Aesthetics November 2015

s tic 15 he 20 ! st ds ow Ae ar k N AwBoo

VOLUME 2/ISSUE 12 - NOVEMBER 2015

Discover the

Silhouette effect

“I couldn’t be happier with the result” Gillian Taylforth

NEW training workshop dates just released.

Book now: silhouettetraininguk@sinclairpharma.com

www.silhouette-soft.com Aesthetics front cover v2.indd 1

Laser-assisted Drug Delivery CPD Dr Firas Al-Niaimi details how lasers can aid the delivery of drugs to treat aesthetic concerns

Female Hair Loss Salvar Björnsson discusses causes and treatments for hair loss in women

Treating Lips Dr Sanjay Gheyi shares his approach to lip rejuvenation using hyaluronic acid fillers and lasers

12/10/2015 11:51

Creating Press Releases

Julia Kendrick explains how to create effective press material for your clinic

Excellence in Facial Aesthetics As you will know, the UK Facial Aesthetic market is now worth £3.6 billion, with over 7.5 million injectable procedures being carried out in the UK each year, and this is growing by 20% year on year.

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Contents • November 2015 06 News

The latest product and industry news

15 On the Scene

Out and about in the industry this month

16 Conference Reports

Reports from the annual BCAM and BACN conferences

18 News Special: Too Much Too Young?

Aesthetics investigates the impact of young people seeking treatment

21 Aesthetics Conference and Exhibition 2016

The latest additions to the ACE 2016 agenda are revealed

Special Feature Facial Resurfacing Page 23

CLINICAL PRACTICE 23 Special Feature: Facial Resurfacing

Practitioners discuss the use of chemical peels and lasers for facial resurfacing in aesthetic clinics

29 CPD: Laser-assisted Drug Delivery

Dr Firas Al-Niaimi examines how lasers can penetrate the stratum corneum to aid treatment of aesthetic concerns

35 Adverse Reactions to Hyaluronic Acid Injections

Dr Maryam Zamani shares advice on how to successfully manage HA filler complications

40 Vitamins in Skincare

Dr Ahsan Ullah explains how essential vitamins can enhance your patient’s skincare regime

Clinical Contributors

43 Treating Lips

Dr Sanjay Gheyi details his approach to rejuvenating lips with lasers and HA fillers

49 Identification and Management of Female Hair Loss

Salvar Björnsson discusses the various causes and treatment options for hair loss in women

53 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 55 Effective Press Releases

Julia Kendrick shares advice on creating your own PR material to meet business and marketing needs

59 Patient Communication

Victoria Smith describes how effective communication with patients can boost your clinic’s reputation

62 The Changing Consultation

Dr Renée Hoenderkamp explains how the patient consultation has evolved and why this is improving aesthetic practice

67 In Profile: Dr Maria Gonzalez

Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon, based at St Thomas’ Hospital in London and is a group medical director of sk:n clinics.

He has authored more than 95 publications and 120 scientific presentations.

Dr Maryam Zamani is a board-certified ophthalmologist with experience in ocuplastic surgery and dermatology. She obtained her medical doctorate from the George Washington University School of Medicine in the US. Dr Ahsan Ullah is an aesthetic and private general practitioner. With vast experience working for the NHS and privately, he is now the medical director of My Skin Clinic in Harley Street and provides dermatology and aesthetic services with a holistic approach.

Dr Sanjay Gheyi is the medical director and laser surgeon at the Coltishall Cosmetic Clinic in Norfolk, which has been established for nine years.

He offers a range of laser, skin and vein care services to his patients.

Salvar Björnsson is a certified surgical assistant in hair transplants from the International Society of Hair Restoration Surgery. He is also the CEO of Vinci Hair Clinics, which offers solutions for men and women in the UK and trains other practitioners entering the field.

Dr Maria Gonzalez reflects on her career in medical aesthetics and highlights the importance of continued learning

69 The Last Word

In Practice The Changing Consultation Page 62

Dr Farid Kazem argues the need for more education on the difference between genuine and counterfeit products

NEXT MONTH • IN FOCUS: Evolution of Aesthetics • CPD: Treating scars in Asian skin • Birthmarks • Using Instagram

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Last chance to book for the Aesthetics Awards 2015 www.aestheticsawards.com

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Editor’s letter Conferences, conferences and more conferences – if I am counting correctly, there have been five in as many weeks!

The highlights include the British College of Aesthetic Medicine and the British Association of Cosmetic Nurses’ events, of which you can Amanda Cameron read the reports on p.16. While conferences Editor can sometimes be exhausting, they serve a valuable purpose within our industry; providing us with more opportunities for education that allow us to progress and grow.

Reflecting on the last few weeks, I have been excited by the dynamic group of young doctors and nurses joining our industry who are not only charismatic, but also keen to learn, knowledgeable and able to present well. The next generation is looking good and I have faith that our new practitioners can support us in our endeavour to ensure UK regulation is made law at last. On a side note, I am still looking for those comfortable, fashionable conference shoes… we’ll publish an exclusive report once I’ve found them!

The next big UK conference will be the Aesthetics Conference and Exhibition (ACE) 2016 and I am delighted to announce that we have all the speakers in place already – it is so gratifying to know that we

can attract such a fantastic team of professionals so quickly. ACE promises to be the biggest and best so far, with an unsurpassed quality of education and practical training and, of course, some surprises! Turn to p.21 to find out more.

This month is our laser edition and, judging by the countless exhibition stands I have passed recently, many laser companies are vying for your business. It must be a complete minefield for those who are looking to purchase a new piece of equipment – where do you start? Hopefully our journal can help de-mystify the process; we have three fantastic articles on lasers in this issue, which each detail the science and practicalities of treating many indications with various types of devices. Turn to p.23 to read up on facial skin resurfacing with lasers and peels, p.29 for our excellent CPD article on laser-assisted drug delivery, and p.43 to learn about combining laser treatments with hyaluronic acid to treat patients’ lips. With so many articles to educate and inform, we are confident that you will thoroughly enjoy this issue. Please do let us know by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com On a final note, this month is your last chance to book tickets to our prestigious awards ceremony – visit www.aestheticsawards.com or call our support team on 0203 096 1228.

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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Acquisition

Talk #Aesthetics

Allergan completes Kythera acquisition

Follow us on Twitter @aestheticsgroup #SkinCancer Dr Anjali Mahto @DrAnjaliMahto Looking forward to having a GP colleague in my #skincancer clinic this morning – vital to improve links with primary care #Conference Dr Uliana Gout @UlianaGout Great day and discussions @MerzMappConference #KateGoldie @pdsurgery @DrStefanieW @MerzAesthetics

#BCAM Dr Nestor @DrNestorD Looking forward to @BCAM01 annual conference this Saturday! Day of education and catching up with friends and colleagues #Training Medikas @Medikas1 Great training day organised by @Galderma team at the RSM @Medikas1, treated 2 models on the non-surgical face lift #PatientSatisfaction Dr Ravi Jain @DrRaviJain It’s all about patient satisfaction. #Harmony @Riverbanks #Ultherapy

Global pharmaceutical company Allergan has announced that it has completed the acquisition of Kythera Biopharmaceuticals in a transaction valued at approximately $2.1 billion. The acquisition adds the treatment Kybella (deoxycholic acid), which became the first Food and Drug Administration (FDA) approved non-surgical injection for submental fullness in April of this year, to Allergan’s portfolio. Brent Saunders, CEO and president of Allergan said, “The completion of the Kythera acquisition is an important moment for Allergan, adding highly differentiated products and development programmes that enhance our product offering to global customers and their patients.” Kybella will join Allergan’s existing portfolio of medical aesthetic products, which includes Botox, Juvéderm XC, Juvéderm Voluma and Latisse.

Standards

GMC releases public consultation update figures The General Medical Council (GMC) has released response figures from its recent public consultation on the guidance available to UK-based doctors offering cosmetic interventions.

The consultation, which ran from June 8 to September 4, was introduced by the GMC to gather public opinion on how doctors can market their services properly and take particular care of young people undergoing treatment, amongst other concerns.

In total, the GMC received a total of 142 responses, 40 from organisations and 102 from individuals. In regards to responses by country, 80 respondents were from England and 26 from other parts of the UK. Scotland provided 11 responses, while four responses came from Northern Ireland. No responses from Wales were recorded.

The final guidance, which is expected to be published in early 2016, will aim to set ethical standards that will be expected of both surgical and non-surgical doctors in the UK. Breast implants

#Training Clinetix @clinetix It was a pleasure to have two enthusiastic nurse practitioners in the clinic today for some advanced training on dermal fillers and toxins #Education Adrian Baker @Nurse_A_Baker @RajAcquilla Thank you for a superb day of learning with you @WeAreMBNS. A practice changing educational event! #Threadlift Dr David Eccleston @DavidEccleston Down at #royalsocietyofmedicine in order to add #threadlift #mash technique of Dr Irfan Mian to our menu @MediZenClinics

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UK regulator suspends Silimed silicone implants The Medicines and Healthcare Products Regulatory Agency (MHRA) has suspended the sale of South American manufacturer’s Silimed silicone implants in the UK after contamination was found during an inspection. The German Notified Body, which monitors the quality of products and medical devices, found the contamination during a visit to the manufacturer’s facilities in Brazil. The MHRA, along with other European regulators, are currently testing and investigating the products to determine their safety. Silimed has stated that it is currently preparing a technical note to show that all devices are compliant with international standards. The company also said that the issue is only limited to the European Union. According to the MHRA, urological implants and other surgical devices are among the suspended appliances and Silimed’s CE mark has been suspended.

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Awards

Last chance to book for the Aesthetics Awards 2015 With the voting process for this year’s awards complete, tickets are selling fast with medical aesthetic professionals preparing for a spectacular evening of celebration and entertainment. The ceremony, which will take place at the Park Plaza Westminster Bridge Hotel on December 5, will play host to more than 500 guests with entertainment from British stand-up comedian Simon Evans, and music and dancing until the early hours.

The awards will celebrate Commended and Highly Commended finalists and winners in 23 categories, as well as the winner of the Schuco International Award for Special Achievement.

Dr Beatriz Molina, who is on the judging panel for this year’s awards said, “I am delighted to be selected as one of the judges – it’s a process and event to celebrate the best in aesthetic medicine and it forms part of a drive to raise standards in our sector.” She continued, “By sharing and celebrating all that is positive, we hope, over time, that the public will become better educated in making informed choices when selecting their aesthetic practitioners.”

Bookings can be made via www.aestheticsawards.com Sexual rejuvenation

Cosmetic Insure and Dr Sherif Wakil partner for sexual rejuvenation treatment cover Aesthetic insurance broker Cosmetic Insure has partnered with P Shot and O Shot trainer Dr Sherif Wakil with the aim of providing an easier route of insurance for all practitioners who perform the sexual dysfunction treatments. Due to what the insurers describe as ‘an increase in patient demand’, the company, with the assistance of Dr Wakil, were able to appoint an underwriter to fully examine the safety of P Shot and O Shot treatments, as well as the training provided by Dr Wakil.

“This will allow practitioners to be fully covered and able to practice these treatments safely. I am very confident that Cosmetic Insure will deliver a safe policy to further develop the popularity of these treatments,” said Dr Wakil.

Pigmentation

Study suggests Picosecond alexandrite laser successfully treats MIP A recent study on patients with minocycline-induced pigmentation (MIP) indicated ‘superior clearance’ of the reaction when treated with a picosecond alexandrite laser. The pigmentation condition is an adverse effect of minocycline therapy, an antibiotic used to treat infections such as acne and rosacea. Researchers studied three patients with MIP in the facial area and treated them with a 755 mm picosecond alexandrite laser. One patient, a 60-year-old white woman, saw complete clearance of the condition at a 12 week follow-up. The two other patients, a 75-yearold and a 59-year-old white man, saw superior clearance – which the researchers described as being ‘near complete resolution’ – after the same treatment and followup appointment. The researchers concluded, “This proved to be a well-tolerated, safe, and efficacious treatment that developed rapid clearance of MIP.” Aesthetics | November 2015

Countdown to ACE 2016 Latest programme updates Mr Dalvi Humzah will lecture on facial anatomy at Conference sessions on the mid-face, perioral and periorbital areas Dr Raj Acquilla and Dr Tapan Patel are set to perform live treatment demonstrations at the Conference session dedicated to the forehead, temple and brow as well as at the Injectables workshop on perioral, chin and jawline treatments with Mr Dalvi Humzah

Insight Consultant plastic surgeon and ACE steering committee chair Mr Dalvi Humzah says: “The Aesthetics Conference and Exhibition is growing every year and a higher standard of advanced educational content delivery is always taken into account during the planning of the ACE agenda.

The steering committee always strives for excellence to provide delegates with practical and cutting-edge tutorials delivered by world leading experts. Practitioners and medical aesthetic professionals who attend ACE will go back to their clinics with enhanced skills and enriched knowledge, and will be able to achieve better results to increase patient satisfaction. ACE 2016 cannot be missed!”

What delegates say “Excellent speakers and wide variety of topics covered” Cosmetic Doctor, London

“It’s great to meet up with all of our colleagues in Ireland and England, it’s very informative and very enjoyable” Cosmetic Doctor, Dublin

“Nice location, good interaction, useful lectures and demonstrations.”

Aesthetic Nurse, Devon www.aestheticsconference.com HEADLINE SPONSOR

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Conference

Registration for ACE 2016 now open Registration for next year’s Aesthetics Conference and Exhibition (ACE) 2016 is now open. With more than 2,000 delegates expected to attend the event, which will take place on April 15 & 16 at the Business Design Centre in Islington, delegates can now register online to secure their places and experience the comprehensive and engaging agenda. ACE 2016 will welcome back the popular free Masterclass, Expert Clinic and Business Track sessions, along with the addition of the Treatments on Trial agenda, where four company representatives will give presentations on their products allowing direct comparison between treatment options. Delegates can register for free, or choose to add the premium content Conference programme to their booking by paying for either a one-day pass for the 15 or 16, or paying for a two-day pass to experience the full Conference agenda, which includes eight sessions focused around anatomical areas. To book your place at ACE 2016 and find out more visit www.aestheticsconference.com Photoageing

StemCutis begins photoageing trial Biotechnology company StemCutis LLC has enrolled the first three subjects of its phase 1/2 clinical trial, which will determine the safety of a single injection of allogeneic mesenchymal bone marrow cells (aMBMC) for the treatment of cutaneous photoageing. The open-label, interventional study, which will be led by board certified dermatologist Dr Curt Littler, is considered to be the first clinical trial in the US to use allogenic stem cells for the treatment of photo-aged skin.

According to the company, the study will be split into two portions, phase 1, which will analyse the ‘Intrinsic Ageing of the Skin’ and phase 2, the ‘Chronic Effect of Ultraviolet Radiation on Normal Skin’. The study will assess the safety and tolerance of IV administration of aMBMC during the twelve month study period, and will record the incidence and severity of adverse events, any significant changes on clinical laboratory tests, vital signs of changes, physical and cutaneous examinations, 12 lead electrocardiograms, spirometry and CT scans of the chest. Dr Littler said, “The unique design of this clinical trial combines low-dose Fraxel laser treatment on the face with a single intravenous infusion of stem cells in the subject’s arm.” He continued, “The administration of low-dose Fraxel laser is expected to create minor inflammation in the facial skin, which is intended to facilitate homing of the stem cells to the face after a single intravenous infusion of Stemedica-manufactured stem cells.” The study will use approximately 30 male and female subjects between the ages of 40-70 years old, for a 12-month period, with an expected completion date of December 2017.

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Acne

Study unveils success of candidate acne drug Biotechnology company Novan Therapeutics has received encouraging results from a phase 2b study analysing a nitric-oxide topical gel candidate drug. SB204, which is the company’s leading drug candidate for the treatment of acne vulgaris, was used in the trial and produced significant results on inflammatory and non-inflammatory lesions at week 12 on a recorded 213 patients. All participants were randomly split into five groups: SB204 2% twice daily, SB204 4% once daily, SB204 4% twice daily and vehicle once or twice daily. According to the study, the 4% dose of SB204 proved to demonstrate the most significant difference in inflammatory lesions, and the 1% and 4% groups were effective at decreasing non-inflammatory lesions. The study noted that patients treated with SB204 had 80% less sebum on the skin’s surface compared to those in the vehicle groups. Nathan Stasko, president of Novan Therapeutics, said, “These study results reproduce our phase 2a trial, which showed a similar separation between the active drug and vehicle.” He continued, “Replicating a 20% differential between SB204 and vehicle in percent lesion reduction gives us great confidence in moving into the phase 3 programme.” Based on the trial results, Novan announced plans to initiate two phase 3 trials with SB204 once daily in the beginning of 2016, with 1,300 patients expected to be enrolled in each study.

Dermal fillers

FDA approves Juvéderm Ultra XC for lip augmentation The Food and Drugs Administration has approved pharmaceutical company Allergan’s Juvéderm Ultra XC for lip augmentation in adults over the age of 21.

Juvéderm Ultra XC is a smooth gel formulation made up of a modified form of HA. Philippe Schaison, executive vice president of Allergan Medical said, “Understanding that the desire with lip augmentation is to achieve a naturallooking and lasting result, we continued our research of Juvéderm Ultra XC for the lips.” He continued. “With this approval, this filler is now the only filler that is approved to last up to one year in the lips while providing natural-looking results.”

The gel formulation also contains a small amount of local anaesthetic (lidocaine), which helps to improve the comfort of the injection. According to the company, common adverse effects for the treatment include redness, swelling, firmness, bruising and discolouration.

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Vital Statistics

Skincare

iS Clinical releases multipurpose moisturiser

Around 1% of men over the age of 25 will develop acne

Skincare brand Innovative Skincare (iS) Clinical has launched a new moisturiser that aims to hydrate the skin and target a multitude of skin concerns. The Reparative Moisture Emulsion aims to prevent DNA damage by using extremophilic enzymes, which work to protect cells and repair fragile proteins, and superoxide dismutase (SOD), a proven antioxidant that is reported to safely absorb harmful free radicals and protect skin from photoageing. The moisturiser also includes 5% hyaluronic acid, which aims to increase skin firmness and resistance to stress, as well as glycosaminoglycans to maintain the structure collagen.

Also included is bio-identical copper tripeptide growth factor, which aims to stimulate the synthesis of collagen in skin fibroblasts for a firmer complexion.

(NHS)

Hair loss affects

approximately 1.2 billion people around the world

(LaserCap Company)

60% of patients source information on cosmetic surgery via search engines

Laser

Lutronic Lasers introduces carbon peel treatment Laser manufacturer Lutronic Lasers has launched a new treatment that aims to aid collagen stimulation and improve the appearance of pigmentation. The Spectra Carbon Peel, which is performed using the Lutronic Spectra XT device, claims to require little to no downtime and works to improve the appearance of fine lines and wrinkles, reduce pore size and smooth uneven skin tone. The procedure begins with the application of a carbon-based lotion to the patient’s face, followed by laser treatment that aims to lightly remove the carbon particles and erode the top layer of skin. The laser energy then heats the skin, causing it to contract to reduce pore size and stimulate healthy new collagen. Jim Westwood, managing director of Venn Aesthetics, the UK distributor of Lutronic Lasers said, “We are delighted to introduce this advanced and novel treatment to the aesthetic market and we are happy to offer clinics a fast, comfortable and highly effective patient treatment.”

(American Academy of Facial Plastic and Reconstructive Surgery)

Eczema affects five million people in the UK every year (National Eczema Society)

In a survey of 527 women, 15.37% said that social media affected their decision to get cosmetic surgery (RealSelf)

Botulinum toxin

Revance Therapeutics begins botulinum toxin topical gel trial for canthal lines Biopharmaceutical company Revance Therapeutics has begun a phase 3 study to evaluate the safety and efficacy of a topical drug candidate for the treatment of lateral canthal lines. The trial of 450 adult patients will determine the effects of RT001, a topical gel that the company claims could be marketed as the first non-injectable form of botulinum toxin type A. Dan Browne, CEO of Revance said, “Success in treating canthal lines would set the stage for potential future indications of RT001 topical gel across other areas of the face and body.” Assessment will be recorded after 28 days using the Patient Severity Assessment and the company plans to release the trial results in the first half of 2016.

At least 100,000 new cases of skin cancer are diagnosed in the UK every year (British Skin Foundation)

In a study of 146,042 psoriasis patients in the UK, 10,400 were diagnosed with depression (JAMA Dermatology)

Aesthetics | November 2015

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Insider News

Events diary 12th – 15th November 2015 20th World Congress of Aesthetic Medicine, Miami www.aaamed.org

14th November 2015 British Cosmetic Dermatology Group 10th Annual Course, London www.bcdg.info

3rd – 4th December 2015 B.A.D Research Techniques Course, London www.bad.org.uk/events

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

28th – 31st January 2016 IMCAS World Congress 2016, Paris www.imcas.com/en/attend/imcas-worldcongress-2016

15th – 16th April 2016 Aesthetics Conference & Exhibition 2016, London www.aestheticsconference.com

Skincare

Schuco International launches UNIVERSKIN Aesthetic skincare distributor Schuco International has announced it is the exclusive UK & Ireland distributor of UNIVERSKIN, a brand which aims to offer personalised skincare to patients.

Developed by plastic surgeons, dermatologists, biologists and pharmacists, UNIVERSKIN aims to treat a range of aesthetic concerns including; oxidative stress, wrinkles and sagging, inflammation, skin barrier disorders, keratinisation, hyperseborrhea and pigmentation.

According to Schuco, UNIVERSKIN allows practitioners to add up to three active ingredients to the base serum, which is then mixed to create a unique formula, tailored to treat each patient’s individual skin concerns.

The company explains that the product’s highly active base serum can aid the treatment of damaged and inflamed skin, applying nanotechnology in a unique minimalist serum that contains omega 3, hyaluronic acid, vitamin E and biomimetic peptides.

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Survey

Survey analyses popularity of aesthetic procedures in UK A survey commissioned by aesthetic manufacturer Intraline Medical Aesthetics has analysed the popularity of medical aesthetic procedures in the UK. The survey of 2,006 respondents over the age of 25, suggested that one in five women undergo dermal filler treatment for anti-ageing benefits, and 40% of those claimed that they would undergo treatment to satisfy their partners. Another finding from the survey indicated that 25% of male respondents regularly have dermal filler treatments to ‘reward themselves’. Weddings were identified as a key milestone in decision-making, with one in 25 women undergoing treatment to look their best on the big day and 10% having a procedure for a significant birthday. Blair French, vice president of marketing for Intraline Medical Aesthetics said, “The market research we conducted showed that men and women are looking at aesthetic treatments as one way to enhance their appearance.” He continued, “Knowing this information, our goal is to ensure these individuals are aware they are not alone in looking into aesthetic treatments and we wanted to provide the necessary information for each individual so they can make an informed decision that they are confident about.”

Weight loss

Non-surgical balloon device receives FDA approval A device designed to help obese adult patients lose weight has been granted approval by the FDA. The ReShape Integrated Balloon System aims to help patients lose weight by taking up space in the stomach; an alternative to having surgery. The FDA said the balloon “may trigger feelings of fullness or work by other mechanisms yet to be understood.” Dr William Maisel, acting director at the FDA’s Center for Devices and Radiological Health, said, “For those with obesity; significant weight loss and maintenance of that weight loss often require a combination of solutions, including efforts to improve diet and exercise habits.” He continued, “The new balloon device provides doctors and patients with a new non-surgical option that can be quickly implanted, is non permanent, and can be easily removed.” According to the company, the procedure requires the patient to be mildly sedated while the balloon is delivered into the stomach through the mouth via an endoscopic procedure. The balloon should then be used in combination with a diet and an exercise plan, for optimum weight loss results.

Industry

Globe AMT announced as UK distributor of DEKA Laser technology manufacturer DEKA has appointed aesthetics distributor Globe AMT as its official UK distributor. DEKA will join other brands and products including the Quantificare 3D skin analysis cameras and the Nevisense EIS diagnostic system in Globe AMT’s extensive portfolio. Neil Roberts, managing director of Globe AMT said, “We’re proud and delighted to be representing such a significant and prestigious brand. DEKA are one of the global powerhouses in laser technologies. The addition into the Globe AMT portfolio represents another significant distribution agreement for our exciting business.” DEKA produce laser technology for the international market that aim to treat aesthetic concerns including; age-related issues, tattoo removal, hair removal, pigmented lesions and psoriasis.

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Industry

Allergan and Intas Pharmaceuticals in agreement after trademark debate US pharmaceutical company Allergan has entered into a settlement with Indian manufacturer Intas Pharmaceuticals on the use of the trademarks ‘Botox’ and ‘BTX-A’ for botulinum toxin. The court order, which was issued on September 9 in the Delhi High Court, stated, “The defendant (Intas Pharmaceuticals) has acknowledged the plaintiff’s (Allergan) exclusive rights in respect of the registered marks ‘Botox’ and ‘BTX-A’ and it has agreed not to use the said marks in isolation or collectively. The plaintiff has also acknowledged and accepted the defendant’s use of the mark ‘BTXA’ without a hyphen and segregating the letters forming part of the word ‘BTXA’.” According to a previous order from Delhi High Court, Allergan claimed that the trademark Botox has been used in India since 1992.

