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VOLUME 2/ISSUE 10 - SEPTEMBER 2015

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Using Pulsed Dye Lasers CPD

Treating Keratosis Pilaris

Aesthetics Awards

Winter01/04/2015 Marketing

Dr Justine Kluk shares her techniques for treating this common skin condition

The finalists for the prestigious Aesthetics Awards 2015 are announced

Charlotte Moreso discusses how seasonal marketing can boost trade

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Contents • September 2015 06 News

The latest product and industry news

14 News Special: Holistic approaches to skin treatments

An investigation into how alternative treatments can complement aesthetic practice

CLINICAL PRACTICE 17 Special Feature: Lights

Special Feature Lights Page 17

Practitioners discuss the various modes and functions of light- based treatments

22 CPD: Using Pulsed Dye Lasers

Dr Firas Al-Niaimi details the history and efficacy of pulsed dye lasers

29 Keratosis Pilaris

Dr Justine Kluk explores the aetiology of this genetic skin disorder

33 The Three-point Facelift

Dr Beatriz Molina presents her technique for non-surgical facelifts using cannulas

36 Managing Inflammation

Dr Kathryn Taylor-Barnes examines why inflammation occurs and how best to manage this for your patients

38 Aesthetics Awards 2015

The finalists for this year’s Aesthetics Awards are announced

45 Treating the Décolletage

Dr Aamer Khan outlines the procedures available to improve signs of ageing on the chest

51 Glutathione

Dr David Jack highlights clinical uses of the glutathione antioxidant

55 Treating Sunspots

Dr Daron Seukeran details the occurrence of photoageing and discusses treatment options for solar lentigos A round-up and summary of useful clinical papers

IN PRACTICE 61 Building a women’s health clinic

Wendy Lewis investigates the incorporation of women’s health treatments into aesthetic practices

65 Winter Marketing

Charlotte Moreso explains how effective marketing can aid patient retention in the winter season

68 Staying Positive

Plastic surgeon Mrs Elena Prousskaia presents her key tips for developing a positive working environment

70 In Profile: Dr Kuldeep Minocha

Dr Kuldeep Minocha shares his journey from GP partner to successful aesthetic practitioner

72 The Last Word: Clinical Trials

Dr Martin Godfrey explains why high quality clinical trials are necessary for nutra-cosmeceuticals

NEXT MONTH • IN FOCUS: Male Special • CPD: Male vs female facial rejuvenation • Treating scars • Doctor to businessperson

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Clinical Contributors Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon. He trained in Manchester and completed an advanced surgical and laser fellowship at the St. John’s Institute of Dermatology at St. Thomas’ Hospital in London. Dr Justine Kluk is a consultant dermatologist based at London North West Healthcare NHS Trust and European Dermatology London. Her particular clinical interest is in skin cancer, having undertaken a post-CCT fellowship in cutaneous oncology. Dr Beatriz Molina practised general medicine for 12 years, before opening her first aesthetic practice in Somerset in 2005. She is a member and the director of conferences at the British College of Aesthetic Medicine (BCAM). Dr Kathryn Taylor-Barnes is a general practitioner in Richmond and founder of The Real You Clinics. She has presented her work at national and international conferences and is currently completing a postgraduate Masters qualification.

59 Abstracts

In Practice Winter Marketing Page 65

Dr Aamer Khan is an aesthetic practitioner specialising in non-invasive treatments. He graduated from The University of Birmingham in 1986 and is dedicated to perfecting anti-ageing skin treatments. He is also co-founder of The Harley Street Skin Clinic. Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Dr Daron Seukeran is a consultant dermatologist at the James Cook University Hospital in Middlesbrough and previously worked at the Royal Berkshire Hospital. He undertakes general dermatology and dermatological surgery, alongside his main interest in laser surgery.

Book your tickets now for the Aesthetics Awards 2015 www.aestheticsawards.com

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Editor’s letter This year seems to be flying past – or is it just me? September always feels autumnal with the change in temperature in the mornings and evenings, dew on the grass and children returning to the first term of a new school year. Amanda Cameron September is also an exciting time of year for the Editor aesthetic industry. Along with being the start of the conference season, the Aesthetics Awards shortlist is announced in this month’s journal! For those who haven’t already rifled through the pages of this issue, turn to p.38 to see the lists of finalists in 23 prestigious categories. September’s issue also has some fantastic articles on this month’s topic of rejuvenation. The word got me thinking – what does it mean to rejuvenate? According to Chambers dictionary, it means to make young again or to make someone feel or look young again, and its derivation is from the Latin ‘juvenis’ meaning ‘young’. So is this what we aim to do for our patients; do we want to make them look younger or simply look good for their age? The décolletage is a notoriously neglected area of the body, and one where many patients seek rejuvenation. As such, Dr Aamer Khan gives a detailed overview on the different ways of treating the neck and chest on p.45, sharing advice on the practicalities of each method

of treatment. Dr Beatriz Molina also presents her three-point facelift technique for non-surgical rejuvenation on p.33, giving a detailed overview for practitioners looking to adopt a new treatment approach. And while well-performed aesthetic procedures are vital for successful rejuvenation, it is also wise to complement both non-surgical and surgical treatments with good skincare. As Dr Martin Godfrey argues in this month’s Last Word opinion piece (p.72), practitioners should be using scientifically-proven products and ingredients that are well supported with clinical trials. With respect to this, Dr David Jack examines the properties of Glutathione as a key antioxidant ingredient in a fascinating article on p.51. As always, we have a comprehensive CPD article that is sure to educate and engage readers. This month Dr Firas Al-Niaimi looks into the history and science behind the mechanisms of pulsed dye lasers on p.22. I shouldn’t leave without another final mention of the Awards. December will be upon us before we know it, so be sure to book your tickets in good time! Visit www.aestheticsawards.com to reserve your place and to vote for your winners. And don’t forget to tweet us @aestheticsgroup if you’re a finalist, or to show your support for those on the shortlist!

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.

experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. Sharon has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).

and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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.

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 Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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Melanoma

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Motivation Dr Justine Kluk @JustineKluk There is no greater feeling as a doctor than seeing your patients get better esp when their condition is so visible #skin #MondayMotivation

#Device Dr David Jack @drdavidjack My new machine just arrived! #laser #inmode #fractora #aesthetics #ipl #london #harleystreet #rosacea #beauty

#Regulation Harley Academy @HarleyAcademy The Joint Council for HEE recommendations has been formed. Regulation is coming to the aesthetics industry at last

#Results Dr Razwan @Skyn_Doctor Always feel re-energised when clients return after treatments and are highly satisfied with results #feelingblessed

#Training Aesthetic Training @GlowTraining Hands on practical #mesotherapy training @58SouthMoltonSt. Thank you to our delegates & models #skinpeel #hydration

#Clinic TheGlasgowSkinClinic @KMcchord Fantastic clinic today with Dr Stephen McChord & KMcchord. From facial rejuvenation to axillary hyperhidrosis. #safetyinbeauty #aesthetics

#Skin BSF @BSFcharity BSF & @TheCPTA survey: 4 out of 10 terms asked have seen patients with skin reactions to black henna temporary tattoos #AvoidBlackHenna

#Training Julia Kendrick @JRKendrick @SkinCeuticalsUK Training day 2: skin analysis – nowhere to hide! #nofilter #uvaware #fixmequick

New skin cancer recommendations for NHS England New guidelines issued by the National Institute for Health and Care Excellence (NICE) has recommended key points for NHS England to address when treating melanoma. The document, which was released in July, has outlined areas that NHS England need to focus on, including information provision, support and communication with patients. The guidelines suggest that written information on the diagnosis and treatment should be made available to patients and ‘information given must be specific to the histopathological type of lesion, type of treatment, local services and any choice within them, and should cover both physical and psychosocial issues.’ It also discusses how every Local Hospital Skin Cancer Multidisciplinary Team (LSMDT) and Specialist Skin Cancer Multidisciplinary Team (SSMDT) should have a Cancer Clinical Nurse Specialist (CNS) to provide a leading support role to patients and carers, as well as provide psychological services. Professor Mark Baker, director of the Centre for Clinical Practice said, “Melanoma causes more deaths than all other skin cancers combined. Its incidence is rising at a worrying rate – faster than any other cancer. If it is caught early, the melanoma can be removed by surgery. If it is not diagnosed until the advanced stages, it may have spread, so it is harder to treat.” He continued, “However, there are a number of options available to help slow the progress of the disease and improve quality of life. This new guideline addresses areas where there is uncertainty or variation in practice, and will help clinicians to provide the very best care for people with suspected or diagnosed melanoma, wherever they live.” The new guideline comes as Cancer Research UK recorded 2,148 melanoma related deaths in 2012, making it the eighteenth most common cause of cancer death. Survey

BAPRAS calls for greater psychological support post treatment The British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) has called for greater measures of psychological support for patients who undergo reconstructive surgery. A survey of more than 100 BAPRAS members showed that plastic surgeons frequently see patients who require psychological support through a range of sub-specialities such as burns treatments to breast cancer reconstruction. Dr Jo Tedstone, consultant clinical psychologist said, “There is plenty of evidence that providing these services improves patients’ mood and quality of life as well as reducing overall healthcare costs.” Of the survey respondents, 93% said that access to psychological treatment is an important factor for their patient group and 64% claimed to see patients who are in need of psychological support every week.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Aesthetics

Industry

Awards

Biopharmaceutical company backs acne scar dermal filler Spanish Biopharmaceutical company Almirall has announced it will support startup aesthetic provider Suneva Medical with an equity investment, in order to aid the launch of the acne scar dermal filler Bellafill. The $15 million deal comes as Suneva Medical also secured a term loan of $20.4 million from investment group HealthCare Royalty Partners. Eduardo Sanchiz, CEO of Almirall said, “We have been attracted by the quality of Suneva’s portfolio and its management team. This partnership will also allow us to further build our understanding of the performance of the aesthetic dermatology market in the US.” Approved by the Food and Drug Administration (FDA) in January 2015, Bellafill aims to be a permanent solution for acne scars and can also be used to treat nasolabial folds. Research

Juvéderm Voluma research indicates lasting results A recent study from the American Society for Dermatologic Surgery (ASDS) has indicated that results from Juvéderm Voluma can last for up to one year with a small risk of adverse events. Led by Canadian cosmetic dermatologist and clinical researcher Dr Shannon Humphrey, the study was a retrospective review of 2,342 patients who underwent facial augmentation treatment with Juvéderm Voluma between February 1, 2009 and October 1, 2014. A total of 11,460 ml of the HA filler was administered during the course of the study in 4,702 treatments, with 50% of patients receiving two or more treatments. Commenting on the research, Dr Humphrey said, “With over five years clinical experience, a cumulative volume injected greater than 11 litres, and increasing in popularity worldwide we published the largest case series of patients treated with Juvéderm Voluma.” She continued, “Our results confirm that this robust volumising filler has a very good safety profile, high patient satisfaction and longer durability than most hyaluronic acid fillers. This provides reassurance and substantial case-based evidence that this volumising filler is in fact a durable, safe and a valuable addition to our therapeutic armamentarium.” Adverse events included erythema and bruising, which were both primarily limited to transient injection site reactions and resolved within five to seven In addition, temporary non-tender nodules developed at the injection site in 21 patients, lasting between one to 16 weeks.

Finalists announced for the Aesthetics Awards 2015

After months of deliberation, the finalists for the Aesthetics Awards 2015 have been announced. The ceremony, which will take place at the Park Plaza Westminster Bridge Hotel on December 5, will celebrate the best in medical aesthetics, recognising Commended and Highly Commended finalists as well as inviting winners to the stage in 24 categories. The Awards recognise the highest standards in achievement, clinical excellence and product innovation, honouring individual practitioners, companies, associations and treatments. The evening will begin with a drinks reception, followed by a formal sit-down dinner and entertainment from British stand-up comedian Simon Evans. The main event will then commence and winners will be presented with trophies in front of 500 members of the medical aesthetics profession. The evening will draw to a close after guests are invited to enjoy music and dancing. Winners will be decided either by a combination of Aesthetics journal reader votes and scores from a panel of specially selected judges, or by the judging panel alone. The winner of The Schuco Award for Special Achievement award will also be announced on the night and will be chosen by the Aesthetics team. See pages 38-42 of this month’s journal for the full list of finalists. To book your ticket or to vote, visit www.aestheticsawards.com

Clinic

The Private Clinic opens flagship practice in Birmingham The Private Clinic of Harley Street has opened a new practice in the West Midlands. The aesthetic and medical cosmetic treatment provider opened the clinic last month, located on Hagley Road in central Birmingham. The clinic, which has three in-house theatres, aims to provide patients with highly-experienced cosmetic specialists and a wide range of cosmetic procedures. Valentina Petrone, managing director of The Private Clinic, said, “As a business, we have more than 30 years of Harley Street expertise and, over time, we have grown our medical team to include some of the country’s brightest and most highly regarded talent. In recent years, demand for

advanced medical expertise and specialist treatment from consumers in the West Midlands has risen considerably. It was only right, therefore, that we responded to this growing demand and extended our operation on a regional level.” She continued, “The new facilities will enable us to offer hair transplant procedures on the premises in Birmingham for the very first time – a significant step forward for us. Over time, we look forward to growing our presence in this region further and continuing to cement our position as an industry leader.” The practice will take the place of The Private Clinic’s former West Midlands-based clinic that was located in Harborne.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Sun

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Skincare

Murad and AAD partner for child sun safety Skincare brand Murad and the American Academy of Dermatology (AAD) have announced their partnership in creating a programme to protect children from UV rays when playing in public parks. The programme, named Shade America, will aim to provide approximately one million children with shade over the next five years, by initiating the build of shelter and shade structures in playgrounds across the US. It will also offer children sun safety education classes. Hilarie Murad, president of the Murad Family Foundation said, “We are extremely excited about this partnership and also thrilled to be able to create a programme that truly supports our mission to help young people lead healthier, happier and more connected lives.” She continued, “Educating the youth in our community about sun safety is a cause that Murad has been fully committed to and it is something I am personally very passionate about.” The creation of Shade America comes as the AAD has estimated that one in five Americans will be diagnosed with skin cancer in their lifetime, therefore the programme is also designed to raise awareness of the need to wear sunscreen and regularly check for suspicious spots. Research

Skincare devices market growing at significant rate A study currently being conducted by P&S Market Research has suggested that the global skincare devices market is continuously growing due to the increasing number of non-invasive treatments performed. The research, which predicts the growth of sales up to the year 2020, discusses the popularity of various treatments and examines usage across all continents, with North America currently taking the lead and Europe expected to transform into a ‘mature’ market. In addition, other factors considered are the manufacturing of more affordable and advanced technologies including consumer devices and higher investment rates from beauty product manufacturers. The research also categorises devices by product type, such as LED therapy leading the treatment market with its extended use in clinics and spas. The study has also reported that the rise in the number of skin cancer patients, as well as disorders including acne, psoriasis and moles in Brazil, China and India are expected to add to the growth of the devices market in the coming years. The report will be published in full later this year. Dermal filler

Study suggests Restylane Lip Volume shows effectiveness for nine months A recent study on the effects of the HA lip enhancement gel Restylane Lip Volume has shown that results of treatment can last up to nine months. Research from the American Society for Dermatologic Surgery explains that 30 patients between the ages of 18 and 60 were treated with the gel, and secondary treatment was offered after three months. Results indicated an overall satisfaction rate, with 96% reporting a natural appearance and between 86% and 97% agreeing the upper and lower lips were ‘improved’. Patient diaries were also used throughout, which recorded local injection site reactions in 10% of patients and 17% of patients experiencing implant site hematoma.

SkinCeuticals launches new Blemish Control Skin System

Skincare company SkinCeuticals has released its new Blemish Control Skin System Kit that aims to address problematic skin in adults. The kit, which is available in the UK and Ireland, includes three products: Blemish + Age Cleansing Gel, Solution and Defense. The products contain active ingredients including: dioic acid, salicyclic acid and glycolic acid, that aim to improve the appearance of blemishes, fine lines and post-blemish hyperpigmentation. Dr Firas Al-Niaimi, consultant dermatologist at the Sk:n clinics, London, said, “The Blemish Control Skin System provides a much-needed solution for patients who are ready for transition from years of effective but potentially dehydrating and sensitising drug therapies to a more tolerable yet efficient solution to treat their breakouts, while improving overall complexion.” E-Learning

Harley Academy partners with OCB Media Cosmetic training provider Harley Academy is working with OCB Media to launch its universitystandard e-Learning modules. OCB Media provide online learning to healthcare organisations including the Royal Colleges, the Department of Health and NHS West Midlands. The modules available through the partnership include dermatology, botulinum toxin and dermal fillers. There will be more than 100 hours of online material that includes videos, interactive diagrams and formative exercises. Students can also access additional modules on ethics, law, the role of the General Medical Council (GMC), health & safety and consent. It is hoped that this will give students a full understanding of the landscape they will enter in as practitioners. Martin Robinson of OCB Media said, “We are delighted to be partnering with the Harley Academy and pushing the boundaries of cosmetic e-Learning.”

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Aesthetics

Vital Statistics

Awards

Institute Hyalual offers cosmetic nurses the chance to win tickets to Aesthetics Awards 2015 Institute Hyalual is to offer two cosmetic nurses the chance to attend the Aesthetics Awards 2015. The opportunity comes as Institute Hyalual is set to sponsor the Aesthetic Nurse Practitioner of the Year Award for the second year running, and is therefore inviting two cosmetic nurses to join the team at its table. Iryna Stewart, managing director of Institute Hyalual said, “Cosmetic nurses have always been a group valued by Institute Hyalual. We constantly support their hard work and efforts, and we will be delighted to reward the winner of this category on the night, but also want to commend all cosmetic nurses for furthering the UK aesthetic market. We are looking forward to maybe meeting some new colleagues to join in the celebrations.” The event is the ideal opportunity to celebrate the aesthetics industry and network with fellow industry professionals, and will be held on December 5 at the Park Plaza Westminster Bridge Hotel in central London. To be in with a chance of winning the tickets, nurses should contact Iryna Stewart by emailing istewart@hyalual.com. Winners will be chosen by the beginning of October.

It is estimated that 137,310 137,310 new cases of melanoma will be diagnosed in the US in 2015 (American Academy of Dermatology)

Since 1997, there has been a 273% increase in the number of procedures performed on men (American Society for Aesthetic Plastic Surgery)

Skincare products make up the largest part of the global cosmetic market, with 35.3% in 2014

35.3%

(Statista)

Cellulite

FDA clearance for Cellfina System

Only 4.5% of women said their stomach is their favourite body part (Syneron Candela)

8 million

An estimated 8 million women in the UK suffer from hair loss (NHS)

Global medical device company Ulthera, Inc has been awarded clearance from the Food and Drug Administration (FDA) for its Cellfina System to improve the appearance of cellulite on the thighs and buttocks. The device, which was acquired by Merz North America in June 2014 and will become available to US-based practitioners this autumn, was used in a multicentre clinical study of 55 patients using a single treatment. Improvement was recorded in 98% of patients in the appearance of their cellulite and 96% reported to be satisfied with the result after two years. In a separate study, Dr Michael Kaminer, associate clinical professor of dermatology at Yale Medical School said, “Our clinical data shows that patient satisfaction with the results of Cellfina treatment improved from 94% at one year to 96% patient satisfaction at the two year mark, and my work in treating my own patients continues to support these results.” A UK release date is expected to be in spring/ summer 2016.

44

In the UK, 44 is the most popular age for patients to undergo a blepharoplasty (MYA)

15% of all cases

of acne occur on the chest (NHS Inform)

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Events diary 5th September 2015 BACN/BACM Joint Regional Scottish Meeting www.bacn.org.uk/events/joint

17th – 18th September 2015 Beyond Aesthetics, Manchester www.beyondaesthetics.org.uk

25th – 26th September 2015 F.A.C.E2F@ce conference 2015, Cannes www.face2facecongress.com/en

26th September 2015 British College of Aesthetic Medicine Conference, London www.bcam.ac.uk

3rd October 2015 British Association of Cosmetic Nurses Conference, Birmingham www.bacn.org.uk/events/bacn-annualconference-exhibition

5th December 2015 The Aesthetics Awards 2015, London www.aestheticsawards.com

Accreditation

Aesthetics gains ABC accreditation

The Aesthetics journal has received accreditation from the Audit Bureau of Circulations (ABC). The industry body for media measurement granted its stamp of approval to Aesthetics in July and will subsequently audit the journal on an annual basis. The endorsement, given by the ABC, confirms that a company is capable of facilitating print and digital trading best practice and that it has transparency in its claims of subscription and circulation. Through its independent audit and compliance services, the ABC delivers certification which verifies that a publication has data and processes that meet industry Reporting Standards and measures reach, engagement and loyalty to demonstrate a publication’s performance.

Aesthetics Journal

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Skincare

iS Clinical releases new Copper Firming Mist Skincare brand Innovative Skincare (iS) Clinical has released a paraben-free Copper Firming Mist to provide hydration and stimulate collagen synthesis. The brand, which encompasses a range of skincare products from cleansers to moisturisers and sun protectants, created the mist for multiple skin concerns. The key ingredients include copper PCA for improving skin elasticity and firmness, kola seed extract to provide antibacterial benefits, guarana extract for toning, and resveratrol for protection against UV photo-exposure. Speaking of the new product, Alana Marie Chalmers, director of distribution of iS Clinical UK said, “As well as being formulated with copper PCA, one of the new miracle-working ingredients of 2015, this antibacterial hydration mist is anti-acneic, sebum balancing, boosts skin’s luminosity in addition to providing antioxidant protection against UV photo-exposure and stimulating collagen synthesis to firm and improve skin elasticity.” The brand also claims that the mist can be well adapted to an existing skincare regime and sprayed over make-up to set the skin and refresh. Patient Support

BAD launches skin support website The British Association of Dermatologists (BAD) has launched an online psychological support service for people who suffer from various skin conditions. Skin Support, which was awarded a three-year grant by The Department of Health Innovation, Excellence & Strategic Development Fund, provides links and information on self-help, support groups and patient information leaflets. Dr David Edey, president of the BAD said of the support website, “The problem is that finding self-help materials can be difficult – patients don’t know where to look and resources are available across so many different websites. The beauty of the Skin Support website is that it brings together lots of content in one easy to navigate place, and it tailors the materials to people’s individual skin disease and any physical impairment this may involve.”  According to the BAD, skin conditions are the most frequent complaint recorded by GPs, and psoriasis alone is linked to 300 suicide attempts annually. Dr Andrew Thompson, a member of the advisory panel associated with the development of the website said, “Skin conditions can have a significant psychological impact on people and it is well acknowledged that access to psychological intervention and even to good quality evidence based self-help is limited. Consequently, the Skin Support project is an important development as it is unique in providing people with skin conditions with information about emotional and social issues associated with dermatological conditions.” He continued, “People visiting the site can also download self-help materials that have been written by qualified clinicians, such as myself, and have been either tested in the NHS or in research. We also hope that the site will encourage people to seek further help from their GP or dermatologist if needed.”

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Psoriasis

BJD publishes psoriasis survey results A recent survey from the International Psoriasis Council (IPC) identifying 21 research priorities has been published on the British Journal of Dermatology (BJD) website. The non-profit council, founded in 2004, conducted the survey, ‘Prioritising the global research agenda in psoriasis: An International Psoriasis Council Delphi consensus exercise,’ to further develop understanding of the condition. The IPC adopted the Delphi method, a structured communication technique to survey psoriasis professionals around the world, and to reach a consensus on the 21 priorities. The three main factors considered throughout were to identify biomarkers that correspond with psoriasis, identify genes that advise awareness to developing psoriasis and whether early and aggressive intervention can make a difference to the disease’s progression. Dr Bruce Strober, the lead author of the article and board member of the IPC, said of the survey, “The Delphi method has generated a more data-driven, unbiased prioritisation of topics important for study. This list will provide both institutions and individuals a better sense of the pressing and relevant research needs in psoriasis.” The results of the survey are also expected to be featured in a future print edition of the BJD. Association

BACN appoints new board member The British Association of Cosmetic Nurses (BACN) has appointed Julie Charlton as a new member of the board. Charlton is a partner in the clinical risk team at the Bevan Brittan law firm, specialising in medical negligence, mental health and human rights law. Sharon Bennett, BACN Chair said, “This appointment reflects the growing involvement of the BACN in policy and procedural matters and in its commitment to improving services to its growing membership base.” Body contouring

CoolSculpting launches mini applicator ZELTIQ Aesthetics has expanded its CoolSculpting portfolio by adding the new CoolMini applicator to target smaller pockets of fat. The new addition has been designed for specific areas such as the chin, knees and underarms, to freeze any stubborn fat and contour the body without any downtime. The CoolMini follows the successful launches of the CoolSmooth and CoolSmooth Pro applicators in 2014, with the company recently estimating that two million treatments have been performed in more than 70 countries. Andy Vutam, director of International Marketing at ZELTIQ said of the new applicator, “The CoolMini is the newest addition to our growing CoolSculpting portfolio, which uses patented fat freezing technology backed by scientific evidence. Our existing applicators for larger areas, such as the abdomen and thigh, have seen great results and there was a demand from both physicians and patients to treat smaller, more specific areas”. He continued, “We’re excited to expand our offerings and further demonstrate the safety, efficacy and long-lasting results of the CoolSculpting procedure with this new applicator.” The UK launch of CoolMini applicator is estimated to be in the autumn.

