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VOLUME 5/ISSUE 6 - MAY 2018

OWN YOUR BEAUTY Let your patients show their emotions with confidence

Susanne, actual BeloteroÂŽ patient, 46

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. 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.

www.belotero.co.uk

M-BEL-UKI-0272 Date of Preparation December 2017

Children & Aesthetics CPD MZ486 OYB FC Advert for AJ.indd 1

Dr Mehvish Khan discusses cosmetic interventions on young patients

Find out more

Special Feature: Attracting and Retaining Men Practitioners advise on marketing to the male patient demographic

Receding at the Temples

Dr Greg Williams details how to treat receding hairlines in young male patients

18/12/2017 09:31 Scam Emails

Insurance manager Naomi Di-Scala recommends how to recognise and manage scam emails


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The Ultimate Sun Solution The World’s First SPF 50 UVA Ultra Sun Protection with Gradual Self Tan & Instant Bronzer Luxury Lotion SUNSCREEN • SPF50 UVA/UVB Ultra sun protection from blended organic ingredients SELF TAN • Gradual daily self tan for face and body that’s odour and streak free BRONZER • Contains a light natural bronze colour to give instant glow HYDRATING • Luxurious Lotion nourishes and repairs the skin with silky finish TANCREAM™ ABOUT THE INGREDIENTS TANCREAM™ is formulated to allow skin to breathe, therefore pores do not get blocked, it leaves a silky smooth finish and also helps avoid prickly heat and skin irritations. • Troxerutin is anti-oxidant and anti-ageing with antiinflammatory properties.It is a free radical scavenger and also accelerates the DHA* tanning process. The skin is protected from any damage caused by DHA on application • High UVA and UVB protection also reduces free radical formation and is a photostable broad spectrum SPF system • The sun protection is a blend of organic sunscreens with added ingredients to form the five star UVA protection • Glycerin is part of the preservative system and is a well known extremely safe moisturiser. *According to the American Academy of Dermatology, the most effective sunless tanning products contain dihydroxyacetone (DHA) as the active ingredient. DHA is a colorless chemical (it is derived from glycerin) that interacts with the amino acids in dead skin cells to produce a brown colour change.

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Contents • May 2018 08 News

The latest product and industry news

15 Conference Reports: AMWC 2018 & Scars 2

Discover the highlights of the Aesthetic & Anti-Aging Medicine World Congress and the second International Scar Treatment Conference

14 Advertorial: Introducing Tor-bac

An introduction to the new single-dose bacteriostatic saline solution

16 News Special: Are You Ready for GDPR?

Special Feature Attracting and Retaining Male Patients Page 20

A look at the new General Data Protection Regulation and how it applies to aesthetic practitioners

CLINICAL PRACTICE 20 Special Feature: Attracting and Retaining Male Patients

Practitioners explore how clinics can attract and retain this key demographic

25 CPD: Cosmetic Interventions on Children

Dr Mehvish Khan explains the impact cosmetic interventions can have on young patients

In Practice Updating Existing Clinic Interiors Page 63

29 Penile Augmentation

Mr Amr Raheem presents an overview of approaches to augment the penis

33 Receding Temples in Men Under 30

Dr Greg Williams discusses how to successfully treat a receding hairline

36 Aesthetics Awards 2018 Overview

A look at which categories you can enter at the prestigious ceremony

43 Performing Thread Lifts

Dr Albina Kajaia shares her experience of using polylactic acid threads

46 Advertorial: Chin Augmentation

Aesthetic nurse prescriber Helen Allen discusses chin augmentation

49 Full Facial Rejuvenation

Mr Ayad Harb details his protocol for rejuvenating the face using dermal filler

52 Advertorial: Skin Boosters

Galderma outlines a ‘boost’ for those looking to achieve their best skin

53 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 55 Incorporating Facial Aesthetics into a Dental Clinic

Dr Krystyna Wilczynski discusses the considerations for dentists to successfully incorporate non-surgical aesthetic treatments in clinic

Clinical Contributors Dr Mehvish Khan holds a degree in Biomedical Sciences and Medicine. Due to her passion for science and art, she has decided to pursue her career in the field of aesthetics and is currently undertaking her Master’s Degree in Aesthetic Medicine at Queen Mary University. Mr Amr Raheem is a specialist in andrology at the University College London Hospital NHS Foundation Trust and medical director of International Andrology. His expertise covers surgical, medical, hormonal, psychological and academic aspects of male health. Dr Greg Williams is the only member of the British Association of Aesthetic Plastic Surgeons (BAAPS) who performs hair transplant surgery on a full-time basis. He is the current president of the British Association of Hair Restoration Surgery. Dr Albina Kajaia is a dermatologist and chief of her dermatology department in Georgia. She is scientific director and founder of the International Caucasian Congress on Plastic Surgery and Dermato-Cosmetology in Kolkhida. 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. He also practices in the NHS as Senior Clinical Fellow in Plastic Reconstructive Surgery.

59 Protecting your Clinic from Scam Emails

Insurance manager Naomi Di-Scala advises on dealing with scam emails

63 Updating Existing Clinic Interiors

Interior designer Benedict Wilhelm details how updating clinic décor can have a positive impact on patients and maximise business potential

67 In Profile: Dr Miguel Montero

Aesthetic practitioner Dr Miguel Montero shares his journey from running a struggling clinic to winning The Med-fx Award for Best Clinic North in 2017

68 The Last Word

Dr MJ Rowland-Warmann argues why she believes the risks of non-surgical nose reshaping are being trivialised online

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• In Focus: Sun Special • IPL lasers • Healing the skin

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Read her lips The Restylane lips range is the secret to soft, naturallooking lips. restylane.co.uk/AJ

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


Editor’s letter Hello and welcome to our May issue! The conference season is now well underway and it is always a challenge to be different while maintaining a high standard of quality content – judging by the numbers of delegates in Amanda Cameron attendance and the excellent feedback we had Editor for the Aesthetics Conference and Exhibition (ACE), I think it’s safe to say that we achieved this yet again – it was a fabulous event focused on education and innovation. The Aesthetics team and I thoroughly enjoyed meeting everyone who spoke, exhibited and attended; we are privileged to have such wonderful, hardworking colleagues, friends, readers and practitioners in this specialty. In this month’s issue we examine the male aesthetic market in a little more detail. It appears that just like wine, Britain’s men get better with age. According to Mintel’s Men’s Facial Skincare 2017 Report, as many as 75% of men aged 65 and over feel confident about the way they look, compared to just over half (56%) of men aged 16-24 and

an average of 61% of all men. What is more, while 67% of all men say they look good for their age, this increases to a self-assured 71% of those aged 65 and over. Yet there are still many men seeking aesthetic treatment. While the demand continues to grow, it is still a way off catching up with the female market. Although, judging by the number of male skincare ranges popping up on supermarket shelves, it may not be long before that happens. As such, our May Special Feature shares helpful advice on how you can make your practice and service more appealing to men to attract them to your clinic and retain their custom. Update your knowledge on p.20. Hair loss is probably one of the main aesthetic concerns men face as they age, so hair transplant surgeon Dr Greg Williams shares his advice on consulting men in their twenties and suitable treatment approaches on p.33 We’d love to hear your experiences of marketing to and treating men – get in touch to share your best tips via Twitter @aestheticsgroup or by commenting on our Facebook page, Aesthetics.

Editorial advisory board

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

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

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

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

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

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

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

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

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

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

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Tanning

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #HairTransplants Greg Williams @Drgregwilliams Delighted to have hosted @BAAPSMedia / @BAPRASvoice aesthetic fellow Mr Will Holmes @FarjoHair. There is no accredited training in the UK for #HairTransplant as it is not part of #PlasticSurgery or #Dermatology curricula. #Consultation #Education #Friends Dr Firas Al-Niaimi @Drfirasalniaimi #ThrowbackThursday: It’s always a pleasure to catch up with dear friends and colleagues during my travels. Here I am with the internationallyrenowned Dr Christine Dierickx at a recent conference, with whom I share a passion for the use of #lasers in #dermatology. #DrFiras #tbt #Charity AesthetiCare Team @AesthetiCareUK Last weekend, Colleen from our Marketing Team took part in a charity boxing event to raise money for York Special Care Baby Unit. After 8 weeks of intense training, Colleen & the other boxers stepped into the ring & raised a WHOPPPING 21K! Fantastic work, well done! #Conference Dr Uliana Gout @UlianaGout Pleasure Chairing the Monaco Cosmeceutical Session – bringing AMWC 2018 to a close – thanks to our wonderful panel of Global Experts! @euromedicome #AMWC2018 #monaco #education #conference #speaker #skincare #skin #skincareroutine #wellness #beauty #bblogger #beautyblogger #Anatomy Jas Coles-Black @JasamineCB #Anatomy gets easier with repetition. Or so they say. Every complicated relation I master (and retain!) is bringing me one step closer to becoming a surgeon. #surgtweeting #ILookLikeASurgeon #IAmASurgeonAnd #sciencemeetsart

Tancream added to AestheticSource portfolio UK distributor AestheticSource has launched the Tancream sun protection lotion to its product portfolio. According to the company, the product aims to combine instant bronzing and gradual self-tan with the protection of SPF50 and five-star UVA. Co-director of AestheticSource, Lorna Bowes said, “We are delighted to add Tancream to the AestheticSource portfolio of technologically-advanced, clinicallyproven products – especially in the contemporary aesthetic industry, where clients are finding their patients are much more sun aware and keen to prevent skin pigmentation, sun damage and ageing by wearing SPF all year round.” Aesthetic nurse prescriber Anna Baker added, “I have been impressed with Tancream – it looks very natural when applied and it’s without streaks. Not to mention the high SPF coverage with factor 50 and antioxidant protection – it’s much more than self-tan.” Suncare

Vitamin C products launched by Obagi Medical PROFESSIONAL-C ™ PORTFOLIO

Skincare company Obagi Medical NEW VITAMIN C has released twoFRESH new vitamin C products to sit PRODUCTS alongside FROM OBAGI its Professional-C range of serums. The products include Professional-C Peptide Complex and Professional-C Suncare SPF 30. The first aims to reduce the appearance of ageing skin while promoting a healthy-looking, youthful glow. It contains kinetin and zeatin, which are synthetic forms of plant growth factors that aim to assist in improving firmness and tone, as well as reducingTMfine Obagi Professional-C Obagi Professional-CTM lines and wrinkles. The Professional-C Suncare SPF 30SPF has30been Suncare Peptide Complex designed to defend against UVA and UVB rays. It is formulated with Reduces appearance of fine lines Broad-spectrum sun protection against 10% L-ascorbic acidandtowrinkles help address the appearance ofrays ageing skin UVA and UVB firmnessradicals and tone usingassociated SNAP-8 Defends radicals and defend againstImproves the free withagainst sunfree damage. Retains skin’s moisture 10% L-asorbic Acid (Vitamin C) Steve Joyce, marketing and technology directorContains at Healthxchange Calms skinUK distributor of Obagi Medical products, Pharmacy, the exclusive said, “Obagi’s Professional-C Serum has been extremely successful Available to order now through your e-pharmacy: for our customers. Vitamin C is an important antioxidant, which can Visit: shop.healthxchange.com Email: Tel: +44 (0) 1481 736837 be highly effective at orders@healthxchange.com improving the appearance of ageing skin. Expanding this range therefore provides our clients with the latest developments in skincare science; using a peptide complex and the proven power of vitamin C in sun protection.”

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Events diary 15 May 2018 th

British Association of Sclerotherapists 2018 Conference, Dorney www.bassclerotherapy.com

14th – 16th June 2018 British Medical Laser Association Laser Skin & Body Conference 2018, Rotterdam www.lasereurope2018.com

22nd September 2018 British College of Aesthetic Medicine Annual Conference 2018, London www.bcam.ac.uk

8th – 9th November 2018 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

1st December 2018 The Aesthetics Awards 2018, London www.aestheticsawards.com Appointment

Eden Aesthetics announces new representative Lindsay Gray has been confirmed as the new London representative for distributor, Eden Aesthetics. She will be managing the London accounts and assist with events, training and demonstrations in clinics. Gray has more than ten years’ experience in medical aesthetics and has previously worked with skincare brand Epionce and pharmaceutical company Galderma, where she worked closely with dermatologists, plastic surgeons and other aesthetic practitioners. Gray said, “I’m exceptionally passionate about skin health and am committed to supporting our customers in growing their business. I love to help my customers drive revenue and deliver outstanding results to happy, repeat patients.”

Aesthetics Journal

Aesthetics

Aesthetics Awards

Entry open for the Aesthetics Awards 2018 Practitioners, clinics, suppliers, distributors, and other companies within the aesthetic specialty can now enter the most wellrecognised, prestigious awards ceremony in medical aesthetics – the Aesthetics Awards 2018. Hosting more than 800 guests, the event will take place at the Park Plaza Westminster Bridge Hotel in central London on December 1. Aesthetics Awards organiser Amanda Cameron said, “After last year’s sell-out success, the Aesthetics Awards 2018 will be an event not to be missed, featuring a live band, comedian, delicious three-course dinner and lively networking event. I encourage everyone who is a part of this amazing specialty to get entering, because if you are even recognised as a finalist in these awards it can be hugely beneficial for you and your business.” New sponsors have also been confirmed for the following categories: The Schuco Aesthetics Award for Outstanding Achievement in Medical Aesthetics, The PHI Clinic Award for Professional Initiative of the Year, The Healthxchange Award for Sales Representative, The AestheticSource Award for Best New Clinic UK and Ireland, The MATA Award for Best Clinic Group UK & Ireland (10 clinics or more), The Enhance Insurance Award for Best Clinic Group UK & Ireland (3 clinics or more), The AesthetiCare Award for Best Clinic North England, The Med-fx Award for Aesthetic Nurse Practitioner, The ABC Lasers Award for Medical Aesthetic Practitioner, The John Bannon Award for Best Clinic Ireland, The iS Clinical Award for Best Clinic South England, The Dalvi Humzah Aesthetic Training Award for Best Supplier Training Provider, The Dermalux Award for Best Clinic London, The Barry Knapp Award for Product Innovation of the Year, supported by Medical Aesthetic Group, The John Bannon UK Award for Best Clinic Midlands & Wales and The Consentz Award for Best Clinic Reception Team. Due to ticket demand, table sizes have been increased for 2018 so you can now seat 12 guests at your table. Entry for the Aesthetics Awards closes June 29 and finalists will be announced September 3. Industry

Scottish nurses to stock POMs Healthcare Improvement Scotland (HIS) has confirmed in a Stakeholder meeting that aesthetic nurses who own HIS-registered clinics can now legally stock prescription-only medications (POMs) such as botulinum toxin and hyaluronidase on premises. A spokesperson for HIS told Aesthetics, “The MHRA has advised us that a nurse or an independent nurse prescriber cannot order and stock prescriptiononly medicines or pharmacy medicines in their own right. However, any ‘persons carrying on the business of an independent clinic’ are able to order and stock prescription-only and pharmacy medicines in connection with the running of the clinic.” Historically, aesthetic nurse prescribers, despite owning their own clinics, were not permitted to hold POMs on premises without the presence of an on-site doctor. According to Scottish nurse prescriber and clinic owner Frances Turner Traill, the biggest issue with this is not being able to hold emergency stock like hyaluronidase on premises. “It’s all about safety. You must be able to immediately respond to a vascular occlusion with hyaluronidase to get the best clinical outcome. It’s important that all practitioners can treat potential aesthetic complications in an emergency situation.” Nurse prescriber Michelle McLean, Scottish regional leader for the BACN, added, “It’s a day in history; this is where things are going to move forward for nurses to become more empowered, it’s a really good thing for both nurses and patients.”

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Disinfection

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

RENEWALS The BACN would like to thank all of our members who have renewed their membership for 2018/2019. The renewal rate has been fantastic, and retention rates have improved year on year. Membership and Marketing Manager Gareth Lewis is available to contact if you have queries.

BACN REGIONAL MEETINGS The BACN is just finishing its Spring round of regional meetings throughout the UK. A big thank you to our strategic partners for delivering fantastic demonstrations and presentations, with a special thank you to Hamilton Fraser Cosmetic Insurance for delivering General Data Protection Regulation (GDPR) webinars, catered specifically to nurses working in aesthetics. The turnout at the meetings was strong and the mix of experienced and newer practitioners demonstrated that there was something for everyone at each event. The Save the Dates for the Autumn regional meetings are on our website.

GDPR We have been working with Hamilton Fraser to deliver GDPR information and advice specific to aesthetics, in order to prepare members for the new penalties coming into force this month. Support can be gathered via the BACN Facebook groups, contacting head office, or by accessing GDPR resources in the BACN members’ area.

WHY BECOME A MEMBER? Michelle McLean, Regional Lead for Scotland said: “In what is often an isolating world of aesthetics, the BACN provides ongoing support and education that’s invaluable.” Simone Sansom, Regional Lead for the North East said: “I love the BACN. It’s vital as a nurse to not work in isolation, and it’s brilliant to meet other nurses throughout the country at events, along with engaging in fantastic opportunities.” This column is written and supported by the BACN

MAG launches NatraSan Skin UK aesthetic product supplier Medical Aesthetic Group (MAG) has released a new hypochlorous acid skin disinfectant. According to MAG, NatraSan Skin delivers ultimate levels of skin and tissue disinfection and is powerfully bactericidal, virucidal, fungicidal, sporicidal, fast acting and kills pathogens on contact. The formula contains water, salt and hypochlorous acid and does not include other common disinfectant ingredients like sodium hypochlorite (liquid bleach), phosphoric acid or alcohol. The company states the product is therefore non-irritant and non-sensitising, even to sensitive skin, and does not inhibit the growth of new tissue. The company also claims that it is effective on all types of skin as well as in and around the eyes, ears and mouth. NatraSan Skin has been independently tested to 12 EN standards including: BS EN 1040 (bactericidal), BS EN 14476 (virucidal), BS EN 13624 (fungicidal) and BS EN 13704 (sporicidal) and has a shelf-life of 18 months, even after opening. David Gower, managing director of MAG said, “We only research and bring to market the highest standard of product effectiveness and efficacy and NatraSan Skin is an excellent new addition to our portfolio.” Eye rejuvenation

Radara microchannelling product released A new Radara microchannelling patch designed for the total eye area has been developed by aesthetic and antiageing manufacturer Innoture Medical Technology Ltd. Following a successful launch of the original Radara Crow’s Feet patch for lateral canthal lines in February 2016, the new extended microchannelling product aims to deliver periorbital and tear trough rejuvenation. Like the original patch, Radara Eye features ergonomically designed, hypo-allergenic patches with microneedles made from patented, cone-shaped, microscopic plastic structures. The new patch has a total of 3,000 microneedles for each eye, almost double that of the original patch. When applied to the skin, the company claims the patches painlessly create physical microchannels in the stratum corneum to allow the flow of the speciallyformulated pure hyaluronic acid serum into the epidermis. “The launch of the new design increases choice and enables patients to choose the Radara product that targets their specific areas of concern. The original Radara design continues to be available for patients who are most concerned about crow’s feet lines,” said Ken Jones, CEO of Innoture.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Aesthetics Journal

Skin rejuvenation

Mrs Sabrina Shah-Desai announced as new Tixel KOL AZTEC Services, the exclusive UK distributor of the Tixel device, has appointed oculoplastic surgeon Mrs Sabrina Shah-Desai as its new key opinion leader. Manufactured by Novoxel, Tixel is a thermal fractional skin rejuvenation system that covers the treatment spectrum of ablative CO2 and non-ablative lasers. Mrs Shah-Desai said, “I am delighted to join Tixel as a UK KOL and we have some very interesting aesthetic treatment protocols in progress. I have found that Tixel has good scientific evidence when comparing their results to C02 laser combined with the benefits of virtually no and/or minimal downtime.” Anthony Zacharek, general manager of AZTEC Services, added, “We are absolutely delighted to have Mrs Shah-Desai as a KOL for Tixel. Her extensive experience and knowledge will be a tremendous benefit to us and Novoxel. Mrs Shah-Desai’s facial aesthetic work, especially around the eyes, will really make the most of the unique benefits of the Tixel system. She is also doing some very interesting work with the Tixel system in the open-channel mode in combination with various topical agents.” Sun

mesoestetic launches new suncare range

Aesthetics

Vital Statistics In a UK study on how mobile technology is elevating patient care, 57% of patients currently use wearables to track health metrics (Zebra, 2017)

When asked which countries were the most concerned about their healthcare system, Hungary came out on top with 72% (Statista, 2018)

Selfies can increase perceived nose size by 30% and nose width by 7%. Nose reshaping is the third most common cosmetic procedure in the US (JAMA Facial Plastic Surgery, 2018)

In a survey of 2,000 women, the top reasons they go to the gym is to improve general health, mood and fitness rather than to lose weight (BetterYou, 2017)

Pharmaceutical and skincare manufacturer mesoestetic Pharma Group has created a new sun protection range. The products are formulated with the company’s mesoprotech complex, which combines physical, biological and chemical filters that aim to give maximum protection against UVB, UVA, high energy visible (HEV) light and infrared radiation (IR) radiation. The new range is made up of six products in total, including three antiageing suncreams: the mineral matt antiaging fluid, light water antiaging veil and the nourishing antiaging oil. The company also offers a new sun protective body lotion, a melan 130+ pigment control product to prevent age spots and the sun protective repairing stick for sensitive areas.

Facebook remains the number one social media platform for those aged 18 and above in the US (Pew Research Center, 2018)

The UK government aims to reduce the number of calories in certain foods by 20% over the next five years (Public Health England, 2018)

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Industry

Laura Schwulst joins BeamWave Device company BeamWave Technologies has appointed Laura Schwulst as its new business development manager for the south of England. Schwulst has nine years’ experience as a Level 4 therapist working in clinics such as EUDELO and sk:n and has extensive experience in field sales within the aesthetics specialty. Nik Kane, general manager at BeamWave stated, “We are thrilled and excited to appoint Laura to the team at BeamWave Technologies. Her passion for the industry shines through and Laura holds the same values, drive and principles as BeamWave Technologies, so she will make a fabulous addition to the company.” Chin reduction

Laser Lipo launches the Strawberry Lift UK laser manufacturer, Laser Lipo has introduced a new treatment that aims to provide a non-invasive, pain-free neck, double chin and jowl reduction in just 12 minutes. Plastic surgeon, Mr Lyle Back said, “Fullness of the neck area below the chin and jaw is an extremely common concern among men and women alike. The Strawberry Laser technology developed for the double chin is the same incredible technology that has been used successfully for years for the body reshaping of thousands of satisfied patients. Extensive research has allowed the technology to be modified and adapted for specific application for the central neck/double chin area.” The chin applicator combines laser technology with a silent ultrasound that aims to eliminate double chins and gently tone the jawline. Mr Back advises that for best results, a course of four treatments is recommended. Infection

Derma-Seal launches A group led by consultant plastic and aesthetic surgeon Mr Dalvi Humzah has developed a new aftercare spray that aims to reduce the number of post-treatment infections. Created in conjunction with three development specialists, Derma-Seal is a disinfectant product which applies an impervious barrier over a puncture wound that has been created by a needle or cannula. Mr Humzah stated, “Any injectable aesthetic treatment that penetrates the skin and causes a hole has the potential to result in complications such as infection. Even if we do apply a disinfectant before and after, I’ve realised that many patients are not listening to their practitioners’ advice not to apply makeup post treatment, which may increase their chance of infection.” He added, “Derma-Seal has become an integral part of my posttreatment programme. It protects the injection points by creating an impervious barrier to seal the hole in the skin. It’s water resistant, lasts for around 12 hours and aims to stop bacteria from entering after makeup application, unintentional touching, contact with hair and environmental contamination.”

