Aesthetics October 2017 by Aesthetics & CCR

s e! tic 17 ot he 20 v st ds to Ae ar nce Aw ha c st La

VOLUME 4/ISSUE 11 - OCTOBER 2017

F I N A L I S T

Treating Asian Skin CPD Miss Mayoni Gooneratne discusses the literature on treating Asian skin

Special Feature: Conversations

Vascular Blemishes

Practitioners explain how to manage difficult conversations with patients in consultations

Nurse prescriber Elizabeth Rimmer details treatment options for vascular blemishes

2 0 1 7

Launch Events PR consultant Jenny Pabila shares advice on hosting clinic events to maximise attendance and success

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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) RadiesseÂŽ 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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Contents • October 2017 06 News

The latest product and industry news

12 Conference Report

Highlights from the British Association of Cosmetic Nurses Autumn Aesthetic Conference 2017

14 On the Scene

Out and about in the specialty this month

16 News Special: Language in Aesthetics

Aesthetics investigates whether the term ‘antiageing’ should be used in the specialty

CLINICAL PRACTICE

Special Feature Difficult Conversations Page 21

21 Special Feature: Difficult Conversations

Practitioners provide examples of challenging patient questions they have experienced and explain how to best answer them

27 CPD: Treating Asian Skin

Miss Mayoni Gooneratne explores the anatomy of Asian skin and highlights effective treatments

33 PDO Thread Outcomes Part Two Dr Irfan Mian discusses reasons behind poor outcomes of PDO threads

in the second of a two-part article

38 Treating Vascular Blemishes

Aesthetic nurse prescriber Elizabeth Rimmer details different types of vascular blemishes and the treatment options available

41 PRP in Facial Aesthetics

Dr Kieron Cooney reviews literature on platelet rich plasma and explores its efficacy in facial aesthetics

49 Foam Sclerotherapy

Mr Philip Coleridge Smith provides an overview of foam sclerotherapy for treating varicose veins

52 Advertorial: SkinCeuticals Learn about the SkinCeuticals Master Physician Programme 53 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 55 Spotlight On: e-MASTR Aesthetics finds out more about the new video-based digital resource platform 57 Building Patient Referrals

Sales manager Lorraine Mcloughlin advises on how to increase patient referrals to maximise business success

59 Aesthetic Launch Events

PR consultant Jenny Pabila offers tips for organising a launch event

64 Benefits of Mentorship

Practitioners and professionals discuss the benefits of having a mentor

67 In Profile: Dr Ariel Haus Dermatologist Dr Ariel Haus reflects on his career and compares his

experience in the UK with his home country of Brazil

69 The Last Word

Mr Muholan Kanapathy and Professor Ash Mosaebi examine the conflicting advice on sunscreen and vitamin D

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In Practice Mentoring Page 64

Clinical Contributors Miss Mayoni Gooneratne is a graduate of St George’s Hospital and is a member of the Royal College of Surgeons. Miss Gooneratne has completed extensive training in aesthetic techniques and created The Clinic by Dr Mayoni in 2016. Dr Irfan Mian is medical director of the Chinbrook Medical Cosmetic Centre in London and has practised medicine for more than 30 years. He is a threadlift and a medical aesthetic trainer and has been a clinical lecturer at King’s and Guy’s Hospital NHS Trust. Elizabeth Rimmer is an independent nurse prescriber. She opened her holistic health and skin clinic, London Professional Aesthetics, in central London, in 2014. Rimmer is also an active member of the BACN and the BDNG. Dr Kieron Cooney is a GP and an aesthetic practitioner at Cosmedica Beauty. Dr Cooney completed his Master’s Degree in Aesthetic Medicine at Queen Mary's University London. He has a special interest in PRP and striae distensae. Mr Philip Coleridge Smith is a consultant vascular surgeon at the British Vein Institute. He is the president of the British Association of Sclerotherapists, which facilitates training of practitioners in the skills needed safely to undertake sclerotherapy treatments.

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Editor’s letter I cannot believe where the year is going – October already and I don’t feel like we have had summer yet. Although, with the multitude of back to school photos on social media, how could I be in doubt! Amanda Cameron We, at the journal, are also back to school Editor as the conference season has well and truly begun, with the British Association of Cosmetic Nurses (BACN) and British College of Aesthetic Medicine (BCAM) events both taking place at the end of September. Read all about the BACN conference on p.12 and look out for BCAM’s report online and in our next issue. We focus on the patient experience this month; a key element for the success of any treatment or business. Get it right and repeat business will follow, get it wrong and you may be looking for a new career! Have a read of our useful articles on the topic, including how to answer difficult patient questions on p.21. The success of a launch event can have a significant impact on the number of new

patients who decide to book with you, so PR consultant Jenny Pabila shares her expertise to ensure all runs smoothly on p.59. This month's Spotlight On focuses on an innovative new website called e-MASTR, which has been launched by a team led by aesthetic practitioner Dr Tapan Patel. Turn to p.55 to learn more about the platform, which features more than 120 high-definition videos that aim to support aesthetic professionals throughout their clinical practice. Don’t forget to also check out our array of clinical articles, which include Dr Irfan Mian’s second article on using threads (p.33), a detailed overview of foam sclerotherapy by Dr Philip Coleridge Smith on p.49 and a valuable CPD article on treating Asian skin by Miss Mayoni Gooneratne on p.27. The votes are tumbling in for the Aesthetics Awards – you have until October 31 to support the companies, practitioners and products that you value most in the industry. Finally, ACE registration is now open! Visit www.aestheticsconference.com to register for free for the leading medical aesthetic conference in the UK!

Editorial advisory board

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

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

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

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

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

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

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

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

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

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

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EDITORIAL

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 • Senior Journalist T: 0207 148 1292 | M: 07741 312 463 kat@aestheticsjournal.com Shannon Kilgariff • Senior Journalist T: 0207 148 1292 | M: 07584 428 630 shannon@aestheticsjournal.com Anna Ramsey • Journalist T: 0207 148 1292 | M: 07572 123 239 anna@aestheticsjournal.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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DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.

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Training

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #TV Harley Street Skin @harleysreigate1 Looking forward to seeing Dr Khan in clinic this Saturday (pictured here with Dr Devine on the Lorraine show) #cosmetic #antiageing #Surrey

#Conference Dr Ravi Jain @DrRaviJain At #ASCD2017 in #Melbourne. Stimulating meeting of Cosmetic Dermatologists. 3 out of 7 lectures delivered #Training Exploring lips and perioral area with our chair Yvonne Senior, sharing her methods at the Filler Forum. #Education #LearningTogether #CPD #Merz #Eczema Miriam Santer @miriam2589 Training in the morning and feedback on research studies in the afternoon. All so useful. Thanks for organising @CebdNottm @eczemasupport #Meeting Anna Baker @Anna32Baker Great to be at @BACNurses Belfast regional meeting with leader Aine Larkin presenting @profhilo_uk @ha_dermauk

#ClinicLaunch Jayne Cowan @JayneCowan Delighted to attend the launch of new #Rhiwbina business @thebeautylabuk this evening – an aesthetics skin and beauty clinic #Congress Doctor’s Equipe @doctorsequipe Dr. Goisis presenting his book on #Anatomy and proportions in Asian patients at #5CCcongress #5CC @5CCongress #Barcelona

BCAM Training Academy launches The British College of Aesthetic Medicine (BCAM) confirmed at its Annual Autumn Conference on September 23 that it has introduced a training academy. The BCAM Training Academy is targeted towards doctors who do not yet fulfil the criteria to become BCAM members, who, for example, do not have certain evidential documents such as completion of three years of General Professional Medical Training. The academy aims to help educate practitioners in the importance of appropriate aesthetic training, patient safety, complication management, CPD sessions, appraisal, audit work and professionalism within the field. Doctors who join will receive an invitation to the annual BCAM Conference, a comprehensive list of BCAM members who are willing to provide advice and support on clinical queries, mentoring with BCAM members, information and support on getting into medical aesthetics, as well as access to lists of BCAM-approved training courses and an online forum. The overall goal is that, through the programme, practitioners will graduate through BCAM and join its group of members who are already committed to excellence in aesthetics. According to BCAM, opening its doors to support new doctors will help build a strong core of professionals within the specialty. “BCAM is committed to ensuring the effective, safe and ethical practice of medical aesthetics. We place a very strong importance on education and training for our doctors and on helping to keep our members at the forefront of their field,” said BCAM president Dr Paul Charlson. Education

Video-based educational resource launches A new website featuring more than 120 high-definition videos that aim to enhance aesthetic learning has been launched by a team led by practitioner and trainer, Dr Tapan Patel. e-MASTR is a subscription-based website that practitioners can use to access a range of educational videos that include, amongst others, animated global and regional anatomy, facial analysis, extensive demonstrations of filler and toxin injections, complication management advice and recommendations for consultation. In addition, there are unbranded patient explainer videos to be used in consultations to help with patient education. Dr Patel said, “We wanted to create a resource that blends with existing educational resources. The beautifully-shot videos create a new way of learning. If you see it, you’re unlikely to forget it.” The videos vary in length from one minute to up to 20 minutes and feature an array of patient types with different indications. Dr Patel explains that he hopes to grow the resource and tailor it to the requirements of aesthetic practitioners. He says, “We want people to engage. We want e-MASTR to become an expanding library. If we get feedback and enough requests for a topic, we can create new content.” Practitioners can purchase an annual subscription to e-MASTR from October 5, with a discount available until December 31.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Pharmacy

Med-fx launches pharmacy for Harley Street clinics Aesthetic supplier Med-fx is launching its first High Street pharmacy which will be located near Harley Street in London. According to the company, the pharmacy will offer a two-hour delivery service for local clinics. Practitioners will be able to order in-pharmacy for immediate collection or online using HarleScript, a digital platform developed by Med-fx. The company states it will sell its range of botulinum toxin, dermal filler, cosmeceuticals and surgery consumables directly to registered practitioners. According to Med-fx, customers will benefit from face-to-face pharmacy support and advice, a locally-based sales team and access to Med-fx’s service offerings. Head of Med-fx, David Tweedale, said, “Harley Street has earned a reputation for being at the heart of facial aesthetics so we’re delighted to launch our first High Street pharmacy and delivery service in the area. The investment of our first pharmacy is a significant evolution of our service and our commitment to be a genuine partner in aesthetics to our customers.” He added, “We see a lot of untapped potential in Harley Street. The clinicians operating there demand convenience when ordering their facial aesthetic products. Being in the area provides a walk-in option for clinicians, or a two-hour delivery service so they know they will be able to get the products they want when their customers need them. We’re excited to open our doors and welcome lots of new Med-fx customers.” The pharmacy is due to open its doors in Marylebone on October 21.

Vital Statistics According to the AAD, women in the US are nine times more likely than men to notice melanoma on another person’s skin (American Academy of Dermatology, 2017)

Out of 32 aesthetic clinics surveyed in the UK, only 4% asked for a patient’s ID before carrying out a lip filler procedure (WhatClinic.com, 2017)

More than 650,000 photorejuvenation procedures were performed in 2016 in the US, a 26% increase from 2015 (The American Society for Aesthetic Plastic Surgery, 2016)

Awards

Stewart Francis to host the Aesthetics Awards 2017 Stand-up comedian and actor Stewart Francis will host the renowned Aesthetics Awards on December 2, 2017. Francis is an international stand-up performer and frequently appears on television, including the popular British panel show, Mock the Week. After performing a live-comedy set showcasing his best jokes, Francis will host the presentation of the 26 categories of Aesthetics Awards. Finalists will be recognised across a range of categories that reward clinical excellence, innovation, customer service and best practice in the aesthetics specialty. The evening will also feature a welcome networking reception with drinks and a delicious three-course dinner. Following the presentation of the Winners' trophies, for the first time, the Aesthetics Awards will also feature a live six-piece pop and rock band with an accompanying DJ set, which will be sure to keep everyone entertained! There are limited tickets left for the Aesthetics Awards 2017. Don’t miss the opportunity to celebrate with your colleagues, clients and peers at the Park Plaza Westminster Bridge Hotel on December 2. To find out more and to book tickets visit www.aestheticsawards.com.

Visual content is 40 times more likely to get shared on social media than other types of content (HubSpot, 2017)

In a survey of 10,500 females across 13 countries, 70% wished the media did a better job of portraying women of diverse physical attractiveness (Dove, 2016)

In 2016, the top cosmetic surgical procedure for men in the UK was rhinoplasty, with 529 procedures accounted for (The British Association of Aesthetic Plastic Surgeons, 2017)

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Events diary 29th November – 1st December 2017 British Association of Plastic Reconstructive and Aesthetic Surgeons Winter Scientific Meeting 2016, London www.bapras.org.uk

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

1st – 3rd February 2018 IMCAS Annual World Congress 2017, Paris www.imcas.com

1st – 5th March 2018 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

27th – 28th April 2018 The Aesthetics Conference and Exhibition 2018, London www.aestheticsconference.com Skincare

Circadia Skincare launches in the UK

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Regulation

Study highlights regulation issues in NHS nursing A study published last month in The Journal of Clinical Nursing, warns of a risk to patient safety in the nursing profession and highlights the need for greater regulation of standards and qualifications within the sector. The report, ‘Variation in job titles within the nursing workforce’, is the result of research produced by a team at London South Bank University (LSBU) who analysed a cohort of 17,960 specialist nursing posts over a ten-year period (2006-2016) within NHS trusts across the UK. Results of their analysis suggest that just under 600 different specialist job titles are currently in use, which they claim is confusing for the public, medical professionals and commissioners of healthcare services, and poses a risk to patient safety. The International Council of Nurses recommends that advanced level nurses, who often prescribe drugs and manage a caseload, have obtained at least a Master’s degree level qualification. But, of 8,064 posts looked at for which educational data was obtained, 323 (4%) were recorded as holding titles such as ‘advanced nurse practitioner’ and ‘specialist nurse’ while having no formal first level nursing qualification registered with the Nursing and Midwifery Council (NMC). LSBU professor and report co-author, Alison Leary, said, “What the results of this study clearly show is that advanced nursing practice needs regulation to help protect the public. Lack of consistency has implications for the wider perception of advanced specialist practice in the worldwide community and the workforce more generally.” Aesthetic nurse prescriber, Lou Sommereux, said, “There is a plethora of different titles within aesthetics which I believe is confusing for the public. Are we cosmetic or aesthetic? Does cosmetic sound frivolous? Or does aesthetic practitioner/nurse give more gravitas? I would like to see unity in our titles across the multi-disciplines.” CEO of the British Association of Aesthetic Nurses (BACN), Paul Burgess, added, “The BACN has always maintained the position that cosmetic nursing should be a specialist category with its own recognised competences and qualifications. We believe if this was the case and nurses were accredited it would lead to greater and enhanced patient safety.” Training

US clinical skincare line Circadia by Dr Pugliese has been introduced to the UK. The range aims to defend the skin from environmental factors during the day and stimulate repair mechanisms at night, to prevent premature ageing and skin damage. The range includes different cleansers, serums, creams and SPF to suit different patient needs. Additionally, the range contains ingredients such as botanicals, vitamins, stem cells and peptides, including green tea, lilac stem cell extract and vitamins A, B, C and E. Circadia has also designed a 22,000 microfibre thread-weave Moisturising Pillowcase to assist in controlling sleep lines. According to Circadia, it helps prevent sleep lines, reduces moisture loss and increases collagen stimulation in sleep and can also be used for post-op care and sensitive skin types. Circadia Skincare is available in the UK exclusively through Unique Skin.

Dalvi Humzah Aesthetic Training announces new neck and décolletage masterclass Dalvi Humzah Aesthetic Training has launched a new practical workshop that will focus on treating the neck and décolletage. Included in The Neck and Décolletage Masterclass will be live demonstrations and hands-on training using a combination of injectable products, chemical peels and topical formulations to create bespoke treatments. The learning outcomes of the one-day workshop include knowledge of topographic anatomy of the neck, an understanding of neck ageing, awareness of safe and appropriate use of injectable and topical formulations, as well as management of adverse effects. Consultant plastic, reconstructive and aesthetic surgeon and lead tutor, Mr Dalvi Humzah, said, “Following facial rejuvenation, the neck and décolletage is a challenging area to treat. We have developed a multimodality treatment pathway combining a unique, minimally-invasive neck stimulation procedure and specific steps in providing an optimal treatment programme for the neck and décolletage. Delegates will be able to develop a bespoke treatment package for their patients to get the best results possible.” The Neck and Décolletage Masterclass is CPD certified and will take place at Wigmore Medical in London on November 15.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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ACE 2018

Brand new Elite Training Experience for ACE 2018 The Aesthetics Conference and Exhibition (ACE) 2018 will return on April 27 and 28 next year with an exciting new training programme – the Elite Training Experience. Four worldrenowned aesthetic practitioners and mentors will bring tasters of their own established training courses over the two-day event, with each session taking place in either the morning or afternoon of each day. The Elite Training Experience will feature Dalvi Humzah Aesthetic Training, led by consultant plastic, reconstructive and aesthetic surgeon surgeon Mr Dalvi Humzah; the RA Academy, led by aesthetic practitioner Dr Raj Acquilla, an aesthetics masterclass led by aesthetic practitioner Dr Tapan Patel; and aesthetic practitioner Dr Kate Goldie will deliver training from her academy Medics Direct. Delegates will have the opportunity to experience each training course for just a fraction of the usual price by upgrading to an Elite Training Experience pass when they register. Aesthetics journal editor and ACE 2018 programme organiser, Amanda Cameron, said, "We are extremely excited this year to be doing something very different with our main agenda. We are partnering with four prestigious training companies to offer the Elite Training Experience where delegates will be able to experience some of the best aesthetic training on offer." Cameron continued, "The standards will be high and the tutors of exceptional quality. We look forward to welcoming delegates next year." Booking for the Elite Training Experience is open now and each session costs £195+VAT. For free access to the Expert Clinic, Masterclasses, Business Track, Networking Event and Exhibition Floor, visit www.aestheticsconference.com Dermal fillers

Revanesse Ultra filler receives FDA approval Medical device manufacturer Prollenium Medical Technologies has announced that its hyaluronic acid dermal filler Revanesse Ultra has been approved by the US Food and Drug Administration (FDA). According to the company, Revanesse Ultra is now indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds in patients over 22 years old. Prollenium founder and CEO, Ario Khoshbin, said, "We have been working towards this goal from the first day the company opened its doors, and to see it come to fruition is a validation of our vision. The US market and its potential will be an exciting challenge for our team, but one that will have many rewards for our business both in the US and globally." Prollenium products are manufactured in Canada and are distributed in the UK by Boston Medical Group Ltd.

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

BACN CONFERENCE 2017 The BACN had a record number of more than 300 nurses and 50+ exhibitors in attendance at the 2017 Conference 'Raising the Bar, Shaping the Future’ in Birmingham on September 16. It was an incredible day celebrating and bringing together aesthetic nurses throughout the UK. Thanks to everyone who attended and to all the exhibitors for making the conference the best one yet.

BACN INITIATIVES We have a number of new initiatives planned for 2017/18 as part of the 2017-2020 Business Plan, including:

• BACN Start-up Programme for nurses entering aesthetics

• BACN Shadowing Programme with experienced practitioners

• BACN Resource Pack • BACN Accreditation Programme

REGIONAL MEETINGS The next round of Super Regional Group Meetings is kicking off in November, starting in Newcastle. There will be a range of sponsors, live demonstrations, and networking opportunities available. Members of the BACN can attend any meeting throughout the UK. 3rd Nov: Newcastle 6th Nov: Leeds 10th Nov: Cardiff 13th Nov: Belfast 20th Nov: Southampton 24th Nov: Birmingham 27th Nov: London 1st Dec: Glasgow 4th Dec: Manchester 8th Dec: Bristol

MEET A MEMBER Sara Jones is a registered nurse and has had a career spanning more than 35 years in the NHS. She has brought her passion and expertise for delivering high quality care and positive patient experience into her new career in aesthetics. Sara is supporting the BACN in the development of robust quality governance systems that support and underpin best clinical practice. A graduate of the University of Wales College of Medicine, Cardiff and Harvard Kennedy Business School, Sara also works as a management consultant, leadership coach and mentor.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Skincare

MATA to deliver postgraduate diploma in clinical education The Medical and Aesthetic Training Academy (MATA) has partnered with Glasgow-based company HC Skills International to deliver a Postgraduate Diploma in Clinical Education. The two-day course, which will be held at Weetwood Hall in Leeds from October 31 to November 1, will be delivered through face-to-face teaching by experienced tutors and educators. It aims to enable learners to understand and apply the principles of teaching and learning, create a lesson plan, teach clinical skills, give effective feedback, as well as design and deliver engaging talks, lectures and presentations. Learners will complete a written examination and must pass observed assessments in microteaching, facilitating discussion, giving feedback and skills teaching. Mr Faz Zavahir, director of MATA, said, "I am delighted that MATA is able to deliver this highly regarded and wellestablished postgraduate qualification. At a time when the work of the Joint Council of Cosmetic Practitioners (JCCP) is gathering momentum, it is vital that cosmetic practitioners not only demonstrate competence and proficiency, but that the clinical trainers and educators responsible for teaching them also have the necessary knowledge and skills to deliver structured, measured and effective learning strategies." The qualification is accredited by UK awarding body EduQual. Nutraceuticals

mesoestetic launches food supplements

Meder Beauty releases new antiageing eye cream Cosmeceutical brand Meder Beauty Science has launched its new antiageing eye cream, Blepharo-Rich. According to the company, the new cream complements their already existing products, Blepharo-Day and Blepharo-Night, and aims to treat thin, dry and ageing skin in the periorbital area. Meder Beauty hopes its product will help to correct the signs of ageing by combining natural ingredients, including jojoba oil, olive scalene and niacinamide, with biotechnology, to restore the skin’s health and enhance its protective and restorative abilities. The company states that the eye cream nourishes and fills the skin, improving microcirculation and brightening the complexion in the eye area. Technology

Consentz launches new management software Software developer Consentz has released an upgraded version of its practice management system, aiming to improve efficiency, profitability and patient experience in medical clinics and hospitals. Consentz co-founder, Dr Natalie Blakely, said, “We are excited to launch our updated software that features pre-populated notes, patient education media, highlighting of consent forms, 'ghosting' tools for photographs and a patient app.” Eyes

DMK introduces new eye product

Skincare manufacturer mesoestetic has introduced six nutraceutical formulations to be used alongside its current skincare products. According to the company, mesocaps provide the body with the supplementation it needs to prevent premature ageing and increase treatment efficacy of other mesoestetic products. Each of the six formulations contains different active ingredients to treat different indications. Included in the range is mesocaps Age Repair, Antiox, Eye Contour Recovery, Krill HA, Sun Defense and Trichology. Managing director of mesoestetic UK, Adam Birtwistle, said, “We are really excited to be launching mesocaps. We feel they really complement the current treatment portfolio of mesoestetic and offer the consumer a new level of pharmaceutical quality food supplements, they are going to be a great addition to a patient's skincare regime.” The products are available in the UK through distributor Wellness Trading.