60

Lee Boulderstone UK Manager for BTL Aesthetics What is the vision for BTL over the next five years? Our vision is to be the largest manufacturer and supplier of non-surgical devices in the fat removal, body shaping and skin tightening markets. With over 50 direct offices worldwide, this is becoming a reality as our reputation for honesty and trust in supplying medically and scientifically tried and tested devices give clinics and consumers the confidence that they have chosen the right company and devices to work with. What is BTL’s focus this year? Education is greatly required in aesthetics, especially with technology. Radiofrequency and ultrasound come in many forms and mistakes can easily be made. Many practices have unfortunately made purchasing decisions after being misled that all these technologies are the same – a problem that could be so easily avoided if the UK had a good regulation system. Once educated correctly, practices can make the right decision for their business and then it comes down to training which is another great passion of BTL. If the device isn’t used correctly, the results will be less evident and too many companies do not spend the time and effort helping the users achieve the best results for their clients. You have had some great success over the last couple of years in being nominated for/winning awards. What is the key to your success? Honesty and trust, along with devices that work with the best training and support programmes is key. Thus giving our clients and consumers the confidence in obtaining the best result-driven treatments that are FDA approved and supported by peer reviewed papers and articles. Our motto is ‘Real People, Real Results’ and that is what makes us an award winning company. What products are you most excited about for the UK market? We’ve have had great success with the Exilis Elite which we believe will continue to do well in the future. The alternative is the BTL Vanquish that is making amazing progress across the world and is set to be the next big thing for BTL Aesthetics UK. This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Conference

First Expert Clinic sponsors announced for ACE 2016 Eight medical aesthetics manufacturers and distributors have been announced as sponsors of Expert Clinic sessions at the Aesthetics Conference and Exhibition (ACE) 2016 on April 15 & 16. Skinceuticals, Healthxchange, AestheticSource, Aestheticare, BTL Aesthetics, Lynton Lasers, Rosmetics and Fusion GT are the first companies to announce their involvement in the comprehensive agenda, with respected names set to deliver live demonstrations showcasing the latest techniques and innovations. Last year the Expert Clinic agenda proved a resounding success, receiving overwhelmingly positive feedback from delegates who were given the opportunity to appreciate exclusive demonstrations. The Expert Clinic sessions at ACE 2016 promise once again to provide practice-oriented and engaging education for delegates aiming to enhance their skills in injectables, skin rejuvenation, body contouring and more. To stay up to date with the latest ACE 2016 news, sign up to the Aesthetics weekly e-newsletter by visiting www.aestheticsjournal.com and registering online. Lasers

New picosecond laser launched by Lynton Lasers Medical device manufacturer Lynton Lasers has announced that the Discovery Pico will be launched later this year. The new addition to the product range aims to combine the efficacy and speed of picosecond pulses, with the safety profile of nanosecond Q-switched pulses at 1064 and 532 wavelengths. It will have the shortest pulse available (375ps), a high peak power of 1.8GW, and an optional upgrade to a ResurFACE fractional attachment. Jon Exley, managing director at Lynton said, “A number of our laser physicists have worked for many years with Picosecond lasers both at Lynton and at the University of Manchester. Whilst I believe there are strong commercial benefits surrounding the pico-lasers for tattoo removal, we at Lynton are convinced that picosecond technology has a place alongside the Gold standard nanosecond Q-switch treatment, and that’s why we’re extremely excited to be launching the Quanta Discovery Pico laser, which incorporates both technologies in one system.” The company say that the combination of both picosecond and nanosecond pulses helps to deliver quick and safe treatments. Submental fat

Kythera seeks European approval of Kybella Biopharmaceutical company Kythera Biopharmaceuticals has announced its submission of a marketing authorisation application seeking EU approval of the submental fat treatment Kybella, also known as ATX-101. The injectable treatment, which was approved by the FDA in April, aims to improve the appearance of fat under the chin with deoxycholic acid, which works to break down dietary fat and destructs fat cells. Keith Leonard, president and chief executive officer of Kythera said, “The submission in the European Union reflects our commitment to make ATX-101 broadly available and marks a key milestone for the global development programme. We look forward to the review of our application and to the potential approval of ATX-101 in Europe as a nonsurgical treatment for women and men seeking an improved chin profile.”

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News in Brief AestheticSource expands its team Skincare distributor AestheticSource has announced it has expanded its team to continue their commitment in supporting their practitioner customer base. Sharen McBride, a qualified nurse and former business development manager for a collection of medical aesthetic products which included NeoStrata, will join the group as the business development manager and training consultant, covering the north of England and Scotland. P-shot and O-shot now available in Kent and Essex Aesthetic practitioners Dr Shirin Lakhani and Dr Kannan Athreya have teamed up to offer the O-Shot and P-Shot treatments at their clinics in Kent and Essex, respectively. Dr Lakhani, the only woman in the UK to be qualified to offer the treatment, was assisted by Dr Athreya when she performed the first P-shot treatment in Kent on August 5. Lumenis launches new website for skincare information Medical device company Lumenis has launched a new online resource that provides information on the latest energy-based skin treatments. AesthetiPedia, which also includes information and key facts on skin conditions such as acne, rosacea and stretch marks, holds an extensive before and after image collection for patients to consider before opting for treatment. Dermagenica welcomes six official certified trainers to its team PDO Threads training course provider Dermagenica has greeted six new certified trainers to its group. Dr Hassan Soueid, Dr Sherif Wakil, Dr Yen Lam and Dr Diana C Marquez Ruiz will be offering training to doctors and dentists, while Lynda Smith and Victoria Parsons will deliver training to nurses. Majestic releases new range of disposable bath sheets Towel and disposable-product manufacturer Majestic Towels has released a new range of disposable bath sheets and towels. The eco-friendly range includes a flexible, multi-purpose disposable bath sheet that measures 100cm x 150cm, which makes it large enough to wrap around patients and cover treatment couches.

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immunomodulation, with probiotic supplementation preventing child allergies, and atopic eczema occurring 50% less in supplemented individuals than those in the placebo group.7 TCM As a practitioner of Chinese medicine, John Tsagaris’ ethos is analogous to Vidhi’s ‘heal from within’ philosophy, he also utilises the mechanical tools of acupuncture in TCM, the synergistic nature of antioxidants and plant actives as topical treatments, and the use of TCM herbs. Tsagaris explains, “The medicinal use of each Chinese herb is determined by the herb’s properties, therapeutic functions and by the herb’s ability to influence certain energetic bodily functions or organs to treat a patient’s condition.”

Holistic approaches to skin treatments Charlotte Maria Mawn investigates the growth of the holistic approach within the aesthetic industry A 2015 study by Wang et al.,1 defined holistic medicine as ‘an interdisciplinary field of study that integrates all types of biological information (protein, small molecules, tissues, organs, external environmental signals, etc.) The holistic approach to medicine can be seen as integrative, multi-tiered and progressive. The approach encapsulates the ethos of treating a patient as a whole, utilising the scope of worldwide medicine to achieve optimal health and wellness. Yet the practice currently exists under the surface of recognition and acceptance from Western medicine. Nutrition and supplementation Vidhi Patel, an Indian-trained homeopathic doctor and nutritionist believes the rationale behind adopting an holistic approach in aesthetic medicine is to cushion the impact of any non-invasive or invasive treatment. Patel’s ethos is, “Health is what you eat, drink and think.” Patel works with aesthetic practitioners to recommend tailored dietary supplementation two weeks prior and post treatment. With the aim of minimising inflammation, side effects, and downtime, she advocates the use of supplements such as Turmeric,2 green tea extract,3 cod liver and flax seed oil,4 as well as resveratrol5 pre and post treatment. Diane Nivern, clinical director and holistic skin therapist at Diane Nivern Holistic and Aesthetic Clinic, argues that practitioners should aim to recognise internal issues that could be causing an aesthetic concern, before prescribing potentially unnecessary or expensive invasive treatment. She exemplifies the case of a patient presenting with acute cystic acne. After testing for food intolerances, eliminating foods and the use of a probiotic, Nivern’s patient’s skin resolved itself almost completely. Nivern explains that the ecology of the gut has a strong link to inflammation and skin condition. This is supported in clinical literature, which links imbalances in gut microflora to numerous conditions such as obesity, allergies and Crohn’s disease.6 Notably, a Lancet study implicated gut microflora in

Acupuncture Acupuncture needles are inserted into the skin, causing micro-trauma to stimulate nerves under the skin and in muscle tissue. Commonly used for pain relief from conditions such as headaches and lower back pain, a 2015 study suggested certain types of acupuncture improve the appearance of nasolabial folds via a fibroblast-collagen synthesis and neovascularisation mechanism.9 “Side effects are minimal, and, if any, it will be light bruising which can be helped by the use of Arnica,” said Tsagaris. He advises that patients with hypersensitivity may be unsuitable for acupuncture treatment. Hormones and the aesthetic link Dr Harpal Bains, clinical director of The Harpal Clinic, an aesthetic practice utilising integrative medicine, explains that she often sees patients presenting with chronic acne and pigmentation, which, are shown to be the result of hormonal imbalances. As such, Dr Bains prescribes hormone therapy while simultaneously treating any skin parameters such as the acne and pigmentation. She says, “Treating the internal factors puts patients on a path of wellbeing, and improving their appearance becomes part of that journey of well being too.” Conclusion The resounding conclusion from the holistic-aesthetic practitioners interviewed is the aim to balance physiological systems through dietary, hormonal, psychological, supportive or topical treatment, collaboratively with aesthetic procedures. While some may argue that evidence for certain alternative therapies is predominantly anecdotal, a growing number of practitioners are adopting holistic approaches to their aesthetic practice in order to endeavour not only to enhance a patient’s appearance, but also improve their overall health, vitality and quality of life. REFERENCES 1. Y. Wang, C. Zheng, C. Huang, Y. Li, X. Chen, Z. Wu, Z. Wang, W. Xiao, and B. Zhang, ‘Systems Pharmacology Dissecting Holistic Medicine for Treatment of Complex Diseases: An Example Using Cardiocerebrovascular Diseases Treated by Tcm’, Evid Based Complement Alternat Med, (2015). 2. Nita Chainani-Wu. The Journal of Alternative and Complementary Medicine. February 2003, 9(1): 161168. doi:10.1089/107555303321223035. pp. 1-2. 3. E. Roh, J. E. Kim, J. Y. Kwon, J. S. Park, A. M. Bode, Z. Dong, and K. W. Lee, ‘Molecular Mechanisms of Green Tea Polyphenols with Protective Effects against Skin Photoaging’, Crit Rev Food Sci Nutr (2015). 4. Artemis P. Simopoulos.’ Omega-3 Fatty Acids in Inflammation and Autoimmune Diseases’, Journal of the American College of Nutrition 21 6 (2002). 5. J. Soeur, J. Eilstein, G. Léreaux, C. Jones, L. Marrot, Skin resistance to oxidative stress induced by resveratrol: From Nrf2 activation to GSH biosynthesis, Free Radical Biology and Medicine, 78 (2015) p.213-223. 6. Jose C. Clemente, Luke K. Ursell, Laura Wegener Parfrey, Rob Knight, ‘The Impact of the Gut Microbiota on Human Health: An Integrative View’, Cell, 148, 6, (2012) p.1258-1270. 7. M. Kalliomäki, S. Salminen, H. Arvilommi, P. Kero, P. Koskinen, and E. Isolauri, ‘Probiotics in Primary Prevention of Atopic Disease: A Randomised Placebo-Controlled Trial’, Lancet, 357 (2001). 8. Jin Hyong Cho, Ho Jin Lee, Kyu Jin Chung, Byung Chun Park, Mun Seog Chang, and Seong Kyu Park, ‘Effects of Jae-Seng Acupuncture Treatment on the Improvement of Nasolabial Folds and Eye Wrinkles,’ Evidence-Based Complementary and Alternative Medicine, (2015).

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Lasers and lights Allie Anderson speaks to practitioners about the various modes and functions of light-based treatments that are routinely used for a number of aesthetic indications Light-based technologies have, over the years, become commonplace in medical and aesthetic clinics as the treatment of choice for a range of problems, from hyperpigmentation and fine lines to acne scarring and skin cancer. Some of the most established modalities are lasers, light-emitting diode (LED) therapy, intense pulsed light (IPL) therapy and photodynamic therapy (PDT), which are discussed in turn herein. Laser treatment There are numerous indications for light-based therapies, each responding better to specific types of treatment. One of the most commonly used is laser treatment, and the indications it can be effectively used to treat can be broadly summarised as:1 • Unwanted hair • Vascular lesions, scars and acne • Pigmented lesions (including tattoos) • Skin rejuvenation • Varicose/leg veins “Every laser device can do something different,” explains Mr Taimur Shoaib, who uses 10 lasers in his clinic. “Some treatments are good for the skin’s surface, some for segments of the skin a little bit deeper, and some for even deeper skin treatments. There are so many different areas of the skin that we can treat, such as bacteria and fine lines and wrinkles at the top of the skin, hair follicles at the bottom, and sun damage in the middle. Each laser system has to be quite specialised in order to deliver the treatment to the area concerned.” The molecules in the skin contain substances called chromophores, which are responsible for the molecule’s colour and which absorb light. When a wavelength of light is applied to the skin, it selectively targets a particular chromophore, which then absorbs the light. The light is then turned into heat energy sufficient to break down the target. In other words, it damages the chromophore.2 The way a wavelength of light affects the skin is in part determined by how deep beneath the skin’s surface it penetrates. The longer the light’s wavelength, the deeper it will penetrate. Therefore, different wavelengths with a different absorption coefficient will target a particular chromophore at a particular depth.3 There are three major chromophores in human skin, which are each associated with different indications that are treatable with lasers: • Haemoglobin, the target chromophore for treating vascular lesions: port wine birthmarks, haemangioma, rosacea, facial telangiectasia, spider naevi, cherry angioma, erythematous (acne) scarring and warts.4 • Melanin, the target chromophore for treating unwanted hair and pigmented lesions: freckles, solar lentigines, café au lait spots, and nevae of Oto and Ita.1 • Water, the target chromophore for skin rejuvenation: lines and wrinkles.5 In skin rejuvenation, lasers are used to target water in the dermis. This water absorbs light at longer wavelengths, and triggers a cellular reaction that, in turn, stimulates the formation of collagen and elastin, which keep the skin firm, plump and supple. Figure 1

outlines indications that respond to laser treatment, the chromophore involved and some of the light wavelengths that effectively target that chromophore. The light emitted by a laser (an acronym for light amplification by stimulated emission of radiation) is what’s known as coherent light. This is where the photons (tiny light particles) travel in phase with one another, all photons changing phase at the same time (see Figure 2). As a result, lasers concentrate the light extremely well and therefore tend to penetrate much more effectively.7 This makes lasers the treatment of choice for some practitioners, who argue that only highly coherent laser beams can produce significant results. “The laser beam is highly concentrated, so it is applied for a very short duration – milliseconds or nanoseconds,” says Mr Shoaib. “Because of that, it doesn’t actually cause damage to any of the surrounding tissues.” Side effects are minimal too, he adds, reporting that patients Figure 1: wavelengths targeting three main chromophores for various indications4,6

Indication Vascular lesions - port wine birthmarks - haemangioma - rosacea - facial telangiectasia - spider naevi - cherry angioma - erythematous (acne) scarring - warts

Pigmented lesions - freckles - solar lentigines - café au lait spots - nevae of Oto and Ita

Chromophore involved

Haemoglobin

Melanin

532 nm 542 nm 578 nm 585 nm

532 nm 694 nm 755 nm 1,064 nm (deep lesions) 510 nm 694 nm 755 nm 1,064 nm

Hair removal

Skin rejuvenation - fine lines - wrinkles

Wavelength (nanometres)

Water

2,940 nm 10,600 nm

are advised to avoid sun exposure after treatment as this could cause unwanted pigmentation. “The only other potential difficulty is in managing a patient’s expectations of the treatment.” Light-emitting diodes (LED) light therapy Other types of light-based treatment use incoherent light, where the photons do not travel in a unified manner, changing phase randomly. As a result, the light spreads over a wider area rather than being concentrated. Thus, even at a high power, incoherent light is transmitted over shorter distances and doesn’t penetrate as deeply as coherent light.6 An example of an incoherent light source

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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is LEDs. LEDs are tiny light bulbs that emit nonthermal, visible wavelengths of light. The treatment covers a larger area than a laser, but being more diffuse also means it needs to be applied to the skin for longer.6 However, LED is used successfully to treat many of the same indications, with anecdotally good results. Lisa Monaghan-Jones is a proponent of this type of treatment, which she performs at her practice – Internal Beauty Clinic in Huddersfield.

Aesthetics

Travel patterns of laser light and LED light

Before After the use of a lay-in device that is fully automated and does not require staff to be present. She explains that it uses blue light at 470 nm to target acne and blemishes; red light at 660 nm to activate cells to produce Dermalux Dual Wave: Red & NIR treatment. Total 12 sessions: collagen and elastin, as well three sessions per week over a period of four weeks as to reduce inflammation and redness associated with rosacea; and, as an additional benefit, infrared light at 940 nm to relieve muscle and joint pain, as well as the pain and stiffness associated with arthritis. “The device is suitable to be used before or after any other treatment to enhance the results of that treatment or to alleviate any side effects such as inflammation,” says Dr Nguyen, adding, “It can also be used to soothe skin immediately after IPL, laser or dermabrasion treatment.” While LED therapy can be used to treat all skin types, it can trigger seizures in patients with epilepsy7,8 and has not been trialled in pregnant women. It is also contraindicated in patients with porphyria,8 a rare hereditary disease affecting the metabolism of haemoglobin, as well as with certain medications.9

“I choose LED phototherapy because it’s clinically proven technology-wise, it has guaranteed results and it’s suitable for all skin types,” she says. “It promotes regeneration and healing on the skin, so it increases collagen, enhances the function of enzyme repair, helps the lymph system, and stimulates new capillaries and new cell growth.” LED is indicated for a range of problems, she says, including acne, eczema, psoriasis, rosacea, pigmentation and ageing skin, as well as to promote healing after radiofrequency treatment, laser treatment, peels and surgery. Dr Rekha Tailor, medical director of Health + Aesthetics in Surrey, uses the same LED treatment protocol, whereby three different coloured lights of specific wavelengths work to combat different skin concerns. “It uses red light at 633 nm to reduce lines and improve tone and texture. It stimulates the fibroblast cells, which triggers the production of collagen and elastin, increases hydration and plumps up the skin,” she explains. “Blue light, which is 415 nm, can help to treat acne by damaging porphyrins, which naturally occur in acne bacteria. It reduces active acne and helps prevent break-outs, by normalising oil production.” An 830 nm near-infrared light has a similar effect, Dr Tailor adds, while also soothing redness and irritation, thereby accelerating skin healing. Alternatively, Dr Ahn Nguyen advocates

Intense pulsed light (IPL) treatment An adaptation of laser phototherapy comes in the form of IPL treatment. IPL works in the same way as a laser, but instead of emitting light of one specific wavelength, as lasers do, the light IPL produces is composed of a spectrum of colours from different wavelengths – commonly 550 to 950 nm. As a result, it can select different targets for absorption, much like using a number of different lasers in a single treatment. Dr Maria Gonzalez from the Specialist Skin Clinic in Cardiff states that IPL has two main skin indications: a condition called poikiloderma of Civatte, whereby (mainly female) patients present with erythema and mottled pigmentation on the neck as a result of sun damage; and red-coloured sun damage on the chest. “These treatments tend to be suitable for patients who are very fair skinned – typically Fitzpatrick skin types I and II – so people who have fair skin and eyes and burn easily in the sun,” she comments. Conversely, she explains, IPL is not suitable for those with olive-toned, Asian or black skin, particularly type VI, who, according to Dr Gonzalez, don’t suffer from these conditions anyway. Dr Gonzalez suggests that the advantage of IPL is that one machine, in its nature, can treat all manner of indications. “With lasers, you have to use a different one for each distinctive problem, which makes it a very expensive way to set up a clinic,” she says. “On the other hand, a laser tends to be able to produce extremely good results for specific, individual problems.” IPL has also been shown to be safe and effective in treating specific concerns, including vascular and pigmented lesions, photo-ageing, and skin conditions such as acne, rosacea and non-melanoma skin cancers.12 Moreover, the results of IPL can be improved by using it in combination with other anti-ageing treatments. For example, IPL combined with botulinum toxin injections has been shown to produce better results in correcting wrinkles that appear when the face is animated or in motion, called dynamic rhytids, than using IPL alone.13 Before

Befores and after 4 IPL treatments for poikiloderma of civatte

After

Before and after 14 treatments with Body Boost Bed lay-in device

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Photodynamic therapy (PTD) PTD is a treatment that uses a drug called a photosensitising agent, combined with a particular wavelength of light, such that when the photosensitising agent is exposed to that light wavelength, it produces a form of oxygen that kills adjacent cells. PTD is licenced for treating non-melanoma skin cancers,14 with evidence demonstrating that PTD has significantly better outcomes for actinic keratosis, superficial and nodular basal cell carcinoma, and squamous cell in situ (known as Bowen’s disease) than other standard treatments.15 Nurse prescriber and aesthetic practitioner Anna Baker performs this treatment protocol using a topical photosensitising agent methylaminolevulinate (MAL, known as Metvix). Baker explains how the procedure works, “Metvix is applied to the skin cancer lesion, and left under an occlusive dressing for three hours, during which time the patient can go off and do what they want to do. The drug is very selective and only binds to certain kinds of cells – dysplastic or neoplastic cells – within the lesion, in which uptake of the drug is rapid. During that three-hour timeframe, these cells become saturated with photoactive porphyrins.” When the wavelength of light is applied later and mixes with these porphyrins, a chemical response is generated, the by-product of which is a form of oxygen called singlet oxygen, which in turn breaks down the damaged cells in the lesion. Sometimes, a small amount of the photosensitising agent is taken up by healthy tissue around the dysplastic or neoplastic cells, but this is minimal. The treatment uses a red LED light with a wavelength of around 630 nm, administered after the area to which the drug has been applied has been cleansed thoroughly. “This light wavelength is typically capable of treating an area roughly around 6x16cm,” Baker adds, “but this is very much dependent on how much patients can tolerate in one Figure 3 – main indications for light colours18

Light colour

RED light

BLUE light

NEAR-INFRARED light

Main indication Main indication: rejuvenation • Stimulates collagen synthesis and growth factor production • Increases hydration levels and moisture retention • Evens skin tone and texture • Reduces pigmentation • Calms redness and inflammation • Shrinks pores and sebaceous glands • Stimulates circulation & lymphatic system • Accelerates skin repair Main indication: acne • Powerful anti-bacterial treatment • Treats all grades of acne without irritation • Reduces oil production • Prevents future breakouts • UV free alternative for eczema and psoriasis • Anti-inflammatory / cooling effect Main indication: deep pigmentation • Most deeply absorbed wavelength by skin tissue • Increases cell permeability and absorption • Reduces pain and inflammation • Accelerates wound healing • Heals cystic acne

session.” One advantage here is that PTD can be repeated as often as is required – particularly useful in cases of field cancerisation, in which multiple lesions cover large areas. “We treat these patients on a maintenance basis, maybe every six months or every year, often for several years.” explains Baker. In addition, there is evidence that PTD can potentially delay the development of actinic keratosis and basal cell carcinoma, with limited evidence that it can prevent invasive squamous cell carcinoma.16 Interestingly, PTD has also been indicated for skin rejuvenation, in which aesthetic results can be significantly improved when combined with pre-treatment systems such as microneedling, microdermabrasion or fractional lasers.17

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Before After In safe hands The light-based technologies discussed are routinely used in a number of treatments and are safe and treatment with Dermalux effective in skilled Dermatitis TriWave: Combined Red & NIR (12 hands. However, treatments over five weeks) severe adverse events can occur when administered by untrained practitioners: Mr Shoaib recalls treating a patient who had been left with a 4cm-diameter hole burnt into their skin due to poorly performed laser tattoo removal. “When you’re performing a treatment, you need to be able to look after and manage the side effects,” he says. That being the case, light-based skin treatments not only remain an established protocol for a range of medical and aesthetic indications, but also show a great deal of promise in treating many more in the future. REFERENCES 1. Patil, UA and Dhami, LD. Overview of lasers. Indian Journal of Plastic Surgery. October 2008; 41 (Suppl): S101-S113. <http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2825126/> 2. Fodor, L, Elman, M, Ullmann, Y, ‘Aesthetic Applications of intense pulsed light’, Light Tissue Interactions, (2011), p.11-20. 3. Ryan, T, and Smith, RKW., ‘An investigation into the depth of penetration of low level laser therapy through the equine tendon in vivo,’ Irish Veterinary Journal, 60(5) (2007), p.295-299 4. Farhadieh, R, Bulstrode, N and Cugno, S. ‘Plastic and Reconstructive Surgery: Approaches and Techniques’, John Wiley & Sons, 2015. 5. Ashton, R and Leppard, B. Differential diagnosis in dermatology. Radcliffe Publishing, 2005. 6. Larsen, Dr AP, ‘Laser vs. LED: What’s the difference?’ Acupuncture Technology News, (2014). <http://www.miridiatech.com/news/2014/02/laservs-led-whats-the-difference/> 7. ‘Photosensitive Epilepsy’, Epilepsy Action, (2010), p.11. <http://neurology. dundee.ac.uk/files/epilepsyaction-booklet-photosensitive.pdf> 8. ‘European Commission, Health and Consumers Scientific Committees’, Health effects of artificial light. 5. What are the effects on people who have conditions that make them sensitive to light? <http://ec.europa.eu/health/ scientific_committees/opinions_layman/artificial-light/en/l-3/5-light-sensitivity. htm#3p0> 9. Dermalux FAQs (UK, Dermalux, 2013) <http://www.dermaluxled.com/FAQ/> 10. Julius, H – ‘ Intense Pulsed Light Complications’, in Management of Complications of Cosmetic Procedures: Handling Common and More Uncommon Problems, ed. by Tosti A et al, (Springer, 2012) pp.57-64. 11. Goldberg, DJ, Complications in cutaneous Laser Surgery (CRC Press, 2004) 12. Goldberg, DJ, ‘Current trends in intense pulsed light’, Journal of Clinical and Aesthetic Dermatology. June 2012; 5(6): p.45-53. <http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3390232/> 13. Khoury, JG, Saluja, R, Goldman, MP. The effect of botulinum toxin type A on full-face intense pulsed light treatment: a randomized, double-blind, splitface study. Dermatological Surgery. 2008; 34(8): p.1062–1069. Epub 2008 May 6. <http://www.ncbi.nlm.nih.gov/pubmed/18462423> 14. NICE interventional procedure guidance IPG155, Photodynamic therapy for non-melanoma skin tumours (including premalignant and primary nonmetastatic skin lesions): Overview. February 2006. <http://www.nice.org.uk/ guidance/ipg155> 15. NICE interventional procedure guidance IPG155, Photodynamic therapy for non-melanoma skin tumours (including premalignant and primary nonmetastatic skin lesions): The procedure. February 2006. <http://www.nice. org.uk/guidance/ipg155/chapter/2-The-procedure> 16. Morton, CA, Szeimies, RM, Sidoroff, A, Braathen, LR. European guidelines for topical photodynamic therapy part 2: emerging indications – field cancerization, photorejuvenation and inflammatory/infective dermatoses. Journal of the European Academy of Dermatology and Venereology. 2012; 27(6): p.672-679. 17. Szeimies, RM, et al. Photodynamic therapy for skin rejuvenation: treatment options – results of a consensus conference of an expert group for aesthetic photodynamic therapy. Journal der Deutschen Dermatologischen Gesellschaft. July 2013; 11(7): p.632-636. <http://onlinelibrary.wiley.com/ doi/10.1111/ddg.12119/full> 18. Dermalux LED Phototherapy (UK, Dermalux, 2013) http://www.dermaluxled. com/LED-Phototherapy/

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Pulsed Dye Lasers Dr Firas Al-Niaimi details the history and efficacy of pulsed dye lasers Abstract The pulsed dye laser (PDL) is a vascular laser that emits a wavelength of 585 or 595 nm in the yellow band of visible light. It is one of the early lasers used in dermatologic practice, which had a fixed short pulse width and was invented primarily to treat vascular malformations. Over the years, technology has evolved and the modern PDL machines now offer a range of selected pulse widths which offer a broad range of treatments, in keeping with the principle of selective photothermolysis which will be discussed below. Currently, this kind of laser technology successfully treats a long list of conditions in dermatologic practice, which will be highlighted in this article. Introduction Lasers have evolved over the past five decades to become an integral part of some aesthetic and dermatological treatments. The current dermatological arena contains a plethora of lasers that can largely be categorised into vascular, pigment-specific, and rejuvenation (both ablative and non-ablative). The PDL has been an evolutionary product, developed over the last four decades and initially conceived to treat congenital vascular conditions.1 Beginning with its early work in the treatment of port-wine stains and haemangiomas, the dye laser has now become one of the key tools both in cosmetic and medical laser treatments. History The first working laser was developed in 1960 by T H Maiman, using a rod of Ruby to emit photons of light.2 In that same decade many other lasers were being invented and trialled in medicine and, in 1963, dermatologist Leon Goldman used the first lasers in dermatologic practice. These included the Ruby, Argon, and Carbon dioxide continuous wave lasers.3 In 1981, a collaboration with John Parish – then the chairman of dermatology at Harvard University – resulted in the first working dermatology laser; a flash lamp pumped organic dye laser.4 The medium used within a flash pump laser was a fluorescent dye that is housed in a transparent cell and powered by a flash lamp, emitting a wavelength of 577 nm.4 Further research led to the discovery of a new wavelength – 585 nm instead of the 577 nm – only to be replaced later by 595 nm, which is still used in two main PDL machines today.5 Studies showed that by shifting the wavelength from 577 nm to 585 nm, and eventually to 595 nm, resulted in a preferential depth of penetration, albeit slightly at the cost of higher fluences requirement.6 Several dyes were considered and used and these included: fluorescein, coumarin, stilbene, tetracene, and umbelliferone.7 Currently most PDL use rhodamine due to its efficiency and relative long life-time.