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News in Brief Med-fx announces extra dates for education seminars Aesthetic supplier Med-fx has added extra dates to its non-commercial education sessions. The CPD-accredited courses aim to bring together quality industry speakers. The sessions will run from 4-8.30pm and will look at three main areas: business advice, dermatology, and indication and complication management. The events will take place on May 28 and 31 in Glasgow and Birmingham. RSM to hold education sessions Aesthetic practitioners have been invited to learn more about abdominal wall and perineal reconstruction at the Royal Society of Medicine (RSM) on May 26-27. The event, titled Abdomen and Perineum – aren’t they connected? is worth 12 CPD points and will feature an expert panel discussing topics such as invasive liposculpting of the abdomen with and without abdominoplasty, vulva and labial dermatology conditions and treatment options, gender reassignment and the biomechanics of pregnancy’s effect on the abdominal wall and soft tissue. Bursary places are available for nurses, students and trainees. For more information visit the RSM website. IMAGE skincare launches new vitamin C products It has been revealed that IMAGE skincare has introduced the Hydrating Water Burst and the Hydrating Overnight Masque to its Vital C collection. The company claims the collection contains three effective forms of vitamin C and intends to target dry, dehydrated, sensitive, environmentally damaged and irritated skin. Alongside the new additions, the existing Vital C Hydrating A C E Serum has a new upgraded formula. IMAGE has also updated the AGELESS Total Pure Hyaluronic Filler to now contain six forms of lower and higher molecular weight hyaluronic acids that aim to smooth wrinkles. Save Face launches data initiative Independent accreditation body Save Face has implemented a new initiative to encourage both patients and practitioners to record negative experiences related to cosmetic practice. The body recognises that there is a lack of data on risks in the aesthetics sector and believes that with more than 550 registered practitioners, it is in a unique position to engage with practitioners and patients to help resolve this. The initiative involves the completion of a new online survey, which can be tailored for either patients or practitioners.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Symposium

Agenda and speakers announced for NeoStrata Symposium The agenda for the 2nd NeoStrata European Symposium on May 18-19 has been announced. The symposium celebrates 30 years of NeoStrata and brings together practitioners from across the globe for two days of peer-to-peer learning. There will be discussions on hydroxyacids, skin anatomy and facial ageing, skincare formulation science, how to treat skin of colour, integrating skincare into clinic, retinoids, combination therapies, and more. Speakers include Dr Mukta Sachdev, Dr Beth Briden, Dr Stefanie Williams, Dr Uliana Gout, Dr Sophie Shotter, Dr Sandeep Cliff, nurse prescriber Anna Baker, business consultant Wendy Lewis and NeoStrata president, Lori Deo. The conference will take place at the Royal College of Physicians in London. Training

Dr Hema Sundaram joins DHAT Dalvi Humzah Aesthetic Training (DHAT) has announced that US-based dermatologist Dr Hema Sundaram will be joining the team as one of its honorary international tutors. Dr Sundaram will aim to provide existing training courses with unique perspectives in global aesthetic development and supply course content. DHAT lead tutor and director, Mr Dalvi Humzah said, “We are very excited to welcome Dr Sundaram to DHAT. Not only is she a successful dermatologist, recognised internationally as a KOL and has published extensively, but she will also be able to provide delegates a global knowledge of our specialty.”   He added, “As we currently run courses in Holland and Poland and are in the process of developing courses in the Far East and US, the international tutors will be in place to assist in the delivery of these. Dr Sundaram will be a great asset in advising us in the development of our courses, especially the US ones.” On the Scene

PLEXR Plus Workshop, London Aesthetic practitioners met at the Royal Society of Medicine on March 23 for a workshop on plasma generation using the PLEXR Plus. Hosted by Naturastudios, the new exclusive distributor of PLEXR Plus, the session was led by aesthetic practitioner Dr Dev Patel, who spoke about the device’s technology and the treatments that it can offer. Attendees comprised both existing users as well as those looking to learn more, who, according to Naturastudios, discovered how to enhance results with PLEXR Plus and how to successfully combine the treatment with other procedures. Live demonstrations of treatments also took place and delegates received exclusive discounts on the day. According to Naturastudios, the PLEXR Plus utilises plasma through a process called sublimation, which turns solid matter into gas by forming an electrical arc. The company claims that the precise nature of this technology enables practitioners to treat the delicate eye area and is one of the most effective devices for baggy eyelid correction, as it does not require any cutting or stitching and requires no downtime after treatment. 

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Dr Galyna Selezneva, aesthetic practitioner based at the Dr Rita Rakus Clinic Which treatments do you offer? Nowadays, clinics not only have to offer the full range of aesthetic treatments, but also focus on the wellness aspect alongside this. As well as providing injectables such as Botox™ and Juvéderm®, we offer treatments using energy-based devices such as ULTRAcel, which can be used on both the face and body. Cosmeceutical ranges are also another mainstay within the clinic, and we offer ranges such as the Dr Rita Rakus Collection, Obagi Medical products and Dr Levy, amongst others. Finally, we have an extensive wellness portfolio, including signature vitamin and antioxidant infusions.    What is your current focus and why? My current focus is a 360° approach, a full body technique for body contouring, focusing on the patient from every angle. I am loving my new LIPOcel machine, as it allows me to ‘free flow’, contouring the body to perfection. Whereas other systems generally focus on larger areas, LIPOcel is incredibly precise making it easier to focus on smaller areas. LIPOcel is a non-invasive system used for fat reduction and precision body contouring.    What does the future hold? A new treatment which we are really excited to introduce at the Dr Rita Rakus Clinic is the new Envy Facial device. Envy Facial is a skin resurfacing treatment that simultaneously combines exfoliation, extraction and infusion of potent serums to target specific skin concerns. We’re working together with Healthxchange Pharmacy on a number of new face and body protocols.    What makes a successful practice? To have a successful practice, you have to really love what you do. I am very lucky and incredibly proud to work at the Dr Rita Rakus Clinic. Dr Rakus is a great mentor, and her dedication to the profession is incredibly motivating. Ensuring that you keep abreast of the latest technology in your treatment areas is also crucial to ensure that you are offering your patient the most effective treatment experience. This column is written and supported by

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


@aestheticsgroup On the Scene

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On The Scene

Let Go of The Handbrake launch, London

On the evening of April 5, more than 50 guests met at the Amba Hotel in Charing Cross to celebrate the launch of Dr Harry Singh’s new book, Let Go Of The Handbrake. Live bhangra music played as Dr Singh entered the room, before he welcomed guests and thanked those who supported him with his writing. He explained that the book aims to teach practitioners how to get started in aesthetics and how they can market their business, manage the patient journey, retain patient cohort and gain new ones, plus manage their finances and make a profit. After his speech, guests enjoyed drinks and canapés and had the opportunity to get a copy of the publication signed. Dr Singh said, “The launch event was fantastic. It’s always a humbling experience to see so many people attend on a weekday evening and enjoy the event. I love that both new and established practitioners see the importance of the business aspects of aesthetics and I can’t wait to dig into the book and implement the contents.”

Dispelling Skincare Myths, London The Black Skin Directory (BSD) held an educational event on skincare myths surrounding black skin on March 29 at Avanti Aesthetics in London. Dija Ayodele, aesthetician and founder of the BSD, explained that the purpose of the event was to correct the misconceptions on the suitability of aesthetic treatments and products for black skin, while offering guests the opportunity to meet skincare professionals on a face-to-face basis. The session consisted of an introduction to the BSD, followed by questions and answers with the audience and guest speakers. Guests all left the event with a goodie bag from the event’s sponsor, aesthetic product distribution company, AestheticSource. Skincare professionals in attendance were founder of Avanti Aesthetics Dr Rikin Parekh, Dr Bhavjit Kaur of Health & Aesthetic Clinic and Dr Barbara Kubicka of Clinicbe. Dr Kaur said following the event, “I was honoured to be part of the Black Skin Directory panel discussion answering burning questions from an interactive audience about the care of black skin.” Ayodele added, “The audience was engaged and the panel provided candid and thoughtful expert answers.”

Advertorial

Introducing Tor-bac Alison Stevenson, managing director of manufacturer Tor Generics Ltd, introduces the new single-dose bacteriostatic saline solution Practitioners offering injectable procedures will be familiar with the use of bacteriostatic saline solution to reconstitute medicinal products for intramuscular/intradermal injection. Those who use the Tor-bac brand will know that each millilitre of solution contains sodium chloride 9mg and 0.9% (9mg/ml) benzyl alcohol added as a bacteriostatic preservative, which is less

painful at the site of administration compared to an ordinary saline. Traditionally, however, bacteriostatic saline solution has only been available in 30ml vials. Until now. Practitioners can now purchase ten 5ml ampoules of Tor-bac, meaning they can use one ampoule per patient. In addition, they are easier to administer and compliant with both single-use botulinum toxin and hyaluronidase applications. With Tor-bac, there’s no risk of cross contamination and the single-use doses means they are cost effective too! Aesthetic nurse prescriber Emma Davies says, “Since a single patient treatment rarely requires more than 2.5ml of saline to reconstitute a single vial of toxin, either practitioners are wasting a great deal of product, or they are in breach of regulations, by reusing a 30ml multi-dose vial for multiple patients. As such, the new 5ml vials offer a valuable solution!” To find out more and purchase your 5ml ampoules, get in touch with: Church Pharmacy: 01509 357 300 info@churchpharmacy.co.uk www.tor-generics.com REFERENCE: 1. Centre for Disease Control, ‘Frequently Asked Questions (FAQs) regarding Safe Practices for Medical Injections’ < https://www.cdc.gov/ injectionsafety/providers/provider_faqs_multivials.html> Last accessed: 19 March 2018.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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AMWC, Monaco Aesthetics reports on the highlights of the 16th Aesthetic & Anti-Aging Medicine World Congress It was another successful year at Monte-Carlo’s 16th AMWC congress on April 5-7. More than 12,000 specialist practitioners from 130 different countries met at the Grimaldi Forum to learn the latest advances in aesthetic dermatology and surgery, preventive and antiageing medicine. There were 350 international speakers presenting at the event, while 250 exhibiting companies showcased more than 400 aesthetic brands. The main theme of this year’s congress was patient safety, and the agenda reflected this, with many sessions discussing the importance of avoiding complications and adverse events, while promoting safe and successful treatments. Some notable sessions included Profiloplasty – Non-Surgical Beautification and Harmony, chaired by French plastic surgeon Mr Thierry Besins; The Miracle of Growing Younger – The Revolution Of Regenerative Aesthetics, chaired by aesthetic practitioner Dr Kate Goldie; and A Better Knowledge of Physical and Human Factors – The Key to Optimise Safety in Aesthetic Injections, chaired by plastic surgeon Mr Steven Dayan. Professor Bob Khanna, Galderma international KOL, who attended AMWC as a chairman and speaker, said, “Each year this conference gets better. It was

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a pleasure to present my very latest concepts and techniques, to enable international clinicians to take their knowledge and skills to the ultimate level when treating patients. This year, my teaching focus was on creating the ideal profiles from forehead to nose, lips and chin. I also ran a key session on male vs. female aesthetics.” Dr Raul Cetto, Teoxane country expert, presented at the Teoxane stand on pre- and post-procedure care, as well as lower face and jawline treatments. He said, “AMWC this year felt bigger; there were lots of people and lots of things going on. I really enjoyed presenting my intimate sessions at the Teoxane stand. We also had two corporate sponsored events where we had 400-500 people that covered talks on tear tough, lips and live demos and more with Dr Wolfgang Redka-Swoboda from Germany and Dr Wayne Carey from Canada, which were well received.” Professor Khanna concluded, “If clinicians wish to remain on top of their game, then they need to be constantly updated. In a conference of this magnitude, they can do so by listening and observing very experienced clinicians from all over the world, who are at the top of their game. Hence this opportunity ought not to be missed!” AMWC in 2019 will take place at the Grimaldi Forum in Monaco on April 4-6.

they can be treated and minimised. The two-day conference saw worldrenowned experts from Israel, UK and Europe, US, Australia, Hong Kong and Thailand gather to present a series of lectures and offer a variety of Aesthetics reports on the scar treatment conference plenary courses and workshops demonstrating the that took place in Tel Aviv on March 21-22 latest skincare innovations from around the world. The programme was split into Under the direction of The Tel Aviv Medical Center, Ichilov, with a number topics that included scar formation, scar mitigation, the Israel Society of Dermatology and Venereology, the Israeli medical and procedural management of scars, laser and light Society for Dermatologic Surgery and the Israeli Society of devices, acne scars and striae, special considerations and the Plastic and Aesthetic Surgery, Scars 2 brought together experts future of scar management. Multiple speakers contributed to from the plastic surgery, aesthetic and dermatology community each session, including clinical scientist Dr Ardeshir Bayat and worldwide to explore the newest, cutting-edge practices in scar consultant dermatologist Dr Firas Al-Niaimi from the UK. Dr Altreatment and aesthetics. With scars affecting so many people on Niaimi said, “It was an absolute honour and highlight in my career a daily basis, the goal of Scars 2 was to elaborate on the progress to be selected to chair a laser session and be on the expert panel of research, bring together all the knowledge and experience in with Dr Rox Anderson, a giant figure in laser science.” the field and put There were a number of supplementary sessions demonstrating the broad topic the ‘same patient, different approach’. For each, two of scars into leading experts analysed the cases presented and offered the spotlight to contrasting treatment protocols. Following the meeting, all the raise a new level speakers gathered to come up with specific, evidence-based of awareness. recommendations of how to use energy-based devices in scar Two of the treatment. This consensus will be published as a paper series main messages at a later date. More than 40 companies from the medical and communicated cosmetic industries showcased the industry’s latest products and at Scars 2 services. Exhibitors included Lumenis, Syneron Candela, Rafa, were that scars Enerjet, Alma Lasers, Venus Concept, Allergan and Stratpharma, to are a medical name just a few. To attend Scars 3 in 2019, practitioners are invited condition and to register their interest via the website.

Scars 2: The 2nd International Scar Treatment Conference, Israel

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Are You Ready for GDPR? A look at the new General Data Protection Regulation and how it applies to aesthetic practitioners From May 25, all companies, including aesthetic clinics, can be charged up to 20 million Euros or 4% of their annual global turnover if they are found to have breached General Data Protection Regulation (GDPR). Breaches include, but are not limited to, unlawful processing of data or failure to inform authorities of a data breach within the required time periods.1 And for clinics who store hundreds, if not thousands, of patients’ data, it is essential that you understand GDPR and do everything you can to ensure you are thoroughly compliant. GDPR replaces the Data Protection Directive 95/46/EC and was designed to harmonise data privacy laws across the Europe Union (EU). Companies processing the personal data of people residing in the EU, regardless of where the company is based, fall under the regulation. It also applies to data subjects who may not be from the EU, but are residing there when their data is being processed.1 Andrew Salmon, CEO of data consultancy company TrueSwift, explains, “This means that if you’re treating a patient from outside of Europe, who happens to be residing in Europe at the time, their data should still be protected by you.”

What is personal data? The definition of personal data has been expanded with the introduction of GDPR. Salmon explains, “Personal data is not just a name, address, date of birth and financial information; it includes physiological and biological information as well. So, this includes voice recordings, video recording, photographs of people, fingerprints and biometric information. Anything that directly or indirectly relates to you is classed as personal information.” Under GDPR, personal data must be processed lawfully, transparently and for a specific purpose. Lawful could have several different meanings under GDPR. It could be lawful if the subject has consented to their data being processed. Alternatively, lawful can mean to comply with a contract or legal obligation; to protect an interest that is ‘essential for the life of’ the subject; if processing the data is in the public interest; or if doing so is in the data controller’s legitimate interest.2 Transparency One of the key changes with GDPR is that businesses must ensure they are completely transparent with why they are collecting personal data, what it will be used for, how it’s going to be kept and processed, and the

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rights of the data subject to have it updated or deleted.1 For practitioners, patients’ data is likely to be obtained through different methods. These include ‘consent’, which could, for example, apply to the storing and use of before and after photographs for medical purposes and marketing. When obtaining consent, practitioners should ensure that they communicate this in a clear and distinguishable format, which is distinguishable from other matters and provided in an intelligible and easily accessible form, using clear and plain language.1 For gathering names, addresses and phone numbers, Salmon explains this would be classed as ‘contract’ because, “They are signing up to a contract and they’re giving that personal information for you to offer a particular service.”3 In terms of marketing to patients, gaining consent to send them information on your latest news, products and treatments has become a lot more challenging. Patients now must ‘opt in’ to communication sent from you, rather than ‘opt out’.4 Salmon advises, “Every time you process your patients’ data, so send them an email for example, you need to be letting them know what their rights are under the regulations.” He suggests that one way to do this would be to include a privacy/GDPR notice on your website, which you link to within your email communication. “As long as it’s not buried away in lots of small print and hard to understand, that should be sufficient. It should be clear and transparent that you’ve got information on their rights available for them to read should they wish to do so,” he says, adding that it should also be reasonable to expect the subject is able to access and read the privacy policy. Other elements likely to be relevant to aesthetic practitioners are ‘legitimate interest’ and ‘vital interest’. If you use someone’s data in a way that they would reasonably expect, and this has a minimal privacy impact, then this is ‘legitimate interest’.5 For example, you will need to store patients’ medical history to refer to if, in the rare event, that they present with a complication from the treatment you gave them a few months down the line, and this is likely to be expected by the patient. ‘Vital interest’ will also be relevant, as it involves the personal data that is necessary to protect someone’s life,6 for example if they have any allergies to ingredients in products that you treat them with.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Right to access Under GDPR, data subjects have the right to request and receive all data held on them by any company, free of charge. Companies have 30 days to action the request and share the data in an electronic format.1 Salmon explains, “Subjects have the right to say they want all of their personal data that you have on them, and this does mean all of it. Whether it’s paper files, backups, archives, online systems, server file systems, databases – everything and everywhere there’s personal data.” Companies then have to share evidence that proves they have completed a full search and presented everything they hold on that person. Salmon notes that one of the challenges that practitioners may face is that one person’s data may be stored in a spreadsheet that contains other patients’ personal information. In this circumstance, practitioners will have to redact all the other personal data on the document to avoid breaching other data subjects’ privacy rights. Data erasure Similarly to access, when someone asks for their data to be deleted, you have to action this within 30 days from the request. It’s important for practitioners to note, however, that you may have the right to retain certain data under other legal requirements, as GDPR does not override other legislation.7 For example, while there isn’t specific advice for aesthetic procedures, the Department of Health Records Management states that GP records should be retained for 10 years after death or after the patient has permanently left the country, unless the patient remains in the EU. It also says that electronic patient records must not be destroyed or deleted for the foreseeable future.8 If, however, it is not necessary for you to retain data – perhaps because a data subject has never been a patient and just opted in for marketing updates from you – then under Article 5 of the GDPR it should be deleted.9 GDPR state that businesses should only keep personal data for ‘as long as necessary’. According to Salmon, this is typically defined by the organisation itself and should be ‘reasonable’. He advises, “Whatever duration is actually chosen by the organisation should be documented, along with the reasoning behind the decision. Often this shows due diligence and demonstrates that policies have been defined and thought through.” Salmon says one of the most common questions he gets asked is, do data subjects have to justify why they’re requesting their data? The answer to this is no; however he

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adds, “Obviously, you’re going to want to understand why they want that data, because it may be a particular subject or time frame that they’re interested in, so that’s going to help speed up your searches to get that information in time,” noting that it will also help the patient receive the information they need rather than lots of unnecessary documents. Data breaches Data breaches can occur in many forms and can have a serious impact on a clinic and its patients affected. For example, viruses transmitted through spam emails could gain access to your digital address book or hack into patient photographs. As such, it is now mandatory for businesses to notify the Information Commissioners’ Office (ICO) of a data breach within 72 hours of finding out it has occurred, where a data breach is likely to ‘result in a risk for the rights and freedoms of individuals’. Business owners must also notify customers ‘without undue delay’ as soon as they are aware of the data breach.1 Data protection officers GDPR states that data protection officers (DPOs) must be appointed in the case of public authorities, organisations that engage in large scale systematic monitoring, or organisations that engage in large scale processing of sensitive personal data.1 There is no exact definition of what quantifies as ‘large’, so is open to interpretation by individual companies. Salmon advises, however, that as aesthetic clinics are likely to fall under Special Category data, which involves personal data that GDPR says is more sensitive as it is medical data, so needs more protection,10 appointing a DPO is recommended. The DPO’s role is to be the point of contact for data access/erasure requests and managing your GDPR processes and procedures. Salmon says, “They should be a responsible person reporting to senior management. They have to give independent advice on what should be done in order to be compliant, and ideally should have no conflict of interest.” He adds that the DPO should have a good understanding of data protection law and their responsibilities. They can have another role within the organisation, for example a clinic manager, which will be the general case for companies that are not dealing with frequent data access requests. However Salmon notes that the work of a DPO can be outsourced; clinics do not need to employ internally. “If you’re not expecting lots of subject access data requests, then

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you can probably outsource this work to a suitable company when needed. You can also hire them to do audit reviews for you every six months or so to ensure you’re still compliant,” he says. Conclusion Salmon’s parting advice for practitioners starting their GDPR journey is, “Documentation, documentation, documentation. Anything you do – any thought you have – document it.” Whether it’s an article you’ve read, a webinar you’ve joined or conference session you’ve attended, it will all support you should a claim be brought against you.” According to Salmon, if practitioners can prove that they’ve taken advice on GDPR beforehand and have attempted to understand the legislation, even if the outcome was wrong, it will help and may result in a reduced penalty or no fine at all. He concludes that it’s very much like learning maths at school, “If you put your workings in the margin, you might get points for the question even if the answer is wrong.” Note: This article is not exhaustive of all GDPR requirements. For more information, practitioners are advised to visit the GDPR or ICO website, employ the services of a data protection advisor or conduct independent research to be confident in compliance. Readers can visit aestheticsjournal.com/ hub/GDPR for further reading on GDPR articles written by Aesthetics contributors. REFERENCES 1. EUGDPR, GDPR Key Changes (EU: EUGDPR, 2018) <https:// www.eugdpr.org/the-regulation.html> 2. Sharon Allen, ‘Practitioner/Practice Guide to General Data Protection Regulations’, Enhance Insurance, 2018. 3. ICO, Contract (UK: Information Commissioner’s Office, 2018) https://ico.org.uk/for-organisations/guide-to-the-generaldata-protection-regulation-gdpr/lawful-basis-for-processing/ contract/ 4. ICO, Consent (UK: Information Commissioner’s Office, 2018) <https://ico.org.uk/for-organisations/guide-to-the-generaldata-protection-regulation-gdpr/lawful-basis-for-processing/ consent/> 5. ICO, Legitimate interests (UK: Information Commissioner’s Office, 2018) <https://ico.org.uk/for-organisations/guide-tothe-general-data-protection-regulation-gdpr/lawful-basis-forprocessing/legitimate-interests/> 6. ICO, Vital interests (UK: Information Commissioner’s Office, 2018) <https://ico.org.uk/for-organisations/guide-to-thegeneral-data-protection-regulation-gdpr/lawful-basis-forprocessing/vital-interests/> 7. ICO, Right to erasure (UK: Information Commissioner’s Office, 2018) <https://ico.org.uk/for-organisations/guide-to-thegeneral-data-protection-regulation-gdpr/individual-rights/ right-to-erasure/> 8. BMA, Retention of health records (UK: British Medical Association, 2016) https://www.bma.org.uk/advice/ employment/ethics/confidentiality-and-health-records/ retention-of-health-records 9. ICO, Principles (UK: Information Commissioner’s Office, 2018) <https://ico.org.uk/for-organisations/guide-to-the-general-dataprotection-regulation-gdpr/principles/> 10. ICO, Special category data (UK: Information Commissioner’s Office, 2018) <https://ico.org.uk/for-organisations/guide-tothe-general-data-protection-regulation-gdpr/lawful-basis-forprocessing/special-category-data/>

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Attracting and Retaining Male Patients Allie Anderson speaks to practitioners to explore how clinics can attract and retain this key demographic The aesthetic clinic has historically always been the domain of female rather than male patients. Besides the fact that women are arguably more invested in their appearance, there has been a long-held stigma against men seeking plastic surgery and other nonsurgical cosmetic treatments to look their best. These stereotypes are increasingly being challenged; yet statistics reveal that in the UK, the overwhelming majority of surgical cosmetic procedures (91%) are still performed on women.1 In the US, the numbers are slightly higher, with men having 13% of the total number of cosmetic surgery procedures in 2016.2 Although it is recognised that there are many types of male patients with different needs and requests, this article aims to explore what the ‘typical’ man wants and how to best engage with him.