Skincare manufacturer Danné Montague-King (DMK) has launched the DMK Limited EYE WEB to its product portfolio. According to the company, the product acts like an invisible web that retracts sagging tissue and fine lines, and is formulated with active nutrients that aim to strengthen, protect and brighten eye tissue. Included in the formulation is VP/hexadecene copolymer, caprylyl methicone, paeonia root extract, Pelargonium graveolens flower oil, avena sativa (oat) kernel extract, hydrolysed wheat protein, tetrahexyldecyl ascorbate, tocopheryl acetate, squalene, Boerhavia diffusa root extract and Zanthoxylum bungeanum extract. The company states that these ingredients help brighten dark circles around the eyes, reduce fine lines and wrinkles, firm eye tissue and reduce puffiness.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Awards

e-MASTR to sponsor Best Clinic Support Partner at Awards The newly-launched educational resource platform e-MASTR will sponsor the award for Best Clinic Support Partner at the Aesthetics Awards. The category will celebrate the partner company deemed to offer the best non-clinical support for clinics in areas such as PR, insurance and clinic management software. Founder of e-MASTR Dr Tapan Patel said, "The e-MASTR team and I are delighted to sponsor the Aesthetics Award for Best Clinic Support Partner. After spending the last few months dedicated to perfecting the e-MASTR educational resource for aesthetic practitioners, we understand the hard work and commitment that the Finalists will have put into the support that they offer clinics. It is fantastic to see so many professionals working towards the same goal of enhancing the aesthetic specialty as a whole. We look forward to celebrating everyone’s achievements and presenting the Winner with the e-MASTR Award for Best Clinic Support Partner on December 2!” To view the list of Finalists for this award and book tickets visit www.aestheticsawards.com Supplement

Heliocare launches new oral supplement Skincare range Heliocare is now providing a new oral supplement, Heliocare 360˚ Capsules with ingredient Fernblock, which is designed to reduce sun damage within the skin. A study carried out by dermatologists in the US highlighted that after taking the first Fernblock capsule, the skin’s own ability to protect itself from free radical damage significantly increased. Additionally, the study suggested that the capsule made the skin behave as though it has a naturally darker skin type, creating a greater capacity to protect itself. The company states that each Heliocare 360˚ capsule contains Fernblock, an extract from the fern Polypodium leucotomos, as well as N-acetylcysteine, vitamins B3, C and E, and prebiotics, which all aim to defend skin against damage. Heliocare products are available in the UK through distributor AesthetiCare. Training

New trainers and locations announced for Profhilo HA-Derma has released new locations for training in hyaluronic acid (HA) injectable Profhilo, with seven brand new trainers. According to the company, there has been a huge demand for training which has led to the decision to branch out from London. Regional centres are now located in Essex, Barnsley, Maghull, Bristol, Solihull, Southampton, Leeds and Glasgow. There are also new trainers, with workshops being led by Dr Beatriz Molina, Dr Fab Equizi, Dr Rovshan Izamov, aesthetic nurse Amanda Otto and aesthetic nurse prescribers Anna Baker, Deborah Forsythe and Sharon Gilshenan. Dr Emma Ravichandran and Dr Irfan Mian, the current trainers in Profhilo – a non-crosslinked, BDDE-free HA product that aims to treat skin laxity, will also continue to train. Practitioners interested in attending any of the courses are asked to contact HA-Derma directly.

News in Brief Lynton offers chance to ‘trade and upgrade’ equipment British laser manufacturer Lynton is offering an exclusive equipment trade-in opportunity to all aesthetic practitioners in the UK. The opportunity allows practitioners to upgrade their existing hair removal technology with Lynton’s new device, the DUETTO MT EVO. Any laser systems will be accepted as a trade-in and all enquiries will be quoted with a trade-in price. The DUETTO MT EVO aims to combine and deliver simultaneous emission of both the Alexandrite 755 nm laser and Nd:YAG 1064 nm laser. Obagi Medical announces Ambassador Network dates Global pharmaceutical company Obagi Medical has announced October dates for its Obagi Ambassador Network day. Taking place in London on October 25 and in Manchester on October 26, the event will cover topics such as pigmentation and acne, while also including The Obagi Ambassador Awards which recognises clinical excellence in medical skincare. There will also be a presentation from medical director of the Hair Loss Restoration Institute, Dr Sam Van Eeden. Skincare application technology developed Technology company Cutitronics has developed CutiTron, a device that advises users on how much skincare to apply and when they should apply it. Engineer Dr David Heath, founder and CEO of Cutitronics, said, "Currently, people apply products using guesswork, which affects its results. This is why we have created patented CutiTron technology which enables assessment of personal skin health, much like how a Fitbit tracks your activity." According to Cutitronics, the technology is likely to be available to patients in two years. Apollo Endosurgery announces CE Mark approval Global medical device company Apollo Endosurgery has gained Conformité Européene (CE) Mark approval for its ORBERA365 Managed Weight Loss System. According to the company, the weight loss system is a non-surgical weight loss solution for obese patients. CEO of Apollo Endosurgery, Todd Newton, said, “The CE Mark approval of ORBERA365 is a strong testimony of the system’s safety and efficacy.”

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Training

Harpar Grace appointed as distributor of Déesse LED facial masks Aesthetic distributor Harpar Grace has been appointed as the UK and Ireland distributor of Déesse LED masks. The Déesse portfolio includes a range of LED facial masks that aim to rejuvenate the skin using low-level light therapy. The masks emit non-visible infrared light, visible red and blue light and the option of a galvanic current. Founder and director of Harpar Grace, Alana Chalmers, said, “Déesse is an exciting brand to work with – this product is great as a new standalone treatment, can enhance existing treatments, enable stockists to upsell on bookings and create new client packages. I am looking forward to the opportunity to leverage my retailing, brand management and commercial experience to establish the range as a leading LED system in the UK and Ireland." Chalmers added, "Our team structure enables us to work closely with every account to form a personal and collaborative approach to securing growth for their business. I am really excited about the creative and commercial opportunities the range offers to the professional sector.”

OFAA announces new complications course Oculo-Facial Aesthetic Academy (OFAA) has introduced a new course that aims to educate delegates on the management of filler complications by dissolution with hyaluronidase. The Anatomical Basis of Prevention and Management of Hyaluronic Acid Dermal Filler Complications & Hyaluronidase Wet-Lab course will be directed by oculoplastic surgeon Mrs Sabrina Shah-Desai, while being instructed by plastic and reconstructive surgeon Mr Benoit Hendrickx and consultant oculoplastic and reconstructive surgeon Miss Julia Sen. According to the OFAA, delegates will learn how to dissolve hyaluronic acid fillers with guidance on the dilution of hyaluronidase, how to manage granulomas, and how to place filler safely based on vascular, bone and ligamentous anatomy. They will also be informed of current recommendations for emergency treatment of blindness and will practise supraorbital and retrobulbar hyaluronidase injections on human cadavers. Mrs Shah-Desai, said, “Delegates of this course will gain an insight into reading the surface anatomy and real-time application of facial injectables with an emphasis on patient safety and avoidance of structures in critical danger zone.” She added, “The course is ideal for all healthcare professionals performing filler injections, as they will gain hands-on training and education on the management of filler complications by dissolution with hyaluronidase.” The course will take place on October 7 in London.

BACN Autumn Aesthetic Conference 2017, Birmingham Aesthetics reports on the highlights from the British Association of Cosmetic Nurses Autumn Conference More than 300 aesthetic nurses travelled to Birmingham for the British Association of Cosmetic Nurses (BACN) annual conference on September 16. Taking place once more at the International Convention Centre (ICC), delegates were greeted with more than 50 stands at the exhibition and a range of talks from experienced and renowned speakers. This year, for the first time, delegates were also invited to take part in pre-conference workshops on September 15, at the ICC. The conference, which had the tagline ‘Raising the bar, shaping the future’, also had an underlining anatomy theme throughout the morning of the main event. Consultant plastic surgeon Mr Taimur Shoaib began the Saturday agenda with a talk, taking an in-depth look into the anatomy of the face. This was followed by aesthetic nurse prescriber Melanie Recchia, who spoke on botulinum toxin and its limitations, which also explored the anatomy in relation to injecting toxin. Recchia stressed it is vital to know your anatomy as ‘good patient education starts with good practitioner knowledge’. She provided advice on patient consultation for botulinum toxin treatment, explaining the importance of using the correct language and tone, and understanding and discussing patient expectations. Continuing with the anatomy theme, aesthetic nurse prescriber and BACN board member Lou Sommereux provided a cadaver training review and spoke about her personal experience of attending a cadaver course specifically aimed at nurses.

Sommereux encouraged delegates to strongly consider attending a cadaver workshop as she believes it 'reinforces confidence and expertise’. In the afternoon, Dr Elizabeth Raymond Brown spoke on clinical photography and queried why, although a patient consultation is all about evaluation, not many practitioners spent enough time taking patient photographs. She then spoke about the importance of copyright and data protection and presented statistics taken from a study in Australia, which found that 23% of doctors accidentally showed someone an image of a patient on their smartphone whilst scrolling through their images. Next, Dr Kuldeep Minocha led a Galderma sponsored session on an individualised approach when treating the full face. He explained the differences between the Restylane range of fillers, the difference in particles size and the G prime, before providing a live demonstration. The event concluded with a Merz sponsored session on defining and shaping the lips with Dr Gertrude Huss and Dr Emma Ravichandran, and an Allergan sponsored session on facial rejuvenation with dermal fillers by Dr Tapan Patel. CEO of the BACN, Paul Burgess, said, “This year was a big year for the BACN as we went from a one to a two-day conference; our Friday workshops were a complete sell out and a fantastic success.” He continued, “Saturday was a great day with excellent presenters and lots of networking. We will soon be looking at dates for next year.”

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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On the Scene

Out and about in the specialty this month

TeoLabs Training Day, London Aesthetic company Teoxane UK hosted around 40 guests at the Royal Society of Medicine in London on September 6 for its first ever TeoLabs Training Day. Guests were welcomed in the Naim Dangoor Auditorium by Sandra Fishlock, managing director of Teoxane UK. Fishlock said, “I hope that you all can go home and take away one small thing to add to your practice, and if you have done that, then we have done our job today.” Following the introductions was a presentation on aesthetic ideals, facial ageing and how to construct a comprehensive assessment of facial rejuvenation by Dr Raul Cetto. Delegates were then separated into four different groups, each entering a room specialising on a specific treatment area. Dr Lee Walker’s session discussed redefining and balancing the lip, Dr Bhojani-Lynch looked at correcting the tear trough, Dr Sarah Tonks focused on skin hydration and correcting fine lines, while Dr Cetto explored contouring and strategic volumisation the face. In their individual presentations, speakers discussed topics such as anatomy, the ageing of their specified area and appropriate product choice, before performing a live demonstration on a patient using different Teosyal RHA fillers with the Teosyal Pen injector. Delegates learnt about each area for 90 minutes, before moving to the next room to observe another treatment. After the day’s conclusion, Teoxane brand manager, Jordan Sheals, said, “We are delighted with the success of the event. The objective was for each delegate to take something new back to their practice, whether that be a greater understanding of hyaluronic acid and gel rheology, handling a complication or a new technique. The feedback we have received from delegates has proven our vision to be correct, that practitioners value an intimate learning environment, which offers freedom to interact with the trainer on a one-to-one level. We will definitely host another TeoLabs in 2018.”

CODAGE Launch, London On September 14, a new range of bespoke skincare was unveiled to members of the aesthetic and cosmetic industry press, over an intimate breakfast event at The Ned hotel in central London. The event began with a talk by the founder of UK aesthetic distributor Harper Grace, Alana Chalmers, who introduced herself and the co-founder of CODAGE, Julien Azencott. Azencott explained how he and his sister Amandine, also a co-founder, grew up admiring their family, who were active in the field of medicine and pharmaceuticals. He explained the idea for the range was based on solving individual beauty issues, having a perfect knowledge of active ingredients, and being precise with dosage. CODAGE, which is French for 'code', includes a portfolio of skincare products alongside face and body treatments, all featuring bespoke formulas. The range also includes two serum collections, prêt-à-porter and haute couture. The prêt-à-porter serums can be used alone, mixed, blended or layered and are complemented by a couture offering – 100% custom-made prescriptions created in the CODAGE laboratory in France that respond to each person’s specific needs at every moment of life. Each serum is said to be highly concentrated, containing up to 70% pure active ingredients for maximum effectiveness. These two collections are complemented by cleansers, masks, and creams to ensure a complete skincare routine. Chalmers said, "CODAGE is an exciting brand to work with – especially as there is so much opportunity within the professional aesthetic sector for a customised formulation offering, such as CODAGE, that has the added reassurance of efficacy. CODAGE really offers a luxury, upmarket professional skincare concept which is perfect for the new generation medi-aesthetic clinic concept without compromising on results."

Vida Aesthetics Symposium, London

UK distributor Vida Aesthetics held a CPD validated symposium to showcase its current offerings and to launch new products at Premier Meetings near Hounslow on September 16. The Vida Aesthetics Symposium was an opportunity for delegates to listen to representatives from the company’s suppliers and included five different seminars from industry specialists who presented and demonstrated products. Speaking at the event was Dr Irfan Mian, who discussed the use of PDO threads and dermal fillers and performed a live demonstration, while aesthetician Silvia Bonino discussed the use of aesthetic machines. Export manager of Bioformula, Anna Valagussa, introduced the company’s injectable range, which includes Jalucomplex, Plenhyage and Evanthia and in the same session, Dr Georgio Astolfi discussed their use and performed a live demonstration. Dr Dina del Socorro from Toskani Cosmetics presented her experiences using mesotherapy and peels, while in a separate session, founder of skincare company Alphascience, Julian Revol, discussed his company’s extensive range. Launching at the Symposium was the three-step patented system for pigmentation, UNIQ-WHITE, by nunii Laboratoire. President and co-founder of nunii Laboratoire, Niamh Cogan, introduced the new system and explained how the technology works. After the event, director of Vida Aesthetics, Eddy Emilio, said, “We wanted to launch our new products and also update our clients on our existing range, so we organised this event so product developers, doctors and business owners could come together to pass on their knowledge.”

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Language in Aesthetics Aesthetics investigates the use of the term ‘antiageing’ and questions whether practitioners should refrain from using it in patient communications In August this year, the editor-in-chief of US-based beauty magazine Allure announced that the publication would no longer use the term ‘antiageing’. In her statement, Michelle Lee said that by using the word, “Whether we know it or not, we’re subtly reinforcing the message that ageing is a condition we need to battle – think antianxiety meds, antivirus software, or antifungal spray.”1 Described by its publisher Condé Nast as ‘an insiders’ guide to a woman’s total image’, Allure has a print audience of 6.2 million and an average monthly online audience of 4.3 million.2 Speaking to the magazine’s millions of predominately female readers, Lee argues that there needs to be more recognition of the fact that growing older is inevitable and we need to celebrate it. “This issue is the long-awaited, utterly necessary celebration of growing into your own skin – wrinkles and all. No one is suggesting giving up retinol. But changing the way we think about ageing starts with changing the way we talk about ageing,” she says, concluding, “We know it’s not easy to change packaging and marketing overnight. But together we can start to change the conversation and celebrate the beauty in all ages.” Whether it’s an appropriate term or not, ‘antiageing’ undeniably creates big business. Countless skincare brands, as well as aesthetic clinics, use the term to promote their products and services – for example, type ‘antiageing’ into Google and it generates more than 11 million results.3 So, Aesthetics asks, is it necessary to stop using the word ‘antiageing’? And if so, how can practitioners start changing the conversation?

The developments in ageing Consultant dermatologist Dr Anjali Mahto supports the notion of changing the language used to communicate with patients. “I think it’s great actually and will really catch on,” she says, explaining, “The concept of ‘old’ has changed – you see 50-, 60- and 70-yearolds who don’t feel ‘old’. What they see in the mirror is a total mismatch from what they see on the inside.” She continues, “The truth is, we don’t like the idea of antiageing

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anymore because women are living a lot longer, they’re working, they’re financially independent; a lot will choose to have children at a much later age. It’s not surprising that if you become a mother at 40 rather than 25, you’re not going to feel ‘old’.” Aesthetic practitioner Dr Sam Robson, however, suggests that we should not stop using ‘antiageing’. “I think ageing is a condition that we do need to battle,” she says, explaining that we can still use the word, but change the conversation to focus on the options available to patients that help minimise the effects of time and the environment by protecting and repairing the skin. “Let’s do all we can to keep ourselves healthy and youthful,” she says. Dr Mahto goes on to emphasise how women’s experience of ageing has developed. “What I personally find interesting is that in the last 100 years or so, life expectancy has increased quite significantly, but the age of menopause has changed very little,” she says, continuing, “So what this means is that there is a larger number of females now spending time in an oestrogen-deficient state.” And, she explains, as most aesthetic practitioners are aware, this means that the majority of a clinic’s business is likely to come from older, post-menopausal women. “In some ways, there’s no point chasing the younger crowd, it’s the older crowd that you want to relate to and explain to them that the skin changes they are seeing are completely normal,” she says.

Changing the language used PR consultant Julia Kendrick also acknowledges the benefits of adopting different words and phrasing in aesthetic clinics. “Women are faced with a culture that values youth and a natural appearance, with youth being thrown at them from every angle. While the magazine was primarily talking about the use of ‘antiageing’ on cosmetic products and over-the-counter creams, it’s imperative that practitioners pay attention,” she argues. On the other hand, Dr Robson notes the common use of the word and says, “By not using the term ‘antiageing’, you risk making it the ‘elephant in the room’. Even if we don’t use the term, we will still think it and react towards it.”

"Women are faced with a culture that values youth and a natural appearance, with youth being thrown at them from every angle" Julia Kendrick, PR consultant

While language such as ‘antiageing’ and ‘reclaim youth’ may make sense logically, women are much more motivated by positive images of ageing, claims Kendrick. To exemplify this, she draws a comparison to the public’s perception of 59-year-old popstar Madonna and actress Helen Mirren who is 72. “The media ridiculed Madonna, not necessarily for the procedures she’s had done, but more so for her fitness, crazy outfits, diet and lifestyle, which seemed to be an attempt to hang on to her youth. It was portrayed as desperate, unattractive and not what women should want as they

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

Aesthetics

age,” she explains. In the case of actress Helen Mirren, Kendrick notes that she is often represented as a positive example of ageing – Allure used her as its cover model for the issue in which its stance on ‘antiageing’ was announced. Lee wrote, “Look at our cover star Helen Mirren, who’s embodied sexiness for nearly four decades in Hollywood without desperately trying to deny her age.”1 For Dr Mahto, avoiding the use of ‘antiageing’ and phrases such as ‘getting older’ is already a part of her practice. She says, “I phrase the ageing process more as ‘as time goes on’ or ‘it’s natural for skin to do XYZ because of XYZ’. For post-menopausal women, I say, things like ‘This is what happens after the menopause; your oestrogen levels drop and it effects XYZ – it’s what happens to everybody’." Kendrick adds that phrasing the results as ‘looking well’ and ‘refreshed’ are also beneficial. She also agrees with Dr Robson’s sentiment and highlights that there will be women who do respond well to ‘antiageing’. She explains, “For some women, beauty is business. They can be very focused career women, who want to keep ahead of the game. For them, they will often relate to a more ‘problem-solution’ approach rather than soft language that taps into emotions.” As such, understanding your patient demographic is vital, says Kendrick. “There’s not one size that fits all,” she says, adding, “You should shape your communications in a way that subconsciously addresses individual patients’ concerns before they even step foot in the clinic.”

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The evolution of communication Both Kendrick and Dr Mahto agree that Allure’s decision to change the language the magazine uses can have a positive impact on patient interactions. “It’s just smart business to tap into the ways in which women need to be communicated to,” says Kendrick, while Dr Mahto adds, “I think it’s sensible to follow suit. If you look at it from a purely commercial point of view, we know that it’s the older population that have the money to spend on these treatments.” Dr Robson, however, suggest that using alternative terminology may risk missing the opportunity to market to people who might not immediately grasp the subtlety of a more 'politically-correct' term. As such, Kendrick emphasises, “The key here is a solid knowledge of your clinic demographic and targeted communications. If your main tranche of customers are women who actively express a high interest in looking ‘youthful’, as opposed to ‘good for their age’ or ‘refreshed’ – incorporating the term ‘antiageing’ into your PR and marketing is likely to resonate more successfully, as it will tap into their desire to ‘fend off’ the effects of ageing and provide a robust solution to their concerns. They will feel that you are listening to their concerns and are providing products or creating treatments tailored to their needs – thus increasing your chances of attracting and retaining this particular audience.” Dr Mahto concludes, “I think it’s really important that this growing sector of post-menopausal women in the market is adequately looked after and they’re not pushed into the sidelines because youth is still a hallmark for beauty.” REFERENCES 1. Michelle Lee, ‘Allure magazine will no longer use the term aging’, (US: Allure, 2017) <https:// www.allure.com/story/allure-magazine-phasing-out-the-word-anti-aging> 2. ‘Allure’ (US: Condé Nast, 2017) <http://www.condenast.com/brands/allure/> 3. ‘Antiageing’ (UK: Google, 2017) <https://www.google.co.uk/search?client=safari&rls=en&q=antiag eing&ie=UTF-8&oe=UTF-8&gfe_rd=cr&dcr=0&ei=G6G6WYm3ConHXov9n5Gg>

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Susanne, actual Belotero® patient age 46

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M-BEL-UKI-0179 Date of Preparation September 2017

Patients today don’t want a filler that ‘owns’ them; they want a filler that naturally integrates into their tissue so that they can retain their identity and express their emotions with confidence. Belotero® is not about painting by numbers for a generic look; it’s a palette of HA fillers that enables a practitioner to tailor treatment by analysing the face and using the correct tools and techniques to respect a patient’s individuality.