Laser physics The term ‘laser’ is an acronym for ‘Light Amplification of Stimulated Emission of Radiation’, and is based on the concept of electron stimulation whereby release of energy occurs as a result.8 The ultimate light and tissue interaction that takes place results, one way or another, in a biological response. This response can broadly be subdivided into thermal, chemical, and mechanical (acoustic).8 Putting it in very simplistic terms; the thermal effects rely on the heat that is produced by the laser energy to either selectively or non-selectively target a tissue component. Photochemical effects occur due to the up- or down-regulation of certain biological pathways, occurring as a consequence of light and tissue interaction.10 This photochemical effect may require the addition of a photosensitiser (a topical drug), a phenomenon called photodynamic therapy. Lastly, photomechanical effects occur predominantly due to the acoustic effects on the tissue (though thermal effects due to the laser energy play a role). This is caused by the combination of short rapid pulses and a rapid peak in the energy that is produced in tissues as a result. The PDL is a vascular laser that has haemoglobin as a target (chromophore), which is present in the red blood cells circulating in blood vessels, and acts predominantly through photothermal effects. Haemoglobin shows absorption peaks in the blue, green, and yellow bands (414, 542, and 577 nm), as well as a peak in the near-infrared portion of the electromagnetic spectrum (700 to 1100 nm).10 It is important to note here that these peaks relate mainly to the oxygenated form of haemoglobin – the so called

Purpura following treatment with a PDL (courtesy of Graham Bissett)

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oxyhaemoglobin.10 Other forms of haemoglobin, such as deoxyhaemoglobin and methaemoglobin, have other absorption spectra, and this will be discussed later in the article.

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Key facts • The PDL is a vascular laser that emits 585 or 595 nm wavelength • It was one of the first lasers to be used in dermatology and was invented to treat vascular malformations • Current PDL machines have ‘tuneable’ pulse widths ranging from 0.45 to 40 ms allowing for greater versatility of treatments • The advent of longer pulse widths allows for some conditions (erythema of rosacea for example) to be treated in a non-purpuric mode to reduce social downtime • Smaller vessels need shorter pulse durations and the reverse is the case with larger vessels • Deep vessels tend to have a larger diameter and therefore require a deeper penetrating mode (large spot size with PDL or the 1064 nm Nd:YAG) and a longer pulse duration • PDL for the treatment of post-procedural purpura is a novel and effective new use of this laser

Current laser systems used in the treatment of vascular lesions emit wavelengths near these peaks,11 however the depth of penetration here is important too. For example, 414 nm has a shallow depth of penetration hence there is no use for it in clinical practice when treating vessels. Green light, emitting a wavelength of 532 nm, is already used in clinical practice (potassium titanyl phosphate ‘KTP’)12 although with a somewhat shallower depth of penetration compared to PDL (585-595 nm). The 595 nm penetrates deeper than the 585 nm but requires higher fluences due to the relatively lower absorption compared to the 585 nm wavelength. It is therefore important that when switching between these two wavelengths, adjustment of the fluences should take place to account for the increased absorption required by the 595 nm compared to the 585 nm. The long-pulsed Nd:YAG laser (1064 nm) is used for deep vessels (predominantly on legs or large blue vessels on the face) due to its advantageous depth of penetration compared to both the KTP and PDL.8 The absorption of 1064 nm Nd:YAG is almost a tenth of the PDL, hence higher fluences are required.

In clinical practice, this means that the incoming pulsed laser will be absorbed by the circulating haemoglobin in the vessels that transform this energy to heat, which radiates to the vascular wall and results in heating up the endothelial vessel wall. In reality, it is the endothelial wall that is the ultimate ‘target’ of the PDL in treating vessels. As described briefly above, the photothermal effects of the laser can either be selective or non-selective. In the selective case, destruction of the chosen target (in this case vessel) should occur without any collateral damage to the surrounding tissue. In order to achieve this, the pulse duration here plays an important role and is based on the so-called ‘selective photothermolysis’ theory founded by Anderson and Parish, which revolutionised the modern use of lasers in dermatology and aesthetics.13 An example of non-selective photothermal effect of lasers is the use of Carbon dioxide lasers which would ablate tissue and cause non-selective heating. Choosing the right parameters One of the main difficulties for novice laser practitioners is identifying the correct parameter for treatment when using any laser modality. The chosen parameters are of great importance both in maximising the clinical effect as well as minimising collateral damage. There are three key components to this: spot size, pulse duration and fluence. The spot size matters both for coverage area as well as depth of penetration. A smaller spot size would have more light scattering and a shallower depth of penetration compared to a larger spot size for a given fluence. When treating vessels this is important as the chosen spot size should correlate to the depth of the vessel. Pulse duration selection relates to the thermal relaxation time of the object which is based on the selective photothermolysis theory.13 This means that a small diameter vessel will cool off

quicker than a large diameter vessel, hence the thermal relaxation time of the former is shorter and therefore requires a shorter pulse duration. Fluence relates to the total amount of energy measured in joules per centimetre square and dictates the total amount of thermal energy given in the chosen pulse duration.8 A given biological target – for example, haemoglobin – requires a certain amount of ‘energy’ to undergo a biological change in structure or function to have, as a consequence, a biological effect on the tissue. In simple terms, a low fluence given over a relatively long pulse duration may not confine and create a biologically important temperature rise in the target to undergo a desired effect, leading to irreversible coagulation and clearance of the targeted vessel. In vessels, a temperature of around 70 degrees Celsius is necessary for coagulation. Conversely, a high fluence in a short pulse duration may lead to an unwanted rise in temperature in a target leading to collateral damage. The chosen fluence per indication is often achieved through a combination of factors including light-tissue interaction, laser physics and experience from clinical settings or studies. Finally, cooling is essential when using the PDL as melanin, which is found in the epidermis, is a competing chromophore which can absorb the incoming laser beam (melanin absorption is a downward curve from 300 to 1100 nm roughly) and this will minimise any epidermal injury such as crusting, blistering, postinflammatory hyperpigmentation, etc.14 Cooling of the epidermis can either be achieved by cold air, contact, or cryogen spray cooling. A sophisticated technology enabling a spatial cooling confined predominantly to the epidermis is the dynamic cooling device (DCD), which allows for a cooling spray of tetrafluoroethane, followed by a delay period before the laser is fired on the skin. This allows for spatial cooling of the epidermis, without significant vessel cooling, that may lead to vasospasm with reduced circulating chromophore as a consequence.15 Currently there is only one PDL machine in the market with this DCD technology (VBeam by Syneron-Candela). Laser tissue interaction in vessel treatment The ultimate goal in vascular laser treatment is to induce vessel wall damage leading to vessel clearance with minimal collateral damage to the epidermis or surrounding tissue. Although

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haemoglobin is the chromophore or absorbing target of the PDL, radial diffusion of the generated heat will ultimately lead to the vessel wall lining being targeted. Scientific studies have demonstrated that the vascular lining (endothelium) needs to be sufficiently heated to a temperature of around 65-70 degrees Celsius for at least one millisecond (ms) in order to cause denature of structural proteins leading to vessel closure and clearance.16 Therefore, in this case, the fluence chosen and the pulse width are very important parameters. Too much heat delivered can result in collateral damage or a rapid rise in intravascular temperature, which leads to steam formation and vessel rupture, clinically evident as purpura. Very short pulse durations additionally lead to a photomechanical effect, again leading to vessel rupture and purpura.17,18 In summary, vessel clearance can be achieved through a photothermal, (choice of fluence and pulse width should get the endothelium temperature to around 65-70 degrees Celsius for at least one ms), or photomechanical effect, (short pulse width with sufficient energy leading to vessel rupture). Vessels have different diameters and therefore the ‘length’ that is required for the heat to diffuse and reach the vessel wall is variable and is termed the ‘thermal diffusion length’.19 It is therefore apparent that larger diameter vessels need more time for the diffused heat to reach the vessel wall compared to a smaller diameter vessel. Clinically, this is reflected in the chosen pulse duration. In practice this means that if the chosen fluence is too low, insufficient heating of the endothelium occurs and vessel closure will not take place. In my experience, most of the individuals seeking treatment for vessels and diffuse erythema do not desire to have purpura and, therefore, one should optimise the photothermal effect of vessel coagulation rather than vessel rupture in this case. Pulse stacking or multiple passes often add a beneficial effect due to the stepwise rise in temperature formation leading to vessel clearance, however this should be performed carefully. Oxygenated haemoglobin is altered following a laser pulse and is transformed into methaemoglobin, which has a higher absorption affinity to light, in particular to the 1064 nm Nd:YAG wavelength.20,21 It is through this understanding that pulse stacking or multiple passes work more efficiently22 and is also the concept of which the dual wavelength vascular laser was designed, using a sequential pulse of 595 nm followed by 1064 nm (Cynergy MultiPlex by Cynosure). The concept is that the first laser shot will be with the PDL which leads to formation of methaemoglobin, allowing the 1064 nm Nd:YAG to have a much better effect in the second pulse.23 I prefer to use this technology on port wine stain blebs or resistant facial telangiectasia and telangiectatic matting on the legs as, in my experience, the PDL alone may often offer suboptimal clearance by simply increasing the fluences. As such, the risk of epidermal injury also increases accordingly. The multiplex mode should not be used in diffuse erythema due to the high risk of ‘bulk heating’ generated from the 1064 nm Nd:YAG. It should be clear now that if a single pulse in a non-purpuric mode is used, the target is oxyhaemoglobin, whilst in stacking, multiple passes, and/or in the use of multiplex technology, the methaemoglobin and formed clot ultimately become the targets. Vessels are heterogenous with varying degrees of depths and diameters so the parameters will need to be adjusted accordingly. Vessels smaller than 0.1 mm on the face are often invisible and present with diffuse erythema. In such cases multiple passes or a purpuric mode tends to yield better results than a single nonpurpuric pass. Vessels between 0.1 to 0.4 mm on the face would

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require a pulse width of 6-10 ms (10 ms pulse width if the multiplex is used), whilst larger vessels between 0.4 and 1.0 mm on the face would require longer pulse widths such as 20-40 ms (40 ms pulse width if multiplex is used). Leg telangiectasia greater than 0.3 mm generally tend to lie deeper than the reach of PDL and are preferably treated with the 1064 nm Nd:YAG. This is because of the wavelength’s deeper penetration profile and relative selectivity for haemoglobin compared to water, which is abundantly found in the dermis. In general, blue and purple vessels contain more blood (larger diameter) and therefore a high chromophore content which requires less fluences compared to small red vessels that contain less chromophore and, therefore, need higher fluences for coagulation. Furthermore, leg veins are generally harder to treat compared to facial telangiectasia due to their increased hydrostatic pressure, thicker vessel wall, and the fact they contain less oxygenated haemoglobin as a chromophore (particularly the blue and purple vessels). Understanding and recognising the clinical endpoints in vessel treatment is essential for optimal results. These include: colour change in vessel (often darkening), vessel blurring, low refill rate (gentle compression on the vessel does not lead to a refill which indicates coagulation of the vessel), and vessel disappearance (often with 1064 nm Nd:YAG). Erythema with subsequent oedema is an expected reaction afterwards. Greying or whitening are ominous signs and imply an epidermal injury with the risk of crusting and/or blistering, and the fluences should be lowered subsequently.24 It should also be noted that purpura on the limbs tend to clear more slowly compared to the face and often results in post-inflammatory hyperpigmentation. Unless indicated per condition, it is therefore preferable to treat vessels off the face in a non-purpuric mode. Clinical indications requiring a purpuric endpoint Despite the increased demand from individuals seeking laser treatments with no or minimum downtime (bruising in the case of vascular treatments); there are certain conditions in which optimal clearance is often only achieved through treatment with purpura as a clinical endpoint.25 Steel-grey purpura is undesirable, implies excessive fluence, and may lead to fibrosis or epidermal injury. In such conditions, the primary vascular pathology is such that vessel rupture is often the only effective way of maximising clinical efficacy. These conditions include: port wine stains, haemangiomas,

The ultimate goal in vascular laser treatment is to induce vessel wall damage leading to vessel clearance with minimal collateral damage to the epidermis or surrounding tissue

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Micropulse Technology

• Classic PDL Technology 4 pulses, dissimilar distribution • New PDL technology 8 pulses, equal energy

Purpura Threshold

Fluence

spider angiomas, cherry angiomas, warts, erythematous striae, and scars.5 The latter two conditions, in my opinion, can also be treated in a non-purpuric mode as, often, post-inflammatory hyperpigmentation due to haemosederin deposition occurs. Facial telangiectasia can be treated in a purpuric mode, as explained above, or in a non-purpuric setting often through pulse stacking or multiple passes. Thick vessels, or those with high ‘intravascular pressure’ such as those on the sides of the nose, require higher fluences and are generally best treated in a purpuric or stacking nonpurpuric mode.

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Time (ms) This table gives an example of how the micropulse technology breaks energy into small pulse trains (in this case using eight pulses) to ensure the energy is gentler on the tissue

Miscellaneous clinical conditions treated with PDL (purpura not necessary as endpoint) The PDL, though initially designed for the treatment of congenital vascular malformations, has now been used in multiple clinical settings for various conditions with a good degree of success and relatively low level of complications. Advances in the current technology in terms of ‘mico pulses’ or so-called ‘pulse train’, whereby an individual pulse is broken down into six or eight micro pulses has led to the advantage of delivering the total fluence in a gentle fashion without causing purpura.26 Furthermore, effective cooling has ensured a greater margin of epidermal protection and safety. As a result, the PDL has successfully been used in the treatment of conditions beyond its initial primarily vascular indication without the need to cause purpura as an endpoint. These include: inflammatory acne, cutaneous sarcoidosis, discoid lupus, psoriasis, molluscum contagiosum, melasma, and sebaceous gland hyperplasia.27 The exact mechanism is not yet entirely clear, however it appears to be a mixture of microvascular targeting, as well as dermal remodelling, and an anti-inflammatory response elicited by the PDL. Studies have shown an inflammatory response as a result of treatment with PDL, with upregulation of mast cells, TGF-beta, and other cytokines.28 The response of the above named conditions to the PDL, in my opinion, is variable and, as such, this modality should not be the first-line treatment. Rosacea can be treated in a nonpurpuric mode but does, however, require more sessions compared to the purpuric mode. The desired endpoint in the non-purpuric setting is a ‘transient purpura’, lasting just a few seconds, and is generally a reliable marker of adequate vessel coagulation.

Novel use of PDL A relatively novel, successful, use of the PDL has been in the treatment of post-filler injection purpura. The first report was published a few years ago but since then there have been numerous articles on the successful use of this modality.29 In my personal experience, the PDL works very well for this indication once the swelling has settled and often after a period of at least 24 hours.

The mechanism is thought to be due to the enhanced clearance of the extravasated haemoglobin that is targeted by the PDL.4 My typical settings in this case are a fluence of 6.0-7.0 joules/cm2 with 6 ms pulse width often with two passes. Interestingly, this method of treatment seems ineffective in the treatment of purpura caused by PDL (in the treatment of port wine stains, for example) and, in this case, relates to the presence of a vasculitic inflammatory aggregate with clotting, which is absent in a non thermally-induced purpura such as vessel puncturing with a needle. Conclusion The PDL is primarily designed as a vascular laser and uses rhodamine dye as its lasing medium. The wavelength emitted is in the yellow band between 580-600 nm. Currently there are two devices with the 595 nm wavelength (Cynergy from Cynosure and VBeam from Candela) and one device with the 585 nm wavelength (Regenelite from Chromogenix). The latter was previously called N-lite when it had a fixed pulse width. All three currently available PDL machines have ‘tuneable’ pulse widths to allow for greater versatility use in keeping with the selective photothermolysis theory. There are currently numerous conditions that can be treated with the PDL and it is still the laser of choice in most vascular malformations, in particular port wine stains. When used in a short pulse and a sufficient fluence, purpura occurs which is a desired endpoint in some conditions. One limitation of the PDL is its relatively limited penetration depth of maximum 1.5 mm with a 10 mm spot, hence, with the exception of very fine telangiectasia measuring less than 0.3 mm, which lie relatively superficial, it is not the laser of choice for the treatment of larger and deeper leg vessels. The PDL technology has seen significant advances in recent years, such as the incorporation of the DCD, as well as the enhanced pulse structure and delivery pattern, and continues to be used and explored in a multitude of conditions, with post-procedural (predominantly filler injection) purpura being a relatively novel one.

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Acknowledgement: The author would like to thank Michaela Barker from Syneron-Candela for providing some of the historical data and literature.

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Disclosure: The author has either received speaker’s fee or acted as an opinion leader for Syneron-Candela and Cynosure.

Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon who trained in Manchester and London. He is a group medical director at sk:n clinics London and an honorary consultant at St. Thomas Hospital where he runs a weekly tertiary referral laser clinic. Dr Al-Niaimi has in excess of 90 scientific publications and is a key opinion leader for the major laser companies.

REFERENCES 1. Tan OT, Morelli J, ‘Laser treatment of congenital vascular birthmarks’, Paediatrician 18(3) (1991) p.204-10. 2. Alster TS, ‘Manual of cutaneous laser techniques’, Lippincott Williams and Wilkins, (2000) p.11. 3. Tanzi EL, Lupton JR, Alster TS, ‘Lasers in dermatology: four decades of progress’, J Am Acad Dermatol, 49 (2003) p.1-31. 4. ‘International Directory of Company Histories’, St. James Press, 48 (2003). 5. Wall TL, ‘Current concepts: Laser treatment of adult vascular lesions’, Semin Plast Surg 21 (2007) p.147-158. 6. Bernstein EF, Lee J, Lower J, et al., ‘Treatment of spider veins with the 595 nm pulsed-dye laser’, J Am Acad Dermatol, 39(5 Pt 1) (1998) p.746-750. 7. Libertini LJ, Small EW, ‘On the choice of laser dyes for use in exciting tyrosine fluorescence decays’, Anal Biochem., 163(2) (1987) p.500-5. 8. Sakamoto FH, Wall T, Avram MM, Anderson RR, ‘Lasers and flash lamps in dermatology’, In Wolff K, Goldsmith LA, Katz SI, et al (eds), Fitzpatrick’s dermatology in general medicine (7th ed), McGraw-Hill, (2008) p.2263-78. 9. Britton JE, Goulden V, Stables G, et al., ‘Investigation of the use of the pulsed dye laser in the treatment of Bowen’s disease using 5-aminolaevulinic acid phototherapy’, Br J Dermatol., 153(4) (2005) p.780-4. 10. Van Gemert MJ, Henning JP, ‘A model approach to laser coagulation of dermal vascular lesions’, Arch Dermatol Res, 270(4) (1981) p.429-39. 11. Tanzi EL, Lupton JR, Alster TS, ‘Lasers in dermatology: four decades of progress’, J Am Acad Dermatol, 49 (2003) p.1-31. 12. Patel BC, ‘The krypton yellow-green laser for the treatment of facial vascular and pigmented lesions’, Semin Ophthalmol, 13(3) (1998) p.158-70. 13. Anderson PR, Parrish JA, ‘Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation’, Science, 220(4596) (1993) p.5247. 14. Nelson JS, Majaron B, Kelly KM. ‘Active skin cooling in conjunction with laser dermatologic surgery’, Semin Cutan Med Surg, 19(4) (2000) p.253-66. 15. Nelson JS, Milner TE, Anvari B, et al, ‘Dynamic epidermal cooling during pulsed laser treatment of port-wine stain. A new methodology with preliminary clinical evaluation’, Arch Dermatol., 131(6)

(1995) p.695-700. 16. Suthamjariya K, Farinelli WA, Koh W, Anderson RR, ‘Mechanisms of microvascular response to laser pulses’, J Invest Dermatol., 122(2) (2004) p.518-25. 17. Garden JM, Tan OT, Kerschmann R, et al, ‘Effect of dye laser pulse duration on selective cutaneous vascular injury’, J Invest Dermatol., 87(5) (1986) p.653-7. 18. Trelles MA, Svaasand LO, Verkruysse W, et al., ‘Purpura without structural vessel damage’, Lasers Med Sci., 13(4) (1998) p.299-303. 19. Kimel S, Svaasand LO, Hammer-Wilson M, et al., ‘Differential vascular response to laser photothermolysis’, J Invest Dermatol, 103(5) (1994) p.693-700. 20. Randeberg LL, Bonesronning JH, Dalaker M et al., ‘Methemglobin formation during laser induced photothermolysis of vascular skin lesions’, Lasers Surg Med, 34 (2004) p.414-9. 21. Mordon S, Brisot D, Fournier N, ‘Using a “non- uniform pulse sequence” can improve selective coagulation with a Nd: YAG laser (1.06 microm) thanks to met-haemoglobin absorption: a clinical study on blue leg veins’, Laser Surg Med, 32 (2003) P.160-70. 22. Rohrer TE, Chatrath V, Iyengar V, ‘Does pulse stacking improve the results of treatment with variablepulse pulsed dye lasers?’, Dermatol Surg 30 (2004) p.163-7; discussion 167. 23. Karsai S, Roos S, Raulin C, ‘Treatment of facial telangiectasia using a dual-wavelength laser system (595 and 1,064 nm): a randomized controlled trial with blinded response evaluation’, Dermatol Surg.,  34(5) (2008) p.702-8. 24. Nanni C, ‘Complications of laser surgery’, Dermatol. Clin 15(3) (1997) p.521-34. 25. Adamic M, troilius A, Adatto M, et al., ‘Vascular lasers and IPLS: guidelines for care from the European Society for Laser Dermatology (ESLD)’, J Cosmet Laser Ther., 9(2) (2007) p.113-24. 26. Tanghetti E, Sherr E. ‘Treatment of telangiectasia using the multi-pass technique with the extended pulse width, pulsed dye laser (Cynosure V-Star)’, J Cosmet Laser Ther., 5(2) (2003) p.71-5. 27. Erceg A, de Jong EM, van de Kerkhof PC, Seyger MM, ‘The efficacy of pulsed dye laser treatment for inflammatory skin diseases: a systematic review’, J Am Acad Dermatol.,  69(4) (2013) p.609-615. 28. Omi T, Kawana S, Sato S, et al., ‘Cutaneous immunological activation elicited by a low-fluence pulsed dye laser’, Br J Dermatol., 153 Suppl (2005) p.57-62. 29. DeFatta RJ, Krishna S, Williams EF,’ Arch Facial Plast Surg., 11(2) (2009) p.99-103.

