Aesthetics October 2016 by Aesthetics & CCR

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VOLUME 3/ISSUE 11 - OCTOBER 2016

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Choosing a Needle Gauge CPD Mr Dalvi Humzah and Anna Baker explore the influence of needle dimension on patient pain

Male Skin Practitioners discuss the skin concerns of their male patients and how they treat each indication

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Earlobe Rejuvenation

Using Google+

Dr Sarah Tonks shares advice on treating earlobes with HA dermal filler

Gemma Johnson explains how Google+ can benefit your business

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Contents • October 2016 06 News

The latest product and industry news

16 Conference Report: BACN

Aesthetics reports on the highlights of the BACN Aesthetic Conference

18 News Special: Microbeads in Aesthetics

Aesthetics investigates the use of the ingredient in skincare

21 Conference Preview: ACE 2017

New features of the Aesthetics Conference and Exhibition 2017 announced

Special Feature Male Skin Page 23

CLINICAL PRACTICE 23 Special Feature: Male Skin

Practitioners discuss the skin concerns and treatment of their male patients

29 CPD: Choosing a Needle Gauge

Mr Dalvi Humzah and Anna Baker discuss the influence of needle dimension on patient pain

33 Ear Rejuvenation

Dr Sarah Tonks shares her technique for rejuvenating the earlobes

38 Case Report: Managing a Mid-face Filler Complication

Dr Yusra Al-Mukhtar shares her experience of treating a mid-face infection

42 Spotlight On: Profhilo

Aesthetics investigates the efficacy of IBSA Pharmaceutical’s new hyaluronic acid injectable that aims to treat skin laxity

45 Lifting the Breast with PDO Threads

Dr Victoria Manning and Dr Charlotte Woodward provide their best technique advice for lifting the breast with PDO threads

50 Managing Botulinum Toxin Complications

Dr Ahsan Ullah provides an introduction to the possible complications and side effects associated with injecting botulinum toxin A

54 Advertorial: Radara

A micro-channelling approach to skin rejuvenation

55 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 56 How to Harness the Power of Google+

Business consultant Gemma Johnson explains how to successfully use Google+ to add value to a clinic’s existing digital marketing strategies

59 Managing Anxious Patients

Dr Jaimini Vadgama discusses the causes of anxiety in patients and effective strategies for managing this in everyday clinical aesthetic practice

62 Taking Responsibility in Waste Management

Clinical waste advisor Rebecca Waters explains how practice staff should be safely and legally disposing of waste

67 In Profile: Mr Basim Matti

Mr Basim Matti details his career in plastic surgery and aesthetics

Social Media Using Google+ Page 56

Clinical Contributors Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director of AMP Clinic in Oxfordshire. He runs the Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Mr Humzah teaches nationally and internationally. Anna Baker is a dermatology and cosmetic nurse practitioner. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a postgraduate certificate in applied clinical anatomy, specialising in head and neck anatomy. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, based at the Chelsea Private Clinic. She practises cosmetic injectables and hormonal based therapies. Dr Yusra Al-Mukhtar is a dental surgeon with several years’ experience in head and neck surgery and facial aesthetics. She is a lead trainer for injectable courses with Oris Medical, based at the Royal College of General Practitioners. Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is a co-founder of River Aesthetics in New Forest and Harley Street. She pioneered the UK’s first non-surgical breast lift in the UK using threads. Dr Victoria Manning is an aesthetic practitioner and GP, with more than 20 years’ clinical experience. She is a co-founder of River Aesthetics in New Forest and Harley Street. Manning is a threads trainer and is also an aesthetics industry media contributor, writer and speaker. Dr Ahsan Ullah is the medical director at My Skin Clinic. He specialises in facial rejuvenation for women, male facial masculinisation, alongside antiageing treatments. He is a member of the BCAM and AAAM and has recently launched My Skin Clinic Training Academy.

69 The Last Word

Plastic surgeon Dr Daniel Medalie argues why it’s time more aesthetic surgeons performed transgender procedures

NEXT MONTH • IN FOCUS: Lasers • Periorbital Complications • Treating Rosacea • Networking effectively

Subscribe Free to Aesthetics Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228

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Editor’s letter The autumn conference season has begun! The much-anticipated annual conferences of the British Association of Cosmetic Nurses (BACN) and British College of Aesthetic Medicine (BCAM) took place last month and you can read Amanda Cameron the highlights of the BACN programme in our Editor report on p.16. Planning is well underway for an exciting and innovative Aesthetics Conference and Exhibition (ACE) 2017 on March 31 and April 1, so put it in your diary now! The event promises to be bigger and better than ever, packed with interactive sessions and plenty of live demonstrations. Given the plethora of aesthetic conferences, the associated costs and the investment of time, we may ask ourselves why do we attend? Criteria for attending events vary but it seems to me there are two key reasons: To learn from the experts – no matter how experienced we are, we are always learning and whether you work in a small or large clinic, ideas and best practice can be shared. To network – meeting old and new colleagues and suppliers so you can be informed of the latest treatments, techniques and products available. Turn to p.21

to find out what we have planned for ACE 2017, and learn about the exciting new Premium Clinical Agenda! The Aesthetics Awards 2016 on December 3 is fast approaching. I hope you have your table booked for the most prestigious Awards ceremony of the year. There are still some tables available for the event, but not many, so if you would like to make the Awards your Christmas celebration I advise you to book now. The votes are rolling in so don’t forget to have your say by October 31 and support the companies, practitioners and products that you value in the industry. Never let it be said that our articles are always the same – this month we have an array of articles, from earlobe rejuvenation (p.33) to using PDO threads for breast lifting (p.45). The October Special Feature looks at treating male patients. Turn to p.23 to hear from fellow practitioners on their approach to improving male patients’ skin with injectables, lasers and skincare, and the difference between the sexes. Make the most of the journal’s free content by also visiting our website www.aestheticsjournal.com, where you can read all our previous features, as well as keep up-to-date with the latest news in our exciting specialty.

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally. Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies. qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments. Dr Tonks has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

years experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide. 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook. for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0203 096 1228 | M: 07867 974 121 chris@aestheticsjournal.com Suzy Allinson • Brand Director T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com Amanda Cameron • Editor T: 0207 148 1292 | M: 07810 758 401 mandy@aestheticsjournal.com Chloé Gronow • Deputy Editor & Communications Manager T: 0207 148 1292 | M: 07788 712 615 chloe@aestheticsjournal.com Kat Wales • Journalist T: 0207 148 1292 | M: 07741 312 463 kat@aestheticsjournal.com Shannon Kilgariff • Journalist T: 0207 148 1292 | M: 07584 428 630 shannon@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com CUSTOMER SUPPORT Sammy Carlin • Customer Support Executive T: 0203 096 1228 | support@aestheticsjournal.com EVENTS Kirsty Shanks • Events Manager T: 0203 096 1228 | kirsty@synaptiqgroup.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

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Regulation

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Team Dr Raj Acquilla @RajAcquilla Beautifying the beautiful people of #SouthAfrica with my gorgeous team @Allergan #Botox #Juvéderm #WorldTour

#Study Dr Stefanie Williams @DrStefanieW Interesting study showed that we might want to increase our daily protein intake as we get older, in order to avoid muscle loss when #aging #WorkingWeekend Dr Tatiana Lapa @Studio_HarleySt Getting ready for a busy weekend ahead! #aesthetics #harleystreet

The JCCP introduces new independent working parties The Joint Council for Cosmetic Practitioners (JCCP) has created two new sub-parties that aim to develop the JCCP register and provide a framework for education, training and accreditation. The Clinical Standards Authority (CSA) will provide foundations for the first working party; Working Party 1: Education, Training and Accreditation, chaired by Dr Anne McNall, which will develop a range of processes for accrediting practitioners, training bodies and training programmes. Professor Mary Lovegrove will chair Working Party 2: Establishment of JCCP Register, which will aim to develop the processes and criteria involved in establishing the JCCP register of practitioners, training bodies, training courses and premises. JCCP interim chair Professor David Sines said, “The process to establish the JCCP and the CSA is complex but is now in full process. It will be the intention to publish regular updates on the progress being made by the Working Parties.” Established in January, the JCCP is a voluntary independent body that aims to provide public protection for non-surgical cosmetic procedures through establishing industry standards. According to Professor Sines, the work of these two sub-parties will take the organisation forward to the formal stage of inauguration by April 2017. Facial redness

#Consulting S-Thetics @MissBalaratnam Good to be back consulting and treating patients today at Bristol Plastic Surgery #Bristol #Juvéderm #Ilovethiscity #Training envisage aesthetics @DrKalpnaPindoli Thank you for a fantastic day of inspired training! @mdhtraining

#SocialMedia Dr Rohit Jaiswal @drVegas Videos of #plasticsurgery on social media don’t always portray the seriousness of surgery and can affect #selfesteem of kids #Celebrity Dr Rabia Malik @DrRabiaMalik It was great chatting with a glowing @trinnywoodall who tried my Mesopeel as we talked skincare @GraceBelgravia

NeoStrata launches Redness Neutralizing Serum Antiageing skincare company NeoStrata has added the Redness Neutralizing Serum to its Restore product range to target the underlying causes of skin redness in sensitive skin types. The formula incorporates NeoStrata’s BioCalm Complex, which aims to treat inflammation and NeoStrata’s bionic polyhydroxy acid formula, which attempts to restore and strengthen the skin’s barrier. It also uses vitamin E and white tea extract to help diffuse UV-induced damage caused by oxidative stress. According to a clinical study of 42 participants, 92% of patients treated with the product twice daily after two weeks noticed a reduction in redness with 33% seeing a significant reduction. “Facial flushing can be a source of embarrassment for many women and men, and signs of discolouration may remain long after the initial trigger has passed,” said vice president of clinical affairs at NeoStrata, Barbara Green. “This serum effectively diminishes the appearance of redness while helping to prevent future cases from occurring,” she added. The NeoStrata Redness Neutralizing Serum will be available in the UK through aesthetic distributor AestheticSource.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Skincare

SkinCeuticals adds new mask to Correct range Cosmeceutical skincare company SkinCeuticals has added the Phyto Corrective Masque to its Correct collection. The mask uses botanical extracts and a concentrated calming dipeptide within a hyaluronic acid base, aiming to reduce the skin’s surface temperature, restoring hydration for optimum skin comfort whilst also minimising downtime and maximising aesthetic results after procedures. In a clinical trial of 30 females, the product indicated an average 20% reduction in visual redness post procedure and a 47% reduction in discomfort immediately after use. Thermal mapping of these subjects also suggested an average skin surface temperature reduction of 2.8ºC. Aesthetic practitioner Dr Askari Townshend said, “I have used the Phyto Corrective Masque to reduce downtime following fractional laser and peel treatments and was pleased to see that patients experienced a positive cooling and calming effect.” Training

MATA launches new level 7 and level 5 qualifications Medical and Aesthetic Training Academy (MATA) has launched two new level 7 qualifications for injectables training and three level 5 qualifications for laser training. The new qualifications, which will be available in London and throughout the UK, will incorporate remote learning and face-to-face teaching and will offer theory and practical elements including hands-on patient treatments and clinic-based assignments. The qualifications are EduQual accredited and according to MATA, reflect the latest Health Education England guidelines. The level 7 qualifications are open to doctors, dentists and nurses who are qualified to level 6 with a valid GMC, GDC or NMC number and the level 5 qualifications are open to doctors, nurses, dentists, pharmacists, tattoo artists, beauty therapists and aestheticians. MATA founder Mr Faz Zavahir said, “I’m very pleased we are able to offer an entire suite of qualifications and courses from which learners can choose to meet their own training needs – all within one academy mapped to the latest HEE guidelines.” Hair

Study suggests men with hair transplants look younger A survey published in JAMA Facial Plastic Surgery has suggested that men with transplanted hair are perceived as younger, more successful, and more attractive than balding men. The 122 participants, who took part in the online survey, were presented with 13 pairs of side-by-side images of each man and asked to compare the image on the left with the one on the right. Seven of the pairs included hair transplant patients – before and after – and six of the pairs included men who had not had hair restoration and were balding. Age, attractiveness, successfulness and approachability were rated. The order of the photographs was randomised for each survey participant. The men who underwent hair transplants were perceived to be a mean of 3.6 years (95% confidence interval (CI), 3.4-3.8) younger after hair transplant and 1.1 years (95% CI, 0.8-1.3) younger than the control cohort.

THE BUSINESS DESIGN CENTRE / LONDON / 31 MAR & 1 APR 2017

COUNTDOWN TO ACE 2017 REGISTER NOW! Aesthetic practitioners and industry professionals are invited to register to attend the Aesthetics Conference and Exhibition 2017, which is set to be even bigger and better than ever before. With a varied clinical and business agenda, packed with the latest technique advice, product innovation, live demonstrations and clinic development advice, delegates at all stages of their aesthetic careers will come away from ACE with the knowledge and skills to enhance their business in 2017. SPEAKER INSIGHT: PREMIUM CLINICAL AGENDA Consultant plastic surgeon Mr Dalvi Humzah will present on the new Premium Clinical Agenda. He says, “I am delighted to once again support ACE, which always delivers lively presentations, expert demonstrations and highly educational content across the whole agenda. The new-to-2017 Premium Clinical Agenda will be split into four separate sessions that will each feature three speakers, myself included, analysing the face of a patient and advising what treatments they would offer. This unique approach will allow delegates to get an insight of treatment recommendations from practitioners working across the aesthetic specialty; with talks from nurses, doctors, dermatologists and plastic surgeons.” WHAT DELEGATES SAY “I love the workshops at ACE, they’re so informative; I love the way they go into the anatomy and teach you the positive and negative points to look out for.” AESTHETIC NURSE, CARDIFF

“ACE is always well structured and it’s good to find out about some new products. An absolutely amazing conference on both days.” AESTHETIC NURSE, ESSEX

“ACE gets better and better each year, it had the best aesthetic clinicians doing live demonstrations, and has provided a lot of informative information on new and upcoming products. I look forward to attending in 2017.” AESTHETIC DOCTOR, LONDON HEADLINE SPONSOR

www.aestheticsconference.com

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Events diary 23rd – 25th November 2016 British Association of Plastic Reconstructive and Aesthetic Surgeons Winter Scientific Meeting 2016, London www.bapras.org.uk

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Conference

Registration now open for ACE 2017

3rd December 2016 Aesthetics Awards, London www.aestheticsawards.com

26th – 29th January 2017 IMCAS Annual World Congress 2017, Paris www.imcas.com

3rd – 7th March 2017 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

31st March – 1st April 2017 Aesthetics Conference and Exhibition, London www.aestheticsconference.com

Threadlifting

4T Medical launches new PDO Thread Cogging Screws New polydioxanone (PDO) Thread Cogging Screws have been introduced to the Honey Derma PDO Thread range. UK aesthetic product supplier 4T Medical claims that, the PDO Thread Cogging Screws are easy to insert and can be placed more superficially than a standard 3D Cog. They aim to treat a variety of areas including the lower face, mid-face, jawline and neck, and can be used for body contouring. They can also be used in combination with 3D cogs to create a brow lift. Managing director of 4T Medical, Julien Tordjmann said, “Cogging screws are a great addition to our Honey Derma PDO Thread range – they can be used independently or in conjunction with our Monos, Twists and 3D Cogs to optimise results for patients.”

Registration for the Aesthetics Conference and Exhibition (ACE) 2017, set to take place on March 31 and April 1 at the Business Design Centre in Islington, London, is now open with a special 10% early booking discount available for Premium Clinical Agenda delegates. This year the Premium Clinical Agenda will comprise four sessions, allowing delegates greater flexibility with the option to attend individual sessions according to their specific interests. The sessions will each feature three leading industry speakers discussing different facial rejuvenation treatments for a single patient. Alongside the Premium Clinical Agenda, the conference will showcase the latest treatment techniques, best practice advice and industry developments at the free Business Track agenda and the free sponsored Expert Clinic and Masterclass sessions. Delegates will also have the opportunity to explore the 2,500m2 Exhibition Floor and network with aesthetic manufacturers, suppliers and distributors to discover the latest treatment and product innovation in 2017. Consultant plastic surgeon Mr Dalvi Humzah, who presented at ACE 2016, said, “Attending these conferences allows you to increase your knowledge, find out what’s new, see whether your skill base is at the right level and also, most importantly, allows you to network with your peers to find out what’s happening and keep you abreast of the current knowledge base. ACE 2017 is going to be a really exciting event.” New supporters have also been announced, including headline sponsor Schuco International, Expert Clinic session sponsors AesthetiCare, AestheticSource, HA Derma, Neocosmedix, Rosmetics and Syneron Candela, as well as a Masterclass session sponsor, Teoxane Laboratories. The early booking discount for the Premium Clinical Agenda will be available until December 31 and further discounts will be offered to those who purchase more than one Premium Clinical Agenda session. For more information or to book your place at ACE 2017, visit the Aesthetics website www.aestheticsjournal.com. Imagery

Wigmore Medical to distribute Next Motion Aesthetic distribution company Wigmore Medical has been announced as the UK distributor for Next Motion. The device allows practitioners to capture standardised imagery for their patients’ before and after photographs. According to the company, the technology aims to save time by allowing for photographs to be taken at 180 degrees in less than a minute, provide accurate before and after videos, and hold them in a simple and secure way to access the videos on different devices. Dr Emmanual Elard, creator of Next Motion, said, “Next Motion is a tool that I created for all of my colleagues to save a considerable amount of time while seeing patients, to better convince our patients of our skills, and to obtain irrefutable proof of the quality of the treatments we provide to each and every patient.”

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Patient safety

Government proposes legislation to publicly rate cosmetic surgery clinic competencies New proposals from the Department of Health (DoH) could result in cosmetic surgery clinics being publicly rated online by the Care Quality Commission (CQC). On August 22, the DoH launched an eight-week consultation to expand the rating programme run by the CQC, an independent regulator of healthcare services in England. Currently the CQC inspects cosmetic surgery facilities but does not rate them or publish the results online as it does with hospitals and GP surgeries. The proposal suggests that cosmetic surgery clinics should be rated as ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’ and should be named online for potential patients to access. Many cosmetic surgeons believe the legislation would be a step in the right direction towards enhanced patient safety and have welcomed the proposal. Mr Stephen Cannon, chair of the Cosmetic Surgery Interspecialty Committee and vice president of the Royal College of Surgeons, said, “It is excellent news that the DoH is proposing to expand the CQC’s public ratings system to cosmetic surgery providers. The easier it is for patients considering cosmetic surgery to identify providers that meet the high standards required for safe surgery, the better.” Mr Foued Hamza, cosmetic surgeon at Queen Anne Street Medical Centre in London added, “This is the first official step towards putting an end to botched procedures which have come to light due to practitioners who don’t respect the guidelines of this job.” The proposal is open until October 14 and can be viewed online.

Aesthetics

Vital Statistics 65%

In a survey of 7,700 women, 65% agreed that facial fillers are more socially acceptable than they were five years ago (The Changing Faces of Beauty: A Global Report by Allergan, 2016)

If current trends continue, 2.7 billion adults throughout the world will be overweight by 2025 (World Obesity Foundation, 2015)

In a study of 992 people with acne vulgaris, 53.7% of smokers showed moderate to severe scarring compared to 35% of non-smokers (British Association of Dermatologists, 2015)

51% of marketers rate email marketing as their most effective channel (UK Digital Marketing in 2015: Statistics and Analysis, from Smart Insights)

Skincare

SkinMed launches new TEBISKIN Reticap Face and Reticap Eye and Lip Dermatological distribution company SkinMed has added the Reticap Face and Reticap Eye and Lip by TEBISKIN to its product range. According to the company, the products encapsulate a six million IU (international units) retinol solution and combine 0.2ml with its 48.8ml cream to deliver 24,000 IU of retinol per millilitre. The retinol products aim to boost new collagen, normalise cell function, encourage skin cell development and normalise pigment production for a healthier, youthful, and more even skin appearance. The retinol ingredient is also combined with ethyl ascorbic acid, which aims to synergise with retinol; N-acetylglucosamine, which aims to boost retinol activity and accelerate hyaluronic acid levels; urea, to smooth skin and improve hydration; and hyaluronic acid, to provide a moisturising and hydrating effect. The products are available now through SkinMed.

A poll of 800 women estimated that they would spend, on average, £100,000 on cosmetics in their lifetime (Hairtrade.com, 2014)

A survey of 1,000 British adults suggests that 24% think a celebrity would inﬂuence their decision to have cosmetic surgery (Fitzroy Surgery survey, 2016)

Reﬂection can greatly increase the power of the sun’s radiation by up to 85% for snow, 17% for sand, and 5% for water (British Association of Dermatologists, 2013)

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Awards

Murad launches InstaMatte Oil-Control Mask Skincare company Murad has launched a new face mask that aims to dissolve excess oil and regulate its production in the skin. InstaMatte Oil-Control Mask is a three-minute deep-cleansing mask that, according to the company, will also help prevent skin breakouts for a long-lasting complexion. Its formula includes oil-control complex, which aims to absorb oil and keep the skin’s pores clear throughout the day; a zinc polymer network, which aims to sustain rinse-off for maximum oil control and maintaining hydration; salicylic acid, to penetrate the pores and clear congestion and prevent blemish breakouts; grapefruit extract for skin tightening; and olive extract that aims to help fight free radicals and pollution. “InstaMatte provides consumers with immediate oil control without stripping the skin of vital hydration,” said Dr Howard Murad, CEO and founder of Murad. “It helps manage the over-production of oil that leads to breakouts to ease the stress that often accompanies the condition,” he added. Industry

Innoture appoints new chief executive officer Aesthetic company Innoture Ltd, manufacturers of antiageing skincare technology Radara, has appointed Ken Jones as its chief executive officer. Jones is a former president and CEO of Astellas Pharma Europe Ltd and brings more than 30 years of global specialty pharmaceutical industry experience to the role. Prior to Astellas, Jones worked for Allergan for 17 years, and was involved in the launch of several Botox therapeutic indications, in addition to the development of the cosmetic indication. “I’m excited about the opportunity to further develop the Radara brand and the broader micro-channelling patch technology platform and am committed to helping Innoture achieve its potential in aesthetics and beyond,” said Jones. “In a short time, Radara has achieved significant success thanks to the combination of innovative technology and the team’s passion and expertise. I believe there is a great opportunity for growth and development in the business and I look forward to driving Radara’s future success.” As CEO, Jones will be responsible for driving growth and development, as well as progressing various medical device and pharmaceutical applications for the micro-channelling patch technology Radara. Ben Fisher, managing director of Innoture, said, “We are delighted to be welcoming Ken to the Innoture team. His wealth of business expertise as well as his understanding of ethical pharma and aesthetic markets will be invaluable as we look to take Radara forward and expand other opportunities in pharmaceutical areas.”

