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VOLUME 1/ISSUE 12 - NOVEMBER 2014
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Botulinum toxin type A free from complexing proteins
Now approved for crow’s feet lines Prescribing Information can be found on the inside front cover Date of preparation October 2014 1181/BOC/OCT/2014/LD
Psychological Screening CPD Article MZ054 1181/BOC/OCT/2014/LD BOCOUTURE .indd 1
Nicole Paraskeva on the routine psychological assessment of patients
Male Body Contouring
Marketing to Men
Injectable 24/10/2014 09:05 Lipo
A discussion of male-specific body contouring treatments
Michelle Boxall looks at the best ways to target your male audience
Dr Vincent Wong addresses the science behind injectable lipolysis
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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid ﬁllers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Tauﬁg A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efﬁcacy, safety, and patient satisfaction of a monophasic cohesive polydensiﬁed matrix versus a biphasic nonanimal stabilized hyaluronic acid ﬁller after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inﬂammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the ﬁrst week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency deﬁned as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, inﬂuenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision,
Tel: +44 (0) 333 200 4140 Email: email@example.com
BEL141/1014/LD Date of preparation: October 2014
blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Inﬂuenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualiﬁcations and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to firstname.lastname@example.org or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1181/BOC/OCT/2014/LD Date of preparation: October 2014
Contents • November 2014 INSIDER 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month
CLINICAL PRACTICE Male Body Contouring Page 23
16 Conference Reports We report from BCAM, AAFPRS, BACN and EADV 19 Training Report: The Management of Non-Surgical Complications Anatomy-led training conducted by Mr Dalvi Humzah 21 News Special A preview of the Aesthetics Conference and Exhibition 2015
CLINICAL PRACTICE 23 Special Feature: Male Body Contouring Leading practitioners discuss the growing demand for male- specific body contouring 28 CPD Clinical Article Nicole Paraskeva addresses the routine psychological screening of aesthetic patients 34 Male Products Dr Rachael Eckel shares her advice on treating male skin 40 Hyaluronidase Melanie Recchia and Mr Adrian Richards look at treating dermal filler complications 43 Injectable Lipolysis Dr Vincent Wong explores injectable treatment of localised adiposity 46 Carbon Dioxide and Oxygen Dr Domenico Amuso on the complementary roles of Carboxytherapy and Oxygen Infusion 48 Absorbable threads Dr Elisabeth Dancey discusses threads for facial lifting 52 Advertorial: Medisico Details about the Body Face Couture aesthetic product range 54 Abstracts A round-up and summary of useful clinical papers
IN PRACTICE Marketing to Men Page 57
Clinical contributors Nicole Paraskeva is a research associate and trainee health psychologist at the Centre for Appearance Research at the University of the West of England, Bristol. Nicole’s research involves trialling a psychological screening and audit tool. Dr Rachael Eckel is a cosmetic dermatologist, US board certified in aesthetic medicine. She is a multi-published author who educates physicians internationally, with a focus on topical skincare agents. Mr Adrian Richards is a consultant plastic and cosmetic surgeon who has specialised in aesthetics for more than 15 years. He is the clinical director and founder of nationwide cosmetic surgery group Aurora Clinics. Melanie Recchia is a Nurse Independent Prescriber specialising in muscle relaxing injections, dermal fillers and specialist skin treatments. She also manages a successful clinic in Buckinghamshire. Dr Vincent Wong is an advanced medical aesthetics practitioner and the founder of Harley street clinic La Maison de l’Esthetique. He has extensive research experience in plastic surgery and dermatology. Dr Domenico Amuso is a general surgeon and cosmetic doctor working in Modena, Italy. Dr Amuso graduated in Medicine and Surgery in 1994 and has a Master’s degree in Surgery and Aesthetic Medicine. Dr Elisabeth Dancey has been practising cosmetic medicine since 1993. She introduced mesotherapy to the UK having studied at Liege, Belgium. She now owns Bijoux Medi Spa in central London.
IN PRACTICE 57 Marketing to Men Michelle Boxall on connecting with your growing male audience 60 The Business of Acne Wendy Lewis shares her advice on building a successful acne clinic 64 Testing and Measuring Kurt Won on the importance of evaluating your aesthetic business 66 In Profile: Beth Briden We speak to Minnesota-based leading dermatologist Dr Beth Briden 68 The Last Word: Technology Mr Vivek Sivarajan on the significance of technological advancements in aesthetics NEXT MONTH
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Editor’s letter We are well and truly in the midst of conference season for the professional organisations, with the British Association of Aesthetic Plastic Surgeons (BAAPS), British College of Aesthetic Medicine (BCAM) and the British Association of Cosmetic Nurses (BACN) Amanda Cameron Editor holding their annual meetings within the last couple of months. So why attend professional conferences? Criteria and reasons for attending events vary between individuals but it seems to me there are some key ones, including first and foremost; education. The importance of continued professional development lies not only in the regulatory requirement but also in the desire to constantly strive to better oneself in a profession where safety and welfare should be at the forefront of everything we do; especially in an industry where advances in both products and techniques are so constant. Additionally, meetings present ideas around clinical best practice and commercial considerations. Not to mention that it is a great chance to network with others who may be facing similar challenges within our profession. For the conferences that we choose to attend, the programmes need to be innovative, exciting and attractive for all audiences. I know this only too well as we move
forward with planning the Aesthetics Conference and Exhibition, and I’m delighted to reveal further details about the agenda in a special preview article in this issue of the journal. From experience, I know that any event you attend should add tangible value to your business, and to really get the most out of your conference attendance you should take steps to implement learning directly into your practice as soon as possible. Following the event, hold a staff meeting and ask the attendees to present their learnings and then work out a plan of action to implement at least two new ideas. These may be new techniques, new methods, new products, or just a new way of speaking to your customers. Ensure you have objective measures to evaluate the outcome and then your conference attendance becomes a valuable tool to yourself and your colleagues. Alongside conference reports, the journal this month is our ‘Male Special’, wherein we provide an opportunity to learn about male body contouring from the experts in our special feature, share advice from Dr Rachael Eckel on cosmeceutical products suitable for men, plus offer insights from Michelle Boxall on how to successfully market your clinic and services to this growing demographic. I hope you find this all of use to your practice, and I look forward to hearing your thoughts on our latest issue.
Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s editorial advisory board to help steer the direction of educational, clinical and business content Dr Mike Comins is fellow and former president of the
Dr Raj Acquilla is a cosmetic dermatologist with over 11 years
British College of Aesthetic Medicine. He is part of the cosmetic interventions working group, and is on the faculty for the European College of Aesthetic Medicine. Dr Comins is also an accredited trainer for advanced Vaser liposuction, having performed over 3000 Vaser liposuction treatments.
experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.
Mr Dalvi Humzah is a consultant plastic, reconstructive and
Dr Tapan Patel is the founder and medical director of VIVA
aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.
and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.
Sharon Bennett is chair of the British Association of
Mr Adrian Richards is a plastic and cosmetic surgeon with
Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. Sharon has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).
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 Christopher Rowland Payne is a consultant
Dr Sarah Tonks is an aesthetic doctor and previous
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.
maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonalbased therapies.
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#Psoriasis Dermatology Times / @DermTimesNow It is estimated that worldwide 125 mil people suffer from #psoriasis. Of this group, 80% have #plaguepsoriasis. #Travel Dr Raj Acquilla / @RajAcquilla Ok so 9 @Allergan #UK Masterclasses in 7 days complete and now to @PHIclinic #France #Russia #Turkey #India #Colombia #Socialmedia GMC / @gmcuk It is important that drs in training are informed about using social media – Today we are talking about the dos and don’ts #gmcnimdta #Conference Dr Askari Townshend / @Dr_AskariT Looking forward to worldwide #SilhouetteSoft expert meeting in Barcelona…. If I ever make it
Sponsorship announced for ACE 2015 Sponsors of the Aesthetics Conference and Exhibition (ACE) have been announced for the industry-leading event, set to take place on Saturday 7 and Sunday 8 March 2015. Aesthetic Source has secured the headline sponsorship for ACE, which is set to attract more than 2,000 delegates to the Business Design Centre, Islington, London in the spring. Director, Lorna Bowes, said, “Aesthetic Source is delighted to be headline sponsor at ACE. We look forward to meeting friends, old and new, and sharing our evidencebased skin fitness products, which have been clinically proven to improve skin health and condition. Make sure you come and see us at stand 48 where we will be delighted to tell you about our exciting innovations and developments.” duction Fat Re
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#Learning P & D SURGERY / @pdsurgery Great day at RCSEng anatomy teaching. Fab delegates. #Aestheticsjournal Dr Carolyn Berry / @FirvaleClinic I am elbow deep in references as I write my article for #Aesthetics journal To share your thoughts follow us on Twitter @aestheticsgroup, or email us at firstname.lastname@example.org
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Galderma begins trials for liquid form of botulinum toxin Global healthcare company Galderma has announced that it has initiated a Phase II clinical trial of a liquid form of botulinum toxin in the US. The multicentre, dose-range study will evaluate the safety and effectiveness of Galderma’s internally developed liquid form of botulinum toxin for the treatment of glabellar lines. President and CEO of Galderma, Humberto C. Antunes, said, “The development of a liquid neurotoxin will allow us to further strengthen our position in the aesthetic category by better meeting physician and patient needs.” Currently, all commercially available botulinum toxins come in powder form and have to be reconstituted with saline before use. Galderma claim that a ready-to-use liquid product would improve aesthetic outcomes and patient experience. Atunes said, “This trial initiation demonstrates Galderma’s commitment to innovation in the aesthetic market and is designed to strengthen and complement our current neurotoxin franchise.” Galderma acquired a portfolio of aesthetic medicine products, which include Dysport and Azzalure, in July 2014. 6
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Aesthetics | November 2014
HEE to hold stakeholder summit Health Education England (HEE) will hold a summit on Tuesday 9 December at the Kia Oval, London. The event will present the proposed educational and training framework for their report: Non-surgical Cosmetic Interventions and Hair Restoration Surgery. It will give stakeholders the opportunity to contribute to aspects of Phase 2 of the project. Policy development manager, Carol Jollie, said, “We really hope that as many people as possible attend our event – whether you are a practitioner or a manufacturer, insurer or training provider – this will be your last opportunity to contribute to the design of our qualification requirements.”
Church Pharmacy launches new online prescribing service Church Pharmacy has launched DigitRx, a new e-prescribing service that aims to streamline the ordering process for aesthetic practitioners. DigitRx saves all prescription details online, meaning that the information can be accessed by an authorised practitioner from any location. Information from past prescriptions is also stored, to aid with repeat prescriptions. Only authorised practitioners can administer an electronic signature in order to finalise prescriptions, however a separate login facility allows office admin to complete orders. With a thorough registration process and the use of a secure PIN in order to maximise security, access to the free online service is more similar to opening a bank account than a facebook account, says Zain Bhojani,
co-director of Church Pharmacy. “The sign up process is so robust and secure, and designed with the practitioner in mind, that you do not need to send us the original paperwork in the post – not only making it very eco friendly but also saving time and money on postage and admin costs,” he said. The paperless service will offer access to all essential non-prescription as well as prescription-only products.
QuantifiCare launches 3D skin analysis application Medical imaging specialist, QuantifiCare, has launched a new application for its imaging system, 3D LifeViz II. The SkinCare module aims to allow practitioners to measure and analyse topical facial skin conditions and generate a full medical report. Up until its September launch, the manufacturers claimed that the device was able to display superior quality 3D patient pictures from a multitude of angles, which could be compared with previous images. Now, according to QuantifiCare, SkinCare enables 3D LifeViz II to generate a complete report that measures skin changes, wrinkles, oiliness, pores, and red and brown spots. They believe that patients’ skin health can be compared with a matching population and the severity of each issue can be visualised in 3D and highlighted on a colour scale. 3D LifeViz II now provides a reference tool, which can assist the practitioner in advising the patient on appropriate aesthetic treatment.
T H E A R T O F FA C I A L R E J U V E N AT I O N
Oxygenetix launches acne-specific foundation Oxygenetix, known for its post-procedure foundation, has now launched a foundation that claims to aid in the treatment of acne, whilst also concealing the condition. Oxygenetix Acne Control Foundation contains 2% salicylic acid to actively treat acne, as well as the patent-pending Ceravitae technology that the manufacturers claim is unique to Oxygenetix products. Oxygenetix purports to promote collagen cell production and connective tissue growth as well as attracting oxygen to the skin, allowing it to “breathe” through the foundation. Like the original formula, Acne Control is aloebarbadensis gel based, to provide anti-bacterial qualities and protect compromised skin, whilst astringently removing dead surface cells. According to Oxygenetix founder Barry Knapp, “Nearly every cream, oil and mineral-based makeup sits on your skin and suffocates it by blocking oxygen. And most make-up contains alcohol-based preservatives that decrease levels of oxygen entering your skin and inflame acne prone skin. But not Oxygenetix. Recent clinical tests confirm Oxygenetix to be the only foundation product to increase oxygen absorption by the skin, as much as four times the amount, as if not wearing any makeup product at all.”
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V Soft Lift launches in UK V Soft Lift, a threading technique using PDO threads, is now available in the UK through Medical Aesthetic Supplies Ltd. PDO threads originate from Korea, where the V Soft Lift technique was first developed, with the aim of changing the classical oriental round face into a more western V shape, which is commonly perceived to be more attractive in Korea. Unlike PLA threads, which use cones and ratchets to hook to the tissue, the manufacturers claim that PDO works by creating new collagen around the thread. The treatment protocol for the V Soft Lift, which has been developed by the Swedish InjectAcademy, involves creating a mesh of PDO threads throughout the area to be treated in order to form a network of supporting fibres and new collagen. The thread is a single monofilament thread with a slight spiralling motion. There are two thicknesses; a 5.0 thread mounted on a 27G x 50mm needle and a 6.0 thread Before V soft
After V soft
mounted on a 29G x 20mm needle. A treatment takes between 30 and 60 minutes, and it has been reported that results can be seen immediately, although it will take around three months to see the full effect. Practitioner Dr Elisabeth Dancey, said, “Threading is a technique that requires skill, manual dexterity, experience and an understanding of the anatomy of the skin and of the face. Only advanced practitioners should be performing the technique. It complements all other treatments such as fillers, toxin and peeling, and it can also be considered as an alternative to fillers and toxin, where the patient does not wish to receive these treatments. V Soft Lift will last much longer than toxin.”
Further disagreement between Valeant and Allergan Valeant CEO, J. Michael Pearson, has offered ‘an olive branch’ to Allergan chairman and CEO, David Pyott. In an open letter, dated September 22, Pearson asked Pyott to “consider the olive branch extended” and engage in “a constructive discussion about value, rather than more mudslinging”. The invitation is the latest move to settle a five-month disagreement regarding the proposed Valeant takeover of Allergan. Pearson said that it was regrettable that their tone in public had become acrimonious at times, but added that he did not appreciate what he believed to be Allergan’s “baseless attacks” on Valeant’s business model. The Valeant CEO encouraged Pyott to discuss matters earlier than December 18, the date scheduled for a special shareholder meeting. He said that his team were prepared to meet the Allergan board directly to answer any questions they may have. Pearson said, “I believe we still have an opportunity to take the temperature down, and come together to see if we can begin a conversation that could lead to even more value for your stockholders, while still being the right transaction for ours.” The attempt was met with further disagreement however, when Allergan CEO, David Pyott, responded, “While we acknowledge your effort as a positive engagement, we continue to conclude that Valeant’s offer is grossly inadequate and substantially undervalues Allergan.” In response to Valeant’s accusation of baseless attacks, Pyott said that Allergan had made statements based on its knowledge of Valeant, its deep understanding of the pharmaceutical industry and the needs of physicians and patients to express concern regarding the sustainability of Valeant’s business model. He said that the Allergan board of directors were, “very much looking forward to the special meeting on December 18 and to continuing to deliver exceptional value for Allergan’s stockholders.” Meanwhile, Allergan’s attempt to acquire Salix Pharmaceuticals has been stalled due to pressure from three of its shareholders. Jackson Square Partners, T.Rowe Price and Pentwater Capital Management all released statements that insisted the Botox maker refrained from making an all-cash deal, which would not require their shareholder approval. Pentwater’s CEO, Matthew Halbower, said that Pentwater believed that Allergan should not make any acquisitions before the shareholder’s meeting in December. He said, “Pentwater does not understand how Allergan’s directors could possibly conclude it is an appropriate exercise of their fiduciary duty to embark on such a large-scale acquisition without first engaging with Valeant.” Allergan said that they appreciated the perspectives of their stockholders and insisted that the board remains confident that the company can deliver significantly more value than Valeant.
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Study finds dermatology patients value photography for educational use
Between 2000-2013 there was a 104% increase in the number of cosmetic procedures performed on men in the US
A study published in the Dermatologic Surgery journal has found that a majority of dermatology patients would allow their photographs to be used publicly as they believe photographs would enhance medical care. 400 patients, representing a broad range of ages, socioeconomic groups and ethnicities, were recruited from four dermatology practices in the city of New York. The patients were given a survey about perceptions of photography, willingness to allow photographs to be used in a variety of settings, preferences for photographer and photographic equipment, and methods of consent. 88% of patients agreed that photography enhanced their quality of care. Most patients would allow their photographs to be used for medical, teaching, and research purposes, with significantly more acceptance when patients were not identifiable in the photographs. More than 94% of patients were more comfortable for photographs to be taken by a physician rather than a nurse or student. The majority (90.3%) preferred photographers of the same gender and there was a notable preference for giving written consent (78.4%) for the use of photography over verbal consent (14.1%). Although there was no association between gender, age, clinic site or socioeconomic status and the general impression of medical photography, there were significant ethnicity-related variations in responses, with 19.7% of Latino patients and 12.5% of black patients reporting that they did not agree that clinical photography could enhance care.
American Society of Plastic Surgeons
60% of all people suffering from acne develop skin lesions on their back NHS Inform
85% of followers of
small and medium-sized businesses (SMB) on Twitter feel more connected with the SMB after following them
Market Probe International
In a blood analysis of adults aged 19 to 64 years, 23% showed evidence of low vitamin D status Public Health England
“Botox bars” prove popular in America A new trend for walk-in injectable clinics is spreading across the US. The concept originated in California, where dermatologist Dr Vicki Rappaport launched the SKN bar, and has now spread to Tucson, where Skinjectables Anti-ageing bar hopes to become a household name. The design of the clinic is based on a bar, with a shot menu and a happy hour. Bar stools accompany the reception desk and patients can book ‘Botox parties’ in either their clinic or their home. UK-based practitioner Sharon Bennett, said, “This idea trivialises a prescribed medical procedure. It implies to the public that there is no risk. It is unlikely that a complete medical consultation and a proper examination of the patient would be carried out in a party atmosphere and latent problems are unlikely to be picked up by the practitioner.” Co-owner and assistant practitioner, Katie O’Brien, told her local news website, Tucson.com, that she hopes the clinic will provide patients with a “hip, trendy atmosphere”. She said, “When people think of coffee, they think of Starbucks. We want people in Tucson to think of Skinjectables when they think of Botox or fillers.” Dr Sarah Tonks, another UK-based practitioner, said, “My problem in this situation would be that you may not have time to build a relationship or work out what would be the most beneficial treatment for the patient in that short space of time.”
26% of men
surveyed want to trim down their stomach area British Military Fitness
One in twelve adults in the UK have eczema National Eczema Society
In the last 4 years Transform Cosmetic Surgery Group in Edinburgh received 60 enquiries regarding male chest reduction, compared to 122 in Northern Ireland Transform Cosmetic Surgery Group
Aesthetics | November 2014
Elizabeth Arden launches professional skincare line
Beauty brand Elizabeth Arden has teamed up with chemist and founder of Priori Skincare, Joe Lewis, to launch a new cosmeceutical range, Elizabeth Arden PRO. With both professional treatments and home-care products available within the range, Elizabeth Arden PRO purports to address skin concerns in five regimens: Problem Prone, Brightening, Age Defying, Hydration and Sensitive. The products contain several patent-pending ingredients, including AHA Retinoid Conjugate, an AHA/vitamin A derivative combination; and Allyl PQQ, a new mitochondrial antioxidant. The in-salon range offers professional-strength chemical peel treatments, with the two core products being the Hydrating Peel Gel and Multifunctional Peel Gel. They aim to create a fresh-faced look, improve hydration, reduce the appearance of lines and age spots and improve overall skin texture. Lewis said, “We believe the combination of these novel technologies offers new simple solutions for clients’ skin conditions with improved efficacy, reduced irritation and therefore better overall results with enhanced compliance.” Elizabeth Arden PRO is available only to the professional skincare market.
BAAPS calls for new measuring system to evaluate cosmetic products At the Annual Scientific Meeting of the British Association of Aesthetic Plastic Surgeons (BAAPS) in September, a new study was presented which revealed that the amount of consumer press coverage for four of the most popular aesthetic devices was 24 times the number of clinical papers behind them. In response to this, the BAAPS has developed a new system, known as the “evidence pyramid”, to evaluate science versus hype. The research found that mainstream press coverage of cosmetic surgery and aesthetic procedures had increased by 7,900% since 1991, but even the peerreviewed coverage, which did exist on some of the most popular new devices, was often superficial – the study’s evaluation of high-profile non-invasive liposuction technologies showed the number of patients studied, varied from just two cases to a few hundred (only 16% involved more than 100 and more than half involved less than 50). All but one were based on less than six months’ follow-up. In addition, 36% of authors disclosed a financial or conflict of interest. The surgical arena uses a colour-coded “evidence pyramid” to evaluate the data published in outlets such as the Aesthetic Surgery Journal, which classifies the level of research behind the study conclusions. This evidence pyramid was presented at the BAAPS conference, along with a simplified version to be presented to the media and public, allowing them to accurately gauge the amount of proof behind new product claims. The pared-down, consumer version of the
evidence pyramid broadly offers four levels of evidence: Top tier: has been studied for more than five years, easily researchable with more than 50 non-sponsored studies in medical/scientific journals Second tier: has been studied for between two and five years and has more than 20 non-sponsored studies in medical/scientific journals Third tier: has been studied for at least a year, with a minimum of five non-sponsored papers in medical/scientific journals Below Surface Level: has been studied for less than one year and may be based on a single case study. Information on the treatment is found almost exclusively via promotional channels rather than presented to peers via scientific conferences or publications. BAAPS president Rajiv Grover commented, “As the research presented today shows, much of what is communicated will inevitably be led by manufacturers, commercial providers or individual practitioners, occasionally making grandiose claims. In the clinical world, there is widespread use of ‘tiers’ which allow us to determine how much research backs findings, so we can make informed decisions based on evidence that goes further than skin deep. However, without a similar filter, there are pitfalls for those who might be swayed by weak data, manipulated photos or paid-for celebrity endorsements. There urgently needs to be a traffic light or warning system for new devices and techniques promoted to the public.”