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Treating Keratosis Pilaris Dr Justine Kluk details the aetiology of this genetic skin disorder and shares best practice techniques on managing the condition Introduction Keratosis pilaris (KP) is a common inherited disorder of the skin with an incidence of between 4%-12% in the paediatric population.1,2 It occurs due to excessive keratinisation within the hair follicle orifice, which leads to stubborn horny plugs. This happens at specific anatomical locations which are described later in this article. It can be recognised clinically by the presence of small, scaly folliculocentric papules often surrounded by a rim of erythema. These papules give a stippled or speckled appearance to the skin and may resemble â&#x20AC;&#x2DC;goose bumpsâ&#x20AC;&#x2122;.3 The disorder usually becomes apparent during childhood and is most likely to arise on the extensor aspects of the upper arms, anterior surface of the thighs and on the lateral aspects of the cheeks, where there may be a background of generalised or confluent redness.3 In severe cases, the skin lesions may be more widespread and can extend to the distal extremities, trunk and buttocks.4 Presentation and associations Although it is most often noted incidentally in otherwise healthy individuals, when diagnosing keratosis pilaris, clinicians and other healthcare professionals should be aware that this dermatosis belongs to a wider group of disorders of follicular keratinisation.5 As such, there is a spectrum of clinical presentations, all of which are characterised by a prominent plug of keratin within the follicular orifice. In most cases, the cause is unknown. The different dermatoses are usually distinguished on the basis of the size, extent and distribution

of the keratotic lesions, as well as the presence of perifollicular erythema and associated scarring. Some of these variants include keratosis pilaris rubra (associated with prominent redness),6 keratosis pilaris atrophicans (a scarring variant which leads to skin atrophy),7 folliculitis spinulosa decalvans (follicular plugging complicated by scarring alopecia)8 and erythromelanosis follicularis faciei et colli (a triad of well-demarcated erythema, hyperpigmentation and follicular papules on the face and neck).9 Furthermore, there are a number of other cutaneous and internal diseases that may be associated with keratosis pilaris. Many of these have a genetic basis with potentially significant implications for the patient and their children, for example Noonan syndrome and cardiofaciocutaneous syndrome. Features of the former include short stature, distinctive facies and cardiac anomalies.10 Those with the latter tend to have a peculiar craniofacial appearance with sparse curly hair, low-set posteriorly rotated ears, moderate to severe mental retardation and cardiac defects.11 Referral to an appropriate specialist such as a dermatologist, paediatrician or clinical geneticist should be considered if the lesions are particularly extensive and persistent, or if there are other indications that one of these syndromes may be present. Within the last decade, mutations in the filament aggregating protein (filaggrin or FLG) gene have been identified as the cause of the common genetic skin disorder ichthyosis vulgaris.12,13 This condition typically presents with keratosis pilaris, xerosis (dry skin), fine scaling on the limbs, hyperlinearity (increased skin markings) of the palms and soles and a predisposition to developing

atopic eczema.12,13 Better understanding of this related condition may help to improve our understanding of the pathogenesis of keratosis pilaris in due course. Another fascinating observation in recent years has been the increased incidence of keratosis pilaris secondary to the use of targeted oncological therapies, such as those prescribed for the treatment of metastatic melanoma; e.g. BRAF inhibitors, such as vemurafenib, and immunotherapies. The use of these agents is rapidly expanding and cutaneous toxicities such as the development of keratosis pilaris are amongst the bestrecognised and most common adverse effects observed.14 Healthcare workers can offer valuable supportive advice to cancer patients who have developed keratosis pilaris as a result of one of their treatments. Other associations with keratosis pilaris have also been described. Like acrochordons (skin tags) and acanthosis nigricans, keratosis pilaris is observed more frequently in obese individuals, particularly females.15 It also appears to be more common in those with type 1 diabetes.16 The precise reason for these observations is unclear, however obesity is responsible for a number of physiological skin changes e.g. effects on skin barrier function, collagen structure and function and wound healing to name a few.15 Treatment options Keratosis pilaris is usually asymptomatic and, in most cases, no specific intervention is required. The size of the lesions are said to increase and decrease over a period of months and can fluctuate in different hormonal states such as pregnancy. Even without therapy, the condition tends to become less prominent with age, although this is not always the case. Some patients describe mild itching, but the majority of those affected are most troubled by the appearance of the skin lesions. This has led to the disorder being regarded by many as a predominantly cosmetic complaint. In light of the genetic predisposition, there is unfortunately no cure for keratosis pilaris and treatment is difficult and may be unsatisfactory. Topical therapies are usually the first line of treatment. As keratosis pilaris is often accompanied by the sensation of skin dryness or roughness, it would seem sensible to avoid harsh soaps and cleansers. Wash products containing 2% salicylic acid or glycolic acid can be helpful and the addition of gentle massage with a polyester sponge in the bath or shower has been demonstrated to improve results.17 Vigorous scouring, however, is likely to cause

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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irritation and should be discouraged. After bathing, a moisturising cream or lotion should be applied to damp skin. Creams should always be massaged into the skin in a downward direction, i.e. in the same direction as the hair growth. Glycolic acid, ammonium lactate, salicylic acid and urea containing humectants may be chosen in preference to simple hydrating emollients for their added keratolytic effects. Salicylic acid 2-3% and 20% urea cream,17 or salicylic acid in propylene glycol combine the properties of an emollient with a keratolytic agent. Patients should be encouraged to apply their treatment cream on a twice-daily basis for a trial period of approximately four to six weeks. When adequate relief of symptoms has been achieved, use of the treatment cream can slowly be tapered to a maintenance phase of once-daily application initially, followed by twice-weekly application if symptoms remain controlled after a further four to six weeks. Patients can return to the more intensive regime if their symptoms recur at any point and some will find that continuous treatment is necessary. Should symptoms persist despite the measures already described, patients may benefit from the addition of a topical retinoid. Lower concentrations of tretinoin such as 0.025% cream should be trialled in the first instance, as irritation is common and treatment may not be tolerated if large areas are involved. Higher concentrations of tretinoin, or alternatives such as adapalene or tazarotene creams, can also be used if tolerated and may help address the redness, roughness and itching of keratosis pilaris if present.18 I would usually recommend applying a topical retinoid twice-weekly at night for four weeks, then on alternate nights for four weeks, and then once-daily at night

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thereafter if tolerated. Once again, frequency of application can be tapered down when relief of symptoms has been achieved. A short defined course of a medium potency topical corticosteroid (e.g. twice-daily for seven to ten days), may sometimes be necessary if there is a significant inflammatory component and should be discontinued when inflammation has resolved, allowing treatment with an emollient or keratolytic to resume. Other topical agents that have been reported in the medical literature include the immunomodulator tacrolimus 0.1% ointment, although the improvement demonstrated was similar to that achieved with Aquaphor ointment (Eucerin) in a small double-blinded study.19 Topical vitamin D analogues such as calcipotriol do not appear to have a role in the treatment of keratosis pilaris as no therapeutic effect was demonstrated in a small randomised right/left comparative study in nine affected individuals.20 Skin discolouration, or hyperpigmentation, following resolution of keratosis pilaris lesions may fade to some degree on its own, but can also be tackled with skin lightening creams containing hydroquinone, azelaic acid or kojic acid. Oral treatment of keratosis pilaris is not usually necessary and would not be considered routinely, however oral isotretinoin has been helpful in patients with some of the more pernicious variants of keratosis pilaris atrophicans, such as ulerythema ophryogenes and atrophoderma vermiculatum where prevention of scarring and disfigurement necessitates a more aggressive approach.21 Laser and light therapies have been used in the management of keratosis pilaris with varying outcomes. In the past, lasers have tended to be better at addressing the redness rather than the textural irregularity

REFERENCES 1. Inanir I, Sahin MT, Gunduz K et al. Prevalence of skin conditions in primary school children in Turkey: differences based on socioeconomic factors. Pediatr Dermatol 2002; 19 (4): 307-11. 2. Popescu R, Popescu CM, Williams HC et al. The prevalence of skin conditions in Romanian school children. Br J Dermatol 1999; 140: 891. 3. Hwang S and Schwartz RA, ‘Keratosis pilaris: a common follicular hyperkeratosis’, Cutis 82(3) (2008), p.177-80. 4. Castela E, Chiaverini C, Boralevi F et al. Papular, profuse and pernicious keratosis pilaris. Pediatr Dermatol 2012; 29 (3): 285-8. 5. Weedon D. Weedon’s Skin Pathology, 3rd ed, Churchill Livingstone, Edinburgh 2010. 6. Marqueling AL, Gilliam AE, Prendiville J et al. Arch Dermatol 2006; 142 (12): 1611-6. 7. Callaway SR, Lesher JL Jr. Keratosis pilaris atrophicans: case series and review. Pediatr Dermatol 2004; 21: 14. 8. Di Lernia, Ricci C. Folliculitis spinulosa de calvans: an uncommon entity within the keratosis pilaris spectrum. Pediatr Dermatol 2006; 23 (3): 255-8. 9. Watt TL, Kaiser JS. Erythromelanosis follicularis faciei et colli. A case report. J Am Acad Dermatol 1981; 5 (5): 533-4. 10. Pierini DO, Pierini AM. Keratosis pilaris atrophicans faciei (ulerythema ophryogenes): a cutaneous marker in the Noonan syndrome. Br J Dermatol 1979; 100 (4): 409-16. 11. Borradori L, Blanchet-Bardon C. Skin manifestations of cardio-facio-cutaneous syndrome. J Am Acad Dermatol 1993; 28: 815-9. 12. Sandilands A, O’Regan GM, Liao H et al, ‘Prevalent and rare mutations in the gene encoding filaggrin cause ichthyosis vulgaris and predispose individuals to atopic dermatitis’, J Invest Dermatol (8) (2006)126, p.1770-5. 13. Ichthyosis vulgaris: the filaggrin mutation disease, Br J Dermatol (6) (2013) 168, p.1155-66.

associated with the condition. Many early studies demonstrated promising reductions in erythema with the 595 nm pulsed dye laser.22 More recent studies report improvements in skin texture with the 810 nm diode laser used on three occasions four to five weeks apart23 and the combination of 595 nm pulsed dye laser, long-pulsed 744 nm alexandrite laser and microdermabrasion, with claims of improved redness and texture and a reduction in hyperpigmentation three months after treatment.24 Conclusion In addition to the more widely used treatments outlined above, some parties have attempted photodynamic therapy, chemical peels, dermabrasion and microdermabrasion with the hope of finding a better solution for those with keratosis pilaris. To date, there is little evidence to support their widespread uptake although they may be considered in individual cases where other methods have failed. The mainstay of treatment remain as emollients, keratolytic agents and topical retinoids. Whilst many of those affected are not especially troubled by their condition, others are more disturbed by its appearance and it will be both interesting and exciting to see which techniques and treatments emerge in this area over the next few years. At this time, however, there are no new products or clinical trials anticipated. Dr Justine Kluk is a consultant dermatologist based at London North West Healthcare NHS Trust and European Dermatology London. Her particular clinical interest is in skin cancer, having undertaken a post-CCT fellowship in cutaneous oncology, however her day-today practice encompasses all general adult and paediatric dermatology.

14. ‘Cutaneous adverse effects of targeted therapies: Part II: Inhibitors of intracellular molecular signalling pathways’. J Am Acad Dermatol (2) (2015), 72, p.221-36. 15. Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of obesity. J Am Acad Dermatol 2007; 56 (6): 901-16. 16. ‘The prevalence of cutaneous manifestations in young patients with type 1 diabetes’. Pavlovic MD, Milenkovic T, Dinic M et al. Diabetes Care (2007), p.1964-7. 17. ‘Practical management of widespread, atypical keratosis pilaris’. Novick NL. J Am Acad Dermatol (11) (1984), p.305-6. 18. ‘Tazarotene 0.05% cream for the treatment of keratosis pilaris’. Bogle MA, Ali A, Bartel H. J Am Acad Dermatol (50) (2004), (suppl 1), p.39. 19. ‘A comparative trial comparing the efficacy of tacrolimus 0.1% ointment with Aquaphor ointment for the treatment of keratosis pilaris’. Breithaupt AD, Alio A, Friedlander SF. Pediatr Dermatol (28) (2011), p.459-60. 20. Kraqballe K, Steijlen PM, Ibsen HH et al. Efficacy, tolerability, and safety of calcipotriol ointment in disorders of keratinization. Results of a randomized, double-blind, vehicle-controlled, right/left comparative study. Arch Dermatol 1995; 131 (5): 556-60. 21. ‘A case of ulerythema ophryogenes responding to isotretinoin’. Layton AM, Cunliffe WJ. Br J Dermatol (129) (1993), p. 645-6. 22. ‘Successful treatment of severe keratosis pilaris rubra with a 595-nm pulsed dye laser;. Kaune KM, Haas E, Emmet S et al. Dermatol Surg (35) (2009), p.1592-5. 23. ‘Treatment of keratosis pilaris with 810-nm diode laser: a randomized clinical trial’. Ibrahim O, Bolotin D, Dubina M et al. JAMA Dermatol (2) (2015), 151, p.187-191. 24. ‘Combination of 595-nm pulsed dye laser, long-pulsed 755-nm alexandrite laser, and microdermabrasion treatment for keratosis pilaris: retrospective analysis of 26 Korean patients’. J Cosmet Laser Ther (3)c (2013), 15, p.150-4.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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The Threepoint Facelift Dr Beatriz Molina details her technique for achieving a non-surgical facelift using cannulas The role of volume augmentation for facial rejuvenation will continue to progress as our knowledge and insight into facial anatomy, ageing, beauty and aesthetic harmony continue to mature. Soft-tissue augmentation has been used with positive results for some time,1 but the focus within the facial aesthetic community as a whole on where to place volume has certainly changed and expanded. With experience, practitioners recognise that filling just a wrinkle or nasolabial fold, for example, can help or, better yet, appease a patient’s concern. True facial rejuvenation, however, requires a more thoughtful scope of evaluation and an expanded treatment philosophy in order to achieve facial harmony. We are now moving a step further by using dermal fillers for a lifting effect. With the cannula we can achieve this with only three points of access, making this treatment extremely comfortable and requiring little-to-no downtime. In this article I will detail my approach to achieving a non-surgical facelift using hyaluronic acid and a three-point technique using cannulas. Consultation Careful patient selection and a detailed consultation are paramount for successful outcomes in any aesthetic procedure, so I would advise practitioners to take their time analysing the face and deciding which product to use, the amount of product needed, and the number of sessions needed to achieve the best possible outcome for your patient. In order to build trust with your patient, it is also imperative that they understand why you have proposed this particular treatment protocol for them. Once the patient has confirmed they are happy to go ahead with the procedure and has signed the relevant consent forms, the next step for the practitioner is to decide how they will be delivering this treatment; will they use needles or cannulas, or even a combination of both? Figure 1: Image demonstrates injection points for the 3-point facelift Point 3

Point 1

Point 2

Treatment preparation In my aesthetic practice, I have always looked for ways to give the best outcome possible for my patients, with minimal trauma and disruption to their lives. Most of our patients want to continue their busy routine with the least amount of downtime possible. As such, I have aimed to perfect my treatments with the cannula in order to deliver these common patient requirements. The reason I choose to use a cannula instead of a needle for my three-point facelift treatment is because it allows access to the whole face with simply three small points of access or less. I also believe that, as we are treating all areas of the face, there are fewer risks associated with using a cannula compared to a sharp needle. The number of entry points (from one to three) for the three-point facelift depends on the patient’s age – they will need more or less lifting depending

The three-point facelift treatment is suitable for any man or woman who starts showing mild to severe signs of ageing on the amount of volume loss in their face. Younger patients normally present with mild mid-facial atrophy, while more mature patients often present with volume loss in other areas such as the lateral cheeks and temples. As we as aesthetic practitioners all know, facial ageing is a complex synergy of dynamic and cumulative effects of skin textural changes and loss of facial volume, combined effects of gravity, progressive bone resorption, decreased tissue elasticity, and loss or redistribution of subcutaneous fat. For each point I use 0.1 ml of lidocaine 2% to make the procedure more comfortable for the patient, as it is important they are relaxed while I am administering treatment. As well as this, if the procedure is comfortable and your patient’s experience was positive, they are more likely to recommend your services to their friends and family and come back to your clinic for future treatments. For the three-point facelift I use a 23G needle as an access point for my cannula. I then use the

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Figure 2

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Figure 3

Figure 4

Administration of treatment using a cannula

25G 60mm (2 inches) cannula as I find that this is the most comfortable to use. The extrusion force this type of cannula provides is easier for depositing most products, which gives me more control when administering treatment. In my experience it also causes less bruising than smaller gauge cannulas, which makes it beneficial to the patient as well. I normally use a fanning retrograde linear threading technique, depositing about 0.1 to maximum 0.2mls of hyaluronic acid per line. Technique The three-point facelift allows me to create a non-surgical facelift using the vectors indicated in Figure 1, through replacing volume in the hollow areas where there is volume loss. I would advise practitioners to think carefully about the product they would use in each area and ask themselves what they are trying to achieve from this treatment; does the patient need more volume replacement or simply firmer skin texture? Practitioners should then adapt the technique to suit the patient’s best interests. • Point One The first point is the most important entry point as this is the one that achieves the most significant lifting effect, while providing mid-facial enhancement and volumising the cheeks and cheekbones. From entry point one I am able to treat a patient’s cheeks and cheekbones, including the tear through, and, if required, the nasolabial folds and marionette lines. • Point Two For entry point two, an incision is made in the same method as entry point one, but this time approximately half way along the jawline. In my opinion, this is the perfect position for delivering the product on the mandibular line, creating not just contouring but support, without accentuating the jowls. It also enables the practitioner to replace volume loss on the lateral cheek, which will give an additional lifting effect (on top of the lift already created by point one), which is our main objective to achieving patient satisfaction. From this point, we are also able to treat nasolabial lines if the patient’s Before

After

nasolabial folds are still too deep, even after lifting tissue medially and laterally. Caution is required in this area and we must be gentle in our technique due to the superficial location of the parotid gland. • Point Three The third entry point focuses on treating the temples, our third area for lifting, and this is particularly suited to more mature patients with hollow temples (Figure 4). In addition, by using this entry point we are also able to treat the tear trough by leaving small deposits of hyaluronic acid, and of course, in the cheeks and cheekbones. For those patients in which the lost volume is more significant, I would advise creating a crosshatch of the product, firstly with point one and secondly with point three. It is important to be gentle and to inject slowly due to the risk of bruising in the temple area; the transverse frontal branch of the superficial temporal artery runs in the sleeves of the superficial temporal fascia on the deep temporal fascia (which is a continuation of the galea of the forehead), along with a plexus of veins.2 Conclusion The three-point facelift treatment is suitable for any man or woman who starts showing mild to severe signs of ageing. The technique demonstrates that we can achieve a facelift with no surgery, simply by placing between 4 and 6mls of hyaluronic acid with just three points of access, a two-inch cannula and minimal downtime. My patients appreciate the technique as it enables them to leave the clinic looking well, natural and fresh; allowing them to continue with their busy lives. Dr Beatriz Molina practised general medicine for 12 years, before opening her first aesthetic practice in Somerset in 2005. She is a member and the director of conferences at the British College of Aesthetic Medicine (BCAM), and teaches beginner and advanced techniques in the use of botulinum toxin and dermal fillers. REFERENCES 1. Jean Carruthers and Alastair Carruthers,‘Soft Tissue Augmentation’, Procedures in Cosmetic Dermatology Series, 3rd ed, edited by Jeffrey S. Dover and Murad Alam (US: Saunders Elsevier, 2012) 2. Peter M. Prendergast, ‘Anatomy of the Face and Neck’, Cosmetic Surgery, ed by Melvin A. Shiffman, and Alberto Di Giuseppe, (Berlin: Springer-Verlag Berlin Heidelberg, 2013) pp. 29-35

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Managing Inflammation Dr Kathryn Taylor-Barnes examines how and why inflammation occurs, while offering advice on how to manage it best for your patients Introduction The skin’s primary role is to protect our body. This protection is a barrier to temperature changes and external trauma, as well as being essential in maintaining homeostatic hydration.1 Our skin is on the ‘front line’ and is a vital component in maintaining body harmony with the outside world. Inflammation is a physical condition that can occur on the skin as a result of both lifestyle choices and aesthetic procedures, which can be irritating and painful to a patient. As such, this article will aim to share advice on how inflammation can be managed successfully with various treatments. Lifestyle choices When we neglect our health and lead a poor lifestyle, our skin can deteriorate significantly. For instance, acne is made worse by eating junk food and poor or inappropriate skincare efforts.2 Eczema and psoriasis need external emollients and good levels of fluid consumption to avoid the skin drying out, which can lead to flareups. In each of these conditions, flare-ups can appear as ‘islands’ of inflammation on the skin. As we already know, sun exposure causes ageing and damage to the skin; solar damage generates dangerous free radicals, which can also cause skin irritation and ignite inflammation. As such, advising patients on the importance of a healthy, balanced diet, staying hydrated and protecting their skin from the sun can certainly play a role in reducing inflammation. In addition, antioxidants, both ingested (polyphenols in green tea)3 and topical (vitamin C),4 as well as physical and chemical sun protection barriers, are key to opposing solar damage. Inflammation following treatment: when, why and how Aesthetic practices routinely advise patients that to achieve younger looking skin, treatments should aim to smooth, refine, brighten and build collagen. Various clinical skin treatments such as lasers, skin peels, topical retinoid and alpha hydroxy acids (AHAs) do this by increasing cellular turnover, excitation of fibroblasts, removal of desiccated skin layers and deliberate stripping of the skin’s surface, in addition to suppressing melanocytes by using topical hydroquinone and tretinoin or retinol creams.5 These types of treatments cause a more uniform and controlled degree of inflammation in the skin. This is opposed to a more confined focus of inflammation caused by injectable treatments, such as botulinum toxin and dermal fillers, mesotherapy, cryotherapy and surgical skin excision. The treated areas can leave inflammation that disrupts the harmony of surrounding skin. This approach may be more damaging and ignite skin ageing Figure 1; Infected eczema caused by excessive sun exposure

Figure 2; Inflammation from lip filler

and ‘inflamm-ageing’, which is why controlling excessive inflammation in these particular treatments may be of greater importance than we might realise. Dermal fillers: an inflammatory provoker After injection, dermal fillers routinely require the practitioner to lightly massage the area to conform to the contour of the surrounding tissues.6 In doing so, the digital pressure can attract fluid causing further inflammation to the hydrophilic HA filler ‘bed site’ and encourage swelling and free radical escape. Having a good serum concentration of anti-inflammatory in the blood at the time of treatment may help slow down the filler-degradation rate and help improve filler stability and longevity. We should be mindful that certain techniques for injecting dermal fillers agitate the skin and increase inflammation. These techniques are fanning injection, rapid bolus deposition and injecting large volumes of product in one area in a single treatment session.7 The larger needle/cannula gauge size may provoke more inflammation. In regards to the common needle vs cannula debate, while many chose to use a cannula to avoid traumatic bruising, I would suggest that we might actually be causing more swelling within the dermis due to more aggressive tissue dissection with our implement. When looking at the array of dermal fillers on offer today, polycaprolactone is different and this difference has an impact on post-injection inflammation. It does not degrade, but instead gradually resorbs without changing shape, and this preferred biologic activity will help prevent the risk of secondary reactions. Dr Pierre Nicolau has had extensive experience with polycaprolactone. He notes that, “The advantage of bio stimulators such as Ellansé is that one has a controlled reaction versus an uncontrolled and unwanted one such as with hyaluronic acid and other dermal fillers. Ellansé disappears without the risk of causing an inflammatory reaction, as proven in histological studies. At the end of the bio resorption process, the shorter polycaprolactone chains simply dissolve and are completely removed from the body through normal metabolic processes.” Dr Nicolau recommends only using dermal fillers that are resorbable so that unwanted side effects can be avoided. BDDE is the crosslinked substance used in the majority of recognised HA fillers. After reaction with HA, the epoxide groups of BDDE are PH neutralised and there is a very small amount of unreacted BDDE that remains in the product.8 This has historically been considered too insignificant to create an inflammatory effect. In my opinion, however, this unreacted portion could have more impact on inflammation than we may have considered in the past. “It’s very difficult to know the exact amount of BDDE that has been used in a given HA dermal filler, the total amount of free-endings of the BDDE, or what is left once the HA has disappeared from the tissues. These factors represent an unknown measure of risk regarding potential adverse events that may occur from using these products,” says Dr Nicolau.9 Some new HA fillers, including Dermafill, have reduced levels of BDDE compared to other HAs on the market. Dermafill exceeds the stricter standards of the FDA very low levels of BDDE controls, as stated in the product guidance note. BDDE is found in all HA fillers but, as I have already mentioned, I believe that the BDDE unreacted portion

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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to be true when injected slowly and without pre-mixed anaesthetic, reducing the occurrence of patients looking red and swollen. Regarding HA filler, the rare but dangerous inflammation-driven side effect, Angioedema can occur within the first two weeks of injection and the incidence is about one to five per 10000.6 Angioedema, caused by IGE mediated immune response together with dermal filler associated nephritis,15 further highlights the dangerous nature of the extreme end of the inflammatory ladder. Figure 3; TA-65 demonstrating how cells can divide over time, telomeres that protect the chromosome shorten and cell division eventually stopping. Image courtesy of T.A. Sciences USA .

may be a factor in inflammation caused by cosmetic injection with HA, although research is needed to verify this. Tools to reduce inflammation I have been interested in oral supplements in the hope they may be complementary to my aesthetic injection treatments and have the added bonus of helping to reduce inflammation and ‘inflamm-ageing’. Methyl sulphonyl methane (MSM) and omega 3 and 6 from flaxseed work well in combination and may reduce the risk of an inflammatory response. MSM inhibits the release of pro-inflammatory mediators, such as nitric oxide and prostaglandin E2.10 These are released in the skin after cosmetic injection treatments or facial and body surgery, causing the area to become red, swollen and sore.Omega 3 from flaxseed inhibits the formulation of platelet-activating factors, which increase the risk of inflammation when produced in excessive amounts.11 It is also important to maximise dietary antioxidant intake in the form of easily absorbed vitamin C (calcium ascorbate) and L lysine. Nutraceuticals such as Skinade, which is a daily drink, contain multiple naturally occurring ingredients together with the supplements listed above to provide a significant anti-inflammatory effect. I have observed that my patients’ skin tolerates procedures better and heals quicker especially when they are already on a course of Skinade at the time of treatment. In fact some plastic surgeons are now routinely recommending their patients take nutraceuticals pre and post surgery as they have observed improved healing rates. Oxidative stress and excessive inflammation are common risk factors for a whole variety of health problems. These inflamm-ageing associated problems include development of insulin resistance, type 2 diabetes, asthma, obesity and metabolic syndrome. Also chronic inflammation and chronic oxidative stress are risk factors for cancer development (e.g. breast, prostate, colon cancer and skin cancer).12 TA-65 is another product that claims to repair damaged telomere ends and halt and reverse biological ageing. A new study has just been released by T. A. Sciences, USA. The TA-65 research group found that after taking two capsules daily (250 units) over sixteen weeks, there was a decline in the expression of inflammatory cytokines. In addition, interleukin 6 and interleukin 8 were found to decline by two-fold and seven-fold. Also with up to seven-fold reduction in inflammation, this could have a significant beneficial effect in treating dermatitis, eczema, psoriasis, rosacea, acne and all the other inflammatory skin conditions.13 When we consult with patients about having a dermal filler treatment, the topic of downtime is always raised. Searching for the ‘holy grail’ I have had extensive experience in my clinics with Stylage (Vivacy), which contains mannitol and has anti-inflammatory benefits, claiming to improve product longevity. A new filler from Italy, Algeness, is composed of polysaccharide sugar gel derived from red algae.14 Algeness HD does not have the hydrophilic properties of its rival HA and, as water is not encouraged into the injection bed, I have found that there is less swelling and release of pro-inflammatory mediators. In my early experience with this new product, I have observed its claims

Stem cells: the future? Stem cells may play a significant role in reducing inflammation, allergic reactions and promoting healing associated with aesthetic procedures. Autologous fat transfer may help reduce the potential for allergic reaction.16 Stem cells in fat are very powerful releasers of growth factors that enhance tissue healing.17 There is, however, a lack of real clinical data on aesthetic use and this needs to be carefully monitored as more practitioners gather clinical observations and research data. Conclusion An opportunity is present to encourage a good anti-inflammatory, skin-friendly diet, possibly including a nutraceutical, as well as appropriate pre- and post-skincare regimes that will enhance what our treatments are trying to achieve, and aim to stop inflammation getting out of control. I would hope that the future will bring new topical, injectable and ingested products and supplements that can help to safely control the inflammatory process, while slowing the ageing process and possibly assisting with skin cancer prevention in our growing ageing population. Dr Kathryn Taylor-Barnes is a general practitioner in Richmond and founder of The Real You Clinics in Surrey, established in 2004. Dr Taylor-Barnes has presented her work at national and international conferences and is currently completing a postgraduate Masters qualification in botulinum toxin at the University of Bournemouth. REFERENCES 1. J. Lademann ‘Determination of the thickness and structure of the skin barrier in vivo laser scanning microscopy’. Laser Phys [2008]Lett 5[4] p 311-315 2. J. Jung ‘The influence of dietary pattern on acne vulgaris in Koreans. ’ European Journal of Dermatology [2010] 20.6 p 768-72 3. N. Morley ‘The green tea polyphenol [epigallo catechin gallate] and green tea can protect human cellular DNA from ultraviolet and visible radiation induced damage .’ Photodermatology,Photoimmunology and Photomedicine [2005] 21.1 p 15-22 4. D. Darr ‘Topical vitamin C protects porcine skin from ultraviolet radiation induced damage’ british Journal of Dermatology [1992] 127 [3] p 247-253 5. Z. Draelos ‘Novel approach to the treatment of hyper pigmented and photo damaged skin’., Dermatological Surgery [2006] 21.s1 p 799-805 6. F. Brandt Hyaluronic acid gel filler in the management of facial ageing [2008] Clin Interv Ageing. 3 [1] p 153-159 7. G.Monheit, R.J.R., ‘The nature of longer term filler and the risk of complications’. Dermatologic Surgery 35(2) (2009), p.1598-1604. 8. K. De Boulle ‘A review of the metabolism of 1,4-butanediol diglycidyl ether-crosslinked hyaluronic acid dermal fillers’, Dermatologic Surgery [2013] 39 p 1758-1766 9. P. Nicolau The European Aesthetic Guide Autumn (2012) (2) www.miinews.com 10. Y.Kim ‘The anti-inflammatory effects of methylsulfonylmethane on lipopolysaccharide induced inflammation responses in murine macrophages.’ Biological and pharmaceutical Bulletin [2009] 32 No 4 p 651-656 11. 11. A.Simopoulos ‘Omega 3 fatty acids in inflammation and autoimmune disease’, Journal of the American College of Nutrition (2002),vol 21 [6] p 495-505 12. A. Lasry, Y.B-N ’Senescence-associated inflammatory response; ageing and cancer perspectives.’, Trends in Immunology 36 (4) (2015), p.217-228. 13. F. Stern ‘Demonstrated Improvement of Prematurely Aged Skin by Oral Intake of TA-65.’ study commissioned by TA Sciences (2015). 14. P. Motolese, ‘Agarose gel long-lasting absorbable filler’ Data on file (Member of SIES and Prof. AMS – Bologna) 15. J. Leonhardt, N.L., ’Angioedema -acute hypersensitivity reaction to injectable HA.’ Dermatologic Surgery 31[5] (2005), p.577-579. 16. E. Gonzalez-Rey ‘Human Adipose-derived mesenchymal stem cells reduce inflammation and T cell response and induces regulatory T cells in vitro in rheumatoid arthritis.’, Ann Rheum Dis [2010] 69 p 241-248 17. M. Murphy, K.M., ‘Mesenchymal stem cells: environmentally responsive therapeutics for regenerative medicine.’, Experimental and Molecular Medicine online, 45 (2013). Images courtesy of Dr Kathryn Taylor-Barnes. TA-65 diagram courtesy of T.A. Sciences USA.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


Aesthetics Awards Special Focus

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The finalists are announcedâ&#x20AC;Ś Following months of deliberation and discussion, Aesthetics is delighted to announce the finalists for the 2015 Awards. With even greater numbers of entries received this year and the standard of applications higher than ever, the competition to get to the finalist stage was extremely tough. See the full list of finalists in 23 categories revealed here or visit the Aesthetics Awards website to vote today. The voting and judging process is open from 1st September until the 30th October, with winners announced at the Aesthetics Awards ceremony on 5th December at the Park Plaza Westminster Bridge Hotel. Commended and Highly Commended finalists will be honoured on the night, with Winners invited to the stage to be presented with their trophies in front of 500 members of the medical aesthetics profession. Tickets can be booked on the Aesthetics Awards website www.aestheticsawards.com

The judging panelâ&#x20AC;Ś An esteemed panel of 44 judges have been selected to consider all entries, with six assigned to each category. These groups have been chosen specifically for their knowledge and expertise in that area, as well as to ensure the avoidance of any conflicts of interest in the judging process. The full list of judges can be found on the Aesthetics Awards website.

