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My team training

So you want to be an aesthetic practitioner? In a unique guide to developing the necessary skills, Tracey Bell shows you how

Before the truth moment

After - eight years on. ‘Thank goodness for aesthetic medicine!’


he first question I would ask anyone considering becoming an aesthetic practitioner or attending one of my courses is: why? Is it a business decision, a method of diversifying your income stream, a call from your patients who want it or simply that you are interested – it looks exciting and you simply fancy giving it a go? All are completely acceptable and for me personally it was one of Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

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the best decisions I ever made, but also one of the hardest. For me as a dentist, the decision originally to ‘dabble’ in aesthetics was an emotive one: I was 32 years old, had five children, was very wealthy, successful and happy, but I had a truth moment. I would define a truth moment as the one when I looked in the mirror one early autumn morning and I didn’t recognise the woman looking back at me. I was tired, drawn looking, my hair was thin, my body looked quite frail and I had lines and wrinkles way beyond my years. Why? Extrinsic ageing really – long hours, a demanding job, and five children – I am sure you can all appreciate how I looked, and believe me the lines on my face told so many stories – I needed to improve what I saw. So, I intend over the next 12 articles to give you a overview of aesthetic medicine – what I believe I can teach you, what information you really need, what tools you need to purchase, the skills you need to learn and, most importantly, how you can enjoy it. Enjoy and let the reinvention of, hopefully yourself, your skills, your staff and your business begin.

AESTHETIC MEDICINE First, a definition: Aesthetic medicine is a branch of medicine focusing on satisfying the aesthetic desires and goals of the patient. This speciality is primarily focused on the physiology of ageing skin and adheres to scientific based procedures. Physicians working in aesthetic medicine are trained in both invasive and non-invasive treatments and typically utilise a combination to meet the needs of the patient.

As a practitioner, this is where I think dentistry plays a huge role. I believe that the combination of dentistry, non surgical treatments, lasers and cosmetic medicine (ie peels, skin conditioners, etc) can all be combined and are often required to produce good aesthetic results. Therefore they can all be completed within a good dental practice.

WHERE DO I BEGIN? 1: RESEARCH The first thing I would advise any practitioner is to do your research into the topic. Look at the types of treatments that you could provide, eg: t Botox t Fillers t Lip fillers t Chemical peels t Lasers t Body/face tightening. Where do you begin your research? Google? Don’t reinvent the wheel or make the thought process difficult. Check out sites such as:,, Alternatively, log on to You Tube and watch the procedures – a great source of

Training my team in San Francisco


Educating patients about injectables

Always find time for education and research information. All you need to do is simply log on to You Tube and type (Watch Botox Injections) All of the above will give you an insight into treatments, along with how they are delivered and what costs are involved. This will give you a good overview. When it comes to reading material subscribe immediately to relevant publications such as Body Language, Cosmetic News, Aesthetic Dentistry or Beauty Guide.

2: OBSERVE The second piece of advice I would give to anyone is to observe. I believe that if as practitioners we collaborated with each other, rather than trying to compete, we would all be much happier and importantly, much wealthier. So, what would I do as a dentist? I would contact your local Botox/cosmetic surgery clinic and inform them that you are interested in watching their procedures. You could even try this with a friendly dentist, particularly if you know them. Often people take it as a compliment that they have received a call. You should also appreciate that quite often, by introducing yourself to local clinics, that they in turn may refer clients or patients to you for procedures such as dentistry, whitening or implants.

3: COURSES/REPS After deciding that you are interested, you

Educating patients on botox need to educate; that is where I am adamant that even if you do not intend to provide all the treatments yourself, you do need to know about them and have experience of them. It is at this point that you need to have a ‘taster’ and then look at commitment. When I say commitment, it is advisable to consider courses available in the very basics to give you an overview. t Skin and ageing. This is often provided very well by reps. The information that they can provide to you is invaluable; additionally the literature they can give proves very helpful t Botox. Not just a single course, but a mentoring course over a period of a few months. Why? Because from a personal experience, no matter how good the courses were, the first injections and patients were terrifying to me. Would the brow droop? Would she be able to see me the next day? This is completely true and I never had anyone to hold my hand! It was a scarily long waiting game and also a steep learning curve. What I would recommend is either to find