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Lipolife laser used for gynecomastia treatment The Lipolife 1470nm diode laser from Alma, distributed in the UK by ABC Lasers, is being used to treat gynecomastia in outpatient settings. The manufacturers claim that Lipolife offers the perfect alternative to surgical liposuction for gynecomastia, as it offers faster glandular tissue destruction as well as excess skin shrinkage. According to Alma, this is best demonstrated using the 1470nm wavelength which is characterised by high water absorption together with a radial emitting fibre that emits energy in a 360 degree pattern, covering the inner and outer parts of the breast tissue. Lipolife features a dual-purpose cannula, spot location view and temperature control setup. Dr Alex Levenberg, an Israeli plastic surgeon who uses Lipolife to treat gynecomastia commented, “LipoLife is an ideal tool for performing gynecomastia procedures. It is easily applied and allows me, as a treating physician, to address all complexities of this procedure. Alma’s unique cannula is designed for simultaneous lasing and aspiration, and together with the radial emitting fibre and Before Lipolife After Lipolife temperature control feature, reduces procedure time and enables me to shrink excess skin. It also assures that the patient will suffer minimal side effects including blood loss. The entire procedure can be performed in an outpatient setting applying sedation and local tumescent anesthesia only. Patients check out with minimal side bruising.” Cosmeceuticals
Personalised skincare: the future of cosmeceuticals? A survey carried out by market research company Canadean has found that many UK consumers would be keen to take the concept of personalised skincare further, with 45% of those surveyed interested in a laboratory approach to find a product that exactly matches their skincare needs. Of those interested in personalised skincare products, 54% say they are ready to provide blood, skin and hair samples to be tested in a laboratory, 51% would be interested in giving a DNA swab samples, and 52% would like to go to a dermatologist consultation. In Russia, IC Lab offers this individualised service, where customers are invited to visit the laboratory to have their skin tested, before formulating a product that is specifically tailored to that person’s skincare needs. The product can take up to a month to be ready, but Canadeans survey results indicate that consumers are prepared to wait for the right product, and 59% are prepared to pay a premium for the service. In Russia, IC Lab charges 3,000 rubles (around £50) for a 15ml eye cream, which is not only formulated with the client’s skin in mind, but also features their name on the packaging. According to Veronika Zhupanova, analyst at Canadean, “Over 22 % of skincare consumption by volume globally is driven by individualism, and with the development of new technologies, manufacturers have opportunities to take it to a whole new level. Factors such as allergies, genetic predisposal, nutrition, climate and exposure to the sun are all individual needs perfect for tailoring.” Aesthetics | November 2014
60 Seconds with… Ros Bown, Founder and CEO of Rosmetics What new products have Rosmetics recently added to their range? STYLAGE® is a key product acquisition in our distribution range as we are now able to provide practitioners with a leading European filler brand in addition to the skincare, peel and device options that we have been providing for a number of years. The diversity of STYLAGE® means it can be used for filling and smoothing wrinkles, natural lip correction, volume restoration, hydration, chin remodelling, tear trough correction, neck, décolletage and hand rejuvenation. We have also introduced the Revitacare product range into our offering. Revitacare is a mesotherapy product, supplied in premixed vials, based on non cross-linked Hyaluronic Acid and multi vitamins to preserve and restore the physiological quality of the skin by promoting the conservation of its elasticity and protecting against external aggressions. It comes in various amounts of HA, along with a specific Hair Growth product to aid in hair restoration. Additionally, I’m delighted to announce that Rosmetics have secured the distribution for Dermagenica PDO Beauty Lift threads. The threads have a CE mark and are suitable for both facial and body skin rejuvenation. What makes Rosmetics best placed as a distributor to ensure that they are offering the leading products to practitioners? As a registered nurse prescriber, and having practised in medical aesthetics for over 20 years, I am able to draw on both my clinical knowledge and practical experience when choosing which products Rosmetics should offer to our customers. What does the future hold for Rosmetics? We are continuing to expand our range in the latter part of 2014 and into 2015. We have secured the distribution for Eurodiet, a four stage diet programme only available in medical clinics. This allows practitioners to offer a tailored diet programme developed by a group of medical practitioners, including menu plans and psychobehavioural assessment for a holistic approach to patient welfare. Drawing on my experiences, we are also currently exploring ways to make the process of prescribing toxins easier and more efficient for nurses within a safe, legal and ethical framework.
News in Brief Meditelle launches new aesthetic surgery couch range British medical equipment manufacturer Meditelle has launched a new range of couches specifically designed for use in aesthetic surgery. Comprising a two-section couch plus a wider bariatric model for larger patients, a three-section couch and a multi-way three-section couch/chair, all of the products are in the “Gillie” range. They are electrically operated and feature an electronic back rest to allow for easy positioning of the client. Medical Aesthetic Supplies personnel update Medical Aesthetic Supplies Ltd and Group companies announce that Pauleen Hume and Steve Hussey no longer have any connection with the companies or their products and services. For a short period during 2013 Steve Hussey offered consultancy services to the company. From late 2012 until mid 2014 Pauleen Hume offered product experience and sales services for STYLAGE, MENE & MOY and INNO Aesthetics. Picosure receives boost update Cynosure’s Picosure laser for tattoo removal has received the boost update, reducing its pulse length from 700 to 550ps. According to the manufacturer, this further shortened pulse length creates a 70% increase in the pressure wave, shattering the ink into tiny particles, making it easier to eliminate persistent ink. Users of the PicoSure machines are currently receiving upgraded boost technology.
Study shows sweat-eating bacteria could improve skin health A study presented at the fifth American Association for Microbiology Conference on Beneficial Microbes has shown that bacteria that metabolise ammonia, a major component of sweat, may improve skin health. In the study conducted by AOBiome LLC, which used a strain of Nitrosomonas eutropha isolated from organic soil samples, human volunteers using the ammonia-oxidising bacteria (AOB) reported better skin condition and appearance compared with a placebo control group. In the blinded, placebo-controlled trial involving 24 volunteers, one group applied a suspension of the live bacteria on their face and scalp for one week, while a second group used placebo. Both groups were followed for an additional two weeks. Subjects did not use hair products during the first and second week and they returned to their normal routine for the third week. Use of a bacterial DNA detection assay demonstrated the presence of AOB in 83-100% of skin swabs obtained from AOB users during or immediately after completion of the one-week application period, and in 60% of the users on Day 14, but not in any of the placebo control samples. The improvement among the AOB users correlated with the levels of AOB on their skin. Neither group had AOB on their skin at the start of the study. Further analysis suggested potential modulation of the skin microbiota by AOB. Importantly, there were no adverse events associated with the topical application of AOB. Industry
Film developed in aid of Safety in Beauty charity Filming is underway for a video that aims to raise consumer awareness of safety within the aesthetics industry. Aesthetic practitioner, Dr Vincent Wong has been developing the film, entitled ‘Confidence is Conscienceless’, to highlight the importance of seeking a fully qualified practitioner, and aiming to dispel myths surrounding cosmetic treatments. Dr Wong also wrote the lyrics to a song to accompany the film, which will be sung by 2009 X-Factor finalist Lucie Jones, whilst the music has been produced by musical director, Rob Archibald. Dr Wong said the process has been a, “challenging yet enjoyable experience.” The film, set to premier in January, is split into three parts. The first part looks at pressure on consumers and celebrity culture, the second details the reconstructive benefits of medical aesthetics, and the third examines safety and regulations in the industry. It will air on Sky TV and be available for download via iTunes. Patients
Medik8 introduces Retinol 6TR Advanced Night Serum Cosmeceutical brand Medik8 has launched a follow-up to its Retinol 3TR serum – Retinol 6TR Advanced Night Serum. Containing 0.6% retinol, the serum is for those who have been using retinol as part of their skincare regime and are looking for something more powerful. The serum contains vitamin E to improve stability and a safflower oil base, which the manufacturer claims allows quick absorption despite the high levels of retinol.
Allergan UK launches Clinic Connector Allergan UK has launched a tool that matches patients to an appropriate clinic or practitioner. Available via its juvederm.co.uk website, the Clinic Connector (CC) can identify what type of a practitioner a patient would like to see and ascertain their level of qualification before the patient has to make contact with the clinic. The tool allows users to select which area of the face they are interested in treating, identify their desired postprocedure outcome, select the type of clinic experience they would feel most comfortable with, and filter results to identify past patient experience. Allergan said that they created the CC following the results of a study conducted by research agency Millward Brown, which found that many consumers required more information about their practitioner before booking a non-surgical aesthetic appointment. The CC builds on Allergan’s previous locator tool, which based results solely on a patient’s proximity to a clinic. Aesthetics | November 2014
Galderma launches skin lightening cream to Indian market Galderma has launched its new skin lightening cream, BI-LUMA in India. Bi-Luma, a non-greasy, steroid free formulation, contains natural skin lightening ingredients, along with UV filters and antioxidants, according to the company. “In India, people generally suffer from various hyperpigmentary disorders such as melasma and post-inflammatory hyperpigmentation (PIH) that result in an uneven skin tone,” said Galderma India managing director, G Sathya Narayanan. “We are confident that our latest product will emerge as an effective dermatological solution for patients suffering from hyperpigmentary disorders and restore their skin with an even tone and glow.” According to the latest IMS figures, India’s hyperpigmentation market is valued at Rs. 391 crores and is growing at 19% per year. Acne
Acne app offers virtual consultation A San Francisco company has launched an app that allows acne patients to undergo an initial “consultation” from the comfort of their own home, connecting them with doctors and a treatment plan. Patients can take photographs of their own skin and upload them to the app, before answering a series of pre-programmed questions. A board-certified dermatologist then reviews their case and sends them a personalised treatment plan including prescription. The Spruce Health app is currently only available to patients in California, Florida, New York and Pennsylvania, but the company behind it, Spruce, says it hopes to roll out its telemedicine platform to more locations and to treat more conditions.
Events diary 6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 29th January - 1st February 2015 International Master Course on Ageing Skin - IMCAS Annual Meeting 2015, Paris www.imcas.com/en/imcas2015/ congress 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com 26th - 28th March 2015 13th Anti-Aging Medicine World Congress www.euromedicom.com/amwc-2015/ index.html
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Aesthetics | November 2014
Insider On the Scene
Syneron Candela Laser Academy, Portugal Medical device manufacturer Syneron Candela held a laser academy at the Oitavos Hotel in Cascais, Portugal, on September 19-20.
The two-day agenda featured clinical updates on the treatment of port winestains, hair removal and bodyshaping, whilst experts shared tips on growing aesthetic businesses and understanding cellulite for successful treatment outcomes. Guest speakers from across the globe included chairman of the Syneron Candela board, Shimon Eckhouse, consultant dermatologist at the Central Manchester Foundation Trust, Dr Vishal Madan, and Professor Moshe Lapidoth, who is head of lasers and senior practitioner in dermatology at the Rabin Medical Centre, Israel. Day one was divided into two sections: Face in the morning, where laser treatments for scars and wrinkles were discussed by Dr Maurice Adatto, founder of the Skinpulse Dermatology & Laser Centre in Switzerland, and Body in the afternoon, which saw a panel of experts answer questions on laser treatments for this area. The second day featured presentations on pigmentation, tattoo removal and R&D developments, with a lecture on combination treatments from Dr Ines Verner, an Israel-based dermatologist. Eckhouse said, “The Syneron Candela laser academy event has been a huge success and we are delighted with the high standard of presentations that our esteemed speakers have delivered. We hope that everyone in attendance can take away valuable skills and knowledge on using lasers in their clinics.”
Healthxchange Academy, Manchester Healthxchange Pharmacy Ltd launched its training academy in Manchester on October 6. Using the latest technology and innovation in aesthetics, the Academy will deliver CPD accredited clinical training to practitioners from across the UK and Europe. Guests were given a tour of the facilities, built to accommodate smaller, more intimate training groups. Camera feeds have been installed so that delegates in a 30-seat lecture theatre can watch live procedures take place in the smaller clinic rooms, and networking areas have been established so that delegates can share their training experiences. Managing director Karen Hill, said, “Not only is the educational offering superb – the environment is inspiring and industry leading, and we cannot wait for the first set of courses in October to really showcase what the Academy can deliver.” Hill informed guests that the response to the training Academy, especially in the northwest, has so far been very positive. She said that visitors had been very impressed with the state-of-the-art facilities and training packages. The Healthxchange Academy also has an on-site pharmacy, giving delegates the option to purchase products on the day of training. Training dates have been confirmed for Obagi, Aqualyx, toxins and dermal fillers up to December 2014, and programme planning is underway for 2015.
Medikas, Bristol Medikas clinic celebrated its Bristol opening on September 25 with a champagne reception and a tour of the new premises. Founder of Medikas, Dr Beatriz Molina, and co-director Dr Ian Strawford gave a welcoming speech that addressed the clinic’s full services. Along with well-known faces from the world of aesthetics, Olympic skeleton champion Amy Williams MBE was in attendance. Williams is set to be the face of Dr Molina’s new make-up brand, MK Minerals, which will launch in London later this year. Dr Molina said, “The event was the exciting culmination of more than a year’s work to get the clinic up and running in the biggest city in the south west: Bristol.” She explained that it has taken hard work to reach the high standard they desired, adding, “We wish to show the UK, and the world, that first-class aesthetic surgery is not just available in London.” The business partners also outlined how they have signed up to Save Face, becoming one of the first members of the accreditation body that aims to promote best practice in the industry. Dr Molina said, “We are proud to be at the forefront of a new movement to promote best practice and patient safety in this sector.”
Dermal Clinic, Edinburgh The Dermal Clinic launched its new, larger clinic on September 26 in Morningside, Edinburgh. The event saw 100 guests visit the new premises and try a selection of free treatments. The new clinic has seven treatment rooms and a minor operating theatre, and features the clinic’s trademark patterned wallpaper, making it a familiar site for past patients and frequenters of the original clinic, located on the same street. In partnership with Edinburgh’s new private hospital, The Edinburgh Clinic, patients will be referred to The Dermal Clinic for aesthetic treatments 14
Aesthetics | November 2014
and minor surgeries. On opening her second clinic, clinical director Jackie Partridge said, “It has taken eight months to take the building from a damp and unloved space to the high-end clinic, enjoyed by so many today. With its seven treatment rooms and minor operation room, we have now taken on many more highly skilled staff. Our services have grown and we now count Mr Zahid Raza – consultant vascular surgeon, as part of the team too.” The Dermal Clinic was one of the first approved Save Face clinics in Scotland, and has recently been chosen as a finalist for The Aesthetics Awards Syneron Candela Award for Best Clinic Scotland.
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BCAM Conference 2014
Aesthetics reports on the annual British College of Aesthetic Medicine congress in London On September 20, the British College of Aesthetic Medicine held its annual conference, exhibition and meeting at the Royal Institute of British Architects in London. The clinical agenda was curated by conference organisers Dr Beatriz Molina and Dr Ruth Harker and provided the 230 delegates in attendance with educational content covering a wide range of areas within medical aesthetics. The day began with a detailed anatomy refresher session by Dr Sotirios Foutsizoglou, followed by presentations on surgical face lifts under local anaesthesia by Mr Dominic Bray, threading by Dr Alexandra Chambers, and a live demonstration of injection lipolsysis carried out by Dr Sach Mohan and Dr Sabika Karim. The masterclasses, which took place in the morning, provided practitioners in attendance with an opportunity to observe a panel of KOLs perform live injection demonstrations using a variety of different products. Presented by Dr Raj Acquilla and Dr Tapan Patel on behalf of Allergan, Dr Christoph Martschin on behalf of Galderma, and Dr Kate Goldie and Dr Tahera Bhojani-Lynch on behalf of Merz, these presentations gave an insightful look into the differing styles of consultation and treatment technique. The afternoon sessions began with an informative session on body dysmorphic syndrome by Dr Lynne Drummond. Skin health was the focus of the sessions in the latter part of the day, including talks from Dr Raina Zarb Adami and Dr Raj Acquilla, and an interactive discussion with Dr Maria Gonzalez. During her presentation, entitled ‘What to treat or not to
treat?’, Dr Gonzalez asked delegates to identify dermatological conditions that their patients may present with, whilst questioning whether practitioners should attempt to treat these or whether referral was the best course of action. A post-conference networking event sponsored by SkinCeuticals brought the BACN conference to a close. The evening gala dinner featured a boat cruise along the River Thames and entertainment from a band and singer. Dr Molina said of the event, “This year’s conference has been a huge success. We have wanted to promote the conference to other professionals who practise aesthetic medicine and we have had a great response with the largest numbers of delegates attending the conference this year. We are planning an even better event for 2015 and we hope we see you all there.”
AAFPRS Fall Meeting Wendy Lewis reports from the American Academy of Facial Plastic and Reconstructive Surgery meeting in Orlando For 2014, the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) selected Brazil as their guest Wendy Lewis country, and one of the highlights included a panel called, ‘Facial Plastic Surgery in a Multicultural Nation: Tips from Brazil,’ that focused on the best techniques for rhinoplasty and skin of colour. “This year’s AAFPRS Fall meeting in Orlando focused on establishing expert consensus on the most up to date protocols for facelift, eyelid surgery, facial volume loss, rhinoplasty,
and treating the ageing ethnic mid face,” said conference chair Dr Philip Langsdon. “In addition to the discussion of new innovations, special sessions reviewed state of the art treatments for non-surgical facial aesthetic techniques with contributions from leaders from all over the world.” Dr Andrew Campell moderated a session on New Innovations and Emerging Trends, including talks on ‘Micronized Botulinum Toxin A for Skin Rejuvenation and Injectable Lipolysis’, by Dr John Joseph, ‘Microinvasive Catheter-Based RF for Skin Tightening, Fat Reduction, and Nerve Ablation’, from Dr
Aesthetics | November 2014
Richard D. Gentile, ‘No Touch Fat Reduction Using Multipolar RF’ by Dr Campbell, and ‘Microneedling for Skin Rejuvenation’, by Dr Philip Miller. Another popular session dealt with dermal fillers and neurotoxin indications and complications of facial fillers. Dr Theda Kontis presented an overview of non-HA fillers on the market including laViv (autologous fibroblasts), Radiesse, Sculptra, and ArteFill (bovine collagen with PMMA). Dr Seth Yellin covered The Liquid Facelift concept by describing how the discriminating combination of several fillers with a toxin can provide optimal outcomes when customised for the individual patient. Dr Steve Metzinger made a case for why he prefers autologous fat grafting over commercially available fillers in the face. Dr Paul Carniol chaired a session on lasers and light-based devices for skin tightening, rejuvenation and fat reduction, along with the newest crop of picosecond lasers for treating tattoos and pigmentation. Hair restoration also took centre stage as Drs Sam Lam and Jeffrey Epstein cochaired an important session on updated method for FUE, the use of PRP and Acell to stimulate hair growth, boutique procedures including brows, lashes and beards, and best techniques treating for women with hair loss. AAFPRS 2015 Annual Fall Meeting, Dallas, 1-3 October.
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Insider Conference Report
British Association of Cosmetic Nurses Conference, Brighton The annual British Association of Cosmetic Nurses (BACN) conference took place at the Hilton Brighton Metropole on October 3-4. Aesthetic practitioners and exhibitors gathered at the seaside resort for the ‘All Things Bright ‘n’ Beautiful’ conference that celebrated becoming a CPD accredited event and featured a plethora of educational lectures. Chair of the BACN, Sharon Bennett, said, “The highlight of the BACN conference this year is that we’re awarding continued professional development (CPD) points; ticking boxes in prescribing, anatomy and patient handling for nurses.” She adds, “We’ve really had some top quality speakers this year and we’re learning more each time.” The two-day agenda featured live demonstrations of treating the periorbital area by Dr Raj Acquilla, treating the lower face by Fiona Collins and Marie Duckett, and the dynamics of introducing multi-application radiofrequency by Dr Sam Robson. Lectures covered, amongst others, the diagnosis and treatment of migraines by Dr Giles Elrington, an exploration of bio-identical hormones by Mary O’Brien, and facial dermatology by Dr Justine Hextall. Jerome
Durodie discussed the inappropriate use of antibiotics, while Andrew Rankin lectured on mesotherapy for skin health. This year’s conference saw the introduction of Paul Burgess, the BACN’s recently announced CEO. Bennett said that the addition of a business developer to the team has been beneficial to the organisation. Burgess said, “I’m overwhelmed by the enthusiasm and dedication of all the people in the association. I’ve got a huge development agenda in place, which will hopefully improve our membership services and how we communicate.” Bennett noted
that whether the nurses in attendance were new to the industry or very experienced aesthetic practitioners, everyone was able to learn something at the conference. This belief was echoed by Karen Rocha, a nurse looking to move into aesthetics. She said, “From a newbie’s point of view it’s pretty daunting coming to a conference like this as you worry that you’ll be out of your depth. But the networking opportunities at the BACN are second to none and being able to meet other nurses is great. “ Bennett concluded, “Everyone’s smiling – that’s the main thing. There’s lots going on in the industry at the moment and, with ACE in the spring, the industry as a whole is really coming together.” As a member of the Aesthetics Conference and Exhibition (ACE) 2015 steering committee, Bennett said that she is looking forward to more involvement with the organisation and assisting the development of another successful event.
ESCAD Meeting, Amsterdam Dr Alain Tenenbaum reports from the European Society for Cosmetic and Aesthetic Dermatology annual meeting The European Society for Cosmetic and Aesthetic Dermatology (ESCAD) meeting took place on October 8, in the Emerald Room at the Amsterdam RAI Exhibition and Convention Centre. As a subspecialty society of the European Academy of Dermatology and Venereology (EADV), the ESCAD at EADV International Annual Scientific Society meeting is held on the day prior to the opening of the EADV congress. The meeting is host to specialists in the field, including professors of dermatology and presidents of dermatology societies. This year’s meeting provided attendees from across the globe with a wealth of lectures and updates from the field of cosmetic dermatology and aesthetic medicine. A variety of excellent speakers addressed various topics without commercial agenda; offering a purely scientific character to the meeting. Highlights of the day included sessions on patient satisfaction (including patient psychology), and a look at dealing with slander on the internet and information on how to protect your reputation as a medical practitioner. Other lectures looked at uses of botulinum toxin, dermal fillers and PRP, needling and cutaneous regeneration, as well as advances in laser and energy-based devices (for the treatment of scars and hair loss). Among the 12 speakers of the day, three doctors presented from different regions of Switzerland, demonstrating the small country’s great potential in the field of aesthetic dermatology. A significant highlight of the day was the presentation of an award to Dr Christopher Rowland Payne, the ESCAD secretary-general, programme organiser and chairman of the meeting. The Society’s current president, Dr Ercin Ozenturk from Istanbul, Dr Alain Tenenbaum
Aesthetics | November 2014
ESCAD (European Society for Cosmetic and Aesthetic Dermatology) – 18th International Annual Scientific Meeting of ESCAD, Amsterdam, 8th October, 2014. From left to right: Pierre André, Christopher Rowland Payne, Leonardo Marini & Erçin Ozunturk
and ESCAD’s president commencing 2015, Dr Oliver Kreyden from Switzerland, gave thanks to Dr Rowland Payne for founding ESCAD and building its reputation to become a world-famous society. Both current and future president credited Dr Rowland Payne with ensuring the continuing excellent reputation of the fields of cosmetic dermatology and aesthetic medicine across Europe. The day concluded with an address from Dr Kreyden on the aims goals for next year’s meeting. ESCAD has annual congresses, with the next set to take place at the Royal Society of Medicine on February 25-29, 2015. It will be London’s fourth EADV/ESCAD Advanced Handson Interventional meeting on Fillers.
Insider Training Report
Aesthetics reports on the recent training session in the management of non-surgical complications through anatomy, led by Mr Dalvi Humzah
Training report: The Management of Non-Surgical Complications Mr Dalvi Humzah led a select group of practitioners through an intimate two-part training day on managing non-surgical complications through anatomy, held at The Royal College of Surgeons in London, on October 10. “An understanding of anatomy will reduce complications,” said Mr Humzah. “And when they do occur, a good knowledge of anatomy will allow treatments to be performed appropriately, will enable practitioners to explain to the patient exactly what has happened, and will also allow practitioners to develop their own practice and experience. “Often complications of treatment are rarely discussed and unfortunately, many complications are due to an inadequate understanding of the anatomy in relation to aesthetic treatments. This is why this kind of training is so important.” Mr Humzah and his colleague, specialist aesthetic nurse Anna Baker, originally began their teaching sessions two years ago. These were purely anatomical training days, aimed at practitioners looking to gain a greater understanding of facial anatomy when using a variety of products. However, they quickly realised that topics of conversation and feedback from attendees kept turning to the matter of complications. “When we were assimilating all the feedback we noticed that people were particularly interested in, and asking frequent questions about, complications,” said Baker. “Or, they were running into certain difficulties in certain anatomical areas; perhaps not understanding the anatomy of that area clearly enough in relation to the product they were using, for example.” In order to satisfy the obvious need for a more focused session, Mr Humzah and Baker formed a new kind of training day, this time with a complete focus on the avoidance and treatment of complications. “We held the first one on the 30th of September,” said Baker, “and had tremendous feedback from that – the November session is fully subscribed as well. The key things that people have relayed back to us is that it’s independent, specialist complications teaching. Which is, as far as I’m aware, the only course out there that has taken this approach and is fully accredited by the Royal College of Physicians and Surgeons in Glasgow.” The first half of the training day focused on the theory surrounding complications in aesthetics; exploring the current evidence, as well as its limitations. This generated detailed discussion between Mr Humzah and the attendees on the current understanding of botulinum toxin and dermal filler management.