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

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Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information:M-BOCUK-0067. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the Xseverity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1ml (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients

may 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). Hypersensitivity reactions have been reported with Botulinum neurotoxin products. 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. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: February 2017. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

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Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143. 1. Bocouture® 50 units Summary of Product Characteristics (SmPC). March 2016. Available from: https://www.medicines.org.uk/emc/ medicine/23251. 2. Bocouture® 100 units Summary of Product Characteristics (SmPC). September 2016. Available from: https://www.medicines.org.uk/ emc/medicine/32426 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomized, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0085 Date of Preparation June 2017

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Aesthetics

Difficult Conversations Practitioners explain how they answer some of the more challenging questions during patient consultation and explain how to say ‘no’ to certain treatment requests The panel: Dr Stefanie Williams (SW) is a dermatologist with special interest in aesthetic medicine. She is founder and medical director of Eudelo, a multiaward winning private skin clinic in London. Jackie Partridge (JP) is an aesthetic nurse prescriber and completed her BSc in Professional Practice (Dermatology) in 2014. Partridge is an honorary board member of the BACN and a global ambassador for Galderma. Dr Jane Leonard (JL) is a GP and cosmetic doctor who specialises in skin conditions, antiageing medicine and bioidentical hormones. Dr Leonard achieved a first-class honours degree in Anatomical Sciences. Dr Tijion Esho (TE) of The ESHO Clinic is a cosmetic doctor who graduated with honours from Leicester Medical School in 2005. He has completed extensive advanced level medical training, and is a member of the Royal College of Surgeons (MRCS). Jennifer Izzarelli (JI) is a board-certified acute care nurse practitioner and aesthetic nurse specialist, located in Southern California. Izzarelli enjoys combining her surgical training with non-surgical aesthetic treatments.

Every practitioner knows the importance of a thorough and detailed consultation. Gathering the patient’s medical history and understanding their requests is not only imperative to assure their safety during the procedure or treatment, but also to ensure the best possible results. Another significant aspect of the consultation is allowing time for patients to ask questions. Most of the time, for experienced practitioners, queries are easily answered. However, there may be occasions when more challenging questions are asked, where there is no straightforward answer. In this article, we ask five aesthetic practitioners how they make sure patients feel comfortable enough to ask questions during their initial consultation, pose eight questions that commonly arise and ask, how do you say ‘no’ to treatment requests?

Creating the setting Aesthetic nurse prescriber Jennifer Izzarelli believes time is the principal factor in making sure patients have the chance to ask questions, “I schedule all of my consultations for 45 minutes and in that time, I let my patients lead the conversation. I hand them a mirror,

sit next to them and together we discuss what brought them in to the clinic, their concerns, their fears and any questions they have.” Asking the patient questions will also prompt the patient to think of their own, according to aesthetic nurse prescriber Jackie Partridge. “We prep the patient by asking them specific questions, which gives them an opportunity to think, ‘Why are they asking that?’ Which may trigger questions of their own,” she explains. Aesthetic practitioner Dr Tijion Esho ensures his consultations are very patient-focused, “It is important to know their ideas, concerns and expectations. The key to this is to ask open questions and listen and reflect on the answers to check they have a full understanding of what the treatment involves.” He adds, “A lot of the time humour and a calming manner, while showing empathy, really settles a patient.” GP and aesthetic practitioner Dr Jane Leonard also agrees that it is important to have a patient-led approach to allow the patients to feel comfortable enough to ask questions. She explains, “We really want them to trust us, so we need to build a rapport; you have got to be open, honest and transparent, and willing to answer questions.” Dr Leonard continues, “I revert back to communication skills ingrained in me from GP training and that is taking a patient-centred approach rather than doctor-centred. This means you give them time to speak freely during the consultation so you can identify their ideas, concerns and expectations regarding the treatment.”

Challenging questions There are many questions that patients ask that may be less straightforward to address than others. Below are eight examples which, according to the practitioners interviewed, commonly arise during consultation, and advice on how they can be effectively answered.

1. Will people be able to tell if I have had something done? TE: There are two groups of people – the first group say they do not want anyone to notice they have had the procedure, so in this case I would say, ‘All treatments will be subtle and natural’. People may just notice you look fresh and more rejuvenated but won't be able to tell why. However, the second group of patients say that they want people to notice the work but say it looks great, not fake. On this occasion, I inform them that, ‘Your results will look natural and I'm confident that you and everyone else will think you look great’. SW: When it is an injectable treatment, I always say, ‘In the first few days there might be bruising and swelling, but, once that has settled, people will not know’. I usually discuss with them that I will firstly do a very conservative treatment, which will guarantee that nobody will be able to tell and then they come back in two weeks for a follow-up appointment and I will add more if it is not enough. JL: I want patients to know that they will look better, they will look

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fresher, and they will see ‘improvement’ rather than ‘change’. I would say, ‘From my experience and from previous patients that have had this, they don’t have people coming up to them saying, oh wow you have had your lips done! But they get reports of people saying they look good and their lips look good’.

2. Is it going to hurt? JP: My opening line with all my patients is ‘I am a wimp, and if I can have this done then so can you!’ I do try and reassure them that I will do everything in my power to make it as pain-free as possible. JL: You need to be clear and tell them the truth. I say, ‘A lot of the treatments we do in clinic that can cause pain, can be controlled’ and I emphasise that if they can’t tolerate it they must let me know straight away. SW: To make patients feel at ease, we explain they will get a 15-minute appointment with my medical assistant an hour before I see them for an injectable treatment and they will have the numbing cream applied. I tell them there could be a mild discomfort still, but it is completely tolerable.

3. I don’t want to have before and after pictures taken – do I have to? JI: I explain that photos are part of each patient’s medical record. I would say, ‘The treatments that are being done are medical procedures and photographs are a great tool to document the journey to create a visual aid to see the improvement after treatment’. SW: I reassure the patient that the images are stored safely and stress the importance of having them taken – sometimes the patient will turn around after treatment and say ‘Look, you made this appear (a lesion, for example)’. So, I explain to them that we may solve one issue but then they may suddenly see something they didn’t notice before and think the treatment caused it. Thus, we need photographs to look back at and show it was already there.

"I would explain to the patient that a cut-price treatment often means that the other practitioner may be cutting costs behind the scene, and that the price of treatment reflects the quality of work, quality of products and the care being delivered" Dr Jane Leonard, aesthetic practitioner

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JP: If patients refuse to have photographs taken then I refuse to treat them. I explain that it is part of my duty-of-care and my insurance policy. I need to have a before photo as a benchmark of what their face looked like before treatment. So actually, if they do not want to or refuse to have them, I say, ‘That is fine but unfortunately, I won’t be able to treat you’.

4. I’ve seen this treatment advertised cheaper elsewhere – can you match the price? JL: In this circumstance, I would explain to the patient that a cutprice treatment often means that the other practitioner may be cutting costs behind the scene, and that the price of treatment reflects the quality of work, quality of products and the care being delivered. If you explain to patients why you cannot lower the price confidently, then they will understand it is not all about the sale. JP: ‘Probably not’, would be my answer, as you get what you pay for. I like to think we are reassuringly expensive, and explain, ‘You are paying for my years of experience and knowledge’. TE: I tell patients, ‘Cheaper is not always better when it comes to aesthetic treatments. I pride myself on delivering a high standard of results with the best products and as such, the price reflects not just this but also the ongoing care our clinic will give you. The price is always fixed to remain fair to all our patients’.

5. How quickly can I have the treatment? Can I have it today? SW: I make it clear to the patient that there has to be a cooling-off period1 where they can think about the treatment. I explain that our appointments are scheduled in a way where we can have a very extensive consultation but I am not going to rush the treatment to have it in the same timeslot. TE: There's never a rush to have a treatment. I explain, ‘Aesthetic treatments are most often a want, not a need and it's important you take time to go over the information given. If you have more questions or, on reflection, you feel you don't want to proceed right now or at all, that is absolutely normal. If you are happy to proceed after reviewing all the information, my team will book you into the next available date based on our availability and yours. This is the safest way to make sure you make the right decision for you’. JP: The answer to this usually depends on the treatment and is also patient-dependant. International patients who travel to see you don’t want to come back the next day for treatment, so we will try and accommodate them as much as possible, for example, we may have already spoken over FaceTime prior to them attending clinic. I am very much using the consultation to see how much they understand what the treatment entails and if they have made an informed decision. If I have any doubt at all, then I will say that I do not want to go ahead with treatment today and ask them to go away and think about it.

6. What products do you use and are they the best? JP: I am really proud of what I use, and I would explain that I use products that have FDA approval and a good clinical history. People will come in and say, ‘I want such and such’ and I will explain that I don’t use that in my clinic but I use ‘this’ and explain why. I will say, ‘I believe that as a practitioner it is going to give you a superior result and that is why I have chosen to use it’. TE: There's never one best treatment or product, only the product that the practitioner feels is the best and safest to use at that particular time. I would say, ‘In your case I will be using X based on Y as I believe this will be the best and safest way to achieve the desired look'. JL: I tend to have preferred brands of fillers I work with but if the

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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patient wanted a different type of filler that I’ve used before and I feel confident in using it, then I would do it. It also comes down to the practicality of it. I would ask ‘Why do they want it?’ To really understand the reason.

7. How likely is it that I will have a complication or side effect? JI: I explain that with any procedure, there is a risk for complications. Experienced injectors know the signs of a complication and can act quickly to minimise any long-term effects, so by having an experienced injector, the risk is lower. JL: You have to be honest and clear. I would explain the common side effects and say, ‘It is likely you could get ‘X, Y, Z’, however, side effects, such as infection and granuloma are very rare’. JP: I explain that it depends on what is being treated. It is my duty of care to inform the patient of all the things that could go wrong or could happen. I would say, ‘There is a needle going into the skin so I can’t guarantee you won’t get a bruise’. I would make sure they are not in a position where they cannot afford to get a bruise, such as if they are going on a date the next day.

Aesthetics

“I do not allow anybody else into the treatment room but they can bring someone over the age of 18 into the clinic to wait in the waiting room” Jackie Partridge, aesthetic nurse prescriber

8. Can I bring a friend or have a chaperone with me? TE: I would say, ‘Your friend is more than welcome to come and observe if this will make you feel more comfortable during the procedure’. Good medical practice states we should have a staff member trained in chaperoning,2 so my clinical assistant will be there to keep them comfortable at all times. JI: I would say absolutely. Having someone present, that patients trust, can ease anxiety. JP: I do not allow anybody else into the treatment room but they can bring someone over the age of 18 into the clinic to wait in the waiting room. This is because the last thing a practitioner needs is a friend fainting during the treatment, which I explain to them. We don’t let anyone under the age of 18 into the clinic at all as we do not feel that it is clinically appropriate.

more’ approach and really explain facial symmetry to them so they understand what looks natural and in proportion. JP: I used to see a patient who had been over-treated elsewhere so I spent a lot of time taking dermal fillers out, rather than putting them in. Over time, she asked if I would treat her with injectables and I explained that her appearance and behaviour suggested she may have some form of BDD. I offered to refer her to a doctor of clinical psychology, who works in our practice, and cover the costs of her treatment. I explained that I would only treat her once she had been seen and was assessed. She refused, so I had to refuse treatment. It was difficult and it meant losing a customer, but I was doing it to protect the patient. My only concern now is that she has gone somewhere else to see someone who might not have the patient's best interests at heart and are only concerned with making a sale.

Saying ‘no’ The practitioners who took part in this article agreed that one of the most difficult situations was saying ‘no’ to patients who they either suspect to have body dysmorphia disorder (BDD), who have already had too much treatment done, or who the practitioner feels does not need that treatment. Finally, we asked the practitioners how they would deal with this situation: TE: I believe what really makes a good practitioner is knowing when not to treat. On these occasions, I state, ‘Although I completely understand why you feel you need this procedure, from my assessment of you, I don't think this is the correct treatment for you because of X. If I’m saying no, it’s because I have your best interests at heart’. JL: I think you have to take the honest approach and do it in a factual way. You say ‘I have heard your point of view and what you are trying to achieve, and from my experience your ideas and expectations do not match what the treatment provides'. Offer them alternatives and say, ‘Well you would be a candidate for another type of treatment’. Even if you don’t do that treatment, you can refer them, so it is not a complete ‘no’. JI: This is always a delicate subject, especially in this day and age of online reviews. I have an honest conversation with my patients and discuss their concerns and goals and explain what can realistically be done. I try to show them what they can achieve with a ‘less is

Conclusion It’s important to allow patients to ask questions and even more important to make sure that patients are given detailed answers, which thoroughly explain the reasoning behind clinical decisions. Although saying ‘no’ to some requests may be more difficult than others, what is of utmost importance is the safety of patient, says Dr Leonard, concluding, “I think when you are under pressure for time, you tend to take a more doctor-centred approach, which is basically asking direct questions. That way, you often get the answers you want, but it could affect your relationship with the patient. The key thing is to make that investment as, if the patient does not trust you from speaking to you, then they are never going to trust you taking a needle to their face.” REFERENCES 1. Guidance for all doctors who offer cosmetic interventions: a public consultation on our draft guidance, GMC, (2017) <http://www.gmc-uk.org/Guidance_for_all_doctors_who_offer_cosmetic_ interventions__consultation_220515_FINAL.pdf_61261996.pdf> 2. Intimate examinations and chaperones, GMC, (2013) <http://www.gmc-uk.org/guidance/ethical_ guidance/21168.asp>

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Treating Asian Skin

Anatomy and physiology

It is useful to consider where Asian skin fits in the Fitzpatrick Scale. The Fitzpatrick Scale takes account of two factors: skin colour and response to UV Miss Mayoni Gooneratne explores the anatomy radiation and sunlight (Figure 1). In comparison to Caucasian skin, Asian skins have of Asian skin and how to most effectively treat it darker pigmentation, and fall within the higher Fitzpatrick categories. However, there is great for aesthetic concerns variation in skin tones within the Asian category. Abstract Whilst Asian skin predominantly falls into categories IV to VI, Chinese The purpose of this article is to explore the differences between skin, usually, falls within types II and III.7 Asian skin and other types of skin, and how these differences impact It is also important to note that skin colour does not necessarily on aesthetic treatments. The article defines what ethnicities are and predict response to UV radiation.7 This is a key consideration if laser are not included in the ‘Asian’ category, it discusses the anatomy or light therapies are to be used, of which more will be discussed and physiology of Asian skin, how Asian skin ages and the signs later in the article. of ageing, before going on to discuss the most effective aesthetic The colour of our skin depends upon the distribution and density treatments and those that should be used with caution. of melanin within it. Melanin is produced in the basal layer of the Asian skin has different levels of epidermal melanin pigmentation epidermis by melanocytes, specialised cells within melanosomes, compared to other ethnic skin types,1 and it is this pigmentation via a complex process known as melanogenesis.8 In this process, 2 which influences the ageing process. This also has implications melanosomes take in tyrosine and enzymes, and chemical for the treatments used to address ageing and other aesthetic reactions between the two convert the tyrosine into melanin. concerns. Practitioners must take account of the tendency towards Melanocytes then remove the melanin from the melanosomes, post-inflammatory hyperpigmentation (PIH), and plan accordingly, passing them to the keratinocytes, which are in the topmost layer taking detailed histories to determine Fitzpatrick skin type. of the skin.9 When melanin is passed to the basal layer in this way, In this article, recent research is consulted to identify the latest it leads to pigmentation.10 findings, opinions, and recommendations made for best practice. Interestingly, all ethnic groups have a similar number of melanocytes within the skin; the different skin tones result because of variances Introduction in the level of melanocyte activity, and how the cells are grouped The British Asian ethnic group has seen some of the largest together.11 In darker skins for example, large melanosomes are population increases in recent times, according to the 2011 UK surrounded by the membrane, whereas in lighter skin, smaller Census.3 This group, which includes those of Indian, Pakistani, melanosomes are clustered together in a single membrane.12 It has Bangladeshi, Chinese and Korean descent – but not those of Arab also been found that, in darker skin the melanosomal packaging is descent, currently makes up 6.9% of the UK population, or just under closer to the basal layer than Caucasian skin.12 3 4.4 million people. Despite many studies into the subject, there is still a lack of Asian skin has structural and functional differences when compared understanding of the significance of differences in skin structure to Caucasian and other skin types,4 and this not only impacts how the between the races. Results of studies are often based on small skin ages, but also the types of treatments that will be most effective. sample sizes, and are sometimes contradictory, or hard to compare Whilst Asian skin benefits from increased photoprotection, thanks due to differing methodologies.13 Many focus on the role of to an increased melanin content, this can bring problems of its own, epidermal pigmentation alone, while potential differences in dermal including more prominent age spots and other pigmentation disorders. composition and epidermal structure are overlooked.13 As well as intrinsic and extrinsic factors, there are cultural differences There is some research that indicates that skin of colour has a when it comes to beauty ideals. Even within the broader Asian skin thicker and more compact dermis,13 whilst other research points to category, there are differences in desired outcomes. For example, differences in dermal collagen structure, the abundance of surface certain cultures are particularly keen to avoid any excess pigmentation lipids, larger fibroblasts and possibly a thinner stratum corneum.11 5 – in China, darker skin is associated with poorer backgrounds – whilst A study published in the British Journal of Dermatology in 2014 other cultures focus on eradicating all lines and wrinkles. Knowledge looked at epidermal morphology and dermal composition in and understanding of all these factors is essential when considering individuals with diverse geographical histories.13 The report the desired outcomes for people of Asian descent, and creating concluded that, ‘While fundamental differences exist in skin structure appropriate treatment plans. and composition in individuals of diverse geographical ancestry […] further research into the functional signiﬁcance and clinical consequences of these Skin type Skin colour Characteristics differences is warranted’.14 I White or very pale Burns very easily, rarely tans II

Pale white

Usually burns, tans gradually

III

Pale to light olive

Sometime burns, average tanning

Light to moderate brown

Rarely burns, tans with ease

Medium to dark brown

Very rarely burns, tans very easily

Black

Does not burn, tans very easily

Figure 1: Fitzpatrick skin type table6,7

Aesthetic analysis The Asian category encompasses a large geographical area, and contains a varied population. It is a mistake to think of the group as homogeneous; there are many facial types and aesthetic ideals within it. In 2016, a consensus group of dermatologists and plastic

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surgeons met with one objective: to optimise aesthetic botulinum toxin type A treatment safety and efficacy for patients of complete or part-Asian ancestry. As a result, ‘A number of treatment indications, strategies, and dosages were identified in Asians, which are distinct to those previously described for Caucasians, due to differences in facial morphotypes, anatomy, and cultural expectations’.15 The group went on to propose a classification of three Asian facial morphotypes. It is a pan-Asian classification, encompassing North and South Asians, although those from the Indian subcontinent or Middle East are not included. The three morphotypes are defined mainly by geographical origin: • Type I, ‘Northern’, includes those from Mongolia, part of Korea and Northern China • Type II, ‘Intermediate’, encompasses Southern China, Hong Kong and Taiwan • Type III, ‘Southern’, includes Malaysia, Indonesian, Vietnam, and other Southeast Asian countries15 This demonstrates the heterogeneity of the Asian group. Analysis of facial structures suggests that Asians have a ‘weaker’ facial skeletal framework than Caucasians – for example higher eyebrow, lower nasal bridge and a flatter mid-face.16 This means that the soft tissue of the mid-face is more subject to the forces of gravity, and Asians are more likely to experience tear trough formation.11 According to an analysis by McKnight et al. of the differences in facial morphology, East Asians typically have narrower mouths, wider lower nasal margins and an elongated intercanthal width, whereas South Asians typically have a well-developed nasal bridge, fuller lips and higher cheek bones.17 It is pondered that these features provide more support as the face ages, than for other Asian ethnicities. While smooth skin and a clear complexion is desirable for most Asians, according to dermatologist Dr Roopal V. Kundu, who spoke at the American Academy of Dermatology’s Summer Academy Meeting in 2010,18 there can be differences in the facial aesthetic preference. In a study by Dobke et al. they aimed to identify where a difference in aesthetic values exists between various oriental Asians. The study was based on a survey regarding facial aesthetics conducted with two selected groups: 50 Korean and 50 Japanese women. Preferences regarding the periorbital region, nose, lip features, and overall harmony of the face were surveyed. Significant differences in preferred beauty features were identified, especially with respect to the periorbital region. Although a supratarsal crease was found to be desirable in both groups, Koreans were found to prefer a larger fold paralleling the lid margin, with elimination of the epicanthal fold. Japanese women desired thinner lips, with more delicate facial features.19

How Asian skin ages The ageing process in Asian skin manifests in different ways from Caucasian and other ethnic groups. Whereas Northern-European women usually experience wrinkles as the first and most evident sign of ageing, Asian women more often notice pigmentation changes first.20 This increased pigmentation in the skin affords Asian skin to have greater photoprotection. The energy of damaging UV photons is converted into harmless amounts of heat, limiting the generation of free radicals.14 This influences the rate of skin ageing as Asian skin ages more slowly than Caucasian skin,20 and, on average, the classic signs of photoageing are not seen until beyond the fifth decade.11 The clinical signs of photoageing, such as lentigines, facial lines

Aesthetics

and wrinkles, and loss of elasticity typically occur 10 to 20 years later than among Caucasians.16 Asian skin also has better protection against some skin cancers – displaying relative protection from basal cell carcinoma and squamous cell carcinoma, for example.16 It is important to note, however, that incidence of skin cancer depends on many other factors, including geographical location, and cultural differences such as how much skin is covered by clothing.21 However, the photoageing process does still affect Asian skin eventually, and is the main factor in increased or uneven pigmentation. It also causes damage to dermal collagen and elastin.11 Asian skin can be particularly badly affected by PIH, and this damage increases with age.16 As the name suggests, PIH is an excess of pigment following inflammation. It occurs within the dermis, when inflammation causes damage to the basal keratinocytes, which then releases large amounts of melanin.16 This melanin is then phagocytosed by melanophages in the upper dermis; the result is a discolouration to the skin at the site of injury.22 The inflammation can be caused by skin disorders, such as acne, allergic reactions, and atopic dermatitis, as well as by therapeutic interventions such as dermabrasion, chemical peels and light therapies.23 Signs of ageing Asians and those with darker skin tones more often experience deeper folds in the skin, in particular prominent nasolabial folds, in comparison to Caucasians who usually see fine lines and wrinkles first.24 Melasma, a form of hyperpigmentation similar in appearance to age spots, presents as large darker spots on the skin of the face and sometimes other sun-exposed areas, such as the forearms. It is most common among dark-skinned Hispanic and Asian individuals, and more common in women than men.7 The exact incidence of melasma is not known, but further reading on the condition can be found in the report 'Melasma: a clinical and epidemiological review' by Ana C Handel et al.25 Dermatosis papulosa nigra (DPN) are small, benign, black or brown lesions, usually appearing on the skin of the face and neck, and are most common among those of South Asian descent.26 They can occur from adolescence onwards, and their incidence increases with age.26 Women are more likely to experience these than men,25 and can be very self-conscious about their appearance.