a mentor or inject with a colleague. You can then share photographs, experiences and learn from each other t Facial fillers – Again, not just a single course, but many. Purchasing of products and practicing, should all be taken into account. Remember, the distributing companies are not going to give you an unlimited amount of syringes to ‘play with’. You will have to pay and that can be costly. To begin with, I would recommend learning with a simple ‘hyaluronic acid based’ product. Every good aesthetic practitioner will need a good skin care range to improve the skin (canvas) and yes, some of them do work! It just takes time to find the right ones. Company reps are a valuable source of information, resources and free courses. Without these my business knowledge and staff would not be where they are today. Some of the best reps I have worked with have been from SanofiAventis, (Heather Morton), Galderma (Azzulue – a type of Botox) (Emma Miller) and Allergan. For education, supplies and contacts, MedFx are a great resource for information, advice and in helping set up an account for supplies. It is so important to build a good relationship with the reps; they not only educate you and your staff on the product, but they also have a wealth of experience regarding facial ageing, marketing, advertising and business plans. If it means selling their products – believe me, they will work for you! I would advise any practitioner who is interested to call the rep for the relevant area direct. Explain that you are considering educating yourself and your team, invite them in. If you have any problems, just let me know! They should welcome your telephone call. Do not be ‘bullied’ into committing to only one product or range – competition is healthy.

LOGISTICS In considering setting up an aesthetic medical unit within your practice, I would say the logistical points to consider are: t Staffing – who in your team could or

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would enjoy this role, either providing or managing? Could you utilise your dental nurse, hygienist or practice manager? I have found some great multitaskers, and in this industry I believe you will find that you have numerous staff who would be interested in helping out – just ask! Aesthetics is interesting, but it is important you find the correct team to help you grow and enjoy your new subject Space – Do you have space to accommodate these procedures? Yes, a dental chair can be utilised, but often deprives the room of ambience; hiding drills etc will help. But do you have

Patient before aesthetic treatments

another room you could utilise? Or does another dental practice known to you have one that could be used? t Time/resources – In order to educate the staff and the team, time, money and commitment need to be considered. When I trained, I trained my staff alongside me. The process was relatively easy, since in comparison to dentistry it was a little more exciting t Insurance – Even to begin, indemnity is required, even though the procedures and treatments are semi-permanent. Insurances are available from Hamilton Fraser, Ceart and Towergate. Dental Protection, from April, do provide cover for certain procedures, but the cover is limited. Do as I did, shop around, complete the forms and receive the quotes. My staff always had the treatments as trials. They thoroughly enjoyed the time to train. They became reinvented, their attitudes changed as they began to love the treatments, ultimately my practices became more successful. I suppose what I am trying to say here is: ‘consider your team’. You need to have a good team behind you, they have to be given the treatments and understand why, sometimes, ‘time for change’ is good! Without a good team or positive mental attitude, any new ideas or business venture will fail – believe me I learned the hard way!


After aesthetic treatments

After treatments

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I think that any new business venture needs to be interesting, you need passion, belief and to enjoy what you plan to achieve. In considering aesthetic medicine, if you enjoy creating a smile and have an eye for detail, it is a good business proposition for you to consider. Remember you have the patients, who hopefully already trust you. You are simply going to offer them another service in the future. But, beware if you hate filling teeth, have no passion for whiteness, creating smiles and think that aesthetic medicine may be an easy way out – dentist beware – the clients and patients know exactly what they want. And that means you have got to be really good!

Before Restylane treatment

After Restylane treatment Next month: Tools of the trade To ask a question or comment on this article please send an email to:

KEY POINTS WHERE TO START Research - the internet and specialist publications Observe - specialist practitioners Attend courses and get advice and information from company reps Logistics - consider staff, space, time and insurance Consider your team Have passion and commitment Be very good at it


The team receive free lectures and education modules


TO WORK WITH YOUR INDUSTRY REP Put your dental industry rep to work, says Tracey Bell. It will build their business, benefit your staff and save you money


here are five key ways for you to work with industry reps to get the best for your business. It’s up to you to get the most help possible from them, but remember, you will reciprocate by helping build their business. Have you ever thought of this question? Can you really get the industry to work for you and with you? In my opinion: yes, yes, yes. t Will they help you train and educate your staff? t Will they provide literature and help to arrange the waiting room? t Can they motivate staff and help you contact your clients? t Do you feel confident these tasks are Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

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being managed so you can continue to drill teeth, eat lunch and sometimes have the odd afternoon off to spend with your family? The answer is always yes - you just have to ask.