Have your say! You can now vote for your winners on the Aesthetics Awards website. Readers of Aesthetics journal should visit www.aestheticsawards.com to view all the finalists and use their Aesthetics login or register today to cast their votes. Select categories will be decided upon by reader votes and an esteemed judging panel, whilst others will be decided by judges alone. Please see details under each category for clarification. Voting and judging will close on 30th October 2015 and there will be no opportunity to vote after this point. Voting is IP address monitored and each individual can only vote once. Multiple votes under the same name will also be discounted from the final total. Multiple voting from within finalistsâ&#x20AC;&#x2122; organisations will be monitored.

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Aesthetics Awards Special Focus

The finalists… Cosmeceutical Range/Product of the Year Winner decided by: reader votes and judging panel

Equipment Supplier of the Year

IMAGE Skincare (Skin Geeks) ZO Skin Health (Wigmore Medical Ltd) NeoStrata® Skincare Range (AestheticSource) Heliocare (AesthetiCare) Epionce (Episciences Europe) Jan Marini Skin Research (JMSR Europe Ltd) Obagi Medical (Healthxchange Pharmacy) SkinCeuticals Range (SkinCeuticals)

Winner decided by: reader votes and judging panel

BTL Aesthetics Syneron Candela UK Lynton Lasers Ltd ABC Lasers Consulting Room Group 3D-lipo Ltd

Treatment of the Year

Distributor of the Year

Winner decided by: reader votes and judging panel

Winner decided by: reader votes and judging panel

Dermalux LED (Aesthetic Technology Ltd) EndyMed (AesthetiCare) Exilis Elite (BTL Aesthetics) VelaOnce (Syneron Candela UK) Dermapen (Naturastudios) Harmony 4D ClearLift (ABC Lasers) HydraFacial (HydraFacial UK) 3D-lipomed (3D-Lipo Ltd)

Wigmore Medical Ltd Harpar Grace International for iS Clinical Eden Aesthetics Distribution AestheticSource Church Pharmacy Medical Aesthetic Supplies Limited Healthxchange Pharmacy Vida Aesthetics Ltd

The Sterimedix Award for Injectable Product of the Year

Winner decided by: reader votes and judging panel

Juvéderm VOLIFT® with Lidocaine (Allergan) TEOSYAL® PureSense Redensity [II] (Lifestyle Aesthetics) Aqualyx (Healthxchange Pharmacy) Belotero® (Merz Aesthetics)

Best Treatment Partner Winner decided by: reader votes and judging panel

NeoStrata® ProSystem Peels (AestheticSource) iS Clinical SHEALD Recovery Balm (Harpar Grace International for iS Clinical) Dr Gabriela Aesthetic Line – Magic Beauty Face Lift Serum and Advanced Molecular Mask (Dermagenica) Oxygenetix (Medical Aesthetic Supplies Limited) Skinade (Skinade) MACOM Crystal Smooth (MACOM Medical)

Aesthetics | September 2015

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Aesthetics Awards Special Focus

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The 3D-lipomed Award for Best New Clinic, UK and Ireland

lipomed

Winner decided by: reader votes and judging panel

AestheticSource AesthetiCare BTL Aesthetics Church Pharmacy Lynton Lasers Ltd Merz Aesthetics

Fat Reduction

Best Customer Service by a Manufacturer or Supplier

Skin Tightening

A Powerful Three Dimensional Alternative to Liposuction

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

Winner decided by: judging panel

Dentelle River Medical Why choose 3D-lipomed? S-Thetics Facial Aesthetics NI Perfect Skin Solutions FAB Clinic The Aesthetic MediSpa Dr SW Clinics A complete approach to the problem

Face and Body skin tightening

Prescriptive

Highly profitable

Multi-functional

No exercise required

Inch loss

National PR support campaign

Cellulite

Clinician use only

Complete start up and support package available from under £660 per month

The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy

Before

Treatment of the Year 3D Lipomed

After

Before

Equipment Supplier of the Year 3D Lipo Limited

Cellulite

This NEW advanced device is dedicated exclusively to the clinical market

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Cavitation (Overall Circumference Reduction) Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss.

Duo Cryolipolysis (Superficial Targeted Fat Removal) Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months. Two areas can now be treated simultaneously.

Radio Frequency (Skin Tightening) Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

After

The Pinnell Award for Product Innovation 3D Lipomed

3D Dermology RF (Cellulite Reduction) The new 3D-lipomed incorporates 3D Dermology RF with the stand alone benefits of automated vacuum skin rolling and radio frequency.

What the experts say... ‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients. 3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

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Best Clinic Scotland

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Winner decided by: judging panel Winner decided by: reader votes and judging panel

Caroline Gwilliam (AestheticSource) Belinda Aloisio (L’Oreal – SkinCeuticals) Iveta Vinklerova (Boston Medical Group Ltd) Louise Taylor (Aesthetic Technology Ltd) Liz Robinson (Healthxchange Pharmacy) Simon Ringer (Naturastudios) Linda Wormald (Healthxchange Pharmacy) Karen Smyth Gaffney (Merz Aesthetics)

The NeoCosmedix Award for Association/ Industry Body of the Year

Age Refined Medical Cosmetic Centre Clinetix Re-Nu Skin Clinic LTD Face & Body La Belle Forme Clinic Temple Medical Ltd dermalclinic Grampian Cosmetic Clinic Ltd

The Epionce Award for Best Clinic North England

Winner decided by: judging panel Winner decided by: reader votes and judging panel

British College of Aesthetic Medicine (BCAM) Private Independent Aesthetic Practices Association (PIAPA) British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) Treatments You Can Trust (Cosmetic Quality-Assurance Ltd) Society of Mesotherapy of the United Kingdom (SoMUK)

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Aesthetics | September 2015

Medizen Limited Air Aesthetics Clinic Mulberry House Clinic Good Skin Days Internal Beauty Clinic Outline Clinic CC Kat Aesthetics face etc... medispa

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The Dermalux Award for Best Clinic South England

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The Oxygenetix Award for Best Clinic London

Winner decided by: judging panel

EF MEDISPA The Rejuvenation Clinic & Medispa London Professional Aesthetics PHI Clinic The Glasshouse Clinic Aesthetic Skin Centre The Cadogan Clinic Absolute Aesthetics

Winner decided by: judging panel

Radiance MediSpa health + aesthetics Medikas Woodford Medical Ltd. Riverbanks Clinic The Skin to Love Clinic Purity Bridge Jill Zander Skin Rejuvenation Clinic

The Skinceuticals Award for Best Clinic Ireland

Best Clinic Wales Winner decided by: judging panel

Winner decided by: judging panel

Cellite Clinic Limited Peaches Bespoke Beauty & Aesthetics Skinfinity Cardiff Cosmetic Clinic Specialist Skin Clinic

Dundrum Skin & Laser Clinic Claudia McGloin Clinic ClearSkin Clinic The Laser and Skin Clinic The DermaClinic Faceworks

The AestheticSource Award for Best Clinic Group UK and Ireland (3 clinics or more)

The Church Pharmacy Award for Clinic Reception Team of the Year

Winner decided by: judging panel

Winner decided by: judging panel

EF MEDISPA The Laser and Skin Clinic The Private Clinic Linia Cosmetic Surgery

Good Skin Days Face & Body La Belle Forme Clinic Temple Medical Ltd PHI Clinic Dermalclinic Riverbanks Clinic Dr Leahâ&#x20AC;&#x2122;s Cosmetic Skin Clinics

The Swisscode Award for Best Clinic Group UK and Ireland (10 clinics or more)

Winner decided by: judging panel

Courthouse Clinics MYA Cosmetic Surgery National Slimming & Cosmetic Clinics sk:n Clinics

Aesthetics | September 2015

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Training Initiative of the Year

Aesthetics

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The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year

Winner decided by: judging panel

Dr Kate Goldie, Advanced Training and Masterclass (Medics Direct, part of European Medical Aesthetics Ltd) Allergan Medical Institute (Allergan) RA Academy (Dr Raj Acquilla) Dr Tapan Patel’s Aesthetic Masterclass (PHI Clinic) Cosmetic Courses (Cosmetic Courses) Mr Taimur Shoaib/Carolyn Fraser (Inspired Cosmetic Training) Facial Anatomy Teaching (Medicos-Rx) Healthxchange Academy (Healthxchange Pharmacy)

Winner decided by: judging panel

Eve Bird Helen Hannigan Michelle McLean Demosthenous Frances Turner Traill Anna Baker Alison Telfer Jackie Partridge Sharon Bennett

Product Innovation of the Year Winner decided by: judging panel

Teosyal Pen (Lifestyle Aesthetics) Fillerina (Medical Aesthetics Supplies Ltd) Cynosure / PicoSure (Cynosure) ResurFX by Lumenis (Lumenis) Swisscode Bionic Stem Cell Recovering Complex (Pure Swiss Aesthetics) Silhouette Soft (Sinclair Pharma) ULTRAcel (Healthxchange Pharmacy) PLEXR (Fusion GT LTD)

The Sinclair Pharma Award for Aesthetic Medical Practitioner of the Year

The Schuco International Award for Special Achievement This award recognises the outstanding achievements and significant contribution to the profession and industry by an individual with a distinguished career in medical aesthetics. The Aesthetics’ judges will select the winner and there will be no finalists for this category.

Book Now! Don’t miss your chance to attend the most prestigious awards event in medical aesthetics. Individual ticket: £225 plus VAT Table of 10: £2,150 plus VAT Visit www.aestheticsawards.com to book your tickets today For further information about the Aesthetics Awards or for any support required for voting or booking call 0203 096 1228 or email support@aestheticsawards.com

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Aesthetics | September 2015

Winner decided by: judging panel

Dr David Eccleston Dr Kate Goldie Mr Dalvi Humzah Dr Beatriz Molina Dr Raj Acquilla Dr Victoria Dobbie Mr Taimur Shoaib Dr Tapan Patel Dr Maria Gonzalez Dr Preema Vig


volumising filler

“Not all HA dermal fillers are created equal. I use Belotero Volume.”

OPTIMAL

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Dr Arthur Swift, Canadian Plastic Surgeon

BEL190/0215/LD Date of preparation: February 2015

Injectable Product of the Year

Contact Merz Aesthetics NOW and ask for Belotero

NEW Volume

Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com

The filler you’ll love

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Fat Reduction

lipomed

Skin Tightening

A Powerful Three Dimensional Alternative to Liposuction

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

Cellulite

This NEW advanced device is dedicated exclusively to the clinical market

Why choose 3D-lipomed? A complete approach to the problem

Face and Body skin tightening

Prescriptive

Highly profitable

Multi-functional

No exercise required

Inch loss

National PR support campaign

Cellulite

Clinician use only Complete start up and support package available from under £660 per month

Before Treatment of the Year 3D Lipomed

After

Before Equipment Supplier of the Year 3D Lipo Limited

Cavitation (Overall Circumference Reduction) Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss. Duo Cryolipolysis (Superficial Targeted Fat Removal) Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months. Two areas can now be treated simultaneously.

Radio Frequency (Skin Tightening) Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

After The Pinnell Award for Product Innovation 3D Lipomed

3D Dermology RF (Cellulite Reduction) The new 3D-lipomed incorporates 3D Dermology RF with the stand alone benefits of automated vacuum skin rolling and radio frequency. What the experts say... ‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients. 3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

www.3d-lipo.co.uk @3Dlipo

3D-lipo


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Treating the Décolletage Dr Aamer Khan provides an overview of the procedures available that aim to improve the appearance of sun damage and ageing on the chest ‘The décolletage is the upper part of a woman’s torso, comprising her neck, shoulders, back and chest, that is exposed by the neckline of her clothing’.1 While we could refer to this area as the chest or the cleavage, the world of aesthetics chooses to adopt the French approach and call it the ‘décolletage’. Unfortunately whatever fanciful terms we use, the décolletage presents a significant aesthetic concern for many women. Whether women have chosen to undergo anti-ageing treatment or simply employ the use of moisturisers and make-up over the years, they have long addressed the fine wrinkles, heavier lines, and skin pigmentation issues that affect the face; only to let the appearance of their chests give their age away. A crepey décolletage can reveal a woman’s age just as easily as her hands; think crinkly chests, lines between the cleavage, and the dreaded age spots. Yet I am constantly surprised by how many women we see in our clinic who have neglected their décolleté and think skincare or sun protection stops at the chin. After the eye area, the décolletage is the most prone to ageing on the body; more delicate than our complexion as it doesn’t produce as much oil in women due to fewer hair follicles, when compared with men,2 as well as being the first place to develop wrinkles.3 This is because of the stresses on the skin from movement, the weight of the breasts, and exposure to UV damage.4 Cleavage wrinkles are deep, vertical creases that appear as the skin becomes older and thinner. There are various physical causes for them appearing more prominent. These include hours spent sleeping on one’s side, where gravity forces the top breast to droop further past the body’s midline than it should, and by wearing sports and push-up bras, which push the breasts together, worsening the appearance of lines and wrinkles, similar to those that occur on the face due to muscular tension exerted on the skin.5 The skin covering the chest area tends to get a lot of sun exposure too, and is thinner than that on the arms and

legs, making it extremely vulnerable to UV damage,6 resulting in sun spots, and other signs of ageing. Once the collagen in the skin breaks down from age and sun exposure, those wrinkles tend to linger and, thanks to gravity, the generously endowed, whether naturally or surgically, tend to be more affected.7 Throw in the volume loss that occurs naturally with ageing, as well as pollution, smoking and repeated rapid weight changes; and the chest quickly loses its youthful appearance. As a result of hormonal changes relating to the menopause and oestrogen deficiency, women in their 40s and 50s are also more prone to ageing in this area. These changes result in an accelerated breakdown of collagen and elastin, leading to skin thinning, dryness and other negative changes referred to as ‘solar elastosis’ or ‘dermatosis’.8 Another problem with older skin is the risk of increased inflammation. While usually not visible to the naked eye, photo-damaged and aged skin can be more reactive and prone to inflammation due to higher levels of inflammatory mediators (cytokines, prostaglandins and other immune mediated factors such as histamine release) and abnormal cellular activity immune system.9 Inflammation increases the production of harmful super-oxidative species (free radicals) and leads to increased cell damage, degradation of the skin matrix and rapid cell death, as well as an increase in the risk of neoplastic change.10 In fact, the décolletage condition, characterised by dilated vessels, red and brown spots, ruddiness, thin crepey skin, and the ‘bubble wrap’ appearance, is referred to as ‘poikiloderma’, derived from the neck condition ‘Poikiloderma of Civatte’.11 There are simple ways of preventing and improving the appearance of the décolletage. Many of the non-invasive procedures that make the face more youthful can also work well on the décolletage. As such, I have detailed some of the most common methods below, with information on how they should be used. Combined CO2 resurfacing and PRP décolletage treatment This 60-minute treatment uses fractional CO2 laser combined with Platelet Rich Plasma (PRP) injections to treat the décolletage. The practitioner should apply topical anesthetic to the entire cleavage area, before using a fractional CO2 laser to encourage new collagen to form. The energy delivered has to be relatively low as the skin in this area is thin, reactive and prone to laser damage. The laser should also be adjusted to the patient’s skin type, as skins of colour can be more reactive, and prone to post-inflammatory hyperpigmentation.12

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Peels are the backbone of good skincare and are often overlooked, yet they can do much to improve the quality of skin including tone, texture and elasticity for all skin types The next stage of the treatment requires the practitioner to inject 50-60 small intra-dermal deposits of PRP,13 (this further stimulates stem cell activity in the skin and hypodermis adipose layer)14 into the décolletage. The skin will be red for approximately seven to ten days, and peeling will occur. The results improve over the next few months as the skin repairs and regenerates, and new collagen is formed. It is essential to advise patients to moisturise the treated area morning and night while the skin is healing. This reduces inflammation and damage to the skin through the skin cracking. While one treatment will see an improvement in texture, tone and tightness, a course of three treatments is advised – one to two months apart. It’s also important that patients use SPF50 on the treated area to protect against further sun damage. In our experience results can last beyond three years. Histological studies have shown that some of the effects of CO2 resurfacing are permanent.15    Biomimetic mesotherapy This 20-minute procedure will aim to treat sun-induced wrinkles with no significant downtime. Biomimetic mesotherapy stimulates the mesoderm (mid-dermis).16,17 First the décolletage is cleansed, then a series of injections containing active ingredients including hyaluronic acid, retinols and peptides, which aim to help boost the collagen and elastin, are placed on the décolletage. The treatment aims to help rejuvenate skin and soften fine lines and wrinkles. Patients should see smoother skin within a couple of weeks, but for best results, a course of three weekly sessions is recommended. Side effects include small bumps and pinprick bleeding, which settles within six to twelve hours.  The limited injury from the mesotherapy starts a healing response in the skin, with increased cellular activity and collagen stimulation. The ‘biomimetic peptides’ mimic growth factors and stimulate the repair activity even more.   Chemical peels In my opinion, peels are the backbone of good skincare and are often overlooked, yet they can do much to improve the quality of skin including tone, texture and elasticity for all skin types. A course of glycolic peels is particularly good for smoothing fine lines on the décolletage, with minimal downtime. Glycolic

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peels are also known as ‘cellular peels’, and work at the cellular level, causing cellular shock, and cells to shed, rather than sheets of skin.18 The peeling process is slower, so often requires six treatments. It is important to note that the skin has to be pretreated with AHA skincare to condition the skin prior to these peels, for at least two weeks, this helps to condition the skin and reduces the risks of skin damage.19 The glycolic solution should be prepared to suit the patient’s particular skin type and then brushed over the décolletage and left on for approximately ten minutes. Following this, the solution is rinsed off with water, and a moisturising lotion and sun block is applied. A course of six peels, one a week, will produce best results. This is because each peel can penetrate a little deeper, addressing more fine lines and discoloration. This treatment will also encourage dermal cellular activity,20 thereby giving the skin a plumper and younger appearance. Results should last up to a year and, in my clinic, we usually advise patients to continue to use skincare that contains AHA for maintenance. For best ongoing results we advise one peel every three months. Stronger chemical peels that cause cellular necrosis and shedding carry a higher risk,21 but can be useful in more severely damaged skin. Newer formulations of combined chemicals are proving safer and effective. Skin conditioning is recommended, and maintenance is the mainstay of lasting results.22   Microneedling As the microneedle roller is rolled over the skin, it creates pinpoint punctures in the dermis – the majority of which temporarily push pores open. This reaction is perceived by the body as damage, thus activating a wound healing response to regenerate the skin and boost collagen levels. As a result, thin skin thickens and fine lines, scars, and uneven skin tone are targeted.23 The skin is then cleansed, a peptide serum is usually massaged in and the roller is gently rolled over the skin several times, allowing the peptide serum to penetrate into the skins layers. Antioxidant serums are then applied. There may be a temporary reddening of the skin for an hour after treatment, and a course of six treatments once every foursix weeks is recommended. The natural healing process lasts for several months in which time skin will carry on improving.24 Maintenance is then advised every three to six months, depending on the age and condition of the skin. Improved results can be gained when this technique is combined with red light and IPL treatments.25   Dermal filler injections and botulinum toxin treatment Hyaluronic acid: As the décolletage is an area of thin skin, I would advise using a hyaluronic acid based filler, which can be finely injected with greater control, to avoid the appearance of unsightly lumps and bumps. The hyaluronic acid should be injected into the skin with lots of tiny microinjections, aiming to replenish moisture and reduce the appearance of fine lines while plumping skin, without the risk of leaving bumps, caused by larger deposits of product. While treating the face with fillers might require a syringe or two, the décolletage could require as many as ten syringes over three sessions to achieve best results. This is because of the large surface area, and the need to minimise the risk of leaving a bumpy outcome. The action of injecting will also contribute to the skin remodeling, as with microneedling.

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Treatment Focus Décolletage

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Avoid using permanent fillers such as silicone, as well as any filler that is long lasting and may result in nodules, which can be difficult to manage. In our experience, the results from hyaluronic acid used in this way should last up to a year. The maintenance with good skin care and SPF protection will give even longer lasting results. Poly-L-lactic acid (PLLA): Diluted PLLA should be administered sub-dermally in small injections, and then massaged into the décolletage. Three to five sessions, a month apart, are advised to get a result that will last up to four years.26 I would advise one maintenance treatment every 18 months in order to maintain the results, as involution of the effects starts about then.27 Botulinum toxin: Small doses of diluted botulinum toxin type-A, injected into the dermis 1 to 2cm apart, also have a smoothing effect on the décolletage. The mediation of this effect is unclear, but may relate to a relaxation of fibres or cells in the dermis, that may have some contractile function. This is a safe treatment with minimal risks, and results can last three to five months.   Radiofrequency Non-ablative: A non-ablative radiofrequency skin tightening treatment can help tighten crinkly décolletage skin by stimulating collagen production. A conductive gel is applied to the décolletage, before the radiofrequency device delivers constant gradual energy to the skin, causing heat to build up where the skin and fat layers meet. The increasing heat modifies the collagen bundles deep inside the skin causing them to contract, thus stimulating the production of new collagen over time. Most patients notice a tightening of the skin after one treatment, with ongoing improvements over the following four to six months as new collagen is formed.28,29 For best results a course of six treatments, two weeks apart, is recommended. The procedure should give lasting effects with one maintenance treatment a month. This gives rise to the best results through tissue remodeling.30 Ablative: Ablative radiofrequency devices, with coated or uncoated pins that create holes in the skin and tissue coagulation, can also be very effective. We do, however, have to be careful not to use very high-energy settings, as the skin in this area is very thin and prone to scarring. Three sessions, six weeks apart with annual maintenance are advised.31   Photodynamic therapy (PDT) PDT is an established method for treating some non-melanoma forms of skin cancer, while also having the added benefits of being a highly effective treatment for rejuvenating the skin and treating pigmentation and sun-damaged chests.32,33 It’s a simple procedure but time consuming, and can be painful for the patient. To begin, an exfoliating mask is used to slough off dead skin cells and prepare the skin for treatment. A cream containing a lightsensitising chemical, 5-aminolaevulinic acid (ALA), is applied to the sun-damaged skin. The treated area will then be covered for up to three hours to allow the cream to penetrate into the sun-

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The décolletage is a greatly ignored area of the body when it comes to antiageing and protection. It is a vulnerable area predisposed to photoageing and the effects of shearing forces, particularly in women who have very few hair follicles on their chests

damaged skin cells. The damaged cells, through active amino acid uptake channels, preferentially take up the 5-ALA, which makes the damaged skin cells very sensitive to the PDT light.34,35 A red LED laser is then used to target the photosensitised cells for ten minutes. The light will target the damaged cells, but not the normal cells. The body then repairs and replaces the damaged cells with new healthy skin cells. After the treatment, patients may notice some redness, blistering, peeling and milia formation for up to two weeks. Advise patients to keep the treated area covered and moisturised for 36 hours.   Intense Pulsed Light (IPL) Despite the latest state of the art treatments, there’s something to be said about the tried and tested treatments such as IPL. The light-based device is used to reduce discoloration, sun damage, and broken capillaries. IPL is also successfully used for treating age spots as it targets melanin in the skin and, with four to six treatments, a significant improvement can be seen.36 There is little downtime, though treated skin may be red for a few hours, and the pigmented areas appear darker before scaling off. This treatment targets both pigmented areas and the vascular elements of the photodamaged skin. In practice, IPL is ‘fired’ at the area to be treated. Photo-filters are used at specific wavelengths to target a specific pigment. This releases low levels of energy into the skin, which then stimulates regeneration of the cells, and also boosts collagen so skin becomes tighter and plumper. High-energy absorption into the target pigment causes photo-coagulation of the tissues, which are then repaired and replaced by the body. Lower levels of energy released also have an anti-inflammatory effect on the

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Aesthetics Journal

healthy tissues. Patients often report that the treatment feels like an elastic band is being pinged against the skin, especially in the areas where the target pigment is at its greatest. A few days post treatment, the treated areas become darker before they fade. Patients may need up to six treatments and the results are likely to last up to 18 months. I recommend patients undergo this treatment in the autumn or winter when they will not be exposed to a sunny climate, as treated areas can burn or become darker when exposed to UV light. As always, I advise my patients use an SPF50 to protect their skin following treatment.   Polydioxanone (PDO) sutures and dermaroller in combination The latest weapon in our fight against the aged and damaged décolletage is the use of PDO sutures inserted sub-dermally to form a structural matrix, followed by rolling a 3mm dermaroller over the surface and PRP application.37 This treatment is performed under topical local anaesthesia. 30G Knotless PDO sutures are positioned in the hypodermis in a crisscross fashion to form a matrix. As they dissolve, they stimulate cellular activity and collagen production. The sutures provide the extra-cellular matrix upon which the collagen is structured and laid down. A 3mm dermaroller is used to produce microneedling trauma to the tissues, in order to increase the cellular activity and healing.38,39 This combined treatment can give excellent skin rejuvenation, which, judging by my experience, can last for more than two years. In my clinic, we are seeing excellent results with this technique. It is also helpful in improving the appearance of stretch marks around the décolletage and breasts.