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Joining the club According to New York-based plastic surgeon Mr Norman Rowe, the gender split belies a simple truth: men want cosmetic procedures, but are often reluctant to have them because society dictates they shouldn’t. “I find that many men do want plastic surgery and nonsurgical treatments, and many women want their men to have them too, yet very few do,” Mr Rowe says. “There’s one main reason for that – societal norms tell men that it is for women. But men shouldn't be a minority, so we need to make it more socially acceptable.” Around a quarter of Mr Rowe’s patient cohort is men, upon whom he performs a myriad of treatments and procedures including botulinum toxin, hair transplants and laser hair removal, neck tightening, non-surgical fat reduction, gynaecomastia treatments, microneedling, and – increasingly commonly – penis augmentation and anal tightening. While Mr Rowe’s male audience is open to addressing the parts of their body and appearances they are unhappy with, he said that they reported that they weren’t quite so relaxed in his clinic’s surroundings. “A lot of men told me they felt uncomfortable coming into clinic with its white walls, flowers and women around them in the waiting room,” he says, adding, “My male patients also wanted more privacy, so I decided to set up The Club House, exclusively for men.” The Club House sits in a discreet location two blocks from Mr Rowe’s main practice, and offers minimally invasive procedures for his male patients. He describes it as like “an English hunting lodge”, with male staff, a roaring fireplace and dark opulent décor. As well as providing a typically perceived ‘masculine’ environment in which men can unwind, The Club House also hosts poker and networking events. “Opening The Club House has certainly driven more male patients because it’s a place where they can feel comfortable and have the procedures they want in an environment that is welcoming to them,” Mr Rowe says. Sending the right message Of course, for most practitioners it’s not feasible to open an exclusively male-targeted clinic. But there are other ways to appeal to men and encourage them through your doors. According to aesthetic nurse prescriber Rachel Goddard, the high proportion of male patients her team sees is a result of the way she promotes her services. “I’ve seen a big change in the last 14 years since I started practising, in that men were very much in the minority in the beginning,” she says, adding, “Now, it’s about a 65-35% split, in favour of women. We treat a lot of men, and that comes down not only to the fact that more men are having treatment, but also to how we

The Club House, New York. Images courtesy of plastic surgeon Mr Norman Rowe.

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advertise.” Goddard explains that her team creates separate marketing materials that are sent to male patients, which are designed to have a more ‘masculine’ appeal. “We talk about the same treatments but we angle the content differently. For example, we might talk about the benefits of a certain treatment for dry skin for men who work outdoors, and about products that can be used after shaving,” she explains.

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“Certain skincare ranges are aimed more at women, in their branding and fragrance, whereas cosmeceuticals are often relatively gender-neutral and may look quite scientific, which might appeal to men”

Body confident In order to tap into the male market, practitioners must be able to understand what Dr Stefanie Williams men want, and why. The British Association of Aesthetic Plastic Surgeons (BAAPS) sheds some light on this, with its 2017 annual statistics highlighting a strong disparity between men and women in terms of the types of procedures they seek. Last year, male treatments for the body decreased. Instead, they chose to focus on enhancing the face, with numbers of men having eyelid, brow and face lifts increasing by 25%, 27% and 16% respectively.1 One possible explanation for this trend shift is the rise in status of the ‘dad bod’. In a survey of more than 2,000 Americans, 70% of respondents reported finding the curvier male body more attractive3 while another study revealed that the men sporting a rounder frame get more matches on online dating apps.4 Anecdotal evidence also supports this theory. According to aesthetic practitioner Dr Tahera Bhojani-Lynch her male patients’ relationship status strongly influences their behaviour. “One of the triggering factors for men is if they're recently separated or divorced,” she says, adding, “When they’re newly single, men want to look their best to attract a partner, and as soon as they have a girlfriend they stop coming.” Dermatologist Dr Stefanie Williams finds that male patients commonly begin having treatment on the recommendation of their female partners. “Very often, we start treating their wives or girlfriends, and they see a great improvement in their skin and send their male partner to review their skincare regime,” she says. Continued comfort As any aesthetic practitioner will attest, it’s important that all patients feel comfortable coming into clinic, and that starts before they even enter the premises. When thinking about attracting male patients,

The Club House, New York. Images courtesy of plastic surgeon Mr Norman Rowe.

consider the overall experience, including how the clinic is projected on websites and social media. “A lot of clinics look quite feminine and that could put men off,” Williams says. “In our case, men have a relatively easy way in because we’re also a medical clinic, and we see patients for skin cancer and mole checks, so the clinic doesn't look feminine – and that's important if you want to attract male patients.” Interviewees also point out that if practitioners want to target both male and female patients, they should avoid colour schemes and décor that could be considered typically ‘feminine’ such as womenoriented imagery and plush furnishings, instead opting for neutral colours and a simple feel. Likewise, the products that practitioners stock and promote could be marketed exclusionary to men. Williams continues, “Certain skincare ranges are aimed more at women, in their branding and fragrance, whereas cosmeceuticals are often relatively gender-neutral and may look quite scientific, which might appeal to men.” According to Goddard, putting thought into how and when to book appointments can contribute to making male patients more relaxed. “Men like discretion and privacy, and that’s often more important to them than the cost of treatment,” she says. “To achieve that, we don’t operate a crowded waiting room and we schedule appointments so that there is never a crossover of more than two people.” Mr Rowe recognises that, even with a dedicated clinic solely for male patients, the timing of appointments is a factor in attracting men. His male patients tend to prefer appointments early in the morning or later in the evening, so Mr Rowe’s Club House clinic times reflect that. “If I didn't have two offices, and I wanted to let my male patients know it's okay for them to come, I’d think about having extended hours once or twice a week where I opened early or late exclusively for men,” he says. “Men are a vastly under-served population of patients, so it’s really important to do what you can to appeal to them.” Keeping things simple Several practitioners report that men often come into clinic having a very fixed idea about what treatments they want, are more difficult than women to persuade otherwise, but have more realistic expectations about what they want to achieve. Aesthetic practitioner Dr Beatriz Molina says, “We are seeing more men and they are very sure about what they want, whereas lots of women come in and say ‘I’ve been looking, but I don’t really know’.” And, while men may have less prior knowledge of what’s involved in treatment – or the commitment required to maintain the results – they often buy into it after a thorough consultation, explains Goddard. “Sometimes, you might have a male patient who thinks he can have

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you’d recommend and the post-treatment advice you’d give,” says Mr Rowe. “Men want results now and they don’t want to take time off work. If I do a facial treatment on a man, I’d tell him not to shave for three days afterwards.” If he needs to be clean shaven for work, for example, that would affect the scheduling of the treatment, and as Mr Rowe points out, such things would need to be considered at an early stage. Similarly, potential adverse effects – such as redness or localised bruising – could render some ‘lunchhour’ treatments that are unsuitable for male patients who have meetings in the afternoon. Women, on the other hand, might be able to cover a small amount of bruising with makeup and therefore go straight back to work. Again, Mr Rowe says, it’s important to make sure patients know what precautions need to be taken ahead of time. As for aftercare, practitioners report that male patients are as equally compliant as women in following advice and post-treatment regimens – as long as skincare is simple. Dr Williams suggests that men are, in fact, often more likely to listen to the recommendations she makes. “I often find with women that when they go shopping to a department store and pass the beauty counter, they are more easily swayed away and distracted from what I recommend,” she comments. “They see the newest miracle cream and they get influenced towards that relatively easily. I don't find this with men. If you tell men a certain product is the best for his skin, they tend to trust you with that.”

“Men like discretion and privacy, and that’s often more important to them than the cost of treatment. We don’t operate a crowded waiting room and we schedule appointments so that there is never a crossover of more than two people” Rachel Goddard, aesthetic nurse prescriber

botulinum toxin once a year, and they’re very surprised when you explain that it’s three or four repeat treatments per year,” Goddard says, adding, “That said, we don’t see any difference between men and women in terms of how often they book treatments and how frequently they come back – and that’s because we do a very good job of educating them at the consultation.” Dr Williams agrees that educating male patients is key, adding that men are highly receptive to the science behind the treatment. “Male patients are quite analytical in their approach, so they want more of an explanation of the mechanism of action and how things work,” she says. “But, in terms of the treatment regime, I tend to keep that very simple for men because they don’t like many steps to their skincare.” While women generally enjoy a multi-pronged daily routine, involving cleansers, serums and creams, men do better with a single-step, all-inone solution, Dr Williams states. At Dr Bhojani-Lynch’s clinic, however, male patients would often visit once for a treatment and not come back, despite reporting that they were pleased with the results. “Men don’t really tend to complain, so if they don’t return it’s hard to tell if they are genuinely pleased with their results or if they said they were just to pacify,” she says. She believes this is because men tend to be task-focused; once they’ve had the procedure they wanted and achieved what they initially set out to, they stop there. To test this theory, Dr Bhojani-Lynch selected 10 male patients on whom she had previously performed a simple injectable treatment, with ostensibly satisfactory results, but who had not returned for a follow-up treatment. She invited them back and offered them additional facial sculpting free of charge – and all of them subsequently came back after to pay for repeat treatments. This demonstrated that these male patients had to see first-hand how different options could enhance their appearance – and achieve better results than they hoped for – before being convinced of their value. Dr Bhojani-Lynch says, “Men very often don’t want to hear it, but they respond very well if they see it for themselves.” Time to heal One of the most significant differences between male and female patients appears to be how much downtime they are prepared to put up with. “There are some nuances with men that affect what

A future-proof clinic for all Looking forward, it’s essential that practitioners identify trends and patterns of behaviour among patient groups to ensure they remain relevant. The rise in demand for male aesthetics could be driven by the fact that it is easier than ever to make changes to the way we look. Non-surgical and minimally invasive procedures have become evermore advanced and widely available, thus normalising the concept of enhancing one’s appearance. According to Dr Molina, men’s perceptions of themselves and of having treatment is really changing. “Younger male patients are more open to everything because they are living in a culture where it is becoming normal to want to look good,” she says, adding, “It’s quite exciting, but at the same time, we have to be very ethical and we need to ensure that we only treat if we feel that it’s a beneficial procedure for our patients.” There are undoubtedly numerous differences between male and female patients. However, more important than what distinguishes them, is what they share in common. The practitioners interviewed for this article emphasise that every patient is an individual and ought to be treated as such. Consultations, treatments and management need to be tailored according to the individual’s needs. REFERENCES 1. British Association of Aesthetic Plastic Surgeons, Cosmetic surgery stats: Dad bods and filter jobs (London: baaps.org.uk, 2018) <www.baaps.org.uk/about/news/1535/cosmetic_surgery_stats_dad_ bods_and_filter_jobs> 2. American Society of Plastic Surgeons, 2016 Plastic surgery statistics report: Cosmetic surgery gender distribution (Illinois: plasticsurgery.org, 2017) <www.plasticsurgery.org/documents/News/ Statistics/2016/cosmetic-procedures-men-2016.pdf> 3. Mike Moffitt, The dad bod is still making women swoon, study finds (San Francisco: SFGATE. com, June 2017) <www.sfgate.com/living/article/Dad-bod-still-making-women-swoon-studyfinds-11222826.php> 4. Amy Nickell, SANTA BABY Bring on the mince pies… Men with ‘dad bods’ get more matches on online dating apps (London: Thesun.co.uk, December 2017) <www.thesun.co.uk/fabulous/5142704/ bring-on-the-mince-pies-men-with-dad-bods-get-more-matches-on-online-dating-apps/>

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Cosmetic Interventions in Children Dr Mehvish Khan discusses the impact cosmetic interventions can have on young patients and advises ethical treatment approaches Worldwide, the medical aesthetic specialty is expected to grow over the next five years from US $53.3 in 2017 to $73.6 billion in 2022.1 Cosmetic interventions are increasingly becoming accepted by the public as ‘normal’ and the aesthetic market is globally expanding, particularly in Asia, Russia and Brazil.1 With this rise in the demand for aesthetic interventions, it can be assumed that the number of children/adolescents seeking cosmetic procedures (surgical and non-surgical) is also expected to rise. In 2016, according to the American Society of Plastic Surgeons, 229,551 cosmetic procedures (surgical and non-surgical) were performed on 13-19-year-olds, the top three procedures being laser hair removal, rhinoplasty, and laser skin resurfacing.2 Not only are these procedures accessible to the younger age group, but they are recognised as desirable. Social media, cosmetic surgery apps and television have a major role in promoting false ideals of beauty that are unrealistic and may pressure the young mind to conform to these at a very susceptible time of their development, damaging their self-esteem and increasing self-consciousness.3 An experimental examination involving 189 participants, majority female (M age = 19.84, SD = 4.82 years) found a correlation between the exposure to reality television shows featuring surgical make-overs and the desire to alter one’s own appearance using cosmetic surgery.4 Puberty is a crucial time at which body image development begins. There are many influencing factors, other than sociocultural influences, that shape how children think of themselves and these include approval, attention, neglect and criticism from parents, close family members or even peers.5 Very little research is available on the psychological state of adolescents who seek cosmetic interventions. This is why, in my opinion, practitioners should place more focus on this when they perform these procedures on such vulnerable patients, whose bodies are still developing and who are still finding their identity and embracing their sexuality.6 It has been concluded by a recent study (2015) by University of Washington researchers, that self-esteem is seen to develop in individuals as early as five years of age.7

Self-esteem and self-worth can either be stable traits or can fluctuate over time.8 Linked to this, however, are many complex processes that contribute to the way an individual behaves such as, physical, cognitive, social, and emotional changes that can disrupt the adolescent's sense of continuity, which may in turn damage self-esteem.9 When dealing with individuals at this crucial age of development and vulnerability, it is vital that practitioners try to understand as much as they can about the young person’s personality, their motivations and aims behind seeking cosmetic interventions, and whether the procedure can be of any benefit to the young patient. As this is a rather unexplored area of aesthetic medicine and the demand for cosmetic procedures for the young is increasing, there is a need for official guidelines targeted specifically at aesthetic practitioners, regardless of their professional medical background, to ensure the intended procedure is in the best interest of the patient. This paper intends to shine light on this growing concern and discusses the professional and legal obligations that practitioners have when dealing with young patients, under the age of 18, seeking either non-surgical or surgical cosmetic interventions.

Professional obligations

Bioethicists often refer to the four basic principles of healthcare ethics when evaluating the merits and difficulties of medical procedures. The principles of ethics published in 2001 by acclaimed authors and philosophers Beauchamp and Childress (Table 1) provide a criteria that must be respected to ensure ethical practice.10 These principles offer a framework that can be applied not only in a clinical setting but anywhere a practitioner is responsible for the welfare of a patient.11 The General Medical Council (GMC), Nursing and Midwifery Council (NMC) and the General Dental Council (GDC) have all established a professional code of practises based on these principles.12,13,14 In November 2017, a self-regulating body that aims to provide a register of safe practitioners for the public, the Joint Council for Cosmetic Practitioners (JCCP) was formed.15 It welcomed the Nuffield Council of Bioethics’ report on ethical issues Autonomy Patient has the right to choose or refuse treatment related to cosmetic procedures, which was released in June 2017.16 Beneficence The practitioner must act in the ‘best interest’ of the patient The release of this report is timely as the nonNon-maleficence Promote more good than harm surgical cosmetic industry is growing rapidly Justice Fairness and equality when deciding who gets what treatment and concerns are rising regarding patient safety, if concerns of scarce resources malpractice and public awareness due to lack of Table 1: The principles of medical ethics outlined by Beauchamp and Childress.10 regulation and guidelines.

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incompetent by the practitioner.25 This is established after an assessment of how the child deals with the decision-making process by analysing their ability to understand the procedure and assess the risks.18 The Family Law Reform Act 1969 also gives the right to consent to treatment to anyone aged 16-18.24 Those below the age of 16 years old can consent if they are deemed ‘Gillick competent’, and if the practitioner considers that the treatment is in their best interest and they cannot be persuaded to involve their parents.24,26 Gillick competency assesses the patient’s transition from child to adulthood and is based on the patient’s maturity and intelligence.26 Where there is a conflict of interest between the patient’s relatives and the young patient in question, the practitioner should decide whether or not to treat based on the best interests of the young patient.27 Here, the practitioner’s professional morals and ethics come into play, as well as their sound judgment on competency.

A psychologist or psychiatrist referral may be useful if the patient’s request is unclear or may seem bizarre, if their expectations are unreal or their perception of their undesired feature is exaggerated Regarding cosmetic interventions in young patients, the publication by the Nuffield Council on Bioethics17 and the General Medical Council (GMC)18 provides some valuable guidelines to practitioners in relation to important questions, addressed below, that may arise when dealing with minors. There are limited other official guidelines for aesthetic practitioners in regard to treating young people other than some manufacturer guidelines and small mentions in the code of practice of some aesthetic companies, associations and bodies.19

To treat or not to treat?

The British Association of Aesthetic Plastic Surgeons (BAAPS) and British Association of Plastic, Reconstructive and Aesthetic Who can seek medical interventions? Surgeons (BAPRAS) clearly state in their codes of practice that Children under the age of 18 are capable of making decisions patients, under the age of 18 years, seeking surgical aesthetic regarding cosmetic treatments for themselves as there is no procedures must undertake a full assessment to assess the risks prohibitory law against it. Some banned procedures for this age and benefits of the treatment as well as the repercussions. The group, such as tattoos, carry no ‘gain’ for the child in question, practitioner must outline these to the patient seeking the treatment whereas, cosmetic interventions for the right reasons and on the through clear and concise communication.29 20,21,22,23 right patients can be considered beneficial. Similarly, the GMC advises that doctors carrying out cosmetic This brings us to the principle of ‘beneficence’; acting in the best interventions on young patients should do an assessment of best interest of the patient when considering cosmetic interventions in the interests by considering the patient’s views as well as the parent’s young. Anyone can seek cosmetic interventions. It is solely down to view and those close to the minor. Practitioners should involve the the practitioner to decide whether to offer treatment, keeping in mind child in the decision as much as possible. Cultural and religious patient autonomy as well as beneficence and non-maleficence.18 beliefs are also taken into account. The GMC states under their 0-18 years: guidance for all doctors that all relevant information How young is too young and who decides? should be provided and discussed with the young patient, whether According to the law, anyone under the age of 18 is a child. or not they have the capacity to consent.18 However, those above the age of 16 are presumed competent to Individuals have the right to choose or refuse treatment and their consent for procedures for themselves unless they are deemed confidentiality must be respected unless it threatens their best interest.18 However, when we are faced with a young patient, to adhere to the principle of beneficence, it is Competent or incompetent? vital to judge as an experienced practitioner whether There is no clear-cut test to rule out an incompetent minor from a the subject is competent or not to make the decision of competent one. However, information that may be relevant in deciding a undergoing a cosmetic procedure.18,17 27 child’s maturity and capacity to judge intelligently may include: This can be achieved by performing a thorough history • Age (closer to age 16)25 to establish the maturity of the patient, their motivations • Their ability to understand the nature and risks of the treatment they are for seeking treatment and their expectations, as this is seeking and its short term and long term physical and emotional effects vital in achieving a rewarding outcome and will ensure by asking them to explain what they have understood the best interest of the young patient. Even if the young • Signs of maturity reflected by how they manage their decisions despite patient is competent, it is encouraged to advise them to influences from peers, family, fear and uncertainties involve their parents or guardians.30 • Evidence of the understanding of ripple effects of their decisions on Minors must be given enough time to ask questions the people around them, such as their family and friends and their and express their feelings and shouldn’t be pressured understanding of moral issues into having a procedure by either parents, peers or • Their psychological and emotional wellbeing – a body dysmorphic partner.31 This would be the duty of the practitioner to 28 disorder (BDD) test should be carried out look out for, by involving the child as much as possible in decision-making.18 It may be useful to possibly offer the

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young patient a private consultation without the presence of a third person or by directing questions and receiving answers only from the patient in concern. Patient history obtained should include any past cosmetic interventions, any past emotional or physical trauma, social interactions, past psychological disorders and how they feel in general about themselves; self-esteem and body image. It is generally acknowledged that it is difficult to assess body image in young people because of the increased self-consciousness and dissatisfaction with physical appearance that is common at this stage of development.5 To adhere to the third principle ‘non-maleficence’, it is crucial to rule out body dysmorphic disorder (BDD), otherwise more harm can be done than good. Psychiatric disorders, such as BDD, can limit a young patient’s ability to make an informed decision about cosmetic interventions and to accurately appreciate the risks and benefits of these procedures that may lead to a worsening of their condition and further destroying their self-esteem.31 In an article by the Penningtons Manches’ specialist cosmetic surgery team, it was reported that there is an increase in significant cosmetic surgery procedures, such as labiaplasty, amongst young teenage girls who suffer from BDD. This led to The Royal College of Obstetricians and Gynaecologists’ (RCOGs’) Ethics Committee to propose a ban on cosmetic labiaplasty for teenagers as they stated that the external genitalia is still developing for girls under the age of 18 and the risks outweigh the benefit.33 In 2005, consultant plastic surgeon Mr Nick Parkhouse spoke to the BBC about how plastic surgery was inappropriate for most teenagers and that, in his opinion, just a very small cases of teenage/child cosmetic surgery, such as cleft palates and prominent ear correction are beneficial.31,32 A Dutch study examined the psychological state of 12 to 22 year olds over a six month period, with some of them undertaking cosmetic surgery. The study found over time that their dissatisfaction with their appearance decreased regardless of whether they had surgery or not, with a higher degree of selfesteem seen in those over 18,34 deeming Mr Parkhouse’s statement valid about the inappropriateness of aesthetic treatments in the young. A psychologist or psychiatrist referral may be useful if the patient’s request is unclear or may seem bizarre, if their expectations are unreal or their perception of their undesired feature is exaggerated. A cooling-off period must be given to all patients after an initial consultation, but I believe that this is particularly important for young patients.31 Where there is an element of doubt of whether to go ahead, the practitioner must consult with other specialists or colleagues to ensure that the procedure is of benefit to the young person.

Conclusion There is no legal restriction in the UK for young patients (under 18) seeking cosmetic interventions. Aesthetic medicine is a rapidly growing sector and cosmetic procedures are performed by practitioners other than those who are medically trained, which increases the need for clear guidelines when dealing with the young vulnerable population. Some guidelines are provided by the GMC, and the Nuffield Bioethics report has addressed this growing concern. Furthermore, practitioners must understand their professional obligations before offering such appearance-modifying treatments and ultimately do what is in the best interest of the physiologically and psychologically developing patient.

