for correction of very fine wrinkles and for its direct rejuvenation properties. Although the exact mechanism of action is unclear, nano fat is thought to work by the action of stem cells and growth factors up-regulating collagen and elastin production.2 Indications for the use of nano fat include intradermal injection for the correction of fine wrinkles, intra and subdermal injection for the correction of sun damage and intra and subdermal injection for the correction of skin discolouration (for example in the lower eyelid).2

Fat grafting protocol Harvesting of fat cells for transfer is carried out by liposuction. Unlike liposuction performed for body contouring, the fat that is aspirated has to be collected in specialised systems that usually filter the aspirate and separate living cells from non-viable adipocytes and lipid (to a greater or lesser extent). The idea behind this is to only inject viable tissue that will not be resorbed â&#x20AC;&#x201C; hence maximise volume preservation. This leaves the practitioner with a viable population of fat cells that can be injected into the recipient site. For large volume fat harvest (such as for breast or buttock augmentation) several dedicated systems are available for efficient harvest of large quantities of lipoaspirate.10,11,12 However, where smaller volumes are required, many

What is fat grafting? Fat grafting or fat transfer is, as the name suggests, the movement of fat cells (adipocytes) from one part of the body (the donor area) to another. The technique of grafting a tissue involves removing it from its blood supply entirely and then relying on the ingrowth of a new capillary network to support the transferred cells once they are at the recipient site.3 It is the establishment of this new blood supply that is crucial to the survival of the transferred tissue. If this fails, it will result in graft loss; in the case of adipocytes, necrosis of the cells, with resorption of their lipid content (and loss of volume at the recipient site).4

Fat grafts are stable, autologous, and part of the normal tissue composition at the recipient site

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practitioners use a fine liposuction cannula mounted on to a syringe. Handling of the fat graft is different from that of normal fillers such as hyaluronic acid, as the cells are sensitive to pressure, which must be kept in mind when injecting, and the liquidity of the fat differs depending on the site of injection. In the malar and temporal regions ‘dry’ graft (non-diluted) is generally the preferred choice by practitioners, but in the periorbital area a more liquid form of graft is utilised (with some practitioners reporting mixing the graft with saline in a 70:30 ratio).13,14 In my experience using a liquid graft in the periorbital region has less likelihood of getting lumps developing under the thin skin of the lids. Injection of the fat into the recipient site can be undertaken by a number of means – all require the use of some form of cannula or needle. Many practitioners use a wide bore needle to introduce the graft material, although most advocate use of fine blunt cannulas for injection, as needles are more likely to puncture a blood vessel, with typical delivery diameters of 0.7mm to 0.9mm.9 My preference is for a blunt tipped 0.9mm cannula. Most users would advocate injection being undertaken during a controlled withdrawal process, though other techniques such as ‘air brushing’ (multiple passes with extremely fine cannula depositing very small volumes but quite rapidly) have been suggested by some experienced practitioners in the field15 – I would suggest that this is for the experienced clinician only. Areas particularly suited to fat graft treatment are shown in Figure 1.15 Figure 1: Facial fat grafting target sites. The figures indicate typical volumes of fat injected in mls. 3 3 3 1 3

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Contraindications The technique is widely applicable, but like all treatments there are certain circumstances where it is contraindicated. Firstly, the patient must have sufficient fat to act as a donor site for the procedure (not usually so much of a problem for facial fat grafting but definitely an issue for larger areas such as the breast). The practitioner must explain to the patient that although it is a permanent procedure, there is likely to be some resorption of graft material and they may require a repeat procedure or touch up to get the ideal outcome. In my practice, smoking is an absolute contraindication to treatment due to its interference with graft take.16 It is important to explain to patients that any areas that have pre-existing scarring will require at least two treatments (the first to treat the scar bed and Preference order

Fat donor site

1

Medial knee

2

Saddle bag (lateral thigh)

3

Flank

4

Abdomen

Figure 2: Fat donor site preferences in order (in consideration of fat stability in relation to alterations in weight).

provide a bed of fat into which further graft can be injected with subsequent treatments delivering increases in volume), and those who have had previous surgery to the area will be particularly hard to inject (due to surgical scar formation). Ideally the patient will have revolumisation done as part of a facial surgery procedure or done prior to subsequent surgery. If a patient has been previously treated with HA dermal filler, it is important to wait until all filler material has been resorbed prior to grafting as filled areas will not be able to provide the graft with vascular ingrowth and the transferred cells will die and resorb.

Complications

3

3

Choosing a donor site As stated above, once vascularised and incorporated into the surrounding tissues, the fat cells are living and will respond to changes in nutritional status like elsewhere on the body. This leads to two considerations – firstly the patients’ weight should be stable prior to undertaking any procedure (or else the result may be unpredictable) and subsequent significant weight gain will have additional effects on the facial appearance. It is possible, however, to mitigate against these potential problems by choice of fat donor site. Transferred fat retains its stability in relation to nutritional status once embedded in its new location and, therefore, the ideal donor site is one that is relatively unaffected by weight loss or gain.16 In practice this means that for facial fat grafting, the first choice donor site is the inner aspect of the knee (see Figure 2 for my donor site preference order).

In the past, a particular area of concern (based on the experience of many surgeons) has been the development of lumpiness within the graft, especially in the perioccular area. With the use of more ‘liquid’ grafting techniques this is now a rare complication, although if it does occur, areas resistant to massage can be treated with the judicious use of dilute steroid injection.17 The most common complication is loss of graft volume. However, as stated above, meticulous harvest and injection techniques helps to reduce the rate of graft loss.18 Infections are rare, but in my practice I always prescribe patients with one week’s worth of antibiotic treatment post operatively as a precaution. As with all injectables, there is the risk of embolism if the fat is injected directly into a vessel with ophthalmic artery embolism being the foremost concern. The use of a blunt tipped cannula and injecting only when withdrawing the cannula mitigates against such complications,17 but in the event of concern immediate contact with the nearest ophthalmic surgery emergency facility is mandatory. Trauma to the surrounding facial structures (nerves, vessels and the eye itself) resultant from the cannula is possible but careful, gentle technique renders this an unlikely eventuality.

After the procedure Post operatively it is important that the patient minimises pressure to the grafted areas and keeps the face warm by avoiding cool

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outside conditions for at least a week. A high carbohydrate intake for four weeks post surgery helps with graft take (thought to be mediated through the actions of insulin-like growth factor).17 It is important to limit patients’ immediate post-operative expectations – it is usual for them to appear swollen and red for two to three weeks following surgery and telling them that they should not expect to see any indication of how they will ultimately look until after the three-week mark is important. Volume changes are normally apparent up four months post procedure, with the final outcome being visible by six months.

Conclusion In summary, facial fat grafting offers an exciting alternative to traditional filler materials when considering facial rejuvenation. It has the additional benefits of being fully autologous, permanent, and seems to have a direct antiageing effect on the skin and soft tissues. Improvements in graft harvest technique and placement have translated into markedly better rates of graft survival. Although still a comparatively rare technique in the aesthetic field, I believe it is likely to play an increasingly important role for practitioners to treat the signs of facial ageing.

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Mr Anthony Macquillan is a consultant plastic surgeon in the NHS and provides consulting and operating services at his aesthetic and cosmetic surgery practice in St. Joseph’s Hospital in Newport and the Wellington Hospital in London. He is particularly interested in facial rejuvenation, rhinoplasty and breast and body reshaping. REFERENCES 1. Sabbagh W, Shafighian A, Harrison DH, ‘Upper labial deficiency in Mobius syndrome: a previously unreported feature and its correction’, Sabbagh W, Shafighian A, Harrison DH, Plast Reconstr Surg, (2003) 112(7), pp.1762-7. 2. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H, Nanofat grafting: basic research and clinical applications, Plast Reconstr Surg, 2013, 132(4):1017-26. 3. Thorne CH Lippincott, ‘Techniques and basic principles in plastic surgery’, Grabb & Smith’s Plastic Surgery. Ed. Thorne CH. Lippincott, 2007. 4. Complications of Fat Grafting: How They Occur and How to Find, Avoid, and Treat Them. Yoshimura K, Coleman SR. Clin Plast Surg. 2015 Jul;42(3):383-8, 5. How does fat survive and remodel after grafting?Mashiko T, Yoshimura K.Clin Plast Surg. 2015 Apr;42(2):181-90. 6. Ueberreiter K, von Finckenstein JG, Cromme F, Herold C, Tanzella U, Vogt PM, ‘BEAULI™ a new and easy method for large-volume fat grafts’, Handchir Mikrochir Plast Chir, 42(6) 2010 pp.379-85. 7. Hoang D, Orgel MI, Kulber DA, ‘Hand Rejuvenation: A Comprehensive Review of Fat Grafting’, J Hand Surg Am, 2016, 41(5):639-44. 8. Coleman SR, Katzel EB, ‘Fat Grafting for Facial Filling and Regeneration’, Clin Plast Surg, 2015, 42(3) pp.289-300. 9. Marten TJ, Elyassnia D, ‘Fat grafting in facial rejuvenation’, Clin Plast Surg, 2015, 42(2):219-52. 10. Humen Med, ‘Lipo Transfer’, Humen Med, (2017) <http://www.humanmed.com/en/technique/lipo_transfer> 11. Mentor, ‘COLEMAN CANNULA’, Mentor Medical Systems, <www.mentorwwllc.eu/body/coleman-cannula>
 12. LipiVage, ‘How does LipiVage work?’, (2017) <www.genesisbiosystems.com/lipivage-system-autologous-fattransfer/>
 13. H.Peltoneimi, Fat Grafting, 13th International BEAULI Workshop, Berlin, June 2016, <http://www.beauli.de/ documents/symp_2016_06.pdf>
 14. Botti G, Panel discussion on peri orbital rejuvenation, Beauty Through Science, Stockholm. May 2016.
 15. Marten T, ‘Panel discussion on peri orbital rejuvenation’ Beauty Through Science, May 2016 Stockholm. 16. Özalp, Burhan & Çakmakoğlu, Çağri, ‘The Effect of Smoking on Facial Fat Grafting Surgery’, The Journal of Craniofacial Surgery, 2016. 17. H.Peltoneimi, Fat Grafting, 13th International BEAULI Workshop, Berlin, June 2016, <http://www.beauli.de/ documents/symp_2016_06.pdf>
 18. Lindenblatt N, van Hulle A, Verpaele AM, Tonnard PL, ‘The Role of Microfat Grafting in Facial Contouring’, Aesthet Surg J, 2015, 35(7) pp.763-71.

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An Introduction to Inflammation Dr Mayoni Gooneratne explains the role that inflammation plays in the skin ageing process and how to treat it There is a wealth of research being conducted into the role that inflammation plays in ageing and disease.3 As each year passes, we learn more about how inflammation affects all of our organs, and the role it may play in the development of age-related conditions such as Alzheimer’s disease and heart disease, among others.1 Inflammation is also believed to play a role in cancer progression, autoimmune diseases and allergies: it is a fascinating area of exploration.2 The Institute of Inflammation and Ageing at the University of Birmingham summarises many of the latest findings and research projects on the News page of its website.3 In this article, I will explore the role of inflammation, and specifically chronic inflammation, in the skin-ageing process. As not only our largest organ, but also our largest external organ, skin is subject to inflammation from many sources throughout our lives. This can be caused by infection, environmental factors or other chemical exposure, and scientists now believe the inflammatory response is a key factor in how our skin ages. When inflammation becomes chronic over time, it is sometimes also known by the portmanteau ‘inflammaging’.4 I will discuss how an aesthetic practitioner can help patients to redress the balance within the skin to both slow down the ageing process, and induce regeneration to repair some of the damage done.