Institute Hyalual to give away tickets for the Aesthetics Awards 2016

Aesthetics Awards 2016 sponsor Institute Hyalual has launched an online competition to give two lucky individuals the chance to win tickets to the Aesthetics Awards 2016 on December 3. UK sales and marketing manager Katie Bennett of Institute Hyalual, which is sponsoring the Award for Aesthetic Nurse Practitioner of the Year, said, “At Hyalual we go above and beyond to provide those in the industry with education, research and practice. We wanted to give the opportunity for those in or associated with the industry to attend an event which they may not normally be able to.” Bennett added, “We are so looking forward to dressing up and seeing everyone from the industry in one place celebrating achievements and seeing who wins our own prize of the Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year.” To enter, applicants must ‘like’ and ‘share’ the competition post on Institute Hyalual’s Facebook page before November 1 for the chance to win. The winners will be announced shortly after this date and will be contacted via Facebook. The Aesthetics Awards will take place at the Park Plaza Hotel, Westminster Bridge on December 3. To book your ticket visit www.aestheticsawards.com Hair

FTG launches MicropigMANtation and Meso4Men Aesthetic manufacturer and product supplier Finishing Touches Group (FTG) has released two scalp pigmentation treatments aimed at men. The products, which were officially launched on September 1 at Mahiki, London, aim to improve patient’s self confidence by offering coverage to general balding, hairline recession, burn or surgeryrelated hair loss, and alopecia. According to FTG, the treatments are able to conceal hair transplant scars or blemishes as a result of trauma to the head, and blend noticeable birthmarks into the scalp. Dawn Forshaw, founder of FTG, said, “From scalp preparation with Meso4Men, to a full aftercare and skincare system, our approach is unique. Whilst scalp tattooing has been around since the late 90s, the FTG technique is unique as it combines permanent and semipermanent hair loss techniques, allowing men with male pattern baldness the opportunity of choosing 24/7 scalp coverage.”

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Aesthetics

Hydrodermabrasion

Neo Elegance adds HiDr8 Facial to its professional product range Aesthetic device company Neo Elegance has launched a hydrodermabrasion treatment that aims to brighten the skin’s complexion, unclog pores and avoid irritation. Neo Elegance claims the HiDr8 Facial device works by exfoliating the stratum corneum to eliminate dead skin cells. The technology is said to use alterable suction power with the infusion of water and a ‘very soft tip’ to extract impurities from the pores, remove dead skin cells, and, at the same time, replenish lost moisture. There is an option of adding water-soluble solutions to the water for a more ‘targeted and tailored treatment’ to suit each individual. The therapy can be used in a single treatment or as part of a more intensive treatment with microdermabrasion and oxygen therapy. Neo Elegance claims the HiDr8 Facial is suitable for all skin types, including those who suffer from sensitive skin. Microneedling

NaturaStudios announces Dermapen Microneedling Course Aesthetic equipment supplier NaturaStudios will hold a microneedling course to help practitioners learn how to utilise the Dermapen device. The Dermapen Medical Microneedling Course will cover the principles of microneedling, the layers of the skin, cellular histology and skin physiology, treatment targets, collagen maturation, acne, hyper- and hypo-pigmentation, treatment protocols and contraindications. The one-day course will provide delegates with level four certification, which can be obtained after providing two case studies in relation to the education taught during the training. Aesthetic trainer for NaturaStudios Andrew Hansford said, “The course covers advanced anatomy and physiology of the skin which will help with ongoing treatment protocols across a variety of skin treatments.” During the course, all post-treatment care will be explained and delegates will have the opportunity to put questions to the NaturaStudios team. Rosacea

Study suggests FMR is effective in the treatment of rosacea A study published in Dermatologic Surgery has indicated that patients with mild-to-moderate rosacea experienced improvement following fractional microneedling radiofrequency (FMR) treatment. Researchers in Seoul, South Korea, conducted a 12-week, prospective, split-face clinical trial of 21 patients – 20 female, one male, with a mean age 42.9 years – with mild-to-moderate rosacea. Thirteen patients had Fitzpatrick skin type III and eight had type IV. FMR was performed on one side of the face during two sessions with a four-week interval. The other side was not treated. Digital photographs were taken at weeks zero and four following FMR treatment and four and eight weeks after the second session. Erythema was measured at each visit, and histologic analysis of skin samples was also conducted. The erythema index, measured using a skin colour measurement device, decreased by 13.6% at week 12. Researchers concluded that FMR treatment alone results in modest clinical and histologic improvement of rosacea.

Andrew Rankin, Independent Nurse Prescriber As a knowledgeable aesthetic practitioner, what is your experience of mesotherapy? Mesotherapy has changed significantly over the 10 years that I have used it. It has moved from the peripheries of cosmetic credibility to the forefront of our understanding of skin and active ingredients. As both our understanding and technology advance, mesotherapy is beginning to shed its stereotype as a treatment for fat and cellulite, gaining a reputation as a viable intervention in the promotion of skin health. These days I perform less treatment for fat and significantly more facial mesotherapy treatments. It is an effective standalone procedure yet I find it invaluable as an adjunctive with, for instance, medical needling. You have worked with RRS Injectable Dermal Implants for many years, what made you choose RRS? I was introduced to RRS at a time when my faith in mesotherapy was at a low. For those of us who remember mixing half a dozen ingredients to form a cocktail, and hoping that it was stable, modern mesotherapy is refreshing (in every sense). Not only are the cocktails pre-mixed, RRS’s CE approval guarantees stability and adds to the product’s credibility. This makes RRS both easy to use and provides peace of mind. Moreover, we no longer have just half a dozen ingredients, within the RRS range there are more than 60. For RRS, these ingredients are well thought out and in-line with current scientific understanding. Even the best products require support for the clinician. RRS is distributed by AestheticSource, which gives an added level of confidence. AestheticSource will not only ensure that training and aftercare is available, but also that the product has relevant scientific underpinnings and CE approvals. What indications can you use mesotherapy for? The RRS range is extensive. Typically, the fat and cellulite indications remain and for body treatments there are options for stretch marks. For the face there are numerous choices depending on the indication we are treating. For instance, I can target pigmentation with RRS Whitening or skin laxity with RRS Tensor. There is even an option to stimulate hair, which I find effective and useful. This column is written and supported by

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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News in Brief Nurse receives suspended sentence for forging botulinum toxin prescriptions A nurse who forged a doctor’s signature to obtain prescriptions of botulinum toxin has received an 18-month suspended sentence. Kate Matthew, a registered nurse and health visitor, submitted six false prescriptions between September 2014 and June 2015 to obtain botulinum toxin worth £3,300 for her private beauty business. Matthew was said to have paid for the botulinum toxin by credit card, but in bypassing the doctor, she avoided paying a ‘signature fee’ for each prescription. Matthew was sentenced at Cardiff Crown Court to 32 weeks in prison, suspended for 18 months, and was ordered to carry out 200 hours of unpaid work over the next 12 months. mesoestetic UK announces new aesthetic trainer Pharmaceutical manufacturer mesoestetic has welcomed a new aesthetic trainer to the UK. Kat Coleman has been working in the medical aesthetics industry for more than 11 years and was previously the training manager at Dermapure. “Joining the mesoestetic team has been a wonderful opportunity for me to showcase my wealth of knowledge and experience within the aesthetic industry,” Coleman said.

Aesthetics Journal

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Sexual health

Sexual Aesthetics Centre opens in Harley Street A sexual aesthetics centre has been opened in London’s Harley Street by Dr Sherif Wakil, who claims that the facility is the first of its kind in Europe. He explained, A number of men and women suffer from sexual dysfunction. After I introduced the O-Shot and P-Shot treatments for male and female sexual rejuvenation with PRP, into Europe and the UK in early 2014, I noticed how these problems for men and women were undermined.” The centre focuses on providing bespoke female and male sexual dysfunction treatments and offers Dr Wakil’s trademarked protocol, the O Concept, which incorporates the O-Shot and P-Shot PRP treatments as well as other non-surgical procedures. Dr Wakil said, “I wanted to launch a ‘Centre of Excellence’ that was dedicated to specifically treat these patients with sexual dysfunction, by offering a wide range of safe, non-surgical, cutting-edge treatments that target the different types of male and female sexual dysfunction. In doing so, I designed the O Concept, which is the first worldwide set of unique protocols formed by blending the latest, advanced technology, treatments and natural supplements to ensure the very best results. It’s a very exciting time to be a the forefront of sexual aesthetics.” As part of his clinic’s protocol, Dr Wakil is also including bioidentical hormone therapy, supplements and bespoke diet and nutrition advice. Nutraceutical

Esthechoc launches limited edition advent calendar

Sunscreen coverage-viewer developed in the US A camera that is designed to allow the user to view their sunscreen coverage and protection has been developed in the US. Sunscreenr permits the user to look at their skin through the camera, which shows protected skin as black and unprotected skin as white, allowing the user to see spots where water, sand or sweat has worn away protection. Sunscreenr is currently still in the development stage and work is taking place on the second proof-of-concept prototype. DMK launches Christmas gift sets Danné Montague-King (DMK) has introduced three Christmas gift sets to celebrate the holiday season. Included in the DMK LIMITED gift set is the new DMK LIMITED Elevate crème, DMK Cellerator tool, a cosmetic mirror and bag hanger. The Super Eyes gift set contains the DMK Eye Tone and DMK Super Serum, DMK Herb and Mineral spray and cosmetic bag and the Holiday Lift gift set includes the DMK Foamy Lift Masque, Exoderma Peel and Deep Pore Cleanser.

Nutraceutical brand Esthechoc has introduced a new limited edition advent calendar to celebrate the holiday season. The Esthechoc Advent Calender includes a 24-day supply of Esthechoc bars, which according to developer Cambridge Chocolate Technologies has an antiageing effect. The company claims the antiageing effect is achieved through increasing the skin’s antioxidant protection, reducing inflammation, boosting microcirculation to the skin and maintaining healthy oxygen levels. It contains a high concentration of the antioxidant astaxanthin, an anti-inflammatory substance, and cocoa polyphenolic epicatechins, which aim to increase oxygen transport in plasma and microcirculation. Cambridge Chocolate Technologies recommends daily consumption of just one 7.5 gram bar, which they claim can reduce oxidative damage related to inflammation by 72%. Practitioners can purchase the product through UK distributor Medical Aesthetic Group.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Aesthetics

Acne

Study indicates lifestyle factors associated with adult female acne Study results published in the Journal of the American Academy of Dermatology suggest a family history of acne and various lifestyle factors are associated with adult acne in women. Researchers measured factors associated with adult female acne in 248 women aged 25 years or older and 270 female controls who were a mean age of 36.4 years old. The control group was diagnosed with undisclosed conditions other than acne. Among the patients with acne, 50.2% had moderate acne, 42% had mild acne and 7.8% had severe acne. Multivariate analysis indicated a significant association between adult female acne and a history of acne in parents or siblings. Other factors associated with adult female acne included history of acne during adolescence, being an office worker compared with being unemployed or a housewife, having no previous pregnancies, having hirsutism, having a high or very high level of reported psychological stress during the previous month and a low intake of fruits or vegetables. “We did not establish an onset date for acne, and our associations may not reflect a causative role but may, at least in part, reflect shared risk factors or consequences of established acne,” the researcher said. “Lifestyle factors may play an important role for acne development in adulthood, but their role should be further assessed in prospective studies,” they added. Cryotherapy

Dr Yannis Alexandrides launches new cryotherapy chamber treatment A cryotherapy chamber treatment has been launched exclusively to Harvey Nichols, London, by creator of skincare range 111Skin, Dr Yannis Alexandrides. 111CRYO uses electrical cryotherapy technology, unlike the traditional nitrogen gas, which cools the atmosphere air in the chamber to -90°C. Dr Alexandrides claims nitrogen-powered chambers aren’t always as efficient as the gas tends to falls to the bottom of the chamber, therefore not treating the whole body. With the electrical technology, Dr Alexandrides claims the temperature remains even throughout and treats the whole body. The aim of the chamber is to increase endorphins and muscle recovery, stimulate collagen production and skin tightening, and offer weight management and pain relief solutions, amongst other benefits. Up to five minutes is spent in the intense cooling treatment, and a follow-up plan is then discussed with an on-site personal trainer, taking into account the patient’s aims, lifestyle and health. “The science behind cryotherapy is very well-known and has been utilised by elite athletes due to its highly restorative and therapeutic benefits,” said Dr Alexandrides. “We have been inspired by innovation and research into the positive effects of extreme cold, and are very excited to be the first company to bring whole body cryotherapy that’s powered by electricity to the UK.”

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

RECORD-BREAKING BACN CONFERENCE 2016 Almost 300 nurses and 50 exhibitors attended the BACN Autumn Aesthetic Conference 2016 in September, which is the best turnout to date. There were lots of new faces amongst delegates, speakers and exhibitors and, alongside excellent clinical treatment demonstrations, there were some great new areas for discussion, including; the psychology involved in patients seeking treatments, a new business support programme for aesthetic practitioners, and the latest updates on regulation within the industry.

NEW BACN BOARD MEMBERS The BACN has appointed two new members to its Management Committee as it looks to expand its range of expertise and provide support to its members in some key new areas. Jenny Pabila, a PR/marketing and promotion consultant, with direct experience of the aesthetics industry, has joined to lead on all aspects of developing social media platforms to promote the BACN and improve the communication links with its members. Anna Baker, an aesthetic and dermatology nurse prescriber, has also joined, reinforcing the strong nursing presence on the Management Committee.

DATES FOR YOUR DIARY 11th Nov: Wales and South West Meeting, Bristol 14th Nov: London, East Anglia & South East Group Meeting, London 21st Nov: South Coast Group Meeting, Southampton 25th Nov: North West Group Meeting, Manchester 28th Nov: Ireland Group Meeting, Dublin 2nd Dec: Central Group Meeting, Birmingham 5th Dec: Scotland Group Meeting, Edinburgh

MEET A MEMBER Sharron Brown is the BACN board secretary and a clinical nurse specialist based at Chelsea and Westminster Hospital in London. She is also joint lead for the BACN’s participation in the NMC revalidation pilot, working hard to support nurses who do not work in traditional NHS structures. Brown is also involved in lecturing, teaching and training, and has contributed to scientific publications.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Oxygen therapy

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Breast Surgery

Vida Aesthetics introduces Ozonetherapy to the UK Aesthetic distributor Vida Aesthetics has launched an oxygen and ozone delivery machine to the UK. The ATO3M machine is a platform that uses a mixture of oxygen and ozone in a concentration ranging from 2 μg/ml to 40 μg/m and aims to improve the appearance of lines, cellulite, stretch marks, wrinkles, acne, chronic candidiasis and other common skin complaints. “The essential difference of Ozonetherapy from other cosmetic remedies and treatments for ageing and pain is its dual action from the outside and inside of the skin, that leads to oxygenation, immune stimulation, improved collagen health and the protection and restoration of some of the most common feminine problems,” said Eddy Emilio, director of Vida Aesthetics. He continued, “Used for many years in sports medicine, chronic pain management, and even gynaecology, we know it’s a versatile, reliable and safe method for men and women looking to improve their skin health from the inside out. The treatment itself is similar to carboxytherapy, and tiny needles transfer ozone gas under the top layer of skin.” Cosmetic surgery

Poll highlights patients’ low confidence in cosmetic surgery A new poll has indicated that 57% of Britons have a negative attitude towards cosmetic surgery, with more than one in six describing their perception as wholly negative. The survey, commissioned by Fitzroy Surgery in London, included 1,008 UK adults. The findings suggested that 24% of Britons think a celebrity would influence their decision to have cosmetic surgery and indicated that the main reason Brits have had or have considered cosmetic surgery is to increase body confidence and self-esteem – 33% for females and 16% for males. The poll also revealed that the biggest worries of patients in relation to cosmetic surgery are complications after surgery (60%), complications during surgery (49%) and botched surgery stories in the media (42%). Sally Taber, Director of the Independent Healthcare Sector Complaints Adjudication Service said there is a lack of unbiased information coming from the cosmetic industry to the consumer. She explained, “This lack of education means that consumers often have an unrealistic view of surgery and what it entails. So when the patient discovers it isn’t a ‘walk in, walk out’ procedure or it can’t give them the body of a celebrity, they are more likely to perceive the procedure as a failure which adds to the poor reputation of the industry.”

Meeting highlights positive effects of pressure wound device More than 160 European professionals in plastic and oncoplastic surgery met in Paris to discuss new data on a single-use negative pressure wound therapy device (PICO), in the prevention of incisional complications following breast surgery. The Plastic Surgery Expert Meeting, hosted by global medical technology business Smith & Nephew, saw surgeons share the latest evidence-based best practice around the use of PICO. Research presented at the meeting included a multicentre-study involving 200 bilateral breast reduction patients, which indicated ‘significantly fewer’ wound healing complications for PICO compared to standard care (p=0.004), and a 38% relative reduction in surgical dehiscence by day 21 from 52 patients (26.4%) to 32 patients (16.2%) (p<0.001). The study also evaluated the scar quality at 42 and 90 days post surgery. PICO indicated ‘significantly better’ scar quality at each time point (p<0.001). Professor Laurent Lantieri, chief of the department of plastics and reconstructive surgery at European Hospital Georges Pompidou, who also chaired the meeting, said, “It is very important to bring some of the most experienced and innovative surgeons together at meetings such as this. It is these small and interactive meetings that are important for the future of education.”

Acquisition

Allergan to acquire Vitae Pharmaceuticals Global pharmaceutical company Allergan has announced it will purchase clinical-stage biotechnology company Vitae Pharmaceuticals. The acquisition will allow Allergan to have access to new dermatology advances, including VTP-43742, an orally active RORγt (retinoic acid receptor-related orphan receptor gamma) inhibitor for the potential treatment of psoriasis and other autoimmune disorders. The deal will also add VTP-38543 to Allergan’s offering. It is a topical LXRβ (Liver X Receptor beta) selective agonist for the

potential treatment of atopic dermatitis and works by decreasing inflammation in damaged skin tissue and repairing the damaged outer layer of skin. “The acquisition of Vitae is a strategic investment for Allergan that adds strength and depth to our innovative medical dermatology franchise,” said Brent Saunders, CEO and president of Allergan. “Vitae has pioneered the discovery and development of highly differentiated first-in-class compounds in atopic dermatitis, psoriasis and autoimmune diseases, areas of medicine where innovation is needed for patients,” he added.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Training

Aesthetics

On the Scene

Mrs Sabrina ShahDesai launches new training academy Consultant ophthalmic plastic reconstructive surgeon Mrs Sabrina Shah-Desai has launched the Oculo-Facial Aesthetic Academy (OFAA), which is offering three new courses aimed at enhancing anatomical knowledge and promoting safe and evidence-based aesthetic practice amongst medical professionals. The new courses cover dermal filler complications management and prevention, facial profile restoration and rejuvenation of the perorbital and perioral using non-surgical injectable treatments. Mrs Shah-Desai said, “Delegates will gain clarity of the complex facial anatomy, how to optimise their outcomes based on current evidence and will learn aesthetic concepts from a national and international faculty of educators.” Joining Mrs Shah-Desai in teaching the courses will be dermatologist Dr Gabriela Casbona, oculoplastic and orbital surgeon Dr Francesco Bernadini, facial plastic ENT, head and neck surgeon Mr Frank Rosengaus, aesthetic practitioner Dr Ravi Jain, and independent nurse prescribers Jackie Partridge and Sharon Bennett.

20 years of Restylane celebration, London Pharmaceutical company Galderma invited guests to a celebratory breakfast at the Charlotte Street Hotel for the 20th anniversary of Restylane. Victoria Baker, senior brand manager for Restylane, opened the event and discussed the journey the brand has taken over the last 20 years. ‘Proof in Real Life’ campaign twins Kelly and Stacey Franklin then discussed their experiences with Restylane dermal fillers and skin boosters. Using the twins as an example, Dr Kuldeep Minocha explained how the products aim to produce natural results. He said, “I’ve worked pretty much exclusively with Restylane for 10 years, and for me everything is about trust in the relationship between you and the patient.” The event also showcased the new Restylane digital platforms, including the Virtual Clinic, the My Skin Journal mobile application and the My Skin Journey website landing page. Speaking about the event as a whole, Baker said, “The event went really well – it is nice to see familiar faces. It was good to introduce our new digital engagement for consumers with our new website which takes you through a virtual clinic, the new before and after app, and the new landing page My Skin Journey,” she added.

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On the Scene

AlumierMD UK launch, London Aesthetic practitioners were invited to learn about the science behind the new AlumierMD cosmeceutical range at a cocktail and canapé reception on September 13 in London. Held at the Connaught Hotel, the event featured talks from UK brand ambassador Dr Simon Zokaie and head of education at AlumierMD UK, Victoria Hiscock. Attendees also had the opportunity to ask questions to the Canadian brand ambassador, Dr Francine Gerstien, via video link. During the presentations, Hiscock discussed the wide range of products that the brand offers, from tinted broad spectrum SPFs, to antioxidants and in-clinic peeling products. Hiscock explained that all products have been created using medically-proven ingredients and emphasised AlumierMD’s strong focus on developing skincare that offers minimal downtime and less irritation. She said, “What’s in the bottle comes first – if the products aren’t results driven and are not efficacious, then the patients won’t buy them either from your clinic or online. Ensuring the efficacy of our products is at the heart of our business.” Dr Zokaie then spoke about why he offers AlumierMD products to his patients, he said, “They’ve really come up with a truly innovative range of products that use fantastic ingredients.” The AlumierMD team then discussed the company’s online purchasing policy, which aims to make it easier for patients to buy online and also incorporates a unique ID tracking system, ensuring no products are being sold through unauthorised sources. Speaking after the event, AlumierMD’s marketing and events manager, Samantha Summerfield, concluded, “I think it’s been a great success; we’ve had a lovely turnout this evening and we hope that our aim to help clinics retain their business and give great service to their patients through effective skincare has transpired.”