Aesthetics Dr Mehvish Khan holds a degree in Biomedical Sciences and Medicine. Due to her passion for science and art, she has decided to pursue her career in the field of aesthetics and is currently undertaking her Master’s Degree in Aesthetic Medicine at Queen Mary University of London. REFERENCES: 1. Prnewswire, ‘Global Medical Aesthetics Industry: Cosmetic Surgery Products Generated $8.8 Billion in 2016 & Have the Potential to Reach $15.3 Billion in 2022’, 2017. <https://www.prnewswire.com/ news-releases/global-medical-aesthetics-industry-cosmetic-surgery-products-generated-88-billion-in2016--have-the-potential-to-reach-153-billion-in-2022-300496022.html> 2. ASPS, ‘Plastic Surgery Statistics Report’, 2016. <https://www.plasticsurgery.org/documents/News/ Statistics/2016/plastic-surgery-statistics-full-report-2016.pdf> 3. The Lancet, Cosmetic procedures: a cause for concern, 2017. 4. Markey CN, Markey PM. A correlational and experimental examination of reality television viewing and interest in cosmetic surgery. Body image. 2010 Mar 31;7(2):165-71. 5. Zuckerman D, Abraham A. ‘Teenagers and cosmetic surgery: Focus on breast augmentation and liposuction’. Journal of Adolescent Health. 2008 Oct 31;43(4):318-24. 6. Simis K J, Verhulst F C, Koot H M. Body image, psychosocial functioning, and personality: how different are adolescents and young adults applying for plastic surgery? J Child Psychol Psychiatry. 2001;42(5):669–678. 7. Implicit measures for preschool children confirm self-esteem’s role in maintaining a balanced identity 8. Harter S, Whitesell NR. Beyond the debate: Why some adolescents report stable self‐worth over time and situation, whereas others report changes in self‐worth. Journal of personality. 2003 Dec 1;71(6):1027-58. 9. Leahy, R. L., & Shirk, S. R. (1985). Social cognition and the development of the self. In R. L. Leahy (Ed.), The development of the self (pp. 123–150). New York: Academic Press. 10. Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford University Press, USA; 2001. 11. UKCEN Ethical Contacts Network, Ethical Framework, 2001. <http://www.ukcen.net/ethical_issues/ ethical_frameworks/the_four_principles_of_biomedical_ethics> 12. GMC, Good Medical Practice, 2018. <https://www.gmc-uk.org/ethical-guidance/ethical-guidance-fordoctors/good-medical-practice> 13. NMC, The Code for nurses and midwives, 2012. <https://www.nmc.org.uk/code/> 14. GDC, General Dental Council Standards of Conduct, Performance and Ethics, 2018 <https://www.dentalschoolscouncil.ac.uk/wp-content/uploads/2015/11/ GDCStandardsofConductPerformanceandEthicsConsultationResponse.pdf> 15. Joint Council for Cosmetic Practitioners, <http://www.jccp.org.uk/> 16. Nuffield Council on Bioethics, Publications, 2017. <http://nuffieldbioethics.org/publications 17. Nuffield Council on Bioethics, Cosmetic procedures: ethical issues, 2017. <http://nuffieldbioethics.org/ wp-content/uploads/Cosmetic-procedures-full-report.pdf> 18. GMC, 0–18 years: guidance for all doctors <https://www.gmc-uk.org/-/media/documents/0_18_ years___English_1015.pdf_48903188.pdf> 19. JCCP, JCCP and CPSA Guidance for Practitioners Who Provide Cosmetic Interventions, 2018. <http:// www.jccp.org.uk/JoinNow/DownloadRegistrationFiles?filename=JCCPCPSA_Code_of_Practice.pdf> 20. Mary H McGrath, MPH Sanjay Mukerji, Plastic Surgery and the Teenage Patient, Journal of Pediatric and Adolescent Gynecology, 2000. <https://www.sciencedirect.com/science/article/pii/ S1083318800000425> 21. Dinulos, James G.H, Cosmetic procedures in children, Current Opinion in Pediatrics, 2011. <https:// journals.lww.com/co-pediatrics/Abstract/2011/08000/Cosmetic_procedures_in_children.8.aspx> 22. Pueschel, S. M., Monteiro, L. A., & Erickson, M. (1986). Parents’ and physicians’ perceptions of facial plastic surgery in children with Down’s syndrome. Journal of Mental Deficiency Research, 30(1), 71-79. 23. Diana Zuckerman, Anisha Abraham, Teenagers and Cosmetic Surgery: Focus on Breast Augmentation and Liposuction, Journal of Adolescent Health, 2008.<https://www.sciencedirect. com/science/article/pii/S1054139X08002322?_rdoc=1&_fmt=high&_origin=gateway&_ docanchor=&md5=b8429449ccfc9c30159a5f9aeaa92ffb> 24. Department of Health, Government Response to the Review of the Regulation of Cosmetic Interventions, 2014. <https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/279431/Government_response_to_the_review_of_the_regulation_of_cosmetic_interventions. pdf> 25. GMC, Guidance for doctors who offer cosmetic interventions, 2016. <https://www.gmc-uk.org/ Guidance_for_doctors_who_offer_cosmetic_interventions_210316.pdf_65254111.pdf> 26. GP Notebook, Gillick competence, 2016. <https://gpnotebook.co.uk/simplepage. cfm?ID=x20050425225920411760> 27. Gore DM. Ethical, professional, and legal obligations in clinical practice: a series of discussion topics for postgraduate medical education. Topic 4: confidentiality. Postgrad Med J. 2001;77(909):443–444. 28. Griffith R. What is Gillick competence?. Human vaccines & immunotherapeutics. 2016 Jan 2;12(1):2447. 29. Body Dysmorphic Disorder Foundation, Questionnaires – Do I have BDD? <https://bddfoundation. org/helping-you/questionnaires-do-i-have-bdd/> 30. PRASIS, Cosmetic Surgery on Under 16/18s, 2016. <http://www.prasis.co.uk/support_guidance/ reducing_risk/cosmetic_surgery_on_under_1618s.aspx> 31. American Society of Plastic Surgeons, Briefing Paper: Plastic Surgery for Teenagers, 2018, <https:// www.plasticsurgery.org/news/briefing-papers/briefing-paper-plastic-surgery-for-teenagers> 32. Crerand CE, Magee L. Cosmetic and reconstructive breast surgery in adolescents: Psychological, ethical, and legal considerations. InSeminars in plastic surgery 2013 Feb (Vol. 27, No. 01, pp. 072-078). Thieme Medical Publishers. 33. Pennington Maches, CUTTING INTO CHILDHOOD - THE DISTURBING GROWTH OF TEENAGE COSMETIC SURGERY, 2014. <https://www.penningtons.co.uk/news-publications/latest-news/cuttinginto-childhood-the-disturbing-growth-of-teenage-cosmetic-surgery/> 34. Royal College of Obstetricians and Gynaecologists, Joint RCOG/BritSPAG release: Issues surrounding women and girls undergoing female genital cosmetic surgery explored, 2013. <https:// www.rcog.org.uk/en/news/joint-rcogbritspag-release-issues-surrounding-women-and-girlsundergoing-female-genital-cosmetic-surgery-explored/> 35. Simis KJ, Hovius SE, de Beaufort ID, Verhulst FC, Koot HM, Adolescence Plastic Surgical Research Group. After Plastic Surgery: Adolescent‐Reported Appearance Ratings and Appearance‐Related Burdens in Patient and General Population Groups. Plastic and reconstructive surgery. 2002 Jan 1;109(1):9-17.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


Contour & Define

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Favourable rheological properties to create contours, shape and definition2 RadiesseÂŽ is designed to contour and define fundamental areas that accentuate facial shape, such as the jawline and lower face.2

The Ageing Jawline 4

M-RAD-UKI-0093 Date of Preparation January 2018

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Bony structure of a youthful jawline*

Bony structure of an ageing jawline*

As patients age, their jaw bone becomes narrower through bony resorption, making the angle of the jaw less acute or sharp3. RadiesseÂŽ has high levels of viscosity and elasticity, allowing you to sculpt and define, to create the desired effect of a youthful bony structure1. *Images courtesy of Merz Institute of Advanced Aesthetics.

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://ww.hpra.ie/homepage/ about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512. 2. Meland Science Brief:Calcium Hydroxylapatite with Integral Lidocaine Demonstrates a Similar Rheological Profile of Viscosity and Elasticity When Compared to Calcium Hydroxylapatite without Lidocaine and the Highest Among Lidocaine-Based HA Fillers. Melissa Meland and Chris Groppi. Poster # 1821. E-POSTER PRESENTATION Saturday, 3/21/2015 from 11:05:00 AM to 11:10:00 AM. 73rd Annual Meeting of the American Academy of Dermatology. 3. Shaw RB, et al. Plast Reconstr Surg 2007; 119-675-81. 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/deviceapprovalsandclearances/pmaapprovals/ucm439066.htm


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Aesthetics

Penile Augmentation

Examination will also identify patients suffering from true micropenis (erect penis size less than 7cm).6 Those patients will most likely require extensive urogenital reconstructive surgery (phalloplasty) which is not covered in this article as it is a separate medical entity. It is important to explain to the patient what is normal; in my practice, I reference Figure 1 when consulting patients.6 Many patients, especially younger men, may be misinformed and once they are informed on Mr Amr Raheem discusses men’s anxiety the average penile length and girth they are satisfied and towards penis size and presents an no further treatment is needed. It is also important to identify overview of approaches for augmentation men who have erectile dysfunction or Peyronie's disease and manage accordingly, as those men may present with Several studies have established that many men would like to have penile size concerns. Men who request penile enlargement as a bigger penis, even though women seem to be less concerned a part of generalised anxiety, stress, problems with their partner about size.1 In fact, 45% of men report that they are dissatisfied with or present with body dysmorphic disorder (BDD) should also be their penile size, which is higher than those reporting dissatisfaction identified and referred accordingly as they would do better with with height or weight (40%).2 counselling or psychiatric help rather than surgery. So, the suitable What is more, I have noticed that the demand for penile enlargement candidate for penile augmentation is someone who has a lowhas significantly increased over the past few years. Whether it is pills, average to average penile size and knows that he is within the creams, non-surgical and surgical approaches or other methods, more normal range, but wants to enhance the size of his penis in order men than ever are coming forward to pursue ways to increase their to boost his confidence and improve his self-esteem. penile size. In our men’s healthcare clinic, International Andrology, For patients who are suitable candidates for surgery, an important penis enlargement or penis size concerns are by far the most element of the consultation process is to make sure that the common issue that men enquire about. patient is fully aware of what can be achieved. This is because, As many men are presenting to non-surgical aesthetic clinics with like many other treatments, many patients will have unrealistic other bodily concerns, it is useful for practitioners to know about expectations. men’s anxiety in this area as well as the different types of treatments available. I believe that although this topic is most relevant to Penile augmentation treatments surgeons, non-surgical aesthetic practitioners may discuss initial concerns with an existing patient. It is therefore useful for aesthetic Penis enlargement exercises or stretching practitioners to be able to give patients a brief introduction of the One of the first attempted methods to enlarge men’s penises are treatments available, before referring to a surgical colleague. exercises. This involves stretching the penis to increase its length. These exercises can be performed with or without the use of medical Consulting patients seeking penis enlargement devices (penile stretchers or vacuum erection devices) and there are treatments various techniques that have been proposed and tried.7 First of all, we should recognise that penis size anxiety is a real There is some evidence that penis exercises and devices can help issue. It is easy to dismiss penis size anxiety as something trivial; increase the penis size (mainly the length)7 and we do recommend however, after consulting and treating many men, you realise that stretching exercises for all our patients who undergo penis surgery. size issues can cause significant distress. Even though we find that However, it is also quite clear that: most of our patients are ‘normal-sized’3 (Figure 1), anxiety about • For the majority of patients, the results will not be very profound size can really affect their self-confidence and sexual life and may and is usually around 1cm; even prevent them from normal social interactions such as being • Even achieving these modest results, requires more than six to with a partner, sports, sauna visits, camping etc. Moreover, one in eight hours of daily stretching for many months; and three men are concerned about size irrespective of age, affluence • Patients need to be quite careful when performing these exercises or educational levels.4 For these reasons, it is extremely important in order to avoid tissue damage. that all patients are properly counselled before any treatment is offered. Like any medical complaint, when counselling patients, it is important to take their complaint seriously. Average Average potential gains penis size through penile augmentation Practitioners should take a full medical and sexual history, in addition to performing a general and genital Length flaccid 9cm +3-5cm examination, recording penile visible length from the pubis (flaccid and stretched) and penile girth. Some men Length erect 14cm +0-1cm may have a normal size, but the penis is buried by a Girth flaccid 9cm +3-4cm (or around 30-40% of initial large suprapubic fat pad. Others may have a big scrotal (circumference) penile circumference) web that masks the penile length. In some cases, too much skin has been removed during circumcision and Girth erect 12cm +2-3cm (or around 20% of initial (circumference) penile circumference) some of these patients may present with penile size dissatisfaction.5 Those patients would benefit from a skin Figure 1: Table showing average penile size3 and the potential gains through penile grafting procedure. augmentation6

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


@aestheticsgroup

Pills and creams With the exception of testosterone replacement for hypogonadism (low testosterone) causing delayed puberty, there is no medicinal treatment that can enlarge the penis. Men with delayed puberty secondary to hypogonadism will benefit from testosterone replacement, which will allow the penis to grow to its predetermined target size.8 Once the penis has reached its target size; no further growth will occur. Men with normal testosterone levels will not achieve any penile size gain if they are given testosterone. Therefore, the pills and creams that are heavily advertised on the

Aesthetics Journal

Aesthetics aestheticsjournal.com

perform this incision if there is tethering at the base of the penis during erections. This can be established during examination by stretching the penis and looking for tethering and tenting of the suprapubic skin at the junction with the base of the penis. This problem can be seen in cases where too much skin has been removed during circumcision. The half-moon incision heals quite nicely with minimal scarring and will be covered by the pubic hair post-operatively. After the suspensory ligaments have been adequately exposed, they are divided. Care should be taken to not only cut the superficial ligaments, as this will not be sufficient to pull the penis out. Thus division is done until the inferior surface of the symphysis pubis is felt by the surgeon's finger. Equally, it is also important not to cut the ligament laterally as this will lead to penile instability. A silicon buffer is then placed to prevent re-attachment of the ligaments. The silicon buffer I use is a testicular implant (solid rather than liquid silicone), which is sutured on the pubic bone using a single 1-0 ethibond on J-needle. Penis girth augmentation There are various techniques that have been tried for penile girth augmentation, but they broadly fall under two categories: 1. Autologous fat or filler (synthetic or hyaluronic acid) injections 2. Surgical placements of grafts (regenerative tissue matrix or dermal fat grafts) or silicon sleeves around the penis

Figure 2: The anatomy of the male genitalia

internet will not lead to any penile size gain and are completely ineffective. The majority of these products have basic ingredients such as complex sugars or vitamins. Some more â&#x20AC;&#x2DC;advancedâ&#x20AC;&#x2122; products might also have PDE-5 inhibitors, or other drugs, that are used to treat erectile dysfunction. In my experience, these products may result in a firmer erection, hence creating the illusion of a bigger penis, but do not actually change penile size. Surgical penile lengthening In all men, part of the penis extends inside the body so is not externally visible (Figure 2). The root of the penis, or the hidden part as it is often referred to, is attached to the pubic bone through the suspensory ligaments. The main function of the ligaments is to help retain an upwards facing erection.9 Ligamentolysis is the basis of a penis lengthening operation and involves cutting the suspensory ligaments. This allows part of the hidden penis to move downwards and outside the body. The visible part of the penis increases as a result (Figure 4). Through the suspensory ligament division, the flaccid state length can increase by 3-5cm.10 Other surgical procedures that may help with length and are offered to patients if required include: surgical excision of the suprapubic fat pad or liposuction, excision of the peno-scrotal web and skin grafting the penile shaft, if there is lack of penile skin after circumcision. Basic method of my ligamentolysis technique A half-moon incision is made at the base of the penis to expose the suspensory ligaments. Some surgeons perform a V shaped incision that is closed as a Y in order to push more skin forward (V-Y plasty) to make the penis hang lower; however, I find that this incision usually leads to dense scarring, which does not look good aesthetically. I only

Given the trade-offs between patient safety, potential complications, efficacy and cost, we only recommend girth augmentation through autologous fat or hyaluronic acid (HA) injection. My preferred method is autologous fat injection since the results, for most patients, are permanent and given that quite a significant amount of material is required (50-80ml depending on the penile size) it is also more cost effective. Moreover, my view is that fat tends to exhibit less issues with migration and unevenness, whilst patients report to us that it feels more natural than HA. Fat is mainly harvested from the inner thighs and if more is needed it is taken from the abdomen. On the other hand, HA injection is an office-based procedure that can be performed with a penile block or local anaesthetic, but will need to be repeated every 12-18 months. It is usually sought from patients who do not have enough fat and might be reluctant to put on weight for the fat injection. The injection technique is quite similar for both Step 1: Half moon incision at the basis of the penis and exposure of suspensory ligaments

Step 3: Insertion and suturing of silicon buffer on the pubic bone

Step 2: Division of suspensory ligaments

Step 4: Closure of half moon incision

Figure 3: Surgical penile lengthening steps. Images courtesy of International Andrology.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


aestheticsjournal.com Before

@aestheticsgroup After

Before

Figure 5: A 32-year-old patient presenting with 10cm flaccid penile length and 8cm girth. Patient four weeks’ after ligamentolysis and autologous fat injection (65ml). Flaccid after length is 14.5cm and girth is 14cm. Deep Dorsal v. Dorsal n. Dorsal a.

Deep a. Corpus cavernosum Corpus spongiosum Urethra

Aesthetics Journal

Aesthetics After

Figure 6: A 43-year-old patient with 9.5cm girth before and 12 weeks after 40ml of hyaluronic acid injection, resulting in after girth of 13cm.

Superficial Dorsal v. 1.Skin 2.Superficial (Dartos) fascia 3.Areolar tissue 4.Deep (Buck's) fascia

Before

After

Figure 7: A 35-year-old patient with 8cm girth during erection before and two weeks’ after 60ml autologous fat injection. After girth is 12cm.

filler (around 20% of patients) and the fact that the HA injection needs to be repeated every 12-18 months thus adding up to a significant total cost. With respect to post-operative care, ligamentolysis patients will need to do penile stretching exercises and girth enhancement patients require penile massaging to maintain the uniform shape of the filler. Most patients can return to normal activities within three to four days and resume sexual activities after four to six weeks.

5.Tunica albuginea

Summary

Figure 4: Penile anatomy showing the space between penis skin and dartos fascia. Image courtesy of Mcstrother, attribution 3.0 Unported (CC BY 3.0).11

HA and fat. We inject the filler (fat or HA) under the dartos muscle (Figure 4), through a small stab incision just above the base of the penis. The injection is done in a fan-shaped manner. Care should be taken to make sure that the filler is evenly distributed across the penile shaft. For patients that are not circumcised, it is quite important to avoid migration of the injectable to the foreskin during and also after the treatment. It is also worth noting that if the injection is wrongly applied inside the corpus cavernosum then the erection mechanism will be destroyed. Furthermore, there would also be a risk of embolism. We have had quite a few patients referred to our clinic, who have had HA injected wrongly, and in such cases, patients may require a penile implant to restore their erectile function. As such, anyone performing this treatment should be adequately trained and well aware of penile anatomy. The aim of a fat or HA injection is to have around a 30-40% increase of the penile circumference. In my experience, further increases will tend to make the penis look swollen and unnatural rather than the aesthetically optimum cylindrical shape. Also beyond this point, significant re-absorption of the fat might occur because the excess fat cells will compete for nutrition. This in turn will tend to increase the occurrence of complications, such as fat migration, development of lumps and unevenness. Complications and post-operative care Based on our experience treating around 150 patients annually, potential complications are usually rare and easily treatable. For ligamentolysis, the most severe complication that can occur postoperatively is infection (less than 1% of patients) of the silicon buffer. In this case, antibiotic treatment on its own is not enough and removal of the silicon buffer is necessary. As for fat injection, the main issue is significant re-absorption of the fat (occurring in around 5% of patients), which in turn can lead to unevenness and lump formation and a reoperation will be required to add more fat and break up lumps. For HA injection, the main issues are migration and rapid absorption of the

Penile augmentation is widely considered as an ineffective treatment with high complications rates. My view, after treating hundreds of men with penis size anxiety, is that as long as patients are properly consulted and consented, have realistic expectations, and only safe and effective treatments are used, which I have summarised in this article, then the patient satisfaction rates can be very high. As mentioned, only practitioners with sufficient knowledge and experience of treating this area should attempt these treatments and refer to those more experienced if necessary. Mr Amr Raheem is a specialist in andrology at the University College London Hospital NHS Foundation Trust and medical director of International Andrology, a leading healthcare group focusing exclusively on men’s health. His expertise covers surgical, medical, hormonal, psychological and academic aspects of male health. He has published more than 80 articles and book chapters in international journals. REFERENCES: 1. Wylie, K. R., & Eardley, I. (2007). Penile size and the “small penis syndrome.” BJU International, 99, 1449 –1455. 2. Johnston L, McLellan T, McKinlay A. (Perceived) Size really does matter: Male dissatisfaction with penis size. Psychology of Men and Masculinity. 2014;15(2):225–8. 3. N Mondaini, R Ponchietti, P Gontero, G H Muir, A Natali, E Caldarera, S Biscioni & M Rizzo, Penile length is normal in most men seeking penile lengthening procedures, International Journal of Impotence Research, 2002, volume14, pages283–286 (2002). <https://www.nature.com/ articles/3900887> 4. Veale, David & Eshkevari, Ertimiss & Read, Julie & Miles, Sarah & Troglia, Andrea & Phillips, Rachael & Carmona Echeverria, Lina & Fiorito, Chiara & Wylie, Kevan & Muir, Gordon. (2013). Beliefs about Penis Size: Validation of a Scale for Men Ashamed about Their Penis Size. The journal of sexual medicine. 11. 10.1111/jsm.12294. 5. Asimakopoulos, A. D., Iorio, B. , Vespasiani, G. , Cervelli, V. and Spera, E. (2012), Autologous split thickness skin graft for penile coverage in the treatment of buried (trapped) penis after radical circumcision. BJU International, 110: 602-606. doi:10.1111/j.1464-410X.2012.10832.x 6. ‘Am I normal? A systematic review and construction of nomograms for flaccid and erect penis length and circumference in up to 15,521 men.’ David Veale, Sarah Miles, Sally Bramley, Gordon Muir, and John Hodsoll. Published in BJU International DOI 7. Dr Clemens Tilke, Phallosan Study: Statistical Report, 2005. <https://cdn.shopify.com/s/ files/1/0691/2467/files/PHALLOSAN-clinical-study-en.pdf?3242 /> 8. Bin-Abbas, Bassam et al. (1999). Congenital hypogonadotropic hypogonadism and micropenis: Effect of testosterone treatment on adult penile size—Why sex reversal is not indicated, The Journal of Pediatrics , Volume 134 , Issue 5 , 579 - 583 9. Novick, A.C., Gill, I.S., Klein, E.A., Rackley, R., Ross, J.H. (Eds.) (2006), Operative Urology, Humana Press 10. International Andrology London, Penis Size & Penis Enlargement, 2017. <https://london-andrology. co.uk/uro-genital-health/penis-enlargement/surgical-techniques-for-penis-length-enlargement/> 11. Wikimedia Comms, Mcstrother, Cross section of penis with emphasis on fascial layers, 2014. <https:// commons.wikimedia.org/wiki/File:Penis_cross_section.svg#filelinks>

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Aesthetics Journal

Aesthetics

father’s side of hair loss as well as the pattern of hair loss, and importantly, the presence of visible thinning in the forelock, mid-scalp and crown.2 Selecting suitable patients for treatment In my opinion, patients with actively progressing hair loss in the hairline and temples should be counselled with regards to trying to stabilise their hair loss prior to embarking on hair transplantation. A hair transplant can take up to 18 months to achieve its full result and in a patient whose hairline is rapidly receding, by the time the transplanted hairs fully mature, the hairline may have receded behind them leaving gaps and requiring a further procedure almost immediately to maintain a natural appearance. Since any treatment aimed at stabilising hair loss is generally accepted to take at least six to 12 months before a judgement can be made on efficacy, at least this period of time should be given to young men in their twenties following an initial consultation, before considering performing a hair transplant. Doing a hair transplant to the temporo-parietal recessions in a man whose hair loss is progressing is likely to result in an unhappy patient before too long. If hair loss continues despite therapeutic interventions, then it might be appropriate Dr Greg Williams discusses the rise in hair to delay hair transplantation until the likely extent of hair transplants in younger men and how to loss becomes apparent and an appropriate hairline can be planned. The hairline level and design that might successfully treat a receding hairline be appropriate for a man who is going to progress to Hair transplant surgery is becoming increasingly popular. This is a very advanced degree of hair loss is likely to be very different from likely to be due, in part, to society’s growing obsession with looks that desired and requested by a young man seeking to regain his and appearance,1 as well as the regular revelations in the media youthful hairline.3 by celebrities who have had the procedure. In the last 24 months In my professional opinion, men under 30 who might be suitable for there have been a number of men in their early twenties who are in a hair transplant to the temples are those whose hairlines have been the public eye and have addressed their temporo-parietal recession spontaneously stable for at least 12 months and who have no family and hairlines with hair transplants. I believe that what is significantly history of advanced male pattern hair loss, or those whose hair loss different with this generation of men, is that they have been posting has been convincingly stabilised with medical treatment. photographs of their immediate post-operative appearance on social Before media sites such as Twitter and Instagram, as is the norm for many Western millennials. There is cause for concern that, with the extensive celebrity following of some of these young public figures, the general male public will see this as an attractive and reasonable option. There are many unscrupulous practitioners who will perform such surgery with short term rather than long term objectives in mind and, from my observations, this is particularly true of overseas clinics where surgery is generally offered on a cheap ‘fly in, have surgery, fly out’ basis. Whilst performing hair transplant surgery to temporo-parietal recessions in men under thirty might be reasonable in certain situations, there are several factors that should be carefully considered by both the patient After and the doctor.