REFERENCES 1. Barnhart, edited by Robert K. ‘Barnhart Concise Dictionary of Etymology’, HarperCollins, (1994) p1. 2. Prost-Squarcioni C. [Histology of skin and hair follicle]. Med Sci (Paris). 2006 Feb. 22(2): pp.131-7. [Medline]. 3. Burns DA, Breathnach SM, Cox N, Griffiths CE, eds. Rook’s Textbook of Dermatology. 7th ed. Malden, Mass: Blackwell Science; 2004 4. Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoaging: mechanisms and repair. J Am Acad Dermatol. 2006 Jul. 55(1): pp.1-19.[Medline] 5. Fongo A, Ferraris E, Bocca M. Skin tension lines and wrinkles. Anatomoclinical observations. Minerva Chir. 1966. 21(13): pp.627-30. 6. Rabe JH, Mamelak AJ, McElgunn PJ, Morison WL, Sauder DN. Photoaging: mechanisms and repair. J Am Acad Dermatol. 2006 Jul. 55(1): pp.1-19.[Medline] 7. Fongo A, Ferraris E, Bocca M. Skin tension lines and wrinkles. Anatomoclinical observations. Minerva Chir. 1966. 21(13): pp.627-30. 8. Borg M; Brincat S; Camilleri G; Schembri-Wismayer P; Brincat M; Calleja-Agius J. The role of cytokines in skin aging, Climacteric the journal of the International Menopause Society, 2013; 16(5); pp.514-21. 9. Borg M; Brincat S; Camilleri G; Schembri-Wismayer P; Brincat M; Calleja-Agius J. The role of cytokines in skin aging, Climacteric the journal of the International Menopause Society, 2013; 16(5); pp.514-21. 10. Baumann L, Department of Dermatology, University of Miami, Miami Beach, FL, USA’ The role of cytokines in skin aging; The Journal of Pathology 2007; 211(2): pp.241-51. 11. ‘Scattone L, de Avelar Alchorne MM, Michalany N, Miot HA, Higashi VS. Histopathologic changes induced by intense pulsed light in the treatment of poikiloderma of Civatte. Dermatol Surg. 2012 Jul. 38(7.1): pp.1010-6. [Medline] 12. The Use of Lasers in Darker Skin Types Eliot F. Battle, Jr, MD. Seminars in CutaneousMedicin and Surgery.2009, 28: pp.130-140 13. Freymiller EG. Platelet-rich plasma: evidence to support its use. J. OralMaxillofac. Surg. 62(8), pp.1047–1048 (2004). 14. Kakudo N, Minakata T, Mitsui T et al. Proliferation-promoting effect of platelet-rich plasma on human adipose-derived stem cells and human dermal fibroblasts. Plast. Reconstr. Surg. 122(5), pp.1352–1360 (2008). 15. A prospective study of fractional scanned nonsequential carbon dioxide laser resurfacing: a clinical and histopathologic evaluation. Berlin AL; Hussain M; Phelps R; Goldberg D. dermatologic Surgery 2009; 35(2): pp.222-8 16. Lacarrubba F, Tedeschi A, Nardone B, Micali G. Mesotherapy for skin rejuvenation: assessment of the subepidermal low-echogenic band by ultrasound evaluation with cross-sectional B-mode scanning. Dermatol. Ther. 21(Suppl. 3), S1–S5 (2008). 17. El-Domyati M, El-Ammawi TS, Moawad O et al. Efficacy of mesotherapy in facial rejuvenation: a histological and immunohistochemical evaluation. Int. J.Dermatol. 51(8), pp.913–919 (2012). 18. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol. 2010 Jul. 3 (7): pp.32-43. 19. Briden ME. Alpha-hydroxyacid chemical peeling agents: case studies and rationale for safe and effective use. Cutis. 2004 Feb. 73 (2 Suppl): pp.18-24. 20. Goldman A, Wollina U. Facial rejuvenation for middle-aged women: a combined approach with minimally invasive procedures. Clin Interv Aging. 2010 Sep 23.5: pp.293-9.

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Treatment Focus Décolletage

Conclusion In addition to the treatments listed above, I advocate the use of skincare packed with antioxidants such as peptides and vitamins to protect, repair and hydrate the décolletage. Vitamin C is a fantastic ingredient for treating this area as it builds collagen (which plumps the skin) and treats, as well as helps prevent, pigmentation.40 Products containing vitamin A are also suitable for use on the décolletage as they will help repair sun damage.41 In conclusion, the décolletage is a greatly ignored area of the body when it comes to anti-ageing and protection. It is a vulnerable area predisposed to photo-ageing and the effects of shearing forces, particularly in women who have very few hair follicles on their chests. The treatments that work on the face also have benefits on the décolletage, however the skin here is slower to heal, and easier to damage. The practice of preparation with skin care including retinoids and vitamin C, with, or without hydroquinone (in Fitzpatrick skin types IV-VI) is always prudent. Experience has taught us that combining treatments can help us to attain better results, with fewer risks and side effects. My advice to practitioners is to use the treatments they already use on the face, but with greater care on the décolletage. There is no right or wrong, as long as we ensure patient safety and effectiveness in achieving expected results. This puts great emphasis on managing patient expectations, and the informed consenting process. All of this starts with the consultation and listening to the patients. Dr Aamer Khan is an aesthetic practitioner specialising in non-invasive treatments of the face and neck. He graduated from The University of Birmingham in 1986 and has dedicated the past 15 years to perfecting antiageing skin treatments. He is also co-founder of The Harley Street Skin Clinic.

21. Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni N. Complications of medium depth and deep chemical peels. J Cutan Aesthet Surg. 2012 Oct. 5 (4): pp.254-60. 22. Glogau RG, Matarasso SL. Chemical peels. Trichloroacetic acid and phenol. Dermatol Clin. 1995 Apr. 13 (2): pp.263-76.’ 23. Doddaballapur S. Microneedling with dermaroller. J. Clin. Aesthet. Dermatol. 2(2), pp.110–111 (2009).’ 24. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 26(2), pp.192–199 (2008). 25. Clementoni MT, Broscher M, Munavalli GS. Photodynamic photorejuvenation of the face with a combination of microneedling, red light, and broadband pulsed light. Lasers Surg.Med. 42(2), pp.150–159 (2010). 26. Grippaudo FR, Mattei M. High-frequency sonography of temporary and permanent dermal fillers. Skin Res. Technol. 16(3), pp.265–269 (2010). 27. Grippaudo FR, Mattei M. High-frequency sonography of temporary and permanent dermal fillers. Skin Res. Technol. 16(3), pp.265–269 (2010). 28. El-Domyati M, El-Ammawi TS, Medhat W et al. Radiofrequency facial rejuvenation: evidence-based effect. J. Am. Acad.Dermatol. 64(3), pp.524–535 (2011). 29. Jay A. Burns thermage: monopolar radiofrequency. Aesth. Surg. J. 25(2), pp.638–642 (2005). 30. ‘Alster TS, Lupton JR. Nonablative cutaneous remodeling using radiofrequency devices. Clin. Dermatol. 25(5), pp.487–491 (2007).’ 31. Reddy BY, Hantash BM. Emerging technologies in aesthetic medicine. Dermatol. Clin. 27(4), pp.521–527 (2009). 32. Shamban AT. Current and new treatments of photodamaged skin. Facial Plast. Surg. 25(5), pp.337–346 (2009).’ 33. Gold MH. Photodynamic therapy for cosmetic uses on the skin: an update 2010. G. Ital. Dermatol. Venereol. 145(4), pp.525–541 (2010). 34. Freymiller EG. Platelet-rich plasma: evidence to support its use. J. OralMaxillofac. Surg. 62(8), pp.1047–1048 (2004). 35. ‘Kakudo N, Minakata T, Mitsui T et al. Proliferation-promoting effect of platelet-rich plasma on human adipose-derived stem cells and human dermal fibroblasts. Plast. Reconstr. Surg. 122(5), pp.1352–1360 (2008). 36. Scattone L, de Avelar Alchorne MM, Michalany N, Miot HA, Higashi VS. Histopathologic changes induced by intense pulsed light in the treatment of poikiloderma of Civatte. Dermatol Surg. 2012 Jul. 38(7.1): pp.1010-6. [Medline] 37. Suh DH; Jang HW; Lee SJ; Lee WS; Ryu HJ. Outcomes of polydioxanone knotless thread lifting for facial rejuvenation, Dermatologic Surgery 2015; 41(6): pp.720-5 38. Doddaballapur S. Microneedling with dermaroller. J. Clin. Aesthet. Dermatol. 2(2), pp.110–111 (2009). 39. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 26(2), pp.192–199 (2008). 40. R. Darlenski; C. Surber; J.W. Fluhr. Topical Retinoids in the Management of Photodamaged Skin: From Theory to Evidence-based Practical Approach. The British Journal of Dermatology. 2010;163(6):pp.1157-1165. 41. R. Darlenski; C. Surber; J.W. Fluhr. Topical Retinoids in the Management of Photodamaged Skin: From Theory to Evidence-based Practical Approach. The British Journal of Dermatology. 2010;163(6):pp.1157-1165.

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Glutathione Dr David Jack details the efficacy and clinical uses of the glutathione antioxidant Over the past few years there has been a surge of interest in antioxidants for both general health and in skincare. Almost every new serum or cream released seems to contain reference, at least, to the anti-ageing benefits of antioxidants. One of the molecules responsible for much of the excitement in this field, and in medicine in general, is glutathione – a thiol tripeptide present in every cell of most animal species, as well as in some plants.1 From my experience and personal observation, there is interest in glutathione in the skincare arena for two reasons: its strong antioxidant activity and its reputed ability to reduce hyperpigmentation and lighten skin. The Japanese skincare industry is awash with glutathione soaps, creams and oral supplements to fulfil the latter purpose. Closer to home, there has been growing interest in glutathione as a supplement in topical skincare, as well as an intravenous or intramuscular supplement for its numerous supposed health benefits. Given the negative press that the depigmentation agent hydroquinone has received recently, (albeit in my opinion on fairly shaky evidence)2 there may be a place in the market for a new means of tackling hyperpigmentation. Does glutathione fill this gap? In this article I outline the basics of glutathione, its clinical uses, evidence so far for its use, and information on the way it has been introduced to the western skincare market. What is glutathione? In humans, glutathione is probably the most important endogenous antioxidant.3 It is produced from the conjugation of glutamate, cysteine and glycine in all cells, however it is found in greatest concentration in the liver, which also acts as a reservoir for glutathione. It exists in two forms: reduced, L-glutathione (GSH), or an oxidised form (GSSH), the former comprising 90% of the total pool of glutathione. In the oxidised state, glutathione is able to non-enzymatically reduce free radical species and reactive oxygen and nitrile compounds, acting as a substrate for conjugation and reduction reactions by virtue of the thiol group of the cysteine amino acid. Glutathione acts alone and in synergy with other antioxidants, such as L-ascorbic acid and alpha-tocopherol to neutralise these damaging molecules throughout the body. It is also involved in various cytochrome P450 reactions, DNA synthesis and repair, amino acid transport, iron metabolism, nitric oxide cycle regulation, protein synthesis, prostaglandin, leukotriene synthesis and many other intracellular processes. Thus, should glutathione levels be depleted or inadequate,

a variety of systems and cell types may dysfunction as a result.4 The emerging importance of the role of oxidative stress in a substantial number of disease processes has resulted in a surge of interest in the use of supplementary antioxidants as an alternative or additive treatment in a variety of conditions as diverse as Parkinson’s disease, conjugation autistic spectrum disorders, various cancers, chronic fatigue syndrome, chronic obstructive pulmonary disease (COPD) and diabetes.5,6,7 It has also been reported that glutathione levels generally decrease with age, possibly contributing to the pathogenesis of Alzheimer’s disease.8 In the cosmetic industry, there has been some interest in the ability of glutathione to alter melanin production and thus be used as a skin lightening treatment, particularly in the Philippines and Japan, as mentioned earlier. The mechanism of this interaction is at present unclear, however, several mechanisms have been proposed. These include: the direct inactivation of melanocyte tyrosinase activity and transport, interruption of L-DOPA function, and mediation of a switch in melanin production from eumelanin production (which does not require GSH) in favour of the colourless pheomelanin, found in paler skin types.9,10 Thus, when GSH is found at high concentrations, production of colourless pheomelanin tend to be higher and at lower concentrations, eumelanin predominate.11 Methods of delivery Although glutathione is a ‘non-essential nutrient’ in humans, (as it is synthesised by all normal cells from the raw amino acid components), there is evidence that a wide variety of wasting conditions including HIV, various cancers, chronic fatigue syndrome, sepsis and Crohn’s disease, among others,12 are associated with reduced levels of GSH (and presumably increased oxidative stress). As a result, glutathione supplementation has been proposed as a novel way of treating many of these conditions. Given the fact that glutathione is a tripeptide, there has been much scepticism that it can be taken orally and absorbed without being completely broken down into its constituent amino acids. Witschi et al13 found that following oral ingestion, very little glutathione actually reaches the systemic circulation. They reported that the majority of the ingested glutathione is thought to remain in gut luminal cells or is rapidly hydrolysed in the circulation by extracellular membrane gammaglutamyl transpeptidases. There is very little evidence to the contrary, however, one non-randomised study indicated a rise in blood (but not liver) levels of GSH following oral supplementation in animal models.14 Given the lack of evidence, at present, parenteral administration of glutathione is considered the gold standard for delivery of glutathione systemically. In Western Europe and the US, many oncology centres

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offer glutathione as intramuscular and intravenous supplements to patients undergoing chemotherapy, with evidence that it may increase length of survival, improve tumour responses and reduce neurotoxicity associated with platinum-based chemotherapy regimens, without reducing the efficacy of the treatments.15 Similarly, in the US, glutathione has been used as an intravenous supplement to attempt to reduce motor symptoms in idiopathic Parkinson’s disease, where reduced GSH levels associated with increased oxidative stress are heavily implicated in its pathogenesis.16 There has been some evidence of a mild improvement in those suffering from this condition in terms of motor symptoms.17 Inhaled glutathione has also been used in COPD and other lung conditions, however this use is not commonplace in the UK.18 In almost every study I am aware of, there seems to be no toxic dose or effects experienced with any form of glutathione. With regard to skincare, there is very little evidence for any particular form of administration over another for the purpose of anti-ageing or skin lightening. The belief, however, that oral administration is less favourable than parenteral and topical approaches has led to the development of a few products that can be delivered in these ways. Glutathione in skincare Japan, Thailand and the Philippines lead the market with glutathionebased skincare, with relatively few products available in the UK. The numerous putative benefits of glutathione, including the antioxidant benefits on sun-damaged skin and reduction of hyperpigmentation via its effects on melanin production make it a potentially ideal constituent of anti-ageing skincare products, particularly for patients concerned with using products such as hydroquinone for hyperpigmentation. The current problem is establishing the ideal topical dosage that can result in a similar outcome to other established treatments of hyperpigmentation for this purpose. As far as I have found, there have been no studies to elucidate this ideal dosage and none comparing glutathione to hydroquinone, for example, in the treatment of melasma or other forms of hyperpigmentation. Medik8’s CE-Thione is one of a small number of glutathione-containing products in the mainstream cosmeceutical market in the UK. This fairly advanced product combines optimal topical doses of vitamins C & E with the chirally correct L-glutathione in an easy-to-use serum. Perricone MD produces a similar treatment, Acyl-Glutathione. Other products containing glutathione such as ARCONA Desert Mist and Paula’s Choice Resist Super Antioxidant Concentrate Serum claim to have anti-ageing and hydrating benefits for the skin, but as with other products of this kind, there have not been any controlled trials as yet to prove their effectiveness. In the UK, other mechanisms of delivery of glutathione to the skin are as part of combination peel treatments, most notably The Perfect Peel. The product was developed in the US, aiming to combine various peeling agents with glutathione to resurface the dermis and homogenise skin tone. The developers suggest that the combination of a self-neutralising mid-to-deep peel, combined with glutathione, would result in ideal penetrance of glutathione to the stratum basale and spinosum where the melanocytes are located. In my own experience, this is one of the most effective peels for hyperpigmentation that I have used so far – it is extremely simple to use and the results I have seen are relatively impressive. Parenteral administration (IV/IM) of liquid or reconstituted powdered glutathione for hyperpigmentation is a much discussed and debated topic at present. However, there is little, if any, substantial evidence regarding the efficacy of this as a mode of delivery, as well as no

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explicit approval for this purpose existing in the UK. Glutathione is available in the UK to administer intravenously and intramuscularly as a supplement, however, ideal dosage and dosage frequency have not yet been established and only one supplier (TAD) is approved by the MHRA. To date, there is only one, relatively limited, randomised controlled trial from Thailand showing an association between the use of exogenous oral glutathione and reduction in skin pigmentation. No randomised controlled trials supporting parenteral administration for reduction of hyperpigmentation has been undertaken as yet.19 Conclusion Significantly more evidence is required before the use of glutathione can be convincingly marketed as an agent to reduce hyperpigmentation, particularly in relation to means of administration, dosage, dosage frequency and potential outcome measures. It does however, show significant potential as there does not seem to be any documented side effects to this treatment, and circumstantial and early evidence does indicate its effectiveness. In addition, the multiple, documented health benefits to this treatment add to the appeal of glutathione over other depigmentation products in my practice. I am sure there will be many interesting developments over the next few years, with this seemingly versatile molecule used in both skincare and in general medical supplementation. Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his nonsurgical aesthetic practice, having worked in this sector part-time for almost seven years. REFERENCES 1. Aw TY, Wierzbicka G and Jones DP ‘Oral glutathione increases tissue glutathione in vivo’ Chem Biol Interact 80(1) (1991) pp.89-97 2. Patel T, Williams S, ‘Skin: Pigmentation’ Aesthetic Medicine August 2014 www.aestheticmed.co.uk/skinpigmentation/ 3. Mari M, Morales A, Colell A, Garcia-Ruiz C and Fernandez-Checa JC Mitochondrial Glutathione, a Key Survival Antioxidant, Antioxid Redox Signal (2009) 11(11) pp. 2685-2700 4. Scholz, RW, Graham KS, Gumpricht E, Reddy CC, Mechanism of interaction of vitamin E and glutathione in the protection against membrane lipid peroxidation Ann NY Acad Sci (1989) 570 pp.514–517 5. Droge W and Holm E, ‘Role of cysteine and glutathione in HIV infection and other diseases associated with muscle wasting and immunological dysfunction’ FASEB J, 11(13) (1997) pp.1077-1089 6. Block KI, Koch AC, Mead MN, Tothy PK, Newman RA, Gyllenhaal C, ‘Impact of antioxidant supplementation on chemotherapeutic efficacy: A systematic review of the evidence from randomized controlled trials’ Cancer Treatment Reviews 33 (2007) pp.407– 418 7. Lamson D, Brignall M, The Use of Nebulized Glutathione in the Treatment of Emphysema: a Case Report Altern Med Review 5(5) (2000) pp.429-431 8. Pocernich CB and Butterfield DA, ‘iElevation of glutathione as a therapeutic strategy in Alzheimer disease’ Biochimica et Biophysica Acta, 1822 (2012) pp.625. 9. Villarama CD and Maibach HI, ‘Glutathione as a depigmenting agent: an overview’, Int J Cosmet Sci, 27(3) (2005), pp.147-153. 10. Matsuki M, Watanabe T Ogasawara A, Mikami T and Matsumoto T, ‘Therapeutic strategy’,Yakugaky Zasshi, 128 (8) (2008) pp.1203-1207. 11. Galvan I, Alonso-Alvarez, C and Negro JJ, ‘ Relationships between hair melanization, Glutathione Levels, and Senescence in Wild Boars’, Physiological and Biochemical Zoology, 85(4) (2012), pp.332347. 12. Droge W and Holm E, ‘Role of cysteine and glutathione in HIV infection and other diseases associated with muscle wasting and immunology dysfunction’ FASEB J, 11(13) (1997) pp.1077-1089. 13. Witschi A, Reddy S, Stofer B and Lauterburg BH, ‘The systemic availability of oral glutathione’ Eur J Clin Pharmacol, 43 (1992), pp.667-669. 14. Aw TY, Wierzbicka G and Jones DP, ‘Oral glutathione increases tissue glutathione in viv’, Biol Interact, 80(1) (1991), pp.89-97. 15. Block KI, Koch AC, Mead MN, Tothy PK, Newman RA, Gyllenhaal C, ‘Impact of antioxidant supplementation on chemotherapeutic efficacy: a systematic review of the evidence from randomized controlled trials’, Cancer Treatment Reviews, 33 (2007) p.407. 16. Martin HL and Teismann P, ‘Glutathione – a review on its role and significance in Parkinson’s disease’, The FASEB Journal, 23(10) (2009), pp.3263-3272. 17. Hauser RA, Lyons KE, McClain T, Carter S and Perlmutter D, ‘Randomized, double-blind, pilot evaluation of intravenous glutathione in Parkinson’s disease’ Mov Disord. 24(7) (2009), pp.979-983. 18. Lamson D, Brignall M, The Use of Nebulized Glutathione in the Treatment of Emphysema: a Case Report Altern Med Review 5(5) (2000) pp.429-431 19. Arjinpathana N and Asawanonda P, ‘Glutathione as an oral whitening agent: a randomized, doubleblind, placebo-controlled study’, J Dermatolog Treat 23 (2012), pp.97-102.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Treating Sunspots Consultant dermatologist Dr Daron Seukeran details the occurrence of photoageing and discusses treatment options for solar lentigos Photoageing refers to skin damage and skin ageing caused by intense and chronic exposure to sunlight, specifically ultraviolet A (UVA) and ultraviolet B (UVB) rays.1 Accounting for the majority of age-associated changes in the appearance of the skin, it is the superposition of chronic UV-induced damage on natural ageing.2 The photoageing process is caused by receptor-initiated signalling, mitochondrial damage, protein oxidation and telomerebased DNA damage responses, displaying as variable epidermal thickness, dermal elastosis, decreased/fragmented collagen, increased matrix-degrading metalloproteinases, inflammatory infiltrates and vessel ectasia.2 It can be characterised clinically by the skin’s coarseness, wrinkling, mottled pigmentation, skin laxity, telangiectasia, and premalignant and malignant neoplasms.3 One visible sign of photoageing is through the development of solar lentigines, more commonly known as ‘sunspots’. Solar lentigines are considered one of the earliest signs of photoageing and are a common aesthetic complaint.4 Most frequently found in sun-exposed sites, they are regularly seen in areas such as the face, shoulders and the backs of the hands, and usually have a uniform shade of brown, often seen in older fair-skinned patients who have had excessive sun exposure.5 The pathological features of a solar lentigo consist of a linear increase in melanocytes at the dermal-epidermal junction, but no cytological atypia of these melanocytes, and no budding down of these cells into the underlying dermis. There is frequently associated actinic damage to the adjacent dermal collagen.6

Diagnosis It is essential that a definitive diagnosis is made, indicating that these pigmented flat lesions on the hands and face are harmless and are not showing any signs of progression to skin cancer, such as lentigo maligna.4 The features of a simple lentigo are usually of a uniformly brown flat macule, most often on the face or on the dorsum of the hands. Benign solar lentigos tend to be uniform in colour with welldefined margins and no history of change within them. A history of there being any change in shape, size or colour associated with a pigmented lesion should lead to concern that this lesion may not be benign or may require further investigation. There needs to be a low index of suspicion as to whether further investigations, such as excision and submission to histology, is required. However, a clinical diagnosis can be made more difficult to ascertain due to pigmented actinic keratosis, lichen planus-like keratosis and lentigo maligna, which each may appear in similar forms.7 It is only when one is confident that a pigmented lesion is benign that one can then consider the best form of treatment.