An application to register the BTX-A trademark was made by Intas Pharmaceuticals in June 2002, which was not granted, but the company secured permission from the Drug Controller of India to sell a drug under the brand name BTXA, where the dispute between both companies originated. A spokesperson for Intas Pharmaceuticals said in a statement, “Allergan had challenged the order of the Delhi High Court before the Division Bench, and both parties have amicably resolved the dispute on the terms that Intas can continue to use BTXA for its product but will not use the trademark Botox or BTX-A.” Training

BAAPS to launch fellowship training programmes The BAAPS (British Association of Aesthetic Plastic Surgeons) is launching a series of fully-funded fellowships for trainees looking to develop a career in aesthetic surgery. The three-month fellowships come as a study, which was presented at the Annual Scientific Meeting of BAAPS by trainee member Mr Reza Nassab, claimed that funding for reconstructive surgery on the NHS has been reduced, and currently there are very few training opportunities for those seeking a career in aesthetic surgery. With support from the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), the fellowships will enable handson practice, mentorship and understanding of how to deal with patient complications.

Brendan Eley, CEO of the National Institute of Aesthetic Research (NIAR) who are collaborating with BAAPS on the programme, said, “Not only will trainees be able to access the expertise and guidance of top surgeons in busy private units, but fellows will be further rewarded for undertaking quality research and audits, which we will be under the auspices of the NIAR.” Mr Nigel Mercer, president of BAPRAS said, “Credentialing will soon be implemented, but this is simply the most basic level for a practitioner to be able to legally practice. We want to develop experienced surgeons operating at the gold standard, and this is what these fellowships are designed to provide. The public deserves no less.”

As part of the training programme, fellows are expected to be exposed to a certain number of treatment cases, including 20 breast treatments, 10 truncal, 20 facial and periorbital and 10 botulinum toxin cases, among others such as nasal, ear and dermal filler injections. Michael Cadier, president of BAAPS said, “As the only association which is solely dedicated to the advancement of aesthetic plastic surgery, we are ready to take up the mantle of responsibility for training with a groundbreaking new programme alongside our colleagues in other plastic surgery societies and the National Institute of Aesthetic Research – for the development of the profession but, most important of all, for patient safety.”

Aesthetics | November 2015

Insider News

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Jim Westwood, Managing Director of Venn Aesthetics What is your background?

My background is extensively within healthcare, having worked for AstraZeneca and Eli Lilly within their healthcare development and market access team for more than 15 years.

Venn Aesthetics is relatively new to the market– tell us about it.

Venn Aesthetics is a distributor of aesthetic equipment in the UK. Our company was developed to deliver innovative and efficacious best-in-class solutions to the aesthetic beauty market for practitioners and patients alike. With the speed of developing technology, Venn always has an eye on the supportive published clinical evidence of any technology. Devices and technology can often develop at a faster rate than that of the clinical research, and Venn Aesthetics ensures practitioners and patients benefit from the most upto-date aesthetic technology available to them. We are a relatively new subsidiary of Venn Healthcare, which offers devices to the healthcare industry.

What does the Venn Aesthetics portfolio offer?

Venn Aesthetics is the UK distributor for Lipotripsy – Shock Wave Therapy for the treatment of cellulite and inch loss. We also offer the full Lutronic laser portfolio of devices that includes Infini, Spectra XT, Clarity, Solari and Petit Lady II. Lutronic was established more than 15 years ago and delivers intuitive and versatile devices that are underpinned by clinical research. Lastly, we have just brought on board Classys, which includes Clattu, the new controlled cooling treatment for fat reduction that boasts the world’s first 360° cooling panel. With our range of devices, I feel that Venn Aesthetics offers a full spectrum of solutions to the ever-growing market place.

What can we expect next from Venn Healthcare?

We are pleased to be announcing the launch of our own Remote Expert technology which will enable healthcare professionals to speak directly to their patients/clients via high definition video either at work or at home. It is a platform that will have application from the high street through to an individual clinic or GP surgery. What is unique about our Remote Expert technology is that it can work from any good quality PC, and the video suite enables scheduled end-to-end consultations with the ability to add in another consultant/healthcare professional to the call should a second opinion be needed.

This column is written and supported by

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Insider News

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Acne

Study monitors adherence to clinical and topical acne treatments A study published in BioMed Central (BMC) Dermatology has suggested that the outcome from clinical treatment with adjuvant therapies, such as facial cleansing, topical treatments and moisturising, can greatly affect the improvement of mild-to-moderate acne vulgaris. The study, which evaluated 643 participants in an observational, non-interventional prospective study, assessed the effects of both clinical and adjuvant methods with 566 patients completing three study visits over a three-month study period. An ECOB, a validated questionnaire used by researchers, was used to assess clinical adherence, as well as a 0-5 point scale to monitor treatment adherence and acne severity post treatment. Overall, clinical improvement was observed throughout follow-up visits with an increased amount of patients reporting reductions of more than 50% on the total number of lesions (two months: 25.2%; three months: 57.6%) and reductions of severity scores (2.5, 2.0 and 1.3 at one, two and three months after treatment). Adherence to treatment was associated with a significant reduction on severity grading, a lower number of lesions and a higher proportion of patients with more than a 50% improvement.

Vitamin C

DMK launches new vitamin C product Skincare manufacturer Danné Montague-King (DMK) has launched a new vitamin C-based product designed to aid the production of collagen, improve skin texture and aid the prevention of acne scarring.

FibroMax C, which is produced in a liquid vial form, is made of 20% pure vitamin C (ethyl ascorbic acid) and silicia silylate to protect the skin’s barrier from external stresses, such as UVB damage and pollution. The manufacturer claims that patients can also apply this product as a topical treatment at home on skin concerns such as pigmentation and fine lines. FibroMax C is available now.

Complications

Blindness from dermal fillers indicated to be rare According to a recent literature review, reported cases of blindness after dermal filler treatment have been indicated as a rare adverse event. The review, which was led by Vancouver-based dermatologist Dr Kate Beleznay, used the National Library of Medicine, Cochrane Library and Ovid Medline to analyse research published up until January of this year. Studies reported that there were 98 cases of vision changes identified. The highest areas of complications were the glabella (38.8%), nasal region (25.5%) nasolabial fold (13.3%) and forehead (12.2%). In regards to the filler type causing this complication, autologous fat was suggested as causing the most instances with 47.9% of cases, followed by hyaluronic acid (23.5%) and collagen (8.2%).

Dr Beleznay said, “With the increased use of soft tissue augmentation for revolumisation, it is imperative to be aware of potential devastating ocular complications.” She continued, “Although the risk is very low, we believe that prevention begins with education and the ability to recognise potentially grave adverse events.”

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Aesthetics | November 2015

Aesthetics

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News in Brief ZO Skin Health introduces Offects Sulfur Masque Skincare manufacturer ZO Skin Health has added a deep pre-medicated cleansing masque to its collection. The Offects Sulfur Masque aims to treat oily or acneic skin by absorbing surface oils, exfoliating dead skin cells and removing pore-blocking dirt and debris. According to the company, the main ingredient is sulphur, a naturally occurring non-metal mineral commonly used to treat acne and skin inflammation.

AAFPRS appoints new 2015-2016 president The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) has appointed reconstructive surgeon Dr Edwin Williams as president of the organisation. Dr Williams, who is a Fellow of the American College of Surgeons, will serve a term as president between 2015-2016 and will work closely on developments in cosmetic surgery, as well as the improvement of AAFPRS education programmes for members.

Dr Kannan Athreya announced as Swisscode ambassador Aesthetic practitioner Dr Kannan Athreya is the new brand ambassador for cosmeceutical skincare manufacturer Swisscode. The company, which developed the Pure and Bionic skincare ranges, aims to offer products that improve the appearance of skin texture, provide protection from UV rays and smooth fine lines and wrinkles.

Vida Aesthetics launches new website Distributor and training company Vida Aesthetics has launched a new website to enhance user experience. The website aims to provide a simplified look with an improved search functionality. Users will now be able to search for new products and ingredients, along with informative videos and articles on treatments.

Cosmedics Skin Clinics expands its team The Cosmedics Skin Clinic in Bristol has expanded its team with the addition of aesthetic practitioner Dr Sarah Thio.

Specialising in minor cosmetic surgery procedures, including removing common skin blemishes and lesions such as moles, cysts, skin tags, warts and lipoma, Dr Thio also trains GP registrars in skin surgery methods.

Dermal filler

Intraline releases two filler products in UK Aesthetic manufacturer Intraline Medical Aesthetics has released two new HA-based dermal filler products to the UK market. Intraline One and Intraline Two aim to integrate themselves naturally into injected tissue.

They contain a natural medical grade HA concentration and a lesser amount of butanediol diglycidyl ether (BDDE), which aims to maintain product purity. Reece Tomlinson, CEO of Intraline Medical Aesthetics said, “I am delighted that Intraline products are now available in the UK, where the aesthetics industry continues to go from strength to strength.” He continued, “At Intraline, we pride ourselves on bringing a fresh perspective and continual innovation to aesthetic treatments and are committed to providing safe and quality products with fantastic results.”

Dr Zack Ally, founder of aesthetic training company Derma Medical and a user of Intraline One and Two, said, “Intraline dermal fillers are pure in composition and have some of the highest molecular densities of any product on the market today.

It is exciting to use a new and effective product, produced by a company who truly value the importance of safety and comprehensive training in aesthetic treatments.”

Hair loss

Kythera submits IND for alopecia treatment Kythera Biopharmaceuticals has submitted an Investigational New Drug Application (IND) to the FDA for further study of a new treatment for androgenetic alopecia (AGA). The company plans to evaluate the safety of KYTH-105, also known as setipiprant, in a human proof-of-concept study on male subjects with AGA, which is an inherited genetic disorder that can result in hair thinning and partial or complete baldness.

Kythera’s chief medical officer, Dr Frederick Beddingfield, said, “This submission is a significant milestone in the development of KYTH-105 for male pattern hair loss. KYTH-105 represents a unique scientific approach to the treatment of hair loss that has the potential to help millions of men achieve a positive self-image.”

According to company data recorded in March of this year, men with AGA were found to have higher levels of prostaglandin D2 (PGD2) in the balding scalp area, which is a possible key variable in hair loss. Setipiprant is a selective oral antagonist of the PGD2 receptor and the KYTH-105 treatment was found to promote hair growth in preclinical and in vitro human hair follicle models.

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S-THETICS industry discussion with Mr Nigel Mercer, Beaconsfield The S-THETICS clinic in Beaconsfield, Buckinghamshire, welcomed practitioners and patients to a discussion session with plastic surgeon Mr Nigel Mercer on the synergy between surgical and non-surgical procedures on September 22. Miss Sherina Balaratnam, founder and medical director of S-THETICS, co-presented with Mr Mercer on topics such as emerging aesthetic trends, the wide array of treatment options available and how practitioners can achieve natural-looking results. Also on the agenda was a discussion of regulatory issues and patient safety; highlighting the importance of patients conducting thorough research before undergoing treatment. To illustrate, before and after images were presented to demonstrate natural-looking results with dermal fillers, blepharoplasty and facial lifting procedures. Miss Balaratnam said, “I am keen to help patients understand the need to carefully consider both the treatments they are considering and the practitioner that may undertake this. It was an honour to have someone of Mr Mercer’s calibre visit my clinic and share his valuable experience and insights with patients.” The evening concluded with a question and answer session and an open forum discussing a range of treatment options from a patient perspective.

Frances Turner Traill Skin Clinic opening, Lanarkshire More than 150 patients and aesthetic practitioners attended the opening of aesthetic nurse prescriber Frances Turner Traill’s new clinic in Hamilton in Lanarkshire on September 24. The evening began with a welcome drinks reception, followed by a series of talks and demonstrations from the new clinic team showcasing treatments that are available, which include; wrinkle smoothing injections, radiofrequency skin tightening, Computer Aided Collagen Induction (CACI) non-surgical facelifts and laser treatments for hair removal, acne and pigmentation concerns. New and existing patients were also given the opportunity to be involved in a question and answer session with Turner Traill to find out more about all of the clinic treatments. Turner Traill said, “This opening represents a major investment in aesthetic services in central Scotland and I look forward to helping a host of new patients achieve their aesthetic aims.”

EF Medispa Clinic Opening, London Medical spa chain EF Medispa invited aesthetic professionals and patients to the opening of their fourth London clinic in Canary Wharf on October 8. Attendees were welcomed with a drinks and canapé reception, followed by the opportunity to experience the clinics new ‘Drip and Chill’ IV infusion treatment within the medispa’s ‘Drip and Chill’ lounge.

Esther Fieldgrass, founder of EF Medispa said, “We decided to open in the city due to the popularity of the ‘Drip and Chill’ treatments in our other locations. When we were looking through our patient base, we noticed that the majority worked in highpressured positions, such as banking and finance, and we felt that we could provide this treatment at a nearer location to those working within stressful environments.”

Aesthetics | November 2015

Insider On the Scene

UltraPulse Masterclass and User Meeting, London

Aesthetic practitioners attended a UltraPulse CO2 laser masterclass and user meeting at the Royal Society of Medicine in London on September 28. The day began with a welcome from Lumenis regional sales manager, Edward Campbell-Adams, followed by a programme of presentations from plastic surgeon Mr Max Murison and dermatologist Dr Gerd Gauglitz. Mr Murison began proceedings with an introduction to CO2 technology, before co-presenting with Dr Gauglitz on particular approaches using the laser, which aims to provide versatility and precision for an array of resurfacing needs. Settings for the UltraPulse include; DeepFX, for treatment of wrinkles, ActiveFX for mild treatment of hyperpigmentation and TotalFX which aims to target the full range of treatment concerns.

Live demonstrations consisting of burn scar treatment and full-facial resurfacing then led to a question and answer session with delegates, and round table discussions on topics including treating acne scarring and combination approach. Mr Murison said of the masterclass, “It was great and the joint input from dermatology and plastic surgery made it an informative event for all the delegates.

The amount of effort put in provided one of the most comprehensive days of instruction I have ever been involved in.” Justin Richards, manager of aesthetics marketing at Lumenis said, “The day was very well received and attended by UK and European based plastic surgeons, dermatologists and aesthetic practitioners.” He continued, “The meeting was the perfect opportunity for us to reconnect with our loyal clients and educate non-users on why UltraPulse is so unique and versatile for everyday procedures, such as resurfacing or treating the thickest, more complex burn scars with SCAARFX.” 15

Conference Reports BACN/BCAM

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BACN Conference, Birmingham Members of the British Association of Cosmetic Nurses (BACN) met at the ICC in Birmingham for their annual conference on October 3.

The day featured presentations on a wide range of subjects, which included treating lips, tear troughs, pigmentation and acne; as well as discussions of the latest BACN activities, working within consent law, and updates on the Nursing and Midwifery Council’s revalidation pilot. Sharon Bennett, chairperson of the BACN, said, “The day went phenomenally well; the speakers were brilliant, lots of topics were covered and the audience seemed to get a lot of information out of each presentation.” To begin the conference, aesthetic nurse Rachael Brown spoke on treating lips. While performing a live demonstration, she emphasised the need to treat the lower face as a whole in order to achieve natural results, and shared her best practice techniques for successful lip volumisation. Oculoplastic surgeon Mrs Sabrina ShahDesai then took to the stage to discuss her techniques for treating the tear troughs. As well as presenting the different classifications of tear troughs, Mrs Shah-Desai spoke on the importance of being aware of patients with body dysmorphia and recognising when to refuse treatment. Nurse prescriber Karen Urquhart discussed the practicalities and challenges of running a nurse-led acne clinic, explaining that building relationships with local GP surgeries can lead to valuable patient referrals. Urquhart also spoke on treating complications, explaining that, although challenging, effective communication and quick management should ensure that your relationship with the patient concerned is not impaired. Nurse prescriber Anna Baker then shared her knowledge of using toxins to treat the lower face.

Her presentation highlighted the need for practitioners to have a thorough understanding of facial anatomy and selecting appropriate patients for treatment. Having this knowledge, she argued, will greatly reduce the numbers of complications we see. Following her session Baker said, “It was great to be at the BACN conference and I was really pleased to be invited. There have been some fantastic speakers, really high-calibre presentations, and the event was very well organised – it’s been a pleasure to take part this year.” The afternoon saw presentations from Dr John Quinn, who discussed the importance of product rheology and depth placement when using hyaluronic acid dermal fillers; Dr Sherif Wakil, who provided delegates with an overview of using threads; and Dr Martyn King, who spoke on prevention and management protocols for complications in aesthetic clinics. Paul Burgess, CEO of the BACN, concluded, “The 2015 BACN conference has been the biggest and best ever. We sold out a week ahead, and with more than 200 delegates and 30 exhibitors we’ve had to turn people away, which we’ve never had to do before. We are absolutely delighted with how the day went and the reaction we’ve had has been superb.”

BCAM Conference, London The British College of Aesthetic Medicine (BCAM) held its annual conference at the Church House Conference Centre in Westminster on September 26.

The day comprised both a clinical and business agenda, which each featured an array of engaging presentations and live demonstrations. Conference director Dr Beatriz Molina said, “Attendance was strong with 250 delegates eager to hear from a range of high-quality speakers, both from within the aesthetic practitioners sector and the wider business community, offering advice and insight on how to run a successful and ethical business.” Following a warm welcome from Dr Molina, Dr Ravi Jain took to the podium to discuss the psychological

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impact of undergoing VASER treatment. Dr Jain advised delegates to always take patient concerns seriously and, if they are unable to offer appropriate treatment, they should refer patients on to colleagues who are able to help. The morning clinical sessions continued with presentations on liposuction and fat grating, lipolysis, and hair transplantation, while the business agenda featured talks on revalidation and appraisal, as well as stress management techniques for practitioners and patients. Journalist and media consultant Fiona Scott shared advice on speaking to the press, arguing that achieving editorial coverage in the media can sometimes be more valuable than advertising in the media.

Dr Samantha Gammell and Dr Jacques Otto then presented on intravenous (IV) nutritional therapy, highlighting the marketing challenges they have faced when launching their new brand. Dr Gammell noted that despite IV nutritional Aesthetics | November 2015

therapy being classified as a medicine in the US and most European countries, in the UK the Medicines and Healthcare products Regulatory Agency (MHRA) has, after much deliberation, now confirmed that IV nutrition therapy is not regarded as a medicine in the UK, and is therefore not subject to MHRA regulation. The day concluded with a live demonstration of PDO vs. Silhouette Soft thread lift techniques, in which Dr Otto and Dr Kuldeep Minocha treated one side of a patient’s mid-face in order to compare the results that can be achieved. Aesthetic practitioner and BCAM delegate Dr Nestor Demosthenous made the trip from his clinic in Glasgow and said, “It’s been an absolutely fantastic day. It’s great to come down to London and meet with friends and colleagues; there are lots of great companies here and the speakers have been secondto-none.”

Dr Molina concluded, “I truly believe we have raised – and will continue to – raise the bar at the annual BCAM conference. I am already working on next year’s conference at the Church House Conference Centre, which will take place on Saturday September 24, 2016.”

News Special Young Patients

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With the consumer press increasingly reporting a trend in young girls seeking aesthetic treatment, Ruth Donnelly investigates the effect this has on the industry

Too much too young?

Ever since 17-year-old American socialite Kylie Jenner admitted to having had lip filler injections in May this year, reports have flooded consumer media that claim more and more young girls are seeking to emulate the heiress. Many of these stories have concentrated on the 20-30 age group, but at the end of September both The Times1 and the Mail Online2 reported that girls as young as 14 were not only requesting, but receiving cosmetic injectable treatments, influenced by celebrities like Jenner and the new ‘selfie’ culture. Many feel that this media uproar reflects badly on the aesthetics industry, but do the statistics support the stories?

The inside track While the press may be awash with stories about teenagers having lip filler, many industry professionals tell a different story. Sharon Bennett, chair of the British Association of Cosmetic Nurses (BACN), explains that she posed a question to BACN members about the number of young girls requesting treatment. She says, “The answer came back that very few under 16s asked for treatment.” Dr Paul Cronin, of the Eternal Youth Clinic in Cheshire, has not seen a noticeable increase either, although he comments, “I have performed botulinum toxin treatments on patients aged 23 or 24 on a preventative basis, but I would feel it unethical to do any significant facial work on someone whose face hasn't finished developing.”

It is difficult to get a true picture of the numbers, as none of the UK professional associations' annual audits cover the age distribution of patients. In the US, however, both the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) produce yearly reports that look at age distribution.

The ASAPS reports a 0.3% increase in the 18

number of patients below the age of 18 undergoing non-surgical procedures in 2014,3 but a 0.7% decrease in the 20 to 29 age group,4 certainly not the surge that the mainstream media would have us believe.

The ASPS figures do show a more significant increase in the number of teenagers seeking treatment, with a 3% rise overall, and a 7% and 6% increase respectively in teens undergoing botulinum toxin injections and HA fillers.5 But can the American statistics be applied in the UK? The lack of data available makes it impossible to attribute any figures to the concern.

Going underground The general feeling amongst the practitioners interviewed on this matter is that if teenagers are receiving cosmetic treatment, then it is not being performed by medically-qualified practitioners. Consultant plastic surgeon Mr Stephen Hamilton says, “This is a potential concern, particularly with the portrayal of cosmetic surgery as an easy choice in some parts of the media, and probably to a great extent in those parts aimed at young women.”

Mr Hamilton adds, “There are certainly a lot of column inches devoted to [cosmetic procedures] in the consumer press and the main concern I have is that this coverage can run the risk of trivialising procedures, encouraging young women to take decisions lightly.” The Mail Online story claims that beauticians are responsible for treating many teenage girls,2 which brings the regulation issue clearly to the forefront: while botulinum toxin, as a prescription medicine, is prohibited for use by unqualified practitioners, dermal fillers are not, and there is no legislation to prevent a beauty therapist from injecting a filler into someone's lips, whatever their age.

Aesthetics | November 2015

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A regulatory issue Regulation – or lack thereof – has long been an issue in the medical aesthetics industry. While Health Education England (HEE) has submitted standards for expected qualifications and education to practise aesthetics, they are still awaiting ministerial approval. Sally Taber, director of Treatments You Can Trust who took part in the HEE consultation, explains, “HEE demands that delivery of injectable cosmetics will be allowed only upon suitable training to Qualification Curriculum Level 7 and we believe this will rule out most beauty therapists currently performing injectable treatments.” In addition to HEE’s work, the General Medical Council began consultation on guidance for all doctors who offer cosmetic interventions in June 2015, including points regarding the specific care of children and young people.6 The final guidance document is due for release early next year, however as beauty therapists are not qualified medical professionals, the guidelines will not apply to them, so this may well have limited impact.

While there is no solid evidence that beauty therapists are injecting teenagers, it is clear that there is a significant lack of UK-based data available that can tell us how widespread the concern is. HEE’s standards of education could of course help reduce the risk of beauty therapists offering injectable treatments, however they will not help us discover how many young people are seeking and undergoing treatment here in the UK; whether this be from beauty therapists or medically-qualified practitioners.

Perhaps, then, a database that collates the age of each person undergoing treatment is the way forward. Hopefully the media furore over Kylie Jenner and her followers might work in the industry's favour and spur the government into taking action.

REFERENCES 1. Danielle Sheridan, ‘Girls risk their lives with cheap lip injections’, The Times, 26 September 2015 <http://www.thetimes.co.uk/tto/ health/news/article4568367.ece> 2. Kate Pickles, ‘The number of teenagers getting risky cosmetic procedures is soaring, with children as young as 14 getting their lips ‘plumped’’, Mail Online, 26 September 2015 http:// www.dailymail.co.uk/news/article-3250112/Ministers-accusedfailing-protect-children-number-teens-getting-risky-cosmeticprocedures-booms.html 3. The American Society for Aesthetic Plastic Surgery, ‘2013 Cosmetic Surgery National Data Bank Statistics’, p.15 <http:// www.surgery.org/sites/default/files/Stats2013_4.pdf> 4. The American Society for Aesthetic Plastic Surgery, ‘2014 Cosmetic Surgery National Data Bank Statistics’, p.19 <http:// www.surgery.org/sites/default/files/2014-Stats.pdf> [accessed 12 October 2015] 5. The American Society of Plastic Surgeons, ‘2014 Plastic Surgery Statistics Report’, <http://www.plasticsurgery.org/Documents/ news-resources/statistics/2014-statistics/cosmetic-proceduresteens.pdf> 6. General Medical Council, Guidance for all doctors who offer cosmetic interventions (UK: gmc-org.uk, 2015) <http://www.gmcuk.org/guidance/news_consultation/27171.asp>

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Aesthetics Conference & Exhibition 2016 With registration now open and aesthetic professionals looking forward to experiencing the Aesthetics Conference and Exhibition (ACE), we can now reveal what you can expect from the exciting new agenda taking place on April 15 and 16. Following the success of last year’s event and overwhelmingly positive feedback from both delegates and exhibitors, ACE has cemented its reputation as the leading educational medical aesthetics event. The comprehensive agenda of free practical content within the Masterclass, Expert Clinic and Business Track programmes, alongside the Conference sessions focused around anatomical areas, will once again attract thousands of practitioners and aesthetic professionals from across the industry.