BACN Autumn Aesthetic Conference, Birmingham

Aesthetics reports on the highlights of the annual aesthetic conference of the British Association of Cosmetic Nurses The International Convention Centre in Birmingham played host to the highly anticipated British Association of Cosmetic Nurses (BACN) Autumn Aesthetic Conference on September 17. Chair of the BACN, Sharon Bennett, opened the event and welcomed the full auditorium to the conference, alongside chief executive officer of the association Paul Burgess. The morning session then began with educational content from ear, nose and throat surgeon Mr Ash Labib, who gave a presentation and live demonstration of the ‘15 minute nose job’. He started his talk by stating that, ‘surgery will always be here and some patients will always require surgery’ but that non-surgical rhinoplasty ‘provides a cheaper, safer and a more natural-looking alternative’ for many patients. Using dermal filler, Mr Labib then performed a live demonstration of the non-surgical rhinoplasty, correcting a female patient’s minor deformities of the nose in less than 15 minutes. Aesthetic nurse prescriber Anna Baker provided a detailed overview of commonly encountered skin lesions and the signs

Wigmore Medical Open Day, London

On September 3 practitioners gathered at the Royal Society of Medicine in London for the Wigmore Medical Open Day. The event incorporated speakers and live demonstrations from the likes of Dr Askari Townshend, Dr Kwon Han Jin, Dr Emmanuel Elard and Dr Maryam Borumand and showcased injectables, skincare, body contouring technology and photography from several aesthetic brands, including ZO Skin Health, glo Minerals, Radara, Algeness and Ivasix, as well as new innovations from Viveve and Next Motion. Alex Bodikian, head of marketing at Wigmore Medical said, “This was our second Open Day of the year, giving clinics a post-summer top-up and look at new innovations we are set to unveil for the latter part of 2016. It was a busy day with some great seminars and demonstrations, as well as a fantastic opportunity to network with industry peers.”

nurses must look out for before performing any skin treatments. She also advised when to refer patients to a dermatologist, and stated, ‘unless you have a definitive diagnosis of a pigmented lesion, do not touch it.’ Baker touched upon the prevalence of skin cancer, showing data from Cancer Research UK, which indicated that the amount of skin cancers in the UK has doubled since 1995, and that men are most likely to be diagnosed with skin cancer on the trunk of the body, whereas women are more at risk on the legs. After delegates enjoyed a hot lunch in the exhibition area, the afternoon sessions began. A highlight of the afternoon was a talk and live demonstration by Dr Simon Ravichandran and Dr Emma Ravichandran on contouring the jawline and lower face with Radiesse+. Dr Emma Ravichandran treated a 41-year-old male patient live on stage and demonstrated how to create a stronger jawline using the dermal filler, before then injecting the patient’s 62-year-old sister for skin laxity of the lower face. The practitioners demonstrated the differences between the male and female anatomy and how to alternate your injection technique in order to masculinise or feminise the lower face. Before aesthetic and reconstructive oculoplastic surgeon Mrs Sabrina Shah-Desai took to the stage to discuss the anatomical lift, Bennett invited up the BACN board members and event organisers to thank them for all their hard work, which received a huge round of applause from the audience. The day then concluded with Dr Raj Acquilla, who spoke about Allergan’s MD Codes and a holistic approach to treating the lips. Bennett said of the day, “It’s been amazing. The response from everyone has been so positive. The presentations have been just incredible; their knowledge, their presentation, their skills, it has enthralled us all.”

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Microbeads in Aesthetics Following the Government’s recent announcement that it plans to ban microbeads by 2017, Aesthetics investigates the use of the ingredient in skincare On September 3 this year the UK government announced plans to ban the selling and manufacturing of microbeads in cosmetics and personal care products by 2017.1 Research has indicated that the small colourful specks commonly found in exfoliating cosmetic products and toothpaste can have a significant impact on the environment, with one study estimating that every square kilometre of the world’s oceans has an average of 63,320 microplastic particles floating at the surface.2 Secretary of State for Environment, Food and Rural Affairs, Andrea Leadsom says, “Adding plastic to products like face washes and body scrubs is wholly unnecessary when harmless alternatives can be used.”1 So, if this is the case, why are microbeads used? What is their environmental impact? And why should aesthetic practitioners take note? Microbeads are microplastics Microbeads are a type of microplastic, which is defined as ‘synthetic non-biodegradable solid plastic particles that are smaller than 5mm in size.’3 According to consultant dermatologist Dr Maria Gonzalez, microbeads are commonly used in exfoliating skincare products to, “Assist the skin in unblocking pores, which are filled with keratin and other materials, which can potentially lead to comedonal acne. In addition, exfoliation removes built-up cells on the outer layer of the skin, which can make the skin look dull and flaky.” Cosmetic scientist Dr Cuross Bakhtiar says companies additionally choose to use microbeads as the production costs are low and results are easily reproducible. He explains, “The colour match and the quality control is uniform so they come out almost identical year on year and you can produce them in various colours very cheaply.” The alternative to microbeads, according to Dr Bakhtiar, are biodegradable beads, which are more expensive for production, or natural replacements using materials such as rice or bamboo. However, he explains that for natural ingredients, “You can’t get the uniformity – so if you use a natural, raw material when you order batch to batch they may smell slightly differently and look different colour-wise.” He explains that this could be a concern for companies that are trying to offer product consistency. Lorna Bowes, director of medical aesthetics distributor AestheticSource, says that the concerns with microbeads are not a new concept for many skincare developers and that one of their brands from the US previously used them. However, she explains, “It was withdrawn several years ago in response to an American recommendation to abolish plastic beads, it’s good that the manufacturers planned ahead and were already dealing with the issue before it hit the press in the UK.” The company is now using an environmentally friendly biodegradable alternative and a plant derivative as its exfoliating agents instead.

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Environmental impact Dr Penelope Lindeque, who has more than 10 years’ experience working in marine research, emphasises that microplastics pose a risk to the environment because they directly affect the eating patterns of small marine animals, called zooplankton, that live near the surface of water.4 Dr Lindeque explains that this is because the animals are both eating the plastics and possibly finding it hard to sort through the plastics to find their food, hindering their survival and causing them to have reproductive issues. She says this is a problem because, “Zooplankton themselves are really important prey for other organisms. The concern is, if the zooplankton aren’t surviving, the food source for animals further up the food chain is affected.” Despite the effect of microplastics on zooplankton, Dr Lindeque’s notes that only, “A small constituent of microplastics is derived from microbeads,” with the rest deriving from sources such as bigger plastics or synthetic clothing.5,6 Studies have suggested that 0.1%7 to 4.1%6 of marine microplastic pollution in Europe is from cosmetic product sources but, even though this percentage is small, Dr Bakhtiar asserts that they shouldn’t be used when there are alternatives. Practitioner responsibilities Dr Bakhtiar believes that all aesthetic practitioners have a responsibility to educate their patients about the ingredients in skincare, “Sometimes practitioners may not be aware of issues such as microbeads and don’t know what to look out for.” As such, he advises that practitioners ask their cosmetic manufacturers or consultant formulators for more information before purchasing new exfoliating products. “It’s important to speak to someone who knows about formulations to know what is being used within products – that’s crucial in the first instance – today’s consumers really want a more natural product that’s not just bodily friendly but also environmentally friendly,” he adds. Dr Gonzalez agrees that patients are now seeking more natural or organic products, “Patients actively seek brands which promote their products as more environmentally friendly as they are much more worried about the long-term impact of cosmetic products both on their bodies and on the environment.” Dr Gonzalez encourages other practitioners to understand ingredients that have the potential to harm both the patient and the environment and provide patients with the correct product advice, “We forget that skincare is washed off our faces and has a direct entry into the environment through water when we shower – it is essential that we consider the long-term effects of these products so that we do not contribute to further environmental neglect.” Future of microbeads If the Government’s plans go ahead, microbeads in cosmetics will be abolished by the end of next year. Dr Bakhtiar says, “I think this should have been done sooner – for the last several years the cosmetic industry has been aware of microbeads and the contamination that they can cause.” Dr Gonzalez adds, “It has been under discussion for a while and I am pleased that action is finally being taken.” REFERENCES 1. Department for Environment, Food & Rural Affairs and The Rt Hon Andrea Leadsom MP, ‘Microbead ban announced to protect sealife Microbead ban announced to protect sealife,’ 3 September 2016, https://www.gov.uk/government/news/microbead-ban-announced-to-protect-sealife 2. UNEP, ‘UNEP Frontiers 2016 Report: Emerging Issues of Environmental Concern’, United Nations Environment Programme, (2016), p.32 3. Bennett O, ‘Microbeads and microplastics in cosmetic and personal care products’, House of Commons Library, (2016). 4. Cole M, Lindeque P, Fileman E, Halsband C, Goodhead R, Moger J & Galloway TS, ‘Microplastic Ingestion by Zooplankton’, Environ. Sci. Technol, 47(2013), pp.6646–6655. 5. Vethaak, Dick, Plastics in Cosmetics, (UNEP:2015) pg.11-13. 6. Sherrington C, Darrah C, Hann S, Cole G, Corbin M, ‘Study to support the development of measures to combat a range of marine litter sources’, Eunomia Research & Consulting (2016). 7. Karen D & Coors A, ‘Microplastics in the aquatic and terrestrial environment: sources (with a specific focus on personal care products), fate and effects’, Environmental Sciences Europe, 26(2016),

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Introducing ACE 2017 Registration is now open for the Aesthetics Conference and Exhibition 2017, encompassing a wide range of clinical and business agendas covering the latest in medical aesthetics Practitioners and industry professionals from across the medical aesthetics sector will once again gather in London for two days of the finest educational content in the UK on March 31 and April 1 at the Business Design Centre, Islington. The Aesthetics Conference and Exhibition (ACE) will be an event not to be missed, with a superior CPD-accredited clinical and business agenda planned for 2017. New supporters have also been announced for the event, including headline sponsor, Schuco International, and a variety of other distributors, suppliers and manufacturers that are supporting the free clinical and business content on offer. “Organisation for ACE 2017 is well underway,” says Amanda Cameron, ACE programme organiser and Aesthetics journal editor. “Last year almost 2,000 delegates attended and, according to our feedback reports, 99% of respondents said they were overall satisfied with their experience at the event. As such, we are focused on ensuring the content maintains its high standards again this year,” she adds. To uphold ACE’s outstanding benchmark, 2017 will see the Premium Clinical Agenda slightly restructured to encompass content more applicable to them. “It is an innovative and exciting platform that is completely independent from the sponsored sessions,” explains Cameron, adding, “This year, delegates can choose from up to four individual CPD-accredited Premium Clinical Agenda sessions, so that they can select the content that is most relevant to them.” Premium Clinical Agenda The Premium Clinical Agenda has been created to offer the highest possible flexibility to delegates. With a change in format for 2017, the agenda will address different facial rejuvenation treatments across four separate sessions, which will enable delegates to purchase individual sessions according to their specific interests. The programme will feature three of the UK’s most knowledgeable speakers, discussing their recommended treatment methods of one face ‘type’. Delegates are encouraged to register for the Premium Clinical Agenda before December 31 to receive a special 10% early booking discount. Further discounts will be offered to those who purchase more than one Premium Clinical Agenda session.

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Expert Clinic In 2016 the Expert Clinics were hugely popular attractions on the free agenda. The agenda this year will be presented in one large space located in the Exhibition Hall, with improved seating quality and access. The sponsored Expert Clinic sessions will comprise practical workshops and demonstrations performed by top aesthetic practitioners on a variety of topics from injectables to lasers and cosmeceuticals. Supporting companies will feature their most knowledgeable speakers, including those representing AesthetiCare, AestheticSource, HA Derma, Neocosmedix, Rosmetics and Syneron Candela, with more soon to be confirmed. Masterclasses The Masterclass presentations will feature industry-renowned practitioners demonstrating the best methods to utilise the companies’ latest treatments and products. The Masterclasses will be showcased in dedicated rooms in the gallery, where delegates can build upon their skills and understanding through informative focused guidance and engaging discussions in each 60-minute session. Teoxane Laboratories is the first confirmed Masterclass session sponsor, with more industry companies set to confirm their session details soon. Business Track ACE prides itself on not only delivering the best in clinical and technological advancements, but also incorporating fundamental business advice through the Business Track agenda. The agenda will provide tips, guidance and advice on how to achieve the ultimate patient experience; ensuring aesthetic businesses run to their full potential. The schedule will expand upon popular topics from last year, including marketing techniques, sales advice, brand building and other company insights. Exhibition Floor Alongside the comprehensive clinical and business content will be the Exhibition Floor, which will house more than 80 diverse stands, featuring and demonstrating exhibitors’ latest products and innovations. Delegates will have the opportunity to explore the 2500m2 hall and discover a wide range of aesthetic companies, while connecting and networking with manufacturers, suppliers and distributors of aesthetic devices, skincare, training course providers and much more. Book now It’s never too soon to start thinking about the Aesthetics Conference and Exhibition, and with registration open and a 10% early booking discount available until December 31, delegates are encouraged to register for 2017 now. ACE 2017 is bound to be an even bigger success than 2016, encompassing the flexible Premium Clinical Agenda, free clinical and business agendas, and exhibition floor. To book your place at ACE 2017 on 31 March and 1 April 2017 or for more information, join the Aesthetics website www.aestheticsjournal.com HEADLINE SPONSOR

2016

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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UPPER FACIAL LINES The first and only aesthetic neurotoxin approved for combination treatment of Upper Facial Lines including: • Horizontal Forehead Lines • Crow’s Feet Lines • Glabellar Frown Lines

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Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 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 upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years 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. Horizontal Forehead Lines: Intramuscular injection, the recommended total dose range is 10 to 20 units, a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50 units/1.25mL). Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with aging or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia

and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. 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, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia). Frequency of adverse reactions by indication is 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). Upper Facial Lines: Very common: Headache. Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. 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 Preparation: July 2016. 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 UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50U Summary of Product Characteristics (SPC). April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0025 Date of Preparation August 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

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Aesthetics

Men in clinic

Treating Male Skin Practitioners discuss the skin concerns of their male patients and how they treat each indication Introduction The male grooming and cosmetic sector has never been bigger. The rise in the number of men having non-surgical aesthetic treatments over the past few years has been well documented, with the American Association of Plastic Surgeons reporting the number of men undergoing minimally invasive non-surgical cosmetic procedures increased 67% between 2000 and 2014, and the number of men undergoing botulinum toxin treatments increased 337% between the same period of time.1 This corroborates with research collected by international market intelligence firm DataMonitor, which suggests that 52% of men across the globe consider their looks and appearance to be either ‘important’ or ‘very important’, more than ever before.2 With an increasing demand from the male demographic, how can practitioners cater for their male patients’ skin needs and differentiate the treatments on offer between the sexes?

Male skin “Due to testosterone production, men tend to have an oily skin type. Even as testosterone starts to lessen with age, their skin rarely becomes dry,”3 says cosmetic surgeon Miss Jonquille Chantrey, medical director of Dr Jonquille Chantrey Expert Aesthetics. She adds, “These skin qualities are often discussed at conferences as a reason why male skin doesn’t age as quickly as female skin.” Although, Miss Chantrey notes that daily shaving, can exfoliate epidermal cells causing irritation, transepidermal water loss (TEWL), and sensitivity to sun exposure, which can lead to collagen degradation.4 Registered nurse and independent prescriber Adrian Baker of MBNS and Qutis clinic in Oxfordshire explains, “Male skin is thicker, oilier, and in the lower face is densely packed with structural hair follicles. Beard growth can actually help provide some protection from sun exposure and the packed follicle ratio provides additional firmness to the structure of the skin.” The average bearded man has 30,000 hairs on his face,5 and these hairs need to be taken into consideration. Dermatologist and medical director of Linia Skin Clinic Dr Simon Zokaie says, “When applying creams to the face, you need to be mindful of facial hair. You need to ensure the products aren’t going to sit on the hair. It’s also important to be aware of the thickness of male skin; I would go deeper when doing microneedling treatments on a man than with a woman, to get the same result.” According to Dr Leah Totton, aesthetic practitioner and medical director of the Dr Leah Cosmetic Skin Clinics, androgens and testosterone cause men’s skin to be up to 25% thicker than females.6 “The collagen density is thicker and the difference in the loss of collagen over their lifespan age is different; a woman’s collagen decreases quite dramatically at several points in her life, such as when she is perimenopausal and menopausal, whereas with men, it is much more consistent.”7

Aesthetic nurse prescriber Emma Chan, clinical director of the Emma Chan Medical Aesthetics and Skin Solutions clinic, says that the amount of men coming into her practice is steadily increasing, and it includes an array of men from different professions. “When I started in the industry nine years ago, it was rather unusual to see men,” she explains. “But now, it is a much more frequent occurrence, and it’s not just men in threepiece suits, it’s manual labourers and outdoor workers as well – they’re from all walks of life.” Dr Zokaie adds, “About 10-15% of my patients are male and over the past year or so, more and more men have been coming into the clinic by themselves, rather than with their partners. I’d say 50% of men come in on their own now and ask for certain treatments, rather than waiting for me to give them the solution.” The treatments men tend to seek differ from females, according to practitioners interviewed for this feature. Dr Totton carried out research in her practice to uncover the most popular requests. “The top three indications for which men seek treatment for are acne scarring, followed by lines and wrinkles or general rejuvenation, and lastly hyperhidrosis. This differs from women, who firstly seek treatment for lines and wrinkles, then sagging skin and thirdly augmentation.” This difference in treatment requests has also been noted by Miss Chantrey, who says, “We see men every day in our Cheshire clinic, and they tend to be more concerned about ‘looking tired’, rather than being overly concerned about fine lines, like a number of women.” Yet, Baker says it’s not always different treatments male patients want, but different results. “The general concerns from male patients I see tend to be the same as females: frown lines, crow’s feet, wanting to look less tired, and even increased lip volume on occasions. However, the results they want to achieve are different if they want a masculine appearance. Most male patients do not want raised, arched brows from botulinum toxin or high cheek bones as a result of mid-face volume loss as that feminises the face.”

The consultation Creating the right environment for the consultation, in order to discuss a patient’s concerns, is what Chan aims to do, putting her male patients at ease. “It’s important that they’re not walking into a clinic that looks as if it just treats women. It’s about making them

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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feel comfortable in their surroundings,” she says. “Let them know it is not unusual for men to be present at the clinic. When we discuss treatments, I show them before and after images of other men; it just makes them more comfortable.” In a typical consultation, Miss Chantrey starts with creating a clear treatment plan, which she says is important so that male patients can understand the level of commitment that may be needed to achieve their desired results. “Male patients tend to like fast outcomes with minimal visits and short downtime, so a discussion around realistic expectations is always important, along with advice about longevity and need for maintenance,” she says. Baker believes that gender is not always the most important factor to consider during consultation, but rather the person as an individual and what they wish to achieve. “Our clinics use a questionnaire that allows me to focus on patient needs regardless of gender. However, when I am advising on treatment options and the results that could be achieved, I find terminology such as ‘define’ ‘sharpen’ and ‘strengthen’ are effective ways to communicate and alleviate any fears of over feminising or emasculating.”

Treatments Skincare Discussing and agreeing on a skincare routine is a vital part of the treatment plan, according to Dr Zokaie. “I find only a few men already have a skincare routine,” he says. “So I recommend a simple four-step regime which involves a facial wash, an antioxidant, a sunscreen and a vitamin A cream – either a retinol or retinoic acid – to be used in the evening. I do this before any talk of injectables.” Miss Chantrey adds, “The right cleanser is crucial and can be the most important aspect of a male skincare regime. Having worked closely with Dr Zein Obagi in clinic, I use a lot of the ZO products because I can create a bespoke protocol suitable for the individual and the oil control products in this range are excellent. Tackling oily skin with products containing salicylic acid can help minimise pores, which is a desirable outcome.” Miss Chantrey believes that many male patients she sees are now over-moisturising, after being influenced by advertising. “This can result in an increased incidence of acne and also a relative sensitivity to products where the skin barrier is iatrogenically weakened.8 Skin disorders such as eczema will create a truly compromised skin barrier and therefore a genuine sensitivity and dryness. These male patients need different management to improve their skin barrier function.” According to market intelligence agency Mintel, moisturiser is the second most commonly used male facial skincare product after soap.9 But what many male patients still aren’t taking into consideration, according to Baker, is sun protection. “Most men do not incorporate effective sun protection on a daily basis and are therefore exposed to UV radiation. There is no excuse for missing that essential step of applying daily UVA and UVB protection,” he says. “Once I’ve recommended a SPF 30+, I then build up their regime over time, maybe adding in a hyaluronic acid gel for postshave burn and TEWL, such as the IS Clinical Hydra Cool.” Chan notes, “When men come to see me with skin concerns, I find that they don’t want to commit to coming into the clinic regularly for medical facials or skin peels, so I generally start the treatment with homecare products; I have my own bespoke skincare range that

Aesthetics

has glycolic acid in it, which I recommend,” she says. “But when it comes to skin, acne scarring is the most common concern.” Acne A study of 749 patients aged 25-58 in the US indicated that 11% of men suffered with acne scarring.10 This type of scarring, especially on the face, is bound to have a profound effect on confidence, according to Dr Totton, who uses a three-pronged approach for her acne patients. She says, “First of all I manage them medically for any active acne, unless they have been in remission for many years. I’d normally start them on a 0.05% tretinoin (retinoic acid). Secondly, I tackle the redness with the Alma Harmony Dye-VL laser; not many men wear concealer, so the redness of the acne scarring can bother them more than women, and it can often bother them more than the indentations on the skin itself.” Dr Totten continues, “Then, I will put them on a retinol product, such as the Obagi Nuderm, to increase cell turnover and use the Alma Harmony to contour the skin and reduce the appearance of any indents.” Dr Zokaie has a different approach to managing male acne scarring, “I find male patients would rather come in several times to clinic to have a treatment, than have just one appointment for one treatment that has a two-week or one month downtime. So I do a lot of microneedling with the DermaPen and get fantastic results.” Botulinum toxin “Men who come to my clinic know they want botulinum toxin before they even come in,” says Chan. “Botulinum toxin is the most popular injectable treatment, especially around the eye. I find with some men, you have already treated their wife and they’ve seen results and then come in themselves.” When using botulinum toxin for lines and wrinkles, it is important Before

After

Before

After

Figure 1: A male patient treated with botulinum toxin in three areas; around the eyes, forhead and glabella region. Images courtesy of Dr Leah Totton.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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“Male patients tend to like fast outcomes with minimal visits and short downtime, so a discussion around realistic expectations is always important” Miss Jonquille Chantrey

to get the right dosage and injection points, according to Miss Chantrey, who explains, “The majority of our male patients prefer to maintain a masculine outcome, so when using botulinum toxin and dermal fillers, just a slight misjudgment of facial assessment can quickly feminise a male face. With botulinum toxin, the frontalis should be managed laterally to prevent an eyebrow arch as this immediately feminises a face.” Baker adds, “Most males will not want feminised raised, arched eyebrows as a result of frown reduction botulinum toxin, therefore I may omit medial brow injection, or inject a large dose in the procerus muscle only.” Dermal fillers “Dermal fillers should be used in a very different way from a female treatment,” says Miss Chantrey. “Overall, when masculinising the face, the aim should be to strengthen the jaw and chin, whilst maintaining appropriate proportions relative to the bizygomatic distance.” She continues, “Management of the tear trough should first include indirect approach through mid-face volume replacement. Curve should not be applied to the zygomatic prominence nor should the anterior malar be over treated. Anterior cheek fullness in a man will be feminising.” When treating lower facial laxity, Baker tends to employ lateral facial boluses of dermal filler via cannula from the lateral zygomatic arch sub-dermally, down to the mandibular angle periosteally. “This creates a wider, stronger facial shape, whilst providing lift to the jowl. In females I would tend to place most volume to the zygoma and only a small dermal bolus to the mandibular arch,” says Baker. Even with injectable products, Dr Zokaie believes that marketing and packaging play an important role when treating men. He says, “There are dermal fillers for specifically men and it’s nice for male patients coming in to clinic to see a brand or box that looks exclusive to men only.”