Treating Receding Temples in Men Under 30

Recognising a receding hairline In adolescence, the typical juvenile male hairline is rounded and, during puberty, it starts to develop the hallmark of an adult male hairline which has temporo-parietal recessions. This might be selflimiting or be the start of progressive male pattern hair loss (MPHL) that might progress to complete baldness. The challenge for the hair transplant surgeon consulting a man in his twenties is to try and predict whether progressive hair loss is likely. Predictors include age of onset, rate of progression, family history on both the mother’s and

Figure 1: Representative photos of temple surgical hair restoration. Image shows before and 16 months post treatment.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Methods of treatment There are effective, proven methods of slowing down hair loss, which include topical over the counter minoxidil and prescription-only oral finasteride medication. Less proven therapies include microneedling, mesotherapy, platelet rich plasma, low level light therapy and adiposederived regenerative cell therapy. A hair transplant surgeon may offer these options to patients who have MPHL in an attempt to stabilise hair loss before a transplant. If a hair transplant is deemed suitable for a patient, they must then decide which method of donor hair harvesting they would prefer – Strip Follicular Unit Transplantation (Strip FUT) which leaves a linear donor scar but yields larger number of follicular unit grafts, or Follicular Unit Excision (FUE) which leaves small round scars but usually requires the donor area to be shaved.4 For relatively small hair transplant surgery procedures, such as addressing temporo-parietal recessions, either technique is likely to yield sufficient grafts. However, the hair in the typical donor zone at the back and sides of the head needs to be worn long enough to cover a Strip FUT scar therefore, in my experience many young men opt for the FUE method so that they can retain the option of a very short haircut. Follicular unit grafts utilise the fact that naturally occurring groups of hairs within the donor scalp contain one, two, three or four hairs. In the FUE technique the grafts are extracted individually, whereas in the Strip FUT technique the grafts are dissected from the excised strip of skin.4 In order to create a new natural hairline, incisions for single hair follicular unit grafts are made in an irregular pattern sometimes called a snail trail, with randomised ‘rogue’ hairs placed in front of the main hairline to simulate what occurs naturally. Two-hair grafts are placed behind the one-hair grafts and the larger hair groupings are placed further back where density is required but their more pluggy, coarser appearance can be hidden from an anterior view. Hair transplant surgery (HTS) is one of two types of hair restoration surgery (HRS), the other being prosthetic hair fibre implantation (PHFI). PHFI should be reserved for patients who do not have any autologous donor hair and should only be considered after consultation with a hair transplant surgeon who offers both forms of HRS so the two options can be fairly assessed. There is no accredited training in HRS in the UK and no specific qualifications required, other than a General Medical Council licence. However, HRS must be performed in a Care Quality Commission (CQC)5 registered facility and the HRS service provider must itself be CQC registered, even if the surgery they offer is done elsewhere in a separate CQC-registered clinic. Advice on what to look out for is offered to patients from the British Association of Hair Restoration Surgery (BAHRS),7 which also offers support for those looking to have their hair transplant done overseas.6,7 Transplanted hairs in the hairline and temporo-parietal recessions are more ‘on show’ than transplanted hair elsewhere on the scalp and, therefore, it is absolutely critical that the surgeon’s technique creates a result where the transplanted hairs are indistinguishable from naturally occurring ones. This is dependent on the incision making process which determines the depth, direction, angle, geometry and density of the transplanted hairs. There is a physical limitation to the spacing of incisions which is usually less than the density of hair unaffected by MPHL; this incision spacing should be further reduced in diabetics and smokers to lessen the risk of skin necrosis. Patient expectations regarding transplant density must be managed to avoid disappointment in the thickness of their hair transplant result. A clear explanation should be given which clarifies that the hair transplant density will be less than their original hair density, but can be increased by repeating hair transplant procedures until a density satisfactory to the patient is achieved.

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Complications Health-related complications are rare and limited to infection, either in the form of folliculitis or cellulitis.8 Excessive bleeding should only be problematic in patients with a bleeding disorder or those on blood-thinning medication. Like with any surgical procedure, a full medical history should be taken prior to treatment to identify any contraindications to hair transplant surgery or precautions to be taken. Donor site scarring is usually described in relation to the Strip FUT donor but FUE over-harvesting can lead to extensive punctate scarring and associated donor zone hair depletion with an unnatural motheaten appearance.9 As expected, significant aesthetic morbidity can occur from incorrect and asymmetrical hairline design, improper hair growth exit angle and direction, poor density, and pitting or cobblestoning at the hair base. In terms of technical success, I have found that 90% of transplanted hairs should be expected to grow. Conclusion During puberty there is a normal progression from a juvenile rounded hairline to a mature masculine hairline with temporo-parietal recessions. This can be self-limiting to a pre-determined genetically programmed hairline level. Conversely, male pattern hair loss is usually an ongoing dynamic process that continues over a lifetime to a predetermined genetically programmed end-point, the severity of which varies from person to person and is impossible to predict. Men in their late teens and twenties who are seeing their hairline receding need to determine whether this is going to be self-limiting or progressive, and this can only be judged over a period of several years. In those patients where it is self-limiting, hair transplantation might be a reasonable option. For those patients where it is progressive, hair transplantation is not advisable. These patients should be counselled to either try to stabilise their hair loss with medical therapy or postpone having a hair transplant until the likely extent of their hair loss can be predicted and an appropriate hairline level and design determined. Dr Greg Williams is the current president of the British Association of Hair Restoration Surgery and chair of the International Society of Hair Restoration Surgery (ISHRS) Ethics Committee. He was awarded the ‘Fellow’ status by the ISHRS which recognises senior hair transplant surgeons around the world and sits on the ISHRS Best Practice Committee. REFERENCES 1. Nuffield council on Bioethics, Cosmetic procedures:ethical issues, Appearance and Appearance ideals <http://nuffieldbioethics.org/report/cosmetic-procedures-ethical-issues/appearanceappearance-ideals> 2. PLOS Genetics, Genetic prediction of male pattern baldness https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5308812/ 3. Gupta, M., Mysore, V., (2016) Classifications of Patterned Hair Loss: A review, J Cutan Aesthet Surg pp3-12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812885/ 4. Berstein Medical Centre for Hair Restoration, Logic of Follicular Unit Transplantation <https://www. bernsteinmedical.com/research/logic-of-follicular-unit-transplantation/> 5. Care Quality Commission, The scope of registration <http://www.cqc.org.uk/sites/default/ files/20151230_100001_Scope_of_registration_guidance_updated_March_2015_01.pdf> 6. British Association of Hair Restoration Surgery, BAHRS Advice to Patients On Factors to Beware of When Choosing a Hair Transplant Surgeon/Clinic, < http://www.bahrs.co.uk/wp-content/ uploads/2018/03/BAHRS-Advice-to-patients-on-factors-to-beware-of-when-choosing-a-hair-tr....pdf> 7. British Association of Hair Restoration Surgery, BAHRS Advice to Patients Considering Having Hair Transplant Surgery Abroad, <http://www.bahrs.co.uk/wp-content/uploads/2018/03/BAHRS-Advice-topatients-considering-having-hair-transplant-surgery-abro....pdf> 8. The International Foundation For Dermatology, Management of Bacterial Infections of the Hair Follicles <http://www.ifd.org/protocols/bacterial-infections-of-the-hair-follicles> 9. International Society of Hair Restoration Surgery, Comparison Between Strip Harvesting and Follicular Unit Extraction: A Fair and Balanced View <http://www.ishrs.org/article/comparison-between-stripharvesting-and-follicular-unit-extraction-fair-and-balanced-view>

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ENTRY IS NOW OPEN! Don’t miss your chance to be celebrated in 2018! After a sell-out success last year, the Aesthetics Awards is back and ready to reward the leading players in the non-surgical aesthetic specialty for their hard work, commitment and achievements in 2018. Taking place on December 1 at the Park Plaza Westminster Bridge Hotel in central London, the prestigious ceremony will recognise winners and finalists in 26 categories, covering all aspects of the aesthetics specialty. With more than 800 guests expected to attend, a live band, comedian, delicious three-course dinner and lively networking event, the Aesthetics Awards is not to be missed!

CATEGO RIE S COMPANIES DISTRIBUTOR OF THE YEAR Distributors play a vital role in bringing new, international products and treatments to the aesthetic market. This award recognises those that have demonstrated this and finalists will be selected based on their customer service, product representation and ongoing support to practitioners.

WHOLESALER OF THE YEAR GET THE RECOGNITION YOU DESERVE By entering the Aesthetics Awards, you could be shortlisted as finalist in one or more of the categories, giving you the chance to be Commended, Highly Commended or a crowned a Winner on the night! It is so valuable to be recognised as one of the best in your field, so you can prove to patients and clients why they should visit your clinic or work with you in 2019. Mr Taimur Shoaib, consultant plastic surgeon and founder of La Belle Forme, which won The Profhilo Award for Best Clinic Group UK & Ireland (3 Clinics or More) at last year’s Awards, said, “The Aesthetics Awards is the only awards ceremony that we regularly enter because, to us, it means so much more than any other awards body in Britain. It’s a peer-reviewed process and it means so much that our peers recognise us. I think we all aspire to be the best we can be and this is why it’s important to enter these Awards.”

If you sell a range of products at competitive prices, then this is the category for you. Wholesalers will be awarded for their outstanding customer service, product range and introductory processes in this category.

BEST MANUFACTURER IN THE UK Are you a manufacturer that offers an up-to-date range of equipment and product developments? Can you demonstrate excellent customer service and ongoing support for practitioners using your products? If you manufacturer your products in the UK, then this is the category for you.

EN T RY C LOS ES: J U NE 30 FI N A L I S T S A NNOU NC ED: S E P TEM BER 3

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BEST UK SUBSIDIARY OF A GLOBAL MANUFACTURER

BEST CLINIC SUPPORT PARTNER

This award will recognise the excellent service provided to clients by subsidiaries of global manufacturers. If you stand-out from your competitors, adhere to high-quality standards and offer on-going support to your clients, then enter this category today.

Many different types of companies can enter this category. Whether you’re a PR, insurance, marketing, CRM, financial or legal services company, or anything else that supports aesthetic clinics, then you’re in with a chance of winning this award. Finalists will be selected based on evidence that demonstrates their products and services benefit the running and success of aesthetic clinics.

THE HEALTHXCHANGE AWARD FOR SALES REPRESENTATIVE OF THE YEAR What do you do to offer unsurpassed levels of customer service to your clients? This award is designed to celebrate the hard work and commitment sales representatives put into their role, recognising how they assist clinics in supporting patients and growing sales of their products.

PRODUCTS INJECTABLE PRODUCT OF THE YEAR Manufacturers and UK distributors of injectables are invited to enter their products in this category. Finalists will be selected based on evidence of good safety and efficacy, optimum duration and tangible benefits over similar products on the market, as well supporting a wide range of aesthetic indications.

ENERGY TREATMENT OF THE YEAR If you’re a supplier or manufacturer of energy treatments and you believe yours is the best in the UK, then you need to enter this category. Your energy treatment must demonstrate outstanding results for patients, treat a wide range of indications and, most importantly, have evidence of safety and efficacy, to be in with a chance of becoming a finalist.

THE BARRY KNAPP AWARD FOR PRODUCT INNOVATION OF THE YEAR, SUPPORTED BY MEDICAL AESTHETIC GROUP Innovation is so vital to this new and exciting specialty, and the Aesthetics Awards will celebrate the products that have truly revolutionised the market in 2018. Judges will look for scientific

evidence, genuine innovation or product advancement that leads to treatment for new indications, quicker or easier treatments, better treatment outcomes and patient safety. To enter your product, it must have launched in the UK after 1 January 2017.

SKIN TREATMENT OF THE YEAR With so many cosmeceutical products and skin treatments on the market, it can be challenging for practitioners to decide which ones to adopt in their clinic. As an award-winner, however, your product or treatment is sure to stand out from the crowd. Judges will select finalists with evidence of product or treatment efficacy, safety, ease of use and high patient satisfaction.

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TRAINING PROVIDERS BEST INDEPENDENT TRAINING PROVIDER

THE DALVI HUMZAH AESTHETIC TRAINING AWARD FOR BEST SUPPLIER TRAINING PROVIDER

This award will acknowledge those who provide an exceptional independent training service, which has advanced the education of medical aesthetic professionals most effectively during the last 12 months. Engaging methods of delivery, continuous development and achievement of measurable outcomes will all be considered for finalist selection.

Aesthetic companies who offer excellent training support to their clients are set to be rewarded for their efforts in this category. If your company goes the extra mile to provide comprehensive and practical training, then ensure you enter today.

REGIONAL CLINICS Clinic finalists in each region across the UK will be celebrated at the Aesthetics Awards, recognised for their commitment to excellence in patient care and safety, customer service and evidence of good feedback from their patients.

BEST CLINIC SCOTLAND

THE JOHN BANNON UK AWARD FOR BEST CLINIC MIDLANDS & WALES

THE JOHN BANNON AWARD FOR BEST CLINIC IRELAND THE IS CLINICAL AWARD FOR BEST CLINIC SOUTH ENGLAND

THE DERMALUX AWARD FOR BEST CLINIC LONDON

THE AESTHETICARE AWARD FOR BEST CLINIC NORTH ENGLAND

OTHER CLINICS THE AESTHETICSOURCE AWARD FOR BEST NEW CLINIC, UK & IRELAND Winning the Award for Best New Clinic will cement your place as an elite aesthetic provider and ensure you stand out amongst your competition. New clinics can enter if they were established after 1 January 2017. Judges will look closely at initiatives to promote growth, as well as patient care, safety, feedback and customer service.

The categories to the right are open to clinic groups 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 CONSENTZ AWARD FOR CLINIC RECEPTION TEAM OF THE YEAR From taking bookings to up-selling skincare, front-of-house staff have a varied role that is essential to the smooth running of an aesthetic practice. Reception teams of any size can enter in the UK & Ireland, and judges will be looking for evidence of outstanding customer service, continuous training and effective teamwork.

THE MATA AWARD FOR BEST CLINIC GROUP UK & IRELAND (10 CLINICS OR MORE)

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Advice

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THE ENHANCE INSURANCE AWARD FOR BEST CLINIC GROUP UK & IRELAND (3 CLINICS OR MORE)

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CLINIC, COMPANY OR ORGANISATION THE PHI CLINIC AWARD FOR PROFESSIONAL INITIATIVE OF THE YEAR After launching last year with extremely noteworthy finalists, the Professional Initiative is back for 2018 to find this year’s most remarkable campaigns that promote consumer education and patient safety. The category is open to associations, companies and individuals that have evidence of activity and outcomes designed to benefit the specialty as a whole.

INDIVIDUAL PRACTITIONERS

THE MED-FX AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR Finalists for this respected accolade will be nurses who prove that their care and clinical expertise have ensured they deliver exceptional results to patients. They will also demonstrate how they have worked hard to continue their professional development and make a difference to the aesthetics specialty within the last 12 months.

THE ABC LASERS AWARD FOR MEDICAL AESTHETIC PRACTITIONER OF THE YEAR Doctors, dentists and surgeons are invited to enter this category for the chance to be made a finalist in this prestigious category. Applicants must demonstrate their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole.

THE SCHUCO AESTHETICS AWARD FOR OUTSTANDING ACHIEVEMENT IN MEDICAL AESTHETICS The trophy for Outstanding Achievement will awarded to a person with a distinguished career in aesthetics who has made a significant contribution to the profession. There will be no finalists in this category and the winner will be selected on the night of the Aesthetics Awards. Readers are invited to share their suggestions for the winner, by emailing support@aestheticsjournal.com.

HOW TO E NTE R • All entries must be made via aestheticsawards.com • You can enter 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 that is distributed by your company. Entries made on behalf of a third party will not be accepted. • You may only enter each category once. Multiple entries from 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.

THE JUDGIN G PROCE SS After the entry closing date, the Aesthetics team consider all the entries to select a list of finalists in each category, which will be published in the September issue of Aesthetics and on the website on September 3. Users registered on the Aesthetics website are able to vote for a winner in some categories, which will also be assessed by an expert judging panel and make up a percentage of the final score. Other categories will be assessed solely by an expert judging panel, carefully selected to avoid conflicts of interest. Entrants should check the category descriptions on aestheticsawards.com to view the full list of judges and confirm how their category will be assessed.

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Histocompatibility of threads (rat soft tissue)

Performing Thread Lifts Dr Albina Kajaia shares her personal experience of using polylactic acid threads and advises the best methods for application After the arrival of surgical thread-lift procedures for the face in the late 90s, many aesthetic practitioners learnt the techniques to offer their patients an alternative option for facial rejuvenation.1,2 Non-surgical thread-lift treatments have now become firmly established in the work of many practitioners because the procedure is less invasive than surgical procedures. The other advantages to thread lifts are that all manipulations are carried out through small puncture wounds that leave no scars, while there is no need for general anaesthesia or long-term rehabilitation. Threads have become popular not only among medical practitioners, but also among patients, as there is the potential to receive instant results without the need for surgery.3

After one week there is fibrous around the thread and stimulation of collagen type 1, at one month there is a fibrous capsule around the thread and the barb, and fomation of collagen type 3. At six months, thereâ&#x20AC;&#x2122;s a contour of fibrous capsule around the thread and collagen type 3, at 18 months the thread is almost fully absorbed, fibrous capsule and collagen type 3 remain.

Tissue reaction The tissue reacts to the implantation of the PLA threads by formation of collagen, type 1 and type 3, and by development of a fibrous capsule. Even after full thread biodegradation, the fibrous capsule continues to hold soft tissue for three to five months (Figure 1).10 The most notable property of PLA threads is the disposition of its multidirectional barbs. This configuration gives the opportunity to evenly distribute the tension of the tissues along the entire length of the thread, and the three-dimensional arrangement of the barbs allows the practitioner to achieve the most reliable fixation (Figure 2).9 The method is universal; it can be successfully applied both for lifting and reinforcement of almost all areas of the face.

Absorbable threads Absorbable threads have been marketed as an alternative to more invasive procedures, such as a facelift, because the recovery time is faster and the cost is lower. Before the development of absorbable threads, permanent surgical ones were used, which were composed of silicone, gold, titan and polypropylene.4 These threads, which required insertion through incision and general anaesthesia, did not bring wide-spread popularity among surgeons and practitioners. This was due to problematic access because of the incision and the deeper penetration of thread insertion. In my opinion, development of threads took a significant step in 2008 with the introduction of a resorbable material consisting of polylactic acid (PLA) and polycaprolactone (PCL). PLA threads Polylactic acid aims to rejuvenate the skin and is the main component of the PLA thread product I use. It aims to stimulate the natural revitalisation of tissues and prolong the ageing process. During biodegradation, lactic acid is released into surrounding tissues, stimulating new collagen production and their rehydration.5-7 PCL, the second component of the thread, aims to slow down the biodegradation, increasing the duration of the tissuesâ&#x20AC;&#x2122; tightening effect and serving as a lactic acid; a delivery system to surrounding tissues.8,9 The full reabsorbtion period for the PLA threads takes between one and a half to two years.10

Figure 2: Comparison of multidirectional (a) and bidirectional barbs (b). Arrows show the direction of barbs on the thread.

In my practice, we use barbed threads that come already placed in cannulas of 15cm and cannulas of 7cm. One of the most important characteristics of these products is that the thread is preinstalled in a special atraumatic cannula, with a hole and a rounded edge, thus aiming to avoid any extra bleeding and swelling after the procedure. The rounded tip of the cannula does not give the possibility to go beyond the right plane and pushes the tissue without any breaks. Thus, superficial muscular-aponeurotic system (SMAS) perforation and damage in deeper lying structures are practically impossible. The risk of the appearance of skin retractions is also minimal as the cannula slides in one plane.

Contraindications The contradications are the same as the majority of thread-lift procedures and include pregnancy and lactation, acute and chronic infectious diseases, presence of benign and malignant tumours, keloid predisposition, disorders of blood coagulation and serious chronic diseases.11

Side effects 1 week

1 month

6 months

18 months

Side effects are temporary and may include: pain, swelling, temporal asymmetry, transient rippling or dimple formation, transient haematoma or bruising, slight depression or skin irregularity. These inconveniences should disappear a few days after treatment.11

Method of application Figure 1: Histocompatibility of threads from week 1 to 18 months

The procedure is conducted in a sterile treatment room. Preliminary preparation of the patient is not required. If the threads are used in

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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combination with botulinum toxin, then I would recommended the toxin to be administered two weeks before manipulation with threads. I often carry out this treatment combination as I find that relaxed muscles give a better thread-lifting result; muscle movements may destroy barbs. Other techniques (for example, mesotherapy) should be applied two weeks after the procedure because, in my experience, this is the time when all side effects have worn off and neocollagenesis is activated. Mesotherapy can help to improve skin tone, structure and quality.12 Before the procedure, the practitioner should determine the indications and contraindications, examine the patient, introduce the technique and warn about possible complications, as well as asking the patient to sign an informed consent form. The practitioner should photograph the patient in five standard positions (one frontal view, two oblique views and two lateral views). Step by step procedure: 1. The local infiltrative anaesthesia is performed using ultracaine or lidocaine solutions, depending on whether the patient is allergic to either one or based on the practitioner’s preference. 2. The marking at injection site and the application area is carried out in an upright position, then the patient is laid horizontally. 3. The cannula with the rounded tip is introduced into the entry point. 4. Depending on the task, different methods of thread application are used, as shown in Figures 3,4, & 5. 5. After installation, the thread is trimmed at the skin so that the tip is hidden under the subcutaneous tissue. 6. At the end of the procedure the patient returns to the upright position, where the practitioner evaluates the asymmetry and soothes the tissues with light massage along the Langer’s lines and the puncture site. 7. The patient is photographed again in the aforementioned five positions. 8. The patient is provided with the post-treatment recommendations below and an ice pack is applied to the intervention zone for 20 minutes. I would propose the following post-treatment recommendations: • Apply ice packs immediately after the procedure • Antibiotics should be prescribed if there is deemed to be a high risk of infection • Analgesics should be taken in case of pain for two to three days • Patients should refrain from applying make-up for a minimum 24 hours Figure 3

Figure 4

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• Patients should sleep face up, in an elevated position on pillows for three to five nights • The face should be washed gently without rubbing or massaging for five to seven days • Excessive face and neck movements should be avoided for about two weeks and face and neck massages for one month • Over-exposure to direct sunlight should be avoided for two weeks • Sports and exercise should be avoided for two weeks • Saunas should not been used for three weeks • No dental surgery should take place for three weeks

I often carry out this treatment combination as I find that relaxed muscles give a better thread-lifting result; muscle movements may destroy barbs

Combination treatment for facial zones Even though thread lift procedures are a big part of my practice, injection techniques have not been replaced by them. Moreover, they are used in combination. Such combinations as botulinum toxin and threads or HA fillers and threads, in my opinion, give the most desirable results. Over the years of using various thread methods, I have developed unique algorithms for combining these methods, depending on facial zones, as described below. Upper third of the face In this area, the procedure should be done in two main steps:

Figure 5

Figure 3: Fan-method: five threads are inserted linearly through one entry point. Figure 4: W-method: used for repositioning of volume, as an alternative to fillers. One thread is inserted with the cannula and a ‘W’ shape is made under the skin (the thread is long enough for this). The cannula is moved back and forward without removing it totally from the entry point. Figure 5: N-method: used for the creation of the contour and volume reposition.