For 2016, the ACE steering committee, led by consultant plastic surgeon Mr Dalvi Humzah, and comprising Dr Raj Acquilla, Dr Tapan Patel, chair of the British Association of Cosmetic Nurses Sharon Bennett and Aesthetics journal editor Amanda Cameron, are dedicated to providing delegates with a packed agenda of CPD-accredited education in more than 58 sessions. Popular speakers from last year’s educational agenda who have already announced their return for ACE 2016 include Mr Taimur Shoaib, Dr Simon Ravichandran, Dr Daron Seukeran and Dr Maria Gonzalez. They will be joined by new additions to the ACE team of industry leaders, including Dr Uliana Gout, Dr Kieren Bong and Dr Kate Goldie.

A novel addition to this year’s agenda is the new Treatments on Trial programme, where delegates will be offered an exclusive opportunity to directly compare products with similar indications in an active debate with company representatives.

During each session, which will take place on Saturday 16, four different company representatives will give demonstrations of their product, describing the main benefits and presenting patient results. Delegates will then be able to get involved in an engaging question and answer debate, discussing product usage, techniques and potential contraindications.

ACE 2016 will again include the extremely popular live demonstration Expert Clinic agenda, with sponsors including Syneron Candela, SkinCeuticals, Fusion GT and AesthetiCare already confirmed. These sessions represent a fantastic opportunity for leading cosmetic injectors and skincare professionals to showcase the best techniques and lend practical advice to delegates. The agenda will also include non-sponsored discussions on managing filler complications, facial anatomy, lasers and chemicals peels from expert practitioners.

Leading aesthetic companies will be welcomed to ACE to host Masterclasses, providing an exclusive opportunity for delegates to learn more about products, best practice techniques and patient outcomes in 90 minute in-depth workshops.

The Business Track agenda will deliver invaluable insights on how practitioners

Aesthetics | November 2015

Conference Preview ACE 2016

and professionals can develop their aesthetic practice. Featuring advice from experienced consultants in marketing, regulation, sales, finance, and law, these sessions will focus on crucial guidance for practitioners and clinic managers in order to create a successful practice and stand out from competitors. The wide-range of discussions will enable delegates to further develop their knowledge and understanding of how to make a practice costefficient, increase retention and improve patient satisfaction. These sessions, which will run across both days, will focus on development across all areas, from front-of-house staff to clinic managers and business owners. For each session attended, delegates will be able to apply for CPD accreditation, with Conference sessions awarded 1–1.5 points, Masterclasses given 1.5 each, Expert Clinic sessions worth 0.5–1 point, Business Track sessions worth 0.5 points and Treatments on Trial attendees awarded 2 points. Alongside the comprehensive educational programme, the 2,500m² exhibition floor will feature more than 100 top medical aesthetic suppliers, with representation from Healthxchange, AestheticSource, Lynton Lasers and BTL Aesthetics among many others who will showcase cutting-edge products, advances in services, and innovations to target an array of medical aesthetic concerns.

Delegates can register for free online to gain access to the Masterclass, Expert Clinic, Treatments on Trial and Business Track agendas, as well as the Exhibition floor. The paid-for premium Conference programme will include eight sessions from a team of more than 20 world-leading speakers, focusing on key anatomical areas of the body, including the stomach, forehead, perioral, periorbital, mid-face, neck and décolletage, temple, thighs and buttocks and vaginal rejuvenation. Delegates will have the choice to book either a one-day pass for the Friday or Saturday, or a two-day pass to experience the whole agenda.

To book your place at ACE 2016 and to find out more visit www.aestheticsconference.com HEADLINE SPONSOR

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Special Feature Facial Resurfacing

Delving beneath the surface of peels and lasers Skin resurfacing using chemical peels and lasers of different modalities are popular and effective methods of rejuvenating skin, as well as treating some skin complaints. Allie Anderson speaks to practitioners about how they should be used in aesthetic clinics They say youth is wasted on the young, and this is perhaps particularly true in relation to the skin. Until the age of around 30, most people are relatively carefree when it comes to looking after their skin, since, to a great extent, the skin appears to look after itself. The process of skin cell renewal is reliable and consistent, and crucially – it’s relatively rapid.1 With age and poor treatment of the skin, however – be it sun exposure, smoking, or lack of an adequate skincare regime – successful skin cell renewal becomes more challenging.1 SKIN REJUVENATION During skin cell renewal, firstly, the outermost layers of the epidermis (the stratum corneum) are shed naturally through a process called desquamation.

New cells are then formed beneath that gradually make their way towards the surface, in a process called keratinisation,1 meaning that damaged skin is renewed regularly. Second, fibroblasts in the dermis deposit wellstructured and plentiful collagen fibres, which keep the skin plump and elastic.2 As a result, the face retains the characteristics of youthful skin, despite behaviours that will, in time, degrade its health. As we age, however, these youth-prolonging mechanisms become less effective. The matrix that holds the stratum corneum together becomes denser, enabling the cells to build up, and consequently making desquamation more difficult and keratinisation slower.1 Moreover, collagen synthesis begins to decline during our 20s and 30s, and the collagen that is produced is increasingly fragmented and degraded thereafter, causing the skin to weaken and lose elasticity.2 Although taking care of the skin from a young age will go some way to staving off the tell-tale signs of facial ageing, they are inevitable.

But for those wishing to turn back the clock, an effective method of rejuvenation is skin resurfacing, the goal of which is to bring new skin to the surface by mechanical or chemical removal of the topmost layer. Perhaps

paradoxically, resurfacing entails controlled injury to the skin in order to improve its appearance. This can be performed by peeling or the application of lasers: a third option – dermabrasion – is not discussed herein.

PEELS In a peeling treatment, chemicals are applied to the skin so that the epidermis peels away, revealing fresh skin beneath. As well as proving effective in combatting and reversing visible signs of skin ageing – such as fine lines and wrinkles; dull, rough skin; enlarged pores; uneven tone; and areas of pigmentation – peels can be used to treat acne and resulting scarring, rosacea and pigmentation disorders such as melasma and chloasma.3 Peel solutions are categorised in part by how deeply they penetrate into the skin, ranging from superficial (or micro/light), medium and deep peels, with results typically improving as penetration depth increases.4 Superficial peels – these commonly contain either alpha-hydroxy acid (AHA), such as glycolic acid; or beta-hydroxy acid (BHA), such as salycilic acid, at various concentrations.5 • Glycolic acid – the preferred treatment at James Willis Faces is a glycolic acid solution, supported by a robust homecare regime both in preparation for and following the peel itself. “We have a mandatory two-week home preparation period that comprises a simple but effective five-step procedure, one of which involves a little bit of glycolic acid,” explains managing director and therapist Alison Procter.

“That routine is maintained for around six months after treatment as well. For the peel itself, we provide a series of six glycolic peels of increasing strength, one a week for six weeks, and the effects are very impressive.” The first peel is normally 40% glycolic acid concentration, and based on a number of factors such as the patient’s age, skin type, the severity of the complaint and the desired result – as well as how the patient reacts to the mildest solution – subsequent peels will contain an added exfoliant (proteolytic enzymes), a higher concentration (70%) of glycolic acid, or both.

• Salycilic acid – this formulation is often favoured when treating patients with skin of colour. Dermatologist Dr Marina Landau says, “For a superficial peel I might use the BHA salycilic acid, which is less inflammatory and can therefore be used relatively safely on darker phenotypes.” Published evidence suggests that such superficial peels are the best and sometimes the only option for Fitzpatrick skin types IV and above.6 This is because deeper peels carry an increased risk of post-inflammatory hyperpigmentation, to which darker skin types are more susceptible.7 Salycilic acid has been shown to elicit more marked long-term Aesthetics | November 2015

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improvements with fewer side effects, and is better tolerated, than glycolic acid in patients with acne.3 • Naturally derived acids – a holistic approach to skincare is imperative to the Diane Nivern Advanced Skincare and Medical Aesthetics clinic, and this is reflected in the resurfacing treatments on offer. “The peels I use mostly comprise acids that are naturally derived, as opposed to synthetic, laboratory-standardised chemicals. That fits more comfortably with our ethos, which entails a whole-person approach to skin health and skin rejuvenation,” Nivern explains.

“These peels will normally contain naturally occurring citric, malic or lactic acid, combined with ingredients that help to feed, peel and restore the skin at the same time.” These include centella asiatica, which has numerous applications in cosmetology and is known for its wound healing properties; it promotes the proliferation of fibroblasts and increases collagen synthesis, inhibiting inflammation and thereby ensuring newly formed skin is stronger.8 Nivern reports that the system she uses produces good results in cohorts of patients with wide-ranging complaints, including: ageing skin; younger people with congested skin; men with ingrowing hairs; people with adult-onset acne or acne pitting and scarring; and irregular pigmentation in black, Asian and Chinese patients.

Medium-depth peels – whereas superficial peels, as their name suggests, penetrate superficially, medium-depth peeling inflicts controlled injury down to the papillary dermis.9 “Most peels are epidermal in nature,” says Dr Tahera Bhojani-Lynch from The Laser and Light Cosmetic Medical Clinic. “If you get a little bit through to the dermis, you produce more collagen; the new skin is a bit tighter and it gives you some additional effects.” An often-used ingredient is trichloroacetic acid (TCA) at strengths of between 15% and 40% concentration. Because the peeling agent penetrates more deeply (according to its concentration), these effects are typically achieved with one treatment, where a series of treatments is needed with a more superficial peel. A comparative study found that single TCA (35%) peels generate significantly greater improvement in cheek wrinkles and are associated with higher patient satisfaction than a series of 30% glycolic peels, although the former is associated with much greater discomfort.10 According to Dr Bhojani-Lynch, a moderate TCA peel is her go-to treatment to reverse signs of ageing in patients who have more severe sun damage, and is safe and effective for darker skin types at a low concentration.6 “You could use a mild TCA peel and repeat it over two or three weeks to get the effect of a moderate peel, but you would need to exercise caution,” she adds.

Special Feature Facial Resurfacing

therefore there is a significant risk of hypopigmentation, even in lighter-skinned patients.11 The advantage, says Dr Bhojani-Lynch, is that you can get the more advanced results associated with deeper penetration. Caution is crucial because of the toxicity profile of phenol, which is rapidly absorbed and can cause serious harm.12 As it’s a much more painful procedure than shallower peels, sedation or anaesthetic may be required.13 “Most phenol peels are only done on very small areas, like under the eyes and across the top lip – and they tend to be performed in hospitals where there are resuscitation facilities,” adds Dr Bhojani-Lynch. In fact, UK guidelines recommend phenol peels are carried out by an experienced surgeon or dermatologist on Care Quality Commission-registered premises.13 APPLICATION OF PEELS The procedure tends to be more or less standard, regardless of the type of peel. First, the face is fully cleansed, often with an acetoneor alcohol-based solution to degrease the skin. A barrier gel may also be applied to the more delicate areas, such as the nasolabial folds. The practitioner applies the peel and, with many types of peels, determines how long it is left on by observing the patient’s response and monitoring changes in the skin’s appearance. “We’re looking for flushing, redness, and frosting of the skin, where it goes very pale,” explains Nivern, “at which point we would immediately neutralise and wash off the peel.” However, not all peel treatments have a visible endpoint that indicates that it has reached optimum success. Procter’s glycolic system involves the peel being left on the treatment area for a set time of 10 minutes (assuming it is tolerated), before neutralising the acid with warm water sponges. After this, and depending on the specific protocol, a combination of serums, moisturisers and – most notably – a high-SPF (30 to 50+) sun cream is applied. Practitioners interviewed concurred that strict, continued use of sun protection and lifelong UV avoidance is the most important factor in the success of any resurfacing treatment, and in preventing and minimising complications.14 CONSIDERATIONS Occasional side effects and complications are possible, as outlined below:

PEEL DEPTH

Potential side effects/complications3 Transient burning Irritation Erythema

Before deep peel

Two months after deep peel

SUPERFICIAL

Scarring (rare) Post-inflammatory Hyperpigmentation (PIH) (rare) Infection (rare)

Pigmentary changes Infection Allergic reactions Images courtesy of Dr Marina Landau

Deep peels – more aggressive peels containing phenol are now rarely used in the UK, because of the increased risk of complications and adverse effects, when compared with superficial and mediumdepth peels.11 These occur because phenol is a stronger solution and penetrates several layers causing a second-degree burn;

MEDIUM AND DEEP PEELS

Aesthetics | November 2015

Compromised skin healing Hypersensitivity Lines of demarcation between treated and untreated areas Scarring Persistent redness

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Special Feature Facial Resurfacing

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The practitioner’s expertise is an important factor in preventing complications: they should identify patients who may be more at risk (those with PIH and keloid scars and people who are deemed potentially uncooperative), and select a peel depth that balances desired results with possible adverse events for each patient.3 Contraindications include isotretinoin, used to treat severe acne; guidelines suggest waiting six months after discontinuing the medication before undergoing chemical peeling.15 Notwithstanding, anecdotal evidence shows overwhelmingly that superficial and medium-depth peels are, for the most part, safe and relatively free of complications, hence their popularity. “Chemical peels are an important part of my treatment armamentarium, and I feel comfortable with this procedure because it has a long history,” comments Dr Landau. Research supports this view, suggesting that dermatological uses date back as far as the 1870s.16 Dr Landau adds, “Patients understand the idea of renewing the skin by peeling off the old layers and the clinical results are impressive.”

LASERS The core component of laser resurfacing is heat, and most often uses light waves for its creation. When a wavelength of light is applied to the skin, it targets substances in the skin’s molecules called chromophores, which absorb the light and turn it into heat energy.

Different light wavelengths penetrate at different depths and target particular chromophores – haemoglobin for vascular lesions,17 melanin for pigmented lesions,18 and water for lines and wrinkles. 19 Generally speaking, two types of lasers are used in skin resurfacing: ablative and non-ablative.

Ablative lasers – Ablative lasers cause wounding to the skin and, consequently, removal of its outermost layers, thereby stimulating renewal of collagen-rich skin beneath.

Non-ablative lasers – Non-ablative lasers also work by boosting collagen production, but they bypass the top skin layers and conduct heat deeper in the dermis. Targeting water chromophores, a cellular reaction is triggered that stimulates the production of collagen and elastin, thus firming and plumping the skin.20 Fractional lasers – A more recent development, the fractional laser is commonly used as an intermediate treatment between the former two, working at both the epidermal and dermal layers. The laser beam is divided into thousands of minuscule columns, each intensely targeting a tiny fraction of the skin at a time while leaving surrounding tissue unharmed. This promotes faster healing than the traditional laser procedures, in which the whole area is exposed.21 Consultant dermatologist and medical director of sk:n clinics, Dr Firas Al-Niaimi, offers a combination of full-area, fractional, ablative and non-ablative treatments, using erbium-doped yttrium aluminium garnet (Er:YAG) and carbon dioxide (CO2) as their media. “Depending on the severity of the condition treated, the patient’s age and skin type, and the downtime request, we can choose the most appropriate laser,” he comments. “The fractional non-ablative laser has a shorter downtime, but it will require a number of treatments because the effects are not as dramatic as ablative. But if someone has a severe form of wrinkling or acne scarring, and does not mind downtime, then obviously the ablative resurfacing will be quicker and give better results.”

Radiofrequency lasers – These (non-ablative) lasers use radiofrequency (RF) energy, rather than light energy, to generate the heat required to affect the resurfacing process. Lucy Xu, treatment director at Premier Laser and Skin, explains, “The system we use utilises gold-plated isolated microneedles to deliver 26

Aesthetics Journal

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Before

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After

Results following treatment with the Lumenis Ultrapulse CO2 laser. Images courtesy of Joseph Niamtu II DMD

RF energy to the deep, middle and upper level dermis and the epidermal layer. This creates controlled thermal damage that generates a tightening effect, and triggers a healing response in the dermis to boost collagen production.”

APPLICATION OF LASERS Machines typically either have a rolling motion, whereby the head is rolled over the skin in a number of passes; a stamping motion, where the hand-piece is moved up and down between adjacent areas of skin to be treated; or a scanning-type mode. The skin is numbed with a topical solution for around 45 minutes: for full resurfacing, which is more painful and requires greater downtime, local anaesthetic is injected. Next, the skin is thoroughly cleansed and when goggles are in place to protect the patient’s eyes, the treatment is applied. The skin is lasered one area at a time based on the laser’s spot size, although, according to Dr Al-Niaimi, best results are achieved by treating the entire face to avoid visible demarcation. “The face is divided into so-called ‘sub-units’. At a minimum, you would treat an entire sub-unit – the whole nose or the whole mouth unit – or, for optimum results, you treat the entire face, but you use a ‘blending’ technique,” he explains. This involves applying a milder form of laser to the rest of the face, feathering the borders with low-pulse energy and density.22 As with peels, post-laser aftercare centres on sun protection. In addition, regular cleansing and moisturising is essential – using occlusive ointments following ablative procedures and lighter moisturisers for non-ablative. “A good antiseptic is the key component of good aftercare to prevent infection,” explains Dr Al-Niaimi. “Patients are able to return to work the day after a RF resurfacing treatment,” adds Xu. COMPLICATIONS Types of complications include: • Erythema • PIH • Infection • Scarring • Swelling • Severe itching • Acne The severity of each complication can be classified as minor, intermediate or major and will vary depending on the type of patient and concern treated, as well as the strength of the laser used.22,23

Aesthetics | November 2015

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Notwithstanding, most devices and types of laser are deemed safe and effective, balanced against the pain and downtime of the procedure itself. Most complications have been shown to be caused not by device malfunction, but by errors on the part of the practitioner.24 In the hands of experienced and reputable aestheticians, one can expect these complications to be minimal.

CONCLUSION Skin resurfacing by application of chemical peels or lasers is a popular choice for patients. Like any aesthetic procedure, especially those that cross over into the realm of medical treatment, it is essential that clinicians fully understand the complexities and potential pitfalls of these options. In capable hands, however, skin resurfacing can be a safe and effective treatment and therefore, a valuable addition to the practitioner’s toolbox.

FURTHER READING Dr Firas Al-Niaimi, ‘Laser complications in aesthetic procedures’, Aesthetics, Volume 1/Issue 11, October 2014.

REFERENCES 1. Howard, D., Skin Exfoliation 101, (Los Angeles: International Dermal Institute) <www.dermalinstitute. com/uk/library/28_article_Skin_Exfoliation_101.html> 2. SmartSkincare.com. Skin collagen: more than meets the eye. <www.smartskincare.com/ skinbiology/skinbiology_collagen.html> 3. Rendon, M et al., ‘Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing’, The Journal of Clinical and Aesthetic Dermatology. 2010 Jul; 3(7): 32-43. <www.ncbi.nlm.nih.gov/pmc/articles/PMC2921757/> 4. Landau, M., ‘Chemical peels’, Clinics in Dermatology. 2008 Mar-April; 26(2):200-8. <www.ncbi. nlm.nih.gov/pubmed/18472061> 5. www.paulaschoice.com/expert-advice/nonsurgical-skin-care-treatments/_/what-does-achemical-peel-do 6. Sarkar, M et al., ‘Chemical peels for melasma in dark-skinned patients’, Journal of Cutaneous and Aesthetic Surgery. 2012 Oct-Dec; 5(4): 247-253. <www.ncbi.nlm.nih.gov/pmc/articles/ PMC3560164/> 7. Ho, SG and Chan, HH., ‘The Asian dermatological patient: review of common pigmentary disorders and cutaneous diseases’, American Journal of Clinical Dermatology. 2009;10(3) 153-68. <www.ncbi.nlm.nih.gov/pubmed/19354330/> 8. Bylka, W et al., ‘Centella asiatica in cosmetology’, Advances in Dermatology and Allergology.

2013 Feb; 30(1): 46-49. <www.ncbi.nlm.nih.gov/pmc/articles/PMC3834700/> 9. Monheit, G., ‘Chemical Peels’, Skin Therapy Letter. 2004;9(2). <www.medscape.com/ viewarticle/469514_3> 10. Kitzmiller, WJ et al., ‘Comparison of a series of superficial chemical peels with a single midlevel chemical peel for the correction of facial actinic damage’, Aesthetic Surgery Journal/The American Society for Aesthetic Plastic Surgery. 2003 Sep-Oct;23(5):339-44. <www.ncbi.nlm.nih. gov/pubmed/19336097> 11. Healthwise, Chemical Peel, WebMD (Atlanta). <www.webmd.com/beauty/peels/chemical-peel> 12. Health Protection Agency., Phenol – Toxicological overview. Gov.uk (London) 2007. <www. gov.uk/government/uploads/system/uploads/attachment_data/file/338247/hpa_phenol_ toxicological_overview_v2.pdf> 13. Department of Health., Review of the Regulation of Cosmetic Interventions, Call for Evidence.

Gov.uk (London) 2012.<www.gov.uk/government/uploads/system/uploads/attachment_data/ file/216906/Call-for-evidence-cosmetic-procedures.pdf> 14. Nikalji, N et al., ‘Complications of Medium Depth and Deep Chemical Peels’, Journal of Cutaneous and Aesthetic Surgery. 2012 Oct-Dec; 5(4): 254–260. <www.ncbi.nlm.nih.gov/pmc/ articles/PMC3560165/> 15. Monheit, GD and Chastain, MA., ‘Chemical peels’, Facial plastic surgery clinics of North America.

2001 May;9(2):239-55, viii. <www.ncbi.nlm.nih.gov/pubmed/11457690/> 16. Brody, HJ et al. A History of Chemical Peeling. Dermatologic Surgery. 2000 May;26(5): 405-409 17. Farhadieh, R, Bulstrode, N and Cugno, S., ‘Plastic and Reconstructive Surgery: Approaches and Techniques’, John Wiley & Sons, 2015.

18. Ashton, R and Leppard, B., ‘Differential diagnosis in dermatology’, Radcliffe Publishing, 2005.

19. Patil, UA and Dhami, LD., ‘Overview of lasers’, Indian Journal of Plastic Surgery, October 2008; 41 (Suppl): S101-S113. <www.ncbi.nlm.nih.gov/pmc/articles/PMC2825126/> 20. Fodor, L, Elman, M, Ullmann, Y., ‘Aesthetic Applications of intense pulsed light’, 2011. Chapter 2, Light Tissue Interactions, p.11-20.

21. Ngan, V., Fractional laser treatment. DermNet New Zealand Trust, 2015. <www.dermnetnz.org/ procedures/fractional.html> 22. Macrene, R et al., ‘The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative laser resurfacing’, Journal of the American Academy of Dermatology. 2008 May; 58(5): p.719-737.

23. Tanna, T., Skin Resurfacing – Laser Surgery Treatment & Management, Treatment, Complications, Medscape. 2014. <emedicine.medscape.com/article/838501-treatment#d13> 24. Zelickson, Z et al., Complications in cosmetic laser surgery: a review of 494 Food and Drug Administration Manufacturer and User Facility Device Experience Reports. Dermaologic Surgery Journal/The American Society for Dermaologic Surgery, 40 (4) (2014), pp. 378-82.

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CPD Laser Drug Delivery

Laser-assisted Drug Delivery: a novel use of lasers in dermatology Dr Firas Al-Niaimi examines how lasers can penetrate the stratum corneum to aid treatment of aesthetic concerns Abstract Topical medicaments are the mainstay of the dermatologists’ therapeutic arsenal. The stratum corneum in the upper layer of the epidermis is rather impermeable to water-soluble and large molecules. Traversing this layer is key to optimal drug delivery.

Studies thus far suggest that laser pre-treatment improves transepidermal absorption of topical agents and allows for a much deeper penetration of drugs than is possible with topical medicaments alone. Laser-assisted drug delivery enhances the ability of topically-applied medicaments to penetrate the skin, which may allow for more efficacious action of current treatments; such that conventional duration of treatment can be shortened or lower concentrations of active agents be used, potentially obviating side effects of treatment. In order to discuss how we eventually got to this stage, it is important to look at the animal model studies that have supported the concept of laser-assisted drug delivery.

There has been a tremendous interest in the application of this modality across a range of dermatologic and aesthetic procedures.

This article will, however, only focus on the aesthetic component; although this modality has been used in dermatologic conditions such as actinic keratosis, Bowen’s Disease, basal cell carcinoma, vaccination, local anaesthesia, haemangioma, and burn scars. For further information on these applications the reader is advised to look up the recent published studies in this field.

the passage of molecules to the cutaneous compartments is comparatively unimpeded.5 Laser technologies deploy a particular wavelength of light to selectively destroy the chromophore of interest. Ablative lasers in common use include the carbon dioxide (CO2; wavelength peak 10,600 nm) and erbium-doped yttrium aluminium garnet (Er:YAG; wavelength peak 2940 nm) devices, both of which have wavelengths targeting water.6 The water molecules are found both intra- and extra-cellularly. Laser devices have traditionally been used in continuous mode, in which the entirety of the water-containing epidermis being treated is ablated.6 More recently, ablative fractional laser technologies (AFXL) have been developed. AFXL exploits fractional photothermolysis, in which multiple vertical columns of tissue are thermally destroyed to create unimpeded channels communicating with the outermost layer of the stratum corneum.1-3 Each channel is surrounded by a cuff of dense thermally-coagulated tissue, collectively referred to as microscopic treatment zones (MTZs).7 Only a fraction of the skin surface is treated, in which MTZs facilitate penetration of topical molecules from the surface to the layer of interest, whilst leaving most of the skin surface area untreated and intact.7 The untreated skin serves as a reservoir of stem cells, growth factors and inflammatory cells that are able to rapidly migrate to the traumatised skin and facilitate faster healing with less scarring.8 The depth of these ablated channels can be determined by the fluence used.