There was a clear emphasis on garnering feedback from attendees on their own personal understanding and experience of complications in non-surgical procedures. The afternoon was dedicated to practical work, looking at the anatomy in relation to botulinum toxin and dermal filler treatment. Using a specimen in a laboratory, Mr Humzah dissected the face of an unembalmed cadaver, revealed its anatomy, and proceeded to demonstrate a safe technique in which to administer botulinum toxin and dermal filler. Attendees had the opportunity to perform the injections with coloured filler material, after which Mr Humzah dissected the area to show them where their product had been injected. The importance of good anatomical knowledge was the focus throughout the day, and attendees were left very satisfied with Mr Humzah’s approach. “The anatomy session was incredible,” said courseattendee and Kettering-based dentist, Dr Marie Thompson. “The fresh frozen specimen is the closest you can get to the real thing, and Dalvi’s experience and technique was really demonstrated as he skillfully dissected the head in sections, showing all the important structures. There was plenty of time for everybody to discuss areas that were of particular interest or concern.” The training day encouraged attendees to fully understand the consequences of injecting in the wrong places, or of using the wrong technique or material. “The most interesting parts for me,” said Dr Thompson, “Were seeing where the infra-orbital foramen actually lies, the amount of blood vessels in the alar region of the nose and seeing the muscles in 3D.”
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News Special ACE 2015
The Aesthetics Conference and Exhibition 2015 With the aesthetics community now looking forward to ACE 2015, we take a look at some highlights from the forthcoming conference To be held on March 7 and 8 in Central London, The Aesthetics Conference and Exhibition 2015 is set to provide an unparalleled selection of live demonstrations, workshops and presentations of the latest innovations and advances in medical aesthetics, along with the opportunity to gain first hand information and discuss practical needs with over 100 exhibitors. “ACE 2015 is shaping up to be an exciting event,” said Mr Dalvi Humzah, the Chair of the Steering Committee, “I’m delighted to welcome Mr Taimur Shoaib as chariman of the main agenda session on body and fat on Saturday morning, and Dr Christopher Rowland Payne and Dr Stefanie Williams. who will chair a dermatology session on Sunday afternoon. Drs Raj Acquilla and Tapan Patel will be working with me to present an incredibly interactive and unique mix of anatomy and practical skills in the two day cutting-edge injectables agenda – where we will be involving delegates in these very special expert sessions. These two injectable sessions, along with sessions on ‘The Role of Fat in Medical Aesthetics’, and ‘The Aesthetic Dermatology Clinic’, will comprise the main four-part conference agenda and be highly interactive and educational. Delegates will be able to choose to attend individual three-hour learning experiences, or alternatively, choose the full two-day programme for the complete learning package in medical aesthetics. Visitors who register for the free exhibition pass will be able to enjoy the sponsored exhibitor Masterclasses, Expert Clinics and Business Track workshops. Following the success of last year’s packed Expert Clinic workshops, ACE 2015 will feature two simultaneous sessions, affording practitioners the chance to watch even more dynamic presentations offering invaluable practical advice and live treatment demonstrations. A host of leading figures from all areas of the profession will present on injection technique, device innovation and skincare best practice. Highlights will include an advanced injectables demonstration from Dr Simon Ravichandran and Dr Emma Ravichandran, who will focus on the anatomical basis of ageing and safety when injecting, whilst showing the results possible for skilled and well-trained injectors. This session will include mid-face revolumisation, lateral cheek, eyebrow, eyelid, forehead and temple treatment with a combination of needle and cannula. With safety and managing complications an integral theme throughout ACE 2015, facial cosmetic surgeon Dr Julian De Silva will present a special clinic on managing filler complications specifically. Dr De Silva said of his session, “Non-
Headline Sponsor surgical filler treatments provide patients with an effective and relatively safe facial rejuvenation. There have been increasing numbers of serious complications including loss of visual function, blindness, skin necrosis and facial scarring associated with the use of filler injections. In this expert session there is a discussion of serious complications from non-surgical filler injections, mechanisms by which these complications occur, treatment and prevention.” The sponsored Masterclasses offer an opportunity for delegates to learn about products direct from manufacturer KOLs, who will present on possible patient outcomes and best practice techniques. These sessions will include special presentations by Sinclair IS Pharma, Institute Hyalual and Medical Aesthetics Supplies. The Medical Aesthetic Masterclass will be presented by Dr Elisabeth Dancey and Dr Sarah Tonks, who will demonstrate how the V Soft Lift uses PDO threads to effectively create a complete face lift; showing how superior results can be achieved in conjunction with PRP, botulinum toxin and/or fillers ,or by the use of threads alone. This treatment is highly suited to doctors with experience of facial anatomy. The Business Track workshops will provide essential information and guidance on all aspects of running a practice in medical aesthetics. Featuring insights from experts in marketing, regulation, sales, finance and law, these sessions will focus on the crucial commercial considerations that practitioners and clinic managers must master in order to create a successful business in this sector. The full list of confirmed speakers and sessions can be found on the ACE website. ACE will provide delegates with vital clinical and commercial support and guidance in a unique interactive format, offering the ideal platform for practitioners to build on their success in 2015 and beyond.
Registration is now open for ACE 2015. Exhibition registration is FREE and includes Expert Clinic and Business Track workshops, as well as entry to the sponsored Masterclasses and the exhibition floor. Each of the main conference agenda sessions are priced at £95 excluding VAT, with a cumulative discount for the more sessions booked. Additionally, there is an extra 10% discount on top of this if you book before 31st December. Visit www.aestheticsconference.com to book your place today.
Aesthetics | November 2014
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Special Feature Body Contouring
Male body contouring Allie Anderson investigates the growing demand for male-specific body contouring treatments in aesthetics In the 21st century, body image is everything. Whether it’s touched-up photographs of models on the front pages of magazines, or sports idols displaying their toned physiques both on and off the playing field, we’re reminded of that modern ‘body ideal’ everywhere we look. This preoccupation with emulating media portrayals of beauty – of creating the ‘perfect’ face and body – has generated a boom in aesthetic treatments and procedures. And now, not content with the odd skin treatment to achieve an image closer to their ideal, greater numbers of people are seeking more advanced techniques to get a better-looking body, through reshaping and contouring. Furthermore, practitioners report a paradigm shift in recent years in terms of who they see in their clinics and on their surgical tables: once purely the domain of women, aesthetic cosmetic surgery is increasingly catering to the body-conscious male. Growing demand According to consultant cosmetic and reconstructive surgeon Dr Mark Soldin, this trend has been led by the US. “Fifty years ago, very few people in the UK had cosmetic surgery. But the fashion in the US of people opting for cosmetic surgery, as well as it becoming more affordable, means that many people in the UK have decided to follow suit to optimise the appearance of their bodies,” he says. “Men have been slower on the uptake – probably because in the UK the need to improve one’s body surgically sits less easily in the male psyche than it does in the female. But men are starting to take it up more and more.” A study by the British Association of Aesthetic Plastic Surgeons (BAAPS), published earlier this year, paints a similar picture, with figures revealing that the number of men undergoing surgery rose by 16% between 2012 and 2013.1 Among men, body-contouring procedures grew in popularity the most, with liposuction and gynaecomastia correction rising by 28% and 24% respectively.1 Overall, the BAAPS study shows that around one in 10 of all subjects undergoing aesthetic surgery are male.1
However, Dr Mike Comins, a specialist in medical aesthetics and medical director of London’s Hans Place clinic, says that in reality, as many as half of the patients he now sees are men. “There’s been a significant increase in the last few years as aesthetic treatments and contouring have become more publicised,” he comments. “The days when the media portrayed these procedures as being for people who wanted to achieve that film star look are long gone. That’s just not true. These are ordinary men with ordinary lives.” Often, Dr Comins says, male patients come to him having spent many years eating a healthy diet and exercising at the gym, but are unhappy with the results. Advancements in technology and developments in the types of procedures available mean that these men can now achieve a highly defined athletic appearance without so much as an overnight stay in the clinic. Anecdotal evidence suggests that one of the most common treatments the modern man wants is for gynaecomastia – Before Vaser Lipo enlarged male breast tissue. According to BAAPS, while some degree of breast enlargement is common in teenage boys, less than 10% will have residual signs of the problem as they reach adulthood.2 However, it increases again with age, meaning that around one in three older men have gynaecomastia.2 Pressure to display the perfect chest is driving men to take action to combat this, says consultant dermatologist Dr Sanjay Rajpara. “In modern society, men are expected to wear skin-tight clothes and take their tops off on holiday. Society demands a muscly chest, so even a small enlargement of After Vaser Lipo the breasts makes men feel quite embarrassed,” he says. “There are procedures to reduce the size Images courtesy of Dr Ravi Jain of ‘moobs’ and make the skin a lot tighter, but it’s important that I make patients aware that it’s not possible to make it 100% better. And if men gain weight afterwards, their ‘moobs’ can come back.” Melting the fat away In the days when traditional liposuction was the best option – and often the only option – for body contouring, patients could expect considerable bruising and swelling lasting up to six months post-surgery – which would be conducted under general anaesthetic.3 Nowadays, the more discerning patient demands a less invasive procedure with faster recovery and guaranteed results. In recent years, this Aesthetics | November 2014
Special Feature Body Contouring
has been achieved by laser-assisted liposuction, in which a wavelength of light is passed through a cannula inserted into the area of the body being treated. The laser applies energy to ‘melt’ and liquefy the specific area of fat, and because it’s more targeted than traditional liposuction, it can pinpoint the area to be treated without affecting or damaging nearby tissue. This option has the added benefit of causing the small blood vessels to coagulate and collagen to contract, as well as inducing new collagen production, thereby tightening the skin at the same time.4,5 Laserassisted liposuction can effectively treat most areas of the body patients wish to target, which in Before Vaser Hi-Def men is typically the chest, abdomen, flanks, back, and jowls. But, for the last six years or so, a ‘high definition’ variant of laser liposuction has been available in the UK that, according to Dr Comins, was initially aimed specifically at the male market. “It’s particularly suitable for people who want an athletic look with really defined abdominal and pectoral muscles, and it tends to be men who seek that highly defined six-pack look,” he says. The standard ‘mid-definition’ version, Dr Comins adds, is the better option for patients who want a toned yet softer appearance. Men are particularly suitable candidates for more advanced and highdefinition versions of laser liposuction, says Dr Ravi Jain, medical director and founder of Riverbanks After Vaser Hi-Def Clinic, because male patients are typically more Images courtesy of Dr Mike demanding than their female peers, requiring Comins and Dr Dennis Wolf the best-possible results. “[Male patients] expect it to work; they take a lot longer making up their minds to have body contouring treatments, and they take far more consulting with than females. Their expectations are extremely high,” he comments. “Whereas women are generally happy with an improvement, men are seeking these procedures to get exactly what they want and expect.” Before Smartlipo High Def abdomen procedure in conjunction with liposuction.
Six months after Smartlipo High Def abdomen procedure in conjunction with liposuction.
Photos courtesy of Dr John Millard
Reconstruction suction The BAAPS study seems broadly consistent with experience in aesthetic practice, but there is another, significant sector of male society that undergoes body contouring not for reasons of vanity. “Body contouring could be aesthetic or 24
Aesthetics | November 2014
cosmetic, but it can also be reconstructive,” explains Mr Soldin, who performs body contouring following extensive weight loss, both in private practice and on the NHS. “After massive weight loss, many parts of a person’s body hang in folds of tissue, so the abdomen is an apron that hangs down over the thighs and sometimes down to the knees. These people are very happy that they’ve lost weight, but they’re very unhappy in their new bodies.” For these patients, of which men comprise a significant number, an abdominoplasty, or ‘tummy tuck’, might be performed to remove the excess skin and fat to tighten the muscle and fascia of the abdominal wall. In cases of very extreme weight loss, usually as a result of bariatric surgery, a belt lipectomy or ‘lower body lift’ might be performed, in which a large section of tissue is removed from around the lower trunk. This procedure removes the overhanging belly and folds from the back, as well as lifting the buttocks. Some areas can also be treated with liposuction to tighten the appearance above and below the navel, and to give an overall improved look. There are a number of criteria that patients must fulfil to have massive weight loss body contouring on the NHS, in accordance with guidance drawn up earlier this year jointly by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the Royal College of Surgeons.6 Mr Soldin, who led the group tasked with drafting the guidelines, explains that such invasive surgery to reshape the body requires more downtime, with bruising and swelling taking several months to subside. “It requires a great deal of commitment on the part of the patient, and there is a comprehensive set of instructions regarding what to do and what not to do to optimise results,” he says. The male of the species This requisite commitment comes less easily to male patients, Mr Soldin continues: “As a group, men are harder to consult with and have a higher complication rate than women. The reason is that no man likes to be told what to do! The same is true of women, but when it comes to consulting with a doctor, I think women understand the need to listen carefully and ask questions more freely than men do. They’re also more compliant.” Consultant plastic surgeon Mr Chris Dunkin agrees that male patients are different from females in their approach to consultation. “Men are more matter-of-fact. They’ll tell you ‘I want a rhinoplasty to make my nose smaller’,” he comments. “But women will identify the area they are unhappy with and ask about the options available to help improve it: they listen to advice better!” Listening is a crucial skill for the practitioner, too, he adds, and is often key to eliciting information from a male patient. “The most important thing is to listen to what the client is telling you he wants and then discuss ways to help
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Special Feature Body Contouring
Whereas women are generally happy with an improvement, men are seeking these procedures to get exactly what they want and expect
Before circumferential body lift and male breast reduction.
Three months after circumferential body lift and male breast reduction.
Images courtesy of Mr Chris Dunkin
them achieve this. For example, excess fat on the lower abdomen may be best treated with abdominoplasty, but liposuction might achieve the improvement they want without the long scar, and with a quicker recovery.” As a result, the patient’s expectations can be managed from the outset and compliance maximised. Although different in the way they handle aesthetic treatments in many ways, men have broadly the same psychological issues as women. A particular concern for practitioners is to eliminate the possibility of an underlying psychological condition that manifests in the desire to alter the body, such as anorexia nervosa or body dysmorphic disorder (BDD). Despite men accounting for just 10% of all cases of eating disorders in the UK,7 a recent study showed that eating disorders among men are growing steadily: the number of males diagnosed between 2000 and 2009 increased by 24%, almost double the rise in females being diagnosed.8 Practitioners have a duty of care to make sure that, should one of these men present in an aesthetic clinic, their condition is picked up through expert examination and consultation. “A patient who is extremely worried about a perceived physical problem – let’s say gynaecomastia – and reports that it affects every aspect of his life, but an objective physical assessment reveals the problem to be a mild one, would make me concerned,” reports Mr Soldin. In such a case, a referral to a psychologist might be the best path to follow, but this must be handled with care, he adds. “You need to address the issue in a very sensitive manner. It’s often handled with the help of the GP, because the GP knows the patient much better than I do, having often treated them since adolescence or childhood.” A thorough consultation helps to draw out patients who need some other form of treatment and support, but it’s also critical in determining the subject’s expectations, and managing them appropriately. “I would be very careful with a middle-aged male patient who, say, had just got divorced, and who was projecting all of their anxieties about an aspect of their life onto a part of their body,” says Dr Comins. “Body contouring might improve that body part, but it’s not going to solve all their problems.”
Before Vaser Hi Def
After Vaser Hi Def
Images courtesy of Dr Mike Comins
Aesthetics | November 2014
Seek, and he will find With increasingly larger proportions of clinic lists made up of male patients, it’s not surprising that most practitioners don’t feel the need to market their services specifically to male audiences. “I don’t believe in hard advertising,” comments Mr Soldin. “I think your work speaks for itself, and word of mouth referral is often the best.” Most patients approach a practitioner having been referred by their partner, who may have seen successful results from a similar procedure. The other big source of custom is the internet. “We don’t target men in forums or in male publications online, but a huge number of men come to us having found out about body contouring on the web,” says Dr Jain. “Our conversion rate of male patients is extremely high, because men have typically done so much research that they’ve already made up their minds that they’re going to have the procedure they want – if they’re given the OK – when they first come to us.” If supplemented with expert advice, careful planning and sound pre- and post-treatment care, and set against an agreed construct of what can realistically be achieved, most male patients can expect to walk out of the clinic having accomplished what they set out to do. Dr Rajpara concludes: “Once I’ve explained about the treatment duration, swelling, bruising and recovery time, men are generally happy because they can plan their working lives around treatment. Most men manage to organise it in a way that affects their life minimally and achieves good results.” REFERENCES 1. Britain sucks: over 50,000 cosmetic surgery procedures in 2013 – Liposuction up by 41% (London: The British Association of Aesthetic Plastic Surgeons, 2014) <http://baaps.org.uk/ about-us/press-releases/1833-britain-sucks>[accessed 25 September 2014] 2. Ibid 3. Ibid 4. The British Association of Aesthetic Plastic Surgeons, Gynaecomastia (London: The British Association of Aesthetic Plastic Surgeons) <http:// baaps.org.uk/procedures/gynecomastia> [accessed 26 September 2014] 5. Ibid 6. The British Association of Aesthetic Plastic Surgeons, Liposuction (London: The British Association of Aesthetic Plastic Surgeons) <http:// baaps.org.uk/procedures/liposuction> [accessed 25 September 2014] 7. McBean, J.C and Katz, B.E, ‘Laser Lipolysis: An Update’, The Journal of Clinical and Aesthetic Dermatology, 4(7) (2011), pp. 25-34. 8. Society of Interventional Radiology, Liposuction melts fat, results in tighter skin (New Orleans: ScienceDaily, 2013) < http://www.sciencedaily. com/releases/2013/04/130415124819.htm> [accessed 25 September 2014] 9. New national body contouring surgery guide launched to promote equality in provision and improved care for weight loss patients (London: British Association of Plastic Reconstructive and Aesthetic Surgeons, 2014) <http://www.bapras.org.uk/baprasvoice/news/ new_national_body_contouring_surgery_guide_launche> [accessed 26 September 2014] 10. NHS, Eating disorders explained (London: NHS Choices, 2013) <http:// www.nhs.uk/Livewell/eatingdisorders/Pages/eating-disorders-explained. aspx> [accessed 26 September 2014] 11. Micali, N and others, ‘The incidence of eating disorders in the UK in 2000-2009: findings from the General Practice Research Database’, BMJ Open, 3(5) (2013)
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CPD Psychological Screening
The routine psychological screening of cosmetic surgery patients Nicole Paraskeva, MSc, Alex Clarke, DPsych, Nichola Rumsey, PhD ABSTRACT In order to improve outcomes, the process of patient selection within the cosmetic industry has received considerable attention from surgeons, psychologists and policy makers. Indeed, as increasing numbers of people are seeking cosmetic procedures it is crucial to ensure that patients are appropriately assessed for their suitability for surgery. Pre-operative screening to identify patients at risk of poor post-operative outcomes is now considered a crucial part of the surgeon’s role in providing appropriate care and treatment. In recognition of the importance of patient selection, we have developed a brief, user-friendly screening tool designed for routine use with cosmetic surgery patients. The tool has been designed to identify psychological factors which are likely to increase the risk of a poor psychological outcome. The tool should be used in addition to a thorough pre-operative consultation and as part of a pathway which includes onward referral where necessary. BACKGROUND The demand for cosmetic procedures continues to grow. The British Association of Aesthetic Plastic Surgeons (BAAPS)1 reported over 50,000 cosmetic procedures in 2013, while 13.4 million minimally invasive procedures and over 1.6 million surgical procedures were conducted in the United States.2 The demographics of individuals interested in cosmetic procedures have become increasingly diverse,3 Increased interest in cosmetic surgery has been found in single women, high achievers aged 45-55 years who want to look younger, and full time mothers.3 There is also evidence of a growing interest in cosmetic surgery among younger females.4 The popularity of cosmetic procedures is thought to have resulted from numerous factors, including cheaper, quicker and less invasive cosmetic procedures coupled with widespread advertising and marketing. Levels of appearance dissatisfaction, described as “normative discontent”,5 increasingly prevalent in the general population and the widespread media coverage of cosmetic procedures (e.g., television shows, magazine 28
articles) are also contributory factors.6 Psychological factors have a significant influence through the entire cosmetic surgery journey. Indeed, motivations to undergo cosmetic surgery typically include the desire to enhance appearance, increase self-confidence and improve self-esteem.7,9 Research has shown that, with a technically satisfactory outcome, the majority of patients undergoing cosmetic procedures are satisfied. However, there is a substantial subgroup of patients who do not derive any benefit following cosmetic procedures.10,11 It is therefore important to identify who is at risk for a poor post-operative outcome and examine the reasons why this is the case. In addition, since the vast majority of cosmetic procedures are conducted in the private sector, prospective patients are rarely referred on by their general practitioner, placing the onus for minimising risk wholly on the provider. There are a number of reasons why patients may be at an increased risk for a poor outcome: 1. Unrealistic expectations (e.g., undergoing surgery to get a job promotion) Most patients seek a cosmetic procedure for the anticipated psychosocial benefits,12 but can have unrealistic expectations of what surgery can achieve. Indeed, despite a technically satisfactory result, patients can experience postoperative distress and dissatisfaction if anticipated psychosocial benefits are not forthcoming. Systematic reviews have shown that unrealistic expectations are associated with poor psychological outcomes.13,14 The clarification of patients’ expectations and goals for surgery preoperatively is associated with a successful outcome,14 therefore a key objective for any aesthetic provider should be to manage and understand patients’ psychosocial goals in addition to their procedural/ surgical goals. One way to reduce the
Psychological factors have a significant influence through the entire cosmetic surgery journey likelihood of introducing unrealistic expectations is to avoid value terms such as ‘prettier’ and ‘nicer’ and instead use objective terms such as ‘straighter’ or ‘smaller’ when discussing the feature for which a patient has requested surgery.15 In many cases it is worth challenging a patient’s expectations; for example, if they hope cosmetic surgery will help them get a new job. In addition to clarifying patients’ psychosocial goals and expectations, it is essential to ensure that patients have a clear understanding of the potential side effects of undergoing a procedure, for example short-term swelling and permanent scarring. Aesthetics | November 2014