What is inflammation? Inflammation is a natural part of the body’s response to tissue injury, irritation or other harmful conditions, such as infection. Indeed, the inflammatory response plays an important role in defending the body, and is essential for tissue recovery. Acute inflammation and the immune response helps the tissue to repair or adapt over the short term.5 However, when inflammation becomes chronic (inflammaging), it results in effects that lead the tissue to degenerate.6 So, what is actually happening within the dermis when inflammation becomes

chronic? Although not yet fully understood, a study by Baylis et al suggests that inflammaging is a ‘consequence of a remodelling of the innate and acquired immune system, which in turn results in chronic inflammatory cytokine production’.4 Essentially, the skin’s natural immune defence mode becomes locked in a repetitive cycle. The skin reacts to environmental free radicals and antigenic load damage by activating the immune response. This causes inflammation and repair, and the production of reactive oxygen species (ROS) that cause oxidative damage. This leads to a release of pro-inflammatory cytokines, which in turn lead to tissue damage and an immune response: and so the cycle begins again.7

What causes chronic inflammation, or inflammaging? It is currently believed that inflammaging is a consequence of a cumulative lifetime exposure to certain stimulants. The resulting inflammatory response cycle causes tissue injury and healing to happen simultaneously.7 The resultant cellular and molecular damage, while not clinically evident, slowly accumulates over the years.7 In fact, there are many stimulants that contribute to the inflammation of the skin. These include environmental factors such as sunlight (UV), pollution and extreme weather,8 as well as exposure to other chemical irritants such as household cleaners or fabric detergents. Inflammation can also be exacerbated by cosmetic products and perfumes, smoking, and diet and alcohol consumption.

In what way is it related to skin ageing? In a study by Borg et al, they propose that the pro-inflammatory cytokines, as described in the chronic inflammation process above, play a key role in the appearance of ageing skin, due to their influence on collagen.9 These cytokines inhibit the production of

collagen, which is vital for the health of the skin.9 Collagen, the most abundant protein in the human body, essentially forms a scaffold that gives skin its strength and structure. It forms a fibrous network in the dermis, the middle layer of the skin, on which new cells can grow. Collagen also plays a role in the replacement of dead skin cells. It is well known that collagen production declines with age (a part of intrinsic ageing), and also that it is reduced by exposure to ultraviolet light (UV) and other environmental factors such as pollution (extrinsic ageing).10 Research by Borg et al indicated that not only do the cytokines reduce the production of new collagen, they also degrade existing collagen by increasing the production of MMP-9.9 MMP-9 is a matrix metalloproteinase which has the capacity to degrade most of the proteins that make up the dermal extracellular matrix.11 This affects the skin’s overall appearance and resilience. There are many factors contributing to the loss of collagen as we age, and it is this loss that causes the skin to become thinner, less resilient and more wrinkled in appearance.

What can be done to slow down the process? Taking steps to reduce exposure to known environmental irritants, and working to improve diet and overall health, can go some way to addressing the effects of chronic inflammation. Encouraging patients to avoid the damaging UVA and UVB rays, for example, will reduce free radical formation in the skin.12 It has been claimed by Dr Diana Howard, vice president of research and development for The International Dermal Institute, that as much as 80-99% of the changes we see on our skin as adults is caused by exposure to daylight.13 However, in reality it is not possible to avoid all possible sources of skin inflammation. Exposure to air pollution, for instance, is something we currently have little control over. So in what ways can we as aesthetic practitioners help patients?

Treatments The good news is that there are many ways that an aesthetic practitioner can address the symptoms of chronic skin inflammation. There are four key approaches that aim to treat both the cause of the inflammation and its effects (such as the reduction of collagen). These approaches all achieve the same aim: the choice of treatment depends on the patient’s preferences.

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They can each be used individually or in combination with one another. Some patients, for example, choose to alternate the different techniques. The intention with each of these approaches is to subject the skin cells to a small, controlled injury. This stimulates new skin growth, improving the appearance and surface texture of the skin. The four treatment approaches are: 1. Medical and prescription skincare There is a large variety of skincare products available that contain active ingredients to reduce inflammation and neutralise free radicals. Anti-inflammatory ingredients such as L-bisabolol14 and resveratrol15 for example, are thought to help reduce chronic inflammation by reducing the proinflammatory cytokine production cycle. Also effective are products containing retinoids such as tretinoin, which has been suggested to assist in the formation of new collagen fibres.16 However, it should be noted that this is not a short-term fix: a treatment period of at least six months is needed to see maintained improvement in collagen formation.16 2. Chemical injury Also known as a chemical peel, this takes the form of a topical product applied to the dermis to create an injury at a specific skin depth. Peels can be superficial, medium or deep, and these differing ‘strengths’ address different skin complaints by acting on different areas of the dermis. Deep peels are particularly effective for photoageing, wrinkling and scarring. They act on the reticular dermis, the lower layer of the dermis, which is densely packed with collagen fibres. The surface texture of the skin is improved by encouraging collagen production.17 3. Mechanical injury Using a microneedling device, such as dermaroller, to make thousands of shallow, microscopic needle holes in the dermis is another option. The microneedles are less than 1.5mm in length and only 0.1mm in diameter. The skin responds with the wound healing process, which induces the production of a new layer of collagen in the dermis.18 This technique is effective on photodamaged skin and wrinkling, as well as scarring.19 It usually takes around six weeks for visible signs of regeneration, and three treatments, spaced around six weeks apart, are most beneficial.

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4. Light therapy This approach delivers specific wavelengths of light to the skin to induce ‘damage’ at a cellular level. Depending on the technique used, this may be either thermal damage (photothermolysis) or a biochemical reaction. These distinctive procedures can be used in combination with each other. Both the thermal damage20 and biochemical reactions21 encourage an immune response and stimulate regeneration and renewal. Light therapy is a non-invasive technique, and as such, is pain-free. The number of treatments recommended is dependent on the individual.

Conclusion There are many methods and approaches at the aesthetic practitioner’s disposal to treat inflammation and help to mitigate its effects. Each of these intends to induce a controlled injury in order to break the chronic inflammation cycle, and also encourage production of new collagen. Further research is needed into the role that cytokines play.9 As we continue to learn and understand more about the process, we can expect further developments in the range of medical skincare products available. Dr Mayoni Gooneratne is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. Dr Gooneratne has completed extensive training in aesthetic techniques over the last few years, which has culminated in the creation of private aesthetic clinic The Clinic by Dr Mayoni in 2016. She is accredited by Save Face and is an associate member of BCAM.

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REFERENCES 1. Shijin Xia, Xinyan Zhang et al, ‘An Update on InflammAging: Mechanisms, Prevention, and Treatment’, Journal of Immunology Research, (2016) <https://www.hindawi.com/ journals/jir/2016/8426874/> (p.6). 2. ThermoFisher Scientific, When Inflammatory Cytokines Are Unbalanced, (2012) <https://www.thermofisher.com/uk/en/ home/references/newsletters-and-journals/bioprobes-journalof-cell-biology-applications/bioprobes-issues-2012/bioprobes67-june-2012/immunoassays-inflammation-cytokines.html> 3. University of Birmingham, Latest news, stories from the Institute of Inflammation and ageing, (2017) <http://www. birmingham.ac.uk/research/activity/inflammation-ageing/news/ index.aspx> 4. D Baylis et al, ‘Understanding how we age: insights into inflammaging’, Longevity & Healthspan, 2 (2013) <https://longevityandhealthspan.biomedcentral.com/ articles/10.1186/2046-2395-2-8> (p. 3). 5. Eric S White and Alberto R Mantovani, ‘Inflammation, wound repair, and fibrosis: reassessing the spectrum of tissue injury and resolution’, Journal of Pathology, 229 (2013) <https://www. ncbi.nlm.nih.gov/pmc/articles/PMC3996448/> (p. 1). 6. Claudio Franceschi and Judith Campisi, ‘Chronic Inflammation (Inflammaging) and Its Potential Contribution to AgeAssociated Diseases’, The Journals of Gerontology, 69 (2014) <https://academic.oup.com/biomedgerontology/article/69/ Suppl_1/S4/587037/Chronic-Inflammation-Inflammaging-andIts> (p. 6). 7. M Borg et al, ‘Understanding how we age: insights into inflammaging’ (Research Gate, 2013) <https://www. researchgate.net/publication/236622235_Understanding_ how_we_age_insights_into_inflammaging> (p 3.). 8. E Drakaki et al, ‘Air Pollution and the Skin’, Frontiers in Environmental Science, 2 (2014) <http://journal.frontiersin.org/ article/10.3389/fenvs.2014.00011/full> (p. 1-3) 9. M Borg and others, ‘The role of cytokines in skin aging’, Climacteric, 16 (2013) <https://www.ncbi.nlm.nih.gov/ pubmed/23659624> (p. 1). 10. James McIntosh, What is collagen? What does collagen do? (Brighton: Medical News Today, 2015) <http://www. medicalnewstoday.com/articles/262881.php> 11. Taihao Wuan et al, ‘Matrix-degrading Metalloproteinases in Photoaging’, Journal of Immunology Research 2016 (2016) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2909639/> (p. 1). 12. RM Tyrell, ‘Ultraviolet radiation and free radical damage to skin’, Biochemical Society Symposium Journal, 61 (1995) <https://www.ncbi.nlm.nih.gov/pubmed/8660402> (p. 2) 13. Dr. Diana Howard, What causes skin aging? (The International Dermal Institute) <http://www.dermalinstitute.com/uk/ library/23_article_What_Causes_Skin_Aging_.html> (p. 1) 14. Maurya AK et al, ‘α-(-)-bisabolol reduces pro-inflammatory cytokine production and ameliorates skin inflammation’, Current Pharmaceutical Biotechnology, 15 (2014) <https://www. ncbi.nlm.nih.gov/pubmed/24894548> (p. 2) 15. Catalina Alarcon de la Lastra and Isabel Villegas, ‘Resveratrol as an anti-inflammatory and anti-aging agent: Mechanisms and clinical implications’, Molecular Nutrition & Food Research, 49 (2005) <http://onlinelibrary.wiley.com/doi/10.1002/ mnfr.200500022/full> (p. 1). 16. Siddharth Mukherjee et al, ‘Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety’, Clinical Intervention in Aging, 1 (2006) <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2699641/> (p. 1). 17. Marta I. Rendon et al, ‘Evidence and Considerations in the application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing’, The Journal of Clinical and Aesthetic Dermatology, 3 (2010) <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC2921757/pdf/jcad_3_7_32.pdf> (p. 1). 18. Pragya A Nair and Tanu H Arora, ‘Microneedling Using Dermaroller A Means of Collagen Induction Therapy’, Gujurat Medical Journal, 69 (2014) <http://medind.nic.in/gaa/t14/i1/ gaat14i1p24.pdf> (p. 1-4). 19. A Singh and Y Savita, ‘Microneedling: Advances and widening horizons’. Indian Dermatol Online Journal, 7 (2016) <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4976400/> 20. SR Cohen et al, ‘Fractional photothermolysis for skin rejuvenation’, Plastic and Reconstructive Surgery, 124 (2009) <https://www.ncbi.nlm.nih.gov/pubmed/19568091> 21. Pinar Avci et al, ‘Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring’, Seminars in Cutaneous Medicine and Surgery, 32 (2013) <http://scmsjournal.com/ articles/view_pdf/low-level-laser-light-therapy-lllt-in-skinstimulating-healing-restoring>

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Introducing Kleresca® for Acne and Skin Rejuvenation Breakthrough innovations to stimulate skin repair at a cellular level Kleresca® for Acne and Skin Rejuvenation

Treatment Modality

Kleresca® is a breakthrough treatment for acne and skin rejuvenation that harnesses the power of BioPhotonics, a unique light conversion system that is designed to stimulate your skin’s own repair at a cellular level. This treatment will significantly and comfortably treat acne and stimulate the tissue’s own repair systems with high safety and efficacy. 

The gel is mixed and once the skin is cleansed, it is applied and illuminated under a multi-wavelength LED light for nine minutes each session. After the light session, the gel is removed. There is limited-to-no downtime after the treatment. Side effects are minimal and can include, redness, hyperpigmentation and slight discoloration of hair. All side effects are seen where transient. Kleresca® for active acne lesions is administered twice a week for six weeks and for skin rejuvenation the protocol is once per week for four weeks.