Increased penetration of drugs or molecules via MTZs can be understood using Fick’s first law in physics (Figure 1), which in its simplest form states that the degree of flux of molecule (J) across a barrier is a product of the partition coefficient (Km, a reflection of the number of molecules available for diffusion across a membrane), the diffusion constant (Dm, a reflection of the inherent diffusibility of a molecule across the membrane) and concentration difference of that molecule on either side of that barrier (ΔC), divided by the path length (L):9

Introduction Topical therapies play an important role in dermatology, whether used for inflammatory dermatoses, (pre)malignant skin disease or aesthetic indications. For optimal therapeutic effect, delivery of the drug to the relevant compartment within the skin is required.

In recent years, ablative laser devices have been employed to aid delivery of biological molecules throughout the various cutaneous compartments.1-3 Whilst other physical mechanisms to enhance transdermal drug delivery have been investigated, including tape stripping, iontophoresis, radiofrequency, ultrasound and J = Km x Dm x ΔC microneedling,1 the focus of this article is to review the rationale underlying laser-assisted delivery of drugs and explore L the future considerations of this modality. Non-laser methods of delivery will Figure 1: Fick’s first law in physics not be discussed here owing to the breadth of the subject.

Increased permeability of the stratum corneum via MTZs increases Mechanisms of laser-assisted drug delivery Km, therefore increasing the overall flux of the molecule. As the The stratum corneum is the outermost layer of the skin and is molecular size of the drug increases, there is greater frictional largely impregnable to compounds with molecular weights greater resistance to movement of the molecule and Dm decreases, hence than 500 Daltons (Da).4 Once the stratum corneum is traversed, decreasing overall flux.9 Aesthetics | November 2015

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Pre-clinical studies: animal models Work on animal models has informed the clinical use of AFXL. Photodynamic therapy (PDT) comprises the photodynamic reaction between a photosensitiser, light of a select wavelength (or band) and oxygen to generate reactive oxygen species that target microbes and malignant cells. PDT is most commonly used in dermatological practice to combat non-melanoma skin cancer (NMSC) and acne vulgaris.10 Haedersdal undertook CO2-AFXL prior to treatment with MAL-PDT on porcine skin creating single MTZs, each 300 micron in diameter and 1850 micron in depth, surrounded by a 70 micron cuff of thermally coagulated tissue.11 In skin treated with AFXL and MALPDT (AFXL-PDT), increased porphyrin fluorescence was observed in a uniform fashion up to 1.5 mm from the ablated channels. This suggested that for MAL, MTZs placed at 3 mm intervals, equating to less than 1% surface area, could be used to treat the entirety of the lesion. This finding is substantiated by an additional study that used an Er:YAG laser to create multiple MTZs, and suggested that there is no increase in lidocaine absorption if the number of pores is increased beyond a certain density.12 Moreover, there was no increased absorption of lidocaine if progressively higher fluences were used to extend the MTZs beyond the stratum corneum into the epidermis or dermis.12 5-fluorouracil (5-FU) is a chemotherapeutic agent commonly used in dermatology for treatment of NMSCs, including actinic keratoses (AKs), Bowenâ&#x20AC;&#x2122;s disease and superficial basal cell carcinomas (BCCs).13 Imiquimod (5%) is a commercially available immunomodulatory agent that is similarly used to treat various NMSCs.14 Work in murine skin has suggested that 5-FU penetration was enhanced 36-133 fold following pre-treatment with Ruby, CO2 or Er:YAG lasers.15 Similar work has demonstrated enhanced transdermal delivery of imiquimod in porcine and murine models following a low-fluence fractional Er:YAG laser,16 with enhanced imiquimod delivery up to 65 fold after one pass and 127 fold after four passes. The authors further demonstrated that reduction in dose of imiquimod to 0.4% delivered equivalent concentrations of imiquimod as topically applied 5% imiquimod (commercially available), which may allow for the future use of lower concentrations of drugs leading to similar clinical efficacy.16 Together, these findings in porcine skin suggest that there is a critical density of MTZs, beyond which additional MTZs confer no benefit with respect to penetration of the drug. Photosensitisers can penetrate superficial and deep levels of skin and conventional settings for the LED illumination can be employed. Pre-treatment with AFXL permits greater penetrance of drug, in particular larger and more hydrophilic molecules, which may act in a shorter timeframe.2,3 Furthermore, AFXL pre-treatment may improve efficacy of topically-applied medicaments and permit lower concentrations of active agents to be used with reduced frequency or duration of application.

Local anaesthetics Many dermatological procedures are performed under local anaesthesia. Topical agents have a long latency before effect takes place and anaesthesia may be incomplete owing to poor penetration of the skin, whilst injections are associated with pain.

Pre-treatment with the conventional Er:YAG laser prior to application of topical 4% lidocaine has been shown to reduce sensation to needle prick within five minutes compared to laser plus placebo (62% reduction) or lidocaine alone (61% reduction).17 Similarly, a 30

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Larger trials with greater numbers within treatment and control arms are required for each of the proposed therapies to corroborate efficacies and side effects of therapy blinded randomised controlled trial (RCT) of 61 patients (adults and children) attending the emergency department who required cannulation showed that pain upon cannulation was significantly lower when pre-treated with the Er:YAG laser prior to application of 4% lidocaine.18 There appears to be no diminution in the degree of analgesia at lower energy laser settings (2.0J/cm2), compared to the high energy (3.5J/cm2) settings used in the aforementioned studies, as inferred from an intra-individual study of 30 patients comparing both settings, with one used on each antecubital fossa.19 These proof of principle studies are supported by clinical applications. In a randomised, split-face clinical study of 12 patients, Yun and colleagues looked at the effect of pre-treating one side of the face with low fluence Er:YAG prior to application of 5% topical lidocaine and whole face resurfacing in two passes.20 Subjective pain scores on the side of the face that had been pre-treated with ablative laser were significantly lower than the side not pre-treated with ablative laser. However, only 56% patients were able to tolerate the second pass of the resurfacing, forcing us to question its value in future work.

Vitiligo Vitiligo is an auto-immune condition in which depigmented patches occur on the skin. In a study involving 25 patients with stable, symmetrical vitiligo, recalcitrant to other therapies, a half-body comparative analysis, in which patches of vitiligo on one half of the body underwent CO2-AFXL, followed by topical application of betametasone solution under occlusion followed by a course of narrowband-ultraviolet B (NB-UVB) phototherapy (treatment), whilst patches on the other side (control) received CO2-AFXL and NB-UVB alone was performed.21 Treatments with CO2-AFXL were given at half monthly intervals, whilst NB-UVB was given two to three times weekly over six months. 44% of patients achieved more than 50% repigmentation on the treatment arm, which was significantly better than the control arm, owing to greater penetration of the topical corticosteroid. Whilst the results are of interest, the protracted course of treatment and associated expense may preclude this treatment in other healthcare systems, however the study provides further support of the application of this concept.

Hypertrophic and keloid scars Improvement in the appearance of scars is often observed following AFXL treatment and is likely attributable to removal of a section of the fibrotic scar and a relative normalisation of collagen

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structure and composition.22 Waibel investigated 15 patients with hypertrophic scars resulting from trauma, injury or burns. Each patient received up to five treatments with CO2-AFXL (10-15% density using the UltraPulse Lumenis machine) followed by topical triamcinolone application (10mg/ml or 20mg/ml).23 Blinded observers noted improvements in texture, degree of hypertrophy and dyschromia at six months following the final treatment session. The authors suggest that AFXL as a method of drug delivery may have benefit over triamcinolone injections owing to uniformity of depth and distribution of triamcinolone, as well as avoiding the pain associated with intralesional injections.

Another group reported the treatment of a total of 70 keloid scars in 23 patients with 2940 nm AFXL (180â&#x20AC;&#x2030;J/cm2, 5% coverage) every other week with concomitant betametasone cream twice daily under occlusion until either complete flattening of the scar was achieved or no further improvement was seen.24 After a median of nine laser treatments, there was a median 50% improvement in scar appearance, gauged through photographic evaluation by two independent observers. Eight months after treatment, keloid recurrence was 22%; all recurrences were noted within two months of cessation of laser treatment.

Atrophic scars Poly-L-lactic acid (PLLA; Sculptra) is commonly used as a subcutaneous filler for facial volume restoration, which is purported to stimulate fibroblast proliferation and collagen formation. 19 patients with atrophic scars from various causes, including acne, trauma and surgery, were treated with CO2-AFXL followed by topical application of PLLA.25 The treatments appeared to be tolerated with postprocedural mild pain, while erythema and swelling were the most commonly cited concerns. Each patient required an average of one single treatment. Four blinded observers reported improvements in scar contour, atrophy and colour three months after treatment.26 Despite the above being a non-controlled study, PLLA is a large molecule and will not be able to penetrate the impermeable stratum corneum.27 The improvement observed suggests the enhanced penetration was achieved through pre-treatment with AFXL. It is also possible that the AFXL effects on upregulating collagen synthesis may have had a synergistic effect with PLLA.

Pre-treatment with the conventional Er:YAG laser prior to application of topical 4% lidocaine has been shown to reduce sensation to needle prick within five minutes

CPD Laser Drug Delivery

Figure 2: The diagram shows columns of fractional ablated tissue with small drug molecules passing through it to reach deeper parts of the skin.

Botulinum toxin Botulinum neurotoxin type A (BoNTA) is a neurotoxin secreted by Clostridium botulinum, an anaerobic, Gram-positive bacterium and is widely used to reduce the appearance of wrinkles and rejuvenate the skin. Recent work suggests that topical application of BoNTA (in its current form) may not penetrate the stratum corneum to elicit clinically discernible endpoints compared with injected toxin.28 A split face study was conducted on 10 subjects involving C02-AFXL of the face with application of topical BoNTA on one side and normal saline on the other side as a control.28 Compared with the control side, topical application of BoNTA resulted in significant reduction in the number of periorbital wrinkles at one week and one month following treatment.

These results suggest that BoNTA delivery can be enhanced pretreatment with AFXL. Comparison with injectable BoNTA and newer topical formulations of botulinum neurotoxin remain to be performed and will likely guide development of this novel method of delivery in the near future.29 Non-ablative fractional laser More recently, work has been undertaken using non-ablative fractional lasers (NFXL), in which a controlled zone of thermal injury is generated, rather than a fully ablated MTZ. Pre-treatment with the non-ablative 1550-nm erbium glass laser has been shown to enhance delivery of Amino-levulinic acid in human subjects, as gauged by cutaneous porphyrin fluorescence.30 Advantages of non-ablative devices are increased patient tolerability and reduced post-procedural downtime.31 Although there has been some use of this technology in combination with topical therapy (bimatoprost for hypopigmented scars for example),32 use of such technology is yet to be used in larger clinical studies. In addition, it is unclear if the effect of pre-treatment with NFXL enhanced the penetration of the molecule, as the latter can penetrate easily through the stratum corneum.

Platelet rich plasma Platelet-rich plasma (PRP) has gained a lot of popularity in recent years and has been used in dermatologic practice in cases of scarring, alopecia, wound healing, and rejuvenation.33 PRP has been used post AFXL in a number of studies although primarily as an adjunctive to enhance synergistic effect of the AFXL and to reduce post AFXL erythema.34 None of the published studies primarily looked at AFXL to enhance the delivery of PRP but it is plausible that the combination of both modalities has synergistic effects.35 In clinical practice some practitioners routinely use the application of PRP post AFXL; primarily to speed up recovery and reduce post-procedural erythema.

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31

CPD Laser Drug Delivery

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1. The stratum corneum is the outermost layer of

3.

4.

5.

the epidermis and is impermeable to large and hydrophilic molecules Ablative fractional lasers create channels of ablated tissue with islands of normal skin in between to hasten recovery Laser-assisted drug delivery through the use of fractional ablative lasers has gathered increasing interest in recent years Currently, most of the evidence with this modality is with the combination of photodynamic therapy and fractional lasers Alternative methods of drug delivery include the use of ultrasound, radiofrequency, electroporation and iontophoresis

Future considerations Larger trials with greater numbers within treatment and control arms are required for each of the proposed therapies to corroborate efficacies and side effects of therapy. Future cohorts will need to account for differing body sites, and efficacy of treatments in varying ages, genders and ethnicities. Optimal laser parameters, including fluence, density and scheduling of treatments, need to be determined to facilitate maximal drug penetration, whilst allowing rapid recuperation of the skin. As well as selecting which drug within a category (such as corticosteroids) is likely to yield the best result, the optimal vehicle for topically applied medicaments, whether gels, patches, creams or ointments, together with duration and frequency of application and the necessity for occlusion is yet to be determined. Additional consideration needs to be afforded to potential toxicity from medicaments, as already has been demonstrated with lidocaine toxicity occurring following AFXL resurfacing.28 Furthermore, these drugs or molecules were designed for topical application and their current concentrations may prove too high or toxic for direct dermal introduction. Rigorous health economic analysis comparing the efficacies and cost-effectiveness of these new modalities of treatment compared to tested, longer-established treatments may ultimately determine the take-up of these new technologies, at least in clinical practice.

Conclusion Work on animal models and preliminary initial studies have supported the use of AFXL technology as a future adjunct to topical therapies. Studies thus far suggest that AFXL improves transepidermal absorption of topical agents and allows for a much deeper penetration of drugs than is possible with topical medicaments alone. This may allow more efficacious action of current treatments, such that conventional duration of treatment can be shortened or lower concentrations of active agents be used, potentially obviating side-effects of treatment. The prospect of using AFXL to facilitate transdermal vaccination and as an adjunct for inflammatory dermatoses and cosmetic indications remain in its infancy. As larger trials are published, involving greater numbers 32

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of patients and utilising various laser and topical medicament parameters, we will enhance our understanding of this nascent modality of treatment delivery and better serve the patients.

Key points

2.

Aesthetics Journal

Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon, based at St Thomas’ Hospital, London.

He is a group medical director at sk;n clinics and has authored more than 95 publications and 120 scientific presentations. Dr Al-Niaimi is also on the advisory board of a number of respected journals.

REFERENCES 1. Bloom BS, Brauer JA, Geronemus RG. ‘Ablative fractional resurfacing in topical drug delivery: an update and outlook’, Dermatol Surg 2013; 39:839–848.

2. Sklar LR, Burnett CT, Waibel JS, et al. ‘Laser assisted drug delivery: a review of an evolving technology’, Lasers Surg Med 2014; 46:249–262.

3. Brauer JA, Krakowski AC, Bloom BS, et al. ‘Convergence of anatomy, technology, and therapeutics: a review of laser-assisted drug delivers’, Semin Cutan Med Surg 2014; 33:176–181.

4. Bos JD, Meinardi MM. ‘The 500 Dalton rule for the skin penetration of chemical compounds and drugs’, Exp Dermatol 2000; 9:165–169.

5. Scheuplain RJ, Blank IH. ‘Permeability of the skin’, Physiol Rev 1971; 51:702-47.

6. Hruza GJ, Dover JS. ‘Laser skin resurfacing’, Arch Dermatol. 1996; 132(4):451-5.

7. Manstein D, Herron GS, Sink RK, et al. ‘Fractional photothermolysis: a new concept for cutaneous remodelling using microscopic patterns of thermal injury’, Lasers Surg Med 2004; 34:426-38.

8. Stumpp OF, Bedi VP, Wyatt D, et al. ‘In vivo confocal imaging of epidermal cell migration and dermal changes post nonablative fractional resurfacing: study of the wound healing process with corroborated histopathologic evidence’, J Biomed Opt 2009; 14:024018.

9. Brisson P. ‘Percutaneous absorption’, Can Med Assoc J 1974; 110:1182–1185.

10. Wlodek C, Ali FR, Lear JT. ‘Use of photodynamic therapy for treatment of actinic keratoses in organ transplant recipients’, BioMed Res Int 2013:349526.

11. Haedersdal M, Sakamoto FH, Farinelli WA, et al. ‘Fractional CO2 laser-assisted drug delivery’, Lasers Surg Med 2010; 42:113–122.

12. Bachhav YG, Summer S, Heinrich A, et al. ‘Effect of controlled laser microporation on drug transport kinetics into and across the skin’, J Controlled Release 2010; 146:31–36.

13. Ceilley RI. ‘Mechanisms of action of topical 5-flourouracil: review and implications for the treatment of dermatological disorders’, J Dermatolog Treat. 2012; 23(2):83-9.

14. Micali G, Lacarrubba F, Nasca MR, Schwartz RA. ‘Topical pharmacotherapy for skin cancer: part I Pharmacology’, J Am Acad Dermatol. 2014; 70(6):965.e1-12.

15. Lee WR, Shen SC, Wang KH, et al. ‘The effect of laser treatment on skin to enhance and control transdermal delivery of 5-fluorouracil’, J Pharm Sci 2002; 91:1613–1626.

16. Lee WR, Shen SC, Al-Suwayeh SA, et al. ‘Laser-assisted topical drug delivery by using a low-fluence fractional laser: imiquimod and macromolecules’, J Controlled Release 2011; 153:240–248.

17. Lee W-R, Shen SC, Fang CL, et al. ‘Skin pretreatment with an Er:YAG laser promotes the transdermal delivery of three narcotic analgesics’, Lasers Med Sci 2007; 22:271–278.

18. Singer AJ, Weeks R, Regev R. ‘Laser-assisted anesthesia reduces the pain of venous cannulation in children and adults: a randomized controlled trial’, Acad Emerg Med 2006; 13:623–628.

19. Koh JL, Harrison D, Swanson V, et al. ‘A comparison of laser-assisted drug delivery at two output energies for enhancing the delivery of topically applied LMX-4 cream prior to venipuncture’, Anesth Analg 2007; 104:847–849.

20. Yun PL, Tachihara R, Anderson RR. ‘Efficacy of erbium:yttrium-aluminum-garnet laser-assisted delivery of topical anesthetic’, J Am Acad Dermatol 2002; 47:542–547.

21. Bachhav YG, Heinrich A, Kalia YN. ‘Controlled intra- and transdermal protein delivery using a minimally invasive Erbium:YAG fractional laser ablation technology’, Eur J Pharm Biopharm 2013; 84:355–364.

22. Qu L, Liu A, Zhou L, et al. ‘Clinical and molecular effects on mature burn scars after treatment with a fractional CO(2) laser’, Lasers Surg Med 2012; 44:517–524.

23. Waibel JS, Wulkan AJ, Shumaker PR. ‘Treatment of hypertrophic scars using laser and laser assisted corticosteroid delivery’, Lasers Surg Med 2013; 45:135–140.

24. Cavalié M, Sillard L, Montaudié H, et al. ‘Treatment of keloids with laser-assisted topical steroid delivery: a retrospective study of 23 cases’, Dermatol Ther 2015; 28:74–78.

25. Rkein A, Ozog D, Waibel JS. ‘Treatment of atrophic scars with fractionated CO2 laser facilitating delivery of topically applied poly-L-lactic acid’, Dermatol Surg 2014; 40:624–631.

26. Mahmoud BH, Burnett C, Ozog D. ‘Prospective Randomized Controlled Study to Determine the Effect of Topical Application of Botulinum Toxin A for Crowʼs Feet After Treatment With Ablative Fractional CO2 Laser’, Dermatol Surg 2015; 41:S75–S81.

27. Sherman RN. ‘Sculptra: the new three dimensional filler’, Clin Plast Surg 2006; 33(4):539-50.

28. Brandt F, OʼConnell C, Cazzaniga A, Waugh JM. ‘Efficacy and Safety Evaluation of a Novel Botulinum Toxin Topical Gel for the Treatment of Moderate to Severe Lateral Canthal Lines’, Dermatol Surg 2010; 36:2111–2118.

29. Lim HK, Jeong KH, Kim NI, Shin MK. ‘Nonablative fractional laser as a tool to facilitate skin penetration of 5-aminolaevulinic acid with minimal skin disruption: a preliminary study’, Br J Dermatol 2014; 170:1336–1340.

30. Massaki AB, Fabi SG, Fitzpatrick R. ‘Repigmentation of hypopigmented scars using an erbium-doped 1550 nm fractionated laser and topical bimatoprost’, Dermatol. Surg 2012; 38(7 pt 1)995-1001.

31. Narurkar VA. ‘Nonablative fractional laser resurfacing’, Dermatol. Clin 2009; 27(4):473-8.

32. Leo MS, Kumar AS, Kirit R, et al. ‘Systematic review of the use of platelet-rich plasma in aesthetic dermatology’, J Cosmet Dermatol 2015 July. EPub ahead of publication.

33. Kim H, Gallo J. Evaluation of the effect of platelet-rich plasma on recovery after ablative fractionalphotothermolysis.’, JAMA Facial Plast Surg. 2015; 17(2):97-102.

34. Zhu JT, Xuan M, Zhang YN, et al. ‘The efficacy of autologous platelet-rich plasma combined with erbium fractional laser therapy for facial acne scars or acne’, Mol Med Rep. 2013; 8(1):233-7.

35. Marra DE, Yip D, Fincher EF, Moy RL. ‘Systemic toxicity from topically applied lidocaine in conjunction with fractional photothermolysis’, Arch Dermatol 2006; 142:1024–1026.

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Adverse Reactions to Hyaluronic Acid Injections Dr Maryam Zamani shares advice on how to successfully manage HA filler complications Hyaluronic Acid (HA) fillers are the most common and popular agents used to treat a myriad of rejuvenation treatments; from filling in fine lines and wrinkles, to volume restoration in the face, neck, chest and hands.1 HA fillers are often preferred because they are long lasting, less immunogenic and can be broken down by hyaluronidase.1 Even in the most experienced of hands, complications can arise, and with the apparent relative ease of treatment with high patient satisfaction, a cavalier attitude towards fillers can increase the incidence of complications.2,3 The focus of this article is to highlight complications, symptoms and possible treatment strategies for immediate, early and late onset complications (Figure 1).

Complications can be related to the actual filler itself but most often it can be attributed to poor injector knowledge, patient or region selection, and technique.2 Many common side effects are local and short lived, lasting between 2-72 hours.

These include pain, tenderness, bruising, redness and swelling, and can often be minimised with good technique. These transient effects can be normal sequelae of placing a foreign HA implant within the skin.3 Significant complications are events that should not occur after treatment and can include infection, nodular masses, inflammation, tissue necrosis from injection

Clinical Practice Filler Complications

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into a blood vessel or compression of a blood vessel, dyspigmentation, and blindness.1,4 Park et al noted in their study on HA complications that, in descending order of frequency, affected locations were the perioral area, forehead (including glabella), nose, nasolabial fold, mentum, cheek area and the periocular wrinkles.1 Immediate onset complications Immediate onset complications can include overcorrection, visibility of HA and vascular compromise. Familiarity with the properties of the HA filler used, proper technique and plane of placement are essential to placing the correct amount of filler at the correct skin depth to provide maximum correction with minimal possibility of overcorrection, visibility or nodularity. When HA filler is placed too superficially, a bluish discoloration can occur called the tyndall effect.2 The only treatment for this is using hyaluronidase, an enzyme that dissolves the HA in the skin, in order to dissolve the filler.5,6 Ischemic events post HA injections are rare but a known serious complication.

Direct intra-arterial HA injection or venous occlusion or congestion can cause significant tissue injury and necrosis.2,7,8 Two particular danger zones, vulnerable to tissue necrosis, include the glabella and nasal ala.1 Typical clinical findings include disproportionate pain on injection, Aesthetics | November 2015

blanching, livedo reticularis, and a dusky blue-red discoloration that can be followed by blister formation and skin necrosis.9 Blindness is an ischemic event and devastating possible complication; it can be caused either from retrograde flow from canulating the supratochlear or supraorbital arteries, or from the anatomical anastomosis from the ophthalmic artery in the periorbita and nasolabial fold.10 Swift recognition is the most critical aspect in treating ischemic events. Arterial occlusion can be apparent immediately, while venous obstruction may take hours to become evident.2 Having a proper protocol in place is imperative in providing your patient with the most advantageous outcome. This includes: 1.

2.

3.

4.

5.

6.

Stopping the injection immediately if any of the signs of ischemic events are present.

Injecting hyaluronidase locally.

Placing Nitroglycerin paste on the skin immediately if the patient is able to medically tolerate it. Nitroglycerin paste vasodilates and improves flow in the dermal vasculature, thereby decreasing and minimising compressive risk causing ischemia.11 Give the patient oral acetylsalicylic acid to help thin blood and minimise ischemic risk.9 Warm compression and vigorous massage.9 If the patient presents after the ischemic event has begun and there is skin breakdown, topical and/or systemic antibiotics can be started.2

Such complications can be minimised by using the smallest needle, using a cannula instead of a needle to minimise risk of cannulising a vessel, injection of small volumes of HA, aspirating before injecting and proper plane of injection.2 Early onset complications (3-14 days after injection) As all fillers are foreign bodies, it can be normal to be able to palpate the material in the first few days. If the nodularity persists, however, it is important to evaluate for pain, tenderness, and inflammation.2 Non-inflammatory nodules are localised accumulation of HA that can initially be treated with massage and reassurance. If this is not sufficient, these nodules can be treated with hyaluronidase, which is able to degrade hyaluronic acid in the event of subcutaneous 35

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Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. United Kingdom www.sinclairispharma.com Date of preparation: October 2015 UK/SIPPER/15/0014

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Aesthetics Journal

Early / Immediate Complications

Erythema Ecchymosis Edema

Cold compresses Apply pressure Observe

Clumping Superficial placement Tyndall effect

Massage Unroofing / puncture Hyaluronidase (for HA) Excision

Erythematous nodule Infection

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Aesthetics

to antibiotics, it is important to empirically treat as an infection in order to prevent further complications.