Although successful removal of these lesions can be achieved, as will be discussed below, the ability to distinguish a benign pigmented lesion from a malignant lesion is very important and requires appropriate training. Stankiewicz et al reported three cases of pigmented lesions that had been referred to a clinic for laser removal of these lesions on the face, and fortunately were recognised to be suspicious and diagnosed as melanomas.4 A French study further found that multiple solar lentigines on the upper back and shoulders of adults could serve as clinical markers of previous severe sunburn, and indicated that it may be used to identify those at a higher risk of developing cutaneous melanoma.8

Prevention The application of sunscreen helps decrease the rate of appearance and the darkening of solar lentigines, and limiting one’s exposure to sun tanning and the use of artificial sources of UV light may help prevent them. The application of a liberal quantity of sunscreen has been shown to be by far the most important factor for effectiveness of the sunscreen, followed by the uniformity of application and the specific absorption spectrum of the agent used.9

Topical Treatment It was suggested that first line therapy in terms of physical treatment for solar lentigines was ablative therapy with cryotherapy, and the occasional use of topical treatments with substances such as retinoids (Adapalene and Tretinoin) have been suggested to provide lightening of lentigines.10 Studies have indicated that a topical agent containing a combination of a retinoid, phenol agent and an antioxidant, was well tolerated and showed a significant improvement in the depigmentation of solar lentigines.11 A triple combination cream with fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05% as adjuvant to cryotherapy for solar lentigines on the dorsal hands was also found to be effective.12 Finally, the effect of a bleaching solution containing 2% mequinol (4-hydroxyanisole, 4HA) and 0.01% tretinoin (Solagé) applied twice daily for three months, on solar lentigines which were present on the back of one hand, demonstrated a significant lightening effect after two months of treatment, and was maintained at least two months after stopping treatment.13

Cryotherapy Some patients, particularly with darker skin types, can experience hypopigmentation or a recurrence of pigment.14 Many consider the first-line therapy for solar lentigines to be

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ablative therapy with cryotherapy.10 This procedure is often successful because of the susceptibility of melanocytes to freezing with liquid nitrogen; while squamous cells resist injury at -20°C, melanocytes freeze at -4 to -7°C.10 In one study, the efficacy and safety of cryotherapy and trichloroacetic acid (TCA) were compared. It was found that cryotherapy showed more positive results than the TCA 33% solution for treatment of sunspots on the back of the hands, and this was particularly effective in lighter-complexioned individuals. It was suggested that for darker complexions, TCA 33% may be preferred. However, it was further stressed that post-inflammatory hyperpigmentation remains a risk for both modalities.15

Lasers and intense pulsed light (IPL) systems: IPL treatment: Intense pulsed light (IPL) devices emit polychromatic light in broad ranges of wavelengths and are selectively filtered to target specific chromophores. Kawada et al confirmed that a broadband (non-coherent in terms of pulsed light) source also led to over 50% improvement in lentigines, though while the smaller solar lentigines responded well, the larger patches showed lack of response. Ephelides or freckles responded very well with 75% of patients showing more than a 50% response.16 In another study of 22 pigmented lesions, a marked improvement was obtained in 17 cases, with a moderate improvement showing in four cases and a slight improvement in one case. It further claimed that no undesirable effects were observed.17 Laser treatment: Various lasers produce beams of light that emit specific wavelengths, which are then absorbed by melanin, the chromophore found in solar lentigines, and converted to heat.18 The development of short-pulsed, pigment-specific lasers to selectively destroy the pigment within the solar lentigo has led to significant clinical improvement, a low risk of high patient acceptance and adverse effects.19 Various studies have shown lasers to be one of the most effective forms of treatment for this indication. Schoenewolf et al noted that the Q-switched ruby laser has been highly effective in the treatment of lentigines on the dorsum of the hands, which is the site where many individuals seek treatment.20 Todd et al7 also found that the frequency doubled in the Q-switched Nd:YAG laser was most likely to provide significant lightening with the fewest adverse effects. It highlighted that out of 27 patients, 25 preferred laser therapy to cryotherapy.21 Laser resurfacing: An alternative approach to removing these solar lentigines has been by laser ablation using erbium-YAG or pulsed CO2 lasers. These lasers remove microns of tissues accurately and thereby often remove the epidermis, down to the reticular dermis. Following this, a new layer of skin forms which is no longer pigmented.20 Fractionated lasers are some of the newest technology in laser rejuvenation. This is where the light is broken up and delivered in neat individual columns, which allow for quicker healing. The new fractionated ablative systems have also been very helpful in this area, leading to less downtime with a good response to treatment.20 A study using a non-ablative 1927 nm fractional resurfacing laser indicated that, after two treatments, it had produced moderate to marked improvement

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in the overall appearance of facial pigmentation with high patient satisfaction. It further indicated that response to treatment was maintained at one and three months follow up, suggesting this to be an effective technique for treating solar lentigines.22

Conclusion The ‘sunspot’ or solar lentigo is a commonly acquired pigmented lesion most often seen on the sun-exposed areas such as the face and the dorsum of the hands, and is a key sign of photoageing. However, before any treatment is confirmed, the practitioner considering administering treatment must be well-trained in the diagnosis and treatment of pigmented lesions, as skin cancers can be missed and treated inappropriately. Once an appropriate diagnosis of a benign solar lentigo has been made, there are then various options of treatment as outlined in this article that can be considered. Laser treatment has significantly improved the outcome of these treatments and is safe and effective in appropriately trained hands.19,20,21 Dr Daron Seukeran is a consultant dermatologist at the James Cook University Hospital in Middlesbrough and previously worked at the Royal Berkshire Hospital. He undertakes general dermatology and dermatological surgery, however his main interest is laser surgery. REFERENCES 1. C Battie, S Jitsukawa, F Bernerd, S Del Bino, C Marionnet, M Verschoore. ‘New insights in photoaging, UVA induced damage and skin types’, Exp Dermatol, 23(1) (2014) pp. 7-12 2. M Yaar, BA Gilchrest, ‘Photoageing: mechanism, prevention and therapy’, Br J Dermatol, 157(5) (2007) pp. 874-87 3. JJ Leyden, ‘Clinical features of ageing skin’, Br J Dermatol, 122(35) (1990) pp. 1-3 4. K Stankiewicz, G Chuang, M Avram, ‘Lentigines, laser, and melanoma; case series and discussion’ Lasers Surg Med, 44(2) (2012) pp.112-6 5. S Monestier, C Gaudey, J Gouvernet et al, ‘Multiple senile lentigos of the face, a skin ageing pattern resulting from a lofe of intermittent sun exposure in dark skinned caucasions: a case control study’, Br J Dermatol, 154 (2006), pp. 438-44 6. JA Newton Bishop, ‘Lentigos, Melanocyte Naevi and Melanoma’, in Rooks Textbook of Dermatology, ed. by T Burns, S Breathnach, N Cox, C Griffiths (West Sussex: Wiley-Blackwell, 2010) pp. 54.3 -54.5 7. A Lallas, G Argenziano, E Moscarella, C Longo, V Simonetti, I Zalaudek, ‘Diagnosis and management of facial pigmented macules’, Clin Dermatol, 32(1) (2014), pp.94-100 8. C Derancourt, E Bourdon-Lanoy, JJ Grob, JC Guillaume, P Bernard, S Bastuji-Garin, ‘Multiple large solar lentigos on the upper back as clinical markers of past severe sunburn: a casecontrol study’, Dermatology, 214(1) (2007), pp. 25-31 9. S Lautenschlager, HC Wulf, MD Pittelkow, ‘Photoprotection, Lancet, 370(9586)(2007), pp. 528-37 10. JP Ortonne, AGLui H Panday et al, ‘Treatment of solar lentigines’, J Am acad dermatol, 54(5,2) (2006), pp. 262-71 11. Camelin et al, ‘The clinical and instrumental evaluation of the efficacy of a new depigmenting agent containing a combination of a retinoid, phenol agent, and an anti-oxidant for the treatment of solar lentigines’, Dermatology, 230(4) (2015) pp. 360-6 12. D Hexsel, C Hexsel, MD Porto, C Siega, ‘Triple combination as adjuvant to cryotherapy in the treatment of solar lentigines: investigator-blinded, randomized clinical trial’, J Eur Acad Dermatol Venereol, (2014) 13. C Pierard-Franchimont, F Henry, P Quatresooz, V Vroome, GE Pierard, ‘Analytic quantification of the bleaching effect of a 4-hydroxyanisole-tretinoin combination on actinic lentigines’, J Drugs Dermatol, 7(9) (2008), pp. 873-8 14. D Leroy, A Dompmartin, A Dubreuil, S Louvet, ‘Cryotherapy of PUVA lentigines’, Br J Dermatol. 135(6) (1996) pp. 988-90 15. M Raziee, K Balighi, H Shabanzadeh-Dehkordi, RM Robati, ‘Efficacy and safety of cryotherapy vs. trichloroacetic acid in the treatment of solar lentigo’, J Eur Acad Dermatol Venereol, 22(3) (2008) pp. 316-9 16. A Kawada et al, ‘Clinic improvement of solar lentigines and ephelides with an intense pulsed light source’, Dermatologic Surgery, 28(6) (2002), pp. 504-508 17. P Campolmi, P Bonan, G Cannarozzo et al, ‘Intense pulsed light in the treatment of nonaesthetic facial and neck vascular lesions: report of 85 cases’, J Eur Acad Dermatol Venereol, 25(1) (2011), pp. 68-73 18. KD Polder, JM Landau, IJ Vergilis-Kalner, LH Goldberg, PM Friedman, S Bruce, ‘Laser eradication of pigmented lesions: a review’, Dermatol Surg, 37(5) (2011), pp.572-95 19. MZ Bukvic et al, ‘Laser therapy for solar lentigonies: review of the literature and case report’, Acta Dermatoveneral Croat, 14(2) 2006, pp. 81-5 20. NL Schoenewolf, J Hafenr, R Dummer, ‘al laser treatment of solar lentigines on dorsum of hands: QS Ruby laser versus ablated CO2 fractionated laser – randomised controlled trial’, Eur J Dermatol, (2015) 21. MM Todd et al, ‘A comparison of three lasers and liquid nitrogen in the treatment of solar lentiginies: a randomised controlled comparative trial’, Arch Dermato,l 2000 136(7) (2000), pp. 841-6 22. JA Brauer, DH McDaniel, BS Bloom, KK Reddy, LJ Bernstein, RG Geronemus, ‘Nonablative 1927 nm fractional resurfacing for the treatment of facial photopigmentation’, J Drugs Dermatol, 13(11) (2014), pp.1317-22

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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A summary of the latest clinical studies Title: Botulinum toxin injections for the treatment of hemifacial spasm over 16 years Authors: Sorgun MH, Yilmaz R, Akin YA, Mercan FN, Akbostanci MC Published: Elsevier Ltd, August 2015 Keywords: Botulinum toxin, Dysport, Hemifacial spasm Abstract: The aim of this study was to investigate the efficacy and side effects of botulinum toxin (BTX) in the treatment of hemifacial spasm (HFS). We also focused on the divergence between different injection techniques and commercial forms. We retrospectively evaluated 470 sessions of BTX injections administered to 68 patients with HFS. The initial time of improvement, duration and degree of improvement, and frequency and duration of adverse effects were analysed. Pretarsal and preseptal injections, Botox and Dysport brands were compared in terms of efficacy and side effects, accompanied by a review of papers which reported BTX treatment of HFS. An average of 34.5 units was used per patient. The first improvement was felt after 8 days and lasted for 14.8weeks. Patients experienced a 73.7% improvement. In 79.7% of injections, no adverse effect was reported, in 4.9% erythema, ecchymosis, and swelling in the injection area, in 3.6% facial asymmetry, in 3.4% ptosis, in 3.2% diplopia, and in 2.3% difficulty of eye closure was detected. Patients reported 75% improvement on average after 314 sessions of pretarsal injections and 72.7% improvement after 156 sessions of preseptal injections (p=0.001). The efficacy and side effects of Botox and Dysport were similar.

Title: Laser Resurfacing for Latin Skins: The Experience with 665 Cases Authors: Triana L, Cuadros SC, Triana C, Barbato C, Zambrano M Published: Springer US, August 2015 Keywords: Laser, resurfacing, CO2, microfractionated Abstract: CO2 resurfacing and CO2 microfractionated laser systems are reliable tools to improve different facial pathologic skin conditions, but are associated with a high rate of complications specially in Fitzpatrick III, IV, and V skin phototypes, predominant in the Latin population, which has pushed many surgeons to change technologies and abandon its use. The study aims to compare patient results with the CO2 resurfacing laser and microfractionated CO2 laser resurfacing in all skin types and show similar results to those obtained worldwide in patients with phototypes III, IV, and V. Standardized review of medical records from a database of private practice patients treated since January 1998 to July 2012 with SlimE30 MiXto SX(®) CO2 laser. Evaluation of outcomes, complications, and satisfaction of three different modalities of treatment was made. A total of 665 treated patients were included. Ablative CO2 was applied to 80.3 %, CO2 microfractionated to 15.1 %, and mixed treatment to 4.5 % of cases. Globally, hyperpigmentation rates were 30.4 % in the CO2 resurfacing group, 16.3 % when a combination of modalities was applied and 11 % in microfractionated CO2 cases. A steady increase of these rates is shown as the phototype becomes higher. Satisfaction rates were high for all groups: 86.7 % in the mixed group, 82.2 % in the microfractionated CO2, and 79.6 % in the CO2 ablative.

Title: Phototherapy in the elderly Authors: Powell JB, Gach JE Published: British Association of Dermatologists, August 2015 Keywords: Phototherapy, ultraviolet, dermatoses, elderly Abstract: Elderly patients present with a unique spectrum of dermatoses that pose particular management opportunities and challenges. The skin of elderly patients differs from that of younger patients, not only in appearance but also in structure, physiology and response to ultraviolet (UV) radiation. In January 2014, we analysed all patients recently referred for, currently receiving or recently having completed a course of phototherapy at a university teaching hospital in England (UK). 249 patients were identified; 37 (15%) were over the age of 65 years (the WHO definition of an elderly or older person). The dermatoses being treated were psoriasis (51%), eczema (11%), nodular prurigo (11%), pruritus (11%), Grover disease (5%) and others (11%). One patient with dementia was deemed not safe to embark on phototherapy, and five patients were yet to start. The remaining 31 elderly patients received 739 individual phototherapy treatments: 88% narrowband (NB)-UVB and 12% systemic, bath and hand/foot psoralen UVA (PUVA). The acute adverse event (AE) rate was 1.89%, all occurring in those receiving NB-UVB. No severe acute AEs occurred. Of those who completed their course of phototherapy, 80% achieved a clear/near clear or moderate response, while just two patients (8%) had minimal response and two (8%) had worsening of the disease during treatment. Of those receiving NB-UVB for psoriasis, 91% achieved a clear or near-clear response.

Title: Prevalence of foot eczema and associated occupational and non-occupational factors in patients with hand eczema Authors: Brans R, Hübner A, Gediga G, John SM Published: Contact Dermatitis, August 2015 Keywords: Foot eczema, irritant contact dermatitis, occupational, tobacco smoking Abstract: Foot eczema often occurs in combination with hand eczema. However, in contrast to the situation with hand eczema, knowledge about foot eczema is scarce, especially in occupational settings. This study aims to evaluate the prevalence of foot eczema and associated factors in patients with hand eczema taking part in a tertiary individual prevention programme for occupational skin diseases. The medical records of 843 patients taking part in the tertiary individual prevention programme were evaluated. Seven hundred and twenty-three patients (85.8%) suffered from hand eczema. Among these, 201 patients (27.8%) had concomitant foot eczema, mainly atopic foot eczema (60.4%). An occupational irritant component was possible in 38 patients with foot eczema (18.9%). In the majority of patients, the same morphological features were found on the hands and feet (71.1%). The presence of foot eczema was significantly associated with male sex [odds ratio (OR) 1.78, 95% confidence interval (CI) 1.29-2.49], atopic hand eczema (OR 1.60, 95%CI: 1.15-2.22), hyperhidrosis (OR 1.73, 95%CI: 1.33-2.43), and the wearing of safety shoes/boots at work (OR 2.04, 95%CI: 1.462.87). Tobacco smoking was associated with foot eczema (OR 1.79, 95%CI: 1.25-2.57), in particular with the vesicular subtype.

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vaginal rejuvenation topics such as labiaplasty has increased 41% year-on-year. In the past three months alone, half a million consumers have conducted research on RealSelf and, in the past year, consumers have viewed 3.8 million pages of content on this topic. Labiaplasty is the most important topic, representing 68% of visits to this subject matter.” The numbers of procedures are increasing every year as vaginal rejuvenation has become accepted as mainstream. Once a procedure that was considered a dirty little secret, women are now actively searching online for practitioners, joining forums to discuss their concerns with other women, and doing research on all of the options available. While some women undergo these procedures to improve their comfort, many also want to improve their self-confidence.

Vaginal Rejuvenation Wendy lewis investigates the incorporation of women’s health treatments into aesthetic practices Frustrated with endless Kegel exercises, hormone creams and adult nappies, more women are turning to procedures that address both their functional problems and the changes that accompany childbirth and ageing. Surgery to reshape the labia and other aspects of the vagina is on the rise. According to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2014, the procedures that showed the largest growth in volume on a year-over-year basis included labiaplasty, which rose by 49%. A visit to RealSelf.com reveals a 94% ‘Worth It’ rating for labiaplasty from 388 posted reviews. According to Tom Seery, CEO of RealSelf, “Consumer satisfaction with labiaplasty has increased over the years, and suggests that women are very satisfied with the outcomes. Traffic to

What women want Many practitioners I have spoken to say that while some women opt for surgery because their labia has caused them physical discomfort, there is also a growing segment of patients seeking treatments who are being encouraged by their partners. According to these practitioners, women are also requesting procedures because they feel self-conscious about their anatomy post-childbirth. Aesthetic concerns 1. Large, hanging, wrinkled or uneven labia minora 2. Unhappy with their appearance due to length, dark pigmentation, asymmetries 3. Pain, discomfort or irritation from exercise or sports 4. Unable to wear certain clothes, lingerie, bikinis, tight jeans 5. Hygiene or odour issues 6. Stress incontinence 7. Multi-directional urine stream 8. Feeling self-conscious or embarrassed by their anatomy, camel toe appearance 9. Inhibited from sexual activity, decreased sensation or friction during intercourse, feeling of loose or wide vagina 10. Unable to participate in routine activities Functional female issues While more and more women seek vaginal rejuvenation treatments for aesthetic concerns, many others simply undergo treatment for

Business opportunities Many of the clinics I work with are reporting dramatic increases in the number of women seeking labiaplasty and vaginal tightening treatments over the last few years. Some members of the medical community attribute this rise to the proliferation of pornography and the establishment of a ‘new normal’ for women’s private parts. It can also be attributed to the fact that there are more available options to women today that are safer, less invasive, less expensive and with less down-time. The increasing numbers of practitioners adding these treatments to their menu of services and honing their skills, coupled with patient referrals

health-related issues. According to the American Urogynecologic Society (AUGS), one in three women will experience a pelvic floor disorder (PFD) in her lifetime.3 These may occur when women have weakened pelvic muscles or tears in the connective tissue, which may cause pelvic organ prolapse, bladder and bowel control problems. These symptoms are more common as women get older, and childbirth is definitely a contributing factor. Vaginal births double the rate of pelvic floor disorders compared to caesarean deliveries or women who have never given birth. Today there is a growing number of non-surgical and surgical treatment options available to address these concerns. Aside from prescription medications for incontinence, an overactive bladder (OAB) can be treated with botulinum toxin injections. Botulinum toxin is injected into the bladder muscle and used to treat OAB symptoms such as a strong need to urinate with leaking (urge urinary incontinence), a strong need to urinate (urgency), and urinating often (frequency). Many women suffer from painful intercourse due to vaginal atrophy, an uncomfortable condition that causes changes in the structure and function of the vagina. It can be caused by hormonal changes associated with menopause, or by a slowdown in oestrogen production, such as after chemotherapy or radiotherapy for cancer or removal of ovaries. This drop in hormone levels can result in a thinning and loss of elasticity of vaginal tissues. The blood supply is reduced and the vagina loses some of its natural lubrication, which can cause itching, burning, dryness, incontinence, laxity and prolapse. Not surprisingly, these symptoms can have a devastating effect on a woman’s self-esteem and relationships.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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from practitioner colleagues, demonstrate that the desire for vaginal rejuvenation has become a topic of interest in popular culture. This newfound acceptance of procedures that enhance the beauty of an area once considered off limits can translate into growth opportunities for aesthetic clinics. Practitioners who are marketing vaginal cosmetic procedures are getting in on the ground floor of this new frontier in cosmetic medicine and surgery. As our culture continuously puts pressure on women to measure up to a certain ideal image, the popularity of this category of procedures is likely to continue to flourish. The art of vaginal reshaping Labiaplasty, as well as other vaginal augmentation procedures, are getting a lot of attention lately. By all accounts, labia reduction appears to be the most popular form of vaginal cosmetic surgery, although that is just where the list of options begins. According to practitioners offering these treatments, vaginal rejuvenation, vaginoplasty, hymenoplasty (revirgination), clitoral hood reduction (clitoral unhooding), labial fat injections, and G-spot enhancement are becoming more commonly requested. For women who are unhappy with the appearance of their vagina, but are reluctant to undergo surgery, there are new and exciting non-surgical alternatives. There has been a recent rise in injectable fillers specifically designed for enhancing women’s anatomy. For example, Desiral by Vivacy is an antioxidant hyaluronic acid based gel formulated to preserve women’s intimate health. Cindy Barshop, founder of the Completely Bare laser hair removal clinics that were later sold and rebranded as Spruce & Bond, has jumped on this trend. She founded VSpot on New York’s Fifth Avenue as the first vaginal rejuvenation spa in the US and is carving out a new niche in the world of beauty. “Until recently, the only option for women who suffered from incontinence, dryness, and painful sex, was invasive surgery with horrific side effects. It’s time to take control of our bodies, our sexuality and our vaginal health. VSpot is literally life changing for so many women,” she says. Although the number of procedures being performed seems to be steadily climbing, not every woman is comfortable telling her practitioner about her concerns. Such hesitation in speaking to medical professionals, however, will likely change as more women’s health clinic models such as VSpot arise, new technologies are developed and more aesthetic clinics add vaginal rejuvenation procedures to their treatment offering. The rise in the specialty of urogynecology, which focuses on the treatment of pelvic floor disorders, is also significant. According to the International Urogynecological Association (IUGA), it has more than 2,900 members from 90 countries, and is affiliated with 29 national societies including the British Society of Urogynaecology (BSUG). There are more practitioners entering the market offering some aspect of women’s health services, from gynaecologists, plastic surgeons, and dermatologists, to aesthetic practitioners. Emerging non-surgical technologies The newest entries into this category include devices using radiofrequency or CO2 fractional energy to promote the recovery of genital mucosa by stimulating the production of collagen and restoring blood flow. Energy may be delivered externally to address tissue laxity, and internally to improve the functional aspects of the vagina. ‘Vontouring,’ short for vaginal contouring, is a new term coined by BTL Aesthetics for their Protege Intimo system (Exilis Protégé in the US). This system uses radiofrequency energy to heat the collagen and stimulate the production of new collagen fibres.

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The range of women’s lasers • • • • • • • •

Mona Lisa Touch – Cynosure Viveve Treatment – Viveve Medical ThermiVa – Thermi Aesthetics Pelleve RF – Ellman, a Cynosure Company Femilift – Alma Lasers IntimaLase - Fotona Protégé Intima – BTL Aesthetics C02RE Intima – Syneron-Candela

The beauty of these systems from a business model perspective is that the procedures are typically performed in a clinic environment, take 15-30 minutes usually without the need for an anaesthetic, and there is minimal to no discomfort, side effects or downtime for the patient. In most cases, it also involves a course of treatment sessions, so patients will be returning to your clinic periodically and for maintenance sessions, leaving an opportunity to introduce them to other treatments on offer. These treatments can also dovetail into other non-surgical cosmetic procedures, including injectables, laser resurfacing and light-based treatments. As more companies enter this space, we can expect to see direct-to-consumer marketing campaigns that will ultimately raise awareness of treatments that address the symptoms that may already be on the minds of women of all ages. This area of practice may still be in its infancy, but everything we have seen so far points to it becoming a big growth market. According to Dr Bruce E Katz, board-certified dermatologist and director of the Juva Skin & Laser Center in New York, “Over the past few years, media attention has given rise to consumer awareness of the options available to women both from a functional standpoint as well as aesthetics. We began offering FemiLift in our practice this year because we see a need for women’s procedures that address incontinence. Most women first notice urine leakage after they have given birth, though it can happen with ageing as well. FemiLift is a 30-minute, minimally invasive therapy that uses a CO2 laser to deliver fractional laser energy that strengthens the walls of the vagina.” Building a women’s clinic Establishing a centre for women’s health takes careful planning, investigation, and some marketing muscle. It requires more effort than just buying a laser and putting out some brochures in the waiting room to generate interest. Here are some pointers to help you get started: • Investigate the various systems on the market, carefully read the clinical data to support the claims being made, and ask colleagues whom you trust for their recommendations. • Visit the company website to see if there is a clinic finder so that patients seeking these procedures can find you. • Look at how many units of the system you are interested in are currently being used in your general area; if there is a system around every corner then the market may be oversaturated for the current state of consumer demand. There is surely a marketing advantage to being the first in your postcode to offer an innovative technology. • Inquire about what the company offers in terms of training or preceptorships to bring the clinic staff up to speed quickly on how to treat patients. • Finally, ask about the availability of marketing programmes and public relations support to help you spread the word.

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The question on the minds of some practitioners interested in adding vaginal rejuvenation technology to their armamentarium is how to start the conversation with new and existing patients. Addressing these intensely personal concerns with women who are feeling vulnerable, especially if you are not a gynaecologist or obstetrician, can be a challenge in the beginning. Some practitioners may not have the requisite bedside manner or temperament for it. Recruiting the right staff is a critical first step. “The consultation process can be a challenge for some practitioners. My advice is to enlist a female nurse or practitioner’s assistant to talk to patients about their needs and goals. We have found that it helps to have a woman who is knowledgeable and comes from a place of credibility speak to patients about these delicate issues. It helps to put them at ease,” says Dr Katz. Plastic surgeon Dr Christine Hamori has the advantage of being one of only a handful of female surgeons performing vaginal rejuvenation procedures in her practice location of Duxbury, Massachusetts. “As a woman, I can speak to female patients from a different perspective. With men, it may sometimes be more difficult. It also helps that I have become known as a specialist in the field so women are coming to our clinic already interested in having these procedures done,” she says. In general, Dr Hamori has found that labiaplasty is the most requested and straightforward procedure. She also performs the ‘labial puff’ with fat grafts to the labia majora for more volume or uses Juvederm Ultra Plus. “When I perform liposuction on the inner thighs, patients will often ask about where they can use the fat. They usually want the fat injected into their facial areas. In some cases, I will gently suggest that we use it to plump up the labia majora,” she says. Practicing in the conservative market of New England, Dr Hamori sees a lot of menopausal women who are most concerned about vaginal dryness. “These women are the perfect patients for these treatments,” she says. Having used the Pelleve RF system successfully, she recently added ThermiVa to her device collection. “ThermiVa works for vaginal tightening and reduces stress incontinence. It is a series of three treatments spaced one month apart. The probe delivers controlled thermal energy externally to the labia and internally for tightening,” says Dr Hamori. Marketing to women Promoting vaginal rejuvenation services requires a lighter touch than some of the tactics aesthetic clinics typically use. Whereas more women today are open to sharing their experiences with injectables and skin lasers with friends and family, this is a far more private decision that doesn’t necessarily lend itself to dinnertime conversation. Taking an aggressive approach is more likely to elicit a negative reaction on the part of many prospective patients and could turn them off. Try to put yourself in the position of a woman seeking intimate treatments and be extra sensitive to her concerns for privacy and professionalism. Having informative patient materials, a website landing page, blog content, and a selection of before and after photographs available are important to make patients feel comfortable and to educate them on what they can expect. If you are serious about building this area of your clinic, a microsite is a good investment. A microsite is a smaller website incorporated into a main website, which aims to give specific information on a particular subject. The benefit of creating an educational microsite on women’s health issues could be, for example, that it helps position your clinic for expertise in this category of treatments. It may be beneficial to use