Step 1: Injections of botulinum toxin. It is better to do injections 10-14 days before thread application. Products and doses are chosen individually. Without blocking the muscles, active gesture may cause breakage of barbs or even of the thread, in particular during the two weeks after the procedure, and the fixation will be lost gradually.13 Step 2: Insert the threads in subcutaneous fatty tissue along blocked muscles. In my experience, the threads will get better fixation and retain results for longer. Middle third of the face Depending on the desire of the patient, we can reposition the volume or simply

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After

Patient before and after using the fan method

Before

After

Patient before and after using the fan method for the mid and lower face

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After

Patient before and after W-technique for the mid-face and fan method for the lower face Before

After

Patient before and after using the N-technique for the mid-face and fan method for the lower face

emphasise the zygomatic area. In the instance where we want to just emphasise the cheekbone area, we use threads. During the procedure, hypercorrection is mandatory. It will disappear in 10-14 days. If the patient wants to create more prominent and voluminous cheekbones, then about 0.5ml of HA filler should be injected each side, two weeks after the thread application.

to the presence of lactic acid and complete resorption of the threads throughout the year, with the formation of a new collagen. Combining various techniques with botulinum toxin injections, HA fillers and threads give the opportunity to achieve the maximum lifting effect, and to administer the desired result of rejuvenation, without surgery, to aesthetic patients.

Lower third of the face In this area, I use the following steps: Step 1: Correction of the oval using botulinum toxin, according to the Nefertiti technique, which aims to define the jaw line. Step 2: Thread application. Step 3: Correction using HA filler (if necessary).

Dr Albina Kajaia is a dermatologist and chief of her dermatology department in Georgia. She is scientific director and founder of the International Caucasian Congress on Plastic Surgery and Dermato-Cosmetology in Kolkhida. Dr Kajaia has had articles published in nine scientific papers and is a member of aesthetic societies.

Results I advise doing a control checkup three, 10 and 18 days after thread lifting. Asymmetry and swelling of the face can remain for about a month; from experience, by the end of the first month, asymmetry should completely disappear and the face is redefined. This period can depend on the individual characteristics of the patient. After the first month there is also a lifting effect, a clear contour and repositioned volume. The skin becomes smoother and looks more elastic and moisturised due to biorevitalisation. According to observations of 420 thread-lift procedures performed at our clinic, desired results in all patients were preserved during the year. The following assessments were obtained: • Excellent: 336 (80%) • Good: 76 (18%) • Average: 8 (2%)

REFERENCES 1. Histocompatibility Study of APTOS threads, (2008) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2840891/> 2. Sarah Tonks, Understanding thread lifting, Aesthetics journal (2015) <https://aestheticsjournal.com/ feature/understanding-thread-lifting> 3. G. Sulamanidze. Aptos Excellence, New possibilities in aesthetic medicine, Tecrussia (2013) http:// www.tecrussia.ru 4. Gold Thread Lift, (2010) <http://faceliftpedia.blogspot.com/2010/12/gold-thread-lift.html> 5. Helen Carroll, Threadlift – Is the Non-Surgical Facelift for You? Learn About the Lunchtime Facelift, (2015) <http://anti.agingarsenal.com/procedures/threadlift-non-surgical-facelift/> 6. JiaolongWang et al. Biodegradable Polymer Membranes Applied in Guided Bone/Tissue Regeneration: A Review. MDPI, (2016) 7. Goldberg D, Guana A, Volk A, Daro-Kaftan E. Single-arm study for the characterization of human tissue response to injectable poly-L-lactic acid. Dermatol Surg. (2013);39(6):915–922 8. A. Kajaia, G. Sulamanidze, T. Paikidze, K. Sulamanidze. Modern aproach to the face modeling: Aptos Excellence Visage, in hands of dermatocosmetologist. Estetic medicine, (2012)-N 4.-С.505-512. 9. Aptos LLC, Products, <http://aptos.global/products/> 10. Stein P, Vitavska O, Kind P, Hoppe W, Wieczorek H, Süchurer NY. The biological basis for poly-l-lactic acid-induced augmentation. J Dermatol Sci. (2015);78(1):26–33 11. Aptos threads information leaflet, in product box 12. Juan Lopez, Mesotherapy for Facial Skin Hydration, Aesthetics journal, (2015) https:// aestheticsjournal.com/feature/mesotherapy-for-facial-skin-hydration 13. Helen Carroll, Threadlift – Is the Non-Surgical Facelift for You? Learn About the Lunchtime Facelift, (2015) <http://anti.agingarsenal.com/procedures/threadlift-non-surgical-facelift/>

Conclusion The features of PLA threads, namely the arrangement of barbs, sets of threads with different lengths, a cannula with an atraumatic rounded tip and a hole aside, determine their advantages and effectiveness of application. PLA threads are effective to create a contour and reposition the volume of different areas of the face and neck, as well as for lifting and soft tissue armouring. An additional advantage is the effect of biorevitalisation due

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Chin Augmentation Using Fillers: A Case Study Aesthetic nurse prescriber Helen Allen talks about use of dermal fillers for chin augmentation Fillers may be best known for improving fullness of lips or cheeks, but they are increasingly being used by aesthetics practitioners to enhance and shape other areas of the face and neck; smoothing wrinkles, plumping the skin or transforming the overall look of the face by balancing out and harmonising features. Traditionally, for transformations around the chin and jawline, patients may have looked at surgical options, but the use of dermal fillers in these areas gives excellent results at a much lower risk and cost to the patient. Quick, straightforward and relatively painless, fillers will create a subtle difference which is immediately perceivable but difficult to pinpoint, making slight modifications towards that ideal face shape and more youthful appearance. Over the years I’ve successfully used fillers in various areas of the face and neck for treatment of signs of ageing or for facial contouring, including foreheads, cheeks, and décolletage, all with excellent results. However, I’d like to concentrate here on the advantages of dermal fillers for adding shape, definition and smoothness to the chin and jawline. As collagen and elastin fibres in the dermis break down over time and muscles loose Before

some of their tone, the face can begin to sag, sometimes resulting in the ‘jowly’ look that many associate with ageing, where the skin on cheeks begins to hang down towards, or below, the jaw. Wrinkles can also form around the chin and marionette lines develop. All in all, the chin and jawline can considerably contribute to the ageing look of the face – in fact some argue that the secret to a youthful look lies in the jawbone. With this in mind, the chin is the perfect area to use dermal fillers to subtly add shape and definition, helping to

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augmentation can be used to even out a pointy or squared chin, or even make a prominent nose appear smaller. There are many scenarios where the use of dermal fillers in and around the chin area can provide a quick, non-invasive and more affordable option than surgery, and many patients will be more inclined to try this route rather than resorting to anything more drastic. Noticeable results will be more-or-less instant, with the effect improving over 14 days as the filler integrates with the skin’s tissue. This produces a very natural look which typically lasts for around 12 months, but potentially up to two years, before requiring a refresh. I have successfully used fillers for chin augmentation in many cases, addressing various problems, but the particular case I’m going to look at involved a patient who presented with signs of ageing around the chin area. As with many patients I meet, this was having a detrimental effect on the way she felt about her appearance and, consequently, was affecting her overall confidence.

Noticeable results will be more-orless instant, with the effect improving over 14 days remove the signs of advancing years from the face. This treatment can also address issues in younger patients, such as a recessed chin or a weak jawline, providing an improvement to the balance of features on the face and working towards that attractive V-shaped jawline. Chin After

Figure 1: Before and after chin and jawline augmentation using Restylane Volyme

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Consultation The process began with an initial consultation during which I assessed the patient’s facial features and pinpointed the chin as a particular area to address, as I believed enhancing this area would be the best way to improve the overall look. We discussed the options and the merits of choosing dermal fillers. For this patient, the reduced cost over any surgical options and the fact that no time off work or lengthy recovery period was required were very appealing. She felt that as only a little discomfort and minor bruising could be expected, this was far preferable to facial surgery. As usual, during my consultation I discussed the possible risks and side effects of the procedure, talked through the products we would be using and also


Advertorial ----------showed before and after photographs of other patients who had undergone similar treatment. My longstanding reputation in the industry reassured her that she would receive the highest level of professional care and safety standards, as well as benefitting from my years of professional experience and expert judgement about how best to address her needs. By the end of the consultation the patient felt confident and eager to begin, excitedly anticipating the results.

Treatment The procedure itself took just under an hour. Restylane Volyme, a product I often rely on, was injected into the dermal layer. Containing hyaluronic acid, Restylane Volyme boosts the skin’s natural hydrating system, lifting, smoothing and promoting elasticity for a very natural-looking result. It works with tissue and supports everyday movement for extra longevity and sustained definition. As the product is produced by Galderma, a leading aesthetic manufacturer, I know I can trust Restylane products as some of the safest and most effective in the aesthetics specialty. I either inject dermal fillers or use a cannula, allowing for a great deal of accuracy, which again improves the outcome.

Results As these before and after photographs show, the results are fantastic. The patient was delighted by the difference in her look and the reversal in the signs of ageing around her chin area. This simple procedure has made an enormous difference to the patient’s life, as she now feels happier with the way she looks and more confident in herself as a result. She’s no longer hiding away or avoiding interactions with people who she hasn’t seen for years! I will continue to promote the use of fillers such as Restylane Volyme to patients wishing for subtle but effective changes to their features, either to reverse the signs of ageing or to adjust and balance their features, bringing facial harmony and a look they can be proud of.

Next Generation Skin Regeneration Restores the naturally youthful look of the skin through deep regeneration, stimulating production of new collagen and elastin in the face, neck, arms and hands. Sunekos. Better because… • Restoring the biological functions of the derma through effective deep hydration • Patent protected combination of Hyaluronic Acid and Amino Acids • Noticeable and lasting improvement for over 6 months*

Helen Allen is the owner and director of Pure Aesthetics in Nottingham. She qualified as a registered nurse in 1997 and established her aesthetics career in 2002. Working as an advanced medical practitioner, Allen offers patients a range of professional treatments and high-end non-surgical facial rejuvenation techniques. She is also a trainer for Harley Academy and an independent nurse prescriber. She has received extensive training in the UK and Europe, including a masterclass by Dr Mauricio Di Maio. She often speaks on BBC Radio Nottingham about aesthetic-related topics, promoting advice and safe practice for the general public.

Restylane Volyme is available from Med-fx. Call 01376 532800 or visit medfx.co.uk to place an order.

Exclusively from Med-fx - with complete support & training from our specialist team. Visit training.medfx.co.uk *Sparavigna A and Orlandini A Efficacy and Tolerance of an Injectable Medical Device Containing Hyaluronic Acid and Amino acids: A Monocentric Six-Month Open-Label Evaluation J Clin Trials, an open access journal ISSN:2167-0870 Volume 7 • Issue 4 • 1000316

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The 3-point Lift The 3-point Lift is a protocol for full facial rejuvenation using a polycaprolactone dermal filler. This is my preferred technique for full facial rejuvenation, targeting both the deep and superficial fat compartments of the face, through three access points, in a systematic and simplified approach. Collagen stimulation The importance of collagen depletion within the dermis and subdermis, and the resultant effects on the integrity and ageing of the skin, cannot be overstated.3 Hence the second strategic goal of the 3-point Lift technique is focused on effective and widespread collagen biostimulation in the subdermis and superficial fat compartments of the face.

Full Facial Rejuvenation Mr Ayad Harb discusses his protocol, the 3-point Lift, for rejuvenating the face The non-surgical facelift is often cited as the â&#x20AC;&#x2DC;holy grailâ&#x20AC;&#x2122; in non-invasive treatment. These innovations are quite distinct from their surgical counterparts, in terms of the procedure, risk profile, recovery and results. When it comes to facial rejuvenation, however, there are some shared principles between the surgical and non-surgical, and essential criteria which form the basic indications for treatment and the outcome targets. Rejuvenation of the whole face is challenging and patient (both surgical and non-surgical) expectations are very high: providing a holistic rejuvenation; treating deep and superficial fat compartments; lifting the upper face; volumising the mid-face and tightening the lower face; and producing visible results while maintaining natural proportions. The non-surgical patients however, demand that this is all achieved whilst also ensuring minimal trauma, pain, bruising and downtime.

Figure 1: Three injection points on the side of the face

There are numerous techniques which have been described and are utilised for full facial rejuvenation. These tend to focus on volume replenishment or collagen stimulation, using common dermal fillers, including hyaluronic acid, calcium hydroxylapatite and collagen stimulator poly-L-lactic acid.

Anatomy of ageing The ageing process in the face is an inevitable interplay between fat pad depletion, bone resorption, ligamentous attenuation and dermal collagen degradation.1,2 The recent identification of the facial fat compartments and their depletion with age, supports the theory of volumetric patterns of facial ageing.1,2 This anatomical knowledge forms the first target of the 3-point Lift, which is the directed and compartment-specific deep volume replenishment .

Figure 2: Marking the deep injections

Figure 3: Marking the superficial injections

Choice of filler Polycaprolactone microspheres found in EllansĂŠ have been shown to be an exceptionally potent stimulator of type-1 collagen in the skin.4,5 In my practice I have found it to be an effective volumiser in the short term and unparalleled in collagen bio-stimulation in the medium to long term. This biostimulatory effect manifests as brighter and smoother skin with a plump and doughy texture. The 3-point Lift technique can be utilised using other dermal fillers, however I feel it is important to distinguish between mixed type1/type 3 collagen stimulation generally seen with most dermal filler injections and the predominantly type-1 collagen stimulation seen with polycaprolactone microspheres.4 Technique The 3-point Lift is performed with a microcannula 25 gauge, and entirely through three injection points on each side of the face, which act both as access points for the deep injections and centres of rotation for the superficial component (Figure 1). The deep treatment consists of boluses of 0.1-0.2ml aliquots, deposited at the site of the deep compartments (Figure 2). The total volume is dependent on the degree of deflation, ranging from a small volume of 0.5ml in mildly deflated cheeks up to 2 ml or 3ml in the severely deflated ptotic cheek that requires a comprehensive revolumisation. The superficial treatment involves linear threading deposition of micro-boluses of no more than 0.02-0.05ml in the sub-dermal plane (Figure 3). This aspect of the treatment is centered at the injection point, allowing a 360-degree angle

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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aestheticsjournal.com Before

@aestheticsgroup After

Aesthetics Journal

Aesthetics

One year post treatment

42 year old patient, no previous treatment; concerns about general ageing of face and appearance of lines. Before, immediately after and one year after.

of rotation and multiple linear threads to be deposited in the sub-dermal plane. Point One The first point is the mid-face. It is centered on the malar prominence and allows access for deep periosteal bolus injections targeting the deep fat pads of the mid-face, temporal and prezygomatic areas, and superficial treatment of the entire mid-face region, from temple to malar and mid-cheek. The treatment area can even cross the nasolabial border to allow superficial bio-stimulation of the upper lip. Point Two The second point targets the lower face and perioral area. The access point is at the prejowl sulcus and it allows access for periosteal treatment of the anterior jawline and chin. Through the same access hole, superficial biostimulation can cover the whole perioral region and cross the mandibular ligament into the mid-face to form a meshwork pattern of superficial micro-boluses. Point Three The third point is placed at the angle of the mandible. This allows access for periosteal injection along the posterior mandible and creation of a well-defined mandibular angle. The superficial component covers the preparotid and upper neck areas and along the length of the jawline. Results The final result is volumisation of the deep fat pads of the face and reinforcement of the boney prominences, as well as widespread infiltration of polycaprolactone microspheres, which form a superficial blanket within the superficial fat and subdermis of the whole face. The immediate results are similar to other extensive dermal filler treatments – obvious volumisation, combined with mild swelling and redness of the skin. Bruising

is uncommon as the whole procedure is performed with a relatively wide gauge blunt cannula. As the treatment is performed through only three access points, which are covered with antibacterial ointment at the end of the procedure, it is my standard practise to allow the patient to apply makeup immediately. This product contains 30% polycaprolactone microspheres suspended in a carboxymethylcellulose (CMC) gel, which comprises 70% of the total volume. The behaviour of this product is such that the initial result is expected to deflate substantially within the first four to six weeks, as the CMC carrier gel is metabolised, leaving behind the polycaprolactone microspheres as the active biostimulatory ingredient. The collagen biostimulation begins to be seen at around six weeks onwards and manifests with improving volume, natural lifting of the face and a softening and tightening of the skin. This process can continue between three to six months. The final result is extremely satisfying and long-standing, being maintained predominantly by the patient’s own new collagen. The duration of effects can last between one to five years, depending on the subtype of the product used.6 Cautions and complications In my experience, this procedure can produce its most dramatic and satisfying results in patients in their fourth or fifth decade with mild to moderate volume loss and skin laxity. It would be my recommendation that this protocol can be a very useful prophylactic intervention for younger patients at the beginning of their collagen decline. Similarly, it is effective as a pre-treatment for building collagen stock in the skin and sufficient volume prior to other treatments such as thread-lifting or even surgery. The 3-point Lift is a useful technique to learn and is aimed at the advanced practitioner who is both proficient in facial anatomy and assessment,

as well as being experienced with microcannula usage. The main challenges I have faced when utilising this technique are related to the individual technique itself as well as the choice of product. It is vital to have an advanced understanding of the facial anatomy to be able to accurately mark and target the individual facial fat compartments, whilst minimising trauma and risk to the patient. Precise handling of the micro-cannula is essential and meticulous injection technique is required to ensure that the superficial boluses are in the correct plane and in the sufficiently small aliquots which will not cause any visibility or palpability of the filler material. This product exhibits a different pattern of behaviour if compared with conventional hyaluronic acid fillers and as such, one has to be able to counsel the patient appropriately regarding the biphasic action of the polycaprolactone and the gradual onset of the final results. It is vital with bio-stimulatory products to avoid overcorrection when performing the treatment, as this might predispose to palpable or visible lumps or an overcorrected final result.

Conclusion In my practice, the 3-point Lift has become the standard for total facial rejuvenation, using three access points and two treatment levels (periosteal and sub-dermal). It is a logical approach which tackles the root causes of ageing in the face – both deep fat compartment depletion as well as collagen degradation. I have found the 3-point Lift technique to be safe with minimal associated downtime. Mr Ayad Harb is a consultant plastic and reconstructive surgeon with an NHS and private practice. He is the director of Qosmetic clinics and founder of The Bicester Clinic. He has developed a number of his own treatment protocols, including the 3-point Rhino and the Collagen Ladder principle. REFERENCES 1. Rorich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007; 119: 2219 2. Pessa JE,Rorich RJ: Discussion. aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg 2012; 129: 274 3. Guyuron B, Rowe DJ, Weinfeld AB, et al. Factors contributing to the facial aging of identical twins. Plast Reconstr Surg. 2009;123:1321–1331 4. Nicolau PJ et al. Neocollagenesis after injection of a polycaprolactone based dermalfiller in a rabbit. Eur J Aesth Med Dermatol 2013;3(1):19- 26. 5. Nicolau PJ. Long-Lasting and permanent fillers: Biomaterials influence over host response.v Plast Reconstr Surg 2007;119:2271-2286. 6. De Melo F, Nicolau P, et al. Recommendations for volume augmentation and rejuvenation of the face and hands with the new generation polycaprolactone-based collagen stimulator (Ellansé®) . Clin Cosmet Investig Dermatol. 2017; 10: 431–440.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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A Boost for Those Looking to Achieve Their Best Skin

While it seems today’s selfie-loving, digitallydriven culture has motivated demand for aesthetic enhancement, a considerable number of those considering treatment are seeking a natural ‘me, but better’ effect. Research shows that a desire to improve self-confidence and preserve a youthful appearance are key motives for those seeking aesthetic enhancements. However,

barriers for those seeking treatment include concern over liking the result, and people noticing they had sought treatment; which is more apparent among those aged over 35.1 Galderma’s range of skin fillers includes a product line specifically designed with these patients in mind. Restylane® Skinboosters™ offer a unique approach to nourishing the skin, and work by delivering deep-skin

Criteria for recommending Restylane Skinboosters • Those looking to minimise the first signs • Improve roughness4,5 of ageing4-6 • Reduce appearance of skin • Boost skin hydration2,3 imperfections such as acne scars7 2,3 • Gradually improve skin condition

Dr Sandeep Cliff, Consultant Dermatologist said: “A number of my patients are looking for solutions to minor imperfections such as the early signs of ageing, or acne scarring, but are concerned at the prospect of a major alteration to their appearance. Restylane Skinboosters are a great option for these patients, offering effective yet subtle results over a period of time. Applied over a series of applications, the results are gradual – offering effective yet gradual clinical results. The product can also be tailored to the individual, whether they are looking for an all over refresh to the skin, or to target specific areas. Often the best way to fight early signs of skin ageing is to tackle fine lines at the cause, whether that be by use of toxin to relax mechanical stresses to the skin, or through treatment with a HA-based product such as fillers, to address a loss of volume or hydration to the skin. Recently there has been a lot of publicity on the use of fillers and many people have the perception that they are intended to achieve a major change to the clinical appearance of an individual – in some cases this is both required and requested. However, they are suitable for a wide range of uses, which is why the specific product used and its application should always be tailored to the individual.” Dr Cliff is a Consultant Dermatologist and undertook his dermatological training in London at St George’s Medical School. Dr Cliff sits on a number of patient groups and aims to provide a comprehensive dermatology service – incorporating the diagnosis and management of the full range of dermatological conditions and cosmetic treatments for the skin aiming to rejuvenate the skin.