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CPD Psychological Screening
2. Inappropriate motivations Motivations for undergoing cosmetic procedures are often categorised as ‘intrinsic/internal’ (e.g., to improve self-confidence) or ‘extrinsic/external’ (e.g., to please a partner). Early studies found that patients motivated by intrinsic factors are more likely to be satisfied following surgery than patients motivated by extrinsic factors and this view is still supported today.16,18 One way of assessing a patient’s motivation for undergoing a cosmetic procedure, is exploring why the patient is interested in a cosmetic procedure now/at this particular time in their life.19 3. Underlying psychological disorders Research has shown that there is a higher prevalence of psychiatric disorders in the cosmetic surgery population.20,21 Patients with underlying psychological disorders, particularly disorders with a body image element, are more likely to seek cosmetic procedures.6 To an extent, elevated body dissatisfaction is to be expected in the population presenting for cosmetic surgery. However, certain behaviours (e.g., social avoidance), emotions (e.g., excessive worry), cognitions (e.g., fear of negative evaluation) and beliefs (e.g., “to be happy and successful I must be attractive”) can be maladaptive and may be symptomatic of an underlying psychological disorder.19 For example, Body Dysmorphic Disorder (BDD) is a psychiatric disorder characterised by a preoccupation with an imagined or slight defect in appearance (DSM –IV-TR).22 People with BDD often seek cosmetic surgery as a way of reducing their concern about a particular feature.19 The prevalence of BDD in the cosmetic surgery population (5-15%) is significantly higher than in the general population (1-3%). Furthermore, studies have found no improvement or worsening of BDD symptoms following cosmetic procedures.23,25 It is now widely acknowledged that cosmetic surgery should be contraindicated for persons with BDD.26 Alternative psychological and pharmacological treatments have been shown to be effective at reducing BDD symptoms and are consequently considered more appropriate forms of treatment.27,29 The National Institute for Health and Care Excellence (NICE) guidelines,30 which endorse a brief screen for all patients presenting for cosmetic procedures, recommend that the aesthetic provider should ask five basic questions to help determine and assess whether the patient has a disproportionate preoccupation with their appearance (i.e., BDD):
1. Do you worry a lot about the way you look and wish you could think about it less? 2. What specific concerns do you have about your appearance? 3. On a typical day, how many hours a day is your appearance on your mind? (More than 1 hour a day is considered excessive). 4. What effect does it have on your life? 5. Does it make it hard to do your work or be with friends? These questions emphasize the importance NICE place on psychological screening. However, they provide little information regarding what level of distress is considered to be abnormal.15 4. Wider risk factors – psychological vulnerability Understandably, the focus of psychological screening is typically on screening for BDD.13 However, there are other psychological factors that play an important role in the outcome of cosmetic surgery. Indeed, psychological vulnerability is likely to be determined by a host of factors. For example, elevated levels of worry, noticeability regarding a particular feature, can have an impact on a patient’s post-operative outcome.15 30
Aesthetics | November 2014
PSYCHOLOGICAL SCREENING IN COSMETIC SURGERY To minimise the risks to patients for post-operative dissatisfaction, it is important that aesthetic providers carefully assess each patient prior to a cosmetic treatment to identify those with unrealistic expectations, extrinsic motivations, and psychological disorders or vulnerabilities. Psychological screening to assess the needs of each patient increases the probability that the patient receives the most appropriate treatment and care. Furthermore, preprocedural screening may reduce the stress, time and expense placed on aesthetic providers who must deal with patients who are dissatisfied and distressed following a cosmetic procedure.31 Providers should have pathways in place for onward referral of patients for whom screening highlights risk. The importance of psychological screening and patient selection has been emphasised in a number of reports, including the National Confidential Enquiry into Patient Outcome and Death (NCEPOD; 2010),32 the All Party Parliamentary Group Report on Body Image (2012)33 and The Professional Standards for Cosmetic Practice published by the Royal College of Surgeons (2013).34 THE RoFCAR; A PSYCHOLOGICAL SCREENING AND AUDITING TOOL To date, only a handful of psychological screening tools have been developed for cosmetic surgery patients.35 Current screening tools have been criticised for being too long, expensive, and difficult to administer and score.13,35 Indeed, some screening tools require the assistance of an expert for administration (e.g., psychiatrist) while the majority of screening measures focus exclusively on screening for BDD rather than wider risk factors.13 Consequently, they are not always practical for routine practice.13,35 In response to the need to develop a suitable tool for the routine screening and audit of patients seeking and undergoing cosmetic procedures, we have developed a brief (single page), user-friendly tool which is currently being trialled in a feasibility and acceptability study.36 The tool ‘RoFCAR’ (developed by researchers and
It is important that aesthetic providers develop and implement a clear, structured referral pathway
clinicians at the Royal Free Hospital London ‘RoF’ and the Centre for Appearance Research ‘CAR’) is intended to be used preoperatively in addition to an extensive consultation, and postoperatively to collect outcome data. The RoFCAR was specifically designed to identify psychological factors which are likely to increase the risk of a poor psychological outcome. There are a total of nine questions on the RoFCAR pre-surgical screening tool and a scoring profile. Questions on the screen ask patients about a range of psychological factors associated with the feature for which they requested cosmetic surgery. They include questions on noticeability, worry, self-consciousness, avoidance of activities and self-confidence. These questions all require patients to circle a single response along a Likert scale where higher scores indicate higher levels of that psychological factor (i.e., higher levels of self-consciousness). In line with screening for BDD, patients are also asked to write down the number of times they check their appearance and the length of time they spend looking in the mirror. The RoFCAR also contains a single open-ended question which asks patients to write down their expectations about the outcomes of the procedure. This question is intended to prompt patients to think carefully about how they expect their life to be different following surgery. Some clinicians have found this particular question helpful in triggering a discussion concerning patient expectations and motivations for undertaking the procedure. The RoFCAR is intended to be administered to all prospective patients presenting for any cosmetic procedure. It is a generic tool (not procedure specific) and contains numerous psychological concepts which are applicable to many different patients. Furthermore, the
CPD Psychological Screening
RoFCAR is a self-report questionnaire which patients complete independently. Studies have shown that patients are more likely to disclose adverse states when completing a measure themselves than when a measure is administered verbally.37 Ideally, the RoFCAR should be administered during a patient’s initial consultation or before the consultation, while they are waiting to be seen. This is because the responses to the questions are relevant to the following consultation and progressing the patient’s request for the treatment. In terms of patient selection, it is important to gather information from a range of sources. This may include collecting information provided from the brief screen (RoFCAR), the in-depth consultation and drawing on the aesthetic provider’s own knowledge and expertise. Furthermore, information gathered from a patient’s behaviour, communications and interactions with office and surgical staff is important when assessing a patient’s suitability for procedures.26 ONWARD REFERRAL PATHWAY It is important that aesthetic providers develop and implement a clear, structured referral pathway for all prospective patients identified as likely to benefit from additional assessment and, if appropriate, intervention. This should be designed to enhance the care, treatment and support they receive. The first step may involve giving all patients the RoFCAR in addition to having a thorough preoperative consultation. For the majority of patients this will be sufficient provision prior to the procedure. However, if there are concerns regarding the patient (e.g., high scores on the RoFCAR) this could trigger an additional, more exhaustive,
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Aesthetic Journal November 2014 Issue
CPD Psychological Screening
practice-based consultation to establish, for example, whether it is the optimal time for the patient to undergo a cosmetic procedure. If the aesthetic provider remains concerned and/ or there is evidence of severe psychological vulnerability, then a more thorough psychological assessment should be recommended and a referral to a specialist (e.g., clinical psychologist) may be the most appropriate action.15 Discussing a referral can be difficult and challenging for some aesthetic surgery providers. Certainly, an angry response or outright refusal from a patient may be a further indication that they are not suitable to undergo a cosmetic procedure.26 Patients may be surprised and puzzled by a referral, it is therefore important to emphasise that a referral is an opportunity to clarify their expectations and goals for surgery.15 For a list of clinical psychologists working locally, see the British Psychological Society. It is also important to check that they are registered with the Health & Care Professions Council which is the regulatory body for practitioner psychologists: www.hpc-uk.org AUDITING PATIENT OUTCOMES The post-operative version of the RoFCAR should be administered to patients at their follow up appointment. The post-operative RoFCAR is almost identical to the pre-operative version to allow for pre/post comparisons. There are three additional
open-ended questions to examine the impact of undergoing a cosmetic procedure on the patient’s life. The routine collection of post-procedural psychological data is an important part of clinical audit, and data can also be used to inform the current limited understanding of the benefits of cosmetic procedures. CONCLUSION The aim of a psychological assessment is not primarily to prevent a cosmetic procedure from taking place but to increase the likelihood of a patient (and aesthetic provider) achieving a positive outcome. The RoFCAR is a brief, easyto-use tool designed to help aesthetic providers identify patients who may be at risk for a poor post-operative result. It is designed to be used in addition to an in-depth consultation. The RoFCAR is also designed to facilitate audit in line with professional guidelines and to provide a clearer understanding of postprocedural psychosocial gains. ACKNOWLEDGMENTS The Healing Foundation and BAAPS funded and supported this body of research. Nicole Paraskeva is a research associate and trainee health psychologist at the Centre for Appearance Research based at the University of the West of England, Bristol, UK. Nicole’s current programme of research involves trialling a psychological screening and audit tool for routine use with cosmetic surgery patients under the supervision of Professor Rumsey and Dr Clarke. Alex Clarke is aconsultant clinical psychologist and visiting professor at the Centre for Appearance Research at the University of the West of England. Nichola Rumsey is Professor of Appearance & Health Psychology and co-director of the Centre for Appearance Research (CAR) at the University of the West of England, Bristol, UK. Nichola has published widely in the field of the psychology of appearance. Her current portfolio of research includes projects relating to psychological aspects of cleft lip and/or palate, burns and cosmetic procedures.
REFERENCES 1. The British Association of Aesthetic Plastic Surgeons. Britain Sucks (baaps.org.uk, 2014) <http:// baaps.org.uk/about-us/audit/1856-britain-sucks> 2. American Society for Plastic Surgeons, Statistics (www.surgery.org, 2013) <http://www.surgery.org/ media/statistics> 3. Department of Health, Independent report: Review of the Regulation of Cosmetic Interventions, (www.gov.uk, 2013) <https://www.gov.uk/government/publications/review-of-the-regulation-of- cosmetic-interventions> 4. American Society for Plastic Surgeons, 2000/2007/2008 National Plastic Surgery Statistics: Cosmetic and Reconstructive Procedure Trends (www.plasticsurgery.org, 2008) <http://www. plasticsurgery.org/Documents/news-resources/statistics/2008-statistics/2008-cosmetic- reconstructive-plastic-surgery-minimally-invasive-statistics.pdf> 5. Rodin J., Silberstein, L., & Striegel-Moore, R., ‘Women and weight: A normative discontent’, in T. B. Sonderegger (Ed.), Psychology and gender (Lincoln: University of Nebraska Press, 1985), pp. 267–307. 6. Crerand C.E, MaGee, L., & Sarwer, D.B., ‘Cosmetic Procedures’, in: Rumsey, N. and Harcourt, D., eds., The Oxford Handbook of the Psychology of Appearance. (Oxford University Press, 2012), pp. 330-349. 7. von Soest T., Kvalem, I. L., Roald, H. E., & Skolleborg, K. C., ‘The effects of cosmetic surgery on body image, self-esteem, and psychological problems’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 62(10) (2009), pp. 1238-1244. 8. Cordeiro C.N., Clarke, A., White, P, Sivakumar, B., Ong, J, & Butler, P.E., ‘A quantitative comparison of psychological and emotional health measures in 360 plastic surgery candidates: is there a difference between aesthetic and reconstructive patients?’, Annuals of Plastic Surgery, 65 (2010), pp. 349-353. 9. Clarke A., Hansen, E., White, P, and Butler, PEM., ‘Low priority? A consecutive study of appearance anxiety in 500 patients referred for cosmetic surgery’, Psychology, Health and Medicine, 17 (4) (2012), pp. 440-446. 10. Thomas J.R, Sclafani AP, Hamilton M, McDonough E., ‘Preoperative identification of psychiatric illness in aesthetic facial surgery patients’, Aesthetic Plast Surg, 25(1) (2001), pp. 64-67. 11. Sarwer D.B, Pertschuk MJ, Wadden TA, Whitaker LA, ‘Psychological investigations in cosmetic surgery: a look back and a look ahead’, Plast Reconstr Surg, 101(4) (1998), pp. 1136-1142. 12. Sarwer D.B, ‘Psychological assessment of cosmetic surgery patients’, in: Sarwer DB, Pruzinsky T, Cash TF, Goldwyn RM, Persing JA, Whitaker LA (eds), Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical and Ethical Perspectives, (New York: Lippincott Williams & Wilkins, 2006) 13. Brunton G., Paraskeva, N., Caird, J., Bird, K. S., Kavanagh, J., Kwan, I., Stansfield, C., Rumsey, N & Thomas, J., ‘Psychosocial Predictors, Assessment, and Outcomes of Cosmetic Procedures: A Systematic Rapid Evidence Assessment’, Aesthetic plastic surgery, (2014), pp. 1-11. 14. Honigman R.J, Phillips K.A, Castle D.J., ‘A Review of Psychosocial Outcomes for Patients Seeking Cosmetic Surgery’, Plast Reconstr Surg, 113(4) (2004), pp. 1229–1237. 15. Clarke A., Thompson, A., Jenkinson, E., Rumsey, N. & Newell, R., CBT for appearance anxiety: Psychosocial interventions for anxiety due to visible difference. (Oxford: Wiley, 2014) 16. Beale S., Lisper, H., & Palm, H., ‘A psychological study of patients seeking augmentation mammaplasty’, Br J Psychol, 136 (1980), pp. 133-138. 17. Edgerton M.T., Meyer, E., & Jacbson, W.E. (1961). Augmentation mammaplasty, II: further surgical and
psychiatric evaluation. Plast Reconstr Surg, 27:279-301. 18. Wright M.R, & Wright WK., ‘A psychological study of patients undergoing cosmetic surgery’, Arch Otolaryngol, 101 (1975), pp. 145-151. 19. Sarwer D.B., Crerand, C.E. & Magee, L., ‘Cosmetic Surgery and Changes in Body Image’, in Cash, T.F and Smolak, L., eds., Body Image A Handbook of Science, Practice, and Prevention, (Guilford Press, 2011), pp. 394-403. 20. Veale D, De Haro L, Lambrou C., ‘Cosmetic rhinoplasty in body dysmorphic disorder’, Br J Plast Surg. 56(6) (2003), pp. 546-551. 21. Sarwer D.B, Wadden, T.A, Pertschuk, M.J, & Whitaker L.A., (1998), ‘Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients’, Plast Reconstr Surg, 101 (1998), pp. 1644-1649. 22. American Psychiatric Association, DSM-IV-TR: Diagnostic and statistical manual of mental disorders, text revision, (American Psychiatric Association, 2000) 23. Phillips K.A., Grant. J., Siniscalchi. J, Albertini. R.S., ‘Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder’, Psychosomatics, 42 (2001), pp. 504-510. 24. Crerand C.E, Phillips. KA, Menard,W, & Fay, C., ‘Non-psychiatric medical treatment of body dysmorphic disorder’, Psychosomatics, 46 (2005), pp. 549-555. 25. Crerand C.E., Menard, W., & Phillips, K.A.. ‘Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder’, Ann Plast Surg, 65 (2010), pp. 11-16. 26. Sarwer D.B, & Spitzer, J.C.. ‘Body Image Dysmorphic Disorder in Persons Who Undergo Aesthetic Medical Treatments’, Aesthetic Surgery Journal, 32 (8) (2012), pp. 999-1009. 27. Phillips K.A., ‘Pharmacotherapy for body dysmorphic disorder’, Psychiatric Annals, 40 (2010), pp. 325-32. 28. Veale D.. ‘Cognitive behavioural therapy for body dysmorphic disorder’, Psychiatric Annals, 40 (2010), 333-40. 29. Ipser J.C., Sander, C. & Stein, D.J., ‘Pharmacotherapy and psychotherapy for body dysmophic disorder’, The Cochrane Database of Systematic Reviews, 21 (1) (2009), pp. 1-29. 30. NICE, Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder (www.nice.org.uk/ 2005) <http://www.nice.org.uk/guidance/ cg31/chapter/1-guidance#/step-1-awareness-and-recognition (section 184.108.40.206)> 31. Ericksen W.L, & Billick, S.B., ‘Psychiatric issues in cosmetic plastic surgery’, Psychiatr Q, 83 (2012), pp. 343–352. 32. Goodwin, A.P.L, Martin I.C, Shotton H, Kelly K, Mason M, On the Face of It: A Review of the Organisational Structures Surrounding the Practice of Cosmetic Surgery, (www.ncepod. org.uk , 2010) <http://www.ncepod.org.uk/2010report2/downloads/CS_report.pdf> 33. All Parliamentary Group, Reflections on Body image (www.ncb.org.uk, 2012) <http://www.ncb.org. uk/media/861233/appg_body_image_final.pdf> 34. Royal College of Surgeons, Professional Standards for Cosmetic Practice (www.rcseng.ac.uk, 2013) <http://www.rcseng.ac.uk/publications/docs/professional-standards-for-cosmetic-practice/> 35. Wildgoose P., Scott, A., Pusic, A. L., Cano, S., & Klassen, A. F., ‘Psychological Screening Measures for Cosmetic Plastic Surgery Patients A Systematic Review’, Aesthetic Surgery Journal, 33(1) (2013), 152-159. 36. Paraskeva, N., ‘Psychological assessment prior to cosmetic procedures: brief report on a pilot study’, Journal of Aesthetic Nursing, 2.2 (2013), pp. 82-85. 37. Fitzpatrick R, Davey C, Buxton MJ, Jones DR, ‘Evaluating patient-based outcome measures for use in clinical trials’, Health Technology Assessment, 2(14) (1998).
Aesthetics | November 2014
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Clinical Focus Male Products
Topical: Male Skincare Dr Rachael Eckel looks at the nuances of treating male skin with cosmeceuticals
surrounding skin. Such juxtaposition influences our perception of the facial gender. This is the reasoning behind females applying makeup; to exaggerate sexually dimorphic attributes, making the face appear womanlier.9 Anatomical differences between sexes also result in ageing disparities. Men show fewer but deeper rhytids when they lose subcutaneous adipose with age.4 This is because of their thicker skin and prominent facial musculature. Conversely, females have more numerous and superficial expression lines, especially in the perioral region.4
Psychological Factors The male population seeking cosmetic improvement is swiftly growing. From 2000 to 2005, there was an overwhelming 44% increase in minimally invasive cosmetic procedures among males, according to the American Society of Plastic Surgeons.1 Similar to women, men hope to display an attractive, vibrant, and healthy outward appearance lending to improved self-confidence.2 There are, however, pivotal differences in expectations, motivations and decision-making. Men want a minimalistic approach and are intolerant of delayed downtime.2 Their decisions are made rapidly and centred less upon youthfulness and more upon increasing attractiveness and marketability in the workplace.1,2 It is important for clinicians to identify the discrete nuances when caring for male patients, which are both anatomical and psychological. Topical agents that are recommended should respect these biological differences, remaining simple yet effective. With a male skincare market worth £25 million in 2012 and growing 4% year on year, this is a demographic that necessitates attention (Table 1).3 2011
Table 1: UK prestige skincare category value growth3
Anatomical Considerations Cutaneous gender differences are extensive, primarily mediated by sex hormones.4 In men, the surge in androgens affects many functions of human skin and its appendages. The impact of testosterone on the sebaceous glands means that male skin is markedly oilier.5 Excess sebum clogs pores leading to blackheads and patulous follicles. Such textural irregularities are particularly prominent over the facial convexities where oil glands cluster. Seborrhoeic eczema is a common consequence classically observed peri-nasally and over the eyebrows.6 Male skin, both epidermis and dermis, is typically 20-30% thicker than that of females.4 This remains true for all ages with extent varying upon anatomical region.4 Similarly, vascularity and skeletal muscle mass are more pronounced. The comparative lack of subcutaneous adipose tissue, irrespective of age, gives a more defined, chiselled appearance to the male facial structure.4 Hormonal influences also affect the distribution of male hair. When present, it offers continuous photoprotection and maintains youthfulness. Conversely, when hair is absent, especially over locations such as the scalp and ears, the risk of developing skin cancer increases considerably.7 This is further compounded by these regions being difficult to self-examine, encouraging late presentations of advanced disease. The habits associated with male grooming (and specifically shaving) can lead to disease such as pseudofolliculitis barbae, which reaches an alarming 85% prevalence amongst males of African descent.8 Excess facial hair also permits an increased surface area for bacterial colonization. This may explain why acne presents more severely amongst males. A 2009 study published in Perception identified a noteworthy difference in skin contrast between genders.9 Regardless of race, female faces have lighter skin when compared to males; hence ‘the fairer sex’. The colour intensity of female eyes and lips however, match those of males, providing a more striking contrast to their lighter 34
Aesthetics | November 2014
There is a relative lack of male-specific studies in aesthetics. But clinical practice and market research strongly suggest that a gender specific stratagem is imperative. The male approach to dermatology and aesthetics tends to be reactive rather than proactive. Men are less concerned with anti-ageing, and present to clinicians with a specific problem, for example, rosacea.Dermatoses tend to be advanced and require numerous ancillary procedures to effectively remedy because of the late presentation. Behaviourally, I find men to be more passive dermatologic patients; they ask fewer questions and are less likely to highlight their concerns. Furthermore, their knowledge about skincare is often misguided and their daily topical regime reflects this disservice. This is particularly compelling with regards to their lack of photoprotection, which lends to men having remarkably higher rates of all types of skin cancer compared with women.7 In fact, men over 50 are more than twice as likely to develop and die from skin cancer.7 The poignant behavioral reasons underlying this are manifold and detailed in Table 2. Although there exists a knowledge gap for the importance of UV protection amongst men, a recent Australian study showed that when men receive information about protecting their skin they respond positively, and adopt a photoprotective regime.10,11 Men can therefore be mobilised to take an active role in their skin health through education about sunscreen, early detection and prompt treatment. With this in mind, the male patient’s general consultation needs to be thorough and directive to engage him. It should be centred upon attentiveness, asking open questions and education. Explanations must be simple yet detailed and video references provided where available, as these have been proven to be more effective than brochures within this patient cohort.12 When advocating topicals, consideration should be given to numerics and marketing. On average, males use half as many daily products when compared to females.13 Typically their skincare regime will fit into one of the following groups, they (1) use soap and water primarily; (2) cherry pick products from their partner; or (3) purchase male specific topicals. Regarding the latter, when manufacturers create a gender-focused product they employ stereotypical ideas of masculinity to target shoppers.
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Clinical Focus Male Products
Product imagery tends toward science and tool-like shapes rather than flowers and fruit showcased on women’s packages.13 Fragrance is another area of divergence, Figure 1: Nodulocystic acne. Patient shown before as is presented and after treatment for eighteen weeks using cleanser (Oilacleanse), mechanical scrub (Exfoliating Polish), ingredients. Women sebostatic pads (Cebatrol), antioxidant protection / are more allured by DNA repair / barrier restoration (Daily Power Defense), sunscreen (Oclipse M SPF 30), alpha-hydroxy acid botanical extracts (e.g. exfoliant (Glycogent), vitamin A (retinoic acid 0.1% and Melamix) Indian gooseberry, liquorice root) and holistic skincare components compared with men. In reality, his and her product lines are indistinguishable.13 They contain almost identical ingredients rebranded to suit the gender and consumer desires rather than skincare needs. While there exists a notable difference in male psychology and marketing
all cutaneous cells are functioning optimally.5 The favoured male approach to achieving such holistic outcome is minimalistic. A regime with few steps and maximal gains will yield the greatest compliance. Remembering that the male client is unlikely to be using an elaborate protocol already, initial topicals selected should focus on providing skincare fundamentals. This includes the removal of sebum and debris, enhancing keratinocyte exfoliation, repairing the barrier function, controlling inflammation and protecting against UV damage. These may be easily achieved by following five practical steps.