Late Complications

Telengiectasias

Laser IPL Hyaluronidase (for HA)

Migration

Excision Hyaluronidase (for HA)

Hypertrophic Scar

Intralesional steroid

Non-inflammatory nodule Granuloma Fluctant Abscess

I & D or aspiration Culture Antibiotics

Recovery

Clinical Practice Filler Complications

Conclusion The best way to manage complications is to try to avoid them. A solid knowledge base is essential in preventing difficulties. All complications should be treated seriously with close patient follow up. The risks associated with HA injections can be minimised with solid knowledge of the anatomy, good technique with a high quality product, and knowledge on properly assessing and treating complications if they arise.

Non-fluctant

Empiric antibiotics

Massage Intralesional steroid Hyaluronidase for (HA) Excision

No improvement

Recovery

Consider Biofilm

Consider Factitious lesion

Culture (3 weeks) Two-drug antibiotherapy Hyaluronidase 5-FU Excision

Prevent contact with lesion Topical wound care Surgical debridement

Dr Maryam Zamani is a board certified opthalmologist with experience in ocuplastic surgery and dermatology. She obtained her medical doctorate from George Washington University School of Medicine in the US, and has worked at Cardiff University in facial aesthetics.

No improvement

Re-culture Change antibiotics

Figure 1: Advice chart on managing filler complications courtesy of Ozturk et al18

nodules or in ischemic events.6 Non-inflammatory nodules need to be differentiated from granulomas and biofilms, which are inflammatory in nature.12 Granulomatous foreign body reactions to HA may be caused by allergy to the material or immunogenic response to the protein in the HA preparation.5 Granulomas are exceedingly rare, occurring in 0.1% of the patients treated with all forms of injectable fillers, not just HA fillers.3,13 Infection can have a devastating effect on patients as well, and infection control is essential to minimise contamination.

Research suggests that chlorhexidine is a better antiseptic compared to povidoneiodine because it is superior in preventing injection site infection.14,15 Such reactions can lead to nodules, inflammation, swelling and erythema. If HA is injected and becomes coated with bacteria, a biofilm forms and the bacteria secretes a protective matrix that gives rise to low grade chronic infection that is resistant to antibiotics.12 It can be difficult to differentiate biofilms from late hypersensitivity reactions. Empiric antibiotic treatment with a macrolide or tetracycline antibiotic should be started for four to six weeks with close

monitoring. If at any point fluctuance is noted, incision and drainage can be performed with tissue culture.2 If the lesion does not respond to antibiotic treatment, HA fillers should be dissolved with hyaluronidase.14 Delayed complications such as persistent erythema or delayed hypersensitivity that is unresponsive to antihistamines may also require treatment with hyaluronidase and, sometimes, oral steroids. In patients with persistent edema unresponsive to antihistamines, oral steroids can be used to help reduce inflammation.16 This can commonly be seen with superficially placed HA, particularly because HA is hydrophilic.2 Delayed onset complications If persistent erythema or telangiectasias occur, they can be treated with hyaluronidase, or 1064 nm Nd:YAG laser.

This type of long-pulsed laser is proven to be a safe and effective therapy for treatment of face telangiectasias.17 Delayed inflammatory nodules and granulomas can also form at a later stage and should be treated as a foreign body infection in the first instance with antibiotics and/or intralesional corticosteroids.2 While they may not respond Aesthetics | November 2015

REFERENCES 1. Park TH, Seo SW, Kim JK, Chang CH., ‘Clinical experience with hyaluronic acid complications’, J Plastic Reconstr Aesthet Surg, 64 (7) (2011), pp.892-6.

2. Sclafani AP, Fagien S., ‘Treatment of injectable soft tissue Filler Complications’, Dermatologic Surgery, 35: s2 (2009) pp.16721680.

3. Gladstone HB, Cohen JL., ‘Adverse Effects When Injecting Facial Fillers’, Seminars in Cutaneous Medicine and Surgery, (2006) pp.34-39.

4. Park SW, Woo SJ, Park KH et al., ‘Iatorgenic retinal artery occlusion caused by cosmetic facial filler injections’, Am J Ophthalmol 154 (2012) pp.653-662.

5. Brody HJ., ‘Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement’, Dermatol Surg. 31 (2005) pp.893-7.

6. Cavallini M, Gazzola R, Metalla M, Vaienti L., ‘The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers’, Aesthet Surg J., 33(8) (2008) pp.1167-74.

7. Hanke C, Hingley R, Jolivette DM, et al., ‘Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant’, J Am Acad Dermatol, 25 (1991), pp.319-326.

8. Friedman PM, Mafong EA, Kauver ARM, et al., ‘Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation’, Dermatol Surg, 28 (2002), pp.491-494.

9. Delorenzi, Claudio., ‘Complications of Injectible Fillers, Part 2: Vascular Complications’, Aesthetic Surgery Journal, (2014) pp.584-600.

10. Lazzeri D, Agostini T, Figus M, Nardi M, Pantoaloni m, Lazzeri S., ‘Blindness following cosmetic injections of the face’, Plast Reconstr Surg, 129 (2012) pp.995-1012.

11. Kleydam, K, Cohen JL., ‘Nitrogylcerin: A review of its Use in the Treatment of Vascular Occlusion After Soft Tissue Augmentation’, Dermatologic Surgery, 38 12 (2012) pp.1889-1897.

12. Charlson, Paul., ‘Aesthetic Dermatology: Complications of hyaluronic acid dermal fillers’, MIMS, 2015.

13. Lowe NJ, Maxwell CA, Patnaik R., ‘Adverse reactions to dermal fillers: Review’, Dermatol Surg, 31 (2005), pp.1616-1625.

14. Krader, CG., ‘Facial Filler Complications Avoidable avoidable with careful injection Technique’, Cosmetic Surgery Times, (2012).

15. Darouiche RO., Wall MJ JR, Itani KM, Otterson MF, Webb AL, Carrick MM ,Miller HJ, Awad SS, Crosby CT ,Mosier MC, Alsharif A, Berger DH., ‘Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical Site Antisepsis’, N Engl J Med, 362 (2010) pp.18-26.

16. Funt, D, Pavicic., ‘Dermal Fillers in aesthetics: an overview of adverse events and treatment approaches’, Clin Cosmet Investig Dermatol., 6 (2013) pp.295-316.

17. Major A, Brazzini B, Campolmi, Bonan P, Mavilia L, Ghersetich I, Hercogov J, Lottit T., ‘Nd: Yag 1064 nm laser in the treatment of facial and leg telangiectasis’, J Eur Acad Dermatol Venereol, 15(6) (2001), pp. 559-65.

18. Ozturk, Li, Tung, Parker, Piliang, Zins, ‘Complications following injection of soft-tissue fillers’, Aesthetic Surgery Journal, 33 (2013), pp.862-877.

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Clinical Focus Essential Vitamins

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note that it is shown to be most effective in those whom wish to combat generalised photoaged skin, where treatments such as botulinum toxin may not be as effective. The toxins cause deeper muscle paralysis and can help smooth out wrinkles, however superficial damaged skin can often require nutritional support too.4 Retinoic acid can be given to patients on a prescription, however it is usually reserved for use by dermatologists in the UK, given its high risk of side effects, especially teratogenic effects, and hence it may need tight monitoring.5

Vitamins in Skincare Dr Ahsan Ullah details the importance of vitamins and how they can enhance your patient’s skincare regime

Vitamin B • Biotin B7 Biotin, (also known as vitamin H), is essential for cells throughout the body. Its main responsibility is the function of fat metabolism, and essential fatty acids that are required for the skin to keep its appearance healthy.6 It is usually deficient in those who consume raw eggs as they contain an antagonist to biotin, which consequently can result in deficiencies. Such deficiencies normally manifest as a dry and itchy dermatitis.6 • Niacin B3 Niacin (niacinamide) is useful in a skincare regime as it has shown to have an antioxidant, anti-wrinkle, and skin ‘brightening’ effect.7 Deficiencies of niacin are quite rare but have been shown to contribute to pellagra, a disease seen in parts of Africa but rarely in the Western world.8 Topical application of niacin can exert antioxidant properties that can remove Reactive Oxygen Species (ROS), which are free radicals causing skin cellular damage.7 Consequently, niacin can help to improve and protect the skin barrier with an improvement in overall anti-ageing effects and, given its vasodilative effects, it can help make the skin appear more youthful and volumised.7

A magic youth pill?

Is there such a pill that can miraculously result in younger looking skin? As practitioners, I’m sure we’re all aware that the answer is rather more complex than a simple yes or no. Patients tend to look for an easy fix, and perhaps there may well be one released in the future. For now, however, what consumers may see as ‘youth pills’ can consist of many well known vitamins and minerals, micro and macro nutrients and essential fatty acids, which all play an integral part in improving the skin’s natural dermatological function. It is often quite confusing as to what advice one should follow and subsequently give to our patients. What can actually be beneficial for our patients needs? What does not have any clinical benefits? New clinical data is always emerging so it is important to keep up with the most up-to-date research. Simple factors such as a healthy lifestyle and dietary advice are essential, and then to optimise the treatment, one can add topical regimes in combination to help achieve the overall desired outcome. As vitamins play a fundamental role in good skincare, this article shall focus on their advantages and detail which ones can be the most beneficial in promoting healthier skin.

Vitamin C Ascorbic acid is the most commonly taken nutritional supplement in the UK due to its variety of benefits, where consumers were recorded to of spent £35.9 million in 2009 on the supplement.9 In terms of skincare, it has been shown to promote collagen synthesis and protect against photodamage by reducing free radicals. Results from two studies demonstrated that vitamin C decreases the appearance of fine wrinkles and improves overall skin texture and tone.10,11 Research has shown that vitamin C used topically can have various cutaneous benefits, including collagen synthesis, photoprotection from UVA/UVB, lightening of hyperpigmented areas and the improvement of a variety of inflammatory dermatoses.12

Vitamin A Vitamin A, in its simplest form, is a fat-soluble aliphatic vitamin occurring in two main forms, ‘preformed vitamin A’, (Retinol and its retinyl ester) – mainly found in animal products, and ‘pro-vitamin A’ (usually carotenes) which can be found in plant-based foods such as fruits and vegetables.1 The role of retinol, or more specifically the oxidised form, retinoic acid, is involved in the control of cell proliferation and differentiation of keratinocytes into mature epidermal cells, and results in the overall health of the skin.2 Its application has been used for many years by dermatologists for the treatment of acne, with research also showing its benefit as an ingredient in anti-ageing skincare as it can improve the appearance of fine lines.3 There are many creams on the market which have retinol present in them, and the type you choose can vary depending on the patient’s requirements. It is important to

Vitamin E Vitamin E consists of tocopherols and tocotrienols, which are both found in a variety of skincare products and aim to improve the skin and help the anti-ageing process. Deficiencies in vitamin E can result in poor anti-oxidation effects resulting in free radicals to damage the skin layers.13 The literature regarding vitamin E is extensive. What we understand is that vitamin E has potent antioxidative properties which have an obvious benefit on sun exposed skin, helping it from ageing prematurely14 – this would suggest it to be a vital tool in overall skincare. Studies have also suggested that, in the long term, vitamin E can reduce the risk of sunburn from exposure to UVB radiation,15 however this should not be a substitute for use of a sunscreen. Medical research has also suggested that due to its antioxidative properties, vitamin E can aid the cell apoptosis process in skin cancers.16

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Vitamin K Vitamin K is a fat-soluble vitamin synthesised in the liver and is well known to play an important part in blood coagulation,17 but some practitioners are not aware of its dermatological benefits. More recently, however, its topical usage has come under the spotlight. Research has shown the benefits of using vitamin K topically to help hyperpigmented areas and dark under eye circles.18 Typically as a 5% cream, vitamin K has shown to diminish postoperative bruising from cosmetic surgery, as well as laser-induced bruising, superior to that of just arnica cream.7 Conclusion As discussed, there are a variety of different vitamins that can help in the overall appearance and youthfulness of the skin, however the application of treatments will vary depending on the patient’s initial concerns and expectations, and should not be generalised for everyone. When choosing skincare, it is important to develop a good professional relationship with your patients.

By both understanding the desired goals versus the realistic outcomes, results can be achieved much more effectively.

Dr Ahsan Ullah is an aesthetic and private general practitioner. With experience working for the NHS and privately, he is now the medical director of My Skin Clinic in Harley Street and provides dermatological and aesthetic services with a holistic approach.

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Clinical Focus Essential Vitamins

REFERENCES 1. Reza Kafi et al, ‘Improvement of Naturally Aged Skin With Vitamin A’ (Retinol) (Michigan, Jama Dermatology, 2007) <http://archderm.jamanetwork.com/article.aspx?articleid=412795> [Accessed 24 August 2015].

2. Dr Diana Howard, ‘What Causes Skin Aging?’ (Surrey, The International Dermal Institiute, 2014) <http://www. dermalinstitute.com/uk/library/23_article_What_Causes_Skin_Aging_.html> [Accessed 24 August 2015].

3. Farris PK, ‘Topical vitamin C: a useful agent for treating photoaging and other dermatologic conditions’, (New Orleans, American Society for Dermatologic Surgery, 2005) <http://www.ncbi.nlm.nih.gov/pubmed/16029672> [Accessed 24 August 2015].

4. Weber C et al, ‘Efficacy of topically applied tocopherols and tocotrienols in protection of murine skin from oxidative damage induced by UV-irradiation’, (Free Radical Biology & Medicine, 1997) 22 (5), pp. 761–9.

5. Chang PN et al, ‘Evidence of gamma-tocotrienol as an apoptosis-inducing, invasion-suppressing, and chemotherapy drug-sensitizing agent in human melanoma cells’, (Nutrition and Cancer, 2009) 61 (3), pp.

357–66.

6. Cohen, JL; Bhatia, AC, ‘The role of topical vitamin K oxide gel in the resolution of postprocedural purpura’, (Journal of Drugs in Dermatology, 2009): JDD 8 (11), pp.1020–4.

7. Leu, S et al, ‘Accelerated resolution of laser-induced bruising with topical 20% arnica: a rater-blinded randomized controlled trial’, (The British Journal of Dermatology 2010), 163 (3), pp. 557–63.

8. Johnson EJ, Russell RM. Beta-Carotene. In: Coates PM, Betz JM, Blackman MR, et al, ‘Encyclopedia of Dietary Supplements’. (London and New York, Informa Healthcare, 2010) (2) pp.115-20.

9. Fuchs E, Green H (1981). “Regulation of terminal differentiation of cultured human keratinocytes by vitamin A”.

Cell, 25, (3): pp. 617–25.

10. Aguirre, C., ‘Vitamin H’ (The International Dermal Institute, 2012) <http://www.dermalinstitute.com/uk/library/94_ article_Vitamin_H.html> [Accessed 24 August 2015].

11. Kumar, P; Clark, M, ‘Kumar and Clark Clinical Medicine’, (UK, Saunders Ltd, 2005), (6), pp. 240-241.

12. Traikovich SS, ‘Use of topical ascorbic acid and its effects on photodamaged skin topography’, (Arch Otolaryngol Head Neck Surg, 1999), 125(10): pp.1091-8.

13. Humbert PG, Haftek M, Creidi P, et al, ‘Topical ascorbic acid in photoaged skin. Clinical topographical and ultrastructural evaluation: double-blind study vs. placebo’, (Experimental Dermatology, 2003) 12, (3): p.237-44.

14. Silke K. Schagen et al, ‘Discovering the link between nutrition and skin aging’, (Dermato Endocrinology, 2012) Jul 1; 4(3): pp. 298–307.

15. Trevithick JR et al, ‘Reduction of sunburn damage to skin by topical application of vitamin E acetate following exposure to ultraviolet B radiation: effect of delaying application or of reducing concentration of vitamin E acetate applied.’, (Scanning Microscopy, 1993), (4): pp.1269-81.

16. Higdon, J et al, ‘Vitamin K’, (Linus Pauling Institute, Oregon State University, 2000) < http://lpi.oregonstate.edu/ mic/vitamins/vitamin-K> [Accessed 21st September 2015].

17. NHS Choices, ‘Supplements Who needs them?: A Behind the Headlines report’, (UK, 2011) <http://www.nhs.uk/ news/2011/05may/documents/BtH_supplements.pdf> [Accessed 21st September 2015}, p.8.

18. Cosgrove, M et al, ‘Dietary nutrient intakes and skin-aging appearance among middle-aged American women’, (American Journal of Clinical Nutrition, 2007) <http://ajcn.nutrition.org/content/86/4/1225.long> [Accessed 23rd September 2015].

V-SOFT LIFT is an innovative and less invasive alternative to traditional cosmetic surgery and dermal fillers. V-SOFT LIFT is performed using fine threads that “lift” your skin, increase elasticity and are completely absorbed. The threads are made of polydioxanone (PDO) which is known to be extremely compatible with the natural tissue in our dermis and has been used for over 30 years. An added benefit is that the material, PDO, stimulates the body’s natural production of collagen making your skin healthier and thicker.

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Technique Lip Rejuvenation

Treating Lips Dr Sanjay Gheyi shares his approach to rejuvenating lips with hyaluronic acid and lasers Introduction The rejuvenation of lips and the perioral area is of prime concern to many patients. The usual indications patients present to us with are loss of lip volume, perioral rhytids (many female patients complain their lipstick bleeds into these lines), smoker’s lines and downturned corners of the mouth. Although patients want a solution to these aesthetic concerns, many fear the risks of side effects, such as the ‘trout pout’ appearance, unnatural-looking results and the potential need for repeat treatments.

In this article, I shall explain my technique in treating lip concerns with hyaluronic acid (HA) dermal fillers and ablative lasers – these are the most commonly used treatments for lips and perioral rejuvenation in my clinic. In addition, I shall also explain how to achieve a successful aesthetic result and provide advice on how to avoid complications.

The approach described works well for me but may not for other practitioners; it is perfectly acceptable that different practitioners use different techniques, however the main outcome in our field of medical aesthetics should always be patient satisfaction.

Patient analysis The ideal lip augmentation technique provides the longest period of efficacy, lowest complication rate, and best aesthetic result.1 In addition, a good treatment requires correct initial diagnosis. It is important that practitioners listen to the patient and determine what he or she desires at the outset. Our patients are often well informed and most will have an idea of what treatments and/ or results they hope to achieve. Sometimes, however, they may not be aware of the intricacies of treatment, so their consultation should be taken as an opportunity for patient education. This will establish a valuable practitioner-patient relationship and avoid a mismatch between patient expectations and results achieved. If you are concerned that the aesthetic results may not reach your patient’s expectations, it is important to remember that you do not have to treat everyone who walks through Before your door – knowing when to say no is an important part of our job.

my opinion, as lips are very mobile, visible and have a vascular structure, there is no reason for using any non-HA injectable implant. Non-HA fillers such as calcium hydroxylapatite (CaHA), can be used for volume augmentation of nasolabial folds and marionette lines but, ideally, should not be used for lip augmentation. It has been suggested that this is due to CaHA’s high viscosity and elasticity, as well as being classified as an adjustable filler rather than being reversible like HA.3 According to Emer and Sundaram, evidence-based and experiential consensus suggests its avoidance in highly mobile areas such as the lips, or in areas such as the periocular region where there may be an increased incidence of nodules.3 Tools and techniques The debate on the pros and cons of using a sharp needle vs. a cannula has been discussed in great detail before. The advantage of a cannula is that there is supposed to be less risk of vascular injury.4 In my view, however, smaller cannulas are capable of vessel injury, especially in areas where tissue resistance to cannula passage is higher. In the perioral area and vermilion borders, the rhytids can be difficult to efface by using a blunt cannula. Use of cannula also requires more filler volume as the filler is usually deposited in a deeper plane due to less tissue resistance.4 A cannula is very useful for patients who are worried about bruising, swelling and recovery time and, from my experience, a 25 or 27g cannula works well for dermal filler injections. I have used an 18g cannula for lip injections but only at the time of full-facial fat transfer procedure, in which I inject fat to add a little volume to the lips. I do not use fat injections for lip augmentation as an isolated procedure as, in my opinion, harvesting fat is not cost effective when a syringe of filler is readily available and much cheaper. I prefer a 30g sharp needle for lip treatments and use 2cc of lignocaine with adrenaline, distributing After treatment with HA filler

HA dermal fillers HA fillers have one great advantage that no other implantable material provides – reversibility with hyaluronidase.2 Various dermal fillers are available, however, in Aesthetics | November 2015

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Technique Lip Rejuvenation

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it along 3-4 injection points along the junction of the lip and gingival mucosa (Figure 1). This provides profound Figure 1: Local anaesthesia injection points. These injections analgesia and are made intra-orally at the junction of gingiva and lip mucosa. vasoconstriction to minimise risk of intravascular injection. Various facial and/or lip proportion analysis techniques and mathematical models have been proposed. I do not use these as, in my opinion, treating the lips is an artistic procedure and should not be based on pure science or mathematics. I prefer to do what suits each patient and what makes him or her happy, still taking into account the most appropriate method of treatment. Usually only 1-2cc of dermal filler volume is required unless there is more volume loss and the nasolabial folds and/or marionette lines are being treated at the same time. By using a sharp needle at the outer border of the vermilion, sometimes it is possible to see the filler run along the vermillion border and it is possible to treat the entire quarter or half of the length of lip from one injection point. I try to use minimum injection points where possible, as each injection point can increase your chances of causing a bruise. Commonly, I would inject the vermilion border, augment lip volume, attempt to efface perioral rhytids and support the angles of the mouth with 1-2 strands of filler material. Philtral columns can also be enhanced using linear threading.

Complications of dermal filler injections A degree of swelling, redness, tenderness and bruising can be considered normal side effects of dermal filler injections and usually settle within a matter of days. A number of complications such as infections, fibrosis, granulomatous inflammation, haematoma, thromboembolism and product migration have been reported.5 The most feared complication is vascular compromise due to vascular compression or inadvertant intra-arterial injection.6 By following the measures listed below, I believe you can minimise the risk of filler complications, irrespective of where it is being injected. To do so, I advocate the following:6,7 • • • • •

Use local anaesthesia with adrenaline.

Use a blunt cannula where possible.

Aspirate before injecting.

Inject small aliquots of filler with low injection pressure.

Keep a watchful eye for tissue blanching which may be very transient. Vascular compromise can be preceded by a transient blanching of skin and this may be at a point distant from the injection site.

• Always have hyaluronidase available for use in an emergency.

How to avoid a poor aesthetic result: • Do no not overfill.

• Keep the facial harmony and balance by treating other perioral regions for volume loss rather than simply focusing on the lips.

• Use fine particle HA fillers and not large particle fillers for lip augmentation to keep lips feeling soft.

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Lasers Non-ablative lasers have a limited use, if any, in treatments of the lip and perioral area; mainly because we have better options available and results are often subtle and unpredictable.

Vascular lasers are useful when patients present with a vascular abnormality or lesion. One such example would be venous lakes in the lips where long pulsed lasers can be used successfully (Figures 2 & 3). For skin rejuvenation, treatment of fine lines, wrinkles and skin textural improvement, ablative lasers are useful and erbium and CO2 lasers are commonly used. My choice is a CO2 laser because of the additional provision of skin tightening.

CO2 laser can be used Before in fractional mode in light skin or darker skin types, such as patients of Asian or Mediterranean origin.

Lighter skin types are suitable for a full ablative Figure 2: Venous lake before treatment laser resurfacing.8 This, After however, does require use of lip blocks and/ or oral sedation and requires a longer period of recovery.8 Fully ablative CO2 laser resurfacing involves the Figure 3: Venous lake after treatment with ND:Yag laser removal of the entire epidermis and upper portion of the dermis, providing significant stimulation to dermal nerve fibres.8 Prior to the advent of ablative lasers, mechanical dermabrasion was a widely used treatment and provided excellent results. Laser ablation has, however, become a more widely used technique in recent times. A prospective study of the clinical efficacy of the 950 microsec dwell time CO2 laser, to that of a manual tumescent dermabrasion in the treatment of upper lip wrinkles showed that both are equally effective.9 Long-term histologic effects of the CO2 laser have been well documented. In a prospective study, biopsy specimens from the upper lip were taken preoperatively, then at six weeks, six months, and one year after CO2 laser resurfacing. Neocollagenesis

Non-ablative lasers have a limited use, if any, in treatments of the lip and perioral area; mainly because we have better options available and results are often subtle and unpredictable

Aesthetics | November 2015

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Before

began at six weeks and progressively increased at six months and one year.10 I have also personally observed this effect numerous times. An early follow-up appointment may not show outstanding results but, with time, results should After improve.

With ablative lasers, it is important to treat the entire cosmetic unit rather than the isolated small areas to avoid lines of demarcation.