Treatment Whenever treating a patient of Asian descent, I recommend that practitioners proceed with caution. The tendency of Asian skin towards PIH, and in particular those of Fitzpatrick skin types IV, V and VI, is an important consideration. The first step should always be to correctly assess the patient’s Fitzpatrick skin type, by taking a detailed history, including asking the patient how their skin responds to sun, and confirming their ethnic background, if possible. A visual assessment is not enough – skin colour alone may not predict response to melanin-targeted therapies,7 such as laser or light therapies. Any treatment that causes inflammation in the skin, for example, injectables, laser and light treatments, and dermabrasion techniques, can trigger PIH.27 Laser devices, for instance, target deeper layers of the skin, but the melanin in darker skins can absorb this energy instead, causing damage.28 In this case, treatment could lead to blistering, permanent changes to pigmentation (dyspigmentation), changes in skin texture, and scarring.7 Taking a detailed history from the patient is also important as in

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

@aestheticsgroup

some cases, where patients exhibit recurrent problems, a referral to an Asian skincare specialist might be the best approach. This will depend on your own level of experience and expertise. Botulinum toxin type A and fillers Botulinum toxin type A has been found to be safe and effective for use on Asian skin,29 as have hyaluronic acid fillers.30 However, particular care must be taken with the areas chosen for treatment. Those of Asian descent typically have a square jawline.15 It is possible to masculinise the face if fillers and botulinum toxin are not used carefully, so this must be borne in mind in the treatment plan.

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of higher quality (including randomisation and controls, for example). The review included both ablative and non-ablative technologies, in the treatment of acne scarring, hypertrophic scars and melasma, as well as photorejuvenation. The review concluded that, for the treatment of melasma, fractionated non-ablative devices should be used with caution, due to the risks of PIH and rebound worsening of the condition.34 Evidence from the review of 11 studies relating to melasma suggests that this risk can be lowered if a greater number of treatments, at lower density settings and with wider treatment intervals, are given.34

Conclusion

A recent review by Wat et al. found that fractional resurfacing is a safe and effective option for the treatment of scarring and photorejuvenation in ethnic skin types Hydroquinone Hydroquinone inhibits melanogenesis, which is the production of the pigment melanin.31 For PIH, I usually prescribe a six-week course of 4% hydroquinone before treatments where PIH could be a problem, and similar follow-up regime. I also recommend vitamin C post treatment. The use of a high SPF sunscreen is also essential, both to ensure the hydroquinone is effective, and to protect the skin.32 Reducing the melanin in the skin means it is more vulnerable to sun damage, and more likely to burn. Hydroquinone should only be used under medical supervision, as long-term use can lead to the condition exogenous ochronosis, a grey-brown or blue-black hyperpigmentation of the skin.33 Chemical peels Chemical peels create an injury to the as such, their use can have adverse effects, such as triggering PIH – but they can also be very effective in treating more resistant pigmentation.15 The use of chemical peels to treat acne and acne scarring in Asians has been supported by research.34,35 The two reports cited give details on specific peels used, but admit that further clinical trials are needed to explore Asian skin in more detail. Light therapies and laser treatments For very resistant pigmentation problems, light therapy and some laser treatments can be helpful. Intense pulsed light (IPL), for example, can be used to treat Fitzpatrick skin types I-IV. However, many current lasers are not suitable for types IV-VI, as they disrupt the natural skin colour.34 A recent review by Wat et al. found that fractional resurfacing is a safe and effective option for the treatment of scarring and photorejuvenation in ethnic skin types.35 The review looked at 103 relevant studies, placing greater emphasis on those

The Asian group is broad and varied, with many differences in skin tone and also in aesthetic ideals. While there remains a dearth of detailed research specifically into Asian skin, there are structural and functional differences that influence not only the rate and nature of skin ageing, but also the types of treatments that are most effective. While the increased pigmentation in Asian skin confers photoageing benefits, it can also be the cause of complaints such as excess pigmentation and age spots. Many aesthetic treatments are themselves capable of triggering more pigmentation problems, as a result of PIH. The most important consideration for any practitioner, and the first step in any aesthetic treatment, is to assess the risk for PIH. As a first step, practitioners should always fully assess the patient’s Fitzpatrick skin type before embarking on any treatments. Skin colour and characteristics will not always correlate, and it is these characteristics that are vital to the success or otherwise of aesthetic treatments. Good skin preparation is also an essential step and I recommend the use of a preparatory and post-treatment hydroquinone cream, as this can help to reduce the likelihood of excess pigmentation problems arising. Where necessary, a referral to a practitioner who specialises in treating Asian skin may be required, especially for those with long-term or recurring skin complaints. Miss Mayoni Gooneratne is a graduate of St George’s Hospital and has been a member of the Royal College of Surgeons since 2002. Miss Gooneratne has completed extensive training in aesthetic techniques over the last few years which has culminated in the creation of private aesthetic clinic The Clinic by Dr Mayoni in 2016. She is accredited by Save Face and is an associate member of BCAM. REFERENCES 1. Alaluf S. et al, ‘Ethnic variation in melanin content and composition in photoexposed and photoprotected human skin.’ Pigment Cell & Melanoma Research, 15 (2002) <https://www.ncbi.nlm. nih.gov/pubmed/11936268> 2. McKnight A et al, Variations of Structural Components: Specific Intercultural Differences in Facial Morphology, Skin Type, and Structures, Seminars in Plastic Surgery, 23 (2009) <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC2884921/> 3. ONS, 2011 Census: Key Statistics and Quick Statistics for local authorities in the United Kingdom - Part 1 (Office for National Statistics, 2013) <https://www.ons.gov. uk/peoplepopulationandcommunity/populationandmigration/populationestimates/ datasets/2011censuskeystatisticsandquickstatisticsforlocalauthoritiesintheunitedkingdompart1> 4. Shirakabe Y et al. A New Paradigm for the Aging Asian Face, Journal of Aesthetic Plastic Surgery, 27 (2003) <https://www.ncbi.nlm.nih.gov/pubmed/14648062/> 5. Fish J, When is a tan socially desirable? (Psychology Today, 2012) <https://www.psychologytoday. com/blog/looking-in-the-cultural-mirror/201209/when-is-tan-socially-desirable> 6. Aesthetic Laser Training, British Skin Foundation, (2017) <http://aestheticlasertraining.co.uk/courses/ vtct-fast-track/lectures/unit-1-lhr/l6/> 7. Low Chai Ling, ‘Ageing in Asian Skin’, in Textbook of Aging Skin, ed. by Miranda A. Farage, Kenneth W. Miller and Howard I. Maibach (Berlin Heidelberg: Springer-Verlag, 2010), pp 1019-1024 (p.1019) 8. Démarchez M, Melanocyte and Pigmentation (Biologie de la Peau, 2011) <https://biologiedelapeau. fr/spip.php?article7> 9. Ferreira dos Santos Videira I et al. Mechanisms Regulating Melanogenesis, Anais Brasileiros De Dermatologia, 88 (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699939/> 10. Eucerin, How does skin differ by ethnic group? (Eucerin, 2017) <https://int.eucerin.com/about-skin/ basic-skin-knowledge/skin-ethnics> 11. Low Chai Ling, ‘Ageing in Asian Skin’, in Textbook of Aging Skin, ed. by Miranda A. Farage, Kenneth W. Miller and Howard I. Maibach (Berlin Heidelberg: Springer-Verlag, 2010), pp 1019-1024 (p.1019) 12. Pugashetti R and Maibach H, ‘Pigmentation in Ethnic Groups’in Textbook of Aging Skin, ed. by

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Miranda A. Farage, Kenneth W. Miller and Howard I. Maibach (Berlin Heidelberg: Springer-Verlag, 2010), pp 503-508 (p.1019) 13. Langton AK et al, Geographical ancestry is a key determinant of epidermal morphology and dermal composition, British Journal of Dermatology, (February 2014) <https://www.researchgate. net/publication/260004589_Geographic_ancestry_is_a_key_determinant_of_epidermal_ morphology_and_dermal_composition> 14. Rawlings AV, ‘Ethnic skin types: are there differences in skin structure and function?’, International Journal of Cosmetic Science, 28 (2006) <http://onlinelibrary.wiley.com/doi/10.1111/j.14672494.2006.00302.x/full> (p. 79) 15. Funt D, Pavicic T, ‘Dermal fillers in aesthetics: an overview of adverse events and treatment approaches’, Clinical, Cosmetic and Investigational Dermatology, 6 (2013) <https://www.ncbi.nlm. nih.gov/pmc/articles/PMC3865975/> 16. Kim GK, Del Rosso JQ, Bellew S, ‘Skin Cancer in Asians Part 1: Nonmelanoma Skin Cancer’, Journal of Clinical and Aesthetic Dermatology, 2 (2009) https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2923966/ (p. 1) 17. McKnight A et al, Variations of Structural Components: Specific Intercultural Differences in Facial Morphology, Skin Type, and Structures, Seminars in Plastic Surgery, 23 (2009) <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC2884921/> 18. AAD, Treating Asian skin requires a delicate balance between clearing the condition, preserving pigmentation (American Academy of Dermatology, 2010) <https://www.aad.org/media/newsreleases/treating-asian-skin-requires-a-delicate-balance-between-clearing-the-conditionpreserving-pigmentation> 19. Rawlings AV, ‘Ethnic skin types: are there differences in skin structure and function?’, International Journal of Cosmetic Science, 28 (2006) <http://onlinelibrary.wiley.com/doi/10.1111/j.14672494.2006.00302.x/full> (p. 79) 20. Vashi NA et al, Aging Differences in Ethnic Skin, Journal of Clinical Dermatology, 9 (2016) <https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4756870/> 21. Davis EC, Callendar VD, ‘Postinflammatory Hyperpigmentation’, Journal of Clinical Aesthetic Dermatology, 3 (2010) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921758/> 22. Davis E and Callender V, ‘Postinflammatory Hyperpigmentation A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color’, The Journal of Clinical and Aesthetic Dermatology, 3 (2010) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921758/> 23. Erwin Tschachler and Frederique Morizot, ‘Ethnic Differences in Skin Aging’, in Skin Aging, ed. by Barbara A. Gilchrest and Hean Krutmann (Berlin: Springer, 2006), pp23-31 (p.28). 24. Handel A et al, ‘Melasma: a clinical and epidemiological review’, Anais Braileiros De Dermatologia, 89 (2014) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155956/> 25. Nowfar-Rad M, Fish F, Dermatosis Papulosa Nigra (Medscape, 2015) <http://emedicine.medscape. com/article/1056854-overview#a4> 26. Funt D, Pavicic T, ‘Dermal fillers in aesthetics: an overview of adverse events and treatment approaches’, Clinical, Cosmetic and Investigational Dermatology, 6 (2013) <https://www.ncbi.nlm.

Aesthetics nih.gov/pmc/articles/PMC3865975/> 27. Alster T S and Tanzi E L, Laser Surgery in Dark Skin (Medscape, 2017) <http://www.medscape.com/ viewarticle/451058_2> 28. Ebanks J et al, ‘Mechanisms Regulating Skin Pigmentation: The Rise and Fall of Complexion Coloration’, International Journal of Molecular Sciences, 10 (2009) <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2769151/> 29. Grimes PE, Thomas JA, Murphy DK, ‘Safety and effectiveness of hyaluronic acid fillers in skin of color’, Journal of Cosmetic Dermatology, 8 (2009) <http://onlinelibrary.wiley.com/doi/10.1111/j.14732165.2009.00457.x/abstract> 30. Handog E et al, ‘Chemical Peels for Acne and Acne Scars in Asians: Evidence Based Review’, Journal of Cutaneous and Aesthetic Surgery, 5 (2012) <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3560163/> 31. How to Use Hydroquinone Products Safely: 6 Things You Must Know Before Using Hydroquinone (Skin Light Skin Bright, 2016) <http://skinlightskinbright.com/how-to-use-hydroquinone-productssafely/> 32. Charlin R et al, ‘Hydroquinone-induced exogenous ochronosis: a report of four cases and usefulness of dermoscopy.’ International Journal of Dermatology, 47 (2008) <https://www.ncbi.nlm. nih.gov/pubmed/18173595> 33. Sundaram H, et al, ‘Aesthetic Applications of Botulinum Toxin A in Asians: An International, Multidisciplinary, Pan-Asian Consensus’, Plastic and Reconstructive Surgery Global Open, 4 (2016) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5222633/> 34. Rendon M et al, ‘Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing’, The Journal of Clinical and Aesthetic Dermatology, 3 (2010) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921757/> 35. Wat H et al, ‘Fractional resurfacing in the Asian patient: Current state of the art’, Lasers in Surgery and Medicine, 49 (2017) <http://onlinelibrary.wiley.com/doi/10.1002/lsm.22579/full>

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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PDO Thread Outcomes In the second of a two-part article, Dr lrfan Mian explains possible reasons behind poor aesthetic outcomes of PDO threads and how to appropriately select patients for treatments In the first of this two-part article, I explained the importance of correct placement, anaesthesia and how to avoid certain complications. For the second part of this article, I shall explain how to accurately select the correct patients for the treatments and the reasons why there could be poor aesthetic outcomes.

Clinical audit An in-house clinical audit at my clinic of some 300 PDO threadlift procedures (cogged and non-cogged), in the maxillary and mandibular regions, has suggested that the outcomes and techniques being used currently do not give consistently satisfactory results. Complaints from threadlift patients having these procedures, which totalled 84, were analysed to determine the reasons behind these poor patient experiences. Most complaints were not of a serious nature and none resulted in any long-term permanent damage or harm to the patients. There were no 'formal complaints' and no implementation of formal complaint procedure protocols needed to be invoked. The common complaints and how they were managed were resolved in-house and protocol variations were produced as necessary. These protocol variations were developed over a three-year time period and included input from the medical team of experienced aesthetic nurses and doctors in my clinic. A very common complaint from patients was that, although initially the procedure was good, they felt that over subsequent months the results deteriorated. From speaking to patients originally treated by different practitioners, the results were poor initially and the practitioner's promise of improvement over the subsequent three or four months did not materialise. In one case, the practitioner had based this on the premise that the aesthetic result would improve due to neocollagenesis and subsequent tissue contraction. Due to the variability and number of factors involved in achieving the final aesthetic outcome, it is my opinion that this advice should be given with caution. Many patients complained that they were not getting the aesthetic result they had hoped for when speaking with other practitioners in consultation or through general discussion, and felt they were not getting 'value for money'. The results of some PDO face and neck lifting procedures using current methodology were found to last six months or less. Poor aesthetic outcomes In my experience, the ideal age for PDO threads empirically seems to be the 40 to 55 age group who are otherwise fit and well, although this can vary due to biological ageing differences.

Aesthetics

The age of the patient is important because, for PDO threads to provide optimum results, the induction of a reaction from the immune system is required, which results in desirable neocollagenesis. The immune system degrades as we age so the speed and degree of this reaction is diminished.1 The older patientsâ&#x20AC;&#x2122; tissues do not generate as much collagen as when they were younger, resulting in a poor aesthetic outcome of short duration. Patients older than 55 may also have greater skin laxity. In my experience, skin laxity greater than 1.5cm does not give a good clinical outcome. The cheek-finger test should be employed, where two marks are placed on the cheek, which is then lifted towards the top of the ear. When doing this, the movement of the marks should be less than 1.5cm â&#x20AC;&#x201C; this is described fully in the previously published 'PDO Threadlifting' article in the Aesthetics journal in 2016.2 From experience, leathery or tough skin in older patients where there is a predominance of type 1 collagen, usually due to photodamage, is difficult to lift with threads, and face-lift surgery may be the only answer. It can be seen that patient selection at the outset is critical to achieving consistent results. Older patients can be treated but they should be clearly informed, ideally in writing so that you have a record of communication, that their threadlift procedure may not give optimal results. They may need a series of threadlift every four to six months using threads of multiple design and size. Younger patients should have a minimum age of 33 years and will usually need fewer threads, usually non-cog. I find patients below this age do not need lifting treatment. Before

After

Figure 1: Before and immediately after threadlift treatment in the lower face

Male and female differences I have found that there is a big difference in outcomes between men and women. Men seemed to need more threads more often, and also had a greater rate of relapse. The reasons may be due to structural skin anatomy variations, genetic factors, ethnicity and body form. Through observation, I have found men less likely to follow post-procedure advice thoroughly when compared to women. Post-procedure support in the form of an elasticated facial garment is demonstrated and given to the patient to be worn daily. Unfortunately, some men were found to not wear this support as instructed. The garment supports the tissue while fibrosis and neocollagenesis takes place. This failure to follow instructions may be a factor in poorer clinical outcomes in men. In addition, men have thicker and firmer skin, which is more difficult to rejuvenate with PDO threadlifting. Genetics We all age at differing rates due to our diets, lifestyle and UV light

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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exposure. This may result in differing volumetric and physiological skin changes, which might explain the variable outcomes when a threadlift is performed. The face is covered by five anatomical layers,3 which are listed below:

Aesthetics

1. Skin 2. Subcutaneous tissue, including the fibrous reticular cutis 3. Frontalis on the upper face or forehead, superficial muscular aponeurotic system (SMAS) in the mid-face, and platysma in the lower face and neck 4. The three layers form a composite anatomical unit, which is fixed in areas through ligaments in the sub-SMAS 5. The investing layer of deep fascia on the muscles of mastication of the face or periosteum

incidence and extent of post-operative facial rippling has been reduced. I discovered that tissue grab by the PDO cog medial to the nasolabial fold caused more rippling, as the denser type 2 SMAS pushed up against the looser type 1 SMAS5 as it was anchored by the barbs. To improve longevity in facial rejuvenation, the main cogs cannot only be crossed – cog to cog – to achieve greater neocollagenesis, but smaller gauge threads can be used in a 'fishbone' design. These supplementary threads can be placed as a forward or reverse fishbone design in addition to cross threads. Cavern screw threads are also useful for this fixation, especially in the nasolabial fold and submental areas. These threads can be placed at the initial procedure stage or added at a later date and act as 'locking' threads.6

Once rippling has occurred, a 'compass massage' can then be carried out, in addition to clockwise and anti-clockwise rotation massage to try and release the barbs

Symmetry It is important to correct any facial imbalance present by good thread placement planning. In all cases, prior to cutting, the cogs are held in place using straight artery forceps and the tension adjusted until the facial tissues are balanced. An assistant is invaluable at this stage to tense and hold the threads while the practitioner makes the necessary adjustments. Once the practitioner is happy that facial balance is satisfactory, the threads are cut using the skin pressure technique. It is recommended to always take a clinical photograph prior to cutting as a record of good symmetrical balance. PDO threads do not need to be treated as a sole treatment modality. Combinations with dermal fillers, both BDDE and thermally cross-linked, platelet rich plasma (PRP), lasers and other light-emitting devices and even botulinum toxin can be used with threads.

Sometimes in fair-skinned individuals or those that have inherently thin skin, the cogs may be felt or seen on the face, such as in the cheek. PDO threads are blue with a purple hue and this colour may also show through on the face. I believe there is no need to treat this as, from my experience, the colour is lost a few weeks after placement due to PDO thread hydrolysis. Ultimately, over six to nine months, all these effects will disappear as the PDO threads are fully hydrolysed leaving no residue. This process can be accelerated if needed by local PH reduction through agents such as vitamin C and sodium bicarbonate.4 Post-operative skin rippling I find that a very common complaint is the development of skin ripples or folds, especially after a maxillary and mandibular PDO cog lift. This may be due to over tightening of the threads prior to cutting, superficial thread placement, placement in the wrong tissue plane, the patient having ‘leathery’ skin, or incorrect placement at the 'tissue grab' stage, which is the final stage prior to removal of the metal cog. One way to overcome this is firstly to place the threads in the SMAS, but then to individually tighten in both a clockwise and anti-clockwise direction to release entwinement in the tissues. Once rippling has occurred, a 'compass massage' can then be carried out, in addition to clockwise and anti-clockwise rotation massage to try and release the barbs. The compass massage consists of massaging north to south and then east to west. This can, in stubborn cases, be coupled with infiltrative pH reduction injections. I have found it is best to inject from the base to the epidermis. By achieving a tissue grab just lateral or at the nasolabial fold, my

Conclusion This short update has looked at important considerations and recommendations when conducting PDO thread therapies. PDO thread placement is an art and a science; our patients will benefit greatly if the practitioner conducting these procedures is well trained and knowledgeable. In conclusion, PDO threads, correctly placed and used, should provide an important clinical tool, giving good, consistent results for any medical aesthetic practitioner. Dr Irfan Mian has dual qualification as a doctor and dental surgeon and is medical director of Chinbrook Medical Cosmetic Centre. He has a special interest in all types of threadlifts for the face, neck and body and is a board member of The Association of PDO Threads UK. Dr Mian is a registered and insured trainer in aesthetic medicine. REFERENCES 1. Encarnacion Montecino-Rodriguez, Beata Berent-Maoz, Kenneth Dorshkind, Causes, Consequences, and Reversal of Immune System Aging, (2013), <https://www.ncbi.nlm.nih.gov/ labs/pubmed/23454758-causes-consequences-and-reversal-of-immune-system-aging/> 2. Mian I, 'PDO threadlifting' Aesthetics Journ Vol 3/issue 5 April (2015) 3. Broughton M Fyfe GM 'The Superficial Musculoaponeurotic System of the Face: A Model explored. Anat Research Inter Vol (2013) Article ID 794682 4. Ludek Stehlik,corresponding author Vladislav Hytych, Jana Letackova, Petr Kubena, and Martina Vasakova, Biodegradable polydioxanone stents in the treatment of adult patients with tracheal narrowing, (2015) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4687362/> 5. Ghassemi et al. Anatomy of the SMAS revisited ResearchGate (2003) <https://www. researchgate.net/publication/8641946_Anatomy_of_the_SMAS_revisited> 6. D’Agostino et al, ‘Invitro analysis of the effects of wound healing of high and low molecular weight chains of hyaluron and their hybrid complexes,’ BMC Cell Biology (2015).