It has shown to improve complexion and benefits the appearance by: • Treating active acne lesions • Inducing collagen production  • Reducing pore size  • Eliminating fine lines and wrinkles • Reducing signs of acne scars 

How it Works Usability is very simple and the whole procedure only takes 20 minutes. Kleresca®’s innovative BioPhotonic treatment uses multi-LED light combined with a photoconverter gel. The gel allows the spectrum of wavelengths to penetrate into the dermis of the skin to kill bacteria and stimulate the skin’s own repair systems. It can successfully treat acne and encourage the build-up of collagen, supporting the repair of acne scarring and skin rejuvenation and activating the elements of healing in the skin:1,2 • The gel enables specific wavelengths from the light device to penetrate the dermis and stimulate the tissue’s own repair mechanisms and normalise cellular activity1,3-7 • Has been associated with collagen stimulation8   • Stimulates the vascular system, which is known to have a positive effect on collagen production1,3-7,9 The below illustrative representation demonstrates the build-up of collagen with Kleresca® Before

Before and after collagen build up

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After

The Science In a randomised, multi-centre, split-face trial that investigated the safety and efficacy of Kleresca® in patients with moderate to severe acne, Kleresca® demonstrated high safety and efficacy:6,10       • 89% response rate (patients with ≥ 1 IGA grade improvement)10 • 52% of patients with ≥ 2 IGA grades improvement10 • 33% of patients reached clear or almost clear skin10    • No serious adverse events reported10    • All adverse events were transient and did not require any intervention by the clinic4,7

Kleresca® in Your Clinic In the clinic, Kleresca® is cost effective and easy to use and requires minimal staff support and patient monitoring and trained professionals can administer the treatment. The company will offer partners access to a number of services and will assist with training of clinic personnel, provide medical advice, as well as other relevant training to facilitate the operations and workflow in a clinic. Kleresca® also aims to support practitioners on treatment optimisation, operations and communications on an ongoing basis to further enhance their practice. Aesthetics | May 2017


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The use of LED lamp with photoconverter gel

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Patient before, 12 weeks after and 33 weeks post-treatment.

Benefits of Kleresca® • Kleresca® provides patients with a pleasant, comfortable experience with studies showing high safety and efficacy5,7 • The light device is compact, easy to manoeuvre and uses simple settings • Preparation of the gel is quick and only requires mixing the contents of two jars, which are easily stored at room temperature5,7

• The treatment is non-invasive and non-abrasive, making it a comfortable experience10,11 • The gel is well-tolerated as it is not absorbed into the skin10,11   • The treatment has little downtime and10,11 fits conveniently into a patient’s busy schedule with active treatment time taking only nine minutes5,7  • No serious adverse events seen in clinical trials5,7

Lee Garrett’s Experiences Using Kleresca® Tell us about your new acne and skin rejuvenation treatment? The new treatment I have introduced to my clinic for acne and skin rejuvenation is called Kleresca®, which is a chromophore gel that is applied to the skin before putting the patient underneath a LED lamp. When I heard about this treatment, which is really popular in countries like Australia, Germany and Italy, I knew I just had to try it on my patients who are suffering from acne and acne scars as these are notoriously hard conditions to treat. There are two different gels, one for active acne and the other for skin rejuvenation. For acne patients, we are looking for patients with moderate to severe acne and for rejuvenation patients they can be anyone from those with acne scars to those with fine lines and wrinkles. What do you like most about Kleresca®? Being an acne sufferer myself, who knows what it’s like to be scarred from the acne lesions on my face, I think Kleresca® is a welcome breakthrough for all acne patients. We have many options available to us in terms of rejuvenation treatments, but nothing that’s as non-invasive such as this that still gives such good results. When you are looking at treating patients with acne, the first thing that you have in your REFERENCES 1. Endothelial cell study, LEO Pharma - Data on file. 2. Skin insert study, LEO Pharma - Data on file. 3. PCL-K1005-001-11, LEO Pharma - Data on file. 4. In vitro release test, LEO Pharma - Data on file. 5. Kleresca® Acne Treatment Instructions for Use. 6. Antoniou, C.e.a., Extension trial, LEO Pharma - Data on file. 2013. 7. Kleresca® Skin Rejuvenation Instructions for Use.

contraindications is lesions on the skin. Now, other than chemical peels, you have a treatment that you can apply to patients that have active lesions on their skin. I think that it’s a very good add-on to have in your clinic and there aren’t many treatments out there for acne that can offer what Kleresca® can. Why I say that is because other treatments can be quite painful and quite costly for patients and often once they have had the treatment their acne may come back. With Kleresca®, there is data to suggest that up to 54 weeks post treatment the patient is still spot-free, so I think that is a really good outcome. What feedback have you had from your patients? I have been using this in my clinic since February 2017, and initially patients seem a bit apprehensive because they need to be under a lamp for nine minutes, but once they have had the treatment I have found that they are absolutely thrilled with the results. The good thing about this treatment is that it treats all aspects of acne; you can do the acne course first, then you can take the patient onto the skin rejuvenation after the acne has cleared and address any scarring or healing issues. If the patient hasn’t got acne you can take them straight

onto the skin rejuvenation gel. As I’ve said, I have suffered from acne so I have tried the rejuvenation treatment myself and what I have noticed is that your skin does feel tighter and much more supple when you touch it; it feels thicker, firmer and more hydrated. I have seen patients go through the whole skin rejuvenation process and we have seen really good results in fine lines and wrinkles and overall skin texture. At my clinic we have acne patients that are on the treatments at the moment and the results so far are very promising.

Lee Garrett is an independent nurse prescriber and is the director of the Garrett Clinic in Harley Street, London and company security of FreedomHealth. Garrett’s understanding of the skin and bespoke treatments has made him one of the most respected practitioners in aesthetics, specialising in acne scarring, facial rejuvenation, dermal fillers, facial reconstructing, anti-winkle treatments and chemical peels.

8. Cho, SB & et al, ‘Non-ablative 1550-nm erbium-glass and ablative 10 600-nm carbon dioxide fractional lasers for acne scars: a randomized split-face study with blinded response evaluation’, J Eur Acad Dermatol Venereol, 2010, 24(8)pp.921-5. 9. KL-K1005-P001, LEO Pharma - Data on file. 10. Antoniou, C. & et al, ‘A multicenter, randomized, split-face clinical trial evaluating the efficacy and safety of chromophore gel-assisted blue light phototherapy for the treatment of acne. International Journal of Dermatology’, Int J Dermatol, 2016. 11. SKR Safety Report, LEO Pharma - Data on file.

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the elderly, or those people undergoing treatment that compromises their immune system, such as chemotherapy. There is also some evidence to suggest that people with diabetes are more susceptible to infection as well, some possible reasons for which include defects in immunity and increased adherence of microorganisms to diabetic compered to non-diabetic cells.5-7 With a wide range of patients who might fall under any one of these categories, it is crucial that aesthetic clinics do what they can to keep pathogens at bay.

Infection Control Clinic waste technical manager Luke Rutterford details the risk of pathogens in clinic and steps to take to prevent infection Pathogens are bacterium, viruses or other microorganisms that can cause disease and over time, microbial pathogens have developed resistance. Some disinfectants are becoming less effective, with pathogens now able to survive destruction by basic decontamination products and establish resistance to a wide range of antibiotics that were once effective against the infections they caused in humans.1-3 However, they still have a long and perilous journey from source to host infection, and it is your job to eliminate them before they can do any harm to your patients. What are the risks? There is potential for an enormous number of different pathogens to pass through an aesthetic clinic on any given day. Each patient entering the premises brings with them their own unique microbiota, which consists of thousands of microorganisms. Studies have suggested that more than 150 bacterial species can inhabit the hands alone, with three species – actinobacteria (the genus of which causes diseases such as tuberculosis and leprosy), firmicutes (partly responsible for the metabolism of undigested food remnants in the gut) and proteobacteria (causing salmonella and Escherichia coli (E.Coli)– accounting for more than 94% of those.4 As patients touch objects and surfaces around the clinic, such as door handles, pens, waiting room magazines, chair armrests and stair rails, some of these microorganisms are transferred from their hands. While not all microbes are harmful, a small percentage are pathogenic. What’s more, some pathogens have the ability to survive on inanimate surfaces and objects for quite some time (as detailed below) after contamination. If not removed, they can be passed onto the next person who touches that surface or object. Whether the pathogen causes an infection in the body at this point depends on three factors: the dose (the number of pathogens attacking), the virulence (capacity of the pathogen to cause damage to the host) and the host’s resistance (how effective the body’s immune system is). Risk of infection is consequently higher for those with immature or weaker immune systems, including young children and

What are we up against? On the basis of cell wall structure and staining ability, bacteria can be split into two groups – gram-positive and gram-negative. The majority of bacteria are classified in the latter group and are characterised by the presence of an outer membrane, a wavy wall, a high lipid and lipoprotein content and a low resistance to physical disruption, while gram-positive bacteria exhibits the opposite features. Most gram-positive bacteria have been found to survive for months on dry surfaces, as have many gram-negative species, some fungi, yeasts and gastrointestinal viruses.8 Subsequently, any untreated surfaces in the cosmetic clinic could harbour a wide range of pathogens from Staphylococcus aureus (which causes a range of infections on the hands, in the blood, lungs and heart, as well as antibiotic resistant strains causing MRSA) to E.Coli, Pseudomanas aeruginosa (causing pneumonia and urinary tract infections), Mycobacterium tuberculosis (TB), Clostridium difficile (infection of the colon causing fever, diarrhoea and abdominal pain), Candida albicans (causing an oral infection/thrush or a yeast infection in the genital area), influenza, HIV, Hepatitis B and C, to name just a few. When present on dry inanimate objects/surfaces, some can survive for more than four years (Figure 1). For people who become infected, there is now concern about the effects of antimicrobial resistance. Understood to be the result of misuse and overuse of antimicrobials in recent years, the accelerated rate of resistance is becoming an ever-greater threat to the worldwide population.11,12,13 Resistance to first-line drugs designed to treat infections caused by Staphlylococcus aureus is already a global problem – methicillinresistant Staphylococcus aureus (better known as MRSA) has

Pathogen

Potential length of survival on dry inanimate objects / surfaces

Campylobacter

1-4 hours9

Candida albicans

1-120 days10

Cold virus

7+ days9

Clostridium difficile (spores)

5 months10

E.Coli

1.5 hours-16 months10

Flu virus

24 hours9

Herpes virus

Up to 7 days10

HIV

1+ week10

Listeria spp. (which causes listeriosis)

1 day-months10

Mycobacterium tuberculosis

1 day-4 months10

Staphylococcus aureus (including MRSA)

7 days-7 months10

Salmonella typhimurium

10 days-4.2 years10

Figure 1: Table details some of the most common types of pathogens that can become present in a clinic and how long they can survive on dry surfaces

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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been a wide-spread concern for some time.14,15,16 According to the World Health Organization (WHO), widespread resistance has been detected in E.Coli as well; there are countries in many parts of the world where antibiotic treatment is now ineffective in more than half of patients.11 What’s more, there were about 480,000 new cases of multidrug-resistant tuberculosis (MDR-TB) in 2014, resistant to the two most powerful anti-TB drugs.2,11 All this means that even infections that were once easily curable are no longer so simple to treat.17 Many regulatory bodies and associations in the healthcare sector are calling for the reduced and more responsible use of antibiotics, including the British government, the British Medical Association (BMA), NHS and European Medicines Agency.18,19,20 Many are attempting to improve education for both the public and professionals so that the drugs are only used when absolutely necessary. However, prevention is definitely better than cure, and this gives further weight to the responsibility all healthcare professionals have to eliminate pathogens before they have an opportunity to infect patients. What can we do? It is vital that all professionals remain diligent. Infection control and prevention might not be the most exciting thing you do all day, but it is one of the most important; protecting yourself, your colleagues and your patients from possible harm. It is essential to establish clear decontamination protocols within the clinic in order to comply with regulations and maintain the safest possible environment. For example, there should be a logical series of steps to follow for all used instruments, whereby they are subjected (preferably) to steam sterilisation.21 All surfaces should also be routinely decontaminated between patients, ensuring all worktops, patient chairs/operating tables, cupboards and equipment are pathogen-free for the next patient. The decontamination policy should also include making records of all actions implemented so that instruments can be tracked through the process and the whole procedure can be audited, with evidence demonstrating the clinic’s compliance to the regulations. The Care Quality Commission (CQC) regulates all providers of surgical cosmetic procedures,22 monitoring infection control standards in line The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance23 (which I recommend should also be followed by providers of non-surgical cosmetic procedures). This states that: • Policy should be supported by evidence-based guidelines (meaning decontamination protocols in the clinic should be supported by clinical studies or research to ensure the very best standards are met) • There is a clear governance structure and accountability that identifies a single lead for infection prevention • Mechanisms are in place by which the registered provider ensures that sufficient resources are available to secure the effective prevention of infection. These should include the implementation of programmes for infection prevention and cleanliness • All relevant staff, whose normal duties are directly or indirectly concerned with providing care, receive suitable and sufficient information, training and supervision in the area of infection control The decontamination products used in your clinic can also influence the quality of your infection control processes. Not only do you want to source solutions from a reputable supplier, but you also need them to be effective against a huge spectrum of pathogens including bacteria,