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Aesthetics

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hydration, improving the skin structure and elasticity, and reducing fine lines and imperfections.2-6 Restylane Skinboosters are made using Galderma’s patented Non-Animal Stabilised hyaluronic acid (HA) (NASHA)™ technology, featuring regularly cross-linked HA, a naturally occurring molecule in the body responsible for supporting skin hydration and structure. The product contains smaller particles than other fillers in the Restylane portfolio, and works by subtly plumping the skin through its biochemical properties, rather than exerting a mechanical effect. The product is applied by micro-injection (supplied with the product) or by cannula, and can be used on the face (including the forehead, cheek, crow’s feet, peri-oral lines, and accordion lines), neck, décolletage and hands. The recommended treatment plan usually includes three treatments, 2-4 weeks apart, with a maintenance treatment every 4-6 months to maintain maximum benefit.2,3 Restylane Skinboosters have been used by aestheticians for over 12 years and over 3.5 million treatments have been performed during this time. Restylane Skinboosters are supported by a number of clinical studies demonstrating an improvement in skin elasticity of the face and hands, for up to 12 months following initial treatment.5,6 The Restylane portfolio • Broadest range of HA dermal fillers • Established safety profile8 • Over two decades of experience • High patient satisfaction9 • Administered in over 30 million treatments worldwide8

REFERENCES 1. RARE research, 2017. 2. Restylane® Skinboosters™ Vital Lidocaine - Instructions for Use. Galderma. 3. Restylane® Skinboosters™ Vital Light Lidocaine - Instructions for Use. Galderma. 4. Kerscher M et al; Rejuvenating Influence of a Stabilized Hyaluronic Acid–Based Gel of Nonanimal Origin on Facial Skin Aging. Dermatol Surg. 2008;34:1–7. 5. Gubanova EI et al; 12-month Effects of Stabilized Hyaluronic Acid Gel Compared With Saline for Rejuvenation of Aging Hands. J Drugs Dermatol. 2015;14(3):288-98. 6. Gubanova EI et al; Injections of stabilized hyaluronic acid with a sharp needle compared with a blunt microcannula for facial skin rejuvenation: 12-month results. Poster presented at the International Master Course on Aging Skin (IMCAS), 29 Jan-1 Feb 2015, Paris, France. 7. Dierickx C. Poster presented at IMCAS, Paris, France. 8. Data on file. MA-31037. Galderma Ltd. 9. Talarico, S et al. High Patient Satisfaction of a Hyaluronic Acid Filler Producing Enduring Full-Facial Volume Restoration: An 18-Month Open Multicenter Study. Dermatol. Surg. 2015;41:1361–1369.

RES18-03-0229 Date of Prep: April 2018


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A summary of the latest clinical studies Title: In Vitro and In Vivo Assessment of Silver Nanoparticles against Clostridium botulinum Type A Botulinum Authors: Aminianfar M, Parvardeh S, Soleimani M Published: Current Drug Discovery Technologies, April 2018 Keywords: Antibacterial, BoNT/A toxin, Clostridium botulinum Abstract: Clostridium botulinum causes botulism, resulting from the ingestion of a botulinal toxin, which is a serious paralytic illness. Due to strong antimicrobial activity of silver nanoparticles' products, the applications of silver nanoparticles in the field of healthcare in particular are being expanded. Therefore, the objective of the current study was to assess a therapeutic strategy for the treatment of botulism toxicity using silver nanoparticles. A preliminary test was conducted, based on the ranges that produce illness in laboratory animals, to determine absolute lethal dose (LD100) of botulinum toxin type A (BoNT/A) in mice. Then, the test animals were divided into six groups containing six mice in each group. Group I, II and III were considered as the negative (botulinum toxin only), the positive control-1 (nano-silver only), and positive control-2 (no treatment); and the remaining groups were allocated to the toxin that supplemented with three nano-silver treatments. The mortality rates of mice caused by BoNT/A significantly reduced in the treatment groups with different doses and injection intervals of nano-silver when compared to the negative control group. BoNT/A toxicity induced by intraperitoneal injection of the toxin of Clostridium botulinum causes rapid death while when coupled with nano-silver results in delayed death in mice. These results, while open to future improvements, represent a preliminary step towards the satisfactory control of BoNT/A by silver nanoparticles for human protection against the challenges bioterrorism threat. Further study in this area will be promising enough to elucidate the underlying mechanism for detoxifying BoNT/A by silver nanoparticles. Title: Formulation and Evaluation of Organogels Containing Hyaluronan Microparticles for Topical Delivery of Caffeine Authors: Simsolo EE, Eroğlu İ, Tanrıverdi ST et al. Published: AAPS PharmSciTech, April 2018 Keywords: Caffeine, Cellulite, Hyaluronan microparticles Abstract: Cellulite is a dermal disorder including the extracellular matrix, the lymphatic and microcirculatory systems and the adipose tissue. Caffeine is used as the active moiety depending its preventive effect on localization of fat in the cellular structure. Hyaluronic acid (hyaluronan-HA) is a natural constituent of skin that generates formation and proliferation of new cells having a remarkable moisturizing ability. The aim of this study is to formulate HA microparticles loaded with caffeine via spray-drying method. Resulting microparticle formulations (33.97 ± 0.3 μm, span < 2, 88.56 ± 0.42% encapsulation efficiency) were distributed in lecithin organogels to maintain the proper viscosity for topical application. Following the characterization and cell culture studies, in vitro drug release and ex vivo permeation studies were performed. The accumulated amount of caffeine was twice higher than the aqueous solution for the microparticle-loaded organogels at 24 h (8262,673 μg/cm2versus 4676,691 μg/cm2). It was related to the sustained behaviour of caffeine release from the microparticles. As a result,

lecithin organogel containing HA-encapsulated microparticles could be considered as suitable candidate formulations for efficient topical drug delivery system of caffeine. In addition to that, synergistic effect of this combination appears as a promising approach for long-acting treatment of cellulite. Title: Localized Telogen Effluvium Following Hair Transplantation Authors: Loh SH, Lew BL, Sim WY Published: Annals of Dermatology, April 2018 Keywords: Hair transplantation, Telogen effluvium, Alopecia Abstract: Telogen effluvium is categorized in nonscarring alopecia, which shows scalp hair thinning and shedding diffusely resulting from inducing factors such as physiological stressful events and several acute or chronic diseases. It usually appears in female patients following parturition, as well as after febrile disease, major surgery, emotional stress, abrupt diet, chronic illness, or the taking of certain medication pills. Two patients who both recalled an operational history of hair transplantation visited our department with their frontal and both temporal hair loss. Physical examination of the both patients showed localized but diffuse hair loss, especially in the frontal and temporal scalp. Histopathological examination of biopsy specimen taken from their temporal scalp revealed normal follicular density and increased numbers of telogen hair follicles without any inflammatory cell infiltration around follicles. These clinical and histopathological findings were consistent with telogen effluvium. Both of them were reassured and placed on close followup without any treatment. From these cases, we demonstrate that localized telogen effluvium could be a cause of hair loss after hair transplantation. Title: Lipidomics Reveals Skin Surface Lipid Abnormity in Male Youth Acne Authors: Gan Y, Zhou M, He C et al. Published: British Journal of Dermatology, April 2018 Keywords: Acne, Lipidomics, Skin barrier Abstract: Alterations of skin surface lipid (SSL) are believed to be one important factor of acne pathogenesis and SSL plays a key role in the initiation of the acne lesions. In this study, a powerful analytical technique, UPLC-QTOF-MS, was used to investigate the SSL variations of lipid main classes, subclasses and individual species. A total of 70 subjects (35 acne patients and 35 controls) were selected for this study. Multivariate data analysis showed significant differences between two groups. Significant increased levels of 3 main classes of glycerophospholipids, fatty acyls, and sterol lipids and significant decreased levels of 2 main classes of prenol lipids and saccharolipids were monitored in acne patients. Subsequent analysis showed that there were 18 subclasses significantly varied and shared the same changing trends of their belonging main classes. Multivariate data analysis indicated that 36 entities were the most important individual species responsible for the discrimination and phosphatidylserines were the majority of differentiating lipid species. In addition, the reduction of ceramides chain length and increase in unsaturated free fatty acids, contributed to an altered lipid organization and decreased skin barrier function in acne patients.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Aesthetics Journal

Aesthetics

Incorporating Facial Aesthetics into a Dental Clinic Cosmetic dental surgeon Dr Krystyna Wilczynski discusses the considerations that need to be made by dentists to successfully incorporate non-surgical aesthetic treatments into a dental clinic Many patients who regularly visit their dentist to improve the appearance of their teeth consider what’s next once their teeth have reached their aesthetic ideal. Often, they start to consider the surrounding external tissues to complete the entire cosmetic picture. This involves aspects of the lips, cheeks, chin structure, jaw position and the overall appearance and quality of the skin. This is the point where many dental clinics will lose their patients to other practices who can deal with these issues if they are not offering facial aesthetic services themselves. In my opinion, dental clinics are ideally placed to offer such treatments. It seems a natural progression for dentists to offer facial aesthetic treatments due to the increased supply and demand from the patient in conjunction with facial anatomical knowledge and injection skills in this area. However, I have noticed that while some clinics are eager to keep their patients and introduce facial non-surgical aesthetic treatments, many find it hard to delve into this new market and struggle to go about doing so successfully. In this article, I will discuss how dental clinics can successfully fit facial aesthetic treatment procedures alongside others into their treatment portfolio.

Why should dental clinics offer facial aesthetics? Apart from keeping their current patients who are leaving them for other practices that specialise in non-surgical aesthetic treatments, there are a lot of reasons why dental clinics should add these treatments to their portfolio. Firstly, dental clinics will already be Care Quality Commission (CQC) registered.1 This means they have a clinical environment that is suitably equipped to perform non-surgical facial aesthetic procedures such as injectables. Secondly, dental clinics also already have a database full of loyal patients who already have their trust, so they are in a good position to offer these new medical treatments to their patients, should they request it. Thirdly, dentists working within a dental clinic have a variety of skills which are useful in the non-surgical medical aesthetic sector. Dentists undergo extensive training in the anatomy, biochemistry and physiology of the head and neck in undergraduate dental training, which is crucial knowledge for administering any botulinum toxin and dermal filler products. Dentists tend to have highly accurate manual dexterity2 and are extremely

familiar and comfortable administering fineneedle injections. Additionally, dentists are familiar with administering appropriate pain relief such as topical anaesthetic on the lips and intraoral anaesthesia. They are also knowledgeable in the management of adverse events such as post-operative pain, sensitivity, swelling and infection, as well as medical emergencies. Dentists have well-practised communication skills between patient and professional, which are taught and developed from the early stages of their career. Excellent communication skills are essential in aesthetics to ensure the patient is aware of any treatment risks, complications and that they have realistic expectations of the results.

Tips for incorporating facial aesthetics into practice If you are a dentist who would like to introduce facial aesthetics into your dental practice, there are several key points you need to consider. I believe the greatest challenges lie in training, insurance and marketing, so have described these in more detail below. Training Before you can even think about adding facial aesthetic treatments to your dental clinic’s portfolio, you must ensure that you have adequate training and experience. You must have completed formal training in each different procedure you wish to include in your practice, and obtained high-level qualifications from a recognised course, to ensure reliable results and appropriate knowledge of complication management. I believe that dentists new to facial aesthetics should be looking to start with a foundation botulinum toxin/dermal filler course that includes simpler treatments like the forehead and lips and then build upon this training thereafter. As a minimum, I recommend that practitioners look for a training course that is led by a practitioner who is currently registered with the GMC/NMC/GDC and research that they have extensive experience in facial aesthetics training. To find a course that is right for you, ask likeminded colleagues for recommendations and do extensive research online. Also, determine whether the course offers support and mentoring following the completion of the training; I believe this is mandatory for safe practice and alleviates fear or uncertainty. I actually find that the main hurdle within a dental practice is to ensure the new non-

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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surgical facial aesthetic area is understood by all members of staff. You need to effectively train your team to incorporate the newly learned information into your existing systems. Some courses and training companies allow you bring your support staff for an extra fee so it’s a good idea to ask if they provide this service. You can also do your own in-house training to make sure the correct information is being relayed to your patients on the new treatment offerings. It is vital that all your support staff are well accustomed to how the procedures work, their costs, time of appointments, materials used in the procedure and its downtime. This is because your patient’s first line of contact is the front of house and patients often ask questions upfront before booking a consultation. Also, ensure staff know the limit to the information they should give at the desk, for example, never instruct them to estimate how many mls of dermal filler a patient might need for a lip augmentation procedure, as this should be only discussed in the consultation after a full facial analysis with a qualified medical professional. During training, I find that one way to engage your clinic staff and get them accustomed to your new treatment offering is by encouraging them to try the treatments. Should they consent, this form of ‘training’ will provide infinite knowledge and awareness of the treatment. This will also further encourage staff to endorse procedures and provide positive experiences to your current and perspective patients. I lastly advise to hold regular staff meetings so that you can identify any gaps in your staff’s knowledge and abilities and hold updated training once a year as a refresher and to build upon their understanding. Insurance It is illegal to work in facial aesthetics without ensuring you are fully indemnified so get an appropriate policy.3 Dental clinics would already have insurance cover for dental procedures such as general dentistry/implant surgery. However, you will need to gain additional cover for your new facial aesthetic treatments and specify these new procedures for them to be covered. Do a lot of research and choose a reputable company that covers all the treatments your practice will offer. There will be an increase in your insurance costs with the addition of new treatments. In my experience, this cost may depend on your level of training, how many hours you work a week, and how much revenue you believe to be turning over in your clinic. It is a good idea to firstly approach

Aesthetics Journal

Aesthetics

your current insurer to determine whether or not you can add your new facial aesthetic treatments to your policy. This is because it may be logistically easier to deal with one insurance company and may be more costefficient. There are two main insurance bodies that dental professionals usually turn to in the UK, the Dental Defence Union or Dental Plans. Both will cover facial aesthetic treatments, so long as all procedures are performed in a dental practice by a dentist. Many dentists tend to have two separate insurances so that they are permitted to practice outside the dental clinic setting too. Reputable insurance providers who will insure clinics and individual dental practitioners wishing to perform facial aesthetics include Enhance Insurance, Hamilton Fraser and Cosmetic Insure.4,5,6 Marketing Introducing facial aesthetics is not a quick process and requires dedication and investment in promotion. Your current dental patients may be interested in undertaking a facial aesthetic or skin treatment, but are unaware that their dental clinic offers this. Obviously, the way you market your dental treatments will differ immensely to how you market your facial aesthetic procedures as general dentistry is marketed as health, whereas aesthetic dentistry is cosmetic. Be aware of the marketing laws and guidance surrounding such treatments, such as those from the Committees of Advertising Practice (CAP)7 and the GDC.8,9 For example, advertising botulinum toxin and other prescription-only medications are illegal, but you can use the words ‘anti-wrinkle’ or ‘muscle relaxant’.10 Also, use of the word ‘Botox’ is trademarked so should not be used. Ensure you update your website to include information about each practitioner and the training they have received to provide such treatment, as well as your new list of treatment options available, with pricing. Although some clinics choose not to disclose their prices until after a consultation, I am always upfront with my costs as I find it affects patient’s decisions negatively if they do not have a preconceived idea of what their treatment may cost. You may want to consider separating your dental site from your facial aesthetics site so that it avoids confusion and allows you to target your patients more precisely. Note that this may involve a live demonstralve more cost, so assess your budget before making this decision. Look to have a presence on social media, and introduce new signage and leaflets for your clinic. Word-of-mouth is an important part of

practice building, so get everyone working at the clinic to talk about the new treatments available to your current patients, as well as their friends and family. Open days and launch events are also helpful as you can provide information to a larger number of interested people. To gain attendees, you can send email invitations to your current patients, press, as well as invite family and friends of your clinic staff. You might like to entice potential attendees with a free consultation, have your practitioners in attendance to discuss possible treatment options and promote discounted special offers and rates. I also find that training courses that offer a live demonstration of the treatment is helpful.

Conclusion Dental clinics and dentists are in a very unique position in that they have the facilities and much of the clinical training available to them to be successful in providing facial aesthetic procedures. They must consider how they can successfully merge these new treatments into their practice. Any dental clinic or dental practitioner wanting to embark on facial aesthetics should take the time to find a reputable course to educate and support them. They should be insured and adhere to a high level of practice standards to avoid any unwanted incidences. Lastly, make sure current patients know about your new services through effective marketing. Dr Krystyna Wilczynski is a cosmetic dental surgeon and aesthetic practitioner. Following the completion of her dental degree at the University of Leeds in 2010, Dr Wilczynski has undertaken postgraduate training in facial aesthetics. REFERENCES 1. CQC, Dentists: information for providers, 2018. <http://www.cqc. org.uk/guidance-providers/dentists> 2. Robinson, E. ‘Intrinsic And Extrinsic Factors of Aging’ The How To For Keeping Your Skin Looking Young And Beautiful’ (2011) <Indiana University Bloomington ‘Manual Dexterity’ <http://hpplc. indiana.edu/ohp/d-md.shtml> 3. Guidance on indemnity, General Dental Council, <https://www. gdc-uk.org/api/files/Guidance%20on%20indemnity.pdf> 4. Enhance Insurance, Medical Professionals, <http://www. enhanceinsurance.co.uk/who-we-protect/medicalprofessionals/> 5. Hamilton Fraser, Private Application Form <http://www.cosmeticinsurance.com/wp-content/uploads/2017/02/HF-PrivateApplication-Form-8.9.16.pdf> 6. Cosmetic Insure,2018 <https://www.cosmeticinsure.com/home. html> 7. CAP, Guidance on the marketing of surgical and non-surgical cosmetic procedures, 2016, <https://www.asa.org.uk/resource/ cosmetic-interventions.html> 8. GDC Guidance on advertising, <https://www.gdc-uk.org/api/files/ Guidance%20on%20advertising%20(Sept%202013).pdf> 9. GDC Guidance on ethical advertising, <http:// dentalwebsitedesigners.co.uk/Ethical_advertising_statement. pdf> 10. Advertising Standards Agency. Our Purpose & Strategy. 2015. Available from: <https://www.asa. org.uk/About-ASA/Strategy. aspx>

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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Protecting your Clinic from Scam Emails Insurance manager Naomi Di-Scala shares her advice on dealing with scam emails In our personal lives, it is highly likely that we will all have received an email which is an attempted scam and, unfortunately, some of us may have fallen for it. The Guardian reported that in 2017, out of the 978 million global victims of cybercrime, 17 million of those were Britons who were targeted by phishing, ransomware, online fraud and hacking.1 Scam emails can take numerous forms and not only occur in our personal lives, but can take place in the workplace too. In this article, we will explore the most common emails that aesthetic practitioners may come up against and what to do if they receive one, or worse, fall for one.

Types of email scams The phishing scam According to Action Fraud, the national fraud and cybercrime reporting centre for the UK, phishing emails play on the word ‘fishing’ in that fraudsters ‘fish’ for potential victims by sending emails, social media messages, texts or phone calls with urgent requests to hand over personal details or money.2 These are often presented to look as if they have come from a website that you already use, such as PayPal for example, and will be sent to your inbox asking for you to check and update your security information with them. You will then be encouraged to click on a link that will appear to look as if it is

going through to an authentic email address or website and ask you to complete your personal details and input your information. However, the link that you have clicked on will not be authentic and will go through to the scammer’s site, where they will record and take all your personal information, which can then be used for other fraudulent purposes such as online purchases.3,4 One of the most common forms of phishing scams is hackers impersonating your bank. You may receive an email from your alleged bank asking for your personal details to be confirmed. When setting up a new bank account most of us will be told that the bank will never send emails of this nature, so do not respond. It is extremely important to note that real banks will never email you for passwords or any other sensitive information.2,3 Yet, millions of people do respond and become victims of this fraudulent activity.1 Historically, these emails were quite poorly put together so they were easier to identify, but over time they have become more and more realistic as the technology has developed and hackers have honed their techniques. Virus emails These emails will contain either a programme or spy application that will monitor what you click on or the details you input into websites, such as bank websites, and then record this

information. This is known as spyware and can be in the form of Internet URL trackers and screen recorders which track what websites are visited or take snapshots of your screen each time it changes.5 Other forms can be chat and email recorders that copy inbound and outbound emails or even password recorders that track typed passwords, for example for your online banking. Spyware may be hidden within the attachment section of an email and may therefore not be that noticeable to most users.3,4,5 It could also be in the shape of an entertaining, funny picture or video that the initial receiver may forward onto many other people. These recipients then in turn forward it to all their friends or clients, and so on. This method can often be a very successful means of obtaining thousands of people’s personal information.3,4,5

Risks of phishing and virus scam emails in aesthetics In aesthetics, it is likely that you will come up against phishing scams or virus emails that have embedded links within them that, once clicked, may cause a virus to enter your computer system or network. This virus may then access all the personal information that you store and reuse it to commit fraud, or worse, the virus may shut down your system and demand a ransom to rectify the problem.3,4 Scammers may also obtain patient information from the clinic’s database and send a fake marketing email, asking for the patients to provide personal information, which then in turn gets sent back to the criminals, not the actual clinic. The criminals can then use this information to imitate patients and carry out transactions in their name. Although not all patient’s may complete this information or may ignore the email, if it is found that there has been a data breach, this could have financial implications if the clinic is fined and also have a negative impact on a clinic’s reputation.7 In October 2017, a wellknown plastic surgery clinic in London had its system compromised and it was reported that hackers stole terabytes worth of names, medical files and photographs from the clinic’s database.6 In this scenario, you have a major breach of General Data Protection Regulation (GDPR) and will be liable for the associated penalty of up to 4% of your annual global turnover when it comes into force on May 25.7 It is important to ensure that you have security on your system that will protect you from an attack. If you are not sure what security you have or whether it is sufficient, then it would

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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be advised to contact your IT or website developer who will be able to guide you. However, even with security in place, it is not always possible to stop the emails coming through to you or your staff. It is therefore vital that all staff are aware of everything you should look out for that could put you at risk of a breach or a hacking attempt.

Top tips to help identify a scam email Check the ‘from’ address If you are in any doubt about an email you have received, then firstly check the source address. You can usually tell whether the email has come from a random personal email address, such as Hotmail or Yahoo for example. As scammers become more sophisticated, they can tailor these email addresses more effectively to look authentic. However, there may still be some elements that do not look quite right, such as fonts or spacing. If you have any suspicions, then it is best to double check by calling the alleged original source before you open it. You

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Check contact information and dates Sometimes, contained within emails from companies there will be a link to ‘contact us’. On a scammer’s email this link may not actually work when you click on it. In addition, scammers may embed links to websites which are not authentic and therefore it would be advisable not to click on any links within an email unless you are absolutely sure it is from the real company. Most emails from businesses should have a copyright date on them or, if you are able to click through to a website, it will be shown on there. A lot of scammers will forget to update these to the current year so this can be an indication that it has not come from a true source. You should always check the company’s official website first, before clicking on any links within an email. Check the branding within the email A scammer is likely to be trying to impersonate a genuine company or brand and, as such, will try and brand their fake emails to reflect this. If you have any feeling that the branding does not look quite right,

In October 2017, a well-known plastic surgery clinic in London had its system compromised and it was reported that hackers stole terabytes worth of names, medical files and photographs from the clinic’s database should retrieve the original source’s contact details from their official website in a separate browser or by other communications, for example, letters that they have sent that you know are definitely from them. Check the greeting If the greeting within the email is impersonal then it could be an indication that it is not from an authentic source. Scammers are getting better at this but some emails may just say ‘Hi’ or ‘Dear Valued Customer’, for example, and leave out the intended recipient’s name.1

for example the graphic design or image quality is poor, or the font used isn’t the one you’re used to seeing, you can open a separate tab and search for the company’s website to compare the branding on both. If there are any inconsistencies, then it is likely that the email you have received is fake. Poor spelling or grammar A lot of fake emails will contain poor spelling or grammar and this can be an indication that the email may not be authentic. Businesses and brands will go

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through numerous compliance checks before sending out emails to their database, and spelling and grammar will always be checked to ensure that it is correct. Hackers do not necessarily go through this process so can be inconsistent with spelling, grammar, the format of the email and presentation in terms of fonts, styles and sizes used. Rushing or trying too hard to be official If a scammer is trying to convince you that their email is genuine, they sometimes use the word ‘official’, ‘urgent’ or ‘act now’ to try and persuade you to respond quickly. An email from a true source would not need to adopt this tactic. In addition, scammers may use account numbers or ID numbers to try and sway you, which a bank, for example, would never do. If your genuine customer or account number appears within an email, then it would be advisable to not take any action with the email but contact the company that it has allegedly come from to check whether or not it is something they have sent out. There may also be timesensitive offers within a scammer’s email, which are designed to try and put pressure on you to sign up and click on the link embedded within the body of the email. You should always take your time and double check by logging into your account via another tab on your web browser to see if the time-limited offer is real.