Complications With any type of intervention, adverse events can occur, but Miss Chantrey believes male patients may be a more vulnerable group. “I think some practitioners treat them in a similar way as they treat women – which isn’t always right. Specific adverse events I commonly see are over-treatment and inappropriate fullness of the tear trough with dermal filler, alongside insufficient correction of the mid-face. Conversely, I also frequently have to correct over-treatment of the mid-face. It is possible that the male face is less studied and

Aesthetics

understood, resulting in a confusion of desirable male proportions.” When it comes to treating acne scarring, Dr Totton says it’s important to be as educated as possible on laser treatments. “You have to be very aware of the sensitivity, as with any laser treatment. I wouldn’t suggest that you put patients on prescription-strength products such as tretinoin unless you are experienced in combining treatments.”

Results and expectations Setting realistic goals during consultation helps ensure both patient and practitioner are happy with the final result, although some practitioners feel men are generally more satisfied with the results anyway, compared with females. “Women are more self-critical so their expectations are higher,” says Chan. “Whereas, if you can show male patients their before and after photos with an acceptable change, then they are quite happy. I find that with women, if you get a noticeable change, even on digital photography, they likely see something else they don’t like.” Miss Chantrey says, “I’ve noticed men tend to want to know a quantitative measure of likely improvement so I tend to express these as percentages following treatment, where possible. This can be challenging, as, of course, aesthetics is not an exact science.” Dr Totton adds, “You need to be open and honest. It is very likely, particularly in acne-scarred patients that they are not going to get a complete resolution or porcelain skin. We tend to aim for about a 1030% improvement. It is a rewarding condition to treat, because it can have quite a significant impact on their confidence and quality of life.”

Conclusion The rise of male patients seeking skincare treatments means that practitioners need to cater for the male sector more than ever before. Chan says that once you have created a setting male patients are comfortable with, they are relatively easy to retain. “You do have to be more flexible with the appointments though,” she adds, “as sometimes they expect to ring one day and get in the next – they’re not necessarily used to having to make appointments and wait for them.” Dr Zokaie believes a dedicated male skin clinic as part of an aesthetic practice is the way forward. “It might be worth offering an afternoon male clinic, where they can come in and not feel embarrassed, as there will just be other men there. When my male patient database reaches 20-25% that would be the time to create something like this.” REFERENCES 1. Cosmetic Surgery Gender Distribution, American Association of Plastic Surgeons (2014) Plastic Surgery Statistics Report 2. Maria Fernandez, Trends in the Cosmetic Market for Men, Canadean Consumer, (2014) <http:// www.canadeanconsumer.com/trends-in-the-cosmetic-market-for-men/> 3. Claudia Aguirre, Understanding Male Skin, The International Dermal Institute, (2016) <http://www. dermalinstitute.com/uk/library/73_article_Understanding_Male_Skin.html> 4. Diana Howard, When Razor Meets Skin: A Scientific Approach to Shaving, The International Dermal Institute, (2016) <http://www.dermalinstitute.com/uk/library/16_article_When_Razor_Meets_ Skin_A_Scientific_Approach_to_Shaving.html> 5. W.A. Poucher, Shaving Products, Poucher’s Perfumes, Cosmetics and Soaps: Volume 3: Cosmetics, Springer Science (1993) 6. Dermalogica, Is a man’s skin really different from a woman’s? The International Dermal Institute, (2016) <http://www.dermalogica.co.uk/uk/yourskin/19_article_is_a_man_s_skin_really_different_ from_a_woman_s_.html> 7. Diana Howard, How does the menopause affect the skin? The International Dermal Institute, (2016) <http://www.dermalinstitute.com/uk/library/12_article_How_Does_Menopause_Affect_the_Skin_. html> 8. Natasha Burton, Is There Such a Thing as Moisturizing Too Much?, Style Caster, (2015) <http:// stylecaster.com/beauty/can-you-over-moisturize/> 9. Mintel, Hairy times for men’s facial skincare: sales of UK men’s facial skincare grow just 1% in 2015, (2016) <http://www.mintel.com/press-centre/beauty-and-personal-care/hairy-times-for-mens-facialskincare-sales-of-uk-mens-facial-skincare-grow-just-1-in-2015> 10. Antonella Tosti, Maria Pia De Padova and Kenneth Beer, Acne Scars: Classification and Treatment, Informa, (2010)

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

Preserve the identity of your patients with natural-looking results.1 Azzalure is proven to reduce the severity of glabellar lines.2 It provides fast onset of action (median 2-3 days)2 and long-lasting efficacy (up to 5 months)2, and almost 90% of patients felt the results “surpassed” or “met” their expectations.1 References: 1. Molina B et al. J Eur Acad Dermatol Venereol. 2015;29(7):1382-1388. 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary. Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517. Website: www.hpra.ie; E-mail: medsafety@hpra.ie. Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Galderma S.A Date of preparation: May 2016 AZZ/003/0216(1)

facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure.To be used for one single patient treatment only during a single session.Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: April 2016

1 oint

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Alam et al., (2015)8 undertook a split-face, double-blinded randomised clinical trial, comprising 20 subjects with moderate glabellar and forehead wrinkles. One side of the subject’s forehead was treated with BoNT-A in saline injected with a 32G needle, whilst the opposite side was treated with a 30G needle. In addition, each patient received randomised injections of saline to both upper inner arms with the same gauge needles. The level of discomfort was reported as greater with the 30G needles (40% of subjects), in comparison to 32G needles (15% of subjects). No difference was noted in the character of pain associated with needle bore for all comparisons. The authors concluded that BoNT-A may be better tolerated when administered with a 32G needle compared to a 30G needle.

Choosing a Needle Gauge Mr Dalvi Humzah and Anna Baker discuss the influence of needle design and dimension on pain experience during botulinum toxin injection One of the main treatment goals of any aesthetic procedure is to prevent complications using safe and appropriate techniques.1 Pain and complications are key concerns for patients and their perception of treatment outcomes. These factors should be considered and discussed during the consultation and consent process.2 Botulinum toxin A (BoNT-A) remains one of the most popular aesthetic non-invasive treatments, with an exponential rise in the approximate number of treatments performed each year.3 The American Society for Aesthetic Plastic Surgeons reports a total of 4,267,038 botulinum toxin procedures undertaken in 2015, ranking as the most popular non-surgical treatment.4 In light of these statistics, providing an optimum patient experience and selecting appropriate tools to administer treatment is an important factor. In this, we will examine the issue of the use of appropriate needle gauge as a factor.5 Needle design and dimensions: what does the current literature say? A small body of literature suggests that cosmetic BoNT-A injections are principally performed with needle gauges ranging from 30G-33G.2,6 A small blinded and randomised study with 20 subjects examined the difference in both pain and bruising between 30G Micro-Fine Plus needles and 33G TSK microneedles.7 The results of the study demonstrated that the 33G needles offered superior comfort across three treated areas of the upper face (glabellar, forehead and crow’s feet), with a statistically lower incidence of ecchymosis. This remains one of the few studies to specify the frequency with which the microneedle pierced the skin before it was changed (four to six injections).7

Conversely, Price et al., (2009),9 report different findings in a similar study comprising 37 subjects whereby the right side of the face was treated at the crow’s feet region with a 30G needle, and the left side was treated using a 32G needle. This was a single blind study and subjects were asked to rate injection pain on an 11-point numerical rating scale and to note any bruising. The study results indicated no statistically significant differences in the amount of discomfort from injection or the level of post-procedural pain and discomfort experienced. Rates of bruising were not statistically different; 27% of subjects reported bruising with the 32G needle, versus 29.7% with the 30G needle. The physician injector reported no preference with either needle size. The authors concluded with no recommendation to use 32G needles in place of 30G needles. However, little explanation was provided concerning the result, or discussion around the potential variables in the study design, in particular, how many injections each subject was administered, and the impact these may have had upon the results. Yomtoob et al., (2009)5 concur with these findings, their study design included treating patients at the periocular region with

The American Society for Aesthetic Plastic Surgeons reports a total of 4,267,038 botulinum toxin procedures undertaken in 2015, ranking as the most popular non-surgical treatment

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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benign essential blepharospasm. No rationale was provided for the chosen anatomical region or clinical presentation. A split face analysis was adopted with 30 subjects who received bilateral injections using 30G needles on one side of the face and 32G needles on the opposite side. The average pain score was 4.38=+/-2.02 for 30G needles and 3.90+/1.65 for 32G needles, however, this was not statistically significant. Therefore, the authors could not recommend a preferred needle gauge.

One of the challenges in analysing the current literature in relation to consensus recommendation for needle size for BoNT-A injection is the lack of consistency in methodology and parameters between the small number of studies

Discussion One of the challenges in analysing the current literature in relation to consensus recommendation for needle size for BoNT-A injection is the lack of consistency in methodology and parameters between the small number of studies. Cohort numbers in the current literature rarely exceed 30 subjects and do not consistently compare the same anatomical areas, or cosmetic indications. The majority of the literature focuses upon analysing the pain score, whereas other crucial treatment outcomes, such as bruising and swelling, potential volume of product wastage, as well as the width of needle are not explored in sufficient detail. The narrow parameters in current literature do not definitively conclude an advantage in the use of 30G needles in comparison to available smaller sizes. In addition, the higher the number of

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Conversely, Arendt-Nielsen et al., (2006)10 argue that needle gauge is a significant parameter and consideration in analysing levels of patient discomfort. The authors performed a study using an automated needle injection system to perform a series of injections whereby the velocity, angle of insertion and depth of injection were controlled. The frequency of pain following needle injections (23, 27, 30 and 32 gauge) was recorded, together with the pain intensity (measured on a visual analogue scale), with the occurrence of bleeding and bruising. The results indicated that the needle gauge was positively and significantly correlated to the frequency of the injection pain: 63% of injections with 23G needles caused pain, 53% of injections with 27G and 31% of injections with the 32G needle caused pain. The authors reported that the 30G needles were found to be more uncomfortable when inserted into the abdomen, compared to the thigh. Yet, insertions into the abdomen were associated with fewer bleeding events (2.5% of insertions, independent of needle diameter). The authors did not analyse any potential correlation with this observation. Outer needle diameter and gauge may not be the only features that may be important for evoked pain. Using thin wall technology, the inner bores of a needle can be made wider, which allows thinner needles to be used for the administration of various drugs. However, widening the inner diameter of the needle affects the needle wall, making it markedly thinner. Such needles are, therefore, more delicate and prone to bending.11 The sharpness of a needle can be lost following a single skin injection12 and blunted needles are more painful to inject requiring a higher extrusion force.11 However this study is based upon analysing needles for diabetic patients, and has limited scope for comparison to cosmetic BoNT-A injections. Gill and Prausnitz (2007)13 observed that needle gauge has been shown to significantly affect the degree of pain during injections into the skin of human subjects with findings to indicate that use of a 27 or 28G needle had an approximate 50% chance of being reported as painful, which was significantly greater than with a 31G needle,

injections per side, potentially the greater the chance of discomfort. In light of the increasing popularity of cosmetic BoNT-A injections, it seems prudent to recommend that future studies attempt to analyse broader parameters to guide clinicians with more clarity on the importance concerning appropriate needle size selection, as patient satisfaction rests not only on minimal discomfort but also successful treatment outcome. There is some non-statistical evidence to speculate that smaller gauge needles may reduce the risk of complications through a higher degree of accurate placement. Furthermore, the studies do not consistently use the same pain assessment tools so data must be interpreted cautiously and do not consistently stipulate which dilutant was used, or the significance of this, which we will discuss in a later review.

The effect of needle thickness on pain has been examined in various studies.10,12,13 Current literature suggests that reducing needle diameter lowers pain and generally increases the patientâ&#x20AC;&#x2122;s pain tolerance and satisfaction. Yet, most of the studies discussed were conducted in diabetic patients, with the goal of achieving higher compliance to insulin treatment. Thus, the areas of injection usually were the abdomen, deltoid, or thigh. A few studies have involved the forearm area of healthy volunteers, but these are challenging to make accurate comparisons to facial parameters. Although existing studies provide some insight, they are limited and clinically insufficient as a basis to consistently assess the effect of needle thickness in minimally-invasive facial procedures, as well as the number of injections to use a needle before changing to a new needle.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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of BoNT-A treatments. Currently, the thinnest available needle in the UK – ‘Invisible Needle’ – is 14% thinner than conventional 33 gauge needles, with a low dead space needle hub designed to minimise product wastage.

In an increasingly competitive market, patients are more likely to remember non-invasive procedures that were painful, potentially affecting retention

Conclusion A variety of factors influence a patient’s tolerance to pain during treatment with botulinum toxin, which include, the individual’s perceived threshold of pain, the anatomical area being treated, as well as depth and technique of injection, needle gauge and width. These factors are not exhaustive, but are some of the most relevant considerations for the clinician. In an increasingly competitive market, patients are more likely to remember noninvasive procedures that were painful, potentially affecting retention. Fortunately, the design of injectable devices continues to evolve with needle lengths and widths becoming smaller and more sophisticated for increased accuracy and minimal wastage of product. Clinicians should consider these factors when choosing the most appropriate needle to deliver injectable treatments. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director of AMP Clinic in Oxfordshire. He also runs the award-winning Facial Anatomy Teaching course and the Aesthetic Clinical Training Course. Mr Humzah worked as a consultant plastic surgeon in the NHS for 10 years and teaches nationally and internationally.

with a 39% chance of causing pain. Furthermore, the likelihood of bleeding was also observed to decrease with decreasing needle diameter. The authors also proposed that increasing needle length may increase pain but there are no robust studies to specifically demonstrate this effect. Skiveren et al., (2010) concur with previously discussed findings from their randomised-controlled trial, analysing the influence of needle size for BoNT-A injection for axillary hyperhidrosis. They compared 27G needles and 30G needles in 38 patients, 50% of patients reported that the side which had been treated with 30G needles, were less uncomfortable, however this study addresses pain in axillary injections and may not be relevant to that perceived in facial injections. This also examined intradermal injection associated pain compared to other studies that look at subcutaneous injections. The average pain level in the present study was lower than that previously reported by Gill et al., (2007), comprising multiple injections per site. The methodology in the Gill et al., (2007) study 2 used one injection administered to every 1cm area of skin, the 2 injection point in the present study was 1.5cm , suggesting that the injection area may be of some importance, yet this was not explored. The pain scores for the 27G and 30G needles peaked after 15 injections, which probably reflects local differences in pain sensitivity in the axilla.14 These injections were administered to central parts of the axillae, where pain sensitivity appeared to be higher, although it was undisclosed if the needle was changed, or how many times it may have been changed, which potentially affects the study findings, depending upon how blunt the needle(s) were. Kim et al., (2013)15 analysed the causative factors of adverse events associated with botulinum toxin injection, through a multidepartment, retrospective study of 5,310 treatments, administered to 1,819 patients. Among their findings, the authors concluded that a needle gauge of <30G, is advisable to reduce the risk of unwanted spread. Council (2015)16 concurs with this recommendation in context 14

Anna Baker is a dermatology and cosmetic nurse practitioner. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching. Baker has a postgraduate certificate in applied clinical anatomy, specialising in head and neck anatomy. REFERENCES 1. Carruthers J.A., Fagien S., Rohrick R.J., Weinkle S., Carruthers A., ‘Blindness Caused by Cosmetic Filler Injection: A Review of Cause and Therapy’, Plast Reconstr Surg., 134(6) (2014), pp.1197-1201. 2. Jack C., Pozner J.N., ‘Putting It All Together: Recommendations for Pain Management in Non-Surgical Facial Rejuvenation’, Plast Reconstr Surg, 134 (2014) 101s-107s. 3. Bonaparte J.P., Ellis D., Quinn J.G., Rabski J., Hutton B., ‘A Comparative Assessment of Three Formulations of Botulinum Toxin Type A for Facial Rhytides: A Systematic Review with Meta-Analyses’, Plast Reconstr Surg 137(4) (2016), pp.1125-1140. 4. Statistics (US: American Society for Aesthetic Plastic Surgery, 2015) <www.surgery.org/media/ statistics> 5. Yomtoob D.E., Dewan M.A., Lee M.S., Harrison A.R., ‘Comparison of pain scores with 30-gauge and 32-gauge needles for periocular botulinum toxin type a injections’, Ophthal Plast Reconstr Surg 25 (2009), pp.376-7. 6. Yavuzer R, Demirtas Y., ‘Painful injections with Botox’, Plast Reconstr Surg., 111(1) (2003), pp.509. 7. Sezgin B., Ozel B., Bulham H., Guney K., Tuncer S., Cenetoglu S., ‘The Effect of Microneedle Thickness on Pain During Minimally Invasive Facial Procedures: A Clinical Study’, Aesthetic Surgery Journal, 34(5) (2014), pp.757-765. 8. Alam M., Geisler A., Sadhwani D., Goyal A., Poon E., Nodzenski M., Schaeffer M.R., Tung R., Minkis K., ‘Effect of Needle Size of Pain Perception in Patients Treated With Botulinum Toxin A Injections: A Randomized Clinical Trial’, JAMA Dermatol, 151(11) (2015), pp.1194-1199. 9. Price K.M., Williams Z.Y., Woodward J.A., ‘Needle preference in patients receiving cosmetic botulinum toxin type’, A Dermatol Surg, 36(1) (2010), pp.109-112. 10. Arendt-Nielson L., Egekvist H., Bjerring P., ‘Pain following controlled cutaneous insertion of needles with different diameters’, Somatosens Mot Res, 23(1-2) (2006), pp.37-43. 11. Egekvist H., Bjerring P., Arendt-Nielsen L., ‘Pain and mechanical injury of human skin following needle insertions’, Eur J Pain, 3 (1999), pp.41-49. 12. Gill H.S., Denson D.D., Burris B.A., Prausnitz M.R., ‘Effect of microneedle design on pain in human subjects’, Clin J Pain, 24(7) (2008), pp.585-594. 13. Gill H.S., Prausnitz M.R., ‘Does Needle Size Matter?’, J Diabetes Sci Technol, 1(15) (2007), pp.725-729. 14. Skiveren J., Larsen H.N., Kjaerby E., Larsen R., ‘The Influence of Needle Size on Pain Perception in Patients Treated with Botulinum Toxin A Injections for Axillary Hyperhidrosis’, Acta Dermato Venereologica, 91(1) (2010), pp.72-74. 15. Kim B.W., Park G.H., Yun W.J., Yun W.J., Rho N.K., Jang A.K., Won C.H., Chang S.E., Chung S.J., Lee M.W., ‘Adverse events associated with botulinum toxin injection: A multidepartment, retrospective study of 5310 treatments administered to 1819 patients’, J Dermatol Treat. 25(4) (2014), pp.331-336. 16. Council M.L., ‘Improving Patient Satisfaction and Quality of care During Aesthetic Use of Botulinum Toxin’, JAMA Dermatology, 151(11) (2015), pp.1179-1180.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ deviceapprovalsandclearances/pmaapprovals/ucm439066.htm

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CONTOUR & DEFINE

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Earlobe Rejuvenation Dr Sarah Tonks details the anatomy of the earlobe and shares her technique for rejuvenation The earlobe is a region not commonly highlighted for aesthetic treatments. This could be because many patients do not see this part of their anatomy as being a focus for priority treatment if there is a budget in mind, or perhaps there is a lack of knowledge that this is an area that can be improved using simple techniques with hyaluronic acid dermal filler. Anatomy The ear is an aesthetically important and defining feature of the face, as demonstrated by the fact that it is a common location for jewellery to be worn.1 It consists of a single piece of fibrocartilage with a complex relief on the anterior side which is concave, and a smooth surface on

Alternative ear functions The shape of the ear can positively identify an individual using a comparative analysis of its morphology. The biometrics of the ear can be used during crime scene investigations, and ear marks can be used in the absence of fingerprints.6 Interestingly, the use of the ear as a tool for human identification began in the late 19th century when Alphonse Bertillon used it as one of the anthropomorphic measurements for his system of identifying individuals.7

same time as facial ageing and so, in my professional opinion, to rejuvenate the face without the earlobe gives a worse aesthetic outcome. Hammoudeh states that, ‘a rhytidectomy without rejuvenation of a deflated ear lobule may fail to address all aspects of facial aging’.1 In 2004 Mowlavi developed a classification system for earlobe ptosis and pseudoptosis, which can be used to assess earlobe height so the ear can be addressed at the same time as the ageing face (Figure 2).5 Dermal fillers5,8,9 and autologous fat1 have been used to successfully treat lobule deflation, rejuvenate sagging, atrophic or irregular earlobes, repair torn earlobes or erase vertical rhytides.10 Personally, I prefer the following method as it is a very simple procedure that does not take too much time to perform. Treatment The area is cleaned with chlorhexidine or alcohol and the hair is pinned back. A 30G needle is inserted at two to three sites, subject to the size of the lobule, along the lateral surface of the lobule, injected into the central mound using either linear threading or serial puncture, depending on the practitioner’s preference and size of the lobule. The hyaluronic acid, usually between 0.2-1ml for both lobules, can be injected directly into the lobe and massaged. Care must be taken to not overtreat this area as the effects of the treatment are generally very long lasting, usually between 18-24 months; which may be due to the lack of movement and metabolic activity in this area.10 The patients are advised to avoid wearing earrings for two weeks.

the convex side. The earlobe is divided into the external, middle and internal parts.2 The lobule of the ear can be either free or attached. Altmann proposed that the free lobule is a dominant trait, while the attached lobule is recessive.3 The lobule is a fibroadipose structure devoid of cartilage. In youth, the lobule is 1.5-2cm in length and the ratio of the length to the long axis of the ear is 25-30%.4 The lobule has two components – the attached cephalic segment and the free caudal segment. The free caudal segment elongates with age but the attached cephalic segment remains unchanged (Figure 1).5 Most published articles regarding the earlobe concern the surgical techniques to reduce the free caudal Figure 1: the anatomical segment, with less landmarks of the intertragal attention being paid to notch (1), otobasion inferius (2), and subaurale (3) are illustrated. the deflated volume of Earlobe height parameters the lobule with ageing. were defined with respect to Earlobe aesthetic It is widely accepted that the ideal earlobe is elastic with good volume and a convex projection perpendicular to the face. Lobule ptosis and deflation are generally undesirable. Deflation of the ear lobule occurs at the

the attached cephalic segment (intertragal notch to otobasion inferius distance) and the free caudal segment (otobasion inferius to subaurale distance).5

1 to 2: attached cephalic segment 2 to 3: free caudal segment

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Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Incidence of ptosis and pseudoptosis in 44 patients seeking consultation for facial rejuvenation operations

Ptosis grade

Free segment (otobasion to subaurale distance, mm)

Incidence of earlobe heights (%)

12.3

1-5

22.2

6-10

38.3

III

11-15

27.2

16-20

>20

Pseudoptosis

Attached segment (intertragal notch to otobasion inferius distance, mm)

Incidence of earlobe heights (%)