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spores, fungi, yeasts and viruses. Those that offer long-term protection and go on working beyond their initial application will deliver the highest safety standards and provide peace of mind that surfaces will remain decontaminated until the next cleaning cycle. Further considerations include choosing products that are non-toxic, so as to prevent any damage to the surface materials they’ll come into direct contact with. Non-irritant products are also important to protect staff from skin conditions, helping them maintain their own health for reduced absenteeism. It is clear that every surface in the cosmetic clinic has the potential to harbour any number of pathogenic organisms that could pose a threat to your patients and your staff. In order to minimise the risk as much as possible, strict surface decontamination protocols must be implemented on a regular basis. Luke Rutterford is technical manager for the Initial Medical and Specialist Hygiene divisions of Rentokil Initial in the UK, with responsibility for training, service development, innovation, quality and compliance. Rutterford also worked within the documentary industry for the National Geographic show ‘Pests from Hell’ and holds a BSc (Hons) in Forensic Science from Anglia Ruskin University, Cambridge. REFERENCES 1. McCarthy A, Shaw MA, Goodman S. Pathogen evolution and disease emergence in carnivores. Published December 2007.DOI: 10.1098/rspb.2007.0884 2. Sironi M, Cagliani R, Forni D, Clerici M. Evolutionary insights into host-pathogen interactions from mammalian sequence data. Nature Reviews Genetics 16, 224-236 (2015) doi:10.1038/nrg3905. Published online 18 March 2017 http://www.nature.com/nrg/journal/v16/n4/full/nrg3905.html 3. Groisman EA, Casadesus J. The origin and evolution of human pathogens. Mol Microbiol. 2005 Apr;56(1):1-7 DOI: 10.1111/j.1365-2958.2005.04564.x 4. Fiere NN., Hamady M., Lauber C.L., Knight R., ‘The influence of sex, handedness and washing on the diversity of hand surface bacteria’, Proc Natl Acad Sci U S A, 18 105(46) (2008), pp.17994-9. 5. Geerlings SE, Hoepelman AI., ‘Immune dysfunction in patients with diabetes mellitus (DM).’, FEMS Immunol Med Microbiol, 26(3-4) (1999) pp.259-65. 6. Muller LM, Gorter KJ, Hak E, Goudzwaard WL, Schellevis FG, Hoepelman AI, et al. ‘Increased risk of common infections in patients with type 1 and type 2 diabetes mellitus’, Clin Infect Dis, 41 (2005), pp.281-8. 7. Vardakas KZ, Siempos II, Falagas ME., ‘Diabetes mellitus as a risk factor for nosocomial pneumonia and associated mortality’, Diabet Med, 24 (2007), pp.1168-71. 8. Kramer A., Schwebke I., Kampf G., ‘How long do nosocomial pathogens persist on inanimate surfaces? A systematic review’, BMC Infect Dis. 6: 130 (2006). 9. NHS Choices, Common health questions. How long do bacteria and viruses live outside the body? (NHS: 2017) <http://www.nhs.uk/chq/pages/how-long-do-bacteria-and-viruses-live-outside-the-body. aspx> 10. Kramer A., Schwebke I., Kampf G., ‘How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.’, BMC Infectious Diseases 6:130 (2006). 11. World Health Organization. Media Centre. Antimicrobial resistance. Fact sheets. Updated September 2016. Link http://www.who.int/mediacentre/factsheets/fs194/en/ [Accessed January 2017] 12. Gov.uk. Department for Environment, Food & Rural Affairs / Department of Health / Public Health England / Veterinary Medicines Directorate. Antimicrobial Resistance (AMR). First published 23 July 2014. Updated 28 December 2016. 13. Food and Agriculture Organization of the United Nations. The FAO action plan on antimicrobial resistance. 2016-2020. Published 2016. http://www.fao.org/3/a-i5996e.pdf 14. Hong X, Qin J, Li T, Dai Y, Wang Y, Liu Q, He L, Lu H, Gao Q, Lin Yong, Li M. Staphylococcal protein A promotes colonization and immune evasion of the epidemic healthcare-associated MRSA ST239. Front Microbial. 2016; 7: 951. Published online Jun 27. DOI: 10.3389/fmicb.2016.00951 15. Rasmussen R, Fowler V Jr., Skov R, Bruun N. Future challenges an dtreatment of Staphylococcus aureus bacteremia with emphasis on MRSA. Future Microbiol. 2011 Jan; 6(1): 43–56. DOI:10.2217/ fmb.10.155 16. World Health Organization. Antimicrobial resistance Global report on surveillance. 2014. < http://apps. who.int/iris/bitstream/10665/112642/1/9789241564748_eng.pdf> 17. The Review on antimicrobial resistance. Chaired by Jim O’Neill. Antimicrobial resistance: Tackling a crisis for the health and wealth of nations. https://amr-review.org/sites/default/files/AMR%20 Review%20Paper%20-%20Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20 of%20nations_1.pdf 18. BMA. News. Call for more responsible use of antibiotics. 15 September 2016. https://www.bma.org.uk/ news/2015/november/call-for-more-responsible-use-of-antibiotics 19. NHS choice. Guidelines set to tackle over-prescribing of antibiotics. 18 August 2015. http://www.nhs. uk/news/2015/08August/Pages/Guidelines-set-to-tackle-problem-of-over-prescribing-antibiotics.aspx 20. European Medicines Agency. Human regulatory. Overview. Public health threats. Antimicrobial resistance http://www.ema.europa.eu/ema/index.jsp?curl=pages/special_topics/general/general_ content_000439.jsp 21. Reference – HTM 01-01:Management and decontamination of surgical instruments (medical devices) sued in acute care. Part C. < https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/545863/HTM0101PartC.pdf> 22. CQC, Guidance about compliance. Essential standards of quality and safety. Outcome 8, Regulation 12, (CQC: 2011) <https://services.cqc.org.uk/sites/default/files/gac_-_dec_2011_update.pdf> 23. Department of Health, The Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance, (Department of Health, 2015) <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/449049/Code_of_practice_280715_ acc.pdf>

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Introducing a Combination Approach for Unwanted Female Facial Hair Female facial hirsutism (FFH) is often considered as an uncommon problem, however in reality over 40% of all women are affected by unwanted facial hair.1 Hirsutism itself affects between 5 and 15% of all women2 and can affect patients from a broad age range. Unwanted facial hair may be considered as a ‘cosmetic’ problem, yet the impact on women’s daily lives can be significant – making women feel ashamed, self-conscious and uncomfortable in social situations.3 In fact, FFH can have a similar effect on women’s quality of life scores to that of asthma, epilepsy, and diabetes.4 Challenges in Current Practice Laser hair removal (LHR) is one of the most common dermatological procedures used to address FFH, as it provides efficient and longlasting hair reduction. However, this method still presents challenges for patients in terms of pain, side-effects (dyspigmentation, scarring), high cost and the number of treatments required to achieve the desired effect.5 In addition, clinical data as well as feedback from clinical practice highlight that a high proportion of FFH patients do not respond adequately to LHR,5 meaning that many will require additional treatment options to provide sufficient hair reduction.

hance LHR results

Introducing VANIQA® (eflornithine 11.5% cream) VANIQA® is the ONLY topical non-hormonal prescription FFH treatment proven to slow the growth of facial hair. This FDAapproved cream is suitable for all skin and hair types, including dark, coarse, and light vellus hair.6,7,8 When used in combination with LHR, VANIQA® is proven to enhance results: clinical studies have demonstrated a significant 30% improvement in results following LHR and VANIQA® combination treatments.5 When used twice-daily between and after laser hair removal treatments, VANIQA® delivers significantly faster, more complete results than LHR alone – meaning that patients were ‘hair-free’ for a longer time (vs LHR alone).5 How it Works VANIQA works by inhibiting ornithine decarboxylase, thus preventing synthesis of polyamines which are essential for hair growth.8 Because this treatment does not affect hair diameter, there is no detrimental effect on the efficacy of simultaneous or subsequent LHR.9 The specific method of action means that VANIQA® can be used alone or in combination with other hair removal methods or treatments.6 In the case of LHR, studies have shown that VANIQA® provides an effective and synergistic treatment combination.7,5 Maintenance Treatment with VANIQA® VANIQA® also provides effective maintenance treatment following LHR: study results showed the treatment was generally well tolerated when applied twice-daily for up to 12 months. 81% of subjects achieved some improvement in their condition after 20 weeks of treatment which was sustained through one year of treatment (n=216).10* Find Out More Discover more about how VANIQA® can support your treatment approach for female facial hirsutism by visiting vaniqa.co.uk VANIQA® is available from Wigmore Medical: pharmacy@wigmoremedical.com T: 020 7491 0111 | F: 020 7491 2111 *Use should be discontinued if no beneficial effects are noticed within four months of commencing therapy REFERENCES 1. Blume-Peytavi U, et al. Derm 2007; 215: 139-146. 2. Azziz R. Obstetrics & Gynae 2003; 101: 995-1007. 3. Lipton MG, et al. J Psychosom Res 2006; 61: 161-168. 4. Primary Care Dermatology Society: Clinical Guidance: Hirsutism. <http://www.pcds.org.uk/clinicalguidance/hirsutism> 5. Hamzavi I et al. J Am Acad Dermatol 2007; 57: 54-9. 6. Shapiro J, Lui H. Skin Therapy Letter 2005/6; 10: 1-4. 7. Smith S, et al. Dermatol Surg 2006; 32: 1237-43. 8. VANIQA Summary of Product Characteristics. <www.medicines.org.uk/emc/medicine/21243> 9. Hoffmann R. Eu J Derm. 2008; 18: 65-70. 10. Schrode K, et al. Presented at 58th Annual Meeting of the Academy of Dermatology 2000, 10-15 March, San Francisco; USA, Poster 294.

Job code UKEFL3691a Date of prep: April 2017

treatments and 12 received 5, due to no hair regrowth (5), missed appointment (6) and postinflammatory hyperpigmentation (1) **NS = not significant

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Aesthetics | May 2017


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Aesthetics

A summary of the latest clinical studies Title: Transcutaneous Brow Shaping: A Straightforward and Precise Method to Lift and Shape the Eyebrows Authors: Pelle-Ceravolo M, Angelini M Published: Aesthetic Surgery Journal, March 2017 Keywords: Eyebrow, brow shaping, botulinum toxin Abstract: The height of the eyebrow is less crucial aesthetically than is the relationship between the lateral and medial portions of the brow. Although various surgical procedures are effective in raising the brow, the authors maintain that transcutaneous brow shaping (TBS) is the only technique that enables precise shaping of the brow and correction of minor asymmetries. For this study, the authors described their experiences with direct TBS alone or in conjunction with blepharoplasty and facelift. A total of 212 patients underwent TBS performed by the senior author. All patients were evaluated clinically and by means of pre- and postoperative photographs. Patients completed questionnaires indicating scar quality and satisfaction with the results. Scar visibility was low, and patients expressed a high level of satisfaction with the aesthetic results of TBS. TBS requires accurate planning, preservation of subcutaneous volume, limited undermining, preoperative application of botulinum toxin, and perioperative administration of local vasodilators. When these requirements are fulfilled, the authors have found that TBS does not yield a visible scar and is the easiest, most precise, and most reliable procedure for brow shaping. Title: A split-face comparison of Q-switched Nd:YAG 1064-nm laser for facial rejuvenation in Nevus of Ota patients Authors: Yongqian C, Li L, Jianhai B, Ran H, Li G, Hao W et al. Published: Lasers in Medical Science, March 2017 Keywords: Nevus of Ota, QS Nd:YAG laser, skin rejuvenation Abstracts: We aimed to investigate the efficacy and safety of using the 1064 nm Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (QSNYL) for skin rejuvenation in patients with Nevus of Ota. A retrospective, randomised, split-faced, clinical study was conducted. Twenty-nine patients with unilateral moderate to severe Nevus of Ota were enrolled. The participants completed 3-13

Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing). Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women. Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects. Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product. For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application. The condition should improve within eight weeks of starting treatment. Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only.

sessions of QSNYL treatments 3-6 months apart. Two independent physicians compared the treated and untreated sides of the face to evaluate the clearance of Nevus of Ota, the wrinkle severity rating scale (WSRS), the global aesthetic improvement scale (GAIS), and adverse event reporting. Patients’ satisfaction levels were also considered. Of the 29 patients, 28 (96.6%) achieved nearly complete pigmentation clearance. After an average of 7.76 ± 2.99 sessions, statistically significant improvement in wrinkles and skin texture were observed, compared with the untreated side. The degree of skin rejuvenation was positively correlated with the number of treatment sessions. Title: The effect of aging on the three-dimensional aspect of the hand: A pilot study Authors: Hoevenaren IA, Wesselius TS, Meulstee JW et al. Published: Journal of Plastic, Reconstructive and Aesthetic Surgery, April 2017 Keywords: Hand ageing, hand volume, three-dimensional imaging Abstract: This pilot study aimed to investigate the possibility of visualising the hand ageing process by 3D stereophotogrammetry. A total of 64 healthy volunteers were divided into four groups based on age and sex, and a 3D photograph of both hands was captured. Differences in the aspect of the dorsum of the hands were quantified and visualised using two methods. The first method quantified the smoothness of the old and young dorsa. The second method visualised the differences between an average young and old hand by creating a color-coded distance map. The first method showed that the young hands were smoother than the old hands; however, this difference was not statistically significant (p = 0.30). The distance map resulting from the second method showed a relative volume loss in the intermetacarpal spaces of the average old hand. These differences were not present when male hands were compared with female hands. This pilot study shows that 3D stereophotogrammetry can be used to visualise the exact areas of volume loss on the dorsum of the ageing hand. On the basis of this finding, specific treatment areas can be identified, and the results of different aesthetic hand surgery procedures can be objectively analysed and compared.

Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain. Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500.Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk. Date of Revision: 10/2015. Item code: UKEFL3336

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 Almirall Ltd.

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Creating Effective E-newsletters Dr Harry Singh discusses the significance of e-newsletters and how to best utilise them to encourage patient retention Newsletters that are published in an electronic form, also known as ‘e-newsletters’, are regularly developed and distributed by businesses offering all types of products or services. When it comes your business, engagement with your patients is the key to ensuring that they continue to feel connected to you after they have visited your clinic for the very first time and are kept up-to-date with any practice news. Staying in touch will also likely prompt them to come back in future.1 Developing and sending out specified e-newsletters to your patients also helps to increase your brand awareness, increase exposure and understanding of your products and service offerings, and acts as a cost-effective marketing tool. You can design your e-newsletter in house and delegate it to a team member who is experienced or competent in graphic design and content writing. This will therefore be cost effective, apart from costs associated with a customer relationship management (CRM) software programme, but you will need to allocate time to the task. There are numerous CRMs available such as MailChimp, Infusionsoft and Salesforce. These are all ‘paid for’ services and these will make your life a lot easier with preformed templates. There are some free CRMs such as Zoho, but these tend to limit the number of free lists. You can alternatively choose to out-source this task to a business, which, in my experience, typically costs £150, dependent on layout and content.

Legal requirements Before sending an e-newsletter, it is vital that you understand the legalities regarding marketing emails.2 As sending e-newsletters is a direct form of marketing, under UK law, you must check that patients want to be contacted or are happy for you to send them offers or promotions by email, and give them the chance to object.2 For new patients, this can be via an opt-in or opt-out tick box when they first register at your clinic and for existing patients, you could seek their permission when they next come to clinic and give them an option to opt in. I would also advise you to inform your patients of what to expect in your e-newsletters and how often they will receive it; I personally do this by showing them an example of an old e-newsletter sent and then have an opt-in box that the patient ticks stating, ‘I am happy to receive e-newsletters from ‘ABC Clinic’, which may include promotional offers and I have been shown an example of what will be sent’. The Controlling the Assault of Non-Solicited Pornography and Marketing (CAN-SPAM) Act outlines what is required from you regarding the sending of permission-based marketing communications. Here is a brief summary of the law’s requirments:3

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• Don’t use false or misleading header information, e.g. your email ‘from’ should identify your clinic so the receiver is aware of who sent it. • Don’t use deceptive subject lines – the subject line must correspond to the content of the email. • Identify the message as an advert if appropriate, e.g. in the subject line you would say ‘special promotion’ or something similar. If the email is purely educational/content based, then there is no need for this. • Tell recipients where you’re located – providing your postal address is critical in case a patient wants to contact you. • Make clear to recipients how to opt out of receiving future marketing emails from you – I recommend adding a line at the bottom of the email stating: ‘If you do not wish to receive further marketing emails from XXX please click here’ with a hyperlink to where the reader can unsubscribe from your emails. You may create a menu to allow a recipient to opt out of certain types of messages, but you must include the option to stop all commercial messages from you. Make sure your spam filter doesn’t block these opt-out requests. • Honour opt-out requests promptly – any opt-out mechanism you offer must be able to process opt-out requests at least 30 days after you send your e-newsletter and you must activate an opt-out request within 10 business days. You can’t charge a fee or require the recipient to give you any personal identification information beyond an email address, or make the recipient take any step other than sending a reply email or visiting a single page on an internet website as a condition for honouring an opt-out request. • Monitor what others are doing on your behalf – the law makes clear that even if you hire another company to handle your email marketing, you can’t contract away your legal responsibility to comply with the law. Both the company whose product is promoted in the message and the company that actually sends the message may be held legally responsible. You will also need to comply with Data Protection Regulation in regards to encryption and security of the email server. Information on this can be found on the Information Commissioner’s Office’s website.4

Creating an e-newsletter We have all been at the receiving end of dull, pointless e-newsletters that we delete

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Aesthetics

Best Open Rates (60%-87%)

Worst Open Rates (1%-14%)

1. [COMPANYNAME] Sales & Marketing Newsletter

1. Last Minute Gift – We Have The Answer

2. Eye on the [COMPANYNAME] Update (Oct 31 - Nov 4)

2. Valentines – Shop Early & Save 10%

3. [COMPANYNAME] Staff Shirts & Photos

3. Give a Gift Certificate this Holiday

4. [COMPANYNAME] May 2005 News Bulletin!

4. Valentine's Day Salon and Spa Specials!

5. [COMPANYNAME] Newsletter – February 2006

5. Gift Certificates – Easy & Elegant Giving - Let Them Choose

Table 1: MailChimp survey open rate results of over 40 million emails showing top and worst five subject lines. Study only included campaigns sent to at least 100 recipients.5

immediately, but, some are indeed helpful and relevant, so what separates the triumphs from the tragedies? What can you do to make sure your e-newsletter receives adequate attention and the intended response from your patients? Subject line The subject line is the first thing your patients will see and will likely determine whether or not they will open the email. A study carried out by MailChimp looked at the importance of subject line in terms of open rates. The highest open rates were in the range of 6087%, while the lowest performers fell in the 1-14% open rate range (Figure 1).5 However, it is important to note that the study did not compare emails from the same company or audience so this may factor in to whether or not recipients opened the email. You should keep the subject line short (no more than seven words) especially because many people open their emails on a mobile device.6 In terms of a regular weekly or monthly e-newsletter, you want to create consistency and encourage readers to identify your emails over others so you can keep the subject line relatively consistent. However, make sure you monitor the open rate; you don’t want to be sending the same subject line if it doesn’t prompt clicks! For promotional emails, don’t keep the same subject line for multiple emails, be creative and change it up. Content You must spend time thinking about the content of your e-newsletter and how you will structure and design it. I always start by segmenting my contact lists into patients that have had different services, which allows

me to see what is interesting and relevant to them according to their past experiences. This allows me to decide what content a patient would like to see and I can then create my e-newsletter to reflect this. For example, for patients that have only received toxin treatments, I’ll add content on skin protection and dermal fillers as they are likely to find these topics interesting, as opposed to topics such as laser for skin resurfacing. Again, a CRM programme will save you a lot of time in terms of segmenting your list. E-newsletters are a communication tool that can be used to tell your patients about news, products, services, trends and education and are not entirely just a promotional tool. I personally divide my e-newsletter into three parts, but always bear in mind that you want to maintain a common thread connecting all these pieces together as to not appear disjointed. For each, let’s assume you are looking to target patients interested in skin: 1. Educational – something that will add value to the reader and solve a problem they are experiencing, for example, information about sun protection in summer or myths about skincare creams. For example, the educational part will include advice on looking after their skin and avoiding sun damage. 2. Personal – this can be about you or your team, examples may include birthdays, weddings or attending industry conferences. As aesthetic treatments are very personal, the business itself is too so we want to treat our clinic and patients like we would our family. For example, the personal part could be about a team member or yourself attending a workshop on skin or having skin treatments carried out on yourself.

3. Promotional – news on a new service or something that may be on offer that would encourage the reader to engage with you further and come back to your clinic. For example, the promotional segment will be an offer on skin products/treatments. Design The layout and design of an e-newsletter is just as important as the content. Keep the design of your e-newsletter simple, clear and concise, and avoid clutter. Make good use of ‘white space’ by spreading text and images to make it easy on the reader’s eye. Using too many colours can also be distracting and you should ensure that the colours match your logo and overall branding (which I recommend to include as this breeds familiarity with your brand). Images are useful in newsletters, but bear in mind that images may take longer to upload especially on older mobile devices (not much of an issue with newer smartphones) so do not have too many. Also make sure images have alternative text (alt text) as some people won’t have images enabled on their devices. Alt text is a word or phrase that can be inserted as an attribute in a Hypertext Markup Language (HTML) document to tell website viewers what the the content of an image is. Images need to be correctly resized for all channels – desktop, mobile and tablet. Call to action You should only have one main objective, or call to action in each of your e-newsletters. This is because the confused mind is likely to take no action. A call to action is what you want the individual reading the e-newsletter to do, whether it’s to book a consultation, visit a blog page, download a report or forward to a friend. Make your call to action clear to the reader, such as incorporating a button with a hyperlink that says ‘click here’ or a sentence that says, ‘go to our website to find out more’. It should be in a prominent position within the newsletter. You can also have other call to actions, however only one should be obvious. For example, if your main objective is for people to book a lip augmentation consultation, you could have a prominent ‘book now’ button to make this clear, but also have smaller calls to action to prompt readers to click on links that provide more information on the treatments.

Testing your newsletter Assess every component of your newsletter before sending, including accuracy, subject

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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1

2

3

4 5

6

7

8

Example of an e-newsletter structure 1. 2. 3. 4. 5. 6. 7. 8.

Subject line, date and company info Header image Educational/news content & images Button (call to action) Personal content Image Promotional content Sender information & opt-out options

line, content, layout, call to action, the ‘sent from’ line, images, white space and simple things such as contact details and spelling and grammar. Send yourself a test email before officially sending, so that you can see what the email looks like from a receiver’s perspective and get other members of your team to check over it. Also be sure to test your newsletter on various formats including mobile devices and tablets; most CRM systems will allow you to preview the email in these formats.

Sending an e-newsletter Before sending, you may choose to personalise your email by displaying that it is coming from you by name, rather than the general enquiries email or brand name. Your patients will appreciate knowing that you are communicating with them directly. For example, instead of using From: enquiries@aesthetics.com you would use From: DrSingh@aesthetics.com. Even though it looks as though it comes from me, I don’t personally answer these emails, the personal email is not my real personal email address but one that goes to my front-of-house team.

Aesthetics Journal

Many practitioners also wonder how often you should send your e-newsletters and some are concerned that they will lose patients if they spam/bombard them too frequently with emails. This can be true, but it all comes down to what the content is and if you are adding value, not just selling your services.9 Test different intervals between when you send your newsletters and ask your patients what they prefer; personally, I would not send more than once a month, but once every week or even every quarter can also work, depending on your business and readership. The time of day that your e-newsletter is sent should also be considered – I suggest that you simply ask your patients. I have found that the best times for my patients tend to be weekday evenings (they are more relaxed and have more time in their ‘own time’ to open and read emails) and at the beginning of the working day between 9am-10am. The unpopular responses I got from my patients were 10pm-9am (most of them were asleep during these hours), 10am-12pm and 2pm-3pm is when most of them are focused on work based activities; although, other research has said that between 10am-4pm are good times for people to open emails.12 Based on my own research, lunchtime emails between 12pm-2pm is when my patients look at the news, celebrity news and recreational material (sports, holidays). Therefore, if your e-newsletter is about news stories, then this might be the best time to send it!