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a different domain name for the site entirely and spend some of your marketing budget on search engine optimisation (SEO). There is a lot of misinformation and widely inflated claims online about how some of these treatments work, the results that can be achieved, and if and when surgery may be indicated. A microsite offers an opportunity to inform consumers about your special expertise and approach to this sensitive area of practice, and answer their questions. Your clinic also needs to be visible to women who are searching for these procedures online, rather than solely by personal referral. Think about the terminology they may be using to search, and invest in the most common keywords in your area. For example, common search terms include; vaginal rejuvenation, vaginal tightening, vaginoplasty, labiaplasty, labial reduction, vaginal reshaping, G-spot enhancement, laser vaginal rejuvenation, vaginal cosmetic surgery, vagina lift, and cosmetic vaginal procedures. Consider where you may be able to get referrals. For example, other medical professionals who have large populations of female patients who are of child-bearing age or peri-menopausal, and who do not already offer similar services, may be ideal targets. Aestheticians, massage therapists, yoga instructors, midwives, and personal trainers may also be worthwhile to tap into. Conclusion Like men who suffer with erectile dysfunction, women are beginning to feel more empowered to take steps to improve their confidence and their sex lives. Dr Hamori believes that Viagra-like drugs for women will go far to advance awareness of women’s health and sexual well-being treatments. At the moment, a pink pill, developed by Sprout Pharmaceuticals, is pending FDA approval to treat Hypoactive Sexual Desire Disorder (HSDD) in women. In addition, at-home devices that mimic the vaginal tissue tightening effects of clinical treatments are currently under development and may be available to consumers by early next year. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy. Lewis is an international figure in the field of medical aesthetics, and is a frequent presenter at national and international conferences. In 2008, she founded Beautyinthebag.com and has served as editor in chief. The author of eleven books, her next, Aesthetic Clinic Marketing in the Digital Age, will be published in the winter of 2015. REFERENCES 1. The American Society for Aesthetic Plastic Surgery Reports Americans Spent More Than 12 Billion in 2014; Procedures for Men Up 43% Over Five Year Period (New York: The American Society for Aesthetic Plastic Surgery, 2015) <http://www.surgery.org/media/news-releases/theamerican-society-for-aesthetic-plastic-surgery-reports-americans-spent-more-than-12-billionin-2014--pro> 2. Search results for “labiaplasty” (US: Realself, 2015) <http://www.realself.com/search/results?gsc. q=labiaplasty> 3. PFD 101: Fact or Fiction (Washington, DC: American Urogynecologic Society, 2015) <http://www. voicesforpfd.org/p/cm/ld/fid=134> 4. BOTOX® (onabotulinumtoxinA) Important Information (Irvine, CA: Allergan, 2015) <https://www. botoxforoab.com/> 5. Vaginal dryness and vaginal atrophy (US, MedicineNet.com, 2015) <http://www.medicinenet. com/vaginal_dryness_and_vaginal_atrophy/article.htm> 6. IUGA, What is urogynaecology? (IUGA, 2015) <http://c.ymcdn.com/sites/www.iuga.org/resource/ resmgr/press_packet/what_is_urogynecology.pdf> 7. Marcarelli R, ‘Female Viagra’ resubmitted for FDA approval by Sprout Pharmaceuticals (US, HNGN, 2015) <http://www.hngn.com/articles/70077/20150217/female-viagra-resubmitted-forfda-approval-by-sprout-pharmaceuticals.htm> FURTHER READING Jillian Lloyd, Naomi S. Crouch, Catherine L. Minto, Lih-Mei Liao, Sarah M. Creighton, ‘Female genital appearance: ‘normality’ unfolds’, BJOG: An International Journal of Obstetrics & Gynaecology, 112 (2005) p. 643-646.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Seasonal Marketing: Getting Winter-ready Charlotte Moreso talks winter marketing and how to keep your patients coming back in the darker months Autumn and winter is traditionally a time, aside from party preparation treatments, that business can take a dip. There are multiple reasons why this can occur. In the autumn, reasons include a shortage of money following patients’ annual summer escapes, and often the chillier weather can deter people from leaving the comfort of their homes. Over the Christmas period, many are simply too busy to fit in appointments and, in many cases, the financial strain of saving up for Christmas means that treatments tend to go to the bottom of priority lists. However, if you make treatments alluring enough and allow the names to

resonate with patient’s own skin or body issues, you are sure to lure traffic into your clinic. To fill your clinics with a steady stream of patients it is helpful to divide this season’s marketing into three segments, all of which are real call-to-action opportunities. 1. Autumn post-holiday skin repair and treatments suitable for Autumn/Winter – September/October 2. Festive party-season preparation for late October/November/ December 3. Christmas gifting for mid-November/December

Autumn Post-Holiday Repair Before you do anything, look at your treatments and list what your patients will be thinking about during this time. Patients’ thoughts, particularly women’s, will turn to the damage the sun may have had on their skin during the summer. As well as worries about wrinkles, this is the time when pigmentation and sunspots may be visible. This is, therefore, the perfect opportunity to target patients with pigmentation treatments and products, facial peels and laser treatments. Once you have your definitive treatment list, it’s time to get creative. You need to stand-out from the other clinics and capture the attention of the consumer. The simplest way to do this is through package names and creatively-named treatments. For example, why not create: 1. The Sundowner Package • Pigmentation Peel – peel away pigmentation in just three treatments • Sunspot SOS Treatment – zap away sunspots with just three laser treatments • Squinting Wrinkle Treatment – wipe away the sun squints around the eyes with our light-based therapies Timing: Promotion to go out the second week of September Other autumn promotional ideas include: 2. Winter Glow/Slough Off the Summer Treatments Take advantage of patients’ lower moods by offering the perfect pick-me-up to return a glow to their cheeks. This is a great time of year for promoting and even discounting any glow-getting treatments. Offer treatments that slough off the summer to reveal healthy, radiant skin. Peels, microdermabrasion and similar treatments can be included in your menu. Timing: Promotion to go out middle/end of September 3. Laser Loves Winter Most lasers can only be used during colder months when sun exposure is at a low and active tans don’t interfere with successful and safe treatments. Create a ‘Laser Loves Winter’ menu, which incorporates facial and body treatments. This is the time to promote laser hair removal to the maximum so that your patients are hair free by spring. Six treatments spaced four to six weeks apart means they need to start their course in September. Timing: Promotion to go out October when tans have faded

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Party Season Preparation The festive season over Christmas and New Year is a huge opportunity for your business. Party season starts in November, so you have two months to capitalise on this segment. The key areas of focus should incorporate both the face and the body: Face: Treatments that contour the face and leave skin radiant Body: Treatments that target the areas on show in the little black dress Create a menu of suitable treatments, that could include: • Bingo Wing Blaster: Dance without dread in your strappy dress (radiofrequency, infrared light, ultrasound, fat freezing) • Little Black Dress Lovely Legs Treatment: Tone and shape your legs and get dance floor ready! (radiofrequency, fat freezing, ultrasound) • Decollate Renewal Treatment: Eliminate crepiness and sun damage in this zone (lasers, peels etc) Festive Face Treatments: • Christmas Glow Facial: (microdermabrasion, radiofrequency, infrared light) • Party Peel: A lighter peel to reveal clear, glowing skin with a more even skin tone • Festive Lift Treatment: Firm and lift the skin on the face (radiofrequency, mircocurrent) Christmas Party Ready Open Day Now is the ideal time to showcase all of your festive treatments. I have witnessed immense success from open days, with patients queueing to pay for bookings – but only if you get them right. Here’s the festive formula for filling the diary with bookings: What: Open up your clinic for a day, or afternoon and evening to all your patients and potential new patients, offering free taster treatments from your Little Black Dress Ready and Festive Face treatment menu. It’s a good idea to ensure you have a few ‘models’ to demo on in quieter spells, as this often draws an audience. When conducting these trials, leave treatment doors open so that people can see what is going on inside. When: Late October or early November is a good time, but avoid half-term, as many of your potential patients may have children and, therefore, other commitments. Deals: Create good value package offerings, redeemable only if they book on the day. This ensures you get the booking right there and then without the risk of losing their interest once they have walked away. Goody Bag: Contact the suppliers of your brands to donate some mini-samples to the goody bag – everyone loves a freebie! Adding Luxury: Serve Christmas themed canapés, sparkling wine and healthy juices. Showcase: Promote your Christmas gift offering.

Christmas Gifting Although a smaller part of your winter campaign, Christmas gifting is a good opportunity to take advantage of. Understandably, your product offerings are likely to be more scientific brands than pampering high-street products, but there may be some

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How: Create a post-card sized flyer with the details and treatment menu on the reverse that can be mailed out via the Post Office to homes in your local area. Buy a beautiful stock shot of ladies in their little black dresses at a Christmas party to use on the front. • Invitation to preview/experience the festive treatments at your clinic • Menu of complementary taster treatments • When and where • Times • Special offers • Goody bag for every attendee • RSVP to reserve your place Special Offers: Great value package offers are a strategic way of attracting bookings but it’s essential that you adhere to Keogh’s recommendations when marketing these offers. The Keogh Review stated, “advertising and marketing practices should not trivialise the seriousness of procedures or encourage people to undergo them hastily.” Avoid offering ‘buy one get one free’, ‘refer a friend’ or doing competitions for cosmetic treatments and steer away from time-limited deals and financial inducements.1 The Science: You may respond to the intricacies of the technology, but the average woman will not. She wants to know if the treatment works, how long until she will see results, will it hurt and how much will it cost? So don’t blind her with science and keep your chats on this subject short and snappy, explaining the key information and, of course, any potential risks. Create a Consistent Campaign Create the strapline for your festive treatment campaign and stick to it. Use this throughout all communication. PR and marketing tools could comprise: • Window sticker • Posters • Leaflets with the treatment menu • Roll-up banners • Press releases Press Release and Reviews: Press releases to journalists: When sending out your press release, include the aforementioned treatment menu to offer journalists the chance to try a treatment from the festive menu. First-hand reviews are very powerful. Journalists must be offered the full-length treatment in order to be able to write a decent and balanced story. Timing: Timing is critical to capture business. You need to reach patients with your messaging and offers in late October when they are starting to think about the Christmas festive period. With regards to your press release, this must go to your local press in October. Email and post the release then follow-up a few days later to ask them if they wanted to book in to review a treatment.

products that could be grouped together as a gift, such as a cleanser, moisturiser and mask. Three products usually suffice for skincare gifts. Purchase some tasteful red/gold/silver gift bags and tissue paper so that these sets are gift wrapped and ready to go. Display one set in front of the bag in reception. The other Christmas gift worth

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considering is vouchers for treatments. It may be worth contacting your local printer to produce some simple gift voucher cards with spaces left blank for the monetary amount or the treatment. Timing: Ensure you create an e-blast with these items on and send it out mid November with a reminder in December for ‘last minute gift ideas’. Use what you have…. Use any press coverage you receive to best effect. Consumers love to see your name in magazines or newspapers, so scan it and post on Facebook, Twitter and your website, or, if the piece is particularly good, produce an email flyer and send to your patient list. Many clinics also produce coverage books or create montages of their coverage as a

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poster or postcard which can be displayed in reception. Finally, it is also worth seeing what support the PR agencies for the aesthetic device companies you work with can offer you. They may have press releases you can use or ideas on how to market the treatment to patients. Charlotte Moreso is managing director of True Grace PR. She has worked as a PR and marketing consultant in the health and beauty industry for more than 20 years, running highly successful campaigns for global commercial brands, smaller UK beauty brands and in more recent years, creating news for the UK’s leading aesthetic treatments, doctors and clinics. Her work has won several industry awards. REFERENCES 1. Department of Health, Review of the Regulation of Cosmetic Interventions (England: Gov.uk, 2013) < www.gov.uk/government/publications/regulation-of-cosmetic-interventions-government-response>

In Practice “We start to think about the New Year as autumn approaches and decide on what we want to celebrate. We host a client event to thank our current patients for visiting us and introduce them to what’s new and what to expect next year. It’s a champagne affair where clients can openly ask questions they have been keen to but haven’t yet, or see treatments happening that they haven’t yet experienced. It’s an open door policy in the clinic, so everyone gets to see inside rooms. Winter equals caring and sharing for Karidis.” Lucy Alice Martin, PR and marketing manager of Karidis MediSpa “Winter; the point where the summer glow and holiday memories wear off and Christmas looms large. It’s a dull time of year and rejuvenation to prepare for party season is just what the doctor ordered. I send seasonal emails to my mailing list and target promotions aimed at getting party and photo-op ready. It’s a timely reminder for existing clients and brings the clinic back into the mind of previous enquirers. Timing is everything and a little incentive pre-xmas is always welcome.” Dr Renee Hoenderkamp, founder of The Non-Surgical Clinic

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to remember every detail about each one. Ensure that either you, or another member of staff, are adding key notes to the patient file that can be checked before appointments, to show that you have taken an interest in them.

Staying Positive Plastic surgeon Mrs Elena Prousskaia highlights her key tips for building a happy working environment Like all practitioners, even undergoing training requires tremendous dedication and years of hard work, often leaving one with little time for anything else other than studying and working. Once you achieve the keenly desired training post, it takes approximately 10 years before you become a consultant. At that point, it’s fairly common for people to look back and reflect on all that they’ve missed. This is not to bemoan my position: I love my job and consider myself extremely privileged to be able to conduct this work. But it’s worth setting the record straight about the road we all take to get here, and the ways we try to stay on track once we’ve done so. For myself, I’m careful to spend time doing a number of things to stay happy and healthy so that I continue to enjoy the profession that I spent so long training for. In this article I will briefly outline some methods that you can employ to try to maintain a positive approach to work. Passion for your vocation I believe that the best people in any profession are the ones who emote pride and professionalism and really love what they are doing. If you’re doing what you love, there’s no need to look at the clock; you’re completely in the moment and focused on the task at hand. One of the great things about the medical profession is that many people share this sense of a greater purpose. We’re here because we want to be – so that puts all the hard work into perspective. Various issues can, however, affect motivation for your job; from working too much, to problems at home – these issues can stretch from simply a difficult day, to a long period of disillusionment with your profession.

If you are struggling to maintain passion in your work, think about the aspects of your job that give you greatest pleasure and try to set aside time to ensure that you are regularly able to enjoy these. For instance, if you see one of your most loyal patients will be visiting your clinic, you may wish to schedule in an extra 10 minutes to the appointment so that you can catch-up before the treatment. This works to both remind them how important they are to you, and to allow yourself dedicated time to enjoy a less formal interaction with a valued customer who truly appreciates your time and skill. Have a genuine interest in your patients When I started my career, I was very technical during conversations with patients. Retrospectively, that seems like a very sensible approach, but can come across as cold. Past medical history, examination, and treatment plans are obviously crucial topics of discussion and we are all limited in our time as clinics can regularly be overbooked. The more I’ve adopted this approach, and engaged my patients as real human beings, the more rewarding I’ve found these professional relationships. For instance, when my breast cancer patients come for their first consultation to discuss reconstruction, they are understandably very stressed. Asking about their interests is as important in some respects as asking about their medical history. I enquire about their favourite hobby, if they love cinema or gardening. Suddenly, the atmosphere in the clinic changes; it feels human and enjoyable, and makes the working day a little more interesting. Of course with many patients on your client list you cannot be expected

Surround yourself with positive influences This can be difficult, but this is crucial in order to create a working environment that is as stress-free as possible. Consider arranging a short staff meeting each Friday to share good news; perhaps you’ve hit a sales target, a member of staff has been promoted, or a new treatment has been proving popular within clinic. Make it one person’s responsibility to collate any patient feedback from the week and to share this with the rest of the team. I’d suggest checking this yourself first for any complaints or issues that are best dealt with on a private basis. Not only will these meetings help you to appreciate the achievements of your business, but by encouraging the whole team to share in these successes, you will help to boost team morale. Delegate and teach Learning how to get the best out of every member of the team and how to delegate and teach can bring enormous joy to daily life in the clinic. It’s also important to remember that delegating tasks can save you time in the long run to concentrate on other aspects of your practice. It is certainly not about working less; teaching is hard and stressful. Of course it involves enormous responsibility, and that is why when you reach a senior position, you have to be capable of taking this responsibility and dealing with it appropriately. The best part of my day can be when I teach a technique to someone and feel their gratitude and appreciation. Think about the particular strengths of each member of your team and discuss with him or her whether there are aspects of their role or the wider business that they would like to explore further. Then come up with a plan to make this happen, including a realistic time frame based on your availability and achievable goals. Compete only with yourself Most people would recognise that my specialty is highly competitive. My personal rule is that if I compete, it is only with myself. Consider the following; how can I become better tomorrow than I was today? How can I perform this complex procedure with even better outcomes for my patients? Constantly comparing yourself to others within your specialty can lead to a great deal of anxiety,

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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which can easily leak into home life if it is not handled properly. Benchmarking success is about seeing a big picture and enjoying the view rather than looking at what others are doing. I am a strong believer that if you are good at what you do, no matter how many people there are doing the same, there will be a place for you in the market. Whether you work alone or in a team, itâ&#x20AC;&#x2122;s important to look outside of your practice to build a wider support network within the industry. Being able to call upon the expertise of other practitioners in a similar position to yourself, can provide a great deal of support in good times and bad. Attending professional meetings and joining membership associations are good ways to create key contacts. Spend a lot of time on education Throughout your career you should continue to prioritise education, training and professional development and consider; how can I become the best I can be? What new skills, including non-clinical ones, are going to enhance my practice, the way I work with others and the way I approach day-to-day

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tasks? Learning a new skill will not only help your business to continue to grow, but can also serve to re-ignite passion in your work. Handling difficult situations Having to manage a patient complaint or deal with a tricky situation with a member of staff can be extremely stressful. To me, dealing with a difficult situation is about honesty and respect. The capacity to work well with others is not about being weak or keeping your head down. It is about being there when problems occur, talking to people and being humble enough to apologise if it is your fault. People will like you because they feel safe with you, because they know they can count on you and feel that you care. Building this type of reputation can be extremely difficult in our highly stressful and demanding jobs, but once you get there, you suddenly find yourself surrounded by people who smile and say thank you for your hard work. Keep levels of care to the highest standards This final rule is simple and crucial; be fully present in the task that you are doing at each moment. We all have busy lives and

having a million worries on your mind is human. When I am with a patient, however, I obligate myself to forget about outside concerns and try to concentrate on doing my best right here, right now. I always advise my juniors that there are no small details in our profession. Acute attention to every single detail before, during and after treatment is key not only to a good result, but also to having a happy patient. And what else can make your day better than a patient attending the follow-up with a huge smile, expressing their appreciation for your care and the treatment that has changed their life? High levels of care can also reduce the risk (and stress) of complications, and ensure the patient comes back time and time again. Mrs Elena Prousskaia is a board certified consultant plastic, cosmetic and reconstructive surgeon, a member of the British Association of Plastic Surgeons (BAPRAS), Royal College of Surgeons, London (FRCS Plast) and European Board of Plastic Surgeons (EBOPRAS). Mrs Prousskaia runs a cosmetic surgery practice in the South East of England.

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Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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“My drive for coming to work is producing incredible results and making someone feel amazing about themself” Dr Kuldeep Minocha details his journey from GP partner to successful aesthetic practitioner With more than 3,500 current patients over four clinics and a fourweek waiting list, Dr Kuldeep Minocha is one of many in-demand aesthetic practitioners. Yet, unlike those who have dedicated their entire medical career to aesthetics, his love and devotion to the specialty only began in 2006. “I’d been a GP partner for 16 years after studying medicine at Southampton University in 1986. But working for the NHS was changing a lot,” Dr Minocha says. “It wasn’t about the doctor/patient relationship anymore or providing the best standard of care for the person sitting in front of you – things were changing, it became more about rationing care.” As such, Dr Minocha tried to divert his expertise into something else and find a new vocation within medicine. “I did some work with Paul McKenna, I was one of his weight-loss consultants. I also became a diabetic specialist. I did things I could devote my time and energy to,” he explains. It wasn’t until he began a botulinum toxin and dermal filler course in 2006, however, that he found his niche. “I instantly thought ‘wow!’ this is interesting. After a three-hour course on each, though, I didn’t have the confidence to go out and inject someone,” he says. Instead Dr Minocha started attending Q-Med’s (now Galderma) injectable courses and, in that first year, turned up to approximately 20 training sessions. “One of the trainers even joked, ‘Do you know that you could actually give these courses yourself now? Why are you here?’” he laughs, adding, “I told her, ‘Because I want to be the best I can be, I want to learn as much as possible.’”After building his confidence, Dr Minocha began decreasing his time spent in general practice and focused more on establishing his aesthetic practice. Three years ago he joined Absolute Aesthetics, and as a result of that, was exposed to the world of public relations. “I built-up my client base on word-of-mouth recommendations and never needed to do any sort of promotion,” Dr Minocha explains, adding, “I’m a very old-fashioned GP at heart; I’m not a business man or entrepreneur and before I joined Absolute Aesthetics I didn’t even have a business card! I warned the team, ‘Don’t expect me to be doing this and that (promotion), just give me my patient and I’ll do my best for them.’” Ethics are very important to Dr Minocha and, he claims, no amount of money or prestige can persuade him to treat patients who don’t need it. “I once had a lady who came from Abu Dhabi, jumped straight on the couch and said, ‘I’ve come for my Botox! I’ve just flown over as my daughter’s getting married in six weeks and I want to look my best.’” He explains that he had only treated her ten weeks ago and felt it was too soon for her to undergo more treatment, as she simply did not need it. “I sat the patient down, we looked at her mirror reflection together, as well as before and after photographs from her last treatment. I then reassured the patient that the treatment was working and it would be unnecessary for her to have any more treatment so soon after. She

respected my honesty and joked, ‘Oh, you and your ethics!’ Patients often lose perspective quickly so when an opportunity such as this presents itself, it’s important for practitioners to act appropriately and do what is best for the patient.” Dr Minocha enthuses that taking part in the Galderma Proof in Real Life Campaign, which aims to build consumer trust in aesthetics, has been his greatest achievement. The campaign involved ten identical twins, with one sibling from each pair been treated with either Restylane and Restylane Skinboosters, or just one of the products, with the aim of demonstrating the natural-looking results that can be achieved through aesthetic treatment. “It was an amazing, emotional journey. Actually seeing people in real-life, in threedimension, with their untreated twin next to them, getting an idea of the quality and texture of their skin – that was remarkable!” Reflecting on his career, Dr Minocha says he wouldn’t do anything differently, “Since the age of seven, all I wanted to be was a doctor. I loved what I did within the NHS, but now I get to see people who choose to see me, I get to help them feel great about themselves. I’m not driven by money; my drive for coming to work is producing incredible results and making someone feel amazing about themself. If I get paid or not, I don’t really care. It’s very much about what we’re doing for the patient.”

Do you have an ethos or motto that you work by? Always be true to yourself and try to be as objective as possible. Always have the strength to say ‘no!’ Do you have an industry pet hate? Huge lips! Do you have any words of advice for people who are looking to get into the industry? Master one or two skills, rather than trying to be a jack-ofall-trades. What aspects of the industry do you enjoy the most? Being involved in a journey that is able to help someone’s self confidence and how he or she feels about themselves is so rewarding. Most of my patients are women, most are in their 40s and most of them are going through a phase in life where they’re trying to redefine themselves as to who they are. Being in this industry creates such positive energy; you do a treatment for somebody and when they come back for their review they look amazing and they feel amazing.

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Now approved for crow’s feet lines

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50  units/1.25  ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30  units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1182/BOC/OCT/2014/LD Date of preparation: October 2014

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The Last Word Dr Martin Godfrey discusses the need for clinical trials in aesthetic medicine Rightly so, regulatory requirements for testing new pharmaceutical products are rigid. They must be assessed using strict quality standards and require a significant investment of time and money. Of course there are very good reasons why pharmaceuticals are so tightly regulated. Since the early 1960s, newspapers have been filled with hundreds of apparent panaceas that have failed to transpire. Many pharmaceutical companies are becoming hesitant to develop new products from the expense and fear that, if they get something wrong, there is a chance they could conjure a new thalidomide epidemic. For cosmetic companies, on the other hand, probably the worst thing that could happen is that somebody develops a nasty rash to one of its new skincare products. As such, we see new cosmetic products on the market almost every day, with many manufacturers appearing to take very little regard to the importance of clinical trials. They claim their product can treat all sorts of aesthetic concerns, with little or no proven scientific evidence to support them. Many will use ‘sciencesounding’ terms and a bucket load of anecdotes to convince consumers that their products are worthy of their hard-earned cash. Not only do some companies market such products with unsubstantiated claims, they also often advertise them as having no side effects or downtime, which is not always strictly the case. In addition to this, more and more cosmetic products are being developed that claim to have medicinal properties and significant health benefits. As their name suggests, the categories of ‘cosmeceuticals’ and ‘nutraceuticals’ are prime examples of this. By definition, nutraceuticals are a ‘food or part of a food that allegedly provides medicinal or health benefits, including the prevention and treatment of disease’.1 In addition, the dictionary definition also states that a nutraceutical may be a naturally nutrient-rich or medicinally active food, such as collagen, garlic or soybeans.2 Then there are cosmeceuticals; marketed as cosmetics but as the definition states, they are, ‘A cosmetic product claimed to have medicinal or drug-like benefits’.3 As such, this leads me to ask questions; if these products really do deliver health benefits, then, like drugs, shouldn’t they be subject to the same rigorous testing that pharmaceuticals have to go through? If they exhibit such powerful properties like drugs, won’t they have side effects like drugs? And, as a result, shouldn’t they be prevented from being advertised to the public? Well, for me, the answer is no. Nutraceuticals are, after all, just foods. When was the last time your evening meal had to go through a randomised controlled trial? Have you ever seen a health warning on your daily fruit and veg? There has to be a line drawn between what is a drug and what is a food and, for the moment, nutraceuticals sit on the non-drug, less-regulated side of the fence. But that should not mean that their manufacturers can relax into the soft world of the cosmetics industry and just tip their hat to the clinical trial process. We are all aware of the limp attempts (or non-attempts) that a great deal of companies in the cosmetic field make to support their claims for efficacy.

Aesthetics aestheticsjournal.com

They partake in tiny trials – often including less than a dozen users; employ purely subjective testing – such as simply filling out a questionnaire with vague or non-existent end points; and include questionable photographic ‘evidence’ of success in their marketing campaigns. I am not trying to argue that nutraceuticals should be made to undergo the sorts of testing that drugs are made to go through. More that if they are ingested, and if they do contain biologically active molecules, then surely the manufacturers have a duty to their customers to test them rigorously? In my opinion, companies that take research and development (R&D) seriously in the world of ‘nutracosmeceuticals’ are few and far between. Even wellknown, household name companies (including pharma companies) have realised the enormous potential that these foods represent in generating profit within the aesthetic market and, as a result, should be taking their research responsibilities seriously. Simply conducting a search on PubMed or other scientific databases will show that only a small number of trials are listed. This situation cannot and hopefully will not continue. The regulators are finally waking up to the fact that they need to protect the public and, as such, are demanding marketing claims are substantiated with statistically robust studies. Maybe the best example is the ASA and the US Federal Trade Commission (FTC). There is some suggestion that these organisations are now looking closely at claims made by nutraceutical and cosmeceutical companies and are no longer accepting six-patient, questionnaire-driven studies as proof of an effect.4 While the companies should focus on sharing honest marketing claims, and regulators should take their monitoring duties seriously, we as practitioners should also take some responsibility for the widespread problem. Rather than just reading the marketing hype and watching some spurious, animated, mechanism-of-action video, we need to dig below the surface. We have to ask; what trial evidence supports the claims being made? How can the company prove the product it’s distributing is safe and effective? We need to do our own due diligence to protect our patients from being misled by over-exaggerated or false marketing claims. And, as healthcare professionals, if the products don’t have the research to back them up, we shouldn’t be using them. Dr Martin Godfrey is head of research and development at MINERVA Research Labs. A trained medical practitioner, Martin has a wealth of expertise in health and nutritional product marketing. His main responsibilities are gaining scientific verification for Minerva’s products through overseeing clinical trials and obtaining the support of medical professionals. REFERENCES 1. www.medicinenet.com/script/main/art.asp?articlekey=9474 2. www.medicinenet.com/script/main/art.asp?articlekey=9474 3. www.medicinenet.com/script/main/art.asp?articlekey=25353 4. mthink.com/intersection-authority-fda-ftc-nutraceutical-regulation/

Reproduced from Aesthetics | Volume 2/Issue 10 - September 2015


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Merz Aesthetics +44 0333 200 4140 info@merzaesthetics.co.uk

Aesthetics | September 2015

Zanco Models Contact: Ricky Zanco +44 08453076191 info@zancomodels.co.uk www.zancomodels.co.uk

Dr. Catalin Calinoiu Contact: +40.724645555 zfill@zfill.forsale www.zfill.forsale


Experience all the benefits of VYCROSSâ&#x201E;˘ technology. Treat various areas of the face using only 3 products. Itâ&#x20AC;&#x2122;s that versatile.

Instructions and directions for use are available on request. Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014

Aesthetics September 2015  

Rejuvenation