>15

12.3

≤15

87.7

Figure 2: Mowlavi’s earlobe ptosis and pseudoptosis classification system

Side effects and complications Erythema can usually present following treatment, however this will go down after a few hours. There is a rich blood supply to the lobule from the middle and inferior branch of the anterior auricular artery, so it is theoretically possible that arterial embolus could occur.11 It should be recognised and treated as an embolism presenting elsewhere i.e. if blanching occurs, the practitioner should treat with immediate hyaluronidase, massage, heat packs, oral aspirin and topical glyceryl trinitrate paste. Discussion There are many types of patients who could benefit from earlobe rejuvenation,

who may not have previously considered it. It may be appropriate for the aesthetic practitioner to mention that this procedure is an option during consultation, as it does occasionally occur that the primary area that the patient has requested treatment for has been corrected, and there is a little dermal filler left over. The anxious patient may not wish to have this injected elsewhere on the face, but may consent to using the remainder of the syringe in the lobule of the ear. A patient who has worn heavy earrings may benefit from a treatment to add volume to the lobule, thus making the tissue more robust and less likely to tear. Alternatively, a patient may perhaps have noticed the loss of volume in

Before

After

the lobules of the ears themselves, made especially noticeable when tying the hair back or wearing the hair short. For practitioners considering adding earlobe rejuvenation treatment to their clinic offering, it is wise to ensure that you are aware of the potential complications that can occur, have an understanding of earlobe aesthetics, and do not overtreat the area. Earlobe rejuvenation can be a quick, simple and safe procedure to add to your repertoire that is of benefit to your aesthetic patients. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at the Chelsea Private Clinic, she practises cosmetic injectables and hormonal based therapies dentistry. REFERENCES 1. Hammoudeh ZS, Small K, Unger JG, Stark R, Rohrich RJ., ‘Ear Lobule Rejuvenation in Face-Lifting: The Role of Fat Augmentation’, Plast Reconstr surgery Glob open [Internet]. Wolters Kluwer Health; 2016 Jan [cited 2016 Aug 22];4(1):e597. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/27104096> 2. Verma P, Sandhu HK, Verma KG, Goyal S, Sudan M, Ladgotra A., ‘Morphological Variations and Biometrics of Ear: An Aid to Personal Identification’, J Clin Diagn Res [Internet]. JCDR Research & Publications Private Limited; 2016 May [cited 2016 Aug 22];10(5):ZC138–42. Available from: <http://www.ncbi.nlm.nih. gov/pubmed/27437349> 3. Altmann F., ‘Malformations of the auricle and the external auditory meatus; a critical review’, AMA Arch Otolaryngol [Internet]. 1951 Aug [cited 2016 Aug 22];54(2):115–39. Available from: <http:// www.ncbi.nlm.nih.gov/pubmed/14856482> 4. Rubin LR, Bromberg BE, Walden RH, Adams A., ‘An anatomic approach to the obtrusive ear’, Plast Reconstr Surg Transplant Bull [Internet]. 1962 Apr [cited 2016 Aug 22];29:360–70. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/14494915> 5. Mowlavi A, Meldrum DG, Wilhelmi BJ, Zook EG., ‘Incidence of earlobe ptosis and pseudoptosis in patients seeking facial rejuvenation surgery and effects of aging’, Plast Reconstr Surg [Internet]. 2004 Feb [cited 2016 Aug 22];113(2):712-7. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/14758240> 6. Meijerman L, Sholl S, De Conti F, Giacon M, van der Lugt C, Drusini A, et al., ‘Exploratory study on classification and individualisation of earprints’, Forensic Sci Int [Internet]. 2004 Feb 10 [cited 2016 Aug 22];140(1):91-9. Available from: <http://www. ncbi.nlm.nih.gov/pubmed/15013170> 7. Dhanda V, Badhan J, Garg R., ‘Studies on the development of latent ear prints and their significance in personal identification’, Probl Forensic Sci. 2011;138:285-95. 8. Carruthers JDA, Glogau RG, Blitzer A., ‘Facial Aesthetics Consensus Group Faculty. Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies--consensus recommendations’, Plast Reconstr Surg [Internet]. 2008 May [cited 2016 Aug 22];121(5 Suppl):5S – 30S; quiz 31S – 36S. Available from: <http://www. ncbi.nlm.nih.gov/pubmed/18449026> 9. Matarasso SL, Carruthers JD, Jewell ML, ‘Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane)’, Plast Reconstr Surg [Internet]. 2006 Mar [cited 2016 Aug 22];117(3 Suppl):3S – 34S; discussion 35S – 43S. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/16531934> 10. Gassia V, Raspaldo H, Niforos F-R, Michaud T., ‘Global 3-dimensional approach to natural rejuvenation: recommendations for perioral, nose, and ear rejuvenation’, J Cosmet Dermatol [Internet]. 2013 Jun [cited 2016 Aug 22];12(2):123-36. Available from: <http://www.ncbi.nlm.nih.gov/ pubmed/23725306> 11. Zilinsky L, Cotofana S, Hammer N, Feja C, Ebel C, Stavrou D, Haik J, Farber N, Winkler E, Weissman O, ‘The arterial blood supply of the helical rim and the earlobe-based advancement flap (ELBAF): a new strategy for reconstructions of helical rim defects’, J plast reconstr aesthet surg, 68(1) (2015), pp.56-62.

Images show before and after earlobe rejuvenation with HA dermal filler

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Case Report: Managing a Mid-face Filler Complication

the manufacturers of the filler used were immediately contacted for further advice, as were members of the committee of the Aesthetics Complication Expert group to seek additional guidance on managing this case. The group comprises experienced aesthetic practitioners who have created complication management guidelines focussed on evidence-based medicine.

Dr Yusra Al-Mukhtar shares her experience of treating a mid-face infection caused by filler injection

Within two days of the patient seeing me, she started to develop a mild swelling on her left cheek, but this disappeared soon after, as did her swelling on the right side. I discussed with the patient the option of injecting the area with hyaluronidase, an enzyme known to break down hyaluronic acid, which would help to break down the product placed to allow full penetration of the antibiotics. The patient declined to do this for fear of losing the bulk of the treatment, and wanted to continue on her antibiotics to see if this would settle without dissolving the product. Indeed, the infection seemed to get better for the coming days, before suddenly returning. On October 18, two weeks after treatment, she developed a diffuse swelling around her right eye and zygoma, which would get better throughout the day and evening only to return by morning. She also started to develop symptoms of extreme pain on the right cheek and itchy skin. Unfortunately Patient A could not come to see me in clinic as she was away on a trip,

On October 3 2015 a 46-year-old female (Patient A) attended an advanced dermal filler course to have a treatment whereby a hyaluronic acid filler suitable for volume replacement was placed in the midface to create a lifting effect. Patient A was medically fit and well, not taking any medication at the time, was not immune compromised in any way and was a nonsmoker. She had a known allergy to penicillin. Patient A had received treatment using a number of different fillers to her nasolabial folds over the preceding eight years. Treatment During the treatment session, it was noted that Patient Aâ&#x20AC;&#x2122;s face was mildly asymmetric and so her left and right mid-face were treated using different volumes of product to correct the pre-existing asymmetry. The non-surgical prep included cleaning the face using 20% chlorhexidine as a surface disinfectant of the skin. An aseptic technique was used, and product was injected using sterile 27-gauge needles. There were three injectors, each qualified doctors, who attended the training course, which I led. The filler of choice was hyaluronic acid, designed to restore

Figure 1: 10 days after treatment

volume and create a lift in areas where marked flattening and volume loss had been noted. The hyaluronic acid filler of choice was deposited supraperiosteally, after aspirating, and a total volume of 0.1ml placed at the zygomaticotemporal suture site on the left and right cheek and 0.3ml on the left at the most anterior projection in the ogee curve of the face to accentuate the anterior projection of the zygoma, whilst 0.2ml was deposited on the right side of the cheek. A further 0.2ml was placed in the base of the nasojugal groove to lift the malar depression and support the tear trough, to improve continuity of the lidcheek junction. Patient A also had 0.1ml of product injected in the prejowl sulcus and 0.1ml to the angle of the mandible on both the left and right side. In addition, she had a total of 1ml of another hyaluronic acid, designed to be injected into the dermis, to her nasolabial folds and marionette lines using a retrograde linear technique in a maximum of 0.05ml per aliquat. Complication Six days post treatment Patient A contacted the team via our emergency email to let us know she had developed a swelling, which had appeared soon after her treatment as a bruise under her right eye, but had started to throb and the pain seemed to be getting worse. She had seen her GP who started her on 500mg of erythromycin four times a day, as she had a penicillin allergy.2 She attended my clinic on October 13, 10 days after her aesthetic procedure. On examination, she had mild swelling over her right zygoma below the infraorbital rim, 1cm in length and 2cm across, a localised swelling that was tender on deep palpation with mild erythema of the overlying skin. The swelling was not fluctuant and there was no pointing (Figure 1). Patient A was prescribed metronidazole and

Figure 2: Two weeks after treatment

Figures 2: Two weeks after treatment

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Figures 4 and 5: 19 days after treatment

so the majority of photographs following from this were taken by the patient and sent to me to review (Figures 2 and 3). By October 22, 19 days after her treatment, the photograph the patient sent showed definitive pointing on the swelling on the right cheek with associated erythema of the skin (Figures 4 and 5). Complication management Patient A was advised to immediately attend her local accident and emergency department for incision and drainage and the hospital was contacted to let them know of her arrival. Unfortunately, the plastic surgery team declined to see her on the basis that she had had private treatment so the NHS would not deal with the associated complication. She therefore had to travel further out to another hospital, where she was seen by the on-call GP who advised her it was beyond his remit to incise and drain the abscess that had formed on her face and to return to see the plastics team the following morning on October 23. By this point, the abscess was draining on its

Figure 6: Abscess being drained by plastics team

own, and was further drained by the team (Figure 6) who started her on clindamycin 500mg. She had also developed a diffuse swelling on the left side of her face, as well as infected raised nodules in the sub-malar region approximately 4cm across (Figure 7). She attended my clinic on her return from her trip on October 27, five days after being seen by the plastics team, with a dressing covering her still draining sinus tract on the right malar region. The swelling was drained further, cleaned and a new dressing applied. She was reviewed again on November 5, approximately a month after the dermal filler was injected. She had finished her antibiotics and advice had been received from the manufacturers as well as the head of the Aesthetics Complications Expert committee, Dr Martyn King, who also provided our team with an evidence-based, peer-reviewed protocol3 that had been developed for managing post dermal filler infections and infected nodules. According to the protocol, the first line measure would be to place the patient on antibiotics, either a macrolide (e.g. clarithromycin 500mg bd)

Figure 7: Infected raised nodules

or a tetracycline (e.g. doxycycline 100mg bd) for two weeks. After two weeks, if there has not been significant improvement then dual antibiotic therapy would be necessary (both a tetracycline and macrolide) and if after this the infection still did not subside, then to continue dual antibiotic therapy with a macrolide and tetracycline or a quinolone for a further two weeks. If the infection still persists, the protocol recommends that the product is then dissolved with hyalase. Due to the potential side effects of quinolones including antibioticassociated colitis and prolonging the QT interval,4 the Aesthetics Complications Expert group recommends that these drugs are used as third-line agents. Despite the fact that the swelling had subsided, the pus drained, and the infection seemed to have settled, a discussion took place with the patient regarding the option of placing hyaluronidase into the area injected with dermal filler to break it down, with the knowledge that this may be a case of biofilm, where the hyaluronic acid from the injected product forms a substrate for bacterial growth and allows the bacteria to form a protective mucous coat which resists the penetration of antibiotics.5 This would mean that although the infection appeared to have been treated, on cessation of antibiotics, there was a risk that the infection would recur. The patient was advised of this and understood the risk of declining hyaluronidase, but had decided that she did not want to have the product dissolved and would watch and wait. Complication treatment review By December 3, two months after initial treatment, and four weeks after the cessation of antibiotics, Patient A started to develop a recurrence of the swelling on the cheeks, and a decision was made to immediately start her on clarithromycin and ciprofloxacin for four weeks. She was treated in clinic on December 5 to dissolve the hyaluronic acid product using hyaluronidase. The hyaluronidase vial of 1500 units was dissolved using 10ml of bacteriostatic saline, and 1ml of this was injected into each cheek using a 30-gauge needle and 1ml sterile syringe under antibiotic cover (Figures 7, 8 and 9). She was reviewed again on December 15, and some residual areas of swelling were noted on the right and left cheek. Areas of induration were again treated using 0.5ml of hyalase. The patient completed an eight-week course of antibiotics, and the infection has not recurred.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Figures 7, 8 and 9: Two months after initial treatment Patient A developed a recurrence of the swelling on the cheeks

During the eight-week course of antibiotics, the patient did suffer from diarrhoea, general feelings of malaise, and an irregular heartbeat, which could have been due to the ciprofloxacin, known to cause an elevation in the ST interval4 and was investigated by her GP. These subsided after stopping the antibiotics.

worth noting that injectors seldom work in theatre conditions, injectors and patients alike usually wear outside shoes and clothing, and may take public transport to and from clinic. As such, we cannot entirely prevent a risk of inoculation. Nevertheless, the injector technique is important. An aseptic technique must be used when administering dermal fillers. The skin Outcome must be thoroughly cleansed of any debris Patient A is left with long-term scarring and and makeup, followed by disinfection with tethering of the skin (Figures 10 and 11) due at least 2% chlorhexidine and 70% alcohol.8 to contraction and fibrosis of the scar, which Hands must be washed before treatment, healed by secondary intention. She used sterile needles must be used, sterile gloves Dermatix in the initial post wound-healing should be worn and needles should not be period and was referred six months on to a touched with non-sterile gloves or wiped on plastic surgery department for subsicison and non-sterile gauze. scar revision, but the referral was rejected. It is also worth noting that hyaluronic acid The patient has now been accepted for syringes are single-use syringes, and any assessment by an NHS maxillofacial surgical unused remaining product in a syringe should team for treatment of this scar. never be shared between two patients, as it The patient was offered compensation for has the potential to spread infection even if a her troubles, which she refused, stating new needle is placed. In addition, remaining she specifically ‘remembered her skin was product should not be stored and used at a cleaned over and over again’ and that she later date for ‘top-up’, as an opened syringe ‘was told of the risk of infection, and made an is no longer deemed sterile and aspirated informed decision and that this occurrence blood proteins along with the now non-sterile was not anyone’s fault but one of the risks’ hyaluronic acid filler form a substrate for she had agreed to take on. potential bacterial growth and biofilm. It is highly unlikely that manufacturers or indemnity Reflection insurance would cover a complication, should This case brings to light several lessons. it arise as a result of such practice. Firstly, in the case of infections, though rare As an aesthetic trainer, diligence is important, and the risk said to be between 0.01-0.1%,7 as is a responsibility to emphasise crossit is most likely that inoculation occurs at the infection control protocols to delegates, point of injection, all measures should be and ensure compliance during injecting so taken to keep the working area sterile. It is that aseptic technique is maintained whilst injecting under supervision and training. It is vital that the pretreatment consent process is thorough and all risks, particularly rare but potentially disfiguring ones, are openly discussed and recorded so that a patient can make an informed decision Figures 10 and 11: Patient A is left with long-term scarring and tethering of the skin of whether or not to

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undergo treatment. When complications do arise, such as an infection, starting the patient promptly on the correct treatment will minimise harm and long-term complications. Prescribing the correct antibiotics and using hyaluronidase where deemed appropriate can reduce the risk of the spread of infection into deeper tissues, as well as reduce the risk of the patient developing permanent scarring. Lastly, though we fear the worst when adverse incidents occur post treatment, both for the patient but also for our reputation as aesthetic practitioners, we as clinicians must be open and honest with our patients about when we can treat or when we need to seek further help, putting our patients’ best interests first at all times. This patient has been left with long term and potentially permanent scarring, yet has not only refused compensation, but later sent flowers to show her appreciation for the care she was given in a distressing time. Whilst we cannot guarantee to our patients that a complication may not occur, we can guarantee that we will do our utmost to manage a complication if it does occur. Good quality care does not go unnoticed and shows your patients that you have integrity in all the work that you do, even if something has gone wrong, and often will result in a loyal, life-long patient. It is my hope that reporting this complication will help to promote best practice and will serve as a learning tool for other practitioners. Dr Yusra Al-Mukhtar is a dental surgeon with several years’ experience in head and neck surgery and facial aesthetics. She is a lead trainer for injectable courses with Oris Medical, based at the Royal College of General Practitioners. Dr Al-Mukhtar has worked as an advanced injector for Destination Skin and works in private clinics in London and Liverpool, performing a range of advanced facial aesthetic procedures. REFERENCES 1. Larry Wu, 8 point lift with Juvederm (US: YouTube, 2013) <https:// www.youtube.com/watch?v=k2E36iE5Tjw> 2. British National Formulary, Indications (UK: NICE, 2016) https:// www.evidence.nhs.uk/formulary/bnf/current/5-infections/51antibacterial-drugs/515-macrolides/erythromycin 3. Aesthetic Complications Expert Group, ‘Management of Delayed Onset Nodules (DONs)’, Reference available upon request. 4. British National Formulary, Quinolones (UK: NICE, 2016) https:// www.evidence.nhs.uk/formulary/bnf/current/5-infections/51antibacterial-drugs/5112-quinolones 5. Alhede M et al, ‘Bacterial biofilm formation and treatment in soft tissue fillers’, Pathogens and Disease, 70 (2014), pp.339-46. <http://www.ncbi.nlm.nih.gov/pubmed/24482426> 6. Drugs.com, Ciprofloxacin (US: Drugs.com, 2016) http://www. drugs.com/ciprofloxacin.html 7. Gloster H, ‘Complications in Cutaneous Surgery’, Springer, (2008), p.202. 8. Dr Martyn King, Emma Davies RN NIP, ‘Management of acute skin infections’, Aesthetic Complications Expert Group, Reference available upon request.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Spotlight On: Profhilo Aesthetics investigates the efficacy of IBSA Pharmaceutical’s (Farmaceutici Italia) new hyaluronic acid injectable that aims to treat skin laxity without the use of BDDE

Aesthetics Journal

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Complications As with any injectable treatment there are minor risks, including bruising and swelling, as well as infection, allergic reaction, vascular compromise and nerve damage; although IBSA claims these are rare. Both the company and practitioners who have experience using Profhilo claim there is no real downtime, due to minimal injection points. “From a safety perspective, Profhilo is highly biocompatible, owing to the fact that it is made from natural hyaluronic acid and stabilised without the addition of chemical cross-linking agents,” says Dr Ravichandran, adding, “But it’s still important as an aesthetic injector to have the protocols to deal with any complications in case they occur.”

What is Profhilo?

In vitro study5

“Profhilo is not a mesotherapy product, neither is it a dermal filler,” says aesthetic dental practitioner Dr Emma Ravichandran, who was one of the first practitioners in the UK to use the product, having incorporated it into her clinic in February 2016. “Profhilo is a stabilised hyaluronic acid (HA) but without any chemical crosslinking agents – the first injectable of its kind,” she explains. Profhilo, distributed by HA Derma, is indicated for the treatment of skin laxity and is free of 1,4-butanediol diglycidyl ether (BDDE) – a viscous liquid, hygroscopic in nature, which links the HA chains to prevent them being broken down by the body.1 Although crosslinking chemicals, such as BDDE, in small doses in dermal filler has been indicated to be safe,2 the BDDE-free concept could be appealing to consumers who are wary of synthetic chemicals being used in products.3

A study published in BMC Cell Biology in 2015 researched the effects of H-HA and L-HA chains of diverse length and a H-HA/L-HA hybrid (0.1 and 1% weight/volume), against a control on skin regeneration. Time-lapse video microscopy in vitro studies indicated that the diverse length HA was capable of restoring the monolayer integrity of HaCat (aneuploid immortal keratinocyte cell line from adult human skin). The hybrid had a faster regeneration rate than the diverse lengths, and, in co-culture scratch tests, wound closure was achieved in half the time of H-HA stimulated cells and 2.5-fold faster than the control. Additionally, type I collagen expression and production were evaluated. Compared to H-HA, L-HA and the control, persistence of a significantly higher expression level at 24 hour for the H-HA/L-HA hybrid was found. The research indicated that, both at high and low concentrations, hybrid complexes performed better than HA alone, thus suggesting their potential as medical devices in aesthetic and regenerative medicine.

The science behind the product According to IBSA, the HA is stabilised by a patented thermal process whereby the natural bonds found in high molecular weight (H-HA) break, and new hydrogen bonds are formed between the H-HA and low molecular weight (L-HA). This allows for 32mg of L-HA (80 – 100 kDa) to be combined with 32mg of H-HA (1100 – 1400 kDa), to form stable hybrid complexes (64mg in 2ml). In practice, the L-HA aims to hydrate and stimulate skin, while the H-HA acts as a dermal scaffold in the skin.4

Results Dr Ravichandran says, “After four weeks, my patients have experienced improvement in lines and tightness of their skin. After eight weeks there is a definite lifting and tightening of the skin – it

In practice Dr Ravichandran says, “Anyone who presents with signs of skin ageing and is suitable for dermal filler treatment is also suitable for treatment with Profhilo.” Usual contraindications include patients with bleeding disorders, immune-compromised patients and those with unrealistic expectations. “The most commonly treated area to date is the submalar and malar area. I use a 25G 1.5 inch cannula subdermally to minimise the risk of bruising or vascular compromise, and also to maximise spread of the product. As a guide, I will use 1ml of the product to cover an area of the skin equal to the area of the patient’s hand. Once injected, the product immediately starts spreading due to the high concentration of HA and its cohesive nature.” For use when treating the submalar area, IBSA has developed a protocol called the BAP (Bio Aesthetic Point) Technique, which involves five bolus injections of 0.2ml on each side of the face using a 29G needle (Figure 1). “The injection sites were identified using a selection criteria which aims to minimise risks to blood vessels and nerves and maximise efficacy through diffusion,” explains Dr Ravichandran. “This is an extremely effective and simple technique to use for injectors who are not comfortable with the use of cannulas.” Two treatments are recommended four weeks apart, with a follow-up appointment at week eight, to be repeated twice a year for optimal results.

1 2

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

Figure 1: BAP technique

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Before

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After four weeks

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After eight weeks

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firmness, elasticity and an overall improved quality of skin, with the effects lasting up to six months.”