Tracking the success Once you have tested and sent out your e-newsletters, it is good practice to measure the success of your email marketing, as the data you gather will give you a statistical idea of how your e-newsletters are performing and their reach to your different patient groups. This will also help to provide you with a better understanding of areas for improvement. You want to be measuring open rates (how many recipients opened the email) and click-through rates (how many recipients clicked a link embedded in the newsletter).10 According to a 2016 report from software and services company Sign-up.to that analysed 1 billion emails sent through its platform aross all sectors and devices, the average open rate was 24.88% and click-through rate was 3.42%.11 Although, this is not necessarily reflected upon the aesthetics sector average open

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and click rates can vary from list to list, and differ by industry, company size, and other factors.13

Summary E-newsletters are an effective marketing tool, but you must have a clear plan to achieve your objective, and ensure you have a sound design template, content and know how to reach each patient with targeted messages.Whilst ensuring it is legally compliant, consider when the best time to reach your target audience is, personalise your content and track the progress and success of your e-newsletters. If you have not already, consider introducing this form of marketing into your business. In my experience, they can increase patient retention rates by maintaining and building upon exisiting relationships. Dr Harry Singh has been carrying out facial aesthetics since 2002. Alongside dental and aesthetic work he has a strong interest and experience in marketing. He has published numerous articles on the clinical and non-clinical aspects of facial aesthetics and spoken at dental and facial aesthetics conferences on these topics. REFERENCES 1. Jakob Nielson, E-Mail Newsletters: Increasing Usability, 2010, Neilson Norman Group, <https://www.nngroup.com/articles/email-newsletters-usability/> 2. GOV.UK, ‘Marketing and advertising: the law’, 2016. <https:// www.gov.uk/marketing-advertising-law/direct-marketing> 3. Federal Trade Commision, Protecting America’s Consumers, ‘CAN-SPAM Act: A Compliance Guide for Business’, 2009. <https://www.ftc.gov/tips-advice/business-center/guidance/ can-spam-act-compliance-guide-business> 4. ICO, Information Commissioner’s Office, ‘Sending personal data by email’ <https://ico.org.uk/for-organisations/guide-todata-protection/encryption/scenarios/sending-personal-databy-email/> 5. MailChimp, Research Subject Line Comparison: The Best and Worst Open Rates on MailChimp, <https://mailchimp.com/ resources/research/email-marketing-subject-line-comparison/> 6. http://www.emailmonday.com/mobile-email-usage-statistics 7. Parry Malm & Claire Shepherd, ‘And the best subject line ever is’, Adestra, <https://www.elixiter.com/files/1213/8075/0387/ Adestra_SubjectLine_Study_July_2012.pdf> 8. Email Monday, The ultimate mobile email statistics overview, 2017, <https://sendgrid.com/blog/sendgrid-releases-studyemail-engagement-subject-line-data/> 9. David Moth, ‘Email frequency: how much is too much?’, Econsultancy, 2014, <https://econsultancy.com/blog/64165email-frequency-how-much-is-too-much/> 10. ‘Email Campaign Reporting’, Campaign Monitor, 2017, <https:// www.campaignmonitor.com/resources/guides/reporting/> 11. Jack Simpson, ‘The ultimate 2016 email marketing benchmark guide’, Econsultancy, 2016 <https://econsultancy.com/ blog/67649-the-ultimate-2016-email-marketing-benchmarkguide/> 12. Davies, C & Khim, D, 2015 REPORT: BEST TIMES TO GET YOUR BUSINESS EMAIL OPENED, Hubspot, 2015, <https:// blog.hubspot.com/sales/best-time-send-email-report2015#sm.0000mnv7varxjdkmqb824b0znzryt> 13. Mail Chimp, About Open and Click Rates, 2017, <http:// kb.mailchimp.com/reports/about-open-and-click-rates>

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Rebranding in Aesthetics Private label cosmeceutical company director Gary Conroy explains why it’s important to create a value proposition when rebranding and how this should be linked to your long-term business development I have come to realise that many professionals working in medical aesthetics have spent a long time becoming very skilled at aesthetic rejuvenation treatments but have often been able to spend less time on truly developing their clinic’s brand. In this article, I will discuss the importance of brand development to motivate your team, increase client retention, loyalty and word of mouth referrals, and create a sustainable and scalable business.

What is a brand? In its most literal sense a brand is a type of product manufactured by a particular company under a particular name.1 It is therefore easy to understand why a business that decides to develop a new clinic name or logo claims they are ‘rebranding’, the results of which can sometimes be very positive but on other occasions may not be successful, and sometimes can seem illogical! As such, to truly develop a prosperous brand, it is important to think of it at a more emotional level. Applying relevance to a medical aesthetics practice is what CEO of one of the largest promotional products distributor, Jerry McLaughlin, outlines in Forbes Magazine.2 He asserts that a brand is what your patients feel or think when your business name is mentioned or they see your logo. We all have emotional relationships with products or services that we have

experienced. Successful companies tend to be so because the brand that they have created evokes positive emotional responses, however the contrary is also true. For me, a great personal example of this is the telecommunications company Talk Talk. When they were a new company, they offered a low cost, appealing, all-inone communication package. My initial emotional relationship with them was positive, I thought they were disruptive and offered a great service. I was loyal and recommended to friends and family that they switch from other providers. Then, they got hacked and I got hacked,7 and my service failed. My emotional relationship changed forever and it appears, by looking at their share price, I was not alone. Between March 2010, when they launched, and May 2015 their share price rose by almost 400% from £1.24 to £4.03, but by January 2016 it had

plummeted to £1.943 (with the hacking having taken place in October 2015) – the love affair was over because their external service proposition no longer matched the customer experience. By April 2016 it was up to £2.67, but continued to plummet once more, with it currently standing at £1.90 as of April 2017.3 For all consumers of products or services, that’s what a brand is – it is the emotional intersection where the promise meets the consumers’ experience and that intersection can be good or bad, depending on whether you deliver what you promise or not.

Why rebrand? If you are considering rebranding, the first thing to consider is why you feel the need to do this. Here is a list of questions that may help: What is my current value proposition? A value proposition is defined as ‘a promise of value to be delivered’. It is a clear statement that explains how your product solves customers’ problems or improves their situation, delivers specific benefits, and tells the ideal customer why they should buy from you and not from the competition.4 If you are specifically clear about what you offer and it is unique and different from your competitors, rebranding may not be right for you, unless of course customer visits are decreasing. What do my staff think our value proposition is? This is an interesting project that should be conducted at all staff appraisals. It is the staff who will be delivering the proposition so clarity in understanding it is key. However, perhaps they are not empowered to deliver it or maybe they have tried and the proposition is not what customers want, so your staff are attempting something else. If this is the case, it may be worth looking into rebranding.

Successful companies tend to be so because the brand that they have created evokes positive emotional responses

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How does the value propostion meet my current, most loyal patients’ experience? What qualitative feedback have you conducted recently to better understand your customers’ experience? If it matched your value proposition then you already have a brand – you should only reconsider rebranding if the experience does not match your proposition or your proposition is only attracting a small number of patients. What was the experience of my lapsed or lost patients? To what extent have you tried to understand why patients stopped visiting your clinic? Again, does the feedback match your proposition? If it does, perhaps you have the wrong proposition and you should consider rebranding. Consider that your proposition may be correct but the customer experience does not meet the proposition and it may be an internal issue that needs to be addressed, not a re-brand. Can I reach a large enough demographic who would value my proposition? Is your current proposition too niche or too broad and therefore only attracting a select or non-targeted patient cohort? How many people live in your catchment area that fit the profile of patients who would be attracted to your proposition? If not many, you need to physically move your clinic to an area where there are more of your target audience or you could re-brand. If there are plenty, there may be something wrong with your proposition or communication strategy.

What is a good value proposition? In my view this is often miscommunicated by many medical aesthetic businesses as the focus tends to be on products delivered or equipment in stock; just scroll through your Facebook timeline or Twitter feed and count the number of practitioners proudly showing off a new piece of expensive equipment. By Googling ‘Anti-ageing clinic London’ it delivers 648,000 results in 0.86 seconds, yet, I couldn’t spot one clinic offering a promise of service to be delivered, the vast majority have a list of treatments or products for sale. A great example of a powerful value proposition is The Harley Street Skin Clinic, which states ‘Look your best, feel your best, expect the best’. (Figure 1) 5 Whilst this may be successful in Harley Street, a similar promise may not work for everyone; your patients may not want ‘the best’ and you may not be the best, it may be off-putting as

they may feel you would be too expensive or you may not feel confident enough to promise you are the best. This is fine and there are plenty of other options. The most important thing is that your value proposition matches your brand ethos. So ask yourself, ‘What is it that I can promise to deliver that my patients are guaranteed to get and, more importantly, enough of them want?’ Here are a few other key words that patients may value:

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Figure 1: Example of a strong value proposition from Harley Street Skin Clinic

Value

Discretion

Safety

Speed

Confidence

Subtlety

However, if you do have something unique to offer that is in demand, your existing patients will tell you what it is – and it may not be what you think. Organising regular focus groups with your patients will help you understand what attracts them to the clinic; I would personally advise using a third party to chair these groups without the clinic staff members’ attendance, so that bias is removed and true insight is delivered. It is also worth remembering that the greater the level of uniqueness you can offer to attract the largest cohort of patients, the more successful you are likely to be. This may also stave off competition, giving you competitive leverage and the chance to meet the needs of local patients that are not currently being met by other clinics in your area, and allow you an advantage to remain established for longer. Implementing your value proposition When you have understood what your patients love about you, why your lapsed patients left you and what those who have never considered using your services would need to know before they would choose you, you will be in a good place to consider whether you and your team are equipped to deliver a new value proposition; this may involve retraining, coaching and, in some instances, recruiting. It is crucially important that the internal communication is clear to all members of

your team and that they know what promise they need to deliver. This includes external suppliers who engage with your patients directly or indirectly. There is little point in developing a promise that is only offered to some patients at some touch points by some staff members or suppliers. Staff who know what they must promise and who are well trained to deliver on this promise will usually be happier and more productive as they will be confident in what they’re delivering, feel engaged and commited to the brand. If they are not, you may have the wrong staff, the wrong service proposition, poor communication or poor development strategies in place. When your team is delivering on a promise that your patients value, they will be more likely to remain loyal and bring their friends and this will go a long way towards you having a sustainable business. This is well documented by Harvard Business School in the Service Profit Chain, which highlights how internal communication can lead quickly to retained customers and increased word-ofmouth referral.6

How do you maximise growth? Now that you have your promise and are delivering on it, your staff should feel empowered and have high job satisfaction and your patients should be referring your services to their friends. However, the job is only half done. Do you have a business plan in place? A long-term business plan needs to be developed in order to set yourself goals to attract the largest share of patients you are trying to include, what milestones you will set in what timeframe, and what tactics you will use to attract them.

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I am amazed at the number of businesses that get by from month to month with short term tactical plans or a few bullet points in a note pad. Business planning should include dedicated time away from the clinic each year to create; attempting to do this between seeing patients whenever you have a spare five minutes will often lead to an incomplete job. Some may well know the difference in sales from one year to the next but have no idea on what is driving sales, what is profitable and what is loss-making. It comes as a surprise to many when the initial influx of new patients begins to dry up and seasonality or the economy is the only rationale they can offer. Many of the manufacturers and service providers within the aesthetic industry can support you through a business plan process – ensure this is part of the service you expect from your suppliers, if it is not offered, ask for it, and if it is not supplied on request, consider what their value proposition is for you and perhaps shop elsewhere. To drive and maintain the initial growth from all your hard work, at the very least a full 12-month business plan should

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be put in place, to implement your tactics to attract your target audience and to monitor success. There is a lot of seasonality in aesthetics due to consumer lifestyle and many patient’s treatment cycle is annual or six-monthly dependant on the treatments they have and their longevity of action. If you are considering scaling or exiting, a five-year plan must be in place.

Conclusion Rebranding in medical aesthetics is not something to be taken lightly; a new logo or buying a new reception desk are only elements of your brand’s anatomy; rebranding is redefining your clinic’s core promise to its intended patients on a longterm basis. It is a thorough, lengthy and often expensive process which involves every member of your team and every touch point you have with your patients or intended target audience. When done well it will set you apart and set your business up for success, but it must be maintained with a solid plan.