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Treating Vascular Blemishes

What are vascular blemishes? Vascular blemishes or burst blood vessels, as people commonly refer to them, are medically termed telangiectasia (small linear blood vessels) and spider naevi (a central arteriole with radiating vessels).5 Presenting in a similar fashion, these can be broadly divided into two classifications, either inherited or acquired.6 The generally benign condition is essentially treated to improve appearance and therefore the emotional wellbeing of the sufferer. Many of the patients I have treated have fallen within two subsets, either rosacea, a chronic inflammatory skin condition of unknown cause,8 or photodamage. Other conditions pertaining to vascular lesions include angiomas and vascular birth marks. One of the main causes of telangiectasia is rosacea. This inflammatory skin condition gives rise to facial flushing; causing repeated episodes of vasodilation, which in turn leads to loss of vascular tone and permanent vessel dilation.9 Rosacea most commonly affects fair-skinned people from northern Europe and is estimated to affect up to one in 10 people in the UK.10

Aesthetics aestheticsjournal.com

Prevention

Aesthetic nurse prescriber Elizabeth Rimmer provides an overview of different types of vascular blemishes and details some of the treatment options available In the last few years, the desire for ‘perfect’ skin has become a common request in the aesthetics specialty. At the time of writing this article, searching ‘how to get perfect skin’ on Google produces 15,300,000 hits.1 Mainstream media often portrays the perfect complexion to be flawless in colour and texture, free from blemishes and radiant in its appearance. However, clever makeup, lighting and air brushing are often used to achieve this look, which can heavily influence individuals’ sense of pressure to conform.2 The real truth is that our skin, ever changing as it is, will be susceptible to constant exposure to the elements of daily living,3 such as pollution and the weather, which can be contributing factors for the appearance of vascular blemishes.4 This article aims to provide a brief overview of the different types of vascular blemishes affecting the face, their underlying causes, treatment options and considerations for preventative measures.

Aesthetics Journal

As discussed previously, some vascular blemishes may have an inherited element to them, meaning that some patients will be more susceptible to developing them. As practitioners offering treatments for these kinds of issues, you should consider lifestyle advice for your patient as an integral component of any skin consultation. Protection from UVA and UVB rays by using SPF is essential.12 This should be carried out daily, regardless of the weather and reapplied throughout the day during higher temperatures. The avoidance of hot water for washing the face, hair and body will reduce vasodilation of facial vessels and lessen the potential for new vessels to develop.13

Treatment options The mainstay of treatment methods for these kinds of problems include the use of heat, light and cold, with some relatively new topical agents. The terminology used for these treatments can be confusing, interchangeable and contradictory at times, due to incorrect use of vocabulary and numerous terms describing the same modality. Heat Electrosurgery, electrocautery, thermocautery and thermocoagulation are all terms used to describe the process of using heat to coagulate blood in vessels, resulting in the shutdown of capillaries. These treatment devices are developed to bring heat to the treated area, without disseminating to healthy surrounding skin. There are large variations in energy output and there is potential to cause damage to local healthy tissue.14 This

The drawbacks of heat treatment include discomfort during the treatment process

can be limited by treating at the lowest possible setting by using effective eye magnification. The drawbacks of heat treatment include discomfort during the treatment process, with a healing period of around between two and six weeks. Side effects can include initial localised erythema, microscabbing lasting around two weeks, as well as hyperpigmentaion and hypopigmentation, which could last several Skin consultation months. Patients should avoid direct sunlight It’s important to take an accurate medical history that includes drug history, and picking the affected area. Repeated lifestyle habits, past medical history including pregnancies, known allergies treatments may be needed.14 7 and family history. As with all medical presentations, this information will be relevant to build a picture of the patient and developing a working diagnosis. Light Also ensure to log the patient’s complaint, when and how it started, pattern of progression and any treatments that have previously been tried along with Lasers their results. Additionally, assess the effects of the patient’s quality of life. It’s Laser treatment itself has many forms and important to do a thorough skin examination and discuss available treatment varies in wavelength, treatment time and options. energy level. There are also variations between different models, which determine the specific

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Aesthetics

Classification

Layman's terms

Causes

Treatment options

• •

Telangiectasi Spider naevi

• • •

Thread veins Burst blood vessels Broken veins

• • • •

Rosacea Photo damage Post trauma Liver disease

• •

Laser Thermolysis

•

Angioma

• •

•

Raised oestrogen levels Liver/thyroid disease Sun exposure

• •

Blood spot Campbell de Morgan spot Cherry angioma Venous lake

Electrosurgery Intense pulsed light (IPL) Potassium titanyl phosphate laser (KTP) Pulsed dye laser (PDL)

• • •

Salmon patches Port wine stains Strawberry naevi

•

Vascular birth marks

• •

N/A

• •

PDL Cosmetic camouflage

and medicated formulations, which aim to help treat vascular blemishes and erythema.20 Topicals can have variable results and include side effects which may include irritation, dryness and rebound erythema.21 According to the NHS, these types of treatments fall under the term ‘procedures of limited clinical value’,22 meaning that they are generally not routinely funded, as they are considered cosmetic procedures.22 Due to this, patients are increasingly likely to present in a private skin clinic.

Conclusion

Vascular lesions can be limited, to an extent, by adhering to lifestyle modifications, but cannot be completely and permanently avoided. In order to offer a fully rounded aesthetic skin service, the inclusion of treatments to address vascular blemishes should be holistic and a variety of options should be provided, to ensure a positive and effective experience for your patient.

Figure 1: A table showing different vascular blemishes, their known terms, causes and suggested treatment options11

conditions suitable for treatment and the expected result.15 There are a wide variety of lasers suitable for treating vascular blemishes, including the potassium titanyl phosphate laser (KTL) and pulsed dye laser (PDL), which are selected for treating telangiectasia and vascular blemishes and generally work by specifically targeting the oxyhaemoglobin whilst preserving the surrounding tissue.15 These treatments may also cause discomfort depending on the duration and setting. As with all treatments there are potential side effects, including hypopigmentation, hyperpigmentation, purpura and erythema, which are more notable in intense pulsed light (IPL) systems, as these systems have less specificity in targeting a small area and will therefore have a higher impact on surrounding ‘healthy’ skin.13 IPL IPL provides a non-ablative light therapy and is sometimes referred to as photorejuvenation. The light of the IPL targets oxyhaeamoglobin. I have found that this form of light therapy is not as effective as laser due to its lack of specificity,15 however, this point is debated by other authors with differing experiences.16,17 Patients can expect discomfort during treatment and may experience some post-treatment erythema with risks of bruising, post-inflammatory hyper pigmentation and blistering.18 Cold Cryotherapy involves the use of liquids, intended to freeze lesions. I believe this modality is unsuitable for treating telangiectasia as it lacks specificity in its application and therefore should not be used when treating microvessels, but may be suitable for the treatment of angiomas. It therefore has the disadvantage of being less adaptable to lesions of a vascular nature. Small angiomas may be treated in a single session, with larger lesions requiring a follow-up treatment. This treatment results in scabbing with a two to six-week healing period. Blistering and infection, although uncommon, is possible, resulting in increased pain and the formation of pus which may require topical antiseptic or antibiotics.19 Topical agents Underlying inflammatory conditions may be helped by treating with daily antibiotics or topical prescription creams to reduce inflammation and dampen down telangiectasia formation. There are also a range of topical agents on the market, ranging from homeopathic remedies to FDA-approved topical vasoconstrictors

Elizabeth Rimmer is an independent nurse prescriber. She opened her holistic health and skin clinic, London Professional Aesthetics, in central London, in 2014. Rimmer is also an active member of the British Association of Cosmetic Nurses and The British Dermatological Nursing Group. REFERENCES 1. Google (How to get perfect skin, 2017) <https://www.google.co.uk search?q=how+to+get+perfect+skin&oq=how+to+get+perfect+skin&aqs=chrome..69i57j0l5. 4054j0j8&sourceid=chrome&ie=UTF-8> 2. Magin P, Adams J et al. ‘Perfect skin’, the media and patients with skin disease: a qualitative study of patients with acne, psoarias and atopic eczema’. Australian Journal of Primary Health 17 (2) (2010) pp.181-185 <http://doi.org/10.1071/PY10047> 3. Valacchi G, Pagnin E, et al. ‘In vivo ozone exposure induces antioxidant/stress-related responses in marine lung and skin’ Free Radical Biology and Medicine 36 (5) (2004) pp 673- 681 4. Helfrich Y, Maier L, Cui Y,Fisher G, Chubb H, Fligiel M, Sachs D, Varani J, Voorhees M (2015 Clinical, histological, and molecular analysis of differences between erythematotelangiectatic rosacea and telangiectatic photoaging. JAMA Dermatological 151(8): 825-836 5. Ashton R & Leppard B, ‘Differential Diagnosis in Dermatology’ 3rdEdition, (Radcliffe Publishing, 2005) p.95 6. Oakley, A. What is telangiectasia? (DermnetNZ, 2014) <https://www.dermnetnz.org/topics/ telangiectasia> 7. O’Neill, J. ‘Taking a Medical History’ (Aesthetics Journal, 2017) Vol 4/Issue 10 8. Torpy J, Shwartz L, et al. ‘Rosacea’ (JAMA Network, 2012) <http://jamanetwork.com/journals/jama/ fullarticle/1172046> 9. Shanler S D, Andrew L ‘Successful treatment of the erythema and flushing of Rosacea using a topically applised selective 1-Adrenergic Receptor Agonist, Oxymetazoline’. (Arch Dermatology, 2007) 143 (11) 10. NHS, ‘Symptoms of Rosacea’ (2016) <http://www.nhs.uk/conditions/Rosacea/Pages/Introduction.aspx> 11. ‘The Dermatology Review’ (The Derm Review, 2015) <http://www.thedermreview.com/broken-bloodvessels-on-face/> 12. Jansen T & Plewig G. ‘Roscaea:classification and treatment Journal’ (The Royal Society of Medicine vol 90, 1997) 3:pp.144-150 13. Sampath, P. ‘Why you shouldn’t wash your face with hot water’ (The Health Site, 2015) <http://www. thehealthsite.com/beauty/why-you-shouldnt-wash-your-face-with-hot-water-pa1214/> 14. Backes, J. ‘Electrosurgery’ (Asian Hospital and Healthcare Management) <https://www.asianhhm.com/ articles/electrosurgery> 15. White M (2016) ‘Treating Facial Thread Veins’’. Aesthetics 3 (2016) pp.53 16. Uddhav P & Lakshyajit D, ‘Overview of Lasers’ (Indian Journal of Plastic Surgery, 2008) S101–S113 17. Ralph A, Katz B ‘Successful treatment of spider leg veins with a high-energy, long-pulse, frequencydoubled neodymium: YAG Laser (HELP-G)’ (Dermatologic Surgery 25 (9) 1999) pp.677-680. 18. Lapidoth M, Shafirstein G, et al., ‘Reticulate erythema following diode laser-assisted hair removal: a new side effect of a common procedure.’ (Journal of the American Academy of Dermatology, 2004) 51(5):774-7. 19. British Association of Dermatologists, ‘Cryotherapy’ (BAD, 2008) <http://www.bad.org.uk/shared/getfile.ashx?id=192&itemtype=document> 20. Nally, JB & Berson, DS. ‘Topical therapies for rosacea’ (Journal of Drugs in Dermatology, 2006) 21. Werner, K & Kobayashi TT. ‘Dermatitis medicamentosa: severe rebound erythema secondary to topical brimonidine in rosacea’ (Dermatology Online Journal, 2015) 22. City & Hackney, Newham, Tower Hamlets and Waltham Forest (WELC) Clinical Commissioning Groups, ‘Procedures of limited clinical value’ (North and East London CCG’s, 2013-14)

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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PRP in Facial Aesthetics Dr Kieron Cooney shares his systematic review of literature on platelet rich plasma to consider its efficacy in facial aesthetics Platelet rich plasma (PRP) is used in many medical settings including orthopaedics, plastic surgery, dental practice and dermatological clinics; mainly advocated for its potential for wound healing and tissue regeneration.1-3 PRP is a concentrated preparation of the patientâ&#x20AC;&#x2122;s own platelets from centrifugation of blood and extraction of the separated platelet-rich layer. Platelets contain numerous growth factors, such as platelet-derived epithelial growth factor and vascular endothelial growth factor, which modulate cell proliferation, tissue remodeling, angiogenesis and inflammatory responses.4-6 PRP is now finding a role in the treatment of alopecia,7 striae distensae8 and acne scar revision.9 However, despite recognition of the healing properties of PRP, and evidence of the role of platelet growth factors in tissue regeneration, there remains a lack of robust evidence for the efficacy of PRP for facial rejuvenation. The objective of this paper is therefore to review the current evidence available for the effectiveness of PRP for facial rejuvenation to improve aesthetic practice.

Systematic review A review of the literature regarding use of platelet rich plasma in aesthetic practice was carried out on May 7, 2017. Searches were performed using PubMed, Medline and Embase. Search terms are indicated in Figure 1. Main search term

Added search terms

Platelet rich plasma

Number of papers 27,298

Platelet rich plasma

+Skin rejuvenation

119

Platelet rich plasma

+Aesthetics

Platelet rich plasma

+Evidence

153

Platelet rich plasma

+Efficacy

772

Figure 1: Table shows search terms and results of the systematic review

Results of the search There were 27,298 papers on PRP, most of which relate to nonaesthetic uses, such as for treatment of tendon injuries, delayed bone healing and experimental in vitro and in vivo studies. The search results indicated that there is limited literature on the use of PRP for facial aesthetic indications. Non-facial applications, animal studies, non-aesthetic indications, non-clinical and in vitro articles were excluded, since this review is aimed at presenting evidence for the practical application of PRP in facial aesthetic practice. Following these exclusions, only seven papers were considered relevant for review, investigating the role of PRP in facial skin

Aesthetics

rejuvenation. Three further papers reporting combination treatments of PRP with other treatment modalities were identified (Figure 3). Papers selected were reviewed with consideration of the level of evidence according to the American Society of Plastic Surgeons rating scale (Figure 2).10 Level of Evidence

Qualifying studies

High-quality, multi-centred or single-centred, randomised controlled trials with adequate power or systematic reviews of these studies

Lesser-quality, randomised controlled trials, prospective cohort studies, or systematic reviews of these studies

III

Retrospective comparative study; case-control study; or systematic review of these studies

Case series

Expert opinions, case reports or clinical examples, or evidence-based studies on physiology, bench research, or â&#x20AC;&#x2DC;first principlesâ&#x20AC;&#x2122;

Figure 2: The American Society of Plastic Surgeons' Levels of Evidence Rating Scale for Therapeutic Studies

Analysis The majority of these studies provided weak levels of evidence as per the American Society of Plastic Surgeons' Level of Evidence Rating Scale. Some were inconclusive case series, with no control or placebo groups, and were non-randomised with small numbers of subjects. Results were based on self-assessment rating scores, wrinkle severity rating scale,18,24 or specialist opinions, which may not always be sufficiently objective or validated (evidence level IV).12-15,17 Two studies provided stronger evidence of efficacy through use of split-face treatment protocols,11,16 although one was only a pilot study with small subject numbers.16 Gawdat11 used a randomised split-face method in 20 subjects to compare the effect of PRP on facial skin appearance. PRP was compared with ready-made growth factors applied using mesotherapy. Evaluation included physician assessment and patient satisfaction questionnaires. A validated global aesthetic improvement scale was used to assess the outcome of the appearance of facial skin after treatment in both groups.24 There was a statistically significant improvement in the appearance of facial skin in both groups after four months but the benefits of PRP-treated skin appeared to be more sustained with better results at six months (evidence level III). Kang16 compared PRP with platelet poor plasma (PPP) supernatant, which was obtained following centrifugation of whole blood and removal of the PPP layer. In his preliminary pilot study of 20 patients, post-treatment assessment was made by subjective patient satisfaction questionnaires, and blinded review of clinical photographs by dermatologists. This is a well-structured, controlled, randomised, blinded prospective pilot study. A control group using saline was included and results showed a statistically significant improvement of wrinkles and skin tone in the PRP group (evidence level II). PRP in combination Three papers were identified that looked at PRP in combination with other modality treatments.19-21 Shin et al. compared PRP alone with PRP combined with fractional laser in 22 Korean subjects. His study used subjective patient satisfaction scores and blinded clinical photographic subjective assessment scores, by two dermatologists. He reported that subjective satisfaction was greater and appearance was improved

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Indication

Intervention

Control

Outcome

Subjects

Evidence Level

Facial wrinkles

PRP vs ‘ready made’ growth factors (mesotherapy). Each side of the patients’ face was randomly assigned either growth factors or PRP. Patients received six sessions at twoweek intervals.

Split-face design

Patient satisfaction in the PRP group was significantly higher using the validated ‘global assessment tool’24 when compared with the mesotherapy group. Overall better skin appearance in the PRP group was reported at six months.

III

Facial wrinkles

PRP with microneedling. PRP was applied three times at two-week intervals to the forehead, malar area, and jaw by dermaroller and was applied using a 27 gauge injector into the wrinkles of crow’s feet.

None

There was a significant difference regarding the general appearance, skin firmness-sagging and wrinkles according to the grading scale of the patients before and after three PRP applications. A significant difference was seen in skin firmnesssagging according to the assessment of the dermatologists.

Face and neck wrinkles

One session of PRP, once a month for three months. Patients received 4ml of PRP, activated with calcium chloride.

None

Satisfactory outcome with subjective patient assessment of appearance after three months. Specialist assessment scores were less than patient scores.

Facial skin wrinkles

Single PRP treatment assessed over eight weeks.

None

Wrinkle severity rating scale (WSRS)18 and patient and dermatologist opinion indicated significant improvement in skin appearance after eight weeks of treatment. The mean value of WSRS reduced from 2.90 ± 0.91 before treatment to 2.10 ± 0.79 after eight weeks of treatment. 14 of 17 subjects with nasolabial folds showed more than 25% improvement in their appearance.

Facial skin wrinkles (pilot study)

Three sessions of PRP at one month intervals.

None

Improved skin appearance and texture from clinician review, (37.5% good, 37.5% sufficient, and 25% insufficient), and subjective patient feedback, (25% good, 37.5% sufficient, and 37.5% insufficient), one month after final treatment. Skin hydration, tone, smoothness and texture improved on instrumental and photographic assessment.

Periorbital / infraorbital skin wrinkles (pilot study)

PRP vs platelet poor plasma (PPP) – prospective randomised.

Split face PRP/PPP/ saline. Prospective randomised

The best results were in PRP-treated areas, based on subjective patient satisfaction (87.5% ‘satisfied’ with wrinkle improvement; 100% ‘satisfied’ with skin tone improvement). Dermatologist opinion, based on blinded review of clinical photographs, (37.6% ‘moderate to good’ improvement in wrinkle appearance; 68.8% ‘mild to moderate’ improvement in skin tone appearance).

20 (16 completed the study)

III

Photodamage

Three consecutive intradermal injections of PRP enriched with growth factors.

None

Significant increase in dermal thickness and subjective improvement in skin appearance.

Figure 3: The studies selected for the review

in the combined group. All 11 of the patients receiving combined laser and PRP treatment reported some degree of improvement in skin texture or fine wrinkles compared with 58% of the control group that received fractional laser treatment alone. Blinded dermatologist review of post treatment photographs reported five patients (45%), in the laser group, and eight (73%), in the combined PRP group, improved. There was histological evidence of increased skin

The authors conclude a possible synergistic beneficial effect of PRP on facial rejuvenation when used with fractional CO2 laser

elasticity and fibroblasts activity in the PRP group (evidence level III).19 In a blinded, split-face study of 13 patients by Hui et al,20 PRP was injected into one side of the face and 0.9% saline into the other side. The whole face of each patient was then treated with fractional CO2 laser. Patients were reviewed after three months of treatment. Subjective patient satisfaction scores were used to assess facial wrinkles in the laser/PRP group and the control laser/saline group, (76.92% and 69.23% respectively); skin texture satisfaction, (84.62% and 76.92%); and skin elasticity, (69.23% and 61.54%). These results were statistically significant. Double-blind assessment by two dermatology specialists showed that in the laser/PRP and control groups, improvement in facial wrinkles was 76.92% and 61.54%, improvement in skin texture was 84.62% and 69.23%, and improvement in skin elasticity was 61.54% and 53.85%, respectively. Additionally, it was noted that there was overall significant improvement in facial wrinkles, and appearance in both treated areas, (laser with and without PRP), suggesting a benefit in laser treatment alone. The authors conclude a possible synergistic beneficial effect of PRP on facial rejuvenation when used with fractional CO2 laser treatment, (evidence level III). Ulusal et al. looked at the effect of a combination of hyaluronic acid (HA) with PRP injections in 94 patients, on the appearance of skin texture, pigmentation and sagging by subjective patient satisfaction

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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scores and dermatologist rating.21 There was a correlation with the number of treatment injections applied – one to eight injections over an ill-defined period, and patient reported improvement, up to 19 months post treatment. Using an overall aesthetic improvement score, there was a significant ‘moderate improvement’ in the general appearance, tone and texture of the skin compared to pre-treatment assessment. There was no comparative or control group using HA or PRP alone and so the benefit of PRP over dermal filler alone was not confirmed (evidence level IV).