Conclusion

Before

After four weeks

After eight weeks

Before

After four weeks

After eight weeks

Figure 2: A female patient before and after treatment of the submalar region using Profhilo. Images courtesy of Dr Emma Ravichandran.

is more hydrated and appears more youthful and in better health.” Some of her patients have reported an immediate improvement after treatment. She continues, “I have now completed 20 patients’ preliminary two-step treatments and am delighted with the results I have achieved (Figure 2). Overall, patients can expect increased

Dr Ravichandran concludes, “Profhilo does not create the volumetric lift or volume replacement associated with cross-linked dermal fillers, however, it creates volume in the tissue where it is needed due to its high spreadability. Owing to this characteristic, it is an ideal treatment for challenging areas as well, such as the neck, perioral area, and hands and arms, where we do not see the significant volume loss, but skin has lost elasticity. I often see patients with artificially enhanced cheeks, which is a result of overfilling because the wrinkle ‘just doesn’t go away’. But, in my experience, Profhilo has been very effective in correcting this concern.” REFERENCES 1. Derek Jones, Injectable Fillers, Enhanced Edition: Principles and Practice, (2010) Wiley-Blackwell. 2. Koenraad De Boulle, A review of the metabolism of 1,4-butanedio diglycidyl ether – crosslinked hyaluronic acid dermal fillers, (2013) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4264939/> 3. Lisette Hilton, CosmeticSurgeryTimes, Future fillers: Profhilo & Belotero Volume, (2016) <http:// cosmeticsurgerytimes.modernmedicine.com/cosmetic-surgery-times/news/future-fillers-prohilobeletaro-volume> 4. IBSA Derma, A New Discovery, (2016) <http://www.ibsaderma.com.ua/en/pdf/Brochure_medico_ Profhilo_en.pdf> 5. Antonella D’Agostino, BioMed Central, In vitro analysis of the effects on wound healing of high- and low-molecular weight chains of hyaluronan and their hybrid H-HA/L-HA complexes (2015) <http:// bmccellbiol.biomedcentral.com/articles/10.1186/s12860-015-0064-6>

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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should improve over time.1 Spiral 3D barbed cogs, which are similar to a surgical sutures but have been modified to have barbs spiralling around the thread in order to anchor the tissue, give an immediate mechanical lift to the breast. The lift will continue to take place via fibrosis and tissue contraction over the next three to four months, offering the patient an immediate result as well as a delayed lift.1 When inserted into the skin, the threads act as a ‘scaffold’ that helps to ‘hold’ the skin against the effects of gravity. The threads are absorbable and from our experience, the body will reabsorb them in about six months, leaving nothing behind but the collagen structure created, which will continue to hold the breast for another 18-24 months. From our clinical experience, treatment can be repeated after two years as long as no contraindications are present.

PDO threads. A thorough medical history should be taken and a full examination of the breasts needs to be conducted to assess suitability. The breast examination is paramount to check for any lumps, skin changes, tethering of the breast tissue or any underlying pathology. If any pathology is found these patients need onward referral and are unsuitable for treatment. Ideally all patients should have a mammogram prior to the procedure, however in practice this may be difficult. Be mindful of patients who appear to be suffering from body dysmorphia or have unrealistic expectations. These patients frequently demand results that a non-surgical procedure like PDO threads cannot achieve. Common sense must also prevail; smaller breasts (A-C cups) will produce better results purely because of the weight of the tissues. Patients with larger, pendulous breasts are more suitable to surgical procedures. It is vital that the limitations of what can be achieved are fully explained to the patient prior to the procedure. Ptosis is a sagging condition where the breast both falls on the chest, and the nipple points downward. In practice we use a common grading system to categorise the degree of breast sagging, or ptosis, (Figure 1). If the nipple falls below the infra-mammary fold, the outcomes will not be as good as those whose nipples lie above the fold. As shown in Figure 1, good results can be achieved with up to Grade II ptosis.

Patient selection As with all aesthetic procedures, patient selection is key. It is important, prior to any treatment, that certain criteria are assessed to determine the patient’s suitability for

Breast anatomy Understanding the anatomy of the breast is critical, not only to reduce complications but also to understand the mechanism of the lift (Figure 2).

Grade 2 Moderate Ptosis: Nipples have dropped below the level of the breast crease, but still higher than the majority of the breast mound.

Pseudoptosis: Lower breast sagging

Lifting the Breast with PDO Threads Dr Victoria Manning and Dr Charlotte Woodward discuss the use of PDO threads for breast lifting and provide their best practice guidance Over the past few years polydioxanone (PDO) threadlifting has become one of the latest evidence-based aesthetic trends for facial skin tightening, lifting and rejuvenation. As well as facial ageing, breasts also age, which can be an aesthetic concern for some women. They may choose PDO thread treatment because it is a less invasive way to address breast sagging than surgery and PDO thread breast lifting has been indicated as effective and safe with less pain and minimal downtime than surgical interventions.1 Although, this technique is not suitable for all patients. In this article we shall explore an innovative new use for PDO threads to lift the breasts, discussing the anatomy, techniques used and possible complications. PDO thread components The threads are made of PDO, which is most commonly used for surgical stitches. PDO threads are used over other types of threads because they are strong and the most cost effective for this procedure. PDO continuously stimulates collagen synthesis under the skin, which means the results

Normal

Grade 1 Minor Ptosis: Nipple is at the level of the inframammary fold

Grade 3 Advanced Ptosis: Nipples have dropped below the level of the inframammary fold, and just at the level of maximum breast projection.

Figure 1: Degrees of breast ptosis

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Figure 2: Anatomical structure of the female breast

The breast is an organ and its structure reflects its primary function: the production of milk for lactation. The epithelial component of the tissue consists of lobules, where milk is made, which connect to ducts that lead out to the nipple. These lobules and ducts are

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glandular mass and in a relatively avascular plane.3 The deeper fascia is thicker and covers the deep aspect of the breastplate. Fibrous processes of this fascia extend up to the skin and to the nipple. They are more developed over the upper part of the breast, where they form suspensory ligaments of Cooper.3 It is the contraction of the ligaments of Cooper that will give the lift. The supporting ligaments of Cooper maintain the tone and shape of the breasts and when healthy, keep the breasts firm and tight on the body.3 The blood supply to the breast comes primarily from the internal mammary artery,

the breast flow in the opposite direction of the blood supply and drain into lymph nodes. Most lymphatic vessels flow to the axillary lymph nodes, while a smaller number of lymphatic vessels flow to internal mammary lymph nodes located deep to the breast.5 The nerve supply to the breast is from the fourth, fifth and sixth intercostal nerves via the anterior and lateral cutaneous branches.5 The procedure The technique for thread insertion is relatively straightforward, provided the practitioner is fully competent in facial PDOs, breast anatomy and in taking a full breast and obstetric history, in addition to making a full breast examination. The procedure does involve mild discomfort, some bleeding and post-procedural bruising for up to 10 days after; further side effects are discussed in more detail below. The initial consultation is carried out discussing risks, benefits and alternatives to the procedure. A two-week cooling-off period is then given, respecting the latest GMC guidance.6 When the patient returns, detailed measurements are taken, as indicated in Figure 3. This allows the practitioner to fully assess the amount of lift achieved at followup consultations. The distance between the sternal notch and the nipple must be measured, which is usually eight to nine inches. This distance should reduce after the threadlift. A pinch test of the upper breast must also be conducted with callipers to measure thickness of tissue â&#x20AC;&#x201C; this thickness should increase after the threadlift due to collagen stimulation. Photographs are also taken, as with any aesthetic procedure, and the position of the threads marked on the breast for future consults. Pre-operative and post-operative photographs are taken, not only to show the patient what has been achieved following treatment, but also to point out any asymmetry that may have been initially present. This can be corrected by varying the lift in each breast.

It is the contraction of the ligaments of Cooper that will give the lift. The supporting ligaments of Cooper maintain the tone and shape of the breasts and when healthy, keep the breasts firm and tight on the body located throughout the background fibrous and adipose tissue that make up the main mass of the breast.2,3,4 Anatomically, the adult breast sits above the pectoralis muscle, overlying the ribcage. The breast tissue extends horizontally from the edge of the sternum out to the mid-axillary line. A thin layer of connective tissue, or fascia, encircles the breast tissue. The deep layer of this fascia sits immediately on top of the pectoralis muscle, and the superficial layer sits just under the skin. The fascial relationships of the breast are of practical importance; the gland lies in a pocket of superficial fascia, in both deep and superficial layers. The superficial layer lies immediately beneath the dermis and enables injections and implantations of threads, avoiding the

which is a branch of the subclavian artery that runs underneath the main breast tissue. The internal mammary artery sends branches along the first, second, third and fourth intercostal spaces, over the pectoralis major and supplying the inner half of the breast, including the nipple.5 Venous drainage of the breast is divided into two systems: superficial and deep. The superficial veins run along the anterior surface of the fascia, following the path of the areola under the nipple.5 The lymphatic vessels of

Sternal notch to nipple A-B

A B

Sternal notch to nipple A-C

Nipple to nipple B-C D F

E G

Diameter of breast D-E Circumference of chest F-G

Figure 3: Necessary breast measurements

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Benefits of PDO breast lift for the patient1 • • • • • •

I nstant and long lasting results for up to two years The procedure stimulates collagen production, improving tissue elasticity Stimulates formation of new blood vessels which improves oxygen supply to skin Reduces pore size due to new tissue formulation Stimulates fibroblasts improving skin texture and tone A quick and relatively easy procedure, with minimal downtime and discomfort

After appropriate sterilisation – concentrating around the nipple due to sebaceous (Montgomery) glands on the areola, which can be a source of infection7 – the breasts are taped together and the patient is treated lying down. Depending on the degree of tissue laxity, the amount of threads will vary, however, a standard breast would take 20-25 90mm cogs inserted with a 21G blunt cannula. Each entry point is anaesthetised with local anaesthetic. The correct tissue plane for the insertion of PDO threads is within the Figure 4: Photo ligaments of Cooper, demonstrating not into the deeper correct thread breast tissue. It is placement important to note that if the threads are placed too superficially in the dermal plane then they could be felt and may even be visible in the skin, while if they are placed deeper the threads can affect the breast tissue and potentially damage the ducts. Also, if placed too deeply, they will not achieve the correct degree of lifting of the tissues or stimulate collagen production. We use the technique that was originally developed by aesthetic practitioner Dr Jacques Otto, to ensure the PDO threads are correctly placed. The PDO thread is inserted into a 1ml syringe that can twist to lock for security, which has been prefilled with local anaesthetic. In practice we find mepivacaine hydrochloride 3% without adrenaline useful because, from our experience, it works quickly. The benefit of this technique is that at any time during the thread placement, you can deliver a small amount of anaesthetic when it is needed. This is important as the breast tissue is much more fibrous than the face so much more pressure is required to insert the threads. An entry point is made and the cannula is inserted into the opening, and two threads are placed per opening. Five entry points are made above and around the nipple in

an arc for the inferior threads, then a further five entry points above pointing down to the nipple. A further five to 10 threads are inserted as anchors from just below the clavicle pointed inferiorly. The cannula is advanced to its end-point. Be aware that this can be quite tender around the nipple region. Once the thread is placed, a 360-degree rotation of the syringe is made to anchor the thread; the free hand is used to ‘massage’ the cannula off the tissues leaving the PDO thread in place. The technique is repeated as required for the placement of other threads. Minimal compression is applied to the threads, unlike when treating the face. After the treatment, the first effects are visible instantly, but considerable improvement appears after two to three months, when induction of new collagen begins.1 Post-treatment recommendations After the procedure the breasts are taped vertically with the tape finishing on the shoulders. The patient is advised to leave this tape in place for the next 48-72 hours to support the breasts. They are also advised to wear a supportive bra, such as a sport’s bra, after the procedure for the next two weeks and a soft bra at night for two weeks. Adverse effects Post-procedural bruising and discomfort are common side effects. In our experience, due to having up to 25 threads per side, sometimes if threads are placed too superficially they may need hydrodissection to lift the skin from them to avoid puckering. This can be achieved by using a 21G needle and local anaesthetic around the thread to infiltrate and lift the skin above the thread. Barbed thread protrusion is possible if the threads are not cut shortly enough at the entry point.

breastfeeding, anticoagulation therapy, body dysmorphic disorder, existing infection, history of keloid formation and patients with unrealistic expectations are all contraindications for treatment, as well as breast implants and previous breast carcinoma.1 Conclusion Breast lifting with PDO threads is a procedure that requires considerable expertise, knowledge and training. In our experience, PDO threads offer a safe and effective method of achieving tissue lifting in the breasts of patients with a grade 1-2 breast ptosis. They should be placed in the correct tissue plane, within the ligaments of Cooper. Due to the number of threads used, the procedure is not cheap, so patient selection is key in order to obtain satisfactory results and happy patients. However, for the right patient this procedure offers a breast lift without many of the complications and risks associated with surgery and general anaesthetic. Dr Victoria Manning is an aesthetic practitioner and GP, with more than 20 years’ clinical experience. She is the co-founder of River Aesthetics in New Forest and Harley Street, which specialises in threadlifting. She is a national threads trainer and is also an aesthetics industry media contributor, writer and speaker. Dr Charlotte Woodward is an aesthetic practitioner and GP with more than 25 years’ experience. She is the co-founder of River Aesthetics in New Forest and Harley Street, which specialises in threadlifting and feminine rejuvenation. She was one of the first in the UK to offer non-surgical breast lifting using PDO threads and is a national trainer. REFERENCES 1. Suh DH, Jang HW, Lee SJ & Lee WS, ‘Outcomes of polydioxanone knotless thread lifting for facial rejuvenation’, Dermatological Surgery, 6(2015). 2. Bannister LH, Berry MM, Collins P, et al., Gray’s Anatomy, 38th ed, (New York: Churchill Livingstone, 1995), pp.417-24. 3. Tobon H, Salazar H, ‘Ultrastructure of the human mammary gland. II. Postpartum lactogenesis.’ J Clin Endocrinol Metab, 40(1975), pp.834-44. 4. Vorherr H, ‘The Breast: morphology, physiology and lactation’, (London, UK: Academic Press, 1974). 5. Seitz IA, Nixon AT, Friedewald SM, et al., ‘“NACsomes”: A new classification system of the blood supply to the nipple areola complex (NAC) based on diagnostic breast MRI exams’, J Plast Reconstr Aesthet Surg, 68(2015), pp.792-9. 6. GMC, ‘Guidance for all doctors who offer cosmetic interventions’, (2016), <http://www.gmc-uk.org/guidance/news_ consultation/27171.asp 7. Nicholson BT, Harvey JA & Cohen MA, ‘Nipple-Areolar Complex: Normal Anatomy and Benign and Malignant Processes’, Radiographics, 23(2009) pp.502-203.

Contraindications Autoimmune diseases, hepatitis B and C, HIV infection, pregnancy and

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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follow-up appointment to discuss any potential concerns. Here the practitioner can address any under-correction, by injecting more into the desired area, or manage overcorrection by injecting the contralateral muscles to oppose the overcorrection. We are all aware of the ‘Spock effect’ with the lateral aspect of the eyebrow being raised too high, leading to the infamous look of Mr Spock from the fictional TV show Star Trek. To correct this, a small amount of BoNT-A can be inserted above the eyebrow in the frontalis elevator muscles, should the patient so desire, to allow the muscle to settle.

An introduction to Managing Botulinum Toxin Complications Dr Ahsan Ullah provides an overview of the possible complications and side effects that can arise when injecting botulinum neurotoxin A and advises the potential management strategies Introduction As with all treatments, there are risks, complications and side effects involved, and, for botulinum neurotoxin A (BoNT-A) injections, there are no exceptions. This article will describe some of the main complications associated with administering BoNT-A injections, categorise them into subjective and short-term complications, and provide an evidencebased protocol for safe and successful management.

Subjective complications of BoNT-A and its management options Undesired aesthetic result Complication: This often can’t be measured as it varies between patients, whose treatments simply may not meet their expectations. However, there is a chance you may have overcorrected or undercorrected the patient’s rhytides. Management: Firstly, it is vital that, during the consultation, practitioners have a full discussion with the patient about their expectations and desired results. It is encouraged that a validated wrinkle scale of resting and dynamic states, such as the Glogau scale, is used to help provide objective recorded evidence. Be honest with the patient and ensure that they are fully aware of what the results are likely to be and do not provide any misleading information. Practitioners must also ensure that they properly assess the patient and their concerns and, once the treatment has been decided, go through an adequate consent process with them. After injecting, practitioners should encourage all patients to attend a two-week

Asymmetric result Complication: For BoNT-A treatments, the main asymmetry is commonly noted in the brow area. Beauty is often described as a symmetry of features, so when one eyebrow is higher than the other the symmetry is disturbed. This can occur when the frontalis muscle is stronger than the other muscle, or if insufficient toxin has been injected. Management: Asymmetry simply requires a follow-up appointment and the area of concern can be injected to either lower the muscle, or alternatively correct the asymmetry by injecting the contralateral muscles. For example, as mentioned earlier, if the brow is raised too high then the frontalis elevator muscle can be injected to drop the elevated eyebrow.

Short-term complications and side effects of BoNT-A and its management options Ecchymosis, swelling, temporary pain, hypoesthesia and headaches Side effect: Ecchymosis or bruising often occurs as a result of injuring a blood vessel at the site of the injection and most commonly occurs around the ocular area.1 Patients might feel temporary pain or discomfort,2 which is associated with the needle puncturing the skin. Pain that is higher than normal is often associated with the practitioner using the incorrect needle size – usually recommended to be 30 gauge.3 Headaches and hypoesthesia are common side effects, which usually last for around 24-48 hours after having BoNT-A treatment.1,4 Management: Even with the best of techniques, experienced injectors can sometimes perforate a blood vessel resulting in a bruise. Managing this with simple tamponade at the time of the bleed, which usually takes between a few seconds to a minute, can decrease the size of the bruise formed or even prevent it from appearing. Preventative methods for bruising include applying ice to the site prior to the injection causing vasoconstrictive effects,1 and also ensuring that the patient is not taking any blood-thinning medications such as warfarin or aspirin, and doesn’t have any underlying clotting problems.1 To minimise pain associated with the injection, topical anaesthetic creams can be used. Technique is also a major factor here, and practitioners need to ensure they have had adequate training, that align with Health Education England guidelines5 to ensure they are comfortable and able to perform BoNT-A injections. To minimise pain, suggested techniques include having the needle bevel up and injecting slowly.6 Headaches are a common short-term side effect as the toxin initially causes muscle spasm and then complete paralysis.7 On occasions, over-the-counter analgesics may help. Allergic reaction Complication: Skin reactions and erythema can occur at any injection site, however sometimes, although rarely, it can be associated with an allergic reaction and, even rarer, an anaphylactic reaction – the signs

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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of which can be immediate reddening of the face, lip swelling and difficulty breathing.8 Management: Erythema should settle within 24 hours; if it lasts any longer then an antihistamine can help. If it is an anaphylactic reaction then this is a medical emergency. In such circumstances, if the practitioner is trained in dealing with anaphylactic reactions, which most UK practitioners are, they should start treatment through an adrenalin injection, however an ambulance should immediately be called before continually monitoring the patient in case of airway compromise.8 It is the practitioner’s responsibility to keep emergency medication on site, although this is not a legal requirement. Practitioners should only prescribe and administer BoNT-A if they are appropriately trained in how to deal with these types of emergencies. To help to prevent allergic reactions, a thorough medical history should be taken to rule out previous allergic reactions to other brands of BoNT-A, and practitioners should be extra cautious in treating someone with multiple allergies as they may have a higher risk of being allergic to BoNT-A. Ptosis and diplopia Complication/side effect: Brow and lid ptosis occurs when incorrect placement or displacement of the toxin occurs too close to the lateral brow resulting in the weakening of the lateral frontalis and localised spread to the levator palpebrae superioris.9 Similarly ptosis of the upper or lower lip can occur if injected too closely to the vermillion border. Diplopia (double vision) is also a risk that can occur.10 Management: Brow and lid ptosis are best avoided by employing a good technique. Brow ptosis is often caused by the treatment of the frontalis muscle in patients with existing brow ptosis, but avoiding the outer brow area when injecting toxins can minimise the risk for those who do not already have it. For lips, avoid the vermillion border when injecting, however if this has already occurred it can be best to wait for the toxin effect to gradually wear off. In such cases, one should act with caution and I recommend that small doses, such as 1-2 units, are given to prevent localised spread and extreme changes in the muscles elevator/depressor functions. Prevention is better than having to treat a complication so I recommend that patients are given smaller doses and called back for a two-week follow-up, where additional amounts can be administered if necessary. If the patient requires immediate improvement, then they should be referred to a local ophthalmologist for further assessment and review. Once the patient has been referred an alpha agonist eye drop may be advised, which causes contraction of the adrenergic muscles and results in a 1-2mm elevation of the lash margin, which can make the ptosis appear more symmetrical. However this symptomatic treatment should be continued daily until resolution of the ptosis.3 If diplopia occurs, then the patient should be referred to the local ophthalmologist for review, as it is likely that one of the intraocular muscles has been injected. An ophthalmologist who has experience in BoNT-A injecting and is skilled in intraoccular muscle surgery would best manage this. I would recommend that practitioners are aware of the ophthalmologists in their area who have these skills and knowledge. The ophthalmologist may be able to inject the antagonistic intraocular muscle to allow correction of the diplopia.10 Spread of toxin from site of injection Complication: Spread of the toxin from the injection site can lead to many complications depending upon the area from where it has spread. Around the eye, for example, complications such as ptosis, lid ectropion, strabismus, lagophthalmos or brow raise can occur.11,12 Incorrect injections on the elevators around the lips can result in

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depression of the vermillion borders of the lips. Management: Injecting the correct recommended doses of toxins as per the manufacturer’s guidance, and having good anatomical knowledge of the injection area can prevent these complications. I recommend that minimal amounts are injected as required and smaller units spread out rather than large bolus injections, which can result in more uncontrolled spread. If these complications arise, you should refer the patient to a local ophthalmologist, who may advise alpha agonist drops. Infection Complication: An area of infection can develop at any injection site if the area is not adequately prepared. Management: To prevent infection, ensure that the injection site is cleaned with an antiseptic solution with all makeup residue removed. To avoid contamination, an aseptic technique should be employed. After the treatment, to prevent infection, the patient should be instructed not to touch the area until it has healed nor apply makeup for at least six hours to allow the open injection sites to close. To manage infections, a course of antibiotics and close monitoring of the area is essential to ensure that an abscess does not form, which could potentially result in a scar.