Gary Conroy has worked in the business of medical aesthetics for 15 years and is highly experienced in bringing new products to market and relaunching and rebranding brands which had previously not met their full potential. He is a co-founder of 5 Squirrels Ltd which supports individual professionals that work in medical aesthetics to launch and develop their own brand skincare, grow and scale. REFERENCES 1. Oxford Living Dictionaries, Brand, (2017) <https:// en.oxforddictionaries.com/definition/brand> 2. Jerry McLoughlan, What is a Brand, Anyway? Forbes magazine, (2011) <http://www.forbes.com/sites/jerrymclaughlin/2011/12/21/ what-is-a-brand-anyway/#1a0631702aa4> 3. Talk Talk Share Price, https://www.google.co.uk/search?q=V olkswagon+share+price&oq=Volkswagon+share+price&aq s=chrome..69i57j0l5.7774j0j4&sourceid=chrome&ie=UTF8#q=talk+talk+share+price 4. Useful Value Proposition Examples (and How to Create a Good One), CXL (2017) <https://conversionxl.com/value-propositionexamples-how-to-create/> 5. Harley Street Skin Clinic, (2017) <http://harleystreetskinclinic. com/> 6. The Harvard Business School, Service profit chain, (2008) <https://hbr.org/2008/07/putting-the-service-profit-chain-towork> 7. BBC News, TalkTalk hacker, 19, pleads guilty at the Old Bailey, (2016) <http://www.bbc.co.uk/news/technology-38300106>

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Utilising Instagram Digital marketing consultant Gina Hutchings explains the benefits of incorporating Instagram into your clinic’s marketing Facebook, Twitter, Google+, Snapchat, Vine, YouTube – these are just a handful of the social media platforms available to businesses worldwide. We are awash with social media apps; we even have apps to manage our apps.1 With more than 1 billion individuals logging on to social media every day, it is a marketing channel that your clinical business needs to nurture.2 Once predominantly a means of making friends and keeping in touch, social media is now also a platform for businesses to market their products and services worldwide and I believe it can provide one of the most cost-effective means of marketing if done correctly. However, using social media for your brand is not simply a numbers game. You need to ensure that your choice of social media platform maximises your brand message and reaches the correct audience. One medium that fits with the aesthetic treatment demographic is Instagram and this article will explain how to utilise this platform effectively within your clinic marketing plan. Instagram Instagram was launched in 2010 as a photo-sharing platform. Although you can access it from a computer desktop, it is designed to be primarily used from a mobile app, making it unique from other platforms such as Twitter and Facebook. Instagram was an instant hit with the ‘hipster generation’ because images were edited to be square in the form of an old-fashioned photograph, and a range of photo ‘filters’ could be applied.3 The platform has grown since its launch and the latest statistics indicate that Instagram has more than 600 million monthly users.4 In 2012, the social media giant Facebook, with more than 1 billion monthly users, acquired Instagram and the platforms merged in the ability to share content.5 Posts can now be shared to multiple platforms in one click instead of logging into different apps. Although a late-comer in the world of social media, Instagram has increased in users every year since its creation, with 100 million users joining the service in the last seven months alone.6 Why?

Perhaps because of its target demographic. Instagram attracts a younger audience most likely between the ages of 16 and 24, with the majority, over 56%, being female.7 It is this generation that are setting the trends for the future and could also be your prospective patients. They will be looking for the latest treatments to enhance their looks, to maintain their youth (in several years’ time) and follow in the footsteps of the celebrities they admire. With a growing amount of users, Instagram should be a staple part of your marketing plan. A survey of 12,000 UK and US consumers, by customer experience management company Market Force, suggested that 78% of consumers make a purchasing decision based on a brand’s social media presence.8 Plus, a study by Instagram in 2015 indicated that 70% of Instagram users search for their favourite brands on social media.9 Business profiles Instagram only began offering business profiles in 2016.10 One major addition was the ability to analyse your users, something that was not previously possible – the business profile allows you to log where your views are coming from in terms of location, age of user and gender. By launching business profiles, the idea was that Instagram would follow Facebook in providing sponsored content or advertisements directed to targeted audiences.11 Sponsored adverts are priced dependant on the competition and audience size but may be something for you to consider. Researching your audience to see which followers are likely to convert to booking treatments can help you target your campaign for the highest ROI. For example, if your audience is

Instagram has increased in users every year since its creation, with 100 million users joining the service in the last seven months

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Unlike Twitter, Instagram won’t limit your character count, this means you can add as many hashtags to your posts as you like, but remember to keep them focused mainly overseas, then advertisements are unlikely to attract conversions but instead build your brand. If your followers are local businesses, people in the area or within reasonable travelling distance, sponsored social ads will be more effective. Whether you use Instagram for your business already and are looking to increase your followers, or would like to begin to use the platform, here are some top tips to using it most effectively. Being visible Adding an embedded code to your website that showcases your Instagram account can be of benefit – this can be on your homepage as a direct feed that displays your Instagram page. Be seeing this, visitors will be encouraged to follow your Instagram page to keep up to date, rather than log on to your website every now and again. You can also increase your visibility at the click of a button as you can cross-promote across different channels; Instagram allows you to post the same content on Facebook, Twitter, Tumblr and Flickr instantly. Another trick is to ‘piggy-back’ on other brands. Find a compatible brand that does not offer the same service or product as you but is related. An aesthetic clinic might find it useful to partner with a hairdressing chain for example: share posts and build a partnership and benefit from utilising two sets of followers. When looking for local or related brands and businesses to partner with, check their social media following; are the followers in your demographic and target audience? Approach the company and offer to co-promote by sharing posts each week and special offers. It acts like a special club, those who get their hair cut at a certain high-class salons can also have 20% of your treatments with proof of salon booking etc. Gaining more followers Post consistently and frequently. This can be two or three times a day as it’s important

to ensure that you communicate regularly with your audience. Set how many times you will post a week and ensure you stick to this. Whatever you decide, make sure it is consistent. Posting in random bursts is of little benefit as it won’t help to build brand recognition. You can also learn about your audience and optimum posting times, for instance you may find you have more engagement after 4pm or on weekends. This can help you tailor your campaigns to the most popular and profitable times, when your audience is likely to view and respond to your posts, as the aim is to increase your conversion rates. Some see it as lazy marketing, but in essence, user generated content (UGC) is the way forward. UGC is the images, videos and comments that are provided by regular users not business profiles.12 To ‘regram’ is one way of sharing UGC on Instagram, which is when a user posts a photo from someone else’s account to their own.13 For example, when a patient posts a photo of their lips before and after treatment and then tags the clinic in the post. You can ‘re-gram’ the post and then ask your ‘Instacommunity’ to re-gram it too. UGC is what makes Instagram appear a more reliable and authentic source. Many of us like to see what our peers are doing, what they recommend, buy, use and places they go; never before as much as in current times where many of us follow celebrity culture online. For the cosmetic and aesthetic industry, it is not always easy to get case studies and imagery that your patients will feel happy to share online. Encourage your followers to submit a favourite image which shows their treatment results, perhaps a photo that portrays their new-found confidence. Post it on Instagram and include a tag to your business page and add tailored hashtags. Sharing of your followers’ images can show your appreciation – give a shout out to the best follower selfies of treatment results, or most creative images, as well

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as encouraging your followers to include hashtags for your brand. Expect images to be filtered so the subject looks their best. When you regram, note that the image is the patient’s own, so it is important to direct readers to see your own portfolio of images on your social media or website. Using hashtags A hashtag – a word beginning with a # symbol e.g. #aesthetics – is used to index keywords or topics. This function was created on Twitter and allows people to easily follow topics that they are interested in by clicking the tags to reveal other posts that have used the same hashtags.14 Unlike Twitter, Instagram won’t limit your character count, this means you can add as many hashtags to your posts as you like, but remember to keep them focused. A simple rule is to include a brand name hashtag, which could be your business name or a specific procedure you offer, as these are what people will search for. Ask your followers to utilise your hashtags in their posts, such as your clinic name. Hashtags can include general terms too such as #antiageingtreatments as well as specific treatments like #marionettelinefiller. One way to broaden your user base is to encourage your current followers to engage with your brand by launching an Instagram hashtag contest. Simply ask followers to upload an image with a unique hashtag and tag your profile, with the offer of a free consultation or skincare product. For example, you could ask followers to post an image of their treatment results with the hashtag #NewMeClinicName (putting the name of your clinic after ‘NewMe’). The follower with the most likes on their image in 24 hours is the winner. By followers posting and sharing with their community, who are likely to be in a similar demographic, you will be reaching your target audience. Take some time to monitor your hashtags, not just for your brand but also for terms associated with your business. Set aside an hour a week to see what is trending, the latest hashtags people are using, including your followers and your competitors to stay up-to-date. Whether you are a clinic or mobile practitioner you can utilise geotagging on Instagram by adding your location to your posts which is plotted on a map. It can benefit your brand in more ways than one. Some users might be drawn to visiting a clinic in their location, once

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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Instagram is seen as an authentic source; it is not packed with advertisements they know where you are and it gives a physical element to your business. By adding your location you will be searchable on Instagram when users use the search button to look for aesthetic clinics in your area. For instance, if they search ‘aesthetic clinic, Brighton’ and you have tagged your location as Brighton, you will show up in the search results. In addition, there’s the benefit that if you travel widely you can demonstrate the areas you cover. Obviously you will need to take care to ensure that you don’t reveal any private details if you share posts from your home address. Adopting the latest trends Much like Twitter, Instagram has created trending posts and themes. Some of the biggest trends on Instagram include the ‘Throwback Thursday’ #TBT tag. This is where users upload an image of themselves from childhood or past years. Couple this trend with the ‘Selfie’ craze – a self-portrait taken on a mobile phone – and you have a trend perfect for the aesthetic industry. Encourage your patients to upload selfies, tag your brand and utilise the #TBT hashtag by showing a before and after treatment. Then you can share and promote your work directly via your audience. Adopting the Instagram tools As with most social media, you can find a variety of tools online that integrate with the software and can be used to enhance your profile; it is worth researching these and using some of them on your own Instagram. One in particular is Linkin.Bio. a product from Later.com.5 This is not a free tool, but for those clinics offering products and bookable treatments online via their website, it could prove to have good returns. Currently – although I predict this will change – you cannot add clickable links to your images online. If you have seen the well-used hashtag #linkinbio you will

understand why. Instagram only allows one clickable URL on your profile and most businesses set this as their homepage. You can showcase your work via the imagery but you cannot add a link to your site or contact information, direct from the post. Linkin.bio allows you to create a ‘shoppable’ feed: you can simply upload an image and create a custom URL to the relevant page on your website if the viewer double taps the image and then clicks on the link. Why it is important? Because you can divert your followers directly to the right pages whether they are blog posts, special offer landing pages or contact forms. You are able to add a URL to posts in the comments section but these are not clickable. Not only is this not user friendly but it also means that you cannot accurately track where your audience and website hits are coming from. Tools like Linkin.Bio allow users to open pages on your website directly in the browser window. You are able to track clicks and drive traffic to the pages with the highest conversion rates. Reviewing and monitoring posts As with all marketing, monitoring and reviewing is vital. Check which of your posts has had the best response rate and engagement, and contributed to an increased following. Use these as a template for future posts. Instagram is seen as an authentic source; it is not packed with advertisements and the ones it does show are highlighted clearly as ‘sponsored’ and there is the option to hide from your feed.15,16 Therefore, don’t make it too promotional heavy. Review your posts and see what is or isn’t working. Increase your shares and likes by showing your followers something interesting, exciting or different; it could be a behind the scenes video before a product launch, an interview with a representative, or a live posting of a treatment. A great means of building content is to include your staff in the profile image. It makes the company more personable and welcoming.