My personal, unpublished experience with PRP is highly encouraging, with good patient satisfaction and subjective improvement when used for facial rejuvenation Discussion There is much research on the effectiveness of PRP in multiple non-aesthetic indications. Many papers present in vitro properties of platelets, mechanism of action of various platelet growth factors, and the potential for healing and restoration of tissues from activated platelet-derived agents. Apart from the limited evidence in facial aesthetics presented in this review, practitioners are now finding a role for PRP in treating skin conditions such as acne,9 striae distensae,8 and hair-thinning alopecia,7 where hair growth benefits have been reported.22,23 My personal, unpublished experience with PRP is highly encouraging, with good patient satisfaction and subjective improvement when used for facial rejuvenation. My own early results on the effect of PRP on appearance of striae distensae, when used in combination with microneedling and radiofrequency, are also very satisfactory and demands more robust investigation. Most of the studies reviewed in this short article were of limited evidence strength – evidence level III or IV – and were based on small numbers of non-randomised design with subjective outcomes. All of the studies reported some degree of beneficial effect of PRP on facial rejuvenation. There is a possibility of reporting bias, although lack of reports of poor outcomes with PRP in aesthetics is encouraging. This review has highlighted the paucity of high level evidence-based research papers in the field of PRP use in facial aesthetics. This probably reflects the many challenges and difficulties encountered in the design and execution of studies in this field. PRP preparation techniques vary and there remains a lack of an agreed definition of what constitutes PRP; for example, the optimal concentration of platelets, and whether to activate or not. The volume of PRP applied and the frequency and technique of injection and the duration of treatment, are also variable factors and no consensus exists as to

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an optimal treatment regime. Objective end point assessments of the effectiveness of PRP in improving facial skin appearance usually rely on subjective patient or clinician rating score questionnaires and photographic analysis. These issues present major challenges in this field of aesthetics, yet to be satisfactorily overcome. Despite these limitations, I believe that current evidence provides optimism that PRP will have an increasingly beneficial role in aesthetic practice in the future and that public and professional interest will continue to grow. Dr Kieron Cooney is a GP, an examiner for the Royal College of General Practitioners and an aesthetic practitioner at Cosmedica Beauty – a finalist for Best Clinic South England at the Aesthetics Awards 2017. Dr Cooney trained at Trinity Hall Cambridge and completed his Master’s Degree in Aesthetic Medicine at Queen Mary’s University London. REFERENCES 1. Hsu, WK. et al., Platelet-rich Plasma in Orthopaedic Applications: Evidence-based Recommendations for Treatment. Journal of the American Academy of Orthopaedic Surgeons. (2013) Jan 1; 21(12): 739-748. 2. Antonino A. et al., Platelet-rich plasma (PRP) in dental and oral surgery: from the wound healing to bone regeneration. Immunity & ageing. (2013); 10(1):23. 3. Cervelli V. et al., Application of Platelet-Rich Plasma in Plastic Surgery: Clinical and In Vitro Evaluation. Tissue engineering. Part C, Methods. (2009) Jan 12; 15(4): 625-634. 4. Lubkowska A et al., Growth factor content in PRP and their applicability in medicine. J Biol Regul Homeost Agents (2012); 26 (2) (Suppl 1) 3s-22s. 5. Marx RE. et al., Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg (2004) 62 489-96. 6. Kim D H et al., Can Platelet-rich Plasma Be Used for Skin Rejuvenation? Evaluation of Effects of Platelet-rich Plasma on Human Dermal Fibroblast Ann Dermatol (2011) 23 (4) 424-431. 7. Trink A et al., A randomized double-blind placebo- and active- controlled, half-head study to evaluate the effects of plaelet-rich plasma on alopecia areata Br J Dermatol, (2013) 169 690-694. 8. Suh DH, Lee SJ, Lee JH et al. Treatment of striae distensae combined enhanced penetration platelet-rich plasma and ultrasound after plasma fractional radiofrequency. J Cosmet Laser Ther (2012); (14): 272-6. 9. Gawdat HI, Hegazy RA, Fawzy MM et al. Autologous platelet rich plasma: topical versus intradermal after fractional ablative carbon dioxide laser treatment of atrophic acne scars. Dermatol Surg (2014); 40: 152-61. 10. ASPS Evidence Rating Scales [online]. Available at: Evidence based clinical practice guidelines from the American society of plastic surgeons <https://www.plasticsurgery.org/for-medicalprofessionals/quality-and-registries/evidence-based-clinical-practice-guidelines/description-anddevelopment-of-evidence-based-practice-guidelines> 11. Gawdat H I; et al. Autologous platelet-rich plasma versus readymade growth factors in skin rejuvenation: A split face study. Journal of cosmetic dermatology; 2017 16 (2) 258-264. 12. Yuksel EP et al. Evaluation of effects of platelet-rich plasma on human facial skin. J Cosmet Laser Ther, 2014 16 (5) 206-8. 13. Redaelli A et al. Face and neck revitalization with platelet-rich plasma (PRP): clinical outcome in a series of 23 consecutively treated patients. J Drugs Dermatol, (2010) 9 (5) 466-72. 14. Elnehrawy N Y et al. Assessment of the efficacy and safety of single platelet-rich plasma injection on different types and grades of facial wrinkles J Cosm Derm, (2017) 16 (1) 103-111. 15. Cameli N et al. Autologous Pure Platelet-Rich Plasma Dermal Injections for Facial Skin Rejuvenation: Clinical, Instrumental, and Flow Cytometry Assessment. Derm Surg: official publication for American Society for Dermatologic Surgery Apr (2017) 16. Kang BK et al. Effects of platelet-rich plasma on wrinkles and skin tone in Asian lower eyelid skin: preliminary results from a prospective, randomised, split-face trial. Eur J Derm (2014) 24 (1) 100-101. 17. Diaz-Ley B et al. Benefits of plasma rich in growth factors (PRGF) in skin photodamage: clinical response and histological assessment. Derm Ther (2015) 28 (4) 258-263. 18. Day DJ et al., The wrinkle severity rating scale: a validation study. Am J Clin Dermatol. (2004) 5 (1) 49-52. 19. Shin M-K MD et al. Platelet-Rich Plasma Combined with Fractional Laser Therapy for Skin Rejuvenation. Derm Surg (2012) 38(4) 623-630. 20. Hui Q et al. The Clinical Efficacy of Autologous Platelet-Rich Plasma Combined with Ultra-Pulsed Fractional CO2 Laser Therapy for Facial Rejuvenation Rejuv Res (2017) 20(1) 25-31 21. Ulusal BG et al. Platelet-rich plasma and hyaluronic acid - an efficient biostimulation method for face rejuvenation. J Cos Derm (2017) 16 (1) 112-119 22. Puig CJ et al. Double-Blind, Placebo-Controlled Pilot Study on the Use of Platelet-Rich Plasma in Women With Female Androgenetic Alopecia. Derm Surg (2016) 42 (11) 1243-1247 23. Anitua E et al. The Effect of Plasma Rich in Growth Factors on Pattern Hair Loss: A Pilot Study. Dermatol Surg (2017) 43 (5) 658-670 24. Carruthers A, Carruthers J. A validated facial grading scale: The future of facial ageing measurement tools? J Cos Laser Ther (2010) 12 235-241.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Foam Sclerotherapy Mr Philip Coleridge Smith provides an overview of foam sclerotherapy for addressing the cosmetic concerns of varicose veins Varicose veins affect about a quarter of the UK adult population1 and may cause problems that can include leg swelling, severe skin damage, leg ulceration, as well as poor cosmetic appearance, which is the most common reason for treatment in my clinic.2 Until about 15 years ago, the main method of treatment was varicose vein surgery. However, there are now many non-surgical methods available to patients with a significantly shorter recovery time. Studies have suggested that the efficacy of non-surgical treatment is comparable with or superior to surgical intervention.3,4 The National Institute for Health and Care Excellence (NICE) has recommended that minimally-invasive methods of treatment are used in preference to surgical treatment.5 The focus of this article is foam sclerotherapy, which uses the wellestablished sclerotherapy principles to destroy the vein by removing its endothelial lining.

Causes of varicose veins The underlying cause of varicose veins is a failure of the valves in the great and small saphenous veins, which are normally present in upper and lower limb veins. This permits abnormal downward flow towards the feet with gravity, causing the veins to increase in both diameter and length. As a result, this leads to the formation of convoluted, superficially lying veins.2 Clinical examination of observing and feeling the leg was previously the only investigation employed to establish the cause of venous problems. However, for the last 30 years, colour duplex ultrasound imaging has been used to identify the anatomy and physiology of the venous system to be treated. Ultrasound imaging was introduced into the practice of phlebology (clinical management of vein problems) in the mid-1980s.6,7 It provides a black and white image of the blood vessels and other leg tissues, which indicates blood flow by a superimposed colour map showing the speed and direction of blood flow. It is also used to guide the application of sclerosants and thermal catheters to the correct location.8

Treatment Surgical treatments performed under general anaesthesia to remove varicose veins were the norm throughout the twentieth century. However, surgical vein removal incurs a large number of risks related to both general anaesthesia and the incisions, which may fail to heal quickly in some cases.9 Damage to cutaneous nerves may also occur and the incisions can leave permanent scars. A recovery period of two to four weeks is also required and surgery often leads to significant post-operative pain and bruising. Several modern minimally-invasive techniques are now in use that are much less likely to lead to post-operative problems. These

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methods are performed under local anaesthetic and most patients recover within one to three days of treatment. All the modern treatments rely on placing an intravenous catheter in the saphenous vein and its tributaries to apply either heat or sclerosant foam to the vein. This requires ultrasound guidance since these veins lie 1-3cm below the surface.3 Ultrasound-guided foam sclerotherapy Sclerotherapy with liquids has been used for about 200 years. One of the earliest solutions used was alcohol, but this was painful. Foam sclerotherapy was first developed in the 1940s, long before ultrasound imaging was invented.10 A sclerosant foam can be readily prepared by vigorous mixing a small volume of liquid sclerosant with gas or air. The detergent sclerosants, sodium tetradecyl sulphate (STS) and polidocanol, are the most commonly used drugs to make sclerosant foam. Once inserted, the foam works by removing the non-stick lining of the veins to allow for blood to stick to the inside of the treated veins which become blocked. Natural healing processes then completely reabsorb the successfully treated veins.10 In the UK, the drug licensed for the management of varicose veins by foam sclerotherapy is STS (Fibrovein).11,12 In 1995, a Spanish surgeon, Dr Juan Cabrera, published his experiences of modern foam sclerotherapy on which current techniques are based.13 In Dr Cabrera’s publication, ultrasound guidance was used to place an intravenous catheter in the saphenous vein at the knee, through which sclerosant foam was injected.13 Ultrasound-guided foam sclerotherapy is effective in the management of almost all varicose veins, from the smallest to the largest, whether the patient has undergone previous treatment or not.14 Foam sclerotherapy is less effective in very large saphenous veins (>12mm) so in these cases, laser ablation or surgical treatment may be more appropriate. Foam sclerotherapy may be used in combination with thermal ablation techniques to manage superficially lying and convoluted veins that cannot be treated by heating. Endovenous thermal ablation methods as well as the use of bio-adhesive glue (‘superglue’) ablation are useful in the management of the main saphenous trunk. All other varicose veins, tributaries and accessory veins have to be treated either by phlebectomy (surgical removal of veins) or by sclerotherapy with liquid or foam.15 Ultrasound-guided foam sclerotherapy should be accomplished by an experienced medical practitioner. Method My colleagues and I have evaluated Dr Cabrera’s technique and have since developed it, leading to several enhancements that have been described in a series of publications.16,17 The method is systematic and straightforward and takes around 20-30 minutes per session.18 The maximum recommended dose of foam sclerosant in one day is 15ml, which is usually sufficient to treat one leg.19 Where both legs are being treated, the second leg can be treated the next day or at a later date. Standard intravenous cannulas are placed in the saphenous vein under ultrasound guidance. In the great saphenous vein, two are used in the thigh and two in the calf. In the small saphenous vein, two catheters are placed. Supplementary cannulas or direct injection of foam is used to treat the saphenous tributaries and larger varices. Sclerosant foam is effective in the vein in which it is injected; the foam extends into incompetent tributaries of this vein and these too are obliterated. This minimises the number of

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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injections required to treat all varices in one leg. Foam is injected into the saphenous trunk via the cannulas previously positioned in the vein. This allows the entire length of vein to be completely and effectively treated and will usually lead to effective obliteration of the saphenous vein. The foam spreads out into many of the varices and tributaries so that these are also treated. The treatment is concluded by the application of a firm compression bandage and stocking. It is common practice to advocate the application of compression to the limb for a period of one to two weeks after the treatment.20 The treated veins are occluded by thrombus forming within the veins as a result of the sclerosant foam removing the non-stick endothelial lining of the vein.21 The amount of thrombus within the treated veins is limited by the compression bandaging. It is conventional to review patients two to three weeks after this treatment to check that the treatment has been effective in all veins. If an excess of thrombus is present, it can cause the veins to become tender, so it can be readily aspirated with a needle and syringe under ultrasound guidance following injection of local anaesthetic. The successfully treated veins are slowly reabsorbed over a period of several weeks or months, depending on the size of the vein.21 After the treatment, there is usually resolution of the varicose veins and associated symptoms combined with an excellent cosmetic result. Adverse events during the recovery period include the development of phlebitis of the treated veins and brown discolouration over the veins. Both are readily managed by aspiration of thrombus from the treated veins under local anaesthetic, combined with compression hosiery and, in any case, will usually resolve without intervention over a period of seven to 10 days. NICE has published a review of ultrasound-guided foam sclerotherapy which provides a detail account of possible adverse events which may accompany this treatment.20 Residual telangiectases and reticular varices are usually managed by conventional sclerotherapy with liquid sclerosants, following conclusion of foam treatment in cases where patients require a perfect cosmetic outcome.21 Recurrent varices are usually minor and readily managed by further foam sclerotherapy. Freedom from varicose veins after five years is seen in 80-90% of patients.22 Studies Good efficacy of ultrasound-guided foam sclerotherapy has been shown for five years following this treatment.14 Researchers studying 82 patients with venous leg ulceration due to varicose veins observed that 67 (82%) healed in a median of one month following treatment. Prevention of recurrence was also seen, with only 5% of ulcers reoccurring two years after healing had been achieved.23 One randomised study of 500 patients, which compared ultrasoundguided foam sclerotherapy with surgery and thermal ablation techniques, found equivalent efficacy concerning the clinical outcome after five years. Patients with varicose veins received one of four treatments: foam sclerotherapy, laser ablation, radiofrequency ablation or conventional varicose veins stripping. Ultrasound imaging and clinical assessments were done at annual intervals for five years. The clinical outcome was identical in all four groups, five years after the treatments had been completed.22 My own study of 167 patients treated with foam sclerotherapy for varicose veins, suggested that recurrence of varicose veins is limited to about 10% of patients after five years, 24 which is consistent with the best reported outcomes for varicose veins treatment.14

Alternative treatments Heat can be applied to the vein through the intravenous catheter in the saphenous vein and its tributaries. The heat treatments include

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Before

Aesthetics aestheticsjournal.com After

Figure 1: Before and two weeks after treatment with ultrasound-guided foam sclerotherapy

laser ablation25 and radiofrequency ablation,26 which apply heat to the saphenous vein from within to destroy it. In these thermal ablation methods, a heating catheter, either a laser fibre optic or an electrically heated, radiofrequency catheter, is passed along the vein from the knee to the groin or along the back of the calf to treat the small saphenous vein. A large volume of local anaesthetic, typically 10ml per centimetre of saphenous vein, is injected around the vein to allow treatment without general anaesthesia. The laser or radiofrequency generator is switched on and the catheter is withdrawn slowly to ensure that heating is applied to the entire length of the vein to be treated. This treatment is effective where the vein is long and straight, which is usually the case for the saphenous vein where no previous treatment has been done. However, in varicose veins that have appeared after previous treatment or following an episode of thrombophlebitis, it may be impossible to pass the catheter along the vein so thermal methods cannot be used. In addition, many tributaries and superficial varices can be too convoluted for a long catheter to be passed.27 Any vein that lies close to the skin or a cutaneous nerve cannot be treated, since skin burns or damage to the nerve may lead to a region of numbness in the leg. Surgical removal of varices can be used as a supplement to thermal ablation, but this incurs the risks of surgical treatment noted above. Bio-adhesive glue, mentioned above, has also been introduced recently to close the vein28 and a mechanochemical method uses a rapidly spinning wire to excoriate the inside of the vein in combination with injection of a sclerosant.29

Conclusion The combination of ultrasound-guided injection and the creation of a sclerosant foam has allowed this treatment to be successful in a wide range of clinical presentations of varicose veins and it is as effective as conventional surgical treatment. It may be used in combination with a range of thermal ablation techniques and recurrent varicose veins, while leg ulcer patients can also be readily treated using foam sclerotherapy. Only experienced practitioners should conduct treatments, and they can receive support and further updates from The British Association of Sclerotherapists.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Mr Philip Coleridge Smith is a consultant vascular surgeon at the British Vein Institute. He is the president of the British Association of Sclerotherapists, which facilitates training of practitioners in the skills needed safely to undertake sclerotherapy for varicose veins, reticular veins and telangiectases. REFERENCES: 1. Evans CJ, Fowkes FG, et al., ‘Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study’, J Epidemiol Community Health, 1999 Mar;53(3):149-53. 2. Whiteley, Mark S, Understanding venous reflux: the cause of varicose veins and venous leg ulcers, College of Phlebology, 2011. 3. Rasmussen LH et al., ‘Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose vein’, Br. J. Surg, 2011; 98:1079-087. 4. Van der Velden SK, Biemans AA, De Maeseneer MG, Kockaert MA, Cuypers PW, Hollestein LM, Neumann HA, Nijsten T, van den Bos RR, ‘Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins’, Br J Surg. 2015 Sep;102(10):1184-94. 5. NICE, ‘Varicose veins in the legs – The diagnosis and management of varicose veins’, NICE clinical guideline 168, 2013, Whiteley Publishing, 2011. <https://www.nice.org.uk/guidance/cg168> 6. Schadeck M & Allaert F, ‘Echotomographie de la sclérose’, Phlébologie, 1991;44:111-130. 7. Vin F, ‘Echo-sclérothérapie de la veine saphène externe’, Phlébologie, 1991; 44: 79-84. 8. Coleridge-Smith P, Labropoulos N, et al., ‘Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles.’, Eur J Vasc Endovasc Surg, 2006 Jan;31(1):83-92. 9. Defty C1, Eardley N, et al., A comparison of the complication rates following unilateral and bilateral varicose vein surgery. Eur J Vasc Endovasc Surg. 2008 Jun;35(6):745-9. 10. Foote RR, ‘Varicose veins’, Butterworth & Co. London, 1949. p 1-225. 11. STD Pharmaceuticals, Fibrovein (sodium tetradecyl sulphate) summary of product characteristics, Medicines and Healthcare Products Regulatory Agency, 2013. 12. Rabe E, Breu FX, et al., European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul;29(6):338-54. 13. Cabrera Garrido JR & Cabrera Garcia-Olmedo JR, ‘Garcia-Olmedo Dominguez M.A - Elargissement des limites de la schlérothérapie:noveaux produits sclérosants’, Phlébologie, 1997; 50:181-8. 14. Bradbury AW, Bate G, et al., Ultrasound-guided foam sclerotherapy is a safe and clinically effective treatment for superficial venous reflux. J Vasc Surg. 2010 Oct;52(4):939-45

Aesthetics 15. Guex JJ, ‘Endovenous chemical (and physical) treatments for varices: what’s new?’, Phlebology, 2014 May;29(1 suppl):45-48. 16. Coleridge Smith P. Foam and liquid sclerotherapy for varicose veins. Phlebology. 2009;24 Suppl 1:62-72. 17. Davies HO, Popplewell M, Darvall K, Bate G, Bradbury AW, ‘A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins, Phlebology, 2016 May;31(4):234-40. 18. Coleridge Smith P, ‘Sclerotherapy and foam sclerotherapy for varicose veins’, Phlebology, 2009; 24(6):260-9. 19. STD Pharmaceuticals, Fibrovein (sodium tetradecyl sulphate) summary of product characteristics, Medicines and Healthcare Products Regulatory Agency, 2013 20. Ultrasound-guided foam sclerotherapy for varicose veins Issued: February 2013 NICE interventional procedure guidance 440 21. Rabe E, Breu FX, Cavezzi A, et al., Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul;29(6):338-54. 22. Lawaetz M, Serup J, Lawaetz B, Bjoern L, Blemings A, Eklof B, Rasmussen L.Comparison of endovenous ablation techniques, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Extended 5-year follow-up of a RCT. Int Angiol. 2017 Jun;36(3):281-288. 23. Pang KH, Bate GR, et al., Healing and recurrence rates following ultrasound-guided foam sclerotherapy of superficial venous reflux in patients with chronic venous ulceration. Eur J Vasc Endovasc Surg. 2010 Dec;40(6):790-5 24. Coleridge Smith P, ‘Five-year outcome of ultrasound-guided foam sclerotherapy for saphenous trunks’, Phlebology, 2009; 24: 215. 25. Sadek M, Kabnick LS, et al., Update on endovenous laser ablation: 2011. Perspect Vasc Surg Endovasc Ther. 2011 Dec;23(4):233-7. 26. García-Madrid C, Pastor Manrique JO, et al., Update on endovenous radio-frequency closure ablation of varicose veins. Ann Vasc Surg. 2012 Feb;26(2):281-91 27. Lowell S. Kabnick and Mikel Sadek. Varicose Veins: Endovenous Ablation and Sclerotherapy Rutherford’s Vascular Surgery 8th edition, Saunders, USA. Chapter 58, 885-901. 28. Morrison N, Gibson K, et al., VeClose trial 12-month outcomes of cyanoacrylate closure versus radiofrequency ablation for incompetent great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2017 May;5(3):321-330 29. Tang TY, Kam JW, Gaunt ME ClariVein® - Early results from a large single-centre series of mechanochemical endovenous ablation for varicose veins. Phlebology. 2017 Feb;32(1):6-12

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Enter Promo Code ‘AESTHETICS’ to get £100 off! Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Aesthetics | October 2017

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P R O UD SP O N SO R O F T HE AEST HET ICS AWAR DS 201 7

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At SkinCeuticals, integrated skincare continues to be at the heart of our mission and the focus of our approach. The SkinCeuticals product portfolio consists of a wide range of retail and professional products, which includes advanced in-clinic treatments, such as chemical peels and facial treatments, as well as a comprehensive home-use range. Backed by clinical studies to confirm safety and efficacy, our products are designed to support skincare professionals in providing the best possible patient satisfaction in their private practice. We believe in combination treatments, where skincare plays an integral role in any aesthetic procedure plan. A committed approach to skincare is essential for achieving a comprehensive improvement in the patient’s appearance, particularly in areas of skin tone, texture and pigmentation. Ultimately, if professionals can enhance the results of in-clinic treatments through the use of evidence-based skincare, this can increase patient satisfaction, improve the overall experience of the clinic and drive loyalty further. Recognising the fact that physicians and clinics require tried and tested success strategies, which engage and retain patients in today’s competitive aesthetics marketplace, we launched the 2nd highly anticipated International ‘Master Physician Programme’ in June this year. Created specifically for aesthetic practitioners, nurses and clinic owners, and hosted by leading key industry experts from the medical and business world, this two-day masterclass included advice and practical support on business management, development strategies and how to build a unique patient retail experience. Our dedication to the medical community as a preferred aesthetic treatment partner has earned us strong credibility worldwide amongst medical specialists and we pride ourselves on a two-way dialogue, where we continue to collaborate with this community to help shape future product development in order to continue to deliver on the real needs of our clinic partners. In this month’s issue, we take an inside look into two of our SkinCeuticals clinic partners, The Laser and Skin Clinic in Ireland and EF MEDISPA in London and discover what it takes to become a highly successful clinic and how SkinCeuticals can give you the edge you need in the marketplace to grow and maintain your patient base. Anna Gunning, Aesthetic Nurse and Clinical Director of The Laser and Skin Clinic in Ireland answers the following questions: What has been your biggest challenge in setting up your own clinic? "When you start out in the aesthetics industry, your eagerness to provide a wide selection of treatments and purchase all of the technology can really consume you. A single laser machine can cost €70,000+ so it isn’t long before you realise you’re either going to sink or swim, especially when you want only the most advanced FDA-approved technology. It’s an expensive business to start out in. In saying this, I would rather have closed the doors than buy any technology that was less than the best and this is why The Laser and Skin Clinic has excelled over the years by continuing to provide impressive technology and results."