It is imperative to know the settings of your device, as Figure 4: After lip-lift surgery and C02 laser resurfacing lasers made by different manufacturers have different energies, pulse durations, spacing and patterns. It is not a good idea to transfer settings of one device and use them on another, as they may not necessarily produce the same results. The best way to learn about laser resurfacing is through careful observation of tissue response, clinical endpoints and observing your patient’s results at follow-up appointments. The tissue’s response to the laser pulse may vary in different patients even though you’re using the same settings. This is due to the hydration levels of the patient’s skin as the target for C02 lasers is tissue water, and may be affected by use of local anaesthesia, either topical or by infiltration.11 For fully ablative CO2 laser resurfacing, a variety of post-operative wound care techniques has been devised.12 These are, broadly speaking, closed and open techniques and involve wiping the lasered char away. The open technique means that no dressings are used, while occlusive dressings are used for the closed technique. I personally tend not to wipe the char away, as it can act like a biological dressing and flakes off when the underlying skin has healed up.

Complications of laser treatment In patients with prior history of herpes labialis, anti-viral prophylaxis is useful for filler injections or laser resurfacing.13 I do not prescribe antibiotics for fractionated resurfacing, but for full laser resurfacing I prescribe antibiotic, antifungal, anti-viral prophylaxis. Although widely used, the role of prophylactic antibiotics has been questioned.14 Adverse effects of laser resurfacing include pain, erythema, bacterial, viral or fungal infections, milia, pigment alterations such as post inflammatory hyperpigmentation (PIH), hyperpigmentation and/ or hypopigmentation. Overly aggressive treatments can result in scarring.15 It is very important to minimise sun exposure and use sunscreens in the post-operative period to minimise pigment issues.16 Hyperpigmentation can be transient and can be treated with use of hydroquinone,17 but hypopigmentation can be very difficult or impossible to treat.18

Technique Lip Rejuvenation

and journals have described a variety of treatments for perioral rejuvenation. These include; mesotherapy, carboxytherapy, skin needling and PRP. I often use botulinum toxin for treatment of dynamic rhytids, almost always in combination with other treatment modalities discussed above. From my experience, two to four units along lip borders and five to ten units of botulinum toxin injected along each depressor anguli oris can produce some nice results in terms of lifting the downturned lip corners and softening perioral lines. One of the benefits of working in a well-equipped clinic with a variety of devices is that I can use treatments that are likely to give the most visible results. The combination of PRP with other therapies is particularly interesting, with studies indicating it may play a role in reducing the downtime associated with laser resurfacing.20 In my opinion future studies should include controls, including incorporation of split-face comparisons, to reduce intersubject variability.

Conclusion Each of the modalities presented has their unique advantages and disadvantages when used for lip rejuvenation. However, through proper assessment and a thorough consultation to establish our patients’ expectations, fears and tolerance to recovery periods, we can determine the best treatment or combination treatments for their concerns. Doing so should allow us to achieve successful lip rejuvenation and happy, satisfied patients.

Dr Sanjay Gheyi is the medical director and laser surgeon at the Coltishall Cosmetic Clinic in Norfolk and offers a range of laser, skin and vein care services to his patients. The clinic has been established for nine years and attracts patients from all over the UK and abroad.

REFERENCES 1. San Miguel Moragas J et al, ‘Systematic review of “filling” procedures for lip augmentation regarding types of material, outcomes and complications’, J Craniomaxillofac Surg, 43 (2015) p.883-906.

2. Pierre A, Levy PM, ‘Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection’, J Cosmet Dermatol, 6 (2007), pp.159-62.

3. Emer J, Sundaram H, ‘Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidencebased review and discussion of current concepts’, J Drugs Dermatol, 12 (2013) pp.1345-54.

4. DeJoseph LM, ‘Cannulas for facial filler placement’, Facial Plast Surg Clin North AM, 2 (2012), pp.215-20.

5. Grippaudo FR et al, ‘Diagnosis and management of dermal filler complications in the perioral region’, J Cosmet Laser Ther, 16 (2014), pp.246-52.

6. Beleznay K et al, ‘Vascular Compromise from Soft Tissue Augmentation’, The Journal of Clinical and Aesthetic Dermatology, 7 (2014), pp.37-43.

7. Kim DW et al, ‘Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management’, J Plast Reconstr Aesthet Surg, 12 (2011), pp.1590-5.

8. Gaitan S, Markus R, ‘Anesthesia methods in laser resurfacing’, Semin Plast Surg, 3 (2012), pp.117-24.

9. Gin et al, ‘Treatment of upper lip wrinkles: a comparison of the 950 microsec dwell time carbon dioxide laser to manual tumescent dermabrasion’, Dermatol Surg, 6 (1999), pp.473-4.

10. Rosenberg GJ et al, ‘Long-term histologic effects of the CO2 laser’, Plast Reconstr Surg, 7 (1999) pp.2245-6.

11. Goldman MP, ‘The use of hydroquinone with facial laser resurfacing’, J Cutan Laser Ther, 2 (2000) pp.73-7.

12. Duplechain JK, ‘Novel post-treatment care after ablative and fractional C02 laser resurfacing’, J Cosmet Laser Ther, 16 (2014), p.77-82.

13. Gazzola R, ‘Herpes virus outbreaks after dermal hyaluronic acid filler injections’, Aesthet Surg J, 6 (2012), pp.770-2.

14. Walia S, Alster TS, ‘Cutaneous C02 laser resurfacing infection rate with and without prophylactic antibiotics’, Dermatol Surg, 11 (1999) P.857-61.

15. Metelitsa A, Alster TS, ‘Fractional laser skin resurfacing treatment complications: a review’, Dermatol Surg, 3 (2010), pp.299-306.

16. Wanitphakdeedecha R, ‘The use of sunscreen starting on the first day after ablative fractional skin resurfacing’, J Eur Acad Dermatol Venereol, 11 (2014), pp.1522-8.

17. Goldman MP, ‘The use of hydroquinone with facial laser resurfacing’, J Cutan Laser Ther, 2 (2000), pp.73-7.

18. Dover JS et al, ‘Lasers in skin resurfacing’, Semin Cutan Med Surg, 4 (2000), pp.207-20.

19. Waldman SR, ‘The subnasal lift’, Facial Plast Surg Clin North Am, 4 (2007), pp.513-6.

20. Leo MS et al, ‘Systematic review of the use of platelet-rich plasma in aesthetic dermatology’, J Cosmet Dermatol, 23 (2015).

Other treatment methods With increasing age the length of the upper lip increases.19 Gravity not only causes sagging of the lower face and neck, it can elongate the upper lip too.19 Pumping the lip with more filler can make this condition worse and should be avoided. A lip-lift procedure, however, can restore the original length of the upper lip (Figure 4). This is a surgical procedure that can be done under local anaesthesia.19 Practitioners Aesthetics | November 2015

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Dr Miguel Montero talks vascular treatments with M22 M22 by Lumenis is a modular multi-application platform for the treatment of over 30 skin conditions and hair removal. Used by physicians around the world, M22 enables you to treat more types of patients and conditions with better outcomes. Dr Montero is one of the UK’s leading doctors on the subject.

The M22 has four different modules, which ones do you use?

I use the long pulsed Nd:YAG and the IPL as I mostly perform vascular treatments. With the IPL I can treat pigmentation, offer photorejuvenation for sun damage and treatments for rosacea, acne, and telangiectasia. I use the long pulsed Nd:YAG to treat telangiectasia anywhere in the body, including the face, as well as reticular veins in the legs.

With regards to the IPL, what treatments do you use it for and how do you rate its usability and results?

I use it for a variety of indications, the most popular being rosacea, pigmentation and photo-damage. I have been using a Lumenis IPL very successfully for the last eight years and regard it as the workhorse of my clinic. I chose it because it is the easiest device to use, changing the filter is very simple, and the pre-set parameters are pretty good starting points. I am very happy with the results, and my patients are also very satisfied as they keep returning for various aesthetic treatments.

How do you compare the Lumenis technology to other systems that you have used previously?

My Lumenis IPL was the first machine I ever bought eight years ago and it has since been an essential part of my clinic. The list of indications Lumenis technology treats is pretty comprehensive, and the results that I have got through the years have been very good, so I’ve never needed a more expensive machine like a PDL. I am getting excellent results not only in vascular conditions but also in many pigmented ones. I don’t need to produce purpura to achieve a great result, and many of my patients who have been treated before with other systems comment how easy it is to resume their activities with minimal downtime, while also emphasising how comfortable and effective the treatments are.

Multiple-Sequential Pulsing (MSP), available in both the Nd:YAG and IPL modules on M22, enables cooling between 46

a sequence of pulses. Do you feel this has had an impact on patient comfort and your ability to treat more safely and achieve desired results?

The ability to cool the skin down in between pulses was a very important deciding factor when I purchased the machine. In my practice I use multiple pulses most of the time, I would say that about 90% of my treatments need MSP, since the targets are usually deep. It does allow me to use higher energy levels without causing any burns or blisters, whilst selectively targeting the deeper lesions. There are many IPL systems out there, which have also incorporated this technology with more or less success, but to my knowledge the M22 is the only one which has specific vascular filters and settings, not forgetting the possibility to add the long pulsed Nd: YAG. This is probably the most underrated module in the system. In my opinion, it is an essential complement to the IPL, which I use all the time to deliver consistent vascular results. In addition, because of its ability to produce MSP, it delivers brilliant results very safely. The only exception in the use of MSP with the Nd:YAG laser is the treatment of facial telangiectasia. For safety reasons, single pulses of no more than 90 J/cm² should be used in the face, avoiding, if possible, the stacking of pulses, as this would defy the objective. I have performed this treatment hundreds of times with only bruising presenting as the main complication, and I have hundreds of satisfied patients.

Do you change the pulse duration and delay to suit your own specifications?

Yes. I find that the Lumenis pre-sets are usually a very safe starting point, but for some patients we need to change the pulse duration, the pulse delay or both to be able to effectively treat the problem that they are presenting to us. The Lumenis interface allows me to very easily change those parameters, so I can be more aggressive if I need to, or more conservative for the darker skin types if, for whatever reason, the skin is reacting and needs more protection. In most cases, I increase the fluence treatment on treatment, but I don’t alter the other parameters.

Aesthetics | November 2015

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Do you use cooling post treatment; a) on all skin types and; b) do you think it reduces PIH? As well as the cooling provided by the equipment in the form of cool light guides, and the pulse delays built-in in the MSP which allow skin cooling in between pulses, as an extra safety measure I use air cooling provided by a Zimmer Cryo during and after the treatment for a few minutes in all skin types. I find that I don’t need to use any steroid tablets, creams or masks by doing so. Occasionally I use a kojic acidbased tyrosinase inhibitor when I treat skin type IV-V as a prophylaxis against PIH for extra security. The combination of all these measures has allowed us, through the years, to have a very low incidence of PIH, even though more than 30% of our patients have a skin type V. Has the Nd:YAG module lived up to its promises treating leg veins, telangiectasia, and haemangioma? Tell us about your experience.

I have been treating telangiectasia and reticular veins practically from the minute I got the machine. I use the Nd:YAG to treat reticular veins, feeder veins (which carry blood from the reticular or deeper veins to the more superficial lesions) and some of the larger telangiectasia in the legs. I find that the combination of the MSP with the extra cooling allows me to use higher settings to treat the deeper veins and this has increased my success rate. I don’t treat any veins larger than 3 mm with laser, if there are any varicosities they need to first be corrected surgically to improve the chances of a successful laser treatment of the more superficial veins.For some patients I also use microsclerotherapy to reduce the size of the larger reticular veins prior to laser. I’m finding that since I’m doing this, the treatments are more comfortable as the size of the target is reduced. I combine the treatments of the long pulsed Nd:YAG with the IPL, which allows me to treat the more superficial telangiectasia. I tend to also use MSP with the IPL, as recommended in the settings preloaded in the system. I find that IPL is particularly effective for the finer telangiectasia matting and is the only tool that safely can be used around and below the ankles. I have treated many small haemangiomas, Campbell de Morgan spots, venous lakes in the lips, spider angiomas and similar vascular lesions all over the body safely and successfully using the 6 mm spot size of the Nd:YAG.

viral warts and verrucae and also fungal nail infections, I have done my own small trials to find out if I could replicate those with my equipment. I have had successful clearances of all the above, and I essential am now offering these treatments as part of my treatment portfolio.

4

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How do you typically treat rosacea?

Laser and IPL are only part of a more comprehensive treatment, ™ ResurFX fractional 1 Have You Ever Desirednon which includes, for some people, oral Everything and topical antibiotics, topical ™ The New Generation of Hair Remov 2 Multi-Spot antioxidants and vitamin A, and mandatory sun protection.

Educating Nd:YAG patients is essential as most of them don’t know about3the Universal condition, IPL and I find that once they learn about it, they also learn to live with 4 Q-Switched Nd:YAG N it, and most of my patients cope much better with the symptoms of this chronic condition. I follow Dr Crouch’s protocol of triple pass, NEW triple pulse. Using the 560 or 590 nm filters, followed by the 615 and 695 nm filters, from superficial to deep, we get a very comfortable Visit our FACE booth N The Starting to of Your and effective treatment which help us reduce the Point severity theSuccess flushes as well as a reduction treatment on the facialJoin erythema and our workshop: telangiectasia. When I want to get an even faster reduction in common the What is the deno LASER HAIR ADVANCED non-ablative and hair rem telangiectasia I combine the long pulsed Nd:REMOVAL YAG using single pulses.

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by Dr. Tretti Clementoni, Dr. Patel Fri | 20th June | 11:30-13:00 | Roo

Born in Almeria, Spain, Gold Miguel has805nm practiced Standard diode laser medicine in England since 1994. Initially working Fast and comfortable in North-West hospitals developing his surgical and medical skills, Miguel then 11 years Intuitive andspent upgradable working as a GP in Burnley. He now combines and affordable his knowledge of surgery,Portable medicine, skin health and laser technology in his full timeHighest role return as our medical on investment director and principal practitioner.

Miguel is a member of the European Laser Association, British Medical Laser Association, British Medical Acupuncture Society and British College of Aesthetic Medicine. He is the lead in CPD and one of only a few doctors to hold a Post Graduate Diploma in Cosmetic Medicine from the University of Leicester.

Miguel is on the lecture team at UCLAN teaching Doctors and Dentists on various aspects of Aesthetic Medicine; works closely with and presents for Lumenis, a world renown laser company; is a speaker at medical aesthetics conferences worldwide and contributes to industry publications.

Have you discovered any other uses for the Nd:YAG module?

Well, they are not my discoveries, but since it has been reported in some papers that the long pulsed Nd:YAG can be used to treat Aesthetics | November 2015

Lumenis (UK) Ltd Telephone: 020 8736 4110 e-mail: UKAesthetics@lumenis.com

Lumenis (UK) Lt 418 Centennial Borehamwood, Telephone: 020 e-mail: UKAesth

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Treatment Focus Hair Loss

Identification and Management of Female Hair loss Salvar Björnsson discusses the various causes and treatments for female hair loss While male pattern hair loss is widely accepted as a normal part of the ageing process, the condition in women can carry a significant stigma. Society places a high premium on hair as part of a woman’s self-image, and hair loss can have serious negative consequences for quality of life. Stress and loss of self-esteem are common outcomes.1 The adverse effects on sufferers mean that effective treatment, or a cosmetic solution, can be a high priority in these cases.

Fortunately, depending on the cause of the hair loss, there is a variety of ways to reduce or even reverse it.

Causes of female hair loss There is a range of potential causes of hair loss in women. These can vary from congenital and dietary factors, to mechanical damage caused by grooming.

Androgenic alopecia This is commonly referred to as male pattern baldness but is also the most common cause of female hair loss – around 40% of women will be affected at some point in their lives, rising to 57% in those aged 80 and above.2 From my experience of treating hair loss in women, I have noted that it does not follow the characteristic pattern of a receding hairline and thinning crown; hair is, in most cases, lost evenly across the top of the head. Androgenic alopecia is a hereditary component, largely determined by the EDA2R Androgen Receptor gene on the X chromosome.3 One specific, recessive variant of the gene is believed to trigger production of a highly potent form of testosterone known as dihydrotestosterone (DHT), which progressively degrades hair follicles to the points at which they cannot produce new hairs.4 The genes that cause male-pattern hair loss are also believed to be linked to the Y chromosome, causing female-pattern hair loss, which manifests as diffuse hair loss across the entire crown.4 Women are more likely to be affected if either parent suffered from the condition.4 Infection A number of bacterial, viral, fungal and parasitic organisms can lead to hair loss. These are usually transmitted by physical contact with people, animals or objects that carry the organisms.5 One example is

the Demodex folliculorum mite, a tiny invertebrate that feeds on sebum.5 Sebum is a waxy substance secreted by sebaceous glands in the skin and within hair follicles, which helps maintain good hair condition. It’s also rich in nutrients, making it an attractive food source for specialised mites.5 When a large number of mites are present, hairs can be deprived of nutrients, leading to early loss. Older people are more likely to carry Dermodex mites, with two-thirds of the elderly being infected.5 Drugs A range of drugs can induce either temporary or permanent hair loss. Chemotherapy is the best-known pharmaceutical cause but there are many others. Medicines used to manage chronic conditions such as coronary head disease or hypertension may also lead to progressive hair loss, particularly those containing warfarin,6 as can antifungals that incorporate fluconazole.7 Diet There is strong evidence that diet can lead to hair loss. Deficiencies of zinc,8 biotin9 and iron10 can all result in thinning. Poor metabolisation of iron may have the same result. A diet high in animal fats (which increase testosterone levels)11 or with excessive vitamin A12 is another possible cause, as is general malnutrition.13 Alopecia areata This is an autoimmune disorder, with no known cause, which induces dormancy in hair follicles. The effect can range from loss of hair in spots to the total loss of all body hair, but spontaneous remission is common.14 Hair follicles cycle through a number of phases of activity, one of which is a telogen (resting) phase where no hair is present. Because each follicle’s cycle is independent, only a small proportion is normally resting at any given time. Stress or psychological trauma can, however, trigger early onset of the telogen phase in large numbers of follicles, causing significant – and often very rapid – hair loss. This can occur following surgery, childbirth, fever, emotional stress or as a corollary to chronic illness or an eating disorder.15 Mechanical trauma There are several ways in which physical damage to hair can result in its loss. Women with cornrows or ponytails are often susceptible to traction alopecia, caused by pulling the hair with excessive force while brushing, braiding or fastening it. Individual hairs may be broken off above the cuticle, reducing volume, or the cuticle itself may be damaged. Trichotillomania, a disorder that involves compulsive pulling and bending of the hair, can cause permanent thinning due to repeated extraction of hairs at the root.16 Finally, radiotherapy applied to the scalp can damage follicles.17

Diagnosis Hair growth is cyclical, and loss of hairs is a normal part of this cycle. It becomes an issue when the rate of loss increases enough to cause significant thinning. There are several accepted diagnostic methods for abnormal hair loss: Aesthetics | November 2015

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COMPOSED • CONFIDENT • MY CHOICE

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Approved for glabellar and 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. Imhof, M & Kühne, U. A phase III study of incobotulinumtoxinA in the treatment of glabellar frown lines. J Clin Aesthet Dermatol 2011; 4(10):28-34.

3. Data on File: BOC-DOF- 012 Bocouture® - Convenient to use August 2015.

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/6/SEP/2015/LD Date of preparation: September 2015

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• The ‘pull test’ is carried out by gently pulling on groups of around 50 hairs, at three different locations on the scalp. If more than ten hairs come loose in an area, the rate of hair loss there is considered abnormal. More than three, but fewer than ten, hairs may indicate a developing problem. Three or less indicates the normal hair cycle is operating.18 • Daily lost-hair counts may be undertaken when the pull test is inconclusive. Loose hairs are collected when the hair is first combed in the morning, for a period of at least 14 days. If the average number of hairs lost per day is 100 or more this is considered an abnormally high loss rate.19 • Microscopic examination of the roots of plucked hairs can be used as a diagnostic aid. The appearance of hair roots varies according to their stage of growth, and if the proportion of hairs in each stage deviates significantly from normal, this can narrow the range of possible causes.19 • A scalp biopsy, usually taken from the border of the affected patch, can be used to differentiate between forms of hair loss.19 • Trichoscopy, using a dermatoscope to examine affected areas of hair and scalp, may also aid in differential diagnosis.20

Prognosis Some forms of female hair loss are temporary, and will cease when the immediate cause is removed. Others may stem from permanent loss of working follicles and are not reversible. Management will depend on the cause and may involve lifestyle changes, medication, use of a hairpiece or even transplant surgery.

Management Because of the potential psychological impact of female hair loss, it is often necessary to begin managing the problem before a precise diagnosis of the cause has been achieved. Depending on the severity of the hair loss, the patient may be able to conceal it by changing their hairstyle. A hat or headscarf can also provide concealment, or a hairpiece can be worn. A common solution for male pattern baldness is to simply shave the head, a style that has lost most of its negative connotations in recent years. This approach is less likely to appeal to women, due to social expectations, but some may embrace it. Other management options will depend on the diagnosed cause. If a dietary deficiency is identified then remedying this – by adjusting levels of protein or other nutrients to bring daily intake within recommended norms – or reducing consumption of testosterone-promoting animal fat – may prove helpful.10 Where the patient is taking medication linked to hair loss, changing to an alternative drug can be effective.

Drugs that affect androgen balance are particularly likely to lead to hair loss, as excess free testosterone increases DHT levels in hair follicles.21 Switching to oral contraceptives from another form of birth control may be indicated in these cases.22 Alopecia areata can be temporarily reversed in around half of cases with corticosteroids such as prednisone, administered in oral form.23 Anthralin may also be effective, although evidence on this is not conclusive at the moment.24 Long-term, daily treatment with minoxidil can promote hair regrowth.25 Minoxidil is more effective when treatment begins shortly after the onset of hair loss; the longer follicles have been inactive the less likely it is that minoxidil will be efficacious in stimulating regrowth. However it will usually be effective in preventing further hair loss.26 Treatment must be continued indefinitely but side effects are usually mild, and are generally associated with the small minority who are allergic to propylene glycol. The most common side effects include itching or redness of the treated areas, or eye irritation. Minoxidil may be used to treat both alopecia areata and androgenic alopecia. In severe

Treatment Focus Hair Loss

cases of permanent hair loss, where significant scalp is exposed, hair transplantation surgery offers a permanent solution. This procedure can be carried out under local anaesthetic and involves removing small plugs of skin, each containing a number of follicles, from unaffected areas of the scalp. These are then implanted into bald areas. The hairs transplanted with the plugs will fall out shortly after the procedure but then regrow permanently.27

Conclusion While hair loss is generally associated with men, it also affects a large number of women, and the impact on quality of life is much more profound in this patient group. While acceptance of hair loss is relatively simple for men, expectations placed on women about their appearance make either clinical management or a cosmetic solution essential for most patients. Permanent reversal of hair loss is difficult to achieve without surgery, although there are a range of effective treatments available, which can prevent further loss and may promote regrowth in many cases.

Salvar Björnsson is a certified surgical assistant in hair transplants from the International Society of Hair Restoration Surgery and is the CEO of Vinci Hair Clinic, which offers a range of hair loss solutions for men and women throughout the UK. He has worked with numerous surgeons and hair loss practitioners around the world and has trained others entering the field.

REFERENCES 1. Torres F, Tosti A, ‘Female pattern alopecia and telogen effluvium: figuring out diffuse alopecia’, Semin Cutan Med Surg, 34 (2) (2015) p.67-71.

2. Gan DC, Sinclair RD., ‘Prevalence of male and female pattern hair loss in Maryborough’, J Investig Dermatol Symp Proc, 10(3) (2005) p.184-9.

3. Levy-nissenbaum E, Bar-natan M, Frydman M, Pras E., ‘Confirmation of the association between male pattern baldness and the androgen receptor gene’, Eur J Dermatol, 15 (5) (2005) p.339-40.

4. Causes of Hair Loss (US, American Hair Loss Association, 2010) <http://www.americanhairloss.org/ women_hair_loss/causes_of_hair_loss.as> 5. Sengbusch HG, Hauswirth JW, ‘Prevalence of hair follicle mites, Demodex folliculorum and d. brevis (Acari: Demodicidae), in a selected human population in western New York’, J Med Entomol. 23(4) (1986) p.384-8.

6. Mc AG, Swinson B, ‘An interesting potential reaction to warfarin’, Dent Update, 39(1) (2012) p.33-4, 37.

7. Pappas PG, Kauffman CA, Perfect J, et al., ‘Alopecia associated with fluconazole therapy’, Ann Intern Med, 123(5) (1993) p.354-7.

8. Abdel fattah NS, Atef MM, Al-qaradaghi SM., ‘Evaluation of serum zinc level in patients with newly diagnosed and resistant alopecia areata’, Int J Dermatol, 2015.

9. Daniells S, Hardy G., ‘Hair loss in long-term or home parenteral nutrition: are micronutrient deficiencies to blame?’, Curr Opin Clin Nutr Metab Care, 13(6) (2010), p.690-7.

10. Park SY, Na SY, Kim JH, Cho S, Lee JH., ‘Iron plays a certain role in patterned hair loss’, J Korean Med Sci, 28(6) (2013) p.934-8.

11. Gromadzka-ostrowska J., ‘Effects of dietary fat on androgen secretion and metabolism’, Reprod Biol, 6 Suppl 2 (2006) p.13-20.