Followers can see the people who will be treating them and talking to them and become more familiar. Conclusion Whether you’re a small independent clinic, or a large-scale business, I’m sure you will have at least considered including social media in your marketing portfolio. With the number of Instagram users rapidly growing and its strong influence on its users, Instagram is a useful tool and should be integral to your marketing programme. Gina Hutchings is a senior digital marketing consultant at Receptional Ltd. She has more than 12 years of marketing experience in a variety of sectors in both B2B and B2C industries. Hutchings also writes for the aesthetic and cosmetic review site The Treatment Tester. REFERENCES 1. Google Play, Smart App Manager, (2017) <https://play.google. com/store/apps/details?id=com.james.SmartUninstaller&hl=en> 2. Statista, Number of social network users in the United Kingdom from 2014 to 2018 (in millions), <https://www.statista. com/statistics/278413/number-of-social-network-users-in-theunited-kingdom/> 3. Braden Goyette, Instagram’s popularity moves from hipsters to politicians: Mayor Bloomberg embraces photo sharing site as tool for extra exposure, NY Daily News, (2012) <http://www. nydailynews.com/news/national/instagram-popularity-moveshipsters-politicians-article-1.1229064> 4. Priit Kallas, Top 15 Most Popular Social Networking Sites, Dream Grow, 2nd Feb 2017 https://www.dreamgrow.com/top15-most-popular-social-networking-sites/ 5. Josh Constine and Kim-Mai Cutler, Facebook Buys Instagram For $1 Billion, Turns Budding Rival Into Its Standalone Photo App, (2012) <https://techcrunch.com/2012/04/09/facebook-toacquire-instagram-for-1-billion/> 6. Saqib Shah, Mark Zuckerberg quietly announces a massive increase in Instagram’s user numbers, (2017) <http://www. digitaltrends.com/social-media/instagram-400-million-dailyusers/> 7. Casey Fleischmann, Facebook and Instagram Usage , Social Media, (2015) http://socialmedialondon.co.uk/facebookinstagram-usage-2015/ 8. Steve Olenski, Are Brands Wielding More Influence In Social Media Than We Thought? Forbes, (2012), <https://www.forbes. com/sites/marketshare/2012/05/07/are-brands-wielding-moreinfluence-in-social-media-than-we-thought/#71e1b93d71e1> 9. Anthony Clasen, 11 Instagram Facts Every Marketer must know, IconoSquare, 19th Jan 2015 http://blog.iconosquare.com/11instagram-facts-every-marketer-must-know/ 10. Instagram Business, (2017) <https://business.instagram.com> 11. Rebecca Stewart, Instagram rolls out business profiles complete with ‘contact’ buttons as it offers advertisers greater insights, The Drum, (2016) <http://www.thedrum. com/news/2016/08/15/instagram-rolls-out-business-profilescomplete-contact-buttons-it-offers-advertisers> 12. Lizzie Davey, What is User Generated Content (and Why You Should Be Using it), (2016), <https://www.tintup.com/blog/usergenerated-content-definition/> 13. Kendall Walters, How to Regram: Best Practices for Reposting Instagram Content, Hootsuite (2016) <https://blog.hootsuite. com/how-to-regram/> 14. Support Twitter, Using hashtags on Twitter, (2017) <https:// support.twitter.com/articles/49309> 15. Stuart Dredge, Instagram ads reach the UK with Waitrose, Rimmel and Channel 4 The Guardian, (2014) <https://www. theguardian.com/technology/2014/sep/23/instagram-adswaitrose-rimmel-facebook> 16. Kurt Wagner, Inside Instagram’s reinvention, recode, (2017), <http://www.recode.net/2017/1/23/14205686/instagramproduct-launch-feature-kevin-systrom-weil>

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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“To have patients calling me to say how my treatments are changing their lives is a blessing” Dermatologist and skincare brand founder Dr Carl Thornfeldt shares his successes in the aesthetics specialty “I have been privileged to have been involved with saving a number of people’s lives; particularly some young children and babies with horrible skin conditions,” explains dermatologist Dr Carl Thornfeldt. “Once I saw a six-year-old child in my clinic with a benign looking mole and the mother told me she was very worried about it, and I was the fifth dermatologist she had seen. It looked perfectly benign but I listened to her and decided to take it off – it turned out to be an invasive malignant melanoma,” he says. Dr Thornfeldt grew up in Idaho, a state in the north-western region of the US, with his father who was a paediatrician. Here they had a small farm which, Dr Thornfeldt says, sparked his interest in science and nutrition. “I wanted to go into human medicine so I went to college based on where had at the highest student percentage of acceptance to medical school,” he says, which turned out to be Oregon Health and Science University. “But I specifically chose to specialise in dermatology because I suffered from a significant skin disease and I wanted to completely understand why those severe diseases occurred and how to prevent them so other people wouldn’t suffer,” he explains. At the time Dr Thornfeldt started practising dermatology in 1983, he was the only dermatologist for 30,000 square miles in eastern Oregon, in south-west Idaho. “By 1985 I felt that I was failing as my patients weren’t getting as well as they should be, people weren’t going into long term remission, so I started looking at the problem; what were we missing?” he says. “And one day it struck me – the number one purpose of the skin is for protection, and yet all the work that was being done in the 70s and 80s with retinoids, hydroxy acids, topical steroids and antibiotics for acne etc., was designed to destroy the skin barrier.” Dr Thornfeldt began researching the hypothesis that if the function and

structure of the skin could be optimised, then maybe skin disease and ageing could be prevented. He says, “In June 1989 we built a team of researchers and started a basic research project to learn everything we could about the epidermis, how the skin barrier regulates itself, how it repairs itself from environmental stress and injury.” Dr Thornfeldt found that, “There were two underlying abnormalities in the foundation of the cause of skin disease and ageing, and that was damage to the stratum corneum barrier and chronic inflammation.” Dr Thornfeldt started his work on putting together products to protect the skin barrier, he explains, “I went to the botanical world looking for molecules and extracts that would protect the skin barrier and prevent chronic inflammation, which we found, and then we went ahead and set up Episciences Inc a couple of years later.” In 2002, Epionce was introduced to the market. “I feel incredibly blessed to have been able to have a theory, do years of basic research, and then three years of clinical and formulation research and then it actually works,” exclaims Dr Thornfeldt. “To have patients calling me to say how my treatments are changing their lives is a blessing.” Continuing his research and education is vital for Dr Thornfeldt, as medicine continues to advance; he says, “Research in the last two years has shown how important the role of pollution is in activating skin ageing and skin cancer. There is also continual new research done with various molecules, so it is very important to keep on top of that.” He continues, “I take more than ten journals a month home and try to read those as at the end of the day, everything I am doing is to help me become a better doctor.” Despite his success, there will be no slowing down for Dr Thornfeldt. He says, “I don’t plan

on stopping; my calling is to provide quality specialty care to a part of the world – the US – where there is a huge deficiency of it.”

What treatment do you enjoy giving the most? I get great joy from the challenge of treating eczema and psoriasis patients because when they do get well I feel those are my greatest accomplishments. Looking back at your career is there anything you would have done differently? Anytime you start on a quest there is going to be sacrifice, unfortunately I think my family sacrificed a lot more than I would have liked them to. My regrets are that I allowed an imbalance, so that the work was more important than the family. Have you been given any good career advice? One piece of excellent career advice came from my father who said always listen to the mother, which I did with the six-year-old patient and it saved her life, and there has been a number of other patients that I have been able to save the life of because I listened to the mother. What do you enjoy the most in your career? When people who have been suffering from various skin conditions come up to me and tell me how much better they are – that is the greatest joy from it. I have had some opportunities to meet and work with some amazing people, but I think that the success of the patients is really the driver.

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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The Last Word Aesthetic nurse prescriber and Chair of the BACN Sharon Bennett debates when it is appropriate to treat the complications of other practitioners’ patients I sometimes find myself with an ethical dilemma when it comes to treating the aesthetic complications of other practitioners. As a nurse and part of ‘the caring profession’, it is in my nature to look after people, but when presented with a patient who is upset and distressed after an adverse event, or a bad outcome, at the hands of another practitioner, I do feel conflicted about whether or not I should be taking this patient on and transferring the responsibility on to my shoulders. Despite wanting to help, should we be saying yes to a patient when we may not fully know the exact details of the treatment they have had done and don’t have access to their treatment history? I do believe that the practitioner who carries out the cosmetic treatment has a responsibility towards their patient, should be handling their own complications and, ideally, be part of a tri-partide relationship with the patient and other practitioners for support. In this article I shall explain why. What is the problem? Working alone in private cosmetic practice is very different from working in the safe haven of the NHS. Problems occurring whilst working within the NHS have the immediate support from a host of people on hand to help. The practitioner involved will be surrounded by other professionals who are

able to access all the documentation, and the patient has a clear chain of authority to go to and will be cared for until a resolution is met. In private cosmetic practice, a patient faced with an unexpected result or an adverse event may not know what to do. Many will return to their original practitioner for correction, advice and further care, until a good outcome is gained. Some will not and will look elsewhere for help. They may even scour the internet in a desperate bid for help. Why is this an issue? When a patient presents at clinic with a result they are unhappy with or a complication, it is essential for us to know the full history of the patient. But the truth is, if this is not your own patient then this is almost impossible, and without access to the patient’s notes, medical and psychological profile, you can never be 100% sure you have all the facts. Having this access is very difficult as some patients will often ‘practitioner hop’ and will have seen many different practitioners for treatments. Patients aren’t always forthcoming with the truth or open about what they have had done; you need to know how many treatments they have had in the past, what they have had, where and when. Perhaps they may not completely understand the treatment they have had and the products they were treated with. Some just say they

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know they have ‘had fillers somewhere’. Correcting these patients without this information means you are treating blindly. Contacting the original practitioner is often not an option; we need patient permission due to patient confidentiality. Patients often don’t want the practitioner contacted for fear of reprisal. Even with patient permission, it is a delicate issue to confront a peer, and they may feel angered, embarrassed and defensive. Are you prepared to do this to get the information you need? Before even considering treating a patient complication from another practitioner, I imagine myself in front of a judge or the Nursing and Midwifery Council (NMC) fitness to practice panel, trying to defend my decision to treat. To have my professional practice picked to pieces and my registration held to question for merely trying to help out another practitioner’s patient makes me think twice before I agree, and ensures I carry out due diligence. There are always exceptions There are often valid reasons why the patient may turn elsewhere for help; they may have been left in a vulnerable position or the initial practitioner may not be supportive. I read and hear widely of poor practice with practitioners being dismissive, defensive, avoiding communication and even turning the patient away. The patient may lose confidence and faith in a practitioners’ skills following a problematic treatment. There may be a personality clash and, even though that practitioner is qualified and capable of correcting, the patient just doesn’t want to go back to them. Then there are those practitioners who were not qualified to treat in the first place, and therefore sending the patient back to them could be disastrous and requires deeper ethical consideration. The counter argument So, should we leave these patients with nowhere to turn? Of course not. The patient’s wellbeing is at the heart of what we do and if we have the skills to care for them then it could be argued that it is negligent not to. I do not personally believe it is negligent, but I do believe it is wrong if we turn the patient away without offering support and directing them to others who may be more experienced to help and are happy to take the patient on. Remember we do have an obligation to protect ourselves firstly. For those merely unhappy with the appearance, and the outcome was not what they expected (not a reportable adverse

Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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event) then we must consider closely all the issues. The treatment may be not what they wished, their expectations may have been too high and we may not be able to improve to their satisfaction. Considerations also to take into account are; what were they like before treatment?, Do they understand that dissolving a product will take them back to what they looked like before treatment? Sometimes worse? Consultation therefore must be thorough, as other problems could occur if they still don’t have the result they expected. There is also the added financial cost for the patient to understand. Alternatively, there may be an occasion when we are faced with a severe complication of someone else’s doing requiring immediate action, such as a clear impending or acute vascular compromise. The swift use of hyaluronidase to alleviate and stop its progression prevents a more serious complication occurring. It can also reduce soft tissue compression in the case of swelling when triggered by a non-HA treatment too, so as an emergency treatment, we would be well supported in opting to treat.

Aesthetics Journal

Aesthetics

The way forward I believe it is vital to surround ourselves with a multi-disciplinary team of experts, and our regulatory bodies, the General Medical Council (GMC) and NMC, expect us to. I believe you need to treat each situation on a case-by-case basis. I don’t think you can completely say ‘no, I don’t treat other people’s problems’ or ‘yes, that is what I do’ as each case presents different issues. I would like to see a culture of engaging with all practitioners and sharing records to become normal practice for the sake of the patient and ourselves. A formal tri-partide partnership or access to documentation, would enable others to have full disclosure. Having a complication should not be seen as a badge of shame (unless it becomes a frequent occurrence). These things happen in every type of medical treatment and individual lessons can be learnt. Caring for our patients completely, including complete support post treatment, is expected by our regulators and swift management of a complication can usually stop it escalating and becoming someone else’s challenge.

Conclusion It is a very challenging issue but there are expert groups in the industry, such as the Aesthetic Complication Expert (ACE) group, who can offer support to practitioners faced with complications. Professional associations have regional groups across the country and those within the BACN, for example, are exceptionally supportive should complications arise. When adopting someone else’s problem the transfer of responsibility for that patient becomes ours and we will be held accountable for any treatment we give, so don’t be too cavalier in accepting a complication unless you know what’s happening under the veil of the skin and are certain you can improve the situation. Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015.

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Reproduced from Aesthetics | Volume 4/Issue 6 - May 2017


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December 2016 UK/0869/2016

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