Summary All toxins are associated with immediate and short-term complications, such as swelling, redness and bruising. It is vital that the practitioner makes the patient aware of these complications prior to treatment and accepts that there is a chance that these can occur, but, when appropriate, assures patients that they often settle spontaneously. Although there has been, and probably will continue to be, stories in the media about BoNT-A complications, with a constructive and active management plan, supported with appropriate experience, practitioners can manage and prevent most of these complications. Dr Ahsan Ullah is medical director of My Skin Clinic and My Skin Clinic Training Academy. With vast experience in the NHS and the private sector, he runs clinics in Harley Street and across London, treating celebrities and international patients. He has recently launched his training academy, training others in the field of medical aesthetics. REFERENCES 1. Christine M Cheng, ‘Cosmetic use of botulinum toxin type A in the elderly,’ Clin Interv Aging, (2007), <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684082/> 2. Highlights of Prescribing Information, Allergan, (2016) <http://www.allergan.com/assets/pdf/botox_ cosmetic_pi.pdf> 3. Cox, SA & Adigun CG, ‘Complications of injectable fillers and neurotoxins,’ Dermatologic Therapy, 24(2012), pp. 524–36. 4. Wilson, F, Botulinum toxin-A risks overcome by proper technique, Cosmetic Surg Times, 12(2001). = 4 not found in text 5. Health Education England, ‘PART TWO: Report on implementation of qualification requirements for cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery’ (2016) <https://www.hee.nhs.uk/sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20 two%20update%20v1%20final%20version.pdf> 6. Candiotti K, Rodriguez Y, Koyyalamudi P, Curia L, Arheart KL, Birnbach DJ, ‘The effect of needle bevel position on pain for subcutaneous lidocaine injection,’ J Perianesth Nurs, 24(2009), <http://www.ncbi. nlm.nih.gov/pubmed/19647661> 7. Burns, RL, Complications of botulinum exotoxin, 25th Annual Clinical and Scientific Meeting of the ASDS; Portland, (May 1998). 8. Resuscitation Council (UK), Emergency treatment of anaphylactic reactions: Guidelines for healthcare providers, London, (reviewed 2016). 9. Klein, AW, Contraindications and Complications With the Use of Botulinum Toxin, Clin Dermatol, (2004). 10. Isaac, C., Chalita and Pinto, L. (2012) ‘Botox® after Botox® - a new approach to treat diplopia secondary to cosmetic botulinic toxin use: Case reports’, Arquivos brasileiros de oftalmologia., 75(3), pp. 213–4. 11. Wollina U, Konrad H, ‘Managing Adverse Events Associated with Botulinum Toxin Type A’, American Journal of Clinical Dermatology 6(2005) pp. 141-150. 12. Kaynak-Hekimhan P, ‘Noncosmetic Periocular Therapeutic Applications of Botulinum Toxin’, Middle East Afr J Ophthalmol, 17(2010) pp.13-120.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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A summary of the latest clinical studies Title: Evaluation of a novel device, high-intensity focused ultrasound with a contact cooling for subcutaneous fat reduction Authors: Lee HJ, Lee MH, Lee SG, Yeo UC, Chang SE Published: Lasers in Surgery and Medicine, August 2016 Keywords: Fat reduction, HIFU, cooling system Abstract: The aim of this study was to investigate the effects of a novel HIFU device for fat destruction with a contact cooling system compared to HIFU without contact cooling. A group of three pigs were administered a series of four HIFU treatments with or without contact cooling over a period of 12 weeks. Energy fluence parameters ranged from 60 to 300 J/cm2. Immediately after the treatment and at 1, 4, and 12 weeks, the tissue was studied by hematoxylin and eosin (H&E), Masson-trichrome, toluidine blue, CD68 staining, and transmission electron microscopy. Three human volunteers also received treatment with this HIFU device with cooling and were evaluated subjectively and objectively by computed tomography (CT). HIFU treatment with a contact cooling decreased the skin surface temperature and prevented epidermal damage. Ecchymosis was observed on the non-cooled area immediately after HIFU treatment, but not on the cooled area. Histological analyses on both areas (cooled and non-cooled) revealed disrupted adipocytes in the treatment area immediately, at 1 and 4 weeks following treatment. Lipophagic histiocytic fat necrosis was evident at 4 weeks. Finally, at 12 weeks all inflammation subsided, and the lobules were markedly atrophied with reduced SAT thickness. The human volunteers experienced a few centimeter-range reduction in waist circumference after 4 weeks. HIFU treatment with a cooling system efficiently destroyed adipocytes.

Title: Subdermal Radiofrequency for Skin Tightening of the Posterior Upper Arms Authors: Wu DC1, Liolios A, Mahoney L, Guiha I, Goldman MP Published: Dermatologic Surgery, September 2016 Keywords: radiofrequency, skin tightening, upper arms Abstract: The purpose of this study is to evaluate the safety and efficacy of subsurface thermistor-controlled monopolar radiofrequency (SMRF) for tightening of posterior upper arm skin laxity. This is a prospective, open-label clinical trial involving 12 subjects aged 18 to 65 with moderate-to-severe skin laxity in the posterior upper arms. Each subject received treatment to the bilateral arms resulting in a population of n = 24 arms in the analysis group. Treatment consisted of SMRF delivered at Day 0 of the trial. Follow-up evaluation was conducted at Day 7, 30, and 90 post-treatment. The primary end point was the assessment of skin laxity by a nontreating physician utilizing a standardized 5 point Skin Laxity Grading Scale at baseline, Days 30 and 90. Subject self-evaluation of firmness, laxity, texture, and satisfaction was also collected. Circumferential and vertical arm measurements were obtained via digital fractional caliper. Significant improvements in skin laxity were observed at both Day 30 and at Day 90 post-treatment as assessed by the nontreating investigator. Subjects also rated significant improvements in the firmness, texture, and laxity of their treated arms. The majority of subjects were “satisfied” to “extremely satisfied” with their results. Adverse events recorded at Day 7 post-treatment included erythema (4%), contour irregularity (4%), and bruising (13%). Thermistor-controlled SMRF is a safe and effective means to treating posterior upper arm skin laxity.

Title: Penile Girth Enhancement With PolymethylmethacrylateBased Soft Tissue Fillers Authors: Casavantes L, Lemperle G, Morales P. Published: Journal of Sexual Medicine, September 2016 Keywords: penile, augmentation, PMMA, dermal fillers Abstract: The aim of this study is to report on a safe and permanently effective method to enhance penile girth and length with an approved dermal filler. Since 2007, the senior author has performed penile augmentation in 752 men mainly with Metacrill, a suspension of polymethylmethacrylate (PMMA) microspheres in carboxymethyl-cellulose. The overall satisfaction rate, using questionnaire, was 8.7 on a scale of 1 to 10. After one to three injection sessions, average girth increased by 3.5 cm, or 134% (10.2 to 13.7 cm = 134.31%). Penile length also increased by weight and stretching force of the implant from an average of 9.8 to 10.5 cm. Approximately half the patients perceived some irregularities of the implant, which caused no problems. Complications occurred in 0.4%, when PMMA nodules had to be surgically removed in three of the 24% of patients who had a non-circumcised penis. After 5 years of development, penile augmentation with PMMA microspheres appears to be a natural, safe, and permanently effective method. The only complication of nodule formation and other irregularities can be overcome by an improved injection technique and better postimplantation care.

Title: Picosecond laser with specialized optic for facial rejuvenation using a compressed treatment interval Authors: Khetarpal S, Desai S, Kruter L, Prather H, Petrell K, Depina J, Arndt K, Dover JS Published: Lasers in Surgery and Medicine, August 2016 Keywords: facial rejuvenation, picosecond, pigmentation Abstract: This study reports the safety and efficacy using a 755 nm picosecond laser with a focus lens array for facial wrinkles and pigmentation. Shorter intervals of 2-3 weeks between treatments were used. Nineteen female subjects and one male, primarily Fitzpatrick skin types II and III, who had mild to moderate wrinkles and sun-induced pigmentation were treated using the 755 nm PicoSure Laser with focus lens array. Adjacent pulses, with minimal overlap (10% or less), were delivered to the full face. Subjects received four treatments, performed at 2-3-week intervals. The laser energy used was 0.71 J/cm2. The physician administered 3-7 passes with an average total of 6,253 pulses per treatment. Follow-up visits occurred at 1 and 3 months post-last treatment. The most common side effects were mild swelling, pain, redness, and crusting, most of which subsided within hours of treatment. At the 1 and 3-month follow-up visits, 94% and 93% of subjects scored themselves as satisfied or extremely satisfied. A compressed treatment interval expedites results without increasing side effects and resulted in a high physician and subject satisfaction rate.

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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only visibility of your business operationally, but it also links to relevant keyword content that you’ve published across the web. This therefore makes your business easier to search for on Google and helps it to rank more highly on searches related in your field.

How to Harness the Power of Google+ Business consultant Gemma Johnson explains how to successfully use Google+ to add value to a clinic’s existing digital marketing strategies According to Search Engine Watch, which provides analysis of the search engine industry, 59% of consumers use Google every month to find reputable, local businesses.1 If the business goals of your aesthetic practice are to actively engage existing patients, find new patients and to strengthen your position as a leader in your field, then I would suggest that including Google’s own social media platform, Google+, in your social media plan is a simple, cheap and logical step. This article seeks to highlight how incorporating Google+ into your existing or emerging social media and content strategy can deliver additional business benefits. Some basics around the reach of Google+ will be covered in this article, as well as what it is used for to give practitioners the general knowledge needed when deciding whether to integrate Google+ into the businesses’ ongoing marketing efforts. What is Google+ The simplest way to understand Google+ is to look at it as essentially a ‘social network’ that has a powerful search engine (Google) running behind it. Google+ is pretty much Facebook, Twitter, Reddit and Pinterest all rolled into one3 and delivers a very powerful tool when marketing your clinic. When you view it in these terms, you can see why

Google+ can add to your clinic’s marketing efforts. Google loves data and what better way to boost your search engine rankings than to publish and share content on a Google platform. With more than 300 million monthly users, it sits just behind Twitter, which has 320 million users; although, it is noted that a question is often raised in terms of how many of these accounts are ‘active’.2 The main purpose of Google+ is to offer its users a simple platform for sharing content (whether created by you or by the people you follow) and a tool for building mini communities around particular interests. It also offers a way for connecting likeminded individuals and, if you strip this down to a basic level, who doesn’t like to read content from people whose views are aligned with theirs? Google My Business Google My Business (GMB) is a relatively new feature, which separates Google+ and Google Business Pages into separate features on a single dashboard. GMB directly links you to customers, irrespective of what digital device they are using and whether they are looking for you using Google Maps, Google Search or Google+, which makes finding your business online easier. By setting up your GMB profile to include your business hours, phone number and directions to your clinic you are providing not

Comparing Google+ to Facebook and Twitter Google+ follows a similar process to Facebook and Twitter in regards to following people, sharing their content and liking (recommending) content with the ‘+1’ button. For many, Facebook and Twitter are the main social media platforms of choice, and these two popular platforms certainly have their merits; but the beauty of Google+ lies in its communities and its link to Google search engine rankings and visibility. Unlike other social media platforms, when using Google+ you can’t separate your personal and professional pages as there is just one dashboard for a single account. If you had a separate gmail account for your personal use and for your business use then in essence you would be working from two separate dashboards. This makes it important that you pre-vet the type of posts you intend to share amongst your ‘circles’. If potential customers were likely to search for you by your name, then one account is recommended because you want the search to go to your professional page. ‘Circles’ are also unique to Google+ and are people/businesses that you create around similar interests, philosophies and objectives. For example, if a particular interest was around dermal fillers or cosmetic surgery, then you could create a circle for each of these interests and add relevant people or businesses and publish or share content to that circle. This builds a niche community of people and content along particular themes. It’s important to note that you should thoroughly vet any personal content such as pictures you use (in particular your profile picture), before you post to your circles.4 The Google+ dashboard also differs as it is almost a hybrid of other social platforms. It allows you to create, manage and optimise your clinic’s page, publish content, share content into your niche circles and build photo collections in a similar way to Pinterest, all from one central place. This makes for a very smooth and user-friendly experience. For me, the YouTube element is the fun bit. Google+ incorporates YouTube, which adds another layer to your marketing efforts

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Key things to remember when using Google+ • Ensure you use the right keywords when setting up your profile so that you will appear in any search engine results, for example ‘aesthetic practitioner’, ‘cosmetic medicine’ • Link your Google+ page to your website (this is a necessary step to allow Google to verify that you are the owner of that website) • Serve your audience first with engaging and relevant content – seek to inform your readers • Be mindful about what you share as content has a high chance of being picked up by Google search • Be active and be helpful – try to schedule time to dedicate to Google+ regularly • Set aside time to search for peers and leaders in your industry. Re-share their posts to increase the chance of them following you back, boosting your ‘authority’

as you can create engaging videos on YouTube and then share them with your patients and communities via Google+. Google strives to give users the very best in search engine experience, so when users search for videos in Google it will also index YouTube video content, making it an even more streamlined experience for the user and publisher of content. Another feature is ‘Google Hangouts’, which is a communication feature that involves a ‘group style’ instant messaging and video chat facility (a bit like Skype) for up to 10 people. Hangouts are a great way to showcase your knowledge and experience to other industry professionals and patients whilst receiving feedback and questions in real-time. The beauty of a hangout is that it can be a cheap and sustainable part of your content strategy. Google+ content A content strategy should be part of your on-going marketing efforts if you want to increase your reach and drive traffic, as well as generate leads. As with all content, it’s important to keep in mind those that you want to engage with. Ask yourself; is this content

useful, informative and relevant to my reader? By sharing content with your different ‘circles’ you have the ability to monitor and analyse what works best for you and your clinic. If you do have content you want to share to a wider audience (outside of your circles) then you can do that too, but you still need to consider your audience and business objectives. One way around this is to have a personal blog if the topics are very separate from your business objectives. You can strengthen your clinic’s online reputation by crafting relevant, informative and engaging content and then using Google+ ‘circles’ to distribute your content to closed groups. By following this mid to longterm strategy, your efforts should result in an increase in traffic, improved search engine rankings in Google and hopefully a direct increase to your bottom line, as you acquire new patients and retain existing ones. Follow and be followed Google+ does a great job at keeping your business at the front of people’s minds and visible to your existing followers because when you ‘+1’ your followers’ content, your business/Google+ profile will then show up

Google+ is pretty much Facebook, Twitter, Reddit and Pinterest all rolled into one and delivers a very powerful tool when marketing your clinic

in their search engine results. Be patient when building your follower list and spend a little time planning who to follow as this is a good way of getting a follow in return. You want to ensure your network for sharing and engaging is one of mutual benefit. When sharing other people’s content, you can tag that person by adding a ‘+’ sign before their name. This is a great way to show up in Google’s search engine rankings when someone searches for that person’s name. As Google is ‘all about data’ rather than sharing content, building up your follower list and engaging with your peers and patients can only be a positive step forward. Conclusion Aesthetic practitioners can take advantage of the many features of Google+ as they encourage and foster engagement with others, which in turn helps practitioners to educate prospective and current patients as well as re-enforcing their position as a trusted expert and thought leader in their field. Establishing yourself as a trusted medical professional online should be part of your development as more and more people flock to the internet to search for healthcare professionals that can offer high quality treatment at a reasonable cost. Google+ offers a rich experience for users that understand its many benefits and features, it’s easy to set up and integrate into an existing content and social media strategy. If you have the time to set aside to create engaging and informative content, then Google will repay your time and efforts with search engine rankings, authority positioning and better visibility for your practice online. Gemma Johnson is a business consultant with more than 10 years of digital marketing experience in assisting brands with their creative, content, social media and PR strategies. Johnson is also a media spokesperson for family finances and digital mastery (using digital technologies in a balanced and productive way) and frequently appears on Radio, TV and writes for The Huffington Post. REFERENCES 1. Jon Schepke, 315 Businesses Boost Rankings by Optimizing Their Google+ Local Pages [Study], (2013) <https:// searchenginewatch.com/sew/study/2305421/315-businessesboost-rankings-by-optimizing-their-google-local-pages-study> 2. Guest Post, Here’s How Many People Are on Facebook, Instagram, Twitter and Other Big Social Networks (2016) 3. Alex Hern, Google+ is alive! But now it wants to be more like Reddit than Facebook, (2015) <https://www.theguardian.com/ technology/2015/nov/18/google-plus-communities-collectionsreddit-facebook-pinterest> 4. Mike Blumenthal, Your Google My Business Profile Image – The Most Important Image?, (2015) http://localu.org/blog/yourgoogle-my-business-profile-image-your-most-important-image/

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Managing Anxious Patients Dr Jaimini Vadgama discusses the causes of anxiety in patients and effective strategies for managing this in everyday clinical aesthetic practice Medical aesthetics and the number of surgical and non-surgical aesthetic procedures performed worldwide is growing at a rapid pace. A survey by the American Society of Plastic Surgeons indicated that the number of non-surgical procedures performed in 2015 has risen by 158% since 2000 and this reflects a worldwide trend.1 With the increase in uptake of aesthetic procedures, practitioners are also seeing an increase in the range of patients who seek these treatments. Patients who were once averse to the idea of undergoing an aesthetic procedure may now be open to learning what treatments are available and how they may benefit from them. Aesthetic procedures that were previously considered the preserve of the rich and famous have found their place in the mainstream within the last 10 years, which is likely thanks to media coverage and, more recently, as a result of increasing social media coverage.2 The social ‘stigma’ that once existed surrounding these elective aesthetic procedures now seems to be diminishing. Although aesthetic treatments are elective in nature, this does not mean that patients who undergo these procedures are not anxious. This article will discuss some of the reasons behind these anxieties and how aesthetic practitioners can effectively manage anxious patients in their everyday practice.

of disappointment.5 In particular, facial appearance is intimately linked to a sense of identity and patients are often apprehensive about the impact these procedures will have not only on how others may perceive them, but also on how they perceive themselves.6 As well as this, in many respects, media coverage has played a positive role in the promotion of aesthetic treatments to the public. However, the media’s tendency to sensationalise negative outcomes and ‘botched’ treatments, commonly seen with lip filler treatments, can fuel patient anxiety in relation to these treatments.

How common is anxiety in patients? Whilst there are very few statistics to show what percentage of patients seeking aesthetic treatment are nervous about it, in my experience, I have found that a high proportion of patients are anxious in some way and it is more likely to be the case if the patient is undergoing a procedure for the first time.

What is anxiety?

Management techniques

Anxiety by definition is a ‘state of apprehension and fear resulting from the anticipation of an event or situation’. Common signs and symptoms of anxiety include the following:3 • Feeling nervous, restless or tense • Having a sense of impending danger, panic or doom • Having an increased heart rate • Breathing rapidly (hyperventilation) • Sweating • Trembling • Feeling weak or tired • Trouble concentrating or thinking about anything other than the present worry • Trouble sleeping • Difficulty controlling worry • Feeling the urge to avoid things that trigger anxiety

Understanding each individual patient’s anxieties and level of anxiety is central to effective management.

Why might patients be anxious? In my experience, a large percentage of patients who are anxious about undergoing aesthetic procedures will be those who have never undergone treatment before. These first-time patients are most likely anxious due to a fear of the unknown. In contrast, previous negative experiences, not limited to aesthetic treatments, can also create anxiety.4 Alongside concerns about loss of control, fear of pain and post-operative complications, aesthetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety

Initial consultation Anxiety can present itself in a number of ways, some of which are not immediately apparent, so an in-depth initial consultation is the single most effective tool in order to make this assessment. Supplementing this with a specific questionnaire based on an ‘anxiety scale’ can give the practitioner an objective assessment of a patient’s anxiety level. This can be achieved with a brief three to five item questionnaire with a consistent answering scheme for each item ranging from 'not anxious' to 'extremely anxious' (Figure 1). This questionnaire can be incorporated into your clinic medical history form so that all patients are effectively ‘screened’ for anxiety at this stage. Patients will gain further confidence and trust if you can show them a wide range of before and after photos of your own clinical work, to illustrate the variety of outcomes that can be achieved. Discussing how you managed another patient’s aesthetic concern and seeing these tangible results is a powerful tool to dampen patient anxiety based on fears of an undesirable outcome. Educating the patient about the procedure that they are considering undergoing will also work to alleviate concerns that may be fuelling their anxiety. If a particular patient’s anxiety

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Questionnaire 1. If you were to undergo an aesthetic procedure tomorrow, how would you feel? ☐ Not anxious ☐ Slightly anxious ☐ Fairly anxious ☐ Very anxious ☐ Extremely anxious

2. If you were sitting in the waiting room (waiting for treatment), how would you feel? ☐ Not anxious ☐ Slightly anxious ☐ Fairly anxious ☐ Very anxious ☐ Extremely anxious

3. If you were to undergo an aesthetic procedure involving local anaesthetic injections, how would you feel? ☐ Not anxious ☐ Slightly anxious ☐ Fairly anxious ☐ Very anxious ☐ Extremely anxious

Score as follows: Not anxious = 1 Slightly anxious = 2 Fairly anxious = 3 Very anxious = 4 Extremely anxious = 5 Total score is sum of all items – range depending on number of items in questionnaire. Patients who score above 75% can be classified as highly anxious and may require more specific management. Figure 1: Example of anxiety scale questionnaire and scoring system

is linked to a previous negative experience, reassure the patient by explaining how you will avoid this occurring again and describe how it will be different this time. Genuine patient testimonials in either video or written format will also give patients confidence in your clinical abilities. Having a number of patients who are happy to discuss their treatment and experience with you is also extremely valuable. Environment Practitioners should not view themselves in isolation and should be mindful of the impact their clinic environment and staff can have on the patient experience. A well-trained and helpful team will create a more cohesive experience for the patient, giving them further confidence in your abilities. Your clinic and support staff are a direct reflection of you as a clinician and a calm, relaxing ambiance will transfer across to your patients. Supportive language Avoid using phrases that appear to minimise their anxiety such as, ‘there’s nothing to be afraid of’. Instead, it’s best to focus on normalising anxiety and using supportive phrases, such as, ‘many of my patients have concerns similar to yours’. Normalising anxiety shows empathy and helps the patient understand they are not alone in experiencing anxiety. Avoid the use of technical jargon and always communicate in simple, clear language. Control Loss of control is associated with anxiety and giving patients an element of control will aid in reducing their nerves.3 Create a signalling system whereby patients can signal to you if they feel they need a break

during the procedure. Find out if the patient wishes to see what you are doing during the procedure. Some patients find it comforting to see the treatment progress gradually, in particular during dermal filler procedures where results are instantly visible. Pain management Fear of pain during injectable procedures is a common cause for anxiety. Use all the tools at your disposal to minimise discomfort for your patients. This can include topical anaesthetics, ice, cold devices and vibrating devices.7 Warming local anaesthetic and using the smallest needle gauge are also well described techniques to minimise injection pain.8 Distraction techniques There are a myriad of techniques based on distraction that can help to ease patients’ nerves including the use of music, a supportive assistant, and as often found in dental surgeries, movies.9 In my clinical practice I find a combination of soothing music or music that the patient has chosen themselves, along with a supportive assistant, works best to provide a good quality distraction. This method still allows for a constant reassuring dialogue with the patient throughout the procedure. ‘Tell-show-do’ technique The ‘tell-show-do’ desensitisation technique is commonly used in clinics and involves a gradual introduction to the procedure. It should start with a verbal explanation of the procedure (tell), followed by the ‘show’ involving the demonstration of the visual and tactile aspects of the procedure (where possible), and culminate in carrying out the procedure (do). An example might be

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when delivering dermal filler treatment with a cannula. You can describe the sensations the patient will experience – for example, while there will be no painful sensation in the treated area, the patient may still be able to feel vibration, movement and pressure. You can then ‘show’ the patient by mimicking the feeling of pressure on the area to demonstrate to them the difference between pain and pressure, sensations that are commonly confused by patients. Finally you ‘do’ the procedure and remember to reassure the patient throughout about what they are feeling and how it is normal. Relaxation strategies These include breathing strategies, such as ‘boxed breathing’, and progressive muscle relaxation that can be easily employed.10 Boxed breathing, sometimes called square breathing, involves utilising diaphragmatic breathing to expand the stomach and not the chest. Have the patient count to four as they inhale, hold their breath for four seconds, exhale to a count of four, and hold their breath to a count of four. Ask the patient to try this technique for four minutes. Progressive muscle relaxation involves helping the patient relax the entire body by tensing and relaxing muscle groups sequentially, usually tensing for 10 seconds, relaxing for 20 seconds, then moving to the next muscle group. To perform this, ask the patient to start at the top or bottom of their body. If they start at the top, ask them to tense (10 seconds), and then relax (20 seconds) their head, neck, shoulders, chest, biceps, etc. in a sequential fashion. Cognitive behavioural therapy (CBT) CBT is a form of talking therapy that aims to help a patient learn to change the way they think (cognitive), and act (behavioural). It can be a useful tool for patients with more severe anxiety. Working with a qualified CBT practitioner can help patients link thought patterns with emotions and behaviours. Understanding these themes then allows the patient to arrive at the underlying core issues of the anxiety and CBT focuses on the development of personal coping strategies that target changing unhelpful thought patterns. Staged progressive treatment A key way in which anxiety is managed in any clinical setting is through gradually building confidence through acclimatisation and exposure techniques. An obvious starting point for many aesthetic patients is botulinum

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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toxin treatment. Any treatment that can be performed quickly and has relatively short and effective results is an ideal introductory treatment for anxious patients. Similarly, hyaluronic acid based dermal filler treatments, which are reversible, can give patients confidence and alleviate anxieties founded on fears of an undesired aesthetic outcome. Discuss with the patient their desired outcome and how you plan to work together to achieve it. When treating patients who are particularly nervous about looking ‘overdone’, discuss the option of starting with a small volume of filler, for example, and how this can always be augmented at a later stage depending on the patient’s wishes. Pharmacological management For anxious patients who are keen to undergo more invasive procedures with significant associated discomfort, such as deep chemical peels, pharmacological management may be a useful aid. In these cases, oral sedation or conscious IV sedation can be useful techniques to manage not only anxiety, but also the pain and discomfort often felt during these types of more invasive procedures.