12. Cheruvattath R, Orrego M, Gautam M, et al., ‘Vitamin A toxicity: when one a day doesn’t keep the doctor away’, Liver Transpl, 12(12) (2006) p.1888-91.

13. When Hair Los Can Be Dangerous (UK, The Belgravia Centre, 2015) <http://www.belgraviacentre. com/blog/when-hair-loss-can-be-dangerous-080/> 14. Hon KL, Leung AK., ‘Alopecia areata. Recent Pat Inflamm Allergy’, Drug Discov, 5(2) (2011) p.98-107.

15. Torres F, Tosti A., ‘Female pattern alopecia and telogen effluvium: figuring out diffuse alopecia’, Semin Cutan Med Surg, 34(2) (2015) p.67-71.

16. Huynh M, Gavino AC, Magid M., ‘Trichotillomania’, Semin Cutan Med Surg, 32(2) (2013) p.88-94.

17. Knopp E., ‘The scalp biopsy for hair loss and its interpretation’, Semin Cutan Med Surg, 34(2) (2015) p.57-66.

18. Soref CM, Fahl WE, ‘A new strategy to prevent chemotherapy and radiotherapy-induced alopecia using topically applied vasoconstrictor’, Int J Cancer, 136(1) (2015) p.195-203.

19. Guarrera M., ‘Additional methods for diagnosing alopecia and appraising their severity’, G Ital Dermatol Venereol, 149(1) (2014) p.93-102.

20. Levy LL, Emer JJ., ‘Female pattern alopecia: current perspectives’, Int J Womens Health, 5 (2013) p.541-56.

21. Rudnicka L, Olszewska M, Rakowska A, Kowalska-oledzka E, Slowinska M., ‘Trichoscopy: a new method for diagnosing hair loss’, J Drugs Dermatol, 7(7) (2008) p.651-4.

22. Schindler AE., ‘Non-contraceptive benefits of oral hormonal contraceptives’, Int J Endocrinol Metab, 11(1) (2013) p.41-7.

23. Joly P., ‘The use of methotrexate alone or in combination with low doses of oral corticosteroids in the treatment of alopecia totalis or universalis’, J Am Acad Dermatol, 55(4) (2006) p.632-6.

24. Shapiro J., Current treatment of alopecia areata’, J Investig Dermatol Symp Proc, 16(1) (2013) S42-4.

25. Yang X, Thai KE., ‘Treatment of permanent chemotherapy-induced alopecia with low dose oral minoxidil’, Australas J Dermatol, 2015.

26. Banka N, Bunagan MJ, Shapiro J., ‘Pattern hair loss in men: diagnosis and medical treatment’, Dermatol Clin, 31(1) (2013) p.129-40.

27. Rose PT., ‘Hair restoration surgery: challenges and solutions’, Clin Cosmet Investig Dermatol, 8 (2015) p.361-70.

Aesthetics | November 2015

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Advertorial SkinCeuticals

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Aesthetics Journal

Expert Opinion: The Secret of Prejuvenation with Metacell Renewal B3 Q&A with Jim Krol, Scientific Director of SkinCeuticals So What Is Prejuvenation All About?

Women are increasingly aware of how early UV damage impacts skin, and are no longer willing to wait until they need ‘rejuvenation’.

Instead, they prefer to get ahead of the clock and ‘prejuvenate’ skin before the effects of photoageing such as rough, dull skin, fine lines, blotchiness, and discolouration become more visible or severe. While everyone’s skin is different, it is never too early to focus on skin health by utilising a daily skin care regimen. Women in their mid-20s want a one-stop solution: a highly-effective corrective product which gives multiple skin benefits within a cosmetically elegant formulation – and this is where Metacell Renewal B3 comes in!

How Does Metacell Renewal B3 Fit the Prejuvenation Solution?

At SkinCeuticals, we are committed to skin health and have built our expertise on older skin, so now we are able to bring that higher-level scientific approach to a younger skincare market. Metacell Renewal B3 has been six years in the making and is specifically designed for younger skins (25+) to correct early signs of photoageing. Metacell represents

an unprecedented level of R&D from SkinCeuticals and contains some of the most powerful ingredients on the market in a high-concentration cocktail of multicorrective actives; including niacinamide (5%), a tightening tri-peptide concentrate, and pure glycerin.

How Does Metacell Work Differently From Other Anti-Ageing Moisturisers?

For me, the standout points of the Metacell Renewal B3 formulation are the high concentration of niacinamide and the unique patent-pending glycerin delivery mechanism.

Most anti-ageing products disrupt the skin barrier to encourage ingredient delivery: subsequently this also promotes toxins or allergens to penetrate the skin barrier, as well as causing irritation and itching. The high concentration of glycerin in Metacell rehydrates flattened keratinocytes, allowing the delivery of potent ingredients while actually reinforcing the skin barrier, not disrupting it – a paradox overcome with years of investment into Metacell’s research and development. Far from being sticky or tacky, the glycerin formulation of Metacell Renewal B3 is very cosmetically elegant – it has a light, fresh emulsion consistency which forms the perfect base for additional skincare and makeup.

Can You See a Difference Straight Away?

Metacell Renewal B3 doesn’t rely on surface enhancing technology or optical diffusers like many entry-level moisturisers on the market. The changes to the skin in terms of brightness and plumpness can be seen within minutes of the first application and this is due to direct improvements in the skin – not by any ‘makeup’ or brightening effects. In young skin, niacinamide really is a ‘wonder’ ingredient because it effectively addresses all the key signs of photoageing to give multiple benefits with just one product, and Metacell has the highest concentration of niacinamide available in a cosmeceutical formulation.

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Aesthetics | November 2015

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What is the Science Behind Metacell Renewal B3?

I’m passionate about pushing the boundaries of scientific knowledge within skincare and for Metacell Renewal B3 we truly went above and beyond, with six years of research and development.

Many skincare products are only tested in vitro, with observations assumed to be the same in live subjects. SkinCeuticals always conducts studies on live skin to fully understand the way our products work and to ensure they have a compounding effect.

Without extensive testing of the products in human volunteers, we would have no way of knowing what kind of results our consumers could expect. For Metacell, we also conducted skin imaging tests, biopsies, and biomarker analyses. Results showed statistically significant improvements in key symptoms of photoageing, including clarity, radiance, smoothness, fine lines, and firmness,1 with an 18% improvement in hydration and a 24% improvement in skin barrier function.i How Can Metacell Renewal B3 Fit Into an Aesthetic Skincare Treatment Plan?

Metacell Renewal B3 is suitable for all skin types as a twice-daily moisturiser and photoageing corrector, as it gives intense hydration and optimised delivery of clinicallyproven and highly potent actives within a fresh emulsion. It could also be used as a maintenance treatment between photofacials and in conjunction with retinoid treatments, so it fits seamlessly into an overall aesthetic skincare regimen to complement and maintain results of other treatments.

Metacell Renewal B3 from SkinCeuticals MRB3 Retail size 50ml | RRP £96, Trade Price: £40 MRB3 PRO size 120ml | Trade Price: £44 SkinCeuticals Stockist Enquiries: www.skinceuticals.co.uk

About Yevgeniy (Jim) Krol Joined SkinCeuticals in 2012 to lead global clinical research and scientific affairs. Published author in top medical journals and frequent lecturer on scientific innovation. He holds bachelor degrees in cell biology and neuroscience, and a master’s in pharmaceutical management.

REFERENCES 1. SkinCeuticals: A dermatologist-controlled 12-week clinical on 56 subjects. Data on File

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Abstracts Clinical Papers

A summary of the latest clinical studies Title: Current Status of Fractional Laser Resurfacing Authors: Carniol PJ, Hamilton MM, Carniol ET Published: JAMA Facial Plastic Surgery, September 2015 Keywords: Resurfacing, ablative, fractionation, laser, treatment Abstract: Fractional lasers were first developed based on observations of lasers designed for hair transplantation. In 2007, ablative fractional laser resurfacing was introduced. The fractionation allowed deeper tissue penetration, leading to greater tissue contraction, collagen production and tissue remodeling. Since then, fractional erbium:YAG resurfacing lasers have also been introduced. These lasers have yielded excellent results in treating photoageing, acne scarring, and dyschromia. With the adjustment of microspot density, pulse duration, number of passes, and fluence, the surgeon can adjust the treatment effects. These lasers have allowed surgeons to treat patients with higher Fitzpatrick skin types (types IV to VI) and greater individualise treatments to various facial subunits.

Immunohistochemical analysis has demonstrated remodeling effects of the tissues for several months, producing longer lasting results. Adjuvant treatments are also under investigation, including concomitant face-lift, product deposition, and platelet-rich plasma.

Finally, there is a short recovery time from treatment with these lasers, allowing patients to resume regular activities more quickly.

Title: Validation of the Vitiligo Noticeability Scale: a patient-reported outcome measure of Vitiligo treatment success Authors: Batchelor JM, Tan W, Tour S, Yong A, Montgomery AA, Thomas KS Published: The Journal of Dermatology, September 2015 Keywords: Vitiligo, pigment, treatment, VNS, repigmentation Abstract: Patient-reported outcome measures are rarely used in vitiligo trials. The Vitiligo Noticeability Scale (VNS) is a new patient-reported outcome measure assessing how ‘noticeable’ the vitiligo patches are after treatment. The noticeability of vitiligo after treatment is an important indicator of treatment success from the patient’s perspective. This study aimed to evaluate the construct validity, acceptability and interpretability of the VNS. Our main hypothesis was that the VNS would be a better and more consistent indicator of treatment success than percentage repigmentation.

Clinicians (n=33) and patients with vitiligo (n=101) examined 39 image pairs, each depicting a vitiligo lesion pre- and post-treatment.

Using an online questionnaire, respondents gave a global assessment of treatment success and a VNS score for treatment response.

Clinicians also estimated percentage repigmentation of lesions (<25; 25-50; 51-75; >75). Treatment success was defined as ‘Yes’ on global assessment, a VNS score of 4 or 5, and more than 75% repigmentation. Agreement between respondents and the different scales was assessed using kappa statistics. VNS scores were associated with both patient- and clinician-reported global treatment success (κ = 0.54 and κ = 0.47, respectively). Percentage repigmentation showed a weaker association with patient- and clinician-reported global treatment success (κ = 0.39 and κ = 0.29, respectively). VNS scores of 4 or 5 can be interpreted as representing treatment success. Images depicting post-treatment hyperpigmentation were less likely to be rated as successful.

Title: Salicylic acid deposition from wash-off products: comparison of in vivo and porcine deposition models Authors: Davies MA Published: International Journal of Cosmetic Science, October 2015 Keywords: Chemical analysis, fluorescence, salicylic acid, deposition, spectroscopy, statistics Abstract: Salicylic acid (SA) is a widely used active in antiacne face wash products. Only about 1-2% of the total dose is actually deposited on skin during washing, and more efficient deposition systems are sought. The objective of this work was to develop an improved method, including data analysis, to measure deposition of SA from wash-off formulae.

Full fluorescence excitation-emission matrices (EEMs) were acquired for non-invasive measurement of deposition of SA from wash-off products. Multivariate data analysis methods, parallel factor analysis and N-way partial least-squares regression were used to develop and compare deposition models on human volunteers and porcine skin. Although both models are useful, there are differences between them.

First, the range of linear response to dosages of SA was 60 μg cm (-2) in vivo compared to 25 μg cm (-2) on porcine skin.

Second, the actual shape of the SA band was different between substrates. The methods employed in this work highlight the utility of the use of EEMs, in conjunction with multivariate analysis tools such as parallel factor analysis and multi-way partial least squares calibration, in determining sources of spectral variability in skin and quantification of exogenous species deposited on skin. The human model exhibited the widest range of linearity, but porcine model is still useful up to deposition levels of 25 μg cm (-2) or used with nonlinear calibration models.

Title: Obesity: a key component of psoriasis Authors: Correia B, Torres T Published: Actabiomedica, September 2015 Keywords: Psoriasis, obesity, safety, cardiovascular, efficacy, inflammatory Abstract: Psoriasis has been associated with several cardiometabolic comorbidities as well as clinically significant increased risk of cardiovascular disease and mortality. Obesity seems to have a key role in linking psoriasis and cardiovascular disease. There are a growing number of epidemiological studies associating psoriasis and obesity. The mechanism responsible for this association is not certain, but it is probably multifactorial, involving genetic, environmental and immune-mediated factors.

Nonetheless, the chronic inflammatory state associated with obesity appears to be a key component of this relationship.

Obesity is, therefore, a major factor in the management of psoriatic patients, with implications in treatment efficacy and safety. The aim of this review is to synthesize the current evidence on the association between psoriasis and obesity, exploring the physiopathological mechanisms that link both diseases and highlighting the importance of obesity control in the efficacy and safety of systemic treatment of psoriasis.

Aesthetics | November 2015

53

Last chance to book Time is running out to book your place at the most popular awards event in the industry.

With less than a month to go until winners are announced and hundreds of medical aesthetic professionals having already booked their tickets, the Aesthetics Awards is the annual event you don’t want to miss.

Celebrate with the best of the aesthetics community on December 5.

Following a networking drinks reception and fantastic formal dinner, you will enjoy an entertaining performance by popular comedian Simon Evans, before the Awards ceremony takes place. Winners will be honoured and invited to the stage to receive their trophies, after which a night of music and dancing with colleagues and friends will bring the evening to a close.

Ticket prices Single ticket: £225 + VAT Table (10 people): £2,150 + VAT

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•

•

Effective Press Releases: The Gateway to Increased Business Potential Julia Kendrick advises on effective methods of creating your own PR material to achieve business and marketing needs Introduction The media is without a doubt a key gatekeeper to increased business potential: it can either let you pass – giving you exposure, credibility and marketing opportunities with their readers, or it can block the road – meaning reduced visibility for your business. Successful navigation through these gatekeepers requires effective communication that meets the needs of journalists. The press release is the mainstay of any media outreach, and is designed to secure targeted media coverage that supports your marketing objectives – such as driving new business, growing your market share or raising your media profile.

External public relations (PR) support is not always a pre-requisite to creating your own communications materials: this easy step-by-step guide will outline not only how to develop your own press releases, but how and when to distribute these to target the media.

Picture that headline!

First and foremost, a press release is a highly focused way of communicating to your targeted audience through a source that they trust: the media. Picture what you want the headline to be in a newspaper, take the time to develop a high-quality press release which gives the journalist everything they need to develop a great piece, and you’ll maximise your chances of securing fantastic coverage. A word of caution, however, as with all PR approaches, you do not have 100% editorial control of the final outputs. The journalist will take your release and implement their own perspective, experience and research angle, so you need to stick to some key rules to ensure your messages pull through.

The five cardinal sins of press releases Before we get started, it might be useful to consider the most common press release faux pas – as any journalist will tell you, these mistakes are seen time and time again, despite being very easy to avoid: • Not newsworthy: If your story is totally devoid of any news value for readers or audiences, it will go straight to the ‘delete’ folder.

•

•

PR Media Material

Also – beware of dressing up old news as ‘new’ – the media will not consider re-hashing old stories with no new angle.

Bad headline: Journalists often receive hundreds of releases each day and your release is a split-second decision away from the bin while they scroll through their email inbox. Make sure the headline (i.e. email subject) is short, snappy and to the point.

Jargon-tastic: Relevant for all industries, but particularly medicine where we can all catch ourselves speaking in jargon and acronyms – avoid wherever possible.

Corporate spiel: Stick to the news and why it matters to readers, don’t regurgitate marketing brochures or wax lyrical on your business acumen.

Typo overload: Bad spelling, structure or grammar will irritate journalists and make it less likely for them to read your whole release. It’s probably a good idea to get a colleague to take a second look and spot these mistakes.

Get writing In my experience, a press release is rarely written in ‘one go’ from start to finish. It’s important to put yourself in the journalist’s shoes – test the strength of your story by asking some key questions to help shape your approach before starting, like “So what? Who cares? What does this story give me?” By making sure your release is newsworthy, timely and has a clear relevance for their readers, you can overcome those early hurdles as a journalist assesses your story.

Overall, your release must answer the five Ws: the WHO, WHAT, WHY, WHEN, WHERE and HOW. The more you can do to provide the journalist all the information without them having to do additional research, the better your chances of coverage. It is also crucial to keep your release clear and concise – just one page long and clearly structured to capture interest.

Other ways to strengthen your release could include linking to an existing story in the mainstream or local press, offering different opinions, insights or data. For example, if your release is talking about a new dermal filler product or technique, you could link to recent stories talking about latest trends or statistics of increased cosmetic procedures. Case studies or quotes from other expert sources can be compelling additions to underline your key messages. Press releases also don’t have to be text only: you can improve your chances of grabbing attention by including infographics, images and illustrations that you own the copyright for. Just beware of file sizes – compress any images to avoid overloading their inbox or being diverted as spam.

The ideal press release structure Now that we have finessed our approach and gathered our ‘raw materials’, we can look at how to combine everything into a strong release structure: • Headline: This must tell the whole story within a punchy five to six word limit (i.e. email subject or desired newspaper headline).

• Sub-header:This gives more context to the headline at a similar length.

• Embargo, author, date: Stipulate when the news will be released (and should not be published before), and indicate the author of this release and the date of issue.

• The first line: The first sentence is crucial and should encapsulate the whole story, but in no more than 25 words. Imagine if the journalist only read the first line – would they still understand and care about your story?

Aesthetics | November 2015

55

Fat Reduction

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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 Inch loss

National PR support campaign

Cellulite

Clinician use only

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

Before

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Treatment of the Year 3D Lipomed

Before

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

Equipment Supplier of the Year 3D Lipo Limited

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Comes Highly Recommended

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For further information or a demonstration call: 01788 550 440

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

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• Paragraphs one to three: The rest of the release should contain the story’s key messages, answering the five Ws and providing some additional expert quotes or case studies to underline the importance/relevance of the story.

• Notes to Editors: Include any additional useful information for the journalist such as a short description of the company, service or product.

I always recommend a personal approach: don’t underestimate the importance of addressing the journalist by name Distribution So you’ve drafted your release, proof-read it thoroughly and you’re ready to send it out to the media. Where do you start?

Contacts Nowadays, 99% of news releases are sent via email – you will either need to do this manually by building up your own distribution list, or alternatively there are a number of online distribution services which allow you to upload your release and send out to a pre-defined list of media contacts. These distribution services can be free or paidfor – thus reflecting the quality of media outlets reached. They often share health and beauty news, connecting journalists, companies and PR professionals. However, the disadvantage is that you lose a personal approach and connection with the media contacts, and it can be difficult to find a service that targets the specific media that you need for a medical aesthetic story. Your media distribution list should be tailored based on the content and relevance of your news story. Consider which media contacts will want to receive your release – be that medical trade press, regional newspapers, local magazines or even national press. If creating your own list, you can research publications that have written about similar topics, find the most appropriate journalist to contact and source their email address through Google. If you can’t find a relevant individual journalist, find out the contact details for the editorial team or newsdesks, who will then field your release to the appropriate contact. Of course, don’t forget to add any media contacts with whom you have a personal relationship.

Timings An important consideration is finding out when the publications targeted go to press – be this daily, weekly or monthly. If you can’t find this information online, it’s best to give them a call as this will inform you of when you need to send your release to maximise the chances of it being seen and covered. The last thing you want is to send something just after the filing deadline, as not only will you miss this window of opportunity, but your release could end up on the bottom of the pile for next time as newer items come through.

Approach I always recommend a personal approach: don’t underestimate the importance of addressing the journalist by name and including some details of why you think this story is relevant to them, or their particular

PR Media Material

publication. Maybe they wrote about a similar topic recently? Maybe their publication includes a regular ‘beauty’ or ‘medical’ focus section?

The more specific you can be, the better – there’s nothing worse than a blanket approach of ‘Dear all’! Keep your email short and to the point, and don’t forget to include details of any further information available on request, as well as your contact details for any additional queries.

It’s a good idea to paste your release into the email body, as well as attaching as a word file (preferably not a PDF) as sometimes there can be issues with attachments not opening or incompatible files. Be conscious of file size – 1MB is the maximum total for any attachments, so make sure you compress any files, and particularly images.

Get feedback Resist the temptation to chase the journalist if you don’t hear anything after an hour or two – they will get back to you if the story is of interest or if they need further info. If you still haven’t heard anything after a day or two, get in touch, (preferably by phone for a more personal approach), to check whether they received it and to ask for feedback.

It’s always useful to understand their take on the release and what they might like to receive from you in the future.

Conclusion You should now feel more confident about creating your own press releases and leveraging these to drive your business marketing objectives. Whether it’s profiling a new treatment offering, highlighting a clinic launch or just developing your own media profile and presence, the media represents a key channel to engage with both new and existing patients in a credible way. By adopting a tailored and personalised approach, as well as ensuring your releases are structured, relevant and compelling – you will maximise your chances of successfully navigating through the media ‘gatekeepers’ to secure valuable coverage of your clinic and services. Ultimately, this approach will help you to build the foundation for ongoing media relationships and will eventually deliver benefits for your business.

Expert Commentary “Like most journalists, I receive an enormous number of emails a day. I do look at all of them – but unless their headline message is very clear and enticing, I am unlikely to read further than the first few lines. A large number of releases are sent to me as image files – I am sure they are gorgeous but my laptop does not automatically download them, so unless they have a particularly exciting message in the subject line, I am unlikely to stop and download these one by one. As such, they are, in effect, wasted. Ditto the releases that are sent as attachments. Really, what I prefer is a personal email with the message kept short and sweet, pointing out why the story is right for me. If it’s of interest, I will follow up fast enough!”

Alice Hart-Davis Freelance beauty journalist Julia Kendrick has 10 years of experience in public relations and communications, and is the founder of new start-up Kendrick PR Consulting, which specialises in medical aesthetics and healthcare PR. A previous winner of the Communiqué Young Achiever Award, Kendrick is passionate about delivering award-winning client campaigns.

Aesthetics | November 2015

57

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Patient Satisfaction Communication

connecting. An example of this is trying to increase social media presence by collecting followers, using incentives and competitions when, in fact, having fewer genuine fans that love the brand (not the freebies), is so much more valuable.

Patient Communication Victoria Smith discusses how effective communication with your patients can boost trade and your clinic’s reputation Communication is an essential tool in achieving productivity and maintaining strong working relationships at all levels of an aesthetic practice. Communication goes beyond the spoken word; it includes visual aids, greeting patients and much more. Without effective communication there can be no mutual understanding between the patient and practitioner. When a patient first enters a clinic, they will instantly form an opinion of their surroundings; is the reception and waiting room area warm and welcoming? Is the receptionist inviting and knowledgeable of clinic protocol and treatments available? Is every member of the team dressed appropriately and do they conduct themselves professionally? Even the colours of the walls can affect your mood, so it is vital to make sure every

last detail of your clinic and service skills of employees has been considered. Colours like blue are said to increase productivity,1 whereas lilac promotes a feeling of calm.2 It is worth remembering that there is no second chance to make a first impression, so providing exceptional levels of communication and care from the very beginning is essential.

Word-of-mouth is the original social media tool. It involves people physically interacting and exchanging information, which in turn can benefit a clinic’s reputation. Word-of-mouth can also create a positive or negative effect on a clinic’s trade. Consumers will often believe recommendations from friends and family over all forms of advertising, marketing or PR. In recent years, businesses have been more focused on collecting rather than

Getting to know your patient on a personal level is vital for building rapport, even if they’ve only been to your clinic once

Aesthetics | November 2015

Avoid routine conversation It is crucial that all staff members are personable and engaging with patients entering their clinic. From the front of house staff, to the nurses and practitioners, everyone needs to exude enthusiasm and positive energy. A prime opportunity to get to know your patient base is in the waiting room. This is the first opportunity you have to build rapport with your clients.

The practitioner could be running late one morning, so other clinic staff may have enough time to go beyond small talk and delve into more impactful topics, such as what the patient does as a career, making them feel genuinely valued. Patients will often require repeat treatments, so making them feel comfortable is fundamental to building a good relationship and ensuring they keep coming back.

During the initial consultation it is expected that the receptionist asks routine questions and obtains contact details, however a powerful spin on this routine procedure would be showing genuine interest in their lives outside of the clinic environment. Open-ended questions will always encourage conversation. Have they had a busy day? Have they travelled far to get to the clinic? Answers to these questions will help front-of-house staff build an accurate picture of the patient, which they can then pass on to practitioners to continue the conversation and avoid repetition. For practitioners, another way to avoid routine conversation is to take detailed notes during the consultation, logging all of a patient’s concerns and what they want to achieve. In a busy clinic environment, you will invariably be faced with a large number of individuals on a daily basis; therefore detailed notes logged into your system will help to ensure each patient feels valued.

Building rapport The most valuable clinic commodity: trust. Trust is more important than ever in aesthetic businesses today, specifically when it comes to patients, employees, and all stakeholders in the clinic. Trust can be described as reliance on the character, ability, strength, or truth of 59

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It is crucial that all staff members are personable and engaging with patients entering their clinic someone or something. Trust is imperative when it comes to building rapport at all levels. Developing trust isn’t easy; it takes time, dedication, and most importantly, humility. This is especially important in a clinic environment as you are treating someone’s face or body and patients can feel very vulnerable during treatment. They are putting total trust in all involved in the clinic to ensure their treatment is safe and they leave unharmed. Building rapport and offering guidance and knowledge will help to build trust, and leave patients feeling at ease in your care. It may seem obvious, but listening intently to your patient can be very beneficial. If they feel they have your undivided attention, you will be able to build a stronger relationship than if they think you are too preoccupied to engage with them. The moment a patient enters the treatment room, a relationship should have already been formed, giving them the chance to fully relax, ask any burning questions and allow you to perform to the best of your ability.