Basic Skin Hygiene (Steps 1-3) The following three daily steps are indispensible. Together they form the pillars for maintaining pilosebacious health through oil reduction, enhanced cellular exfoliation, and inflammation suppression. The skin’s delicate lipid bilayer that contributes to barrier function must be simultaneously respected and restored by selecting balanced formulations. • The face should be washed twice daily for 40-60 seconds with a cleanser that Table 2 solubilizes and facilitates the removal • Men prefer a baseball cap style for protection yet this only protect the of sebum and skin soils. Salicylic acid, a forehead and frontal face. The neck, ears, and sides, the most high risk beta-hydroxy acid, is particularly effective at anatomically for male skin cancer, remain exposed. digesting such irritants. Tepid or cold water • Men spend 10 more hours a week in the sun compared to women due to should only be used, as heat is irritating. outdoor work and sports. Washes that contain micro-beads are • A recent survey found that 1 in 2 men had not applied sunscreen in the particularly appealing because they assist in past 12 months and only 32% considered themselves knowledgeable shedding dead cells. about how to properly use it. Furthermore, nearly two-thirds of these men believed women needed sunscreen more because female skin has • An exfoliating mineral scrub used once greater UV sensitivity. daily for 40-60 seconds will gently lift • Men are three times more likely to avoid physicians when there is a dead keratinocytes, and promote cellular persisting minor medical symptom. Men present with larger, thicker, turnover. Such mechanical exfoliation will more invasive melanomas and this is likely the reasoning. Furthermore, simultaneously clean pores from pollutants they neglect routine screenings for skin cancer, even if sent reminders and improve irregular texture. Ingredient and offered free of charge. edges should be finely polished so as not to • Education and advertisements for sunscreen appear primarily in cause microtears and irritation. publications aimed at women. In a 5 year review of 24 different • To remove any residual impurities and magazines, 77% of sunscreen ads were in female magazines and none minimise inflammation throughout the day, mentioned correct application method. oil control pads containing a blend of witch • 53% of women protect themselves at least sometimes with sunscreen, hazel and chemical exfoliants (e.g. alphacompared to only 36% of men. They also apply too little volume and hydroxy acids, mandelic acid) should be reapplication is seldom. employed twice daily. These will reduce Table 2: Behavioral considerations underlying male sunscreen usage irritation while maintaining a small pore size strategy, it is important to remember that clinicians should base and smooth texture through enhanced keratinocyte exfoliation. An their product recommendations on science and efficacy. Of note, emollient complex can be further added to soothe skin and restore approximately 80% of all cosmeceuticals currently available on the vital lipids lost through cleansing and shaving. market use ingredients that have not shown any clinically proven benefit.5 Antioxidant Protection, DNA Repair, and Barrier Restoration (Step 4) A skincare line that combines active ingredients based on novel A comprehensive topical agent containing antioxidants, DNA repair science with targeted delivery systems is a preferred choice. enzymes and barrier replenishing agents should be applied to the skin Fragrance should be limited as this is irritating, but where present it daily. The reasoning for this is as follows: should be clean and unisex. • A diverse bouquet of antioxidants (e.g. vitamins A, B, C, E, Coenzyme-Q10, plant extracts and stem cells) will provide a Skincare in Execution multimodal benefit platform to both repair and protect against When men describe the skin they hope to achieve, they use oxidative stress. Topical antioxidants are also particularly effective adjectives such as clean, fresh, vibrant, clear and smooth. at quelling UV and pollution-generated free radicals. Once daily On a cellular level this translates into homogenous melanin application will yield 24 hour-long protection, and a cumulative distribution, effective keratinocyte turnover, ample collagen and benefit occurs when used regularly. elastin output, absence of active disease, natural hydration and • Sun exposure damages DNA, leading to skin cancer and wrinkling. intact barrier function. This, by definition, is healthy skin where DNA repair enzymes can be applied to skin to mend such ruin. These 6,9,10
Aesthetics | November 2014
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Utilising the latest technology available you can work in conjunction with topical skincare to ensure that hydration and comfort are not compromised whilst delivering excellent peeling results.
Radio Frequency Tri-polar Radio Frequency is the most advanced technology available for skin-tightening ensuring excellent results without the discomfort associated with mono or bi – polar devices.
Mesotherapy Non-invasive mesotherapy ensures that the active ingredients are delivered where they are needed most without the need for needles.
LED Full canopy LED ensures both rapid treatment time and excellent results are achieved. Available wavelengths Red (640nm - 700nm), Blue (425nm - 470nm), Yellow (590nm) and Green (520 - 564nm) ensures effective treatment for anti-ageing, pigmentation, acne and detoxification.
3D-skintech peels and clinical skincare A compact range of medical grade peels and cosmeceutical skincare products complete the Skintech’s unique offering and enables you to both use as a “stand-alone” service or combine with equipment protocols. ‘To compliment our core injectable business the 3D-skintech has added an array of new result driven facial services to our clinic’s menu as well as the combination services for our more curative patients. We recognized that this device offered the stand alone quality of each technology in a unique machine that will ensure that we both deliver the results but equally can make money from the start due its affordability. As a clinician too many times in the past we have invested huge sums of money in a single concept that has proven difficult to profit from. In my opinion this type of system represents the future in our industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic
Clinical Focus Male Products
scan mitochondrial and nuclear DNA for injury and subsequently fix the distorted portion. One sub-type, roxisomes, speeds up DNA repair from 24 hours down to two. These enzymes also reduce UV-generated cell death, cytokines, and matrix metalloproteinases. Together with antioxidants, they increase the skin’s innate resistance to UV light, and the subsequent inflammation induced. • The specialised barrier function of the epidermis is delicate; easily disrupted and lost. UV radiation and pollution are common culprits that compromise the skin’s integrity leading to sensitivity and dryness. To replenish and preserve the skin’s barrier, a diverse group of physiologically relevant lipid fractions and humectants (e.g. ceremides) should be strategically applied daily. UV Protection (Step 5) Daily application of a broad-spectrum sunscreen with an SPF value of 30 or greater is advocated. A comprehensive formulation suited to the skin type and colour should be selected. Physical blocks (e.g. titanium dioxide, zinc oxide) are superior to their chemical counterparts because they are less irritating and last twice as long. Fractionated melanin is a novel ingredient to look for in sunscreen, providing 10 hours of continued protection against High Energy Visible (HEV) rays, which can be more injurious and penetrate deeper than UVA. Optional Shaving Balm The most popular product purchased by men in the UK is a shaving lubricant.3 If facial grooming involves shaving, this should follow the exfoliating scrub step. It is ideal for the chosen product to be free from fragrance and colour to minimise irritation. The latter will also benefit patients with ‘designer beards’, permitting more precise grooming. Formulations replete with antioxidants (e.g. vitamin E) and anti-irritants (e.g. niacinamide) are particularly appealing to concurrently soothe the skin. The incorporation of physiologically relevant lipids (e.g. glycerin, mannitol) will preserve the delicate barrier function and mitigate the mechanical damage caused by razors. Incremental Additions Once the male has integrated these five basic steps successfully into their habitual daily practice, other topical agents can be supplemented to augment the regime efficacy. These should be introduced incrementally (e.g. every six weeks, one skin cell cycle) to capitalise on compliance. The following ingredients represent the most appropriate additions to consider: • Alpha-hydroxy acids (e.g. lactic acid, glycolic acid) will increase cellular turnover to curtail trapped sebum and soften texture. Pore minimisation that occurs will also have a direct impact on suppressing the superficial output by the sebaceous gland. • Benzoyl peroxide is a useful supplement for patients with particularly oily skin. It diminishes seborrhea and acts as an antimicrobial agent. Micronized technology should be preferentially elected, as it does not induce irritation.13 • Vitamin A provides extensive improvements to the epidermis and dermis. These include softer skin, sebum reduction, smoother texture, smaller pores, improved hydration, a decrease in lesion counts, evening of pigmentation, reduced sensitivity, and potent anti-ageing benefit. When disease is present retinoic acid should be used up to 18 weeks, and the retinol moiety long term for maintenance purposes.4,13 • Although conditions of pigmentation (e.g. melasma) are less frequent amongst males, when present they must be addressed. Hydroquinone can be used in a brief, pulsed manner to control 38
disease and a non-hydroquinone approach adopted for maintenance. Unnecessary skin lightening tends to be avoided in males as this feminises the face.8 Interestingly, geographic location has an impact on product selection and grooming attitude. Within the UK, men in London, the North West, Yorkshire/North East/Borders and Ulster display a more sophisticated outlook to skincare.3 In particular, London males are early adopters, and are more likely to purchase luxury items.3 With this in mind, the clinician may choose to adapt their recommendations to suit the cultural climate. Likewise, when cutaneous disease is present causing disfigurement and distress, the incremental approach may be dismissed. In such circumstances, male patients are keen to rapidly inactivate the condition and dedicate more time to skincare. More lengthily regimes may instead be appropriate at the therapeutic onset, and reduced for maintenance.
Conclusion The male market seeking cosmetic improvement is growing sizably and with this follows increased questions about skincare. In order to successfully treat this cohort, clinicians must remain aware of the existing anatomical and psychological nuances. Consultations should focus on education and this is especially critical in relation to the male skin cancer epidemic. To drive compliance, initial regimes must be minimalistic, focusing on fundamental skin health principles. These can be further supplemented incrementally to augment the programme efficacy whilst nurturing a habit. Topical agents selected should contain active ingredients that are science based with proven results. A holistic approach is advocated to achieve maximal skin health by restoring, protecting, and strengthening all cellular functions. Dr. Rachael Eckel is a cosmetic dermatologist, U.S. board certified in aesthetic medicine. She is a multi-published author who educates physicians internationally, with a focus on topical skincare agents. Dr Eckel graduated with Honours from the Royal College of Surgeons in Ireland and received six first place medals for outstanding achievements. REFERENCES 1. Allison Van Dusen, Most Popular Plastic Surgery for Men (Forbes.com, 2006) <http://www.forbes. com/2006/10/31/plastic-surgery-men-forbeslife-health-cx_avd_1101plast. html>[accessed 6 September 2014] 2. Julie Ann Woodward, Cosmetic surgeons shed light on male patients’ expectations, psychological needs (Cosmetic Surgery Times, 2012) <http://cosmeticsurgerytimes. modernmedicine.com/cosmetic-surgery-times/news/modernmedicine/modern-medicine-now/ cosmetic-surgeons-shed-light-male-pat> [accessed 6 September 2014] 3. NPD Group, Men’s grooming is booming (NPD Group, 2013) <https://www.npdgroup.co.uk/wps/ portal/npd/uk/news/press-releases/mens-grooming-is-booming/> [accessed 6 September 2014] 4. Terrence Keaney, Understand facial aging in skin of color for cosmetic outcomes (Dermatology Times, 2013) <http://dermatologytimes.modernmedicine.com/dermatology-times/news/ understand-facial-aging-skin-color-cosmetic-outcomes> [accessed 6 September 2014] 5. Obagi, Zein. ‘Sebum’, in The Art of Skin Health Restoration and Rejuvenation. 2nd edition (London: CRC Press, 2014) p. 332. 6. Amanda Oakley, Seborrhoeic eczema (DermNet NZ, 2014) <http://dermnetnz.org/dermatitis/ seborrhoeic-dermatitis.html> [accessed 6 September 2014] 7. Skin Cancer Foundation. You Are At Risk (Skin Cancer Foundation, 2014) <http://www.skincancer. org/healthy-lifestyle/anti-aging/you-are-at-risk> [accessed 6 September 2014] 8. Lisette Hilton, Men with skin of color require subtle differences in care (Dermatology Times, 2013) <http://dermatologytimes.modernmedicine.com/dermatology-times/news/men-skin-color-require- subtle-differences-care#> [accessed 6 September 2014] 9. Gettysburg College, Why Cosmetics Work: More Depth To Facial Differences Between Men And Woman Than Presumed (ScienceDaily, 2009) <http://www.sciencedaily.com/ releases/2009/10/091020153100.htm> [accessed 6 September 2014] 10. Candy Sagon, Men and Sunscreen: Why Aren’t They Using Any? (AARP, 2012) <http://blog.aarp. org/2012/07/05/men-and-sunscreen-why-arent-they-using-any/> [accessed 6 September 2014] 11. Skin Cancer Foundation, Men and Skin Cancer: Solving the Knowledge Gap (Skin Cancer Foundation, 2014) <http://www.skincancer.org/prevention/are-you-at-risk/men-and-skin-cancer- solving-the-knowledge-gap> [accessed 6 September 2014] 12. Sarah Thuerk, Video-based education boosts men’s skin health awareness (Dermatology Times, 2014) <http://dermatologytimes.modernmedicine.com/dermatology-times/news/ video-based-education-boosts-men-s-skin-health-awareness> [accessed 6 September 2014] 13. Amanda Chan and Meredith Melnick, Men’s Products: Are They Really Any Different From Women’s? (The Huffington Post) <http://www.huffingtonpost.com/2012/02/09/mens-grooming- products-different-womens_n_1264137.html> [accessed 6 September 2014] 14. Rachael Eckel, Rosacea: The Strawberry Fields of Dermatology, PRIME Journal, 6 (2014), 30-40 (p.38).
Aesthetics | November 2014
Treatment Focus Hyaluronidase
Case Report 2
Hyaluronidase Melanie Recchia and Mr Adrian Richards discuss the role of hyaluronidase in managing dermal filler associated peri-orbital swelling We report on two cases that have recently presented to our clinic. Both had upper face hyaluronic acid (HA) dermal filler treatments and developed significant periorbital swelling some time after the initial treatment. The long-standing swelling was treated successfully with hyaluronidase. This article discusses the causes of HA dermal filler associated peri-orbital swelling and its management.
Case Report 1 In September 2011, a 46-year-old patient underwent HA dermal filler treatment to her tear trough area. She had previously been treated in other areas including cheeks, naso-labial folds and lips without incident. Each tear trough area was treated with 0.4mls of HA dermal filler placed in a subcutaneous position. Her immediate recovery was uncomplicated. She contacted the clinic two months later saying that she had developed a persistent swelling to her left lower eyelid. Conservative treatment, which included massage, did not help to resolve the swelling. The area was therefore treated with 25 units of hyaluronidase, reconstituted as
per protocol (Figure 1). The patient reported a slight improvement in the area two weeks following treatment. The patient presented again four months later reporting worsening swelling of her left lower eyelid. No palpable filler was noted at that time. She was treated with a further 25 units of hyaluronidase and a short course of oral prednisolone. Again, the patient reported slight improvement in the area one week following treatment. The patient presented 18 months later with recurrent swelling and skin excess in the lower section of her left eyelid. She was referred to an oculoplastic surgeon who recommended further hyaluronidase treatment. He noted possible residual dermal filler and felt that the use of hyaluronidase may still have some benefit, even though it was three years following her initial tear trough treatment. The isolated swollen area was treated by our lead practitioner with 25 units of hyaluronidase. The patient reported a significant improvement in the area within 24 hours of treatment. Within a week the swelling and skin excess had completely resolved and she remains happy with the result.
Figure 1: Hyaluronidase Reconstitution Guidelines 1. 1ml bacteriostatic saline 0.9% drawn up from a 30ml vial. 2. Inject that 1ml into the ampoule of Hyalase. 3. Draw up the contents of the ampoule and re-introduce into the 30ml vial of bacteriostatic saline 0.9%. 4. You now have 1500 units of Hyalase in 30mls bacteriostatic saline 0.9%. 5. This is equivalent to 1ml = 50 units: 0.1ml = 5 units: 0.05mls = 2.5 units. 6. Study results suggest for a 0.8ml syringe of HA you may need up to 80 units of hyalase or 1ml HA may need up to 100 units. 7. Inject slowly into the centre of the product you are trying to remove. 8. Review in 24 hours.
Aesthetics | November 2014
A 64-year-old female had been having HA dermal filler to her cheeks on an annual basis for approximately three years. The areas were usually filled with 0.8mls in the left cheek and 2 x 0.8mls to the right, due to asymmetry. Eight months after her last treatment, the patient presented with a very obvious soft swelling under the right eye, as seen in Figures 2 and 3. She reported that the swelling had started approximately five months previously. At this time the patient declined treatment and opted to continue to see if it would resolve naturally. Four months later, the patient returned for review. The area under the right eye had not changed so the use of hyaluronidase was discussed and treatment went ahead using 30 units. At her next appointment â€“ 24 hours later â€“ the swelling in the area showed considerable improvement. The patient was reviewed again two weeks later, and a complete resolution was seen (Figures 4 and 5).
Discussion Peri-orbital swelling has been reported to be associated with a variety of fillers.1,3 In this report, lower eyelid swelling occurred in patients following migration of the filler from the malar area. Peri-ocular swelling and diplopia have also been reported following hyaluronic acid-based dermal fillers.2 In the article a 38-year-old female presented with diplopia and bilateral lower eyelid swelling one and a half months after hyaluronic acid filler injection of tear trough deformity. An eye examination demonstrated an inferior oblique muscle restriction on the right eye. Diplopia and bilateral lower eyelid puffiness were treated by injection of hyaluronidase, which resulted in the disappearance of both diplopia and bilateral lower eyelid puffiness. Hyaluronidase is a hyaluronic acidmetabolizing enzyme. Cross-linked hyaluronic acids have been shown to be susceptible to hydrolysis by hyaluronidase when contained within the intact facial artery in a cadaver model, indicating that direct intra-arterial injection of HYAL is not necessary to help restore the circulation of ischemic tissues.4 Most hyaluronidase is ovine or bovine in nature and some brands are derived from cobra venom. It is preferable to do a skin test before use to check for potential allergic reactions. Hyalase (Wockhardt UK Ltd) is the brand
Treatment Focus Hyaluronidase
period following dermal filler treatment, hyaluronidase treatment rapidly resolved the swelling even though we would have expected the filler to have dissolved.
Patient 2 before hyaluronidase treatment showing soft swelling under the right eye
Patient 2 after hyaluronidase treatment showing a significant reduction in swelling
used in the UK, and is supplied in a 1500 unit ampoule. It is a prescription only medication. A study of 14 patients with periorbital oedema associated with hyaluronic acid filler treatment demonstrated that it rapidly resolved eyelid swelling after one treatment.3 No adverse effects were noted and the resolution of the swelling was permanent in the patients with hyaluronic filler associated swelling. The study concluded that, “The infiltration of hyaluronidase is rapid, safe and currently the only effective option for the management of eyelid oedema.” Our findings support previous reports on eyelid swelling following regional dermal
filler treatments. The swellings in our patients were long standing and remained even though we would have expected the dermal filler to be absorbed. We were pleased that the hyaluronidase worked so effectively and quickly on these patients to resolve their issues.
Conclusion Peri-ocular swelling following regional dermal filler treatments has been well documented. We have reported on two cases of long-standing eyelid swelling following treatment. These were successfully treated with hyaluronidase injections. Even after a prolonged
Adrian Richards is a consultant plastic and cosmetic surgeon who has specialised in aesthetics for more than 15 years. He is the clinical director and founder of nationwide cosmetic surgery group Aurora Clinics, as well as training provider Cosmetic Courses, which offers aesthetic training to medical professionals. Melanie Recchia is a nurse independent prescriber specialising in muscle relaxing injections, dermal fillers and specialist skin treatments. She also manages a successful clinic in Buckinghamshire. REFERENCES 1. AH Alsuhaibani, N Alfawaz, ‘Lower eyelid swelling as a late complication of Bio-Alcamid filler into the malar area’. Saudi Journal of Opthalmology, 25(1) (2011), 75-9. 2. MB Kashkouli, A Heirati, F Pakdel, V Kiavash, ‘Diplopia after hyaluronic acid gel injection for correction of facial tear trough deformity’. Orbit, 31(5) (2012), 330-1. 3. S Hilton, H Schrumpf, BA Buhren, E Bölke, PA Gerber, ‘Hyaluronidase injection for the treatment of eyelid edema: a retrospective analysis of 20 patients’. European Journal of Medical Research, (2014) 19(1):30. 4. C. DeLorenzi, ‘Transarterial degradation of hyaluronic acid filler by hyaluronidase.’, Dermatol Surg. (2014) 40(8) 832-41.