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What has been your biggest achievement so far? "Expanding The Laser and Skin Clinic from one clinic to three successful clinics within the first five years was only a dream at first and now it’s a reality! Winning two trophies at the Aesthetics Awards was another pinnacle moment for us, demonstrating the level of expertise within our clinics and our dedicated team." How does SkinCeuticals give you an edge in the marketplace and help to grow and maintain your patient base? "SkinCeuticals gives us the edge simply by delivering results every time! Being an early adopter of the brand in Ireland almost 10 years ago, it has gone from strength to strength and really helped us to differentiate our service from other clinics. We are huge advocates of SkinCeuticals for many reasons, from its groundbreaking research to the extensive medical-grade clinical testing each product goes through to prove efficacy, which truly sets it apart from other cosmeceutical brands on the market. One of the many benefits of SkinCeuticals is that it allows us to treat and visibly improve the appearance of a variety of common skin concerns under the one brand, which has helped to grow and maintain our client base over the years." Esther Fieldgrass, Founder and Creative Director of EF MEDISPA clinics in London adds: “EF MEDISPA and SkinCeuticals share a results-driven approach. As our clients are knowledgeable about skincare, they demand products that are incredibly effective. Therefore, we must ensure that the products we can provide our clients will benefit and complement the treatments we offer and we trust SkinCeuticals to do just that! We've seen many changes in the past decade, but our focus on innovation and results driven treatments has helped to secure our position as a market leader in the aesthetics industry.” Contact details Twitter: @SkinCeuticalsUK Instagram: @SkinCeuticals_uki Email: contact@skinceuticals.co.uk

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A summary of the latest clinical studies Title: Lasers and Intense Pulsed Light (IPL) Association with Cancerous Lesions Authors: Ash C, Town G, et al. Published: Lasers in Medical Science, September 2017 Keywords: Actinic keratosis, IPL, lasers, malignant melanoma, UV Abstract: The development and use of light and lasers for medical and cosmetic procedures has increased exponentially over the past decade. This review article focuses on the incidence of reported cases of skin cancer post laser or IPL treatment. The existing evidence base of over 25 years of laser and IPL use to date has not raised any concerns regarding its long-term safety with only a few anecdotal cases of melanoma post treatment over two decades of use; therefore, there is no evidence to suggest that there is a credible cancer risk. Although laser and IPL technology has not been known to cause skin cancer, this does not mean that laser and IPL therapies are without long-term risks. Light therapies and lasers to treat existing lesions and CO2 laser resurfacing can be a preventative measure against BCC and SCC tumour formation by removing photo-damaged keratinocytes and encouraged re-epithelisation from stem cells located deeper in the epidermis. A review of the relevant literature has been performed to address the issue of long-term IPL safety, focussing on DNA damage, oxidative stress induction and the impact of adverse events.

Title: An Update on New and Unique Uses of Botulinum Toxin in Movement Disorders Authors: Jankovic J Published: Toxicon: Official Journal of the International Society on Toxinology, September 2017 Keywords: Botulinum toxin, movement disorders, Parkinson’s disease Abstract: The therapeutic applications of botulinum toxin (BoNT) have grown manifold since its initial approval in 1989 by the US Food and Drug Administration (FDA) for the treatment of strabismus, blepharospasm, and other facial spasms. Although it is the most potent biologic toxin known to man, long-term studies have established its safety in the treatment of a variety of neurologic and non-neurologic disorders. This review focuses on some novel and uncommon uses of BoNT in the treatment of movement disorders, such as oromandibular dystonia, including bruxism, anterocollis, camptocormia, tremor, tics, tardive and levodopainduced dyskinesia, and restless legs syndrome. Despite a paucity of randomized controlled trials and lack of FDA approval for these movement disorders, there is growing body of evidence that BoNT provides benefit to patients with these hyperkinetic movement disorders and that BoNT is a safe treatment when used by clinicians skilled in the administration of the drug for these conditions.

Title: Hyaluronic Acid Microneedle Patch for the Improvement of Crow's Feet Wrinkles Authors: Choi SY, Kwon HJ, et al. Published: Dermatologic Therapy, September 2017 Keywords: Crow’s feet, HA filler, hyaluronic acid, microneedling, wrinkles Abstract: Hyaluronic acid (HA) has an immediate volumizing effect, due to its strong water-binding potential, and stimulates fibroblasts, causing collagen synthesis, with short- and long-term effects on wrinkle improvement. We investigated the efficacy and safety of HA microneedle patches for crow's feet wrinkles. Using a randomized spilt-face design, we compared microneedle patches with a topical application containing the same active ingredients. We enrolled 34 Korean female subjects with mild to moderate crow's feet wrinkles. The wrinkle on each side of the subject's face was randomly assigned to a HA microneedle patch or HA essence application twice a week for 8 weeks. Efficacy was evaluated at weeks 2, 4, and 8. Skin wrinkles were measured as average roughness using replica and PRIMOS. Skin elasticity was assessed using a cutometer. Two independent blinded dermatologists evaluated the changes after treatment using the global visual wrinkle assessment score. Subjects assessed wrinkles using the subject global assessment score. Skin wrinkles were significantly reduced and skin elasticity significantly increased in both groups, although improvement was greater in the patch group at week 8 after treatment. In the primary and cumulative skin irritation tests, the HA microneedle patch did not induce any skin irritation. The HA microneedle patch is more effective than the HA essence for wrinkle improvement and is a safe and convenient without skin irritation.

Title: Periorbital Facial Rejuvenation; Applied Anatomy and PreOperative Assessment Authors: Kashkouli MB, Abdolalizadeh P, et al. Published: Journal of Current Ophthalmology, September 2017 Keywords: Blepharoplasty, eyes, eyelid, periorbital, rejuvenation Abstract: Since different subspecialties are currently performing a variety of upper facial rejuvenation procedures, and the level of knowledge on the ocular and periocular anatomy and physiology is different, this review aims to highlight the most important preoperative examinations and tests with special attention to the eye and periocular adnexal structures for general ophthalmologist and specialties other than oculo-facial surgeons in order to inform them about the fine and important points that should be considered before surgery to have both cosmetic and functional improvement. English literature review was performed using PubMed with the different keywords of "periorbital rejuvenation", "blepharoptosis", "eyebrow ptosis", "blepharoplasty", "eyelid examination", "facial assessment", and "lifting". There were 254 articles in the initial screening from which 84 articles were found to be mostly related to the topic of this review. The number finally increased to 112 articles after adding the pertinent references of the initial articles. Static and dynamic aging changes of the periorbital area should be assessed as an eyelid-eyebrow unit paying more attention to the anthropometric landmarks. Assessing the facial asymmetry, performing comprehensive and detailed ocular examination, and asking about patients' expectation are three key elements in this regard. Furthermore, taking standard facial pictures, obtaining special consent form, and finally getting feedback are also indispensable tools toward a better outcome.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Spotlight On: e-MASTR Aesthetics finds out more about the new videobased digital resource platform This month sees the launch of a new subscription-based website that comprises more than 120 high-definition videos created to support clinicians throughout all areas of their aesthetic practice – from consultation processes to techniques for injection. Known as e-MASTR, the digital platform has been developed by a team led by aesthetic practitioner and trainer Dr Tapan Patel, who has worked in the medical aesthetic specialty for more than 16 years. According to the team, the unique resource was created not to replace traditional methods of learning within aesthetics, but to enhance the existing experiences on offer to practitioners. Dr Patel explains, “The way the team and I look at it, training has got to be multidimensional. We wanted to create a resource that blends with existing educational resources.” He continues, “For people who want to make aesthetics their career, the learning journey just doesn’t stop. e-MASTR has been designed to perfectly complement traditional training – people should still go to workshops, subscribe to journals and attend conferences. The beautifully-shot videos create a new way of learning. If you see it, you’re unlikely to forget it. More importantly, the content can be viewed anywhere and anytime." And this is where e-MASTR comes in, according to Dr Patel. With an annual subscription, practitioners will have access to animated videos on global and regional anatomy, detailed facial analysis, expert tutorials on filler and toxin injections, complication management advice, as well as candid discussion on successfully consulting with patients. Patients featured include male, female, young, old, those with lots of treatment indications and those with minimal treatment indications, identical twins, mother-daughters, and sisters. The high-definition videos vary in length between one minute snippets of explanation to more detailed 20-minute rejuvenation sequences. “The idea was to make them small enough to keep practitioners engaged and allow them to dip in and out of the resource, as Dr Tapan Patel, founder and when they need it,” explains Dr Patel. He continues, “If you run a busy clinic, but

"We wanted to create a resource that blends with existing educational resources"

at 8 o’clock in the evening you think you want to spend an hour improving your knowledge of nasal anatomy, you can. You may be comfortable treating a chin, but a patient has come to see you and she’s got a complex chin – following the consultation you can say to yourself, ‘Let’s see what’s in the resource library!’ You watch a few videos on chin anatomy and treatment options and decide, ‘This is a really nice way of treating the chin – I’m going to try that with my patient!’” As well as being an e-learning tool, e-MASTR also offers advice on running a successful clinic, explains Dr Patel, noting, “It’s something that people can use day in and day out in their practices to help facilitate their consultations. Not everybody is, by their own admission, an effective communicator. Sometimes patients ask questions that can be difficult to answer in a clear way. For example, ‘What’s the difference between Botox and filler?’ We all know the answer, but can we give a concise and elegant answer in the constraints of a consultation? So, there’ll be a video that practitioners can use that will answer that. It’ll be totally unbranded, educational and for the patient’s benefit.” Dr Patel explains that his experiences of learning have helped shape the e-MASTR offering. “We have some amazingly elegant techniques that I’ve learnt from practitioners. This is definitely a tribute to all the people I’ve interacted with over my aesthetic journey. It’s a bit of Mauricio de Maio, Arthur Swift, Jean Carruthers, Woffles Wu,” he says, adding, “It is an amalgamation of all the things that I’ve learnt from them and many others over the years.” The aim for Dr Patel is to now grow e-MASTR into a community of aesthetic practitioners that strive to build their knowledge base and share best practice. He says, “The videos do not describe the definitive way to perform treatment. They are simply a single practitioner’s experience and are open to constructive criticism and challenges. If we can collectively find a better way of doing something then we should discuss it.” He continues, “It would be my dream to collaborate with people from around the world and get their input. We want people to engage. We want it to become an expanding library. If we get feedback and enough requests for a topic, we can create new content. I think that practitioners will ultimately feel that it’s the go-to resource for aesthetic medicine.”

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Building Patient Referrals Regional sales manager Lorraine Mcloughlin provides tips on building patient referrals within an aesthetic clinic I’m often asked by customers how they can increase the number of new patients coming to their clinic. My answer is always this – do everything you possibly can to retain and please the ones you have and the new patients will follow. It’s an approach I learnt in my first role within facial aesthetics as a clinic manager for a Harley Street practice. I recognised that if we met patient expectations, there was high chance that they would then become a returning customer. However, if we exceeded their expectations, they would not only become a loyal and returning patient, they would also tell their friends, family and colleagues about us – who, in turn, would become patients too. For clinic owners who have the ambition to grow their clinic, the value of patient referrals cannot be overstated. Acquiring a new patient through recommendation is a compliment – it means you’re gaining a reputation, which is built on patient trust, loyalty and respect. In our specialty, this is invaluable. So how do you exceed patient expectation to encourage referrals?

between patient and practitioner is incredibly important. Clinics that build relationships increase their patient lists – it’s that simple – and communication is a key part of a patient’s experience. There needs to be empathy, honesty and, ultimately, trust: • Empathy – often, patients don’t feel particularly confident when they first come to you. Perhaps it’s their first experience in aesthetics and they are anxious, or they are unhappy about their appearance and they feel uncomfortable. Whatever their situation, it’s important to show that you understand, that you care and that you’re there to give them their confidence back and put them at ease. • Honesty – patients appreciate sincerity. Being open and direct ensures that your patients’ expectations are realistic and enables them to be aware of cost, limitations of treatment, possible complications and likely outcomes. That also includes saying no to a patient’s request for treatment which, in your clinical view, isn’t necessary or appropriate. • Trust – the former points ultimately build trust in your relationship with your patient.

Patient experience A patient may come to you for the first time for a free consultation, or they could be spending thousands of pounds on a treatment and product. Either way, it’s essential to make sure each patient receives the same level of patient care and customer service. This is because both types of patient are likely to talk about their experience, which could eventually lead to more patient referrals. Every patient that comes to you needs to be made to feel special from the moment they walk through the door to the time they leave. It’s important to put yourself in a patient’s shoes and constantly ask yourself – what more could we do to enhance their experience? Communication I’ve always believed that the relationship

The personal touch It’s important to keep your patients happy which will ultimately lead to them referring people. A tip I’ve used and shared throughout my career is to send patients a card on their birthday. Make sure the card is personalised, hand-written if possible, and thank them for their custom. If your patient database is too large to make this viable, consider creating an e-card that you can personalise and email to them instead. It’s a small token, but I have found that it’s a great way of keeping in contact with patients and showing them that you value their business. I also recommend giving former patients an incentive to come and see you, a good way of doing this is by giving them a birthday bag of the latest cosmeceuticals or a complimentary treatment with a new booking, to entice them back to your clinic.

Patient feedback Asking for patient feedback is important as it enables you to get an honest opinion about your clinic and treatments. It also builds a relationship with your patients in the process. Ask patients what they enjoyed about their experience at your clinic, what makes you different/better than other clinics they’ve visited, what do they want more/less of and what would improve their experience with you? And of course, the all-important question – would they recommend you to others? Remember, if you don’t ask, you don’t get. Feedback from your patients allows you to grow and when you make changes they’ve suggested, it shows that you value their recommendations and you care about offering the very best experience. A natural time to encourage referrals is if your patient compliments your services, which often occurs at the end of the treatment. Respond to the compliment by saying, “We are glad that you had such a positive experience at our practice. We would love for your friends, family, co-workers and relatives to have the same great experience and would welcome them as new patients.”

Spread the word There are many ways of getting your clinic noticed, but I’m a huge advocate of social media and I recommend that all practitioners take advantage of the opportunities available on sites such as Facebook, Instagram and Twitter. If your patients are on social media, they are likely to share content with their friends and followers on their social accounts. Using before and after photographs of a patient, with their consent, is a good way of engaging with a wider audience and getting your patients to publicly endorse you on these social platforms. Remember to ask a patient to write a short testimonial on their Twitter, Facebook or LinkedIn. Again, this will enable your patients to publicly endorse you and increase the chance of gaining patient referrals through their recommendation. Regular communication through a patient newsletter or e-newsletter is also an easy way to increase patient referrals and can have a far-reaching impact. You should provide meaningful information on new trends or technology in your practice with details on any upcoming events and launches your clinic may have. By making sure you fill the newsletter with interesting content, there is a higher chance of patients sharing it with their

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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friends, families and co-workers. It’s important to give something to your patients following their appointment to help boost referrals. A simple business card, listing your services and contact details, is an excellent tool to encourage patients to pass on your clinic’s details to others. Keep them on the reception desk for patients to pick up and ensure that you always have them on you to give them in person. I also advise to give a referral form to the patient following their treatment, for them to obtain details for people interested in attending your clinic. Included in this form should be both your regular patient and potentially new patient’s name, address and contact details, as well as your name, clinic address, email and contact number. Additionally, I recommend to provide a checklist of the types of treatments your clinic offers so you can establish what exactly patients are looking for.

Acknowledgement When a patient refers somebody else to your practice, they deserve a genuine thank you to acknowledge their support. For me, heavily discounting treatments or products never really feels like the right response or show of appreciation. Instead, I’ve always found that a simple face-to-face thank you the next time they come into your clinic goes a long way and, if you do want to offer a treatment such as a skin peel or facial, I would suggest that it’s complimentary rather than discounted so the patient feels the gesture is sincere. Make sure you go that extra mile to show patients that you appreciate their support. Nothing lights up a patient’s face more than when you share a new tip, treatment or product recommendation with them before anyone else. For especially loyal and frequently returning patients that you consider important to the growth of your business, take this a step further by perhaps inviting them to an exclusive treatment event you’re hosting and/or offer them a goody bag of samples for them to try and share with their friends and family.

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Conclusion Growing your business through patient referrals is hard work, but because you’re expanding through loyalty, confidence and trust, the pay-off to your business in the long term is immeasurable. People buy people, so relationships built on trust and respect is very important in maximising your potential growth. By fulfilling a patient’s experience in your clinic, acknowledging and valuing their feedback and utilising the strength of communication via social media, your patient referrals should increase, leading to an evergrowing client base. Lorraine Mcloughlin is the regional sales manager covering the south of England for UK facial aesthetics supplier, Med-fx. Prior to this, Mcloughlin worked as a clinic manager at sk:n on Harley Street. Mcloughlin is currently an Aesthetics Awards 2017 Finalist for The Healthxchange Award for Sales Representative of the Year.

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Aesthetic Launch Events Public relations consultant Jenny Pabila provides her top tips for organising a successful launch event Whether you are a practitioner, clinic owner, distributor or brand founder, at some point you may decide to hold a launch event. Launch events offer the opportunity to showcase your clinic practice, treatment portfolio, expert team and retail product line with an audience, as well as allowing you to develop and strengthen beneficial relationships. As with most marketing and public relations activity, there is a huge checklist of pre-event preparation to run through. In this article, I will outline the key points to consider to ensure your launch event runs smoothly to maximises the success of your clinic.

What are the benefits of hosting a launch event? With so many practitioners, clinics, products and technologies now available for patients to choose from, you need to ensure that what you offer is ‘seen’ and not just ‘heard’ to make you stand out from the crowd. By hosting a launch event, you create an opportunity to invite your current patients and/or target audience into your clinic and give them a ‘brand experience’, enabling you to develop a relationship with them first-hand. In addition, with careful planning and organisation, your launch event can include opportunities to increase your visibility and generate online brand

awareness across various social platforms. There are a number of different types of launch events that can be held, which can be hosted independently for patients and for press, or as a combination of the two, depending on relevance and format. Below I have detailed the main three launch events that you might host. Clinic launch or re-launch A clinic launch event enables patients to experience your new clinic, speak with the practitioners, network with fellow guests, book consultations or exclusive packages, and take away information to review. A re-launch provides the opportunity to refresh your brand/clinic and can involve rebranding by changing your name or logo or by changing your brand identity, proposition and offering. A re-launch will enable current and new patients to be familiar with your brand/clinic’s recent changes. Ideally, it is worth waiting to ‘officially’ launch a clinic so that you can address any issues that would surface after you start trading, such as equipment malfunctions and product lines/treatments that aren’t doing so well. I find that two to three months is an acceptable time to have an official launch after opening the doors – you can term this period between opening for business and the official launch date as the ‘soft launch’ period.

Treatment or product launch Holding a dedicated new treatment or product launch event allows you to showcase what’s now being offered in the clinic. You may promote this through presentations, live demonstrations and a question and answer session for patients to obtain information first-hand from the team and, potentially, the treatment/product partner. The date on which you hold your event should be evaluated on a case-by-case basis, for example, if you are 100% confident in the product and its efficacy, then you can hold the event as soon as you take delivery. Otherwise, it is a good idea to allow enough time to get used to the brand and ensure that you and your team can confidently work with the product and flag any issues that may arise, before you launch it on a wider scale. Meet the clinic experts If you have a new member of staff in your clinic, you can do a ‘meet the new resident expert’ launch event. At this event, you can offer expertise and advice from this practitioner on concerns that can now be addressed at the clinic. For example, if you only specialise in injectables and were to employ a practitioner in your clinic who offers something that you do not, you could invite your patient base and other potential patients in your locality to meet the ‘hormones doctor’ or ‘acne treatment specialist’. This could encourage your injectable patients to book a treatment with your new practitioner for a separate concern and/or generate further word-ofmouth recommendations that could result in additional clinic revenue and a widened database.

Inviting press and media Although there is often the opportunity to combine press with your customer-facing launch events, it is worth bearing in mind that journalists have a very specific information requirement and, to maximise results, it is worth dedicating this effort separately. Generally, I would not advise combining the two, unless you were inviting celebrity/ high profile patients to your customer launch because this might encourage journalists to come. Note that celebrities may be happier to attend a specific press event rather than a patient event because press tend to be more familiar with interacting with celebrities. A public relations launch event can increase your brand or clinic awareness within the press and media industry and can create a ‘media buzz’ on social platforms such as

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Instagram, Facebook and Twitter if they share pictures and posts from the event. By inviting journalists and media professionals to visit and experience the brand it offers an opportunity to engage directly with them, with a view to receive potential press coverage and feature placement. You can choose to invite both consumer and trade press. Consumer press coverage can support driving product and clinic demand as well as brand awareness to your consumer audience, while trade press will aim to cover a launch story within your industry, which can help establish your brand awareness or profile value. This can be useful if you wish to develop your value as a brand partner or key opinion leader.

How to organise your launch event If you are planning your first launch event and have little or no experience in event organisation, I strongly suggest that you conduct research and devise a list of everything that you need to include, so that you do not forget anything. If you are

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having trouble doing this yourself, you can choose to employ the services of an experienced consultant or agency to organise the event for you or even just to create a plan that you can implement. Their expertise could help you negotiate industry rates for elements of the launch such as catering, photography, artwork and design. In addition, if you are inviting an audience that the consultant has preexisting relationships with (such as press) then they might be able to increase your attendees and support the development of a long-term brand relationship and press coverage. If you choose to work with an agency, ensure you outline your expectations and obtain a clear outline of their fees and breakdown of activity to avoid any unbudgeted costs, which can range depending on the agency and the event requirements. In the circumstance that you plan the event yourself, you need to consider what you should do before and after the event. As a guide, you can structure your event planning

as outlined below, which can be adapted based on the scale of the event. Pre-launch Objectives: Decide on key objectives for your launch event; do you want to generate awareness for a new treatment/practitioner on offer to existing patients? Attract new patients? Or generate sales for a specific seasonal treatment? Music, decorations and gifting can all enhance or detract from your launch objectives so consider the benefits before deciding to have these in place. Budget: I recommend identifying how many guests you want to have at the event and then research costs for drinks, food and entertainment, investigating how much of this you can obtain sponsorship for. For catering, I estimate two to three drinks and four to five canapés per guest for a two-hour event will suffice. You can include an extra portion if you want to ensure you do not run out. Do not forget hidden costs like flowers to decorate the venue, printing invitations, staffing and goody bags. Work out what is essential and what you can go without.