What should you do if you identify a scam email? If you receive a scam email, Action Fraud advises that you should not click on any of the links within it, not reply to the email and never contact the senders in any way. Instead, report this to Action Fraud directly via their website and attach a copy of the email to this.2 Action Fraud will not respond to you, but they will investigate the email. Once reported, you should delete the scam email and if you have the facility to block the email address via your system (there is no set way as all systems are different) then it would be advisable to do so. You should not click on any of the links within the email, which includes the unsubscribe link. Instead you should report it and delete immediately.6 If you have staff within your business, you should also make them aware of all this information so that they do not click on an email by accident. If they are unsure, then they should always check with you or another owner/manager to determine if an email is fraudulent or not.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


What should you do if you fall victim to a scam email? Unfortunately, despite all of the awareness and media regarding hacking and online/email scams, people still click on links that they should ignore and end up compromising their systems and, potentially, the personal data held on these systems. In the event of a hacking attempt that bars you from accessing your system, you should contact your IT or systems service provider, who will be able to assist you with rectifying the situation and getting your system up and running again. There may be charges to do this, but if you have a cyber liability policy in place this would assist with any associated costs. If there are breaches to your patient’s personal data, you have a duty to notify the Information Commissioner’s Office and the patients themselves within 72 hours of becoming aware of the breach.7 Cyber and data liability policies are a common and in-demand form of insurance and can be found within all types of insurance policies, including your own home insurance. In the event that you were to experience a breach, either via email or another means, then a cyber and data liability policy would assist you in getting back up and running as soon as possible. They would do this by investigating where the breach came from in the first instance and would deal with the fallout from your patients.8

Summary Scam emails are a common occurrence in today’s digital savvy society, so ensuring you know how to identify them, how to protect your online data and what action to take in response to a scam is an essential factor in running a safe business. It is vital for all aesthetic clinic staff to have the confidentiality of their patients at the forefront of their mind when using emails and digital systems. Naomi Di-Scala joined Hamilton Fraser insurance in 2008 as claims team leader, managing claims and dealing with complaints relating to medical. Di-Scala became cosmetic manager in 2016 and now focuses on ensuring that cosmetic practitioners have the right cover and claims support and regularly provides educational talks and materials for practitioners to protect themselves and their businesses. REFERENCES 1. The Guardian, Cybercrime: £130bn stolen from consumers in 2017, report says. <https://www. theguardian.com/technology/2018/jan/23/cybercrime-130bn-stolen-consumers-2017-reportvictims-phishing-ransomware-online-hacking> 2. Scam Emails, Action Fraud 2018, <https://www.actionfraud.police.uk/scam-emails> 3. Phishing, vishing and smishing, Action Fraud, 2018, <https://actionfraud.police.uk/fraud-azvishing> 4. National Cyber Security Centre. Threat intelligence case studies: cyber attack types. 2016. <http:// tinyurl.com/ya9nyhjx> 5. Brian VanNess and Joanne C. Weaver, What Types of Spyware are Out There? <http://www. toptenreviews.com/software/articles/types-of-spyware/> 6. BBC News, Hackers Breach Top Plastic Surgery Clinic, 2017, <http://www.bbc.co.uk/news/ technology-41735104> 7. GDPR FAQs EU GDPR, 2018, <https://www.eugdpr.org/gdpr-faqs.html> 8. Hiscox, Cyber and Data Risks Insurance, 2018. <https://www.hiscox.co.uk/businessinsurance/cyber-and-data-insurance> 9. Hamilton Fraser, Cyber Essentials, 2018. <https:// hamiltonfraser.co.uk/about-us/hamilton-fraser/cyber_essentials/>

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journey’. Patient satisfaction is the foundation to a successful business and by creating a bespoke environment to visit for their aesthetic treatment is likely to make them feel comfortable, relaxed and in good hands. A full refurb or even a basic upgrade should not be perceived as a costly necessity nor a necessary evil. It is in fact an opportunity to add value and future proof your business, rectify some initial wrong decisions and perhaps even recreate your clinic.

Updating Existing Clinic Interiors Interior designer and creative director Benedict Wilhelm discusses the importance of décor in clinic, detailing how this can have a positive impact on patients and maximise business potential Does the following sound like a familiar scenario? It has been a few years since you first moved into your current space, the flooring, furniture and most of its fabric is dated and worn. Even though the clinic has been repainted at least once a year since its opening, the repaints are now showing, especially around sockets and switches. You wanted to revive not hide your clinic, but your attempts at making it look better are gradually becoming indicators of its age. In many ways it doesn't feel fresh, it just feels outdated. Not only could the wear and tear be letting your space down, it is lacking in other ways. The business has developed and so have your treatments, but the additions or inclusion of new products are making your retail area look overcrowded. Over the years, technology, style and fashion have moved on and this should be reflected in your clinic space. You may have felt there might be an opportunity to add another treatment room to increase your revenue, rearrange the waiting area to optimise work flow or simply create more storage for some of your equipment, in order to maximise space and elevate the overall customer experience. But how do you do this effectively?

Research If bringing in a professional isn't feasible, there’s nothing stopping you from completing your clinic’s refurbishment yourself. So, where do you start and how should you approach a project like this, while minimising risk? The starting point to finding answers is by asking the right questions, not only amongst your directors or stakeholders, but also amongst your staff. They are at the heart of your business and thus could provide valuable insight that could develop your plan. We advise splitting questions you may want to address into three categories: functionality and productivity, atmosphere and design, and identity and branding.

Unique customer journey What your clinic needs is a finely-tuned update that allows you to stand out from the crowd. You want to deliver to your patients not just the exceptional service and expertise that your reputation has been built upon, but also create a powerful experience that resonates long after your patient leaves. We call this your, ‘unique customer

Functionality and productivity For aesthetic clinics, you are looking at whether the space works from a functional point of view and if not how can you make this work better. For example, making the best use of staff in reception and retail area is always important. You want to make sure your patients are attended to 100%, this means

Calling in the professionals If your budget allows, I would recommend bringing in a professional. An interior architect or designer with a proven track record within the industry, who isn’t afraid of scale, can help you with your planning, design and important regulations such as health and safety. Only too often clients have come to my studio after jumping into the deep end, only to realise too late that it just doesn’t work or, in some cases, might be deemed illegal. Be sure to check the Care Quality Commission (CQC) and building regulations set out by the UK government, specifically the Health Building Note, which states that health buildings should ‘provide a therapeutic environment in which the overall design of the building contributes to the process of healing and reduces risk of infection’.1 Often it is as simple as having sockets too close to the sinks or not highlighting stair treads accurately. Lucky, these issues are easily rectifiable but in some cases are more substantial and require intervention. For example, many cases may not cater for The Building Regulations 2010, Part M2 that address things like sufficient corridor widths in regards to wheelchair users. Knowledge of how to work with and around these regulations in order to develop a visionary design, as well as having a clear understanding of the brand and your customers, is so important; all of which is something a qualified designer can help with. The designer will go through a process of stages including research, concept, concept development, detailing and implementation, in order to arrive at a viable and workable space.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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taking calls and making bookings as well as advising on treatments and products from your retail selection simultaneously. Working out a layout and design that minimises over-staffing by keeping these areas close together is one of many solutions. You should also consider customer flow and workflow in the reception, retail area, corridors and treatment rooms. Maximising the space is essential and there may be potential to add value in regards to additional treatment rooms in a business sense. If this is something that you would want to do, then I would advise reviewing the current layout, looking at both the front of house and back of house and evaluate if they are both working to the best of their ability. Atmosphere and design There have been a number of studies to suggest that patient satisfaction is linked with the atmosphere of their treatment room. Professor of marketing at Northwestern University, Philip Kotler, has stated that often ‘businessmen neglect atmosphere as a marketing tool’.3 As a result of this, start asking, do our patients look great with our lighting within the space no matter where they are? Lighting has huge impact on making the patient not only look great but potentially making them feel calm and comfortable. On every project we always bring in our lighting designer as a vital part of the design. However, if you want a simple upgrade, just add flexibility by making your lights dimmable. There are plenty of wireless systems out there, which will allow you to achieve this with an easy retro fit and without having to rewire the entire practice. Also ask yourself and staff, is the temperature in the treatment rooms and waiting area adequate throughout the year and do we have the ability to regulate this for the individual patient requirements? Not only that but do we have an all senses approach? Human beings are sense driven and responsive, especially on a subconscious level, so keeping this in mind is probably one of the most important aspects when designing. In my experience, the starting point to any project is asking ourselves, what does the customer want to smell, hear and feel and how do we translate this into a physical working environment. Does the clinic offer complete privacy and a sense of anonymity? Most conversations held with the aesthetic practitioner are private and of intimate nature. However there is also the sense of wanting your own space in

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the waiting area, for example. This can be resolved by specifying wing back chairs or in the treatment room scenario, adequately insulating the walls and ceiling.

make all the difference. We find marking out on site is invaluable, for example, take tape and highlight everything from wall location to sockets.

Identity and branding Branding is one of the most crucial elements of any business as it is how we are perceived by the outside world. You could be offering renowned treatments and a great service, but if your branding isn’t reflective of this then consumers may be left with a sense of uncertainty.4 Ask yourself, does the branding still work or is it time to upgrade? The easiest solution here is to do a survey with patients, friends and staff asking a series of questions. Asking these questions will allow you to gauge what changes may be necessary. Prioritise them so that once you look at designs, budgets and timings, you will be able to put together a plan that you can feel confident and proud of. It is also a good time to assess whether you want to move into a more digital setting and what may be required from your space to cater for this. For example, a back-drop location for online consultations, social media marketing or even branded screens to showcase 3D technology.

Implementation Your refurbishment is about to commence. Make sure you have a fixed cost contract for the work in order to avoid any unexpected and hidden costs, as well as a final confirmed handover date. Give yourself a few extra days after the official completion date to adjust to the new layout and cater for any unexpected delays or last minute alterations. You will also want to make sure that information has been communicated with your staff and patients, so it’s always good to set up a marketing email and social media post to inform them of any temporary closures whilst the work is taking place. The length of the refurbishment or redecorating will depend on the scope required. I’ve learned that it is always better to do this in one go rather than splitting it into stages of any number, it’s false economy and in my experience rarely works.

Concept Once you have completed the research stage, put together a concept. This can be as simple as pulling together some simple sketch layouts, creating a mind map, reference images and material samples ready for discussion with your team and partners. My preferred personal approach to putting together a concept is working in a team and bouncing ideas off of one another. I believe all good ideas come from collaboration, not just one person. Concept development Here you should test your concept with a selection of proposed builders, building control consultant and discuss feasibility with the Care Quality Commission (CQC) and laser consultants. Before you go any further, you want to make sure it works and is of course legal. Detailing Even though the actual drawing up of plans will be produced by your contractor and other sub-contractors, make sure you understand them. Again, taking time out and going over these a few times, as well as making the contractor explain in detail how they have interpreted your vision, will

Conclusion Your clinic interiors are a vital part of your business. Allow time to do it properly once, rather than half-heartedly twice. In my opinion, I recommend allocating most of your budget to your front-of-house refurbishment as your patients will appreciate and notice it; then you can work your way back. Redecorating or refurbishing your clinic will disrupt your business, but by putting in the extra hours at the start and creating a plan for the work, you will be able to vastly reduce disruption and unwanted extra costs. Benedict Wilhelm is the founder and creative director at Benedict Wilhelm Design, a London-based design studio specialising in projects within the hospitality, retail, beauty and residential sector. Wilhelm’s vast portfolio of clients include Burberry, EF Medispa, Dunhill, D. Thomas, Selfridges, Harrods and many more. REFERENCES 1. HM Government, Health Building Note 00-01 <https://assets. publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/316247/HBN_00-01-2.pdf> 2. HM Government, The Building Regulations 2010, Access to and use of buildings <https://assets.publishing.service.gov. uk/government/uploads/system/uploads/attachment_data/ file/540330/BR_PDF_AD_M1_2015_with_2016_amendments_ V3.pdf> 3. Philip Kotler, ‘Atmospherics as a Marketing Tool’, Journal of Retailing, Volume 49 (4), (1973), (p. 48) 4. Aesthetics journal, Developing your brand identity <https:// aestheticsjournal.com/feature/developing-your-brand-identity>

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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“The most rewarding cases are when you can do something using aesthetics to help patients move on with their lives” Allie Anderson speaks to Dr Miguel Montero about his passion for lasers and winning the Med-fx Award for Best Clinic North England at the Aesthetics Awards 2017 Hailing from Almeria in the south of Spain, Dr Miguel Montero came to the UK in 1994 to follow a career in trauma surgery, having become interested in the specialism during a stint in the Spanish Army. “I was a Second Lieutenant in the medical corps and that got me into trauma surgery,” he explains. When Dr Montero arrived, he worked in a surgical trainee capacity for East Lancashire NHS Trust until 2000. From then he undertook GP training until 2003, before becoming a full-time partner at a GP surgery. “My dad was a GP, so I followed in his footsteps. After finishing in the army, I had a brief spell working with my dad in his clinic, and he had a soft, low-level laser, which he used to treat sports injuries,” explains Dr Montero, adding, “That’s what got me really interested in lasers, so when I became a GP I had a little more control over my career path and in time, I decided to pursue that interest.” He undertook his first qualification in lasers and lights in 2007, and the following year Dr Montero and his wife, Gill, established Discover Laser Medical Aesthetic Clinic in their hometown of Burnley. Dr Montero admits that, in hindsight, it wasn’t a great time to change careers and start up a new business – just a few months after opening the clinic’s doors, the Monteros found themselves on the precipice of the recession. To keep afloat, he continued to practice as a GP during the week and treated patients at Discover Laser in the evenings and at weekends. “The clinic grew very slowly because I couldn’t dedicate the resources to it that it needed, and because Burnley isn’t the most affluent area my patients couldn’t dedicate resources to having treatment either,” he recalls. “It was a very intense period of my life; I had no life other than work.” Very gradually, however, his hard work began to pay off; the business stayed afloat and became more profitable year-on-year until eventually, Dr Montero realised that to make Discover Laser the success it had the potential to be, he would

need to make a huge sacrifice. “In 2015, I had to make one of the hardest decisions of my life – to quit as a GP and focus on aesthetics full time,” he says. Since then, the business has gone from strength to strength. At the very heart of what Dr Montero does – and the ethos behind setting up Discover Laser – is the use of aesthetics in a medical context to help patients to boost their wellbeing and confidence. “It’s important not to forget that we are doctors,” says Dr Montero. “The most rewarding cases are when you can do something using aesthetics to help patients move on with their lives.” It was this passion for combining medical treatment with aesthetic techniques – and having achieved safe, effective results for more than 5,000 patients – that struck a chord with judges at the 2017 Aesthetics Awards and led to Dr Montero and his team winning the Med-fx Award for Best Clinic North England. “It was a great achievement not just for me, but for the whole team,” Dr Montero says. “It reflects the quality of the team we have and all the hard work everyone puts in. It’s really important that the years of training and improvement are recognised. We never settle and always strive to get better and that’s reflected in an award like this.”

Indeed, education and continual professional development are a key part of Dr Montero’s success. Just two months after the Aesthetics Awards win he graduated from the University of Central Lancashire with a Master’s degree in non-surgical facial aesthetics, which he believes cemented his reputation and further endorsed his clinic’s position as the very best in the north of England. “I’d like to think our commitment to training also impressed the judges,” Dr Montero adds. “I'm very passionate about raising standards and I hope that was reflected in the entry.” His advice for this year’s entrants is simple: “Be truthful. What you write in your entry must honestly reflect the quality of services you offer.” He also credits his award entry with having an outsider’s view; the clinic’s marketing professional had input into the application and gave valuable insight over how to make the clinic’s strengths shine through. “That was really useful to give us perspective that you sometimes lose when you are too involved with the business,” Dr Montero adds. “So I would advise people to ask family, friends or colleagues who know the business well for their input on some of the questions, because that can help to give context and also to frame the judges' view of your business.”

What is your motto? ’Patients before profits’. We always try to offer the best for our patients and they will always come first. This is something we live by and drill into our colleagues in our clinic. What’s the best piece of career advice you’ve ever been given? I’ve had many exceptional colleagues who have given me very good advice. The main thing I’ve learned is to be upfront and honest with patients and don’t hide away from difficult discussions. If you keep trying to bury things, they will always come back to haunt you. What would you tell someone starting out in aesthetics? To start a business and find out there are no regulations over what anyone can do can be a minefield. I would urge people to keep training, keep attending conferences, and be aware of your personal limitations to keep patient safety at the fore of what you do.

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


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The Last Word Dr MJ Rowland-Warmann argues why she believes the risks of non-surgical nose reshaping are being trivialised by posting procedure videos on social media Non-surgical rhinoplasty (NSR) procedures are the fastest growing cosmetic trend of 2016, particularly between those aged 18-24, and currently receive 6,600 monthly Google searches in the UK.1 For a demographic as tiny as this, it’s an enormous search volume. The treatment is seen by many patients as the accessible and simple alternative to surgery and is generally advertised by practitioners as the quick, cheap and low risk option. This combined with the rise in promotion of procedures on social media has me deeply concerned for patient safety. My observations indicate that there has been a recent rise in the ‘how-to’ nose job video for consumption by unqualified, untrained practitioners and, in my opinion, presented, directed and starring those who should know better. You’ll have surely seen them: a short clip on Instagram, YouTube or Facebook of a step-by-step guide of this most hazardous procedures promoted to arm-chair ‘practitioners’ the world over. The motive: ‘educational’. But for whom? The risks of NSRs A NSR is a procedure that should always be considered high risk. It requires an experienced practitioner to complete and achieve the correct proportions of the nose and reduce the possible risk to the patient. Vascular complications are fortunately rare. Yet evidence compiled in 2016 suggests

59% of skin ischaemia cases and 42% of vision loss cases relating to dermal filler occur after treatment to the nose.2,3,4 Whilst swift management of complications results in over two thirds of cases of skin ischaemia resolving without long term effects, vision loss can be permanent and irreversible. Most worryingly, following my research of the social media posts being shared on NSR procedures, it seems that blindness is an aspect of this treatment often being ignored, overlooked or trivialised by many. Using social media to promote NSR treatments: what’s the issue? Social media is a great tool for attracting new patients, increasing personal visibility online and demonstrating authority on a subject. There is no disputing that showing patients before and after pictures is a good way of demonstrating the scope of a proposed procedure. There’s also no doubt we should all be promoting our educational qualifications and experience. Most importantly, practitioners should be making patients aware of procedure risks, especially with treatments such as NSR, and educating patients on how to choose competent and experienced practitioners. Social media is a great place to do this effectively. However, we’re all aware of the existence of unqualified, unregistered

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practitioners operating in aesthetics and using social media as their only marketing channel. What clinicians posting their procedure videos don’t seem to realise is that it’s not only their prospective patients watching these videos in order to become informed of the procedure. There are people watching who are trying to learn this procedure quickly and cheaply to make maximum profits for their businesses. To me this is a plain case of what Ryan Holiday, the former director of marketing for American Apparel, editor-at-large for the New York Observer and author of Trust me, I’m Lying: Confessions of a Media Manipulator, dubbed, ‘Self-indulgent prostitution of serious issues in a relentless and cynical pursuit of clicks, likes and shares’.5 Clinicians may forget that anyone with a debit card and a couch can pick up a syringe of dermal filler and have a go at treating patients in the UK. I am seeing a worrying trend in practitioners posting these ‘how-to’ videos online without any warnings to practitioners or patients, in a way that trivialises patient safety to an alarming extent. Restrictions and regulations In terms of regulation, YouTube and social media platforms have policies on posting harmful or dangerous content, which explains that whilst it may not seem fair to restrict what can be shown, a line is drawn at content that encourages ‘dangerous activity or [those] that have an inherent risk of serious physical harm’.6 Whilst social media platforms are putting in place additional steps for protecting people from harmful content, there’s a colossal amount of content out there that needs to be policed. Practitioners posting NSR videos may think that just because their content is not taken down, it is suitable and appropriate. We are healthcare professionals and subscribe to higher standards than this – ethical standards – which, in my opinion, are not even remotely present at these poorly regulated social media organisations like YouTube who seem to value ‘freedom of expression’ and financial gain over potential for harm. The General Medical Council, General Dental Council and Nursing and Midwifery Council all offer guidance on using social media and emphasise the importance of behaving responsibly online.7,8,9 I put it to you that posting these types of videos is precisely the opposite and shows a lack of insight. Practitioners

Reproduced from Aesthetics | Volume 5/Issue 6 - May 2018


who genuinely care about the safety of patients and the impact of their actions on their community may think twice before releasing this type of content. What’s the solution? It’s true that education is at the forefront of what we do as aesthetic practitioners but, in my opinion, educating patients by walking them through the minute detail of their upcoming procedure, before they’ve even visited you for a consultation, is unnecessary. Education is not about the myopic profiling of your skills – it’s about giving your patients a balanced picture that demonstrates to them the gravity of the intervention they are considering and the potential wonderful benefits it might yield. I would advise practitioners to consider whether it is sufficient to show patients the possibility of treatment with before and after images rather than a step-by-step video of the procedure with instructions of how it’s performed. After all education is not about the teacher it’s about the student. Any enlightened educator must ask themselves, ‘What will people do with this information?’. Conclusion I believe that posting videos openly demonstrating the precise methodology of a treatment with such grave and serious potential risks as NSR, is reckless and irresponsible. And with each impression, like and share of a video, the reality of a patient suffering from a serious complication draws closer. I also believe there should perhaps be a little mystery surrounding professional techniques – brilliant clinicians consistently strive for mastery by critical thinking, flawless execution and countless hours of practice and training. And I think we can all agree that nobody ever achieved true mastery of anything by spending time on social media. Patients may commit to filler procedures without being adequately aware of the risks. And due to the lax regulations regarding practitioner status, poor advertising controls and the derisory state of social media regulation, patients are at risk of serious harm. As aesthetic practitioners, we should consider what is in the interests of our patients, and the wider community, and consider the implications of using NSR videos to promote our brands. Dr MJ Rowland-Warmann is the founder and lead clinician at Smileworks, based in Liverpool. In 2016 she completed her MSc in Aesthetic Medicine (with a distinction) from Queen Mary University of London. She has a special interest in the management of complications; writing extensively on the subject. REFERENCES 1. Dentistry.co.uk, Non-surgical rhinoplasty named fastest growing cosmetic trend. http://www. dentistry.co.uk/2017/04/19/non-surgical-rhinoplasty/, 2017. 19.04.2017. 2. DeLorenzi, C., Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J, 2014. 34(4): p.584-600. 3. Cohen, J.L., et al., Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations. Aesthet Surg J, 2015. 35(7): p. 844-9. 4. Rowland-Warmann, M., Midface rejuvenation with Hyaluronic Acid: A critical appraisal of the vascular complication risks and the development of evidence based protocols for their prevention and management. (2016) <https://www.smileworksliverpool.co.uk/wp-content/ uploads/2017/05/Dermal-Filler-Vascular-Complications-2016.pdf> 5. Holiday, R., Trust Me I’m Lying: Confessions of a Media Manipulator. 2018. 6. YouTube, Policies and Safety. <https://www.youtube.com/yt/about/policies/ - communityguidelines> 7. Council, G.D., Guidance on using social media. 2016. 8. Doctors’ use of social media (General Medical Council, 2013) <https://www.gmc-uk.org/guidance/ ethical_guidance/21186.asp> 9. Social Media Guidance (Nursing and Midwifery Council, 2018) <https://www.nmc.org.uk/ standards/guidance/social-media-guidance/>

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Date of preparation: January 2018 RES18-01-0031c

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