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Spotlight On Injectable Lipo
Dr Vincent Wong explores the development of injectable lipolysis
Injectable treatment of localised adiposity What is lipolysis? Lipolysis, in biological terms, is the hydrolysis of triglycerides.1 This process can be divided into intra-adipocyte or intracellular lipolysis and extracellular lipolysis. Intra-adipocyte lipolysis is carried out by hormone-dependent lipases, which catalytic activity is directed at the lipidic reserves within intracytoplasmic vacuoles.1 This physiological phenomenon results in adipose cells releasing quantities of triglycerides (hence reducing intravacuolar level and adipocyte volume), which are split into long-chain fatty acids and glycerol. Intra-adipocyte lipolysis is a complex biochemical reaction, which begins when betareceptors on the cell membrane are activated by molecules such as catecholamines and cortisol (typically released in large quantities during fasting).1 Through second messenger activities (cyclic adenosine monophosphate, phospholipids and ions), the inhibition of phosphodiesterase is induced.1 This interrupts the blocking action of phosphodiesterase on intra-adipocyte hormone-dependent lipases that are now active and available to carry out the hydrolysis of triglycerides. Extra-cellular lipolysis on the other hand, is carried out by lipoprotein lipases which originate from muscular and adipose tissues. Lipoprotein lipases bind to the endothelium of vessels and split triglycerides into glycerol and fatty acids. The fatty acids are then used by the cells for energy or re-esterification into triglycerides in the adipose tissue and hence increasing the volume of intracytoplasmic vacuoles.1 Background and evolvement through the years Over the last fifteen years, the use of injectable solutions to reduce localised adiposity underwent a fundamental evolution. In 2003, we were introduced to phosphatidylcholine-sodium deoxycholate, which, at that time, was the only therapeutic alternative to liposuction. This non-surgical tool was made up of polyunsaturated phosphatidylcholine, which was made soluble by sodium deoxycholate, a detergent substance. Although the proper indication of this solution was the treatment of pulmonary fatty embolism, it was introduced to the cosmetic market after an early attempt to reduce xanthelasmas. The excitement within the industry was evident when the off-label use of this drug spread quickly. For the aesthetic treatment of localised adipose tissue, solutions containing phosphotidylcholine and sodium deoxycholate were injected subcutaneously, directly into the target tissue. The multiinjection treatment would sometimes be combined with various mesotherapy solutions. Many hypotheses exist on the mechanism of action of phosphatidylcholine on adipose tissue, but these were unsupported by any scientific data and often conflict with the general notions of human physiology.1 The other component of the drug, sodium deoxycholate, however, has been proven to have an emulsifying action at the cellular membrane level leading to cellular lysis.2,3 It is thought that it is likely that the detergent power
of sodium deoxycholate towards the cell membrane is controlled by phosphatidylcholine, due to its restorative action on adipose cell membranes.1 Pasquale Motolese concluded in 2008 that the term Before After 1 session adipocytolysis (cell lysis) appears more appropriate and even more indicative of the phenomenons tied to the action of phosphatidylcholine solutions introduced directly into the adipose Images courtesy of Prof P. Motolese, the inventor of AQUALYX tissue. Following the exclusive detergent action of sodium deoxycholate, a purely chemical destruction of adipose tissue would be achieved. Not long after its introduction, due to lack of scientific studies and serious concerns over nerve damage, permanent scarring, skin deformities and deeply painful knots under the skin in treated areas (all reported to the FDA), the drug was withdrawn from the aesthetics market in almost all countries. As the solution was not licensed for the reduction of fat, both the FDA and MHRA have raised concerns over misleading information and unlawful advertising of the drug as a cosmetic product for lipolysis.4 While British physicians can still inject phosphotidylcholine-sodium deoxycholate for fat removal, the drug cannot be promoted for that purpose and malpractice insurance for the use of the drug for fat removal has also been ceased. The great interest and widespread use of phosphotidylcholine has led to more research in this field. After rejecting the initial hypothesis of a lipolytic action of phosphatidylcholine, formulation of new injectable solutions emerged where only sodium deoxycholate was present as active ingredient. Given the aggressiveness of the molecule, this was unsuccessful due to the high risk of skin necrosis (Rauso, 2011).3 This further confirms the theory that phosphotidylcholine plays a role in controlling the exclusive detergent activity of sodium deoxycholate. Today, one method of administering injectable lipolysis is to use an aqueous, micro-gelatinous solution containing a biocompatible and biodegradable sugar-based slow release system. This new injectable formulation (Aqualyx) is a result of better understanding of physiology and the mechanism of action of previous solutions. The CE-approved solution does not contain phosphatidylcholine, but a mix of detergent compounds from the deoxycholate family that has been physically modified to reduce the biological halflife. The ingredients are a polymer from 3, 6-Anhydro-L-Galactose Before
Aesthetics | November 2014
After 5 sessions
Spotlight On Injectable Lipo
and D-Galactose, buffer systems, sodium salt of (3α, 5α, 12α) - 3, 12-dihydroxy-5-cholan-24-acid, water for injection purposes and sodium chloride. The solution is formulated to predispose the adipocytes to lysis amplifying the effects of external ultrasound, hence why it is recommended that the treatment be combined with an ultrasound for best results. The lipolysis injection causes the dissolution of fat cells, after which the body then expels the released fatty acids naturally2 (Salti, 2012). During treatment the product must be injected into the subcutaneous fat with a special technique, using a sharp cannula. By using this injection technique (branded Aqualysis), the number of punctures is reduced, therefore limiting the pain of injection sites for the patient. When the treatment is carried out correctly, patients generally tolerate the treatment very well with minimal discomfort. Pain during treatment is often a sign of incorrect technique, for example, contact with the bone or muscle. Treatment Aqualysis is a minimally invasive option for men and women who want to reduce stubborn pockets of local subcutaneous fat. An ideal patient would be someone who has a healthy diet and exercise plan but cannot shift small but resistant areas of fat such as saddle bags, thighs, back fat or ‘muffin tops’. The Aqualysis treatment is indicated for lipohypertrophy, subcutaneous lipohyperplasia, “buffalo hump”, superior lateral region of the thigh, medial thigh area and medial zone around the knee and hips. However, usage in other areas of the body, as deemed suitable by the physician after careful assessment, is common in practice. With over two million vials sold in the past five years in 49 countries, Aqualysis is easily tolerated by patients who want a small area treated and want to avoid more invasive options. As the treatment only destroys the fat cells in the treated area and works best in small areas, it can be recommended to patients as part of a healthy lifestyle regime. When looking at adiposity treatments in general, this can be seen as an alternative to more invasive methods when the areas of fat are localised and where the patient would prefer a minimally invasive option. It can also be used to ‘top up’ a liposuction treatment where there are minor adjustments to be made. It is important to bear in mind that this type of treatment is not recommended for obese patients. A pinch test result of between 1.5cm and 3cm is considered ideal for this treatment. As with all treatments, each patient will respond differently. An example being that the length of time to see an effect in younger patients is sometimes longer than older patients due to the better health of the fat cell walls. Results are usually seen over a course of treatments and it is recommended that the treatment cycle is three to four weeks. The treatment can be combined with an ultrasound treatment for best results. In Europe, around two thirds of physicians are not using the ultrasound and are still getting very effective results. The treatment takes less than an hour and the injected solution can also be combined with lidocaine for better patient comfort. In terms of side effects, this treatment is comparable to other needle-based treatments. Common side effects include swelling, bruising, minor aches and erythema. Case Study A 24-year-old female of Caribbean heritage presented with localised pocket of adipose tissue in her abdomen. This pocket of subcutaneous fat was located periumbilically, and was resistant to 44
Many hypotheses exist on the mechanism of action of phosphatidylcholine on adipose tissue, but these were unsupported by any scientific data and often conflict with the general notions of human physiology diet and exercise. As a full time model, this was a concern for her and she wanted the adipose tissue removed. Upon physical examination, her pinch test result was more than 1.5cm. The injection of an aqueous micro-gelatinous solution was proposed. She was fit and healthy, and was not on any medications. She was not pregnant or breastfeeding, and there were no obvious contraindications to the proposed treatment. The subject was fully informed of the side effects and the possibility of mild discomfort, and that results are usually seen over a course of treatments. The patient accepted the treatment conditions and gave an informed consent for the procedure. Photos were taken prior to the commencement of the procedure. Two sessions were proposed and eventually performed with one-month interval. In each session, two 8ml-vials of the aqueous micro-gelatinous solution were injected into the subcutaneous fat using intralipotherapy large area needles, as recommended. Ultrasound was not used with the treatment. At each sitting, the area to be injected was cleaned with 0.2% clorexidine, sterile gloves were used and asepsis rules were followed. After each session, subject reported light swelling and some bruising, which disappeared within a week. No other complications were reported. Clinical improvement was documented with photographs and reported by the patient. The patient was reviewed 8 weeks after the last session to assess the results. Throughout the treatment period, the patients diet and exercise plan remained the same. The proposed treatment was successful and the patient reported that she was very pleased with the outcome. Conclusion The aqueous, micro-gelatinous solution containing a biocompatible and biodegradable sugar-based slow release system was developed as a result of better understanding of the mechanism of action of existing solutions. Its use seems to be a safe and effective way to reduce stubborn areas of localised subcutaneous fat. Dr Vincent Wong is an advanced medical aesthetics practitioner and the founder of Harley Street clinic La Maison de l’Esthetique. He has extensive research experience in plastic surgery and dermatology and has presented his work at several national and international conferences. BIBLIOGRAPHY 1. Motolese, P., ‘Phospholipids do not have lipolytic activity. A critical review,’ Journal of Cosmetic and Laser Therapy, (2008) pp. 114-118. 2. Salti, G., ‘Cavitational adipocytolysis with a new microgelatinous injectable for subcutaneous adipose tissue volume reduction: ex vivo histological findings’, The European Journal of Aesthetics Medicine and Dermatology, (2012), pp. 94-97. 3. Rauso, R., ‘Non surgical reduction of buffalo hump deformity’, European Journal of Aesthetics Medicine and Dermatology, (2011), pp. 29-34. 4. MHRA, Lipostabil (2005) < http://www.mhra.gov.uk/Safetyinformation/ Safetywarningsalertsandrecalls/Safetywarningsandmessagesformedicines/CON1004243>
Aesthetics | November 2014
Training workshops will be running throughout September & October 2014 To book your place email ellansetraininguk@ sinclairpharma.com
Ellansé™ for Natural, Youthful and Longer-lasting Results Ellansé™ dermal fillers provide immediate lift for the correction of wrinkles and folds and stimulate the generation of the body’s own collagen Ellansé™-S
www.ellanse.com For more information please contact us at Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street. London W1T 2RQ. United Kingdom Telephone +44 (0) 207 467 6920 www.sinclairispharma.com Date of preparation: September 2014
Treatment Focus Oxygen and C02
Combined benefits: The use of Carbon Dioxide and Oxygen in aesthetics Dr Domenico Amuso explores the individual and combined uses of Carboxytherapy and Oxygen Infusion to achieve optimal aesthetic results The use of Carbon Dioxide and Oxygen to achieve skin rejuvenation is a tale of two methodologies that work very successfully individually, but add another dimension when combined. This article describes uses of carboxytherapy and oxygen in skin rejuvenation and how the therapies can be combined to enhance results. Carboxytherapy Carboxytherapy is defined as the use of medical carbon dioxide (CO2) administered with intradermal and subcutaneous inoculations by medical professionals, typically using a device connected to a cylinder of medical CO2 which enables the gas to be supplied in a controlled way, and programmable according to the resistance encountered in the patients’ tissues. The first effects following CO2 injection is a strong vasodilatation, a blood flow increase and a higher pO2 in the treated area. The Bohr effect describes the tendency of haemoglobin to have less affinity for oxygen when the blood concentration of CO2 is increased.1 This lower affinity leads the haemoglobin to better release the oxygen in superficial tissues and muscles. The presence of CO2 also promotes collagen remodelling as well as thickening and smoothing the overlying skin. Relating to blood circulation, Carboxytherapy causes active arteriolar vasodilation, increasing the blood flow to the treated area. This also effectively eliminates the build-up of fluids and toxins between the cells causing lymphatic drainage.2 The treatment is safe for all kinds of patients, and for face and body therapies. Carbon Dioxide is non-toxic, does not cause embolisms and is compatible with the human body that produces it constantly and eliminates it through Images courtesy of MBE the lungs via the venous system. Medical Division Oxygen ‘Oxygen Infusion’ is a technique where oxygen with a purity of between 94-98% is ejected onto the skin through proprietary hand pieces fitted with shaped ‘oxygen caps’ at a pressure two or three times higher than normal atmospheric pressure. Fick’s first law of diffusion, modified by Higuchi,3 states that the capacity to carry 46
a substance through the epidermis is directly proportional to the solubility and the ability of the applied substance to diffuse. The cutaneous barrier function resides in the corneal layer. During the infusion process, the oxygen, when it comes into contact with the skin, has a latent period in which the gas reaches a state of balance with the skin. Once the point of balance is reached, a constant flow of penetration begins, the scale of which is proportional to the concentration and to the pressure of the gas. This methodology enables the gas to pass transcutaneously. This occurs to a small extent through glandular annexes (pilosebaceous apparatus and eccrine glands) and through intercellular and/or transcellular paths. The therapeutic action of Oxygen Infusion is characterized by the angiogenetic properties typical of oxygen. It is also believed that Oxygen Infusion influences the long-term regulation of tissue ematic flux, delivering an increase in the entity of the vascular bed of tissue microcirculation, causing a true angiogenesis.4 Oxygen Infusion acts on the three primary components of the connective dermal tissue, keeping up an adequate production for quantity and quality of glycosaminoglycans (hyaluronic acid), elastic and collagen fibres. When infused, Oxygen can be effective in the treatment of P.E.F.S. (Fibro Sclerotic Edematous Panniculitis), wrinkles, stretch marks, lax skin, localized adiposity and dyschromia.4 Combined Therapies Gas Contouring is a technique consisting of localized injections of carbon dioxide followed by localized infusions of pure oxygen pressurized at more than two atmospheres. Compared with Carboxytherapy, a therapy that has been in use since the thirties, this new technique has shown considerable benefits. To evaluate the clinical action of the two when used together, a clinical study5 was conducted using sixty Caucasian female patients aged between 21 and 56 years of age. Of the sixty participants, 20 were treated solely with oxygen infusion, 20 with carbon dioxide and 20 with a combination of oxygen and carbon dioxide. The areas that underwent treatment were the ‘saddle bags’ and the abdomen. All the patients were evaluated clinically and particular attention was paid to the measurements, in centimetres, of the abdomen and thighs and to the measurement of skin elasticity and hydration. There were 12 sessions in the treatment and patients’ levels were recorded at the beginning, at the sixth session and at the twelfth. With Oxygen Infusion, the result was an improvement of 35.3% in skin elasticity and 19.9% in skin hydration. With Carboxytherapy, an improvement of 41.8% in skin elasticity and 15.6% in skin hydration was seen. With the combined action of Oxygen Infusion and Carboxytherapy, an
Aesthetics | November 2014
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improvement of 53.6% in skin elasticity and 27.9% in skin hydration was observed. There was also a clear reduction of localized fat deposits on the abdomen and thighs of the third category of patients. A further study6 was undertaken to investigate the effects of Carboxytherapy and Oxygen Infusion when used together for Fibro Sclerotic Edematous Panniculitis treatment. Improvements in skin texture in terms of grain, lines and depth of wrinkles and an effective lipolytic action in specific areas were noted.
Mesotherapy HAIR COCKTAIL PLUS MESOLIFT COCKTAIL ANTIAGING COCKTAIL FCE COCKTAIL SLIMMING COCKTAIL LOCALIZED CELLULITE COCKTAIL ANTICELLULITE COCKTAIL RADIANCE COCKTAIL PURIFYING COCKTAIL REGENERATING COCKTAIL TOSKANI are manufacturers and suppliers. We offer training and comprehensive protocols
Images courtesy of MBE Medical Division
Conclusion From my own experience in this field, and that of my colleagues, I am convinced that the synergic action of Carboxytherapy and Oxygen Infusion: • enables synthesis of dermal fibres having a filling effect (collagen I and III) • intensifies the synthesis of fibres having a supporting effect (collagen IV and VII) • tones the skin and fills the micro-grooves to give the surface density and volume to the skin • stimulates the synthesis of GAGs (glycosaminoglycans) collagen type I, III, IV, VII to restore the density and cohesion of the skin • promotes the synthesis of amino acids that make up the NMF to moisturize the skin • acts on cellular oxidation (cellular ageing) and tissue glycation or caramelization (ageing tissue) • counteracts the loss of elasticity and tonicity of the dermis and the consequential formation of FEF and stretch-marks • affects adipose tissue: carbon dioxide breaks down the membranes of the fat cells and oxygen infusion promotes the splitting up of the triglycerides into fat acids, reducing fat accumulation. Dr Domenico Amuso is a general surgeon and cosmetic doctor working in Modena, Italy. He graduated in medicine and surgery in 1994 and has a Master’s degree in surgery and aesthetic medicine from the US. Dr Amuso is responsible for the aesthetic section of the International Observatory of Oxidative Stress in Salerno, Italy. REFERENCES 1. Bohr, Chr., K. Hasselbalch, K., and August Krogh, The Influence of the Carbon Dioxide Content of Blood on its Oxygen Binding, (www.udel.edu, 1997) <http://www.udel.edu/chem/white/C342/ Bohr(1904).html> 2. Scilletta, Alessandra, ‘Carboxytherapy as a safe and very effective treatment for cellulite’, study available from MBE Medical Division. 3. Costa, Paulo, Manuel Sousa Lobo, Jose, ‘Modelling and comparison of dissolution profiles’, European Journal of Pharmaceutical Sciences, 13 (2001), pp. 123–133. 4. Amuso, Domenico, Battista, Antonella, Carbone, Alfonso, ‘Oxygen Infusion: Gold Standard for Anti-age Treatments’, study available from MBE Medical Division. 5. Botticelli, Annibale, Lalla, Michele, Amuso, Domenico, Battista, Antonella, ‘Oxygen Infusion and Carboxitherapy: Comparison and Synergy’, study available from MBE Medical Division. 6. Paolo Alberico, Francesco, ‘ Medical gas Synergies in endamatous fibrosclerotic Panniculopathy treatment; preliminary experiences and lipolytic tests’, study available from MBE Medical Division.
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Carboxytherapy & Oxygen Needling and Infusion Carboxytherapy uses localized microinjections of medical CO2 to increase the skin tone, increase skin elasticity and increase skin brightness. As CO2 is naturally occuring, the treatment is perfectly safe for the patient. Oxygenated Needling combines oxygen infusion with needling and achieves amazing results when compared with needling alone. Oxygen infusion has no contraindications, is perfect for all skin types, is used in Orthopaedics, Physiatrics, sport medicine, aesthetic medicine and dermatology and as a way of applying homeopathic medicines. Tel: +44 (0)1306 646526 firstname.lastname@example.org www.vidahealthandbeauty.com
due to the sheer number of threads inserted. Stimulating threads should be considered as microfillers and lifters, providing a meshwork of new collagen, with initial tissue support.
New generation absorbable threads Dr Elisabeth Dancey discusses advances in threads for facial lifting HISTORY Lifting the face with threads is not a new treatment, and we can draw comfort from this time-tested technique. More than 20 years ago, gold threads were created to lift the face and there are still practitioners using this technique today. In 1999 the permanent lifting thread Aptos was created from polypropylene (Anti-Ptosis). More recently, the development of dissolvable threads has created a resurgence in interest of this proven technique. TYPES OF THREADS Threads can be classified according to their design and mode of action. PERMANENT – Polypropylene (eg Silhouette, Aptos) NON-PERMANENT – gold, V soft (polydioxanone PDO), Silhouette Soft (Poly Lactic acid) ANCHORING/LIFTING – Silhouette, Silhouette soft, Aptos STIMULATING – V Soft, other PDO threads. This article will focus solely on the technique and results associated with non-permanent threads. MODE OF ACTION In general, anchoring/lifting threads have a mechanism whereby the tissue catches onto the thread and is then lifted as part of the treatment. The mechanism may be barbs, hooks or cones and can be uni-directional or bi-directional. The axis of lift depends on the direction of insertion and the direction of the cones. The thread material can also create new collagen; for example Poly lactic acid (PLLA). As the PLLA dissolves it creates collagen in the same way as Sculptra, another form of PLLA. The fact that a powder available to us for 20 years can be made into a thread is an amazing feat of technology. Thus this type of thread provides both lift and new collagen. Stimulating threads are smooth and monofilament, readily threaded onto a small needle. They are made from PDO (polydiaxanone) used in surgery for 20 years and made by Ethicon. These threads initiate growth factor release through tissue trauma. Fibroblast activation commences new collagen formation, which is remodelled at four weeks. New collagen has a tendency to shrink as it is remodelled. The effect is one of volume and shrinkage 48
ANCHORING THREADS In my opinion, the newest generation of absorbable anchoring threads have provided us with a magnificent lifting tool. The technique requires a skill but this should be simple to acquire for most manually dextrous cosmetic doctors, and this type of thread is probably the most familiar. PLLA in a thread format is ready placed onto a 25G needle. The thread may measure up to 12cm and contain several cogs/ barbs/ratchets. Insertion is performed under strictly sterile conditions after the face is marked, locating the entry and exit sites of the needle. The entry and exit sites are anaesthetised with lidocaine-adrenaline mix. The needle is inserted at 90 degrees to the skin and then along the subdermal plane 5mm deep. The needle exits at the marked exit point. The needle is cut off and another thread is inserted. Two or more may be used in both sides of the face. Once the threads have been inserted, the thread is pulled against the tissue so that a reassuring ‘click click’ is heard as the tissues pull up on the cogs/ratchets or barbs. The thread is cut close to the skin and the small wounds protected. STIMULATING THREADS In my practice I choose to use the V Soft threads, which are made in Korea under a patented process. They are CE marked as a class 3 medical device and distributed in the UK. They are ready threaded and are made from high-quality needle stainless surgical steel, diamond cut for precision entry into the skin. There are two threads that form the basis of a treatment: • 29G needle mounted with a 30mm PDO thread (6.0) • 27G needle mounted with a 50mm PDO thread (5.0) The needles serve to insert the thread into the tissues and are then removed. The threads must be placed strictly in the sub dermal plane. All of the threads dissolve within 200 days, however they induce new collagen by release of growth factors and fibroblast activation. The improvement of the skin and subdermal tissues follows a four-stage process: Stage 1: Increased coagulation. Inflammatory phase; vasodilatation, fibrinogens enter tissue. Fibrins develop to form protective shell essential for recovery phase. Stage 2: Degradation phase. Growth factors released, epithelium stimulated, angiogenesis, inflow of fibroblasts and development of myofibroblasts. Stage 3: Collagen threads form a three-dimensional scaffold at day two-three. Stage 4: Three weeks later remodelling of new collagen to form stable, flexible structure. This stage may last up to one year. Thus, it is the sheer number of threads and their positioning that creates the ultimate correction. USING STIMULATING THREADS From my experience, I find stimulating threads extremely versatile. They can be used for eyebrow shaping, to achieve a forehead lift, to open the eyes, fill cheek lines and treat
Aesthetics | November 2014
Skin Care Management System MD This revolutionary, multi-award winning system utilises synergistic layered technology to comprehensively address all the skin’s needs for measurable improvement in the appearance of common skin conditions such as: • Acne • Fine Lines and Wrinkles • Hyperpigmentation • Rosacea The Skin Care Management System was designed for prolonged use with little to no irritation or acclimation. The System is easy and intuitive to use for the patient with immediate improvement observable from the first application. Over time skin will appear noticeably smoother and healthier. By following the daily regimen, results will be sustained and improved over time.
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Applications Each type of thread can be used alone or in combination. The indications are similar, although best results are achieved when both types are used in one treatment. Applications and Indications for Anchoring and Stimulating threads Mode of action
Skin laxity Sagging
Cheeks Jawline Forehead Neck
Volume loss Skin laxity Thinning skin Revitalisation
Forehead Eyes Lifting and shaping eyebrows Cheeks Chin Jawline Lips Neck
extended crow’s feet. Top-ups are possible, and it is a far less invasive technique that anchoring threads. The results are seen immediately and then improve over three months. The procedural requirements are as per filler injections, and the skin can be anaesthetised with topical anaesthetic for an hour. FACIAL ASSESSMENT The key is to define the vectors of the face as these will be the insertion sites for the larger, 27G needles, of which about 10 will be used per side. Thereafter, the aim is to create a meshwork of the finer, 29G needles with 6.0 threads. TREATMENT It is best to have an assistant. Lay up the trolley with the 27G and the 29G needles, in two piles for each side, left and right. Cleanse the skin and mark the vectors with the patient sitting up. The patient may be flat or semi-recumbent for treatment. Insert the 27G needles, through skin at 45 degrees. Change direction once through skin, and continue the insertion along the subcutaneous tissue plane to the hilt. Don’t twist or wiggle the needle, or touch the thread. Leave needles in for a few minutes to start the stimulation phase then take them out smoothly. Apply pressure to any bleeding points. Then create the meshwork with the 29G. Insert these at 45-90 degrees to the vectors, across the lines of Langerhans. The 29G are much easier to insert. The number of threads determines the result; depending on the area. For a full face you will use about 70 in total. The treatment should take less than an hour. There will be some bruising and discomfort. The face should be kept clean and dry for 24 hours. The patient can eat, sleep flat, clean their teeth and perform all facial movements, in the knowledge that it might be a bit sore. I like to encourage a diet rich in protein, fruit and vegetables as a reminder of the collagen creation that will follow the procedure. The skin can become dry for a few days. This responds to moisturiser. Sun avoidance is standard. ANTICIPATED COMPLICATIONS Bruising: Just about every patient will bruise, especially with the 50
Contraindications to treatment are standard: pregnancy/breastfeeding, cheloid tendency, poor wound healing, extreme age, recent or current infection and current use of roaccutane. Stimulating threads are not a substitute for anchoring threads but can be used instead, for example when: • A young person is requesting rejuvenation • There is an absence of sag • A person not wanting anchoring threads • An anchoring thread patient is not fully satisfied • Treating a small area Or as well as because: Anchoring: • Provides substantial lift Stimulating: • Improves skin quality • Perfects lift • Immediate results continue to improve • Allows less anchoring threads to be inserted
stimulating threads. Pain: Both procedures can be painful but with adequate anaesthesia it is tolerable. Invasion threshold: All patients have a limit of tolerance for procedures. The anchoring threads are not acceptable to everybody; stimulating threads less so. Discomfort afterwards: Anchoring threads tend to be more painful afterwards. Limitation of activities: Anchoring threads restrict activities for a few days after the procedure. UNEXPECTED COMPLICATIONS Infection: It is rare for the skin to become infected after a procedure due to its rich blood supply. However, the procedure for anchoring threads is more invasive and carries a slightly higher risk of infection. Nerve compression: This is marked in the consent form but to date there has been no complication of this nature associated with nonpermanent threads, to my knowledge. Asymmetry: Any perceived asymmetry can be remedied at three months with either thread depending on the site and degree. Always take before and after pictures. Cheloid formation: This is more common in young people. Ask the patient about cheloid tendencies. SUMMARY Threads have now become a part of our repertoire. They lift, reposition fat pads, stimulate new collagen and oppose tissue sag. They may be combined with all other treatment modalities (with about four weeks between each treatment) to create a natural look that lasts about 12–18 months. Dr Elisabeth Dancey trained in the UK, France and Belgium and was one of the founders of cosmetic medicine in the UK. She introduced mesotherapy and electrorido puncture to the UK in 1993. She is the author of “The Cellulite Solution” and has assisted Johnson and Johnson, L’Oreal and Vibrant Medical with various campaigns and product launches. Disclosure: Dr Dancey is the UK trainer for V Soft Lift.