Conclusion Establishing a good rapport and open dialogue with the patient from the outset can go a long way to greatly diminishing their anxiety. Building trust and showing the patient that you understand their anxiety and empathise with them sets the tone for your care, and emphasises that you are committed to managing their concerns. Using this approach along with a combination of the described techniques is a powerful way to manage nervous patients in everyday practice.

Aesthetics REFERENCES 1. American Society of Plastic Surgeons, 2015 Plastic Surgery Statistics Report (2015), pp.1-23. <http:// www.plasticsurgery.org/Documents/news-resources/statistics/2015-statistics/plastic-surgery-statsiticsfull-report.pdf> 2. Montemurro, Paolo, et al, ‘The influence of social media and easily accessible online information on the aesthetic plastic surgery practice: literature review and our own experience’, Aesthetic plastic surgery, 39(2015), pp.270-277. 3. Mineka, Susan, and Kelly A. Kelly. “The relationship between anxiety, lack of control and loss of control.” (1989). Steptoe, Andrew (Ed); Appels, Ad (Ed). (1989). Stress, personal control and health (pp. 163-191). Oxford, England: John Wiley & Sons, pp.163-191. 4. Locker, David, David Shapiro, and Andree Liddell. ‘Negative dental experiences and their relationship to dental anxiety.’, Community dental health 13.2 (1996), pp.86-92. 5. Rankin, Marlene, & Gregory L. Borah, ‘Anxiety disorders in plastic surgery,’ Plastic and reconstructive surgery, 100(1997), pp.535-542. 6. Lennon, Sharron J, & Nancy AR, ‘Linkages between Attitudes toward Gender Roles, Body Satisfaction, Self Esteem, and Appearance Management Behaviors in Women’, Family and Consumer Sciences Research Journal 23(1994), pp.94-117. 7. Kuwahara, Hiroaki, and Rei Ogawa, ‘Using a Vibration Device to Ease Pain During Facial Needling and Injection’, Eplasty, 16(2016). 8. Lundbom, Janne S., et al., ‘The influence of Lidocaine temperature on pain during subcutaneous injection’, Journal of Plastic Surgery and Hand Surgery, (2016) pp.1-4. 9. Sadideen, H., et al., ‘Is there a role for music in reducing anxiety in plastic surgery minor operations?’ The Annals of The Royal College of Surgeons of England, (2015). 10. Payne, Rosemary A & Donaghy M, Relaxation techniques: A practical handbook for the health care professional, Elsevier Health Sciences, 2010.

Dr Jaimini Vadgama is a dentist and aesthetic practitioner based at Woodbury Dental and Laser Clinic in Kent. She qualified from King’s College London and is currently undertaking an MSc in Implant Dentistry. She has a special interest in the management of anxious patients and is Dental Phobia certified.

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Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Taking Responsibility in Waste Management Clinical waste advisor Rebecca Waters explains how practice staff should be safely and legally disposing of waste In 2013, it was reported that the cost to dispose of clinical waste for the National Health Service (NHS) is five to 10 times more than domestic waste. Even though the amount of recycled waste is increasing, with an 18% growth in the NHS between 2007/8 and 2011/12, the cost of clinical waste disposal for the government is still predicted to rise.2 Every clinical setting, including private aesthetic clinics, must have a waste segregation and disposal policy to ensure they are helping to tackle this growth. The principal of ‘waste minimisation’ is key, although not always practical and achievable, and so strategies to recycle and then segregate appropriately need to be put in place. This is where the ‘waste hierarchy’ comes into fruition to help guide all healthcare professionals, including those working within the cosmetic setting, in their responsibilities. Why is correct waste disposal so important? Effective waste disposal procedures help to protect both staff and patients from harm. Hazardous waste in particular can contain a variety of pathogens that have the potential to infect anyone they come into contact with, including those that cause HIV and hepatitis B and C. Sharps injuries among professionals can also be avoided by careful handling and disposal of needles. What’s more, safe segregation of waste streams ensures that all waste is disposed of in the safest and most efficient way, protecting the environment from pollution. It is also important to note that clinic owners could be faced with legal ramifications if they do not comply with regulation. Failure to comply with the regulations is a criminal offence subject to an unlimited fine on conviction. In

Hazardous waste in particular can contain a variety of pathogens that have the potential to infect anyone they come into contact with, including those that cause HIV and hepatitis B and C

addition to potentially damaging the environment and/or putting people’s health at risk, an incompliant aesthetic clinic could also be suspended or closed and faced with substantial remedial costs before it is able to reopen.3 The waste hierarchy The UK currently follows the principles of waste management set out by the European Waste Framework Directive, which ensures that all countries within the European Union (EU) are aligned in their strategies and implementation.4 With the UK leaving the EU, it is yet unclear how this will affect businesses’ need to comply with the regulations. However, it is likely that at least the majority of the guidelines will remain in place in order to ensure the safety and efficiency of waste processes. The current waste hierarchy ranks the different waste management choices in order of their environmental impact. The overarching aim is to eliminate the generation of waste in the first instance. When this cannot be practically achieved, the framework below provides the next best order of options available, always keeping the environment in mind. 1. Prevention: eliminating or reducing waste at the source e.g. minimising the amount of packaging used. 2. Preparing for reuse: when waste cannot be prevented, where possible it should be directly reused, renewed or treated for reuse. 3. Recycling or reprocessing: materials that can be reclaimed as a secondary raw material e.g. cardboard. 4. Other recovery: where none of the above is feasible, the energy content of the waste should be used e.g. offensive waste can be transported to energy-from-waste amenities. 5. Disposal: this is the last option and stringent segregation mandates should be followed for health and safety reasons and environmental impact. Assessment, segregation and storage Any waste created must be assessed by the producer of that waste and segregated according to policy. Any member of staff can take responsibility for this, as long as they are appropriately trained. A lot of the waste produced can be easily categorised, however, sometimes it is not so clear-cut and clinical judgment or the use of documentary evidence may be required. Some staff may err on the side of caution and segregate all waste from cosmetic procedures as infectious, but with proper training and by following the clearly defined framework, they can build confidence in their decisions. This can significantly help to reduce unnecessary processing procedures, which are costly – both

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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Colour

Waste Stream

Description

Black

Mixed municipal waste

General waste. • Packaging • Tissues • Disposable cups and drinks cans • Food wrappers • Cut flowers (that have wilted or died)

Tiger

Offensive/hygiene waste

• • •

Blue

Medicinal waste

All medicinal waste should be kept in its original packaging when discarded to facilitate identification in case of an accident. • Anaesthetic cartridges • Tablets in containers • Blister packs • Unopened medicine vials • Waste pharmaceuticals or out-ofdate or denatured drugs

Nappies Feminine sanitary products Incontinence pads

White

Dental (amalgam) waste

Dental amalgam releases mercury vapour, which has been associated with health effects in the brain and kidneys.6 It is therefore important to install amalgam separators to filter out amalgam in waste water, and safely dispose of the substance.

Purple

Cytotoxic and cytostatic waste

Any items contaminated with cytotoxic or cytostatic substances. • Any personal protective clothing • Blister packs • Tablets in containers • Patches • Wipes • Syringe bodies and tubing • Syringes • Needles • Scalpel blades

Orange

Clinical and infectious waste

Waste arising from healthcare activities that could pose a risk to public health or the environment, unless properly disposed of e.g: • Swabs • Gloves • Paper towels • Dressings • Masks • Aprons

Yellow

Clinical and highly infectious waste

This type of waste involves any disposable items that are contaminated with bodily fluids of patients with known or suspected infections. • Gloves • Masks • Aprons • Dressings

Figure 1: Waste segregation5

financially and environmentally. Figure 1 provides examples of waste items that might be generated in aesthetic clinics, along with their allocated colour-codes, as set out by the Department of Health’s (DoH) best practice waste management guidelines:5 The actual waste container used for each waste stream should also be considered. All sharps must be disposed of in rigid sharps containers that can be securely closed when full. All other waste must be segregated according to its state – rigid containers are needed for all liquid or glass waste and bags are only suitable for hard waste. The colour-coding system detailed in Figure 1 is universal across the UK and Europe, providing a quick visual indicator to help make the segregation process as convenient and as easy as possible. This element should be integral in staff training and many suppliers provide helpful educational posters that can be positioned around the clinic and near waste containers and bins for reference when required.

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Policy, audits and staff training The DoH’s Health Technical Memorandum (HTM) 07-01: safe management of healthcare waste states that healthcare providers should have access to a waste management policy within their working environment. It provides a list of the minimum requirements that the policy should contain, including the aims and rationale of the policy, legal and statutory obligations, up-todate waste management contracts, the person responsible for waste procedures and what their duties are, information on safe transportation and specification for the correct use of containers and bags.5 Waste audits are necessary to ensure that the policy is being followed and should be carried out at least every five years5 in aesthetic clinics by a nominated person, who is responsible for waste management and trained in the audit procedure. Alternatively, an experienced waste audit contractor or consultant could conduct the audit.7 The administrative side of waste management is a legal requirement and pivotal in audit checks.8 A staff training protocol is an important part of the policy documentation and it should clearly specify what education is provided for new starters in their induction plan. HTM 07-01 suggests the key areas to focus on are the risks associated with healthcare waste; its segregation, handling, storage and collection; personal hygiene; procedures for spillages and emergencies; and use of protective clothing. Relevant training in the form of written information, photos and verbal instruction will prove effective refreshers for all existing members of staff. While there are no strict guidelines for frequency of training, annual training is recommended by professionals in the field. All professionals working within a clinic that offers any kind of cosmetic procedure need to understand and comply with his or her responsibility in waste management to ensure staff, patients, and the environment, are protected from harm. Working with an experienced and professional waste management company can support healthcare worker’s responsibility with confidence and peace of mind.

Rebecca Waters is the category manager for Initial Medical and has worked in the healthcare sector for the past 13 years. Waters keeps up to date on all developments within the clinical waste management industry and is an active member of the Chartered Institution of Wastes Management, Sanitary Medical Disposal Services Association and British Dental Industry Association. REFERENCES 1. QCR, ‘Recycling Equipment. The NHS is losing its battle with the costs of waste disposal’ (2013) <https://www.qcr.co.uk/news/nhs-waste-disposal> 2. QRC recycling Equipment, The NHS is losing its battle with the costs of waste disposal (2013) <https:// www.qcr.co.uk/news/nhs-waste-disposal> 3. Controls on the disposal of healthcare waste (UK: Gov.co.uk, 2013) <https://www.gov.uk/guidance/ healthcare-waste> 4. EUR-Lex, Directive 2008/98/EC of the European Parliament and of the Council of 19 November 2008 on waste and repealing certain Directives <http://eur-lex.europa.eu/legal-content/EN/ TXT/?uri=CELEX:32008L0098> 5. Department of Health, Health Technical Memorandum 07-01: Safe management of healthcare waste <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/167976/HTM_0701_Final.pdf> 6. Nylander M, Friberg L, Lind B., ‘Mercury concentrations in the human brain and kidneys in relation to exposure from dental amalgam fillings’, Swed Dent J., 11(5) (1987), pp.179-87. 7. Department of Health, Health Technical Memorandum 07-01: Safe management of healthcare waste. Section 6.20, <https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/167976/HTM_07-01_Final.pdf> 8. Department of Health, Health Technical Memorandum 07-01: Safe management of healthcare waste. Section 6.24, 6.25, <https://www.gov.uk/government/uploads/system/uploads/attachment_ data/file/167976/HTM_07-01_Final.pdf>

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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*stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 2. Ulthera System Instructions for Use, 1001393IFU Rev H 3. Lee HS, et al. Dermatol Surg. 2011;1-8 4. Data on File: ULT-DOF-008 – Ultherapy Mechanism of Action White Paper 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 7. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 8. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed May 2016 9. CE Certificate 3808396CE01, DEKRA April 2012 Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

www.ultherapy.co.uk

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“You learn from your mistakes and that is the best thing you can do; always be critical in everything that you do – always think, can I do better?” Mr Basim Matti details his career in aesthetics and discusses the importance of mentorship and training “Medicine has always been in my family, although I am the only surgeon,” explains Mr Basim Matti, who emigrated from Iraq to the UK in 1980 to progress his medical career. He says, “Coming from my home country of Iraq and becoming a consultant plastic surgeon has been an excellent achievement – being in this part of the world, which is a much more peaceful world, is wonderful.” Mr Matti studied medicine in Mosul, Iraq, and graduated in 1973. He says, “As a doctor, I have always regarded helping people as being very important. If you can help the patient, particularly if you can make them feel better, that’s wonderful.” Following his medical training, Mr Matti obtained a Fellowship to the Royal College of Surgeons in 1981 and trained at the Plastic Surgery Centre in Sheffield and St Andrew’s Hospital in Billericay, Essex. During this time, Mr Matti met Mr Freddie Nicole – who would later become his mentor and business partner – at a meeting in Glasgow in 1986, where he was asked to complete a six-month Fellowship with him in London. Later he went on to become senior registrar at West Middlesex Hospital and Hammersmith Hospital in London, before becoming a consultant at Charing Cross Hospital, London. He explains that, “In 1989 I came back and joined Mr Nicole at his clinic and I have never looked back.” Mr Matti worked with Mr Nicole for nearly 10 years; after this he took over Mr Nicole’s consulting room on Harley Street and has been running it himself ever since. Despite being in the industry for such a long time, Mr Matti is still very passionate about his job, explaining, “I have now been doing this work for more than 30 years and I still very much enjoy it.” Prior to private practice, Mr Matti was predominantly doing reconstructive surgery, an experience that he says, “Has to be the basis for any surgeon who wants to be a good plastic, aesthetic surgery consultant because it gives you a wide range of experiences that can be adapted for many types of procedures.” He explains that now he works in private practice, his workload consists mostly of cosmetic plastic surgery procedures. “I enjoy seeing the change in the patient’s life, in their confidence and in their look – I’ve found that it’s absolutely imperative for some people and their psychology,” he says. Mr Matti credits much of his success to the invaluable mentorship he has received throughout his career from those such as Mr Nicole, which he says is essential for any aesthetic practitioner. He explains, “I think having mentors is very important. It helps you in the longterm with networking and provides opportunities that you might not otherwise come across. It also allows you to learn from others’ mistakes before you have to make them yourself.” Mr Matti emphasises that as with any medical profession, training and education is key, “Every single patient is important, and, as we say, ‘you’re only as good as your last operation’, so it is very important that you make sure that every procedure you do is your best.” For those

looking to further their skills, Mr Matti suggests approaching a more experienced practitioner. “There is no shame in this,” he says, adding, “Go to the meetings, go to conferences and read the journals.” He also urges practitioners against rushing into trying new procedures, “Be trained properly – not just through a weekend course – make sure you do several courses and continue your training throughout your career. Make sure that you are able to inform the patient of the details of the treatment and are capable of delivering it effectively, whether it’s surgical or non-surgical – stick with the area in which you are interested in and capable of doing.” To be successful in the industry, Mr Matti says it is vital to stay updated, but not to just simply follow the latest trend, “Don’t just go for the fad of the day – there are a lot of them that come and go in this industry so we have to be careful to give advice that is for the benefit of the patient, not for the practitioner’s pocket. You’ve got to treat patients with respect, and they will respect you too.” He also advises those entering the industry to always consider the patient above their own agendas, “Make sure the patient comes before your profit. Sadly a lot of people are rushing into the industry to make a ‘quick buck’ when we should be focusing on patient care,” he says. Mr Matti notes that throughout the last 30 years of practising cosmetic surgery he has always strived to do better, and urges others to do the same. He says, “You learn from your mistakes and that is the best thing you can do; always be self critical in everything that you do – always think, can I do better?” Do you have an ethos or motto you follow? Do your best and do no harm, money is the last thing you should think about. What treatments do you enjoy performing the most? I enjoy doing facelift surgery and rhinoplasty because they are difficult procedures to undergo both physically and mentally. What’s your favourite part of your job? When the patient is happy and is thanking me for my work – it makes me feel very lucky – what more could you want? It’s wonderful. What’s your best advice to other practitioners? As a surgeon, you need to remember that there is more than just surgery and more than a knife – there is also a needle that can be used to help the patient in a non-surgical way.

TO WATCH THE VIDEO INTERVIEW WITH MR BASIM MATTI VISIT WWW.AESTHETICSJOURNAL.COM

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016

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The Last Word Plastic surgeon Dr Daniel Medalie argues why it’s time more aesthetic surgeons performed transgender procedures I have been a plastic surgeon for 17 years and during my first job at the University of Kentucky, I was approached by transgender individuals who requested some minor feminisation procedures. Based on my experience as a resident, and having had some training in transgender surgery, I was open-minded and happy to help out. When I moved to the University Hospitals of Cleveland and Case Western Medical School three years later, several other transgender individuals contacted me. I was surprised to learn that most of them had approached multiple surgeons prior to reaching out to me, and they had been continually told that the surgeon did not perform any type of procedure on transgender individuals. I have always been open to performing transgender surgeries, but, over the years, it has appeared that some of my colleagues are not. Treating these patients can be some of the most rewarding and satisfying work as a plastic surgeon, and I believe it’s time for aesthetic surgeons around the globe to open the doors to these patients. What’s the issue? Transgender individuals who I have spoken to frequently state that there are few surgeons in their home countries willing to perform the surgeries, and the ones that do are not necessarily well-qualified, as there is no requirement in plastic surgery training programmes for experience in transgender surgery. Some patients have to travel across the world to find a surgeon willing to operate, and at a price they can afford. Those seeking gender reassignment in England wait, on average, 18 months for an initial consultation and then a further three years for the surgery, at one of only eight centres in the country.1 When I have asked some of my colleagues why they don’t operate on transgender patients, usually, the response is vague. Lack of experience may be an issue for genital surgery but it should not be an issue for breast, body or facial contouring, which are the basics of plastic and aesthetic surgery practices. They tend to state that they don’t feel comfortable with the patient population and are worried other patients might avoid the practice if they realise there are transgender patients in the waiting room. In my experience, just the opposite is true. My non-transgender patients have been overwhelmingly positive when they have found out that I have a large transgender patient population. Refusing to treat transgender patients purely because you do not agree with it is not okay. It is prejudice, goes against good medical practice and does a grave disservice to the transgender community.2 I have been sending out pre-op surveys to my patients for two years and the majority of the responses indicate that transgender patients who don’t live in a large urban centre have had trouble getting even basic medical healthcare. Resolving the issue If a patient can afford to undergo surgery, there is a lack of trained surgeons who can reliably perform these types of operations. There is an urgent need for plastic surgery programmes to start performing the surgeries in a systematic way, as well as training their residents. In a positive move, this year, a transgender module has been

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mandated for the plastic surgery education network of the American Society of Plastic Surgery (currently in production), and Mount Sinai Medical Center in New York City announced a Transgender Fellowship starting in 2017.3 In England, the NHS, who stated centres were limited due a shortage of ‘suitably qualified staff’, has now put an additional £4m funding into the services.1 Ultimately it would be an admirable goal to create an international professional society of aesthetic surgeons dedicated to discussing transgender procedures. This would rapidly serve to disseminate useful advice and techniques. There are now very good criteria outlined by the World Professional Association for Transgender Health (WPATH) that offer a way for surgical practitioners to better understand their patients and ensure they consent and understand the risks.4 This association’s mission is to promote evidence-based care, education, research, advocacy, public policy, and respect in transgender health. It works with all health professionals and any member of a professional community who may need or want to interact with transgender individuals. I require all of my mastectomy patients to have a therapist’s letter stating that they conform to WPATH standards and understand the irreversibility and life-changing nature of the procedure. I have now performed close to 1,500 double mastectomies and have never been sued by a transgender patient or had one contact me with severe regret. Practitioners who are worried about the prospect of being sued should ensure all patients produce the therapist’s letter to further support their case.

Those seeking gender reassignment in England wait, on average, 18 months for an initial consultation Conclusion These are all significant steps forward, but the most important step is the acceptance by the plastic surgery community that taking on transgender cases is, in fact, necessary and desirable. It is the unfortunate attitude of many aesthetic surgeons that this is fringe surgery and that it would be best if ‘someone else’ performed these types of operations. But there is no one else. We are the most qualified practitioners to perform transgender procedures. Patients seeking surgery should be treated with the utmost respect for their needs and desires, in the same way a practitioner would treat any other patient. I urge my fellow surgeons to free their minds and embrace a new surgical and aesthetic opportunity, which is both demanding and extremely rewarding. Dr Daniel Medalie is a board-certified plastic and reconstructive surgeon and chief of plastic surgery at the Cleveland VA Medical Center. For the last 14 years he has served as an assistant professor at University Hospitals and Case Western Reserve University in Cleveland. He has been named by US News as one of America’s ‘Top Doctors’. REFERENCES 1. BBC, Transgender patients in England face ‘long wait’ for appointments, (2016) <http://www.bbc. co.uk/news/uk-england-35605956> 2. GMC, Respect, confidentiality and the law, Good Medical Practice, (2016) <http://www.gmc-uk.org/ guidance/ethical_guidance/28861.asp> 3. Mount Sinai Hospital, Center for Transgender Medicine and Surgery, (2016) http://www.mountsinai. org/patient-care/service-areas/center-for-transgender-medicine-and-surgery 4. WPATH, About, World Professional Association for Transgender Health (2016) <http://www.wpath.org/ site_home.cfm>

Reproduced from Aesthetics | Volume 3/Issue 11 - October 2016