Do’s and don’ts • DO allow enough time to plan: 16 weeks may seem indulgent, however attention to detail increases success and you need to factor in time for third party supplier and partner support such as copywriting, design, proofing, issuing a save the date and event supplier orders. People also need plenty of notice to fit the event into their busy schedules. • DO include brand partners: your skincare or other product providers may wish to support or sponsor elements of your launch to generate more awareness of their brand. Offer them the opportunity to sponsor parts of the event such as refreshments, entertainment or goody bags. They may even wish to bring their key opinion leaders or trainers to the event to conduct demonstrations or treatments for guests, which is potentially beneficial for your clinic sales and their repeat purchase sales from your clinic. • DO create an event hashtag: display your social media handle at the event or have a selfie spot to encourage your guests to post live from the event, using a designated hashtag. This will create engagement with your brand and could increase followers and traffic to your social media sites, where you can promote your products and services. • DON’T plan a date without research: there are set times of the year, days of the week and even times of the day that affect the probability of people attending an event. Find out if there are major local social or sporting events on that may reduce the availability of your target guest list attending. • DON’T assume people will turn up: do not assume your guests have received a save the date or event invitation. Ensure all invitations are followed up with a personalised email/text that contains the event details and give guests a call 24 hours in advance to confirm attendance. This will also help you to budget for costly items such as catering and goody bags. • DON’T centre the launch around something that is not guaranteed: ensure that the main ‘hook’ or attraction for your launch event is guaranteed to be in the clinic before the event and not expected to be delivered on the day. If this cannot be organised in advance, choose a different focus.

Dates: Identify potential launch event dates and research when your invitees are likely to be available. If it takes place at your clinic, decide whether you do this during practice hours, out of hours and as a daytime or evening event. If you have a busy city clinic, an attractive time might be at the end of the day when people can stop by to enjoy refreshments and socialise whilst avoiding the peak-hour commute. Location: Will you have your event at your clinic? Events for the press can take place in the clinic or in a centrally located venue (to maximise attendance) where guests can attend for a briefing and receive an invitation to view the clinic or experience a treatment at a later date. The benefits of hosting an event at your clinic include being able to offer the ‘real’ experience and awareness of your clinic, while developing an emotive relationship and direct engagement between your team and the press/patients. Third parties: Research and shortlist all supplier options for the various elements that form the structure of your event, such as catering, and obtain confirmation of availability for all relevant parties. For most events, I’d recommend creating custom designs for communications and event materials, so be sure to brief your design

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Goody bags Your goody bag can include things like a full size or travel-sized product, such as a lip balm or a moisturiser, which has been donated from your brand suppliers. It could contain something branded to your clinic or product launch like a USB stick, candle or notebook. These are great to increase social posting and generating a social media ‘buzz’. You should also include printed material for the press (press kit) or clinic offers and treatment details (for patients).

team thoroughly and ensure they can make any necessary amends or updates in time for your deadline. It is worth contacting all your third-party suppliers again at least 24 hours before the event to reconfirm your event requirements and their point of contact on the day. Invitations: Issue a save the date to customers and/or press six to eight weeks in advance or longer if the event takes place during key social periods of the year. Use a table detailing the guest list and their contact details with space to record notes. Request an RSVP via email or phone to a specific email address/number that is monitored throughout the day and ensure you send a follow-up invitation if you do not hear back. Once you have your guest list, extend a personalised invitation to make them feel valued four to six weeks before the event or as soon as the details are confirmed. You can also encourage your invitees to bring a friend or partner, which can potentially attract new patients. You may also wish to invite a celebrity patient or brand ambassador. Press release: You should draft and issue a press release to notify journalists that the event is taking place. It should contain information about the launch event and communicate what is new, if there is any new clinical data, technology, ingredients, treatment information and before and after images and also showcase any experts with comments or question and answer content. Schedule: Plan and check the order of your launch event with all the required parties (e.g. speakers, ribbon cutter, demonstrators) and confirm the checklist of activities to all parties involved, which may also include technicians

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in charge of the opening speech, spotlights and music. Ensure that delivery of all materials and elements required at the launch event is taken with enough time to set up, and confirm all speakers and announcement information the day before the event. Set up: Aim to set up as many elements of the event as possible 24 hours in advance to avoid last minute issues such as printing and compiling press or information packs. Ideally, test any technologies such as presentations and logistics to ensure that they work the day before.

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night. Offer to supply expert comment or additional information and invite them back to the clinic to experience a treatment or test a product to review it in their publication/media. Note that free treatments won’t guarantee coverage, but might help build relationships and encourage further publicity. Event evaluation: Conduct a post-event evaluation and run through the event management from beginning to end with your team to analyse any challenges and how to improve or avoid them in the future.

Conclusion Event inclusions: Typically, you need to plan to ensure your launch event includes: • Registration upon arrival so you can keep track of your attendees • A dedicated person to meet and greet guests and take them into the event space to ‘hand’ them over to a clinic or brand representative, who will make them feel comfortable • A reasonable time for people to arrive, network and relax before the event starts (in my experience, this is usually about 30-40 minutes) • An opening speech to introduce guests and disclose the format of the event, ideally presented by the clinic owner • Any special offers or exclusives as an extra incentive to attend • A demonstration of treatments or products if relevant • An introduction to the team for further information at the event and/or a question and answer session if relevant • A leaving process where guests are thanked and handed a goody bag and/ or an invitation to contact you or your team for more information or to book a treatment

Once you have identified clear strategic launch objectives, with careful and creative planning, it is possible to execute a successful launch event. Your previous experience in event organising, as well as the format and scale of your event, will dictate whether you may want to consider external support to help you. It is important to plan as far in advance as possible to ensure you are fully prepared so you do not to forget anything. Remember to thank guests and sponsors for their attendance and support, and keep the event buzz alive by showcasing the coverage on social media and following up with potential PR leads. Jenny Pabila is an independent beauty and aesthetics public relations consultant with more than 22 years’ experience in public relations, marketing communications and brand building. Having personally executed launches in London, Dublin, Europe, Dubai and New York, Pabila has developed key press relationships globally to support international brand communication. FURTHER READING: • Andy Green, Creativity in Public Relations, Kogan Page, 2009. • Ruth Dowson and David Bassett, Event Planning and Management: A Practical handbook for PR and Events Professionals, Kogan Page, 2015.

Post-launch Communications: Ensure you thank all sponsors and event partners separately. Repost and showcase all social media coverage as appropriate, as this will continue to generate event awareness and will create a buzz, which could potentially increase your brand opportunity to connect and engage with a new audience. Press: Issue a post-event press release containing images and quotes from the night to secure coverage in trade and local media. You should also individually thank each person and follow-up with an electronic version of the press pack supplied on the

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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Benefits of Mentorship Aesthetics explores the mentoring process and investigates how to make the most of the unique learning experience The nature of medical aesthetics means that many practitioners will work alone when they’re starting out. They will attend a reputable training course, learn the essential skills needed to begin treating patients, receive their certification and then be left to start practising alone. For some, this can be a daunting prospect. While they may be well-equipped in using dermal filler for most indications, for example, they could one day receive a request for a treatment area they’re unfamiliar with. Of course, as an ethical practitioner they could refuse treatment or refer to a more experienced practitioner, but what if they wanted to learn how to offer this procedure? The cost and time associated with completing an additional training course may not be appropriate on this occasion, so where can they turn? For many practitioners, building relationships with more experienced professionals offers a solution. In what is a relatively new specialty, with continuous updates and developments yet limited formal training, clinicians have expanded their skills by sharing their

experiences and knowledge of their various fields. This can come through attending annual aesthetic conferences or workshops held by product suppliers, but it can also come from finding an aesthetic mentor – someone to turn to for one-to-one advice, who is willing to share their techniques and best practice methods with the common goal of enhancing the specialty as a whole. Finding a mentor The Royal College of Nursing (RCN) describes a mentor as, ‘A role model willing to help a student develop clinical competence through support, honesty, appraisal, reflective communication and being a critical friend’.1 Before approaching anyone to become your mentor, aesthetic nurse prescriber and mentor Frances Turner Traill advises that you should always check their credentials. “Always approach with caution as there are a lot of people who claim to be an expert, but have limited evidence to prove that,” she says, recommending, “Ask what their experience

“Always approach with caution as there are a lot of people who claim to be an expert, but have limited evidence to prove that” Frances Turner Traill

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is, what qualifications they’ve got, whether they’ve mentored before and what the outcome has been for the practitioners they’ve mentored.” Business coach and mentor Adrian Wales adds, “It’s good to have a clear understanding of what you’re looking to get out of the relationship before you approach the individual. It’s also important to give some acknowledgement of specifically why you’ve approached that person to give them clarification on how they can help.” For practitioners working within a clinic, Wales suggests approaching your line manager for support in finding an appropriate mentor. This, he says, has benefits for both the manager and the employee, “Having somebody outside of immediate line management that can build a trustful relationship with a person requesting support can be invaluable. They can share their expertise and wisdom, give good advice, but won’t hold them accountable,” adding, “Often, the line manager will have more of an understanding of how other senior members of staff can help.” Becoming a mentor Mentoring less experienced aesthetic practitioners can be hugely rewarding, says Wales. He explains, “It’s enormously reaffirming when someone approaches you and says they’d love to spend more time with you to understand how you work. It enables you to look at what you do from the eyes of somebody else – most people don’t really stop and analyse what they do, how they do it and what they know. Working with a mentee can help you look ethically at what you’re doing and make sure it’s understandable to someone else.” Turner Traill adds, “It gives you a chance to reflect and critically examine your knowledge base, your skills, your attitudes and your competence. It can help map out your own strengths and weaknesses so you can identify where you are and consider where you want to be.” As a board member of the British Association of Cosmetic Nurses (BACN), Turner Traill has become part of the Aesthetic Nursing Revalidation Mentor Programme, which aims to support nurses through their revalidation process and mentor them appropriately to achieve high standards of competency and safe practice. She explains, “We aim to address gaps in knowledge and experience by going through a detailed process so the mentor and mentee can identify the gaps and work

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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towards a programme where these are filled.” She explains that there is a stringent application process in which practitioners need to prove that they meet the relevant competencies to become a mentor, “You need to show how many procedures you’ve done, how many complications you’ve managed, what the outcomes were, the clinical pathway used; you’ve got to have a very good audit trail to become an accredited mentor.” While this is one option specifically for BACN members, Wales acknowledges that mentoring doesn’t necessarily need to involve such a formal process. He says, “I think one of the most important things is for the mentor and the mentee to agree ways of working together when they start. You ideally want to have a terms of reference document, which addresses what you both hope to get out of the arrangement and how you will measure its effectiveness.” Turner Traill notes that her early experience of mentorship was very informal but ‘invaluable’ to her development as it enabled her to observe numerous specialist treatments and techniques. She explains, “I worked with a maxillofacial surgeon who I would go and watch in theatre whenever I could.” Establishing a successful working relationship As Wales mentioned previously, discussing the goals of both the mentee and mentor is imperative to a successful relationship. “As much that can be agreed upfront the better,” he says, noting, that some people will have very specific ideas in mind in terms of time frames and work processes, while others may be very relaxed and happy to adapt to each situation as it comes. “I’ve known mentors and mentees who’ve

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worked together for more than three years – they may not see much of each other but they know that there’s somebody there at the end of the phone or to spend time with when necessary,” he says. Turner Traill agrees, explaining, “Mentoring can be an ongoing process because learning should be ongoing. Practicalities can change; for example, you may agree to mentor someone for two full days in clinic but you identify, as you go on, that their goals aren’t quite being met. As the mentee is critically evaluating their performance as well, they will often agree that perhaps they need longer.” The biggest obstacle of mentoring is time, says Turner Traill, with Wales agreeing that finding diary space can be hard. However, they note that with careful planning, this can of course be overcome. Wales also highlights the importance managing a mentee’s expectations, “You could spend three months with Richard Branson, but that doesn’t mean that after three months you’re going to come away with the same success as Richard Branson.” He explains, “You’re likely to pick up some useful skills but it’s important to highlight that no matter how much you admire someone, they’re not you and you’re not them. You can get some great ideas, tips and techniques, but you’ve got to find a way of making them work for you.” Turner Traill concludes by emphasising the value of mentoring to everyone involved, “Everyone’s got something they can bring to it. Every day’s a school day – you can always learn from somebody.” REFERENCES 1. Royal College of Nursing, Mentorship (UK: RCN, 2008) <https://www.rcn.org.uk/library/subjectguides/mentorship>

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Aesthetics Journal

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“I do not believe in offering a quick fix” Dermatologist Dr Ariel Haus reflects upon his career so far and compares his experience in aesthetics in the UK to his home country of Brazil “I am somebody who always wants to help people, so I decided that a career in medicine was the best option for me,” explains Dr Ariel Haus. Although London is his home now, it is not where he started his professional journey. He says, “I went to Souza Marques University in Rio de Janeiro and in my second year, when I was a junior doctor, I started training in A&E in Santa Casa de Misericórdia Hospital. During this period, I learnt about many different specialties and, since the beginning, dermatology stood out to me. I also had influential dermatology professors who encouraged me to get more involved and it was then that I discovered my passion for skin. So, after I finished medical school in 1999, I took my post-graduate qualifications in dermatology.” Upon completing his training in 2006, Dr Haus opened his first dermatology and aesthetic clinic in Rio de Janeiro, which he still visits when time allows. At this point, he decided to expand upon his knowledge by travelling. "I travelled all over Europe, and while I was here, I decided to settle in the UK and open a London clinic,” he says, continuing, "I got my GMC registration in November 2009 and opened my practice on Harley Street in early 2010. A few months later, I was invited to work in the NHS, which to me was an amazing opportunity. I love working in the NHS because you experience such a range of different and difficult cases.” Dr Haus says that he finds aesthetics in the UK to be quite different from Brazil. He explains, "Unlike the position in the UK, the specialty in Brazil is very regulated and non-invasive procedures can only be performed by doctors, and in reality it is mainly plastic surgeons and dermatologists who specialise in aesthetic medicine. There is also a cultural difference with patients. In my experience, they are much more open to new treatments, technologies and trends and often tell their friends and relatives that they have had treatment. Here in the UK, it’s the opposite; patients are much more discrete and there is more of a ‘less is more’ approach. Although, I do believe that it is changing here and patients are becoming more open.” Dr Haus uses the ‘Brazilian Butt Lift’ as an example of this progression, saying, “UK patients are starting to catch on to this trend. I was among the first doctors to offer this in the UK because I wanted to make sure that my UK patients had access to this developing treatment.” Outside his private clinic and NHS duties, Dr Haus is a member of many societies such as the American Academy of Dermatology, the European Academy of Dermatology and Venereology and the British Association of Dermatologists, to name a few. He also regularly presents at national and international conferences. This, he says, is a fundamental part of his role as a practitioner, “I try to do at least two lectures, conferences or workshops a month and, because they’re often in a different country, you get a cultural exchange in experience and information as well.” When asked about the highlights of his career, Dr Haus says, “My biggest achievement is being able to

work here in London, which I think is the greatest city in the world, in both private practice and the NHS. I like that I have so many patients from abroad, which provides a unique experience as I can treat different types of patients,” Dr Haus notes. He adds, “I am also proud that I can treat all patients the same, whether they are from my private practice or the NHS. Safety and giving the best service to my patients is the most important thing to me.” Although Dr Haus has been working in dermatology and aesthetics for years, he still finds it challenging. He explains, “Aesthetics isn’t easy because unlike other parts of medicine, you have to balance patient wants with patient needs. You also have to understand that sometimes patients just want ‘more’ and you have to have the strength to tell the patient, ‘stop, you’ve had enough’.” When asked about his approaches to treatment, Dr Haus says, “I do not believe in offering a ‘quick fix’. I am in favour of creating a treatment plan for the long-term, to reach an overall goal for my patients. Aesthetics and dermatology are specialties that I really enjoy and am proud to work in. I love my work and I love the contact with patients. For me, the best thing is when the patient starts to bring their family for treatment, like their mother or child if they have a skin problem, which I think is quite fascinating. I also like feeling a part of the family – for me this is priceless.”

What’s your professional ethos? I try to inspire others, like my previous professors inspired me, and my goal is to always give the best to my patients by having the leading, newest and safest technology available. What treatments do you advocate? For me, technology is essential because I focus on offering preventative treatments. I like to induce collagen production in the body instead of injecting something at a later stage. The secret is knowing that there is not just one technology, you can combine multiple technologies to give the patient everything they need. What’s your industry pet hate? I don’t like companies who make new practitioners believe that they know everything after a quick workshop. I also don’t like it when people use the term ‘clients’. I have ‘patients’ and their health and safety is the most important part of my practice. What’s the best part of your day? It’s meeting all my patients. I have patients that have been under my care for nearly 20 years and I know them and their family well – I love it, it’s fascinating!

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017

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The Last Word Mr Muholan Kanapathy and Professor Ash Mosahebi discuss the conflicting advice surrounding sunscreen and vitamin D As we well know, overexposure to ultraviolet (UV) radiation is a major risk factor for skin cancer. Consequently, strict UV protection by using sunscreens and other measures form the basis of most skin cancer prevention campaigns. However, as at least 80% of the human body’s need of vitamin D is synthesised in the skin by the action of solar UV rays,1 particularly the ultraviolet B (UVB) radiation, strict UV protection is claimed by some studies to promote vitamin D deficiency.2,3 Communicating the risks and benefits of sunlight exposure to patients can be challenging. In addition, many practitioners have differing opinions as to whether sunscreen affects vitamin D absorption to a point which could be detrimental to patients if sunscreen is or isn’t applied. On one hand, patients may have been advised to protect their skin from the sun to avoid skin cancer, while on the other hand, they may have been advised by aesthetic practitioners or their GP to expose themselves to sunlight to ensure that they get enough vitamin D. This conflicting advice is an issue and could be contributing towards conditions such as melanoma and vitamin D deficiency. For aesthetic practitioners, this is an important concern, as they regularly advise patients on how to protect and nourish their skin. The guidance The latest National Institute for Health and Care Excellence (NICE) guidelines on the risks and benefits of sunlight exposure mention the need for protecting skin against UVA and UVB by applying sunscreen, but it does not address the effect of sunscreen on vitamin D absorption.1 The NICE committee expert testimony, which advises on these guidelines, however, confirmed that frequent, liberal use of high-protection sunscreen may prevent vitamin D synthesis, (this was not included in the guidelines) although the committee claim this is usually only true under research conditions and unlikely the case in practice.1 This is because people may inadvertently miss some areas of skin when they apply sunscreen and also tend to apply much less sunscreen than the manufacturer’s

recommended amount. A study suggested sunscreen users customarily apply half or less of the amount of product stipulated by the Food and Drug Administration to generate the stated level of protection (2mg/cm2) and hence achieve far less protection.2 Therefore, it is our belief that sunscreen use has little impact on vitamin D absorption. The concern Nevertheless, there are many practitioners that believe sunscreen-use does severely impact on vitamin D absorption, this could be because an SPF 30, when properly applied, absorbs about 97.5% of UVB. The unintended consequence is that an SPF of 30 reduces the capacity of the skin to produce vitamin D by 97.5%.4 However, they may be unaware that the majority of people do not use sunscreen as recommended. This enforces the need for more education to be available on ensuring stable vitamin D levels through other means. The solution The optimal frequency and duration of sun exposure for the best ratio of benefit to risk depends on a range of biological, environmental and behavioural factors, but this must be communicated more clearly with patients. Practitioners need to explain to patients that controlled and balanced exposure to UV with the use of sunscreen is essential to avoid photoageing and cancer risk, without unduly raising the risk of vitamin D deficiency. This can be achieved by practitioners improving their knowledge and reading more research on vitamin D and sun exposure, before advising. We also believe the creation of more detailed guidelines for practitioners, as well as guidelines on application techniques of sunscreen are needed. Regardless of one’s complexion or extent of UV exposure, daily oral vitamin D supplementation can compensate for lack of cutaneous vitamin D photosynthesis, and this should also be recommended.2 Patients can be informed that vitamin D can also be obtained from natural dietary sources and supplementation, such as oily fish like mackerel, salmon and sardines, as

well as fortified margarine, cereals and egg yolks. In fact, the recent NICE guidelines state that it is not possible to get enough vitamin D from sunlight between October and March in the UK, emphasising the need for supplementation.1 The Department of Health already recommends supplementation (10mg of vitamin D a day) for pregnant and breastfeeding women, young children, older people and those at risk because of low sun exposure.5 Summary Sun exposure is the main source of vitamin D, but excessive sun exposure is the main cause of skin cancer.1 Healthcare practitioners should communicate the importance of maintaining balance to protect skin from photoageing and cancer without resulting in vitamin D deficiency to the best of their ability, utilising as much research and clinical studies as they can. For those patients who are concerned about vitamin D deficiency, practitioners should advise them on alternative ways to ensure stable levels, such as dietary sources and supplements. Mr Muholan Kanapathy is a clinical research fellow in plastic surgery at the University College London and Royal Free Hospital London. Mr Kanapathy’s PhD research focuses on clinical trials and cellular biology of skin, particularly in wound healing. Professor Ash Mosahebi qualified at Guy’s and St Thomas Medical School in London. His plastic surgical training was in London Deanery and he has had further specialist training in reconstructive and aesthetic surgery in New York and Belgium. Professor Mosahebi is a consultant and service lead at Royal Free Hospital, London. REFERENCES 1. Sunlight exposure: risks and benefits 2016 (2017) <https://www. nice.org.uk/guidance/ng34> 2. Gilchrest, B.A., Sun exposure and vitamin D sufficiency. Am J Clin Nutr, 2008. 88(2): p. 570s-577s. 3. Rathish Nair and Arun Maseeh, Vitamin D: The “sunshine” vitamin, J Pharmacol Pharmacother, (2012) <https://www.ncbi. nlm.nih.gov/pmc/articles/PMC3356951/> 4. Kockott D, et al, New Approach to Develop Optimized Sunscreens that Enable Cutaneous Vitamin D Formation with Minimal Erythema Risk. PLoS One. 2016 Jan 29;11(1):e0145509. 5. Wyatt C., et al., Vitamin D deficiency at melanoma diagnosis is associated with higher Breslow thickness. PLoS One, 2015. 10(5): p. e0126394.

Reproduced from Aesthetics | Volume 4/Issue 11 - October 2017