Aesthetics | November 2014
V-SOFT LIFT is an innovative and less invasive alternative to traditional cosmetic surgery and dermal fillers. V-SOFT LIFT is performed using fine threads that “lift” your skin, increase elasticity and are completely absorbed. The threads are made of polydioxanone (PDO) which is known to be extremely compatible with the natural tissue in our dermis and has been used for over 30 years. An added benefit is that the material, PDO, stimulates the body’s natural production of collagen making your skin healthier and thicker.
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Speedy Revitalisation... V-SOFT LIFT can transform downturned mouth corners, eyebrows, smooth the chin and lift the cheeks. It is a simple, speedy way to revitalise and freshen the face, and results show immediately after the treatment and then continue to improve for about four weeks by which time you will notice the skin and the face looking fresher, fuller and more youthful. Results last for one year or more. For further information about V-SOFT LIFT please contact: Medical Aesthetic Group on 02380 676733 or visit www.magroup.co.uk MAGROUP V-Soft Lift
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Aesthetic Journal November 2014 Issue
Body Face Couture Is Going To Revolutionise The Aesthetic Market Do You Want to Be Part of the Revolution?
Treatments that deliver results in less than 1 hour to suit any budget; under a consumer brand with huge investment in national advertising, PR and online marketing campaigns driving consumers directly to your clinic door! And, if that’s not enough – a customer service package that is second to none. Meet Body Face Couture!
The treatment offering at Body Face Couture clinics is unique and results orientated. Body Face Couture is directly responsible for standards and consumer satisfaction – boldly taking the responsibility of the sales and marketing of treatments for clinics and even offering money back guarantees.
Body Face Couture has launched the next generation of aesthetic treatments directly to the public, with a price point for everyone, making aesthetic treatments accessible at the click of a button. Consumers can now buy aesthetic treatments online and under a national brand with assurance of quality and efficacy. The Body Face Couture aesthetics product range is characterised by competitive pricing and high impact results.
Body Face Couture is achieving astonishing results by using the very latest in dual modality radio-frequency technology operated by expert, highly trained and fully accredited clinicians. This two-stage treatment gently resurfaces the top layer of skin, replacing it with new, fresh and supple skin. The thermal treatment head, which tightens the tissue beneath the surface and causes new collagen to grow, restores youth gently and naturally.
So How Does it Work?
Treatment packages are consumer friendly, and treatment protocols are specifically tailored to the following branded consumer products:
Currently launching around the UK, it works by offering Body Face Couture branded aesthetic treatments to clinics, yet allowing them to maintain their own identity. Existing skin, laser, dental and medical clinics can remain as individual establishments, merely opting into the Body Face Couture brand and therefore the treatment offerings and marketing campaigns. Following a thorough accreditation process, clinic practitioners are fully trained by Body Face Couture qualified medical experts. The clinic then has access to the brand’s extensive customer services and is listed on the brand’s website as trustworthy, reliable and a fully trained establishment to receive Body Face Couture non invasive aesthetic treatments. These accredited clinics are then a point of call for consumers who are often overwhelmed with the amount of choice on the market and are being driven to the brand for its focus on safety, efficacy and through its national marketing campaigns. The Body Face Couture brand offers reassurance to the consumer who no longer has to find and do the research on individual clinics. Body Face Couture is being rolled out with huge advertising, online marketing and PR campaigns and has already achieved success with Hello, Daily Mail and The Telegraph to name but a few.
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How does the service work for the consumer? It really is as easy as a click of a button for Body Face Couture customers. Body Face Couture has its own website which is central to purchase. Customers simply visit the website and select and purchase which treatment(s) they would like. The treatments, which are all based around the latest radio frequency technologies, promise instant results from their extensive menu for the face and body, whether they require rejuvenation, slimming or sculpting. From here, the customer is directed to the nearest Body Face Couture clinic where they receive their selected treatment and come out feeling and looking amazing.
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Aesthetics | November 2014
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minded minded people people whowho are more are more like family.” like family.” BodyBody FaceFace Couture Couture is setistoset become to become one of one theoflargest the largest aesthetic aesthetic chains chains and therefore and therefore seeksseeks to challenge to challenge the the scientific scientific language language typically typically usedused in theinmarketing the marketing of light of light and ultrasound and ultrasound aesthetic aesthetic treatments. treatments. The brand The brand will focus will focus on marketing on marketing themselves themselves in a way in a that way consumers that consumers who who are are new to new aesthetic to aesthetic treatments treatments will understand. will understand. Furthermore, Furthermore, clinics clinics will receive will receive unrivalled unrivalled support support and customer and customer service service to ensure to ensure the Company the Company can deliver can deliver on itson brand its brand promise promise of of immediate immediate results results or your or your money money back!back!
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Stephen Stephen Soos, Soos, CEOCEO of Medisico of Medisico PLC,PLC, comments: comments: HowHow to Become to Become a Body a Body FaceFace Couture Couture Clinic? Clinic?
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on the on 8-9th the 8-9th November November 20142014
Aesthetics | November 2014
Abstracts Clinical Papers
A summary of the latest clinical studies Title: Two-Treatment Protocol for Skin Laxity Using 90-Watt Dynamic Monopolar Radiofrequency Device With Real-Time Impedance Monitoring Authors: D McDaniel, R Weiss et al Published: Journal of Drugs in Dermatology, September 2014 Keywords: radiofrequency, digital imaging, skin laxity, lines, wrinkles Abstract: Multiple devices are currently on the market that employ radiofrequency to non-invasively treat skin laxity and wrinkle reduction. The study device was a unique monopolar radiofrequency device FDA cleared for the treatment of wrinkles and rhytids. The delivery system allows constant monitoring of the real-time local skin impedance changes, which allows radiofrequency energy to be more uniformly dosed over an entire treatment area. The objective was to validate effectiveness of a modified treatment protocol for a unique monopolar radiofrequency device, which has been engineered with greater power and self-monitoring circuitry. Twenty-four female subjects received bilateral monopolar radiofrequency treatments to the mid and lower face from the sub malar region to the submentum. Subjects completed 1 and 3 month follow ups with digital imaging. Skin biopsies (on 4 subjects) and ultrasound measurements (on 12 subjects) were completed. Assessments demonstrated a reduction in skin laxity of 35%, a reduction in fine lines/wrinkles of 42%, and a reduction in the appearance of global photodamage of 33%. Expert photograding demonstrated 92% of subjects showing at least a mild improvement in skin laxity at three months post treatment. 50MHz ultrasound measurements in 12 subjects showed an increase of 19% in skin density. Histology showed a marked increase in dermal collagen and elastin fibers in two subjects who demonstrated a clinically noticeable reduction in skin laxity and minimal changes in two subjects who demonstrated minimal clinical improvements. There were no significant adverse events reported. This modified radiofrequency device and treatment protocol was well tolerated and produced improvements in the appearance of skin laxity and overall anti-aging effects in the majority of subjects. Objective measurements including ultrasound and histology help explain the clinical outcome. Title: The impact of education on the perception of facial profile aesthetics and treatment need. Authors: F Falkensammer F, A Loesch et al Published: Aesthetic Plastic Surgery, August 2014 Keywords: perception, attractiveness, education Abstract: The purpose of this study was to evaluate the influence of education on the perception of various male and female Caucasian profiles with respect to attractiveness and treatment need. Four hundred questionnaires were distributed among six groups of raters (nonacademic laymen, academic laymen, preclinical students, clinical students, orthodontists, and maxillofacial surgeons). Male and female profile images were altered digitally in the sagittal and vertical dimensions resulting in nine different male and female profiles. The 54
raters had to assess the images according to attractiveness and treatment needs. Three hundred and four questionnaires were completed in this study. Age and gender of the rater had no significant influence on the perception of profile attractiveness. The different groups of raters perceived the Class I normodivergent profiles as most attractive. Significant differences in the perception of attractiveness were seen between laymen, orthodontists, and maxillofacial surgeons. The orthodontists and maxillofacial surgeons reported treatment needs the most. The orthodontists were most sensitive in discerning profiles. Attractive male and female profiles are recognizable by any rater. Education seemed to have a significant influence on facial profile perception and recommendation for treatment need of unattractive profiles. Professionals should be aware of their judgment discrepancy to laymen. Title: Non-ablative fractional photothermolysis in treatment of idiopathic guttate hypomelanosis. Authors: P Rerknimitr P, S Chitvanich et al Published: Journal of the European Academy of Dermatology and Venereology, October 2014 Keywords: pigment, laser, dermatology Abstract: Idiopathic guttate hypomelanosis (IGH) is a common pigmentary disorder affecting a large number of individuals. Many patients seek medical attention due to aesthetic concern. However, no standard treatment is available. To evaluate the efficacy and side-effects of nonablative fractional photothermolysis (FP) as a treatment of IGH. A total of 120 lesions from 30 patients with IGH were treated. In each patient, two lesions on the extremities were assigned to treatment group, while lesions from the other side served as control. The treatment was delivered by fractional 1550-nm ytterbium/erbium fibre laser for four times at 4-week intervals. Lesional skin colour was measured by colourimetry. Digital photographs and dermoscopic digital photographs were taken at weeks 0, 4, 8, 12 and 16. In addition, patient satisfaction score and side-effects were recorded. All clinical photographs were evaluated by three experienced dermatologists to determine clinical improvement using a quartile grading scale. Colourimetry of the treatment side showed normalization of skin colour at each visit and was statistically significant when compared with control after two treatments (week 8) and continued to decrease until 4 weeks’ follow-up (week 16) (P = 0.047, 0.016 and 0.06 respectively). Physicians’ improvement grading score showed that 83.34% of the lesions in treatment group vs. 18.34% in the control group showed some improvement. The difference was statistically significant (P < 0.05). Common side-effects were erythema and oedema in treatment area, which were mild and transient. No post-inflammatory hyperpigmentation was observed. Nonablative FP appears to be an effective way to treat IGH. The improvements are documented by both objective and subjective measurements.
Aesthetics | November 2014
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Marketing Male Focus
well as women, and this has added value to the success of the launch.”
Changing faces: marketing to the male customer Michelle Boxall examines the different approaches for connecting with your growing male audience The profile of a typical aesthetic customer is changing fast, and this is presenting treatment providers with progressively more opportunities to develop, grow and market to a new clientele. Patients are now entering the market from all walks of life. This is partly driven by the fact that having ‘work’ done (as it is often termed by consumers), is not only considered acceptable, but is now accessible to the mass market. Undergoing an aesthetic treatment is even considered fashionable in some circles – a trend fuelled by celebrity culture. While aesthetic treatments are no longer considered niche, (and you only need to read the Daily Mail to have proof of this), it naturally follows that marketing to the male customer provides a magnificent opportunity for growth in the sector. According to the British Association of Aesthetic Plastic Surgeons (BAAPS), the number of men having cosmetic surgery rose by 16% in 2013; and those having aesthetic procedures accounted for one in 10 (9.5%).1 However, much of this growth has arisen organically, with many clinics and brands neglecting male patients in their past marketing and communications. Dr Maria Gonzalez, who runs the Specialist Skin Clinic in Cardiff, says, “I do not specifically market to men. I do not have any treatments specifically for men either, but I do have male customers and notice that there are some treatments that are more commonly requested by this group. These include tattoo removal, laser hair removal for ingrown hairs in the beard, treatment of nasal vessels and our most popular request is for the treatment of ‘red’ face, secondary to rosacea.” Despite the fact that in-clinic it seems practitioners’ focus on men is ostensibly withstanding, we can see that the aesthetics sector wants to market to men through the influx of male products and treatments that clinics are adding to their treatment menus. New aesthetic consumer brand, Body Face Couture, is a prime example – they have recently launched their marketing campaign with male models and treatments specifically tailored to men; for example ‘Tight Torso’, a treatment to firm and sculpt the male torso area. Cynosure, a leading developer and manufacturer of aesthetic laser technology, recently launched a new product with marketing materials designed in black – a significant move away from the company’s usual orange and silver branding. Cynosure’s managing director Neil Wolfenden comments, “the Picosure launch was focused around tattoo removal; an aesthetic treatment which could potentially draw in a huge male audience. We therefore chose to make a statement with our marketing to attract men as Aesthetics | November 2014
Juvea Aesthetics, a clinic based in London’s Harley Street, has experienced an increase in male clients requesting hair removal, body and facial treatments. To address this growth, the clinic places emphasis on differentiating between the sexes during the consultation process. Dr Faz Zavahir at Juvea says, “When it comes to treatments, men are interested in the science behind them; therefore when communicating with men we will go into detail about how, for example, a laser or product might work. We have also found that our male clients seek aesthetic treatments to boost their self-esteem, and to combat the signs of ageing – so we will go into detail about how we can help them to achieve this.” It makes sense for aesthetic clinics and practitioners to have different approaches to treating male patients, and to tailor to the patient’s personality and individual needs in a consultation situation. However, it can be difficult to come up with successful marketing campaigns that work in a male mass-market when the aesthetic and grooming market is often singularly associated with the metrosexual male. This is despite the fact that a range of men visit an aesthetic clinic because they are suffering with a particular skin or body issue, and under normal circumstances wouldn’t even include application of a facial moisturiser in their daily routine.
Marketing When advertising to men, in general, we don’t seem to have moved very far from dealing exclusively in stereotypical profiling, for example – the gay, the metrosexual, the house husband, the macho man. For aesthetic clinics, these stereotypes are not necessarily useful, particularly when trying to grow your market and broaden appeal. For most men, looking good is about being strong, confident, first, and the best.2 Clinics should aim to offer treatments, and market their products and services, with this male ideal in mind. Researchers have found that the male brain is hardwired differently to the female brain,3 and therefore, these differences can simplify the marketing process for clinics who want to devise successful marketing strategies for the male customer. Men typically prefer marketing communications that are informative;2 preferring technical data rather than emotion-based messages that are aimed at triggering certain feelings, such as hope, sympathy, sadness or joy. From my experience, men don’t want to be told how a product or treatment can reform their life but, rather, how a treatment can reform their skin. A Mintel report published in 2013,4 reinforces the argument that evidence-based marketing works better on men, claiming that beauty and personal care 57
Marketing Male Focus
products marketed to men were more likely to be dermatologically tested than products for women. In clinic, detailed treatment information, case studies and before and after photographs can provide evidence-based marketing tools that are particularly suited to your male patients; these also provide good marketing fuel for any PR and social media campaigns, which are made invaluable with before and after photographs and case histories. Even though male stories are deemed less enticing than female stories within the media, case studies are still a proven formula in driving consumer enquiries. Online marketing is another crucial tool when setting out to market to male patients. Research suggests that men prefer to problem solve using the internet and are more likely to solve their health issues online compared to their female counterparts.5 Men are less likely to speak to friends about their health or body issues and therefore the internet provides an opportunity to capture their attention, inform and educate potential male consumers on why your treatments will work for them. Men are fast becoming the sophisticated shopper, and used to having health and beauty products tailored specifically for them. The Mintel report4 discussed earlier revealed that beauty and personal care launches specifically targeted to men had increased globally by 70% between 2007 and 2012. The same report claimed men’s grooming products typically use ‘manly codes’, such as the use of black, blue and grey colours; therefore men often look out for products that are specifically targeted to their gender. These figures suggest that tailoring messages to your male patients is a worthwhile enterprise. Hans Place Practice in Knightsbridge separates its treatment menu by gender providing its male audience with a completely different customer experience, both visually and in terms of content. The body and facial issues addressed, treatment options and outcomes all differ to the treatment menu tailored to women. Dr Mike Comins explains, “It is important to me that my male patients feel that they are not alone. I’ve always had male clients and have long recognised that there will always be a significant number of men interested in improving their looks. I therefore try to make the
Marketing to the male customer does not have to be a huge challenge; new marketing communications can be rolled out in stages 58
male customer journey easier and less embarrassing. Men don’t like downtime; they’re not good at recuperating, and therefore communicating to them directly also allows me to tailor my product offering.” Stephen Handisides, founder of MyFaceMyBody agrees that marketing to the male patient is a must for clinic owners. He says, “There are several areas of concern and subsequently treatments that are exclusive to men, for example hair loss and gynaecomastia (enlarged male breast tissue). Even when treatments are similar we naturally try to find points of difference, i.e ‘brotox’. Men need to feel comfortable in coming forward to have these treatments and where possible brand, product and treatment providers should ensure they are making available to their male audience informative materials, in the right format and style of language.” Marketing to the male customer does not have to be a huge challenge; new marketing communications can be rolled out in stages. The important step is recognising the opportunities you already have within your clinic to tailor your current marketing activity – your quick fixes can build from making changes around what you are already doing, rather than from an original standpoint. How do you currently communicate with men in clinic? Can you find ways to communicate to men through your existing email campaigns, marketing materials, advertising and PR campaigns? Relatives to the women already in your clinic could be another good place to start. You could engage patients’ brothers, husbands and friends in a male specific social media campaign, as well as making them the target of your gender differentiated direct mail and text promotions. In your client base, find your biggest male fans and ask them to provide testimonials, and where appropriate encourage WOM (word of mouth). Media coverage, while an ongoing expense, can significantly upscale the power of any WOM and testimonial successes. Interesting male cases should be pushed out to consumer press, along with highlighting your clinic’s areas of expertise, exclusive male products and treatments, and unique techniques specific to your practitioners. Men are increasingly under pressure to look good and are becoming more comfortable with the use of products and services to help them comply with the progressive shift in society’s demands. Improving oneself aesthetically, rather than normalising specific features is a motivating factor for men, and therefore the strength in association between women, beauty and aesthetics is no longer the only valid proposition for marketing aesthetic treatments. The man in the mirror is a changing face! Michelle Boxall is the managing director of Image Box PR – one of the UK’s leading marketing communications agencies, specialising in aesthetic PR. Michelle holds a bachelor degree in public relations and has more than 19 years communications experience working across health, beauty and aesthetics. REFERENCES 1. Britain sucks (London: BAAPS, 2014) http://baaps.org.uk/about-us/press-releases/1833-britain-sucks [accessed October 15 2014]. 2. Derrick Daye, Marketing to Men (US: Branding Strategy Insider, 2010) http://www. brandingstrategyinsider.com/2010/04/marketing-to-men.html#.VD-MmL4f-fR [accessed October 15 2014]. 3. Steve Connor, The hardwired difference between male and female brains could explain why men are ‘better at map reading’ (UK: The Independent, 2013) http://www.independent.co.uk/life- style/the-hardwired-difference-between-male-and-female-brains-could-explain-why-men-are-better- at-map-reading-8978248.html [accessed October 15 2014]. 4. Beauty and personal care product launches targeted to men increase by 70% over the past six years (UK, Mintel, 2014) http://www.mintel.com/press-centre/beauty-and-personal- care/beauty-personal-care-product-launches-increase-substantially 5. http://www.mcppnet.org/publications/ISSUE20-5.pdf [accessed October 14 2015]
Aesthetics | November 2014
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Treatment Menu Business of Acne
The business of acne Wendy Lewis discusses the different acne patient groups and advises practitioners on how to grow a successful acne treatment clinic Acne is the most common skin condition, according to the American Academy of Dermatology (AAD), and nearly 85% of all people have acne at some point in their lives, most often on the face, chest, and back.1 For some, it may just be an occasional pimple that appears. For others, acne can be severe and disfiguring. For most people affected, the condition falls somewhere between these two extremes. Acne also affects more than just a patient’s skin. It can have an impact on their entire life in many ways. Acne has a dramatic impact on self-esteem and self-confidence. Even mild breakouts can negatively affect the way people feel about themselves in social and professional situations. Acne is also not just a teenage thing. It can occur at any age, from birth through to the post-menopause years. Although it tends to start in teens, some adults continue to get acne as they age, or for the first time in their 30s or 40s. Cases of adult acne are also on the rise, which is often attributed to stress, cosmetic use, lifestyle and simply neglecting the skin. Upwards of 20% of all adults have active acne.2 There are many effective remedies and treatments that can help get acne breakouts under control for the short term and for the long term. Noninflammatory acne may be the most common variation, but inflammatory acne patients are even more motivated to seek out a treatment that works. Target Audiences There are many causes of acne, including stress, hormonal fluctuations especially around menstruation, pregnancy, peri-menopause, and menopause, oral contraceptives, medication side effects, plus hair and skin care products used. According to Dr Zein Obagi, a Beverly Hills-based dermatologist, “Since the causes of acne are diffuse, including genetics, hormones, excessive oil production, diet, sleeping habits, hygiene, and stress, a successful acne treatment must be specialised to each patient.” Treating patients effectively should begin with a comprehensive history, including lifestyle, skincare habits, and also ethnic background. A thorough inquiry into what treatments the patient has used in the past, what worked or did not work, any possible side effects or allergies to topical agents, their expected outcomes, 60
tolerance for downtime, budget, and availability to return to the clinic at regular intervals should factor into your treatment plan. Patient compliance is also a key issue when it comes to successful outcomes with acne protocols. If the patient is unwilling or unable to continue long-term therapy, results may not be satisfactory which can lead to missed appointments that waste clinic staff time, or unhappy patients who post negative reviews online. Acne can occur on the face, back, neck, chest and other parts of the body. The area that most patients will be seeking treatment for is usually the face and neck area as it is always visible. Athletes, swimmers, and men are also often concerned with back acne. The same goes for brides and girls leading up to graduations when the ability to wear low cut and backless gowns is an important consideration. Teens Offering a programme of monthly or bi-weekly medical extractions can be very appealing to teenagers who find it difficult to stick to a daily skincare routine. A medical grade facial with extractions will immediately improve existing active acne lesions while helping to prevent future flare-ups. Teens need detailed instructions for how to care for their skin at home in between clinic visits. Many patients cause harm by squeezing lesions that can cause scarring and spread infections. Medical grade facials to safely extract comedones are a popular service for this patient group. Peels and microdermabrasion treatments are also effective ways of improving blackheads. By removing the top layers of the skin, pores become unclogged and the dirt and oil that causes blackheads is reduced. Homecare products and prescription-grade topicals go hand in hand with clinical acne treatments. Most notably, benzoyl peroxide formulas help to reduce oil, and keratolytics in the form of glycolic and beta hydroxy acids help loosen debris and assist with cell turnover. Retinoids can decrease the production of sebum in the skin, both in an oral form (isotretinoin, Roaccutane) and topical forms (retin-A, Adapalene, Differin). Certain hormonal treatments, such as androgen inhibitor Spironolactone and oral contraceptives may also help to decrease sebum production.3 Water-based concealing products are a useful addition to the teen acne patient’s product selection. Men In my experience, men tend to be the least motivated and least compliant of all acne patient sectors. It is more challenging to get them back to the clinic on a regular basis, so extra thought should be given to more aggressive therapy, such as oral medications and/or topical agents, that may deliver longer lasting results. Light-based therapy, such as blue light or Isolaz which vacuums pores and kills Propionibacterium acnes (p. acnes), the bacteria that is the primary pathogenic agent responsible for acne vulgaris, can be very helpful in treating male patients. It may be more difficult to persuade them to undergo deeper treatments when there is some downtime required. Men are frequently resistant to any procedures that require time out of work, sports, or the sun. It is important to bear in mind that some topical ingredients may come with too many side effects or sun sensitivity to be practical for long-term usage, so I would advise that you discuss with the patient how much time they spend outdoors. Aesthetics | November 2014
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Treatment Menu Business of Acne
Adults Adult acne is potentially more upsetting for patients as most people expect to grow out of it past their university years. Adults also need to be treated more gently without harsh ingredients that cause dryness, redness and peeling. In female patients, it is important to manage their acne effectively so they are able to wear foundation and non-comedogenic cosmetics. An overly aggressive regime that causes roughness and flaking may be a problem for adult women, and interfere with compliance. New York City dermatologist Dr Judith Hellman has developed a large acne practice that serves a wide variety of patients. She attracts patients from young to mature, and gets referrals from local hotels when visitors need to see a doctor for an emergency steroid injection or facial to unclog their pores. “It’s important to emphasise with adult acne patients that a haphazard approach
When you are successful in helping acne patients achieve clear, radiant, even toned skin, they will be yours forever won’t work,” she explains. “They may expect that after one session with Pulsed Dye Laser (PDL) they won’t break out again. I always explain that acne requires the right treatments and the right products, and some tough love. I tell patients that we’re going to be together for a long time, but I will improve their skin substantially,” says Dr. Hellman. Female patients with acne and rosacea do well with mineral makeup that offers superior coverage yet is lighter and easier to tolerate. Professional mineral makeup brands are true multi-taskers for acne prone patients. They are a hybrid of makeup and skin care, and camouflage blemishes, conceal hyperpigmentation, and protect sensitive skin from environmental damage, without clogging pores. If your clinic treats women with these conditions, concealing cosmetics should be an essential component of your product selection. Acne Technology Most practitioners agree that acne responds well to combination therapies. The ideal regime may include a customised plan of peels, microdermabrasion, light- based treatments, as well as lasers, coupled with extractions, intralesional steroid injections for cysts and nodules, and topical skincare. Among the wavelengths currently indicated for acne, diode, pulsed dye, fractional, infrared, radiofrequency, photodynamic therapy, blue light, are commonly used. Some of these energies target p.acnes bacteria, such as blue light, while others, such as pulse dye lasers, shrink sebaceous glands and cystic acne. SOME COMMON DEVICES FOR ACNE MANAGEMENT Isolaz Photoneumonic therapy treatment combines an intense pulsed light (IPL) laser with a gentle vacuum. It works by removing excess oil and dead skin cells from clogged pores, and is effective for comedones and pustules. Elos Plus – AC Handpiece for Acne Treatment By combining optical energy with bi-polar radio frequency (RF) energy, the elōs Plus system incorporates a special handpiece 62
designed to treat pore-clogging bacteria and oil that result in acne and to reduce and facilitate healing time of existing acne. VBeam Perfecta A pulse dye laser system, the energy within each pulse is distributed across micro pulses so the practitioner can select higher overall energies and effectively target redness from acne with less downtime and purpura. Photodynamic Therapy PDT utilizes a photosensitizing molecule – usually Aminolevulinic Acid (ALA) - that is applied to the area to be treated. It is left on to incubate for a specified period of time (minutes to hours), and it then becomes activated by light exposure to reduce oil gland function to treat acne. Blue Light Therapy Blue light specifically targets and kills the P. acnes bacteria. These light-based therapies work by exciting a particular molecule called a porphyrin, which is produced in large quantities by P. acnes bacteria. Excitation of porphyrins with blue light causes them to release free radicals into the bacteria thereby killing them. Visible light can treat mild-to-moderate inflammatory acne. Infrared Light This type of low level laser light (LLLT) is used to treat mild-tomoderate inflammatory acne. It destroys the sebaceous glands by photothermal mechanism to reduce acne lesions. SilkPeel Pore Clarifying System The Pore Clarifying System is specially designed to treat acne with Dermalinfusion, by using an abrasive tip to remove the top layers of the skin and infuse active alpha and beta hydroxyl acid solutions. It increases cell turnover to prevent acne from progressing to more severe stages. HydraFacial HydraFacial is performed using a vacuum based exfoliation tip that is used with a customised combination of serums, including antioxidants and hyaluronic acid to address common skin issues. It combines cleansing, exfoliation, extraction, hydration and antioxidant protection in one treatment. Acne Scarring If you are building an acne clinic, also consider technologies that can diminish acne scarring, which is an all too common consequence of not getting treated properly soon enough to prevent post inflammatory hyperpigmentation and scar formation. The typical protocol recommended is to first get active acne under control, and then deal with the main issues for the patient. Areas of post inflammatory hyperpigmentation can be treated with a series of peels, IPL and lasers that target pigment. Acne scarring can be effectively improved with RF, as well as fractionated non-ablative or ablative technology. “Treating acne scars typically requires a combination of subcision, excision of scars, laser resurfacing and filler injections or dermal grafting,” says oculoplastic surgeon Brian Biesman in Nashville, Tennessee. “Laser skin resurfacing also plays a pivotal role in the treatment of acne scars today. Numerous types of laser resurfacing procedures have been used to treat acne scars: traditional laser resurfacing (CO2 laser), Er;YAG skin
Aesthetics | November 2014
THE ACNE OPPORTUNITY While very treatable, of those who suffer from acne, only 11% actually get to a doctor’s clinic, and over 40% do not seek treatment at all. • 11% will see a physician • 20% will go to a skin care centre • 30% will use an over-the-counter medication from a drug store or pharmacy • 40+% will do nothing SOURCE: The Acne Resource Centre Online
resurfacing, noninvasive laser treatments, fractional laser resurfacing,” he says. “Choosing the best laser for each patient requires consideration of the extent of scarring, downtime or recovery time the patient is willing to endure, and relative safety profile. In most cases, I feel that ablative fractional resurfacing is the best option for patients with acne scars. I typically advise that more than one resurfacing treatment will be needed to achieve the desired outcome.” Product Selection As acne is chronic, in all cases, a home care regime of some form of topical therapy and/or oral prescription medications may be required to maintain clearance long term. Among the most widely used topical acne medications, retinoids, antibiotics, and benzoyl peroxide rank supreme. Oral medications for acne include oral antibiotics, anti-androgen medications and retinoids, such as Roaccutane. “Drug store and prescription treatments that claim to treat acne can actually perpetuate the problem,” says Dr. Obagi. “From synthetic oils in cleansers claiming to be ‘oil-free’ to pore-clogging agents in moisturisers, unnecessary ingredients can aggravate acne, leaving people afflicted with the condition to assume that their skin issues are incurable. The fact is, with the right regimen, many people can clear up their skin without a prescription.” An appropriately selected home care regime is vital for the acne patient to keep breakouts under control in between clinic visits. There are many professionally dispensed brands that offer a wide selection of cleansers, exfoliants, body scrubs, light gel moisturisers, oil-free sunscreens, concealers, powders, and foundations that are ideally suited for acne prone skin. When you are successful in helping acne patients achieve clear, radiant, even toned skin, they will be yours forever. As this patient segment tends to be more vocal and open to sharing their experience and advice with friends, family and online, happy acne patients can become true brand advocates for your clinic. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on anti-ageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications. REFERENCES 1. American Academy of Dermatology, Acne (www.aad.org, 2014) http://www.aad.org/media- resources/stats-and-facts/conditions/acne 2. The Acne Resource Centre Online, Acne Statistics (http://www.acne-resource.org) http://www. acne-resource.org/understanding-acne/acne-statistics.html 3. Ebede, Tobechi L., Arch, Emily L., Berson, Diane, ‘Hormonal Treatment of Acne in Women’, J Clin Aesthet Dermatol, 2 (12) (2009), pp. 16-22.