Individualisation Offering bespoke treatments will keep the clinic one step ahead of the competition, and gives practitioners the opportunity to tailor treatments to the individual, providing a service which is unique to them. This kind of service goes beyond the treatment menu, and offers a personalised experience. This strategy also applies to any homecare products you stock; practitioners should aim to create a programme specific to the patient’s treatment in order to maximise desired results and to encourage the patient to come back for more personalised service. Introducing unique ways to engage with your patient base is a key component to remain or to develop your clinic as a market leader. The waiting room is an ideal place to subtly promote the clinic’s wide array of services. This could be in the form of a visual aid, such as a waiting room television showing patient testimonials. Many patients trust 60

testimonials, and there is no better way to figure out if a treatment is going to be appropriate for you than to get another patient’s candid opinion.

Keeping in contact with patients Getting to know your patient on a personal level is vital for building rapport, even if they’ve only been to your clinic once.

If you are able to build a good rapport from the first meeting, keeping in touch will be a lot easier. Always follow up with the patient after an appointment to show an element of care, but also to make sure the procedure went to plan, and to address any concerns the patient may have. Social media is taking over as a main form of communication for businesses, and some clinics have created a service where patients are now able to book appointments through this medium, as well as using platforms such as Twitter to champion or to complain about their experiences. Social media creates instant attention and delivers immediate feedback, allowing it to potentially make or break a reputation. Communicate in a way the patient prefers; some will like text alerts, others phone calls and some email updates. During telephone conversations or initial consultations, it could be beneficial to take notes and add to patient files for future reference.

Patient communication comes in many forms, from the initial phone booking to the treatment follow-up phone call, there are several ways to reach out to patients in order to collate feedback, and to make sure their experience was a positive one. This also gives staff members the chance to resolve any issues or answer concerns and queries. A follow-up call can be extremely effective, especially if a patient feels too uncomfortable to mention any concerns specifically to the practitioner in the treatment room. Offering the patient the opportunity to air anxieties or give feedback about their experience over the phone is beneficial in helping the business grow and address what is Aesthetics | November 2015

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and is not working. Sending text reminder messages to patients 24 hours prior to their appointment, giving them an option to cancel without having to pick up the phone, is also an effective way of reducing no-shows and keeping on top of the diary ahead of appointments.

Social media, word-of-mouth, testimonials, treatment offers and literature such as treatment leaflets and brochures all work together to increase a patient base. However, none of these avenues would be effective if it weren’t for human interaction and exceptional in-clinic service. A successful way of promoting a clinic’s key messages is through a social media campaign, whereby the end goal is for people to book in for consultations and treatments. Giving it a hook and a campaign title that sounds more appealing really works to grab consumer attention.

An example could be to create a Twitter campaign based around the winter months, possibly promoting skin rejuvenation treatments to prepare for the ‘office Christmas party’.

Conclusion In today’s society, we are fast becoming disconnected from personal conversations in many ways. The convenience and efficiency of our high tech, yet impersonal ways of communication has left many of us yearning for human contact and interaction.

The aesthetic industry is one of the few industries left that lends itself to meeting this need. This gives practitioners a very special advantage that no machine, technology or product can replace. It provides you with the opportunity to offer a personal service that goes far beyond the ability to treat your patient’s needs, and gives you the power to positively impact their clinic experiences more profoundly.

Victoria Smith is the clinic director of Absolute Aesthetics in Surrey. Her specialisms include non-invasive skin procedures, as well as the removal of complex lesions and cysts. Smith graduated from the University of Gloucester in 2002 with a degree in Community Studies.

REFERENCES 1. Bailey, C, ‘The exact color to paint your office to become the most productive’ (2013) <http://alifeofproductivity.com/angelawright-interview/> [Accessed 28th September 2015] 2. Huffington Post Home, ‘Stress-Reducing Colors: Calming Hues To Decorate Your Home With’, (2013) <http://www.huffingtonpost. com/2013/04/18/stress-reducing-colors_n_3102683.html> [Accessed 28th September 2015]

LIFT, CONTOUR & REJUVENATE 1,2

with sustained collagen stimulation2

RAD/7/SEP/2015/DS Date of preparation: September 2015

Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

The Lifting Filler

1. Sundaram H. J Drugs Dermatol. 2012 Mar; 11(3): S44-S47 2. Yutskovskaya Y, et al. J Drugs Dermatol. 2014; 13(9): 1047-1052

Call Merz Aesthetics Customer Services now to find out more or to place an order

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Aesthetics Journal

The Changing Consultation Dr Renée Hoenderkamp explains how the patient consultation has evolved in recent years and why this is working to improve aesthetic practice Running an aesthetic clinic is an all consuming and ever-evolving process.

Never has this been truer than over the past five to ten years where we have seen an evolution of the non-surgical consultation. Many things have contributed to this change, ranging from informed consent, increasing treatment solutions and products, and new technology. An understanding of these developments and the desire to constantly grow, adapt and learn, make the challenge of running or owning a clinic exciting and fulfilling; even though sometimes challenging. We must all strive to have an efficient, informative and legally satisfying consultation process for the safety of our patients and longevity of the industry.

Consent With the non-surgical market remaining largely unregulated, those practitioners who aim to run ethical clinics have learnt from other areas of medicine how important consent is. A major change in the consent process has seen the patient become an active and equal partner alongside the practitioner. This ‘duality’ of consent empowers the patient with full, understandable and digestible information, thus allowing them to adequately weigh-up the risks and benefits of the treatment they are considering. The decision to embark upon a particular treatment is made by the patient once in complete knowledge of the facts.

There should be no question unanswered, and recent litigation indicates that however rare, all possible complications should be discussed.1 Only with such thoroughness can the patient make a fully informed decision.

It is considered good practice to have clear consent pathways within the clinic environment that satisfy basic levels of good practice, as identified in the ‘Review of the Regulations of Cosmetic Interventions’, which was published in April 2013 and led by Sir Bruce Keogh.2 Aimed at anyone delivering non-surgical treatments, practitioners and nurses now have guidance from their registration bodies, all of which focus on the consent process. The general tenet of all of this guidance is summarised in the ‘Professional Standards for Cosmetic Practice’.3 The Keogh Report garnered much publicity with the often quoted catch phrase, “You have more 62

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protection when buying a ball point pen than when having fillers.”2 So what has happened over the past five to ten years to attract such attention to the aesthetics industry, encouraging the government to create guidelines aiming to grow public awareness of good practice?

Although a relatively young area of medicine, nonsurgical treatments have grown exponentially over the past five years, worth an estimated £2.3bn in the UK alone in 2010 and predicted to reach £3.6bn by 2015.2 By the very nature of an industry that has seen such rapid growth, both in terms of the number of practitioners, clinics and patient numbers; the consultation has naturally evolved. All of the enquiry recommendations and professional guidance accepts and encourages the need for informed consent with a move towards duality of consent.

What does consent mean and how has it affected the consultation?

A critical part of the consultation process is the discussion of the possible risks involved. A clear explanation of any inherent treatment risks must be fully explained. How many practitioners include ‘blindness’ as part of their filler risk profile? I am sure my colleagues, as do I, see patients who’ve had fillers in the past but were never told of the risks. In my opinion, the decision to undergo a non-surgical treatment is a journey that the patient is embarking on with the practitioner. The decision must be in line with the recommendations and the patient needs to understand the risks involved. The practitioner is also expected to explain that other treatments are available from other practitioners, if it is in the patient’s best interests. For example, Roaccutane for acne could work as well, or even better than a skin peel, and tear trough surgery may be more beneficial for some patients than fillers.

All professional bodies, such as the General Medical Council (GMC) and the Royal College of Surgeons (RCS), recommend that the person conducting the treatment must carry out the consent process.3 This has therefore seen clinics, which have traditionally used different practitioners to consent the patient and carry out the procedure, having to consider and change their consultation process.

Finally, as the main consent method previously detailed is a one-off process, unless a new treatment is added, it is now becoming more common to have an ongoing consent card that the patient signs at each visit to confirm that nothing has changed in their medical history, no new medications are being taken and that they’re not pregnant.4 Clearly, if there were new medical issues to consider, the consent process would need to be revisited and documented accordingly.

Crucially, once all of the above has been discussed and a treatment plan agreed, there must be a written record and a form signed for consent. The patient should also take away with them written aftercare instructions.

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A major change in the consent process has seen the patient become an active and equal partner alongside the practitioner Another recommendation from the Keogh report, which is supported by the main professional bodies, such as the GMC and the RCS, is for consent and treatment to be a two-stage process to give the patient time to consider the treatment fully.2 A ‘cooling-off’ period before treatment is also becoming more commonplace. For example, I consult and consent for thread lifts at the initial appointment and carry out the procedure at a future date. Clearly, this changes the timing and planning of appointments and could potentially result in cancellations or no-shows, but follows good practice guidelines. If this isn’t your practice, be satisfied that the patient fully understands the risks and benefits and feels able to ask informed questions or say no to going through with the procedure. A possible method, which can be worthwhile, is allowing patients 30 minutes back in the waiting room to consider whether they would like to go through with treatment.

Technology It is clear that the consent process has altered the consultation dramatically, and, in addition, has added more time and paperwork to the process. There are, however, technologies which may help streamline the process, and others that give you time back as they aid the decision making process. For example, over the past three years, there have been mobile phone/tablet apps, which replicate the entire consultation process and serve to securely store the medical questionnaire, consent and photos together. These apps can negate the need for paper records and the associated risks of storing and accessing confidential patient records. They could also solve the issue of uploading photos from a camera and either printing or collating with the patient record. Currently still relatively early in their uptake, they hold the promise of streamlining the consultation.

There is also the use of 3D simulation to demonstrate the effects of non-surgical treatments. Already being used in the USA5 and Australia,6,7 the simulation works as an addition to the consultation that will allow both patient and practitioner to have a realistic idea of treatment results before committing – if the technology lives up to its promise. Such an advance may limit patient dissatisfaction or manage unrealistic expectations, but will inevitably add more time to the consultation process.

Having said this, many clinics have started to use Computerised Photo Imaging Skin Analysis8 in the consultation process. This is another addition over the past 10 years and the 3D technology would be used in a similar way.

Range of treatments The variety and depth of non-surgical treatments on the market has increased. The treatment list no longer contains just fillers and botulinum toxin for anti-ageing. The solutions now include lasers, sculpting, radiofrequency, cryoneuromodulation, hydradermabrasion, PRP, collagen stimulators, hyaluronic acids and micro-needling, to name a few.9 64

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Within each treatment type, there are multiple choices of products from a range of manufacturers. In regards to different filler treatments, the choice for the patient and practitioner depends on; the area being treated, desired effect, product structure and composition, longevity, and patient preference. Each product type requires specialist training by the practitioner and often a different consent form. Such complexity and more demanding consent makes for a more time consuming consultation, with a detailed explanation covering which treatment of many might be most suitable, what it involves and the risks.

The other transformation affecting products over the past five years has been the addition of lidocaine in fillers. This has changed the requirement for topical anaesthetic prior to treatment, which ultimately speeds up the process.

The knowledgeable patient The internet, social media and growing interest in the market has educated patients as to what is available and what to ask. Social media has allowed engagement in a way never seen before and the sources of information are vast. It not only highlights new treatments and technology quickly, it also addresses bad practice and enables bad news to spread quickly and prompt questions. The engaged patient searches and follows practitioners and is able to ask questions and retrieve answers quickly. Social media empowers the patient: they use it to gather information, research practitioners and interact purposefully. The more the patient knows, the more understanding they bring to the consultation and the more questions they want answered to clarify areas of concern.

Conclusion There is no doubt that the non-surgical consultation has changed radically over recent times and will continually evolve. Change can be difficult to process, but when changes are in place for improvement, adaptation produces a superior experience for everyone involved.

The changing consultation has become more complex and somewhat crowded, but the options are vast, the tools ever expanding and the results that can be achieved keep on improving. The outcome should see happier patients, achieve better patient safety and a more skilled and regulated industry.

Dr Renée Hoenderkamp is a GP registrar based in London, having qualified as a doctor in April 2010. With a special interest in aesthetics and women’s health, she founded The Non Surgical Clinic in 2011, offering naturallooking solutions for facial ageing and deformity.

REFERENCES 1. Hart, D QC, ‘Supreme Court reverses informed consent ruling: Sidaway is dead’, (UK Human Rights Blog, 2015), <http://ukhumanrightsblog.com/2015/03/13/supreme-court-reverses-informed-consentruling-sidaway-is-dead/> [Accessed 28th September 2015] 2. Sir Bruce Keogh, ‘Review of the Regulations of Cosmetic Interventions’ (Department of Health, 2012) <http://researchbriefings.parliament.uk/ResearchBriefing/Summary/POST-PN-444/ > [Accessed 2nd September 2015] 3. Professional Standards and Regulation, ‘Professional Standards for Cosmetic Practice’ (RCSENG, 2013) <https://www.rcseng.ac.uk/publications/docs/professional-standards-for-cosmetic-practice > [Accessed 2nd September 2015] 4. British Medical Association, ‘Consent tool kit’, (BMA, 2015), < http://bma.org.uk/practical-support-atwork/ethics/consent/consent-tool-kit> [Accessed 29th September 2015] 5. Biometrix Medical, ‘Botox 3D Stimulation’ <http://www.biometrix.com.au/face-procedures/botox-3dsimulation> [Accessed 2nd September 2015] 6. Biommetrix Medical, ‘Cheek Lift Augmentation Stimulation’ <http://www.biometrix.com.au/faceprocedures/cheek-lift-augmentation-simulation> [Accessed 2nd September 2015] 7. Understand.com ‘Collagen or Injectable Fillers – 3D Stimulation’ (Ocean Clinic, 2011) <http://www. oceanclinic.net/botox-and-injectable-filler/collagen-3d-simulator.php> [Accessed 2nd September 2015] 8. Emage, ‘Image Pro I: Our Most Affordable Skin Imaging System’, <http://www.emagemedical.com/ image-pro-i/> [Accessed 2nd September 2015] 9. Consulting Room, ‘Non-surgical treatments’, <http://www.consultingroom.com/treatments/nonsurgical.asp>, [Accessed 2nd September 2015]

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In Profile Dr Maria Gonzalez

“You have to love aesthetics and strive to deliver good results for your patients” Dr Maria Gonzalez reflects on her career in medical aesthetics and highlights the need for more education within the specialty Consultant dermatologist Dr Maria Gonzalez developed a passion for medicine when she was just a small child. “My friend’s father was a doctor, and from the age of six or seven, he greatly influenced my career ambitions,” she explains. In 1992, Dr Gonzalez moved from Trinidad to the UK to pursue a career in dermatology, before beginning her medical aesthetics career in 2002. She now runs the successful Specialist Skin Clinic in Cardiff, which won Best Clinic Wales at the Aesthetics Awards 2014, and holds consultations every other week at Dr Rita Rakus’ clinic in Knightsbridge. In 2002, a colleague who had purchased an Intense Pulsed Light machine encouraged Dr Gonzalez to join her in a private venture treating aesthetic concerns at St Joseph’s Hospital in South Wales. It was from this experience that Dr Gonzalez began introducing new aesthetic technology to the hospital and developed an interest in setting up her own services for the NHS. “I set up a service for hair removal and treating acne scars in an NHS hospital,” she says, explaining, “It was also established to help provide education for the postgraduate doctors who may be tasked with treating these concerns.” Dr Gonzalez explains that creating these services enabled her to enhance patient results and offer a wider range of treatments aside from prescription tablets and creams. As the director of all dermatology programmes at Cardiff University between 2000-2012, teaching postgraduate students how to use the machines she had introduced fuelled Dr Gonzalez’s passion for education. She stresses the importance of continued education within the aesthetics industry, and continues to teach postgraduate dermatology students at Cardiff University.

In addition, Dr Gonzalez has created a 12-week online course for the university, titled, ‘An Introduction to Dermoscopy’, which, she explains, has received very positive feedback from the university’s Department of Dermatology. “I hope the future of industry education will progress further as I do think that the aesthetic market in the UK needs more educational support,” she says, adding, “I would also like to see more dermatologists involved in teaching and I think that we should encourage juniors to look at this as a viable option.” Along with

Even through coming up with a witty presentation title, education can allow you to express your creativity effectively

teaching students in a university environment, Dr Gonzalez regularly presents at industry conferences and discusses an array of topics, from achieving patient skin confidence and management of acne scarring, to conducting laser and chemical peel workshops. She says that teaching and presenting also allows her to utilise her skill and passion for writing, explaining, “I like to provide my audiences with a creative perspective when I’m teaching and presenting. Even through coming up with a witty presentation title, education can allow you to express your creativity effectively.” Dr Gonzalez notes that one of the negative sides of the industry is that many practitioners decide to enter aesthetics under false pretenses, suggesting that the financial and glamour aspects can overpower certain practitioners’ decisions. “I think a lot of people are jumping on the bandwagon because it can seem like quick and easy money – if that’s your motivation then it’s the wrong reason, you have to get into aesthetics for all the reasons people do medicine. You have to love aesthetics and strive to deliver good results for your patients.”

For anyone looking to develop a career in aesthetics, Dr Gonzalez advises, “If you are a clinically trained practitioner, you need to always uphold what a practitioner’s ethos is, which is to help patients improve their quality of life, and avoid negative outcomes. If you focus on these values then success will eventually transpire.”

What treatment do you enjoy giving the most?

I like treating pigmentation using lasers, which can be very challenging. It requires a lot of patience, so I take great pleasure in performing it well and I always strive to get a good result.

What technological tool best compliments your work?

Lasers – I like working with gadgets. My clinics are heavily based on lasers and my patients have always received very good results.

Do you have an industry pet hate?

I don’t like the fact that the aesthetics industry in the UK is unregulated. It’s disappointing that it seems as though the UK, which usually has a very high standard of medical care and education, has somehow neglected this part of medicine.

What aspects of medical aesthetics do you enjoy the most?

What makes my day fun is the interaction that I have with patients. Without that, my typical day would be too hard, and, luckily, compared to when I used to work in the NHS, private medicine allows you to spend more time getting to know your patients.

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The Last Word Dr Farid Kazem argues the need for more education on the difference between genuine and counterfeit products The aesthetics market is booming. Market researcher, Key Note, expects the industry to reach a total value of £913m by next year, up from £725m in 2014.1 Helping to fuel this growth – despite the number of people choosing traditional plastic surgery falling by 3.6%2 – is the increase in the number of people undergoing minimally invasive aesthetic procedures. In the UK, non-surgical treatments currently make up 75% of the market value, with nine in ten procedures undertaken being non-surgical;3 while in the US, 13.9 million out of a total 15.6 million cosmetic procedures are minimally invasive.4 This development has been acknowledged by the British Association of Aesthetic Plastic Surgeons (BAAPS), an organisation that has spoken regularly about the new aesthetic ideal of ‘tweaked, not tucked’, with a demand for more subtle treatments now outperforming the more traditional and invasive treatments.5 However, this boom in demand and growing market for non-invasive treatments is not all good news for the industry, as, subsequently, there has been a rise in the number of counterfeit aesthetics treatments.6 A counterfeit product can be described as something made in exact imitation of something valuable with the intention to deceive or defraud.7 The rise of counterfeit treatments is a problem that needs to be addressed, and the Government, regulatory bodies and the aesthetic industry should work together to educate the public on the dangers of these devices and protect them from the risks.

Currently in the EU, there are limited restrictions in place to prevent the emergence of counterfeit devices. When a patient chooses to undergo plastic surgery, they can learn more about my qualifications and my practice on the European Association of Plastic Surgeons register; as we are aware, however, there is currently no similar system in place for all aesthetics procedures. As a starting point, compiling a list of registered centres where genuine approved or patented treatments are available would help patients to find reliable information, allowing them to make an informed decision and feel assured that they are not undergoing a counterfeit treatment.

The CE mark system shows that a product meets EU safety, health or environmental requirements8 – and while this is of course important, more still needs to be done to protect the industry from counterfeits.

For a drug to be marketed in the EU, applications must be made through the European Medicines Agency (EMA),9 (or Food and Drug Administration in the US).10 While these processes can be expensive and time-consuming, they are in place for a reason, helping to combat the emergence of substandard pharmaceuticals.

The Last Word Counterfeit Products

A move in this direction for the aesthetics industry would help to prevent unsafe and inefficient counterfeit devices becoming available on the market. This is where the Government needs to take action and ensure appropriate regulations are introduced to help protect patients.

However, it is also important for us, as practitioners, to help educate our patients. Communications are often sent directly to us offering treatments cheaper than the market value.11 Some products and accompanying marketing materials look almost identical to those of the genuine brands, and as healthcare professionals we need to be aware of these counterfeits as our patients will not always be. Although many companies have the best intentions, I have seen numerous examples of counterfeits of cryolipolysis, the fat freezing treatment that is already patented worldwide. A patient who visited my clinic after receiving what she thought was a genuine cryolipolysis treatment, suffered fourth-degree burns from frostbite as the counterfeit device had no safety mechanism in place. Even if treatments do not cause lasting physical damage, there is a high chance results will be ineffective, leading to disappointment and an increase in financial cost if the individual then moves forward with the genuine treatment. Distrust of practitioners is also commonplace, with doubt over the effectiveness of even genuine treatments following a bad experience with a counterfeit device. These factors damage the reputation of legitimate brands and the aesthetics industry as a whole. As mentioned, it would be advisable to have a register for those who perform cosmetic interventions. However, this would provide no guarantee that those listed do not use counterfeit devices.

To solve the ongoing problem with counterfeit devices, a register of centres where approved or patented treatments are available would be a good starting point. It may seem that this problem is too great for just one group to tackle alone. Indeed, I believe that the aesthetics industry and the Government have a combined responsibility to educate the public and enforce restrictions to protect individuals at risk from these harmful devices.

Dr Farid Kazem completed his medical studies at the Zuiderziekenhuis in Rotterdam and specialises in plastic surgery. He has extensive experience in breast enhancement, eyelid corrections, tummy tucks and skin rejuvenation.

Disclosure In his clinic in the Netherlands, Dr Kazem provides CoolSculpting®, owned by ZELTIQ® who patented Cryolipolysis®.

REFERENCES 1. Lauren Davidson, Have we reached peak plastic surgery?, 2015 <http://www.telegraph.co.uk/finance/ newsbysector/retailandconsumer/11569454/Have-we-reached-peak-plastic-surgery.htm> 2. Sarah Gubbins, Popularity of non-surgical cosmetic procedures soars as demand for cosmetic surgery falls, 2015 <http://www.penningtons.co.uk/news-publications/latest-news/popularity-of-nonsurgical-cosmetic-procedures-soars-as-demand-for-cosmetic-surgery-falls/> 3. Department of Health, ‘Review of the Regulation of Cosmetic Interventions’, 2013 https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_of_ Cosmetic_Interventions.pdf [accessed 5 August 2015] 4. American Society of Plastic Surgeons, ‘2014 Plastic Surgery Statistics Report’, 2014 http://www. plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/plastic-surgery-statsitics-fullreport.pdf [accessed 5 August 2015] 5. The British Association of Aesthetic Plastic Surgeons, ‘New statistics show extreme surgery’s gone bust – surgeons welcome more educated public’ 2015< http://baaps.org.uk/about-us/pressreleases/2039-auto-generate-from-title> 6. Wendy Lewis, The rise in black market aesthetic products, PRIME Journal (2014) < https://www.primejournal.com/the-rise-in-black-market-aesthetic-products/?loginredirect=1> [accessed 27 August 2015] 7. Oxford Dictionaries, counterfeit, 2015 <http://www.oxforddictionaries.com/definition/english/ counterfeit> 8. Department for Business, Innovation & Skills, CE Marking (London, UK Government, 8 October 2012) <https://www.gov.uk/ce-marking> [accessed 14 August 2015] p. 1 9. European Medicines Agency, ‘What we do’,< http://www.ema.europa.eu/ema/index.jsp?curl=pages/ about_us/general/general_content_000091.jsp&mid=WC0b01ac0580028a42> [accessed 27 August 2015] 10. U.S. Food and Drug Administration, ‘Development & Approval Process (Drugs)’(2014) < http://www.fda. gov/Drugs/DevelopmentApprovalProcess/> [accessed 27 August 2015] 11. W. Grant Stevens, Michelle A. Spring, Luis H. Macias, ‘Counterfeit Medical Devices: The Money You Save Up Front Will Cost You Big in the End’, Aesthetic Surgery Journal, (2014), pp.786-788

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MedivaPharma 01908 617328 info@medivapharma.co.uk www.medivapharma.co.uk Service: Facial Aesthetic Supplies

Aesthetics | November 2015

Sinclair Pharmaceuticals info@sinclairpharma.com 0207 467 6920 www.sinclairispharma.com

t Thermavien Contact: Isobelle Panton isobelle@thermavein.com 07879 262622 www.thermavein.com

z 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

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients.

In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis.

Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection.

Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions.

Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

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 Galderma (UK) Ltd.

AZZ/019/0313

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Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014