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Business Process Testing and Measuring
The Importance of Testing and Measuring for Success Kurt Won explains how taking time to evaluate your business can make the difference between success and failure As an inventor, Thomas Edison made 1,000 unsuccessful attempts at inventing the light bulb. When a reporter asked, “How did it feel to fail 1,000 times?” Edison replied, “I didn’t fail 1,000 times. The light bulb was an invention with 1,000 steps.” So let me ask you this: Can you succeed without failing? As a baby, can you start walking without falling a few times first? Can you build a successful business without making mistakes? The answer is no. The problem is that we have all been taught to think about failing and making mistakes as a negative event – that if you make a mistake or fail, then that you as a person are a “failure”. Make mistakes in school and you’re told you are wrong. Make a big enough mistake in your job and you get a warning or get fired. But having this mind-set and belief system won’t get you very far as a business owner. The truth is that succeeding in business, and in life, requires failing and making mistakes. But it’s how you learn the lessons from those mistakes that will build your wealth of experience and success. Our conditioning has taught us that making mistakes and failing hurts, so we avoid it. We want things to be perfect before we begin and hence sometimes never actually get started. Einstein said that insanity is doing the same thing over and over again and expecting a different result. The lesson I take from this is that, to be successful in business, you have to continuously evolve and improve the way you work, the way you market your business and the way you operate. If you’re looking at your business right now and it is not doing as well as you believe it should be, you may need to change a few things. I’m not an advocate of changing everything at once, but I am a big advocate of testing and measuring procedures for sustainable improvements. A lot of business owners don’t measure their performance or activity, so it is difficult for them to pin point exactly what needs to change. One of my current clients had seen their turnover level-off. Because they had never recorded their daily sales activity and performance, they had no idea what level of activity produced what sort of results in their business. 64
When I started working with this client in February, the first thing I asked them to do was to record and measure their daily activity in what we call a dashboard – something very simple, yet very powerful. Figure 1 shows what I encouraged the client to record. # Calls
Mon, 11 Aug 2014 Tue, 12 Aug 2014 Wed, 13 Aug 2014 Thu, 14 Aug 2014
Figure 1 – Business productivity dashboard
By doing so, this information started giving me a more in-depth picture of what was happening in the business. Every week we would review the numbers and debrief on what had happened during the week. Based on what the numbers looked like, we would test a new way of speaking to clients, and prospective clients, and measure the outcome of each method. If one method hadn’t worked as well as we had hoped, we would make adjustments until we found the best communication formula. After six months of testing, measuring and holding the team accountable for their targets, the weekly turnover rose from an average of £5,800 a week to a new high of £16,072. We had to fight through a lot of mental resistance from the team as the process took them out of their comfort zone. But once you can empower your team to try new things, in a systematic way, you will begin to see results. You should also start to test and measure your marketing, point of sale displays, and the packages you sell as they all contribute to your weekly turnover. Email Subject Line
# Email Sent
# Emails Opened
# Click throughs
Exclusive new treatment at ABC Clinic Re: Your new Look
Figure 2 Recording email marketing campaign success
Figure 2 shows an example of how to test and measure your marketing campaigns – specifically email campaigns. Suppose you create an email campaign with the aim of inviting previous clients, as well as prospective clients, to book an appointment at your clinic or practice for a new treatment you’re offering. The first thing you need to do is create a dashboard, similar to the one here. (Your client relationship management system [CRM] system may create reports like this for you). Aesthetics | November 2014
Next, write the main body of the email, followed by two different – but equally engaging – subject lines. When it comes to email campaigns the subject line is one of the most important variables to measure; a poor subject line can cause your campaign to crash and burn, while a great subject line will boost sales and bookings. Send the email with subject line #1 to half your database and measure what happens; how many people open the email, how many click through to book an appointment, etc. Send the same email, but with subject line #2, to the other half of your database and compare the open and click-through statistics to find out which subject line is most effective. If subject line #1 performs better, and gets more open rates and bookings than subject line #2, resend the same email with subject line #1 to the second half of your database (those who originally received subject line #2) – then measure and record the results again.
Business Process Testing and Measuring
Tip: When testing and measuring the effectiveness of anything, change only one variable at a time. If you change too many things at the same time, you don’t know what, specifically, is positively or negatively influencing the result.
measure the effectiveness of your website through Google analytics and heat maps. Ask your website designer for more information about this. The most important part of split testing is that you need to measure the results of each test and, as mentioned above, change only one variable at a time. This way you can find out which variable has the greatest or least impact on performance. Sometimes the simplest of things can add the greatest of value. To give you a real life example, I have a new book due to be launched in January next year, called, The Startup Survival System. My publisher told me to ask my online audience and followers which version of the book cover they liked best. The only difference is that one has my photo on it and the other doesn’t. So far, the vote is 50/50 so I will keep the voting live for longer. Doing so will hopefully garner more data in order to aid my publisher’s decision on which cover to use. As busy, hardworking business owners, I can understand that you may be thinking, “I don’t have time to do all this and why should I waste my time testing and measuring performance?” In response, my question to you would be; “How much do you really want to succeed?”
If you’re launching a new website, you can do what marketers call “split testing”. Ask your website designer to create two websites – for example, one in one colour, and then the same website in another colour. When you split test, the programme will send a certain number of online visitors to one website and a certain number of visitors to your other website. You can then
Kurt Won is the co-founder and co-CEO of SalesPartners UK, a multi-award-winning business consultancy that has helped over 850 business owners and entrepreneurs to make and keep more money, by driving sales, increasing profitability and building championship business teams. He has spoken at various aesthetic and beauty conferences.
I M C A S 1 7 th A N N U A L W O R L D C O N G R E S S
The leading subjects on aesthetic surgery and cosmetic dermatology « This is the most enjoyable and the best teaching conference I can remember. The cadaver workshop is spectacular. I can not remember a meeting with more positive and enthusiastic feedback from the audience. So many people told me how much they have learned and have enjoyed this meeting. This is a wonderful learning experience. » Dr Joel Pessa, Plastic Surgeon from the United States
« I truly think it is the meeting at which I learn the most and become inspired about how I treat my patients. Each year I take home innovative new techniques to improve my skills. I have always found IMCAS to provide the most exciting professional learning experiences. It is an honor to be a part of this conference. » Dr Susan Weinkle, Dermatologist from the United States
« Congratulations for this excellent academic conference. You did a fabulous job. You have built and organized a meeting which is truly impressive. I continue to be impressed by your meeting, in organization, scope, and quality. » Dr Jonathan Sykes, Facial Plastic Surgeon from the United States
« I congratulate you all for the commitment in the organization of the congress and care of the details. I must say your meeting is an example of professionalism and seriousness for the sake of science in the aesthetic field. » Dr Alessandra Nogueira, Dermatologist from Brazil
« By not attending IMCAS on an annual basis, every aesthetic physician/surgeon would be starving him/herself of the most valuable updates available. The most illuminating tool and up-to-date conference on aesthetics that one can attend. It can never be taken away. An absolute MUST! » Dr Hugo Kitchen, Cosmetic Surgeon from the United Kingdom
IMCAS Annual World Congress JAN 29 to FEB 2015 NOVEMBER 14 to1,16, 2014
Feedbacks taken from the IMCAS World Congress previous edition.
10/8/14 4:29 PM
In Profile Dr Beth Briden
“We still can’t fool mother nature – not yet” Dr Beth Briden is medical director and CEO of the Advanced Dermatology and Cosmetic Institute, Minnesota. A leading dermatologist, adjunct clinical professor and lecturer, Dr Briden shares her journey into medical aesthetics After graduating medical school in her home state of Minnesota, Dr Beth Briden started her 25-year career in aesthetics. The senior partner in the clinic where she began practising dermatology was involved in the initial studies of Retin-A for the treatment of photo-ageing. “The partner did not actually like aesthetics,” she explains. “So he asked me to be their spokesperson and become involved in the clinical studies for the treatment of fine lines and wrinkles.” This, along with discoveries such as the effect of the alpha hydroxyl acids on the skin by Dr Eugene Van Scott and Dr Ruey Yu, meant that practitioners could renew skin and potentially reverse photoageing. From then on her interest in improving the skin both medically and aesthetically increased. Dr Briden explains that although aesthetics was in its infancy, the late 1980s was an exciting time for newly qualified practitioners. “You had to keep educated and up-to-date with all the new advancements in cosmeceuticals, lasers, fillers and chemical peels,” she says. In 1996 Dr Briden opened her combined general and cosmetic dermatology clinic and, in 2000, she became one of the founding members of the American Society of Dermatologic Surgery (ASDS), serving on its board of directors for four years. As she continues to travel the world, lecturing colleagues in aesthetic and dermatologic advancements, Dr Briden advises, “When you give lectures at these meetings, you have to review all of the literature and make sure you are up-to-date on everything. I also like to go to the exhibit halls and take a look at all the new treatments and products. Although, you must do your own research to see if the product is as good as they say.” Before graduating, Dr Briden had wanted to become a cardiologist. But, she admits that she found being unable to help very ill patients more challenging than she anticipated. Instead, she chose to practise dermatology, another of her favourite subjects at medical school. “You get to see all types of patients and age groups; babies, teenagers, young adults and some older people,” she enthuses. “There was more variety, which I liked, and I had the opportunity to do surgery, as well as study the internal aspects of medicine such as the cause of drug rashes, and how some dermatologic conditions have systemic effects.” Although she says aesthetics is an enjoyable part of her work, Dr Briden notes each patient, whether his or her concern is health-based or purely aesthetic, should be given equal time and attention in the consultation period. “The biggest complaint we get from patients is that they previously saw another doctor who didn’t give them enough attention. They didn’t spend time or listen.” Dr Briden advises, “In the long run it helps to do so because you will build a life-long patient.” Managing expectations is also important to Dr Briden. “Explain to patients that there’s no fountain of youth and no product or procedure can take care of everything. 66
We still can’t fool mother nature – not yet,” she affirms. Advising both patients and practitioners on the aesthetic benefits of a healthy diet has become an essential part of Dr Briden’s remit. She explains that working in anti-ageing medicine has led her to study the effects of glycation and nutraceuticals. “I’m becoming more interested in diet as we find out more about nutrition and food products,” she explains. This year she has given a number of lectures on glycation and the effect it has on the skin. But the achievement she is most proud of is starting her own clinic 18 years ago. She explains that many of the employees she hired then, still work for her now, as well as patients she first treated as children. “It’s fun to see the children you treated, now grown up and having children of their own,” she says. Looking to the future, Dr Briden hopes to expand the skincare she sells in her clinic. “It’s a fun interest,” she says. “We currently sell a big consortium of therapeutic skincare products that we try to tailor and prescribe to patients’ individual needs.” Dr Briden notes that she has been very lucky to experience such a varied and gratifying career: “I’ve met lots of wonderful people and seen some wonderful sights.” She adds that the key to her success is her enjoyment of her work. “You spend too much time at work not to enjoy it. Aesthetics is an exciting field and it is important to keep up-to-date with the industry and spend time with the patients – you can learn a lot from them.”
Q&A What treatment do you enjoy giving the most?
Chemical peels because you can converse with the patient whilst treating them. What’s your favourite technological tool?
Probably our IPL lasers as we use these the most. In Minnesota we have a lot of fair-skinned patients with rosacea and age-spots; the laser can take care of those. What is your industry pet-hate?
Probably the industry promising too much, whether that be skincare products or lasers that don’t match up to expectations. There’s often not enough clinical studies or scientific evidence behind products and the claims that manufacturers make. What aspects of the industry do you enjoy the most?
The opportunities that are out there: all the techniques, scientific advances and knowledge that’s available. Do you have an ethos that you practise by?
Be honest and do your best, that’s all you can do. Give patients realistic expectations and try not to oversell products.
Aesthetics | November 2014
Aesthetics Awards Special Focus
Last chance to book for the premier awards event in medical aesthetics With the voting and judging processes over, the winners for The Aesthetics Awards 2014 will be chosen in twenty-one prestigious awards categories, recognising individuals and companies for their services to the profession and industry. The Awards will be held at the four star Park Plaza Westminster Bridge Hotel in Central London and will present the perfect opportunity to celebrate a successful year with colleagues and peers. The evening will begin with a networking reception, followed by entertainment from professional comedian Dominic Holland. Alongside delighting guests with his award-winning comedy, Dominic will also host the Awards ceremony with the help of voice artist Peter Dickson, who returns by popular demand as the master of ceremonies. After a fantastic three-course meal, the highly anticipated trophy presentations will take place as the winners are announced. Finally, guests will be able to celebrate well into the night with music and further networking opportunities. Join us at The Aesthetics Awards 2014 for a night to remember!
BOOK NOW! Saturday 6th December, Park Plaza Westminster Bridge, London Individual tickets: ÂŁ200 plus VAT Table of 10: ÂŁ1,900 plus VAT To book your tickets visit www.aestheticsawards.com, call 0203 096 1228 or email email@example.com
Save Face Aesthetics | November 2014
The Last Word Technology
The Last Word According to Mr Vivek Sivarajan, technology is a doubleedged sword, which should be wielded responsibly When describing to a patient the damage done to their skin by sun exposure, I have the option of using technical, medical phraseology such as rhytids and lentigines, or I can use more colloquial expressions like lines and age spots. In addition, patients often use words such as “bigger” or “smaller”, even “droopy” or “firm”, during their consultation – these words can mean different things to different people – making it difficult for both the patient and practitioner to communicate their expectations and intentions effectively. This has always posed a problem for the aesthetic industry; a practitioner may tell a patient what is possible, yet the patient still retains an unrealistic expectation of what can be achieved. If a patient does not truly understand what their practitioner is proposing, they may be fearful or lack confidence in the expected results. Technology, as ever, is providing at least a partial solution to this problem through the wider availability of increasingly sophisticated scanning and visualisation devices. Better still, they are an affordable investment for private clinics. Many new technologies allow patients to see first-hand, realistic pictures of facial skin problems. From acne scarring to sun damage, improved technology can allow patients the opportunity to face up to the realities of their complexion – good and bad. So many patients only see problems that they want to see, which means they could over or under estimate the extent of an issue. Accurate 3D scanners are valuable 68
patient-educational tools, which allow us to personalise treatment to each patient, and have greater confidence that they understand any proposed treatment. Going one step further, scanners allow us to show images to patients of what can, and cannot, realistically be achieved through clinical intervention. As a practitioner, this is hugely welcome as it significantly increases the comfort of knowing patients are making informed decisions. Procedures such as rhinoplasty are greatly aided by such devices as patients can digitally ‘play’ with options, based on the contours of their own face, until they reach the look they want. This also provides the practitioner with a clear blueprint of what is desired, giving both the patient and practitioner greater confidence that they are in agreement of what will be achieved. Technology has also enabled non-surgeons to carry out a wide range of non, or less invasive treatment. Over recent years, there has been a huge growth in procedures being performed for problems that were previously only addressed by plastic surgeons. Techniques such as the one-stitch facelift, iGuide neck lift and the PRP vampire facelift all promise results with less cost and recovery time than traditional surgical procedures. In general, it is hugely advantageous to have an increased scope of options to offer people with widely different needs. However, we need to ensure that anyone carrying out these techniques has been provided with Aesthetics | November 2014
sufficient training to ensure that patients are treated safely and are likely to benefit from a less invasive option. Currently, technology based diagnoses and treatments remain, within the cosmetic surgery industry, insufficiently regulated. It is imperative that any practitioner, surgeon or not, is qualified to assess a patient’s suitability for particular techniques. Problems could arise when such techniques are offered when, in fact, an invasive option may offer the best results, which could leave patients underwhelmed and disappointed with the outcome. At this point, any lesser cost ceases to be an advantage and damages the reputation of our industry results. My own preference is to offer less invasive techniques alongside, or as an accompaniment to, traditional surgical procedures. These can help in reducing recovery time and the need for hospitalisation and anaesthesia. The use of forehead endotine anchors for instance, work well for patients seeking a brow lift – but can now be done under local anaesthetic, within a clinic environment. Previously this procedure would have required an endoscopic browlift under a general anaesthetic and a hospital stay. In some ways, I think we are at a crucial point in our use of technology in cosmetic surgery. It has been a huge force for good but we must ensure that proper training and regulation are put in place to ensure that patients receive the care they need and the results that they desire. Insufficient regulation is not only bad for the reputation of the industry but is unacceptable in terms of patient care. It may also lead to an unfair mistrust of new technologies which could genuinely make a difference when applied correctly. Improving regulation, alongside mandatory training in the parameters and explanation of what is, and is not, possible, are key to the continued growth of our industry. By this means, technology would allow a wide range of practitioners to work side by side, serving different aspects of the market. Patients would know, more than ever, that they could rely on non-invasive practitioners achieving predictable, reliable results. Mr Vivek Sivarajan is a consultant plastic surgeon and medical director of the Elanic clinic in Glasgow, which specialises in surgical and non-surgical treatments. He is an Honourary Clinical Senior Lecturer at Glasgow University Medical School and is author of over 20 research papers, which have been published internationally.
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Aesthetics | November 2014
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