1: THE REPS Let’s say they appear at your reception. Your receptionist should never tell them you are unavailable. Instead you should invite them in and give them 15 minutes of your time. Remember, this is the start of a meaningful relationship and business arrangement. Over the last three years reps from different companies have really helped me. I did not spend thousands with each of them, I was simply nice to them and most of all loyal. It is important to ask if they will they educate your staff and assist with training sessions The answer must always be yes. The staff will love an independent team-building


exercise; it builds rapport and keeps them updated. I have reps from implant and orthodontic companies help with this regularly. The benefit to my business is huge. The upsell from my staff is also enormous. With the non-surgical companies I am even provided with business development managers, a great asset to help me build the business.

2: OPEN EVENINGS Plan an open evening and ask your representative to attend. I have even had contributions towards food and help with the emails or direct mail invitations. All I had to do was to provide All the staff have their teeth whitened courtesy of the industry the data and some staff who had already been trained by the rep. This is a great way to build clients, create 4: PR local news and bring new patients into the We have all heard of PR and there are many practice. Who helps and provides it? The rep, of us who have stepped into these murky of course. waters. Beware, the waters certainly are murky. There are lots of piranhas, and hordes of ‘yes’ men and women who generally take a 3: DEMONSTRATION AND BEAUTIFYING lot of money – for a little self adulation. THE STAFF What I learned though, was that a lot of the A staff member could be a guinea pig for larger companies had PR firms who they even the latest whitening treatment, implant or paid to represent them, who were just crying ceramic inlay. How many of you have ever out to be provided with stories, pictures, and thought to ask for a ‘free sample’ for your successful before and after pictures – at no staff? Well, it’s always worth asking! cost to me. All my staff on reception have had their So, the next time your representative is teeth whitened. Why? Because they sell me, in, ask if they have a PR company. Even if the treatment and the brand. I simply asked they do not, ask them if there is a way you the my whitening company and told them can work together on marketing: reps have I would aim to reach the target. When I did often helped me place small adverts in local achieve it, my staff reaped the benefits. The newspapers and pay per click ads on Google. same goes for the labs. I often get a deal for Again, all I did was ask for a little assistance. my staff bills, sometimes complimentary. Remember, they are often only too happy How about aligning teeth? Two of my to help. receptionists wear aligners. Of course the treatment is provided free of charge by me and my dentists. Nevertheless, the laboratory 5: TRAINING YOU bill is often supported by the company’s There are many training courses from representative – and yes, we have a good Botox, implants and sedation to general uptake on treatments. conservation. Ask your representative what Always remember, the relationship training they can provide in house. between you and your rep is crucial and there Many non-surgical providers offer is many a win:win deal to be done together. products with training and ongoing support.

These companies have a wide network of individuals who can offer ongoing advice, handholding and education. I have also been fortunate when dealing with implant companies to receive helpful courses for my nurses, reception staff and restorative courses for my other dentists. I have had to purchase products and stay loyal, but at the end of the day both the company representatives and your company can prosper from a complete understanding of how to work together.

FACTFILE: GETTING THE MOST OUT OF YOUR REP Give them your time Ask them to help with open evenings Get your staff involved Some of their PR budget can help with your marketing Get them to help with training

To ask a question or comment on this article please send an email to: ppd

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FACIAL AESTHETICS GETTING ‘TOOLED UP’ In her second article for aspiring aesthetic practitioners, Tracey Bell examines what you need in your tool bag


eople often ask me: what exactly do you need to set up as an aesthetic practitioner? Let’s keep this basic and, as I do start at the beginning. A good aesthetic practitioner with a good practice needs a ‘great tool bag’ in order to make an aesthetic practice work. So, first of all let’s decide who and what you want to be. Then we can determine what tools you need. For me this was very simple; my main aim was to educate myself, team and staff, but above all, to do as I had done in dentistry and ‘do no harm’ with a minimal outlay.

I would recommend this standard to begin with, it must be applied to all the people in the practice who touch, interact with and educate the patient. In aesthetic medicine, I have learned that you have to do lots of good. Under promise, over deliver and most of all make the patient feel and look better - this is ‘emotive beauty’. I am a true believer that you can begin a practice with minimal outgoings. If we keep it simple I would suggest that the three key areas you look at are what I call: t Canvas - skin t Lines - static or dynamic t Volume - volume/fat loss in the face. If we are going to look at the above, we would need to learn about: t Botox t Fillers t Chemical peels/microdermabrasion t Skin - its effects. Let’s leave the lasers, lights, fat-busting technology to those that are big risk takers, have huge amounts of money to spend and who want to play with the big guys.


Tracey Bell at work

Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

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Botox will basically relax lines and wrinkles caused by animation in the forehead, around the eyes and also in advanced users around the mouth. At present there are four main types of Botox on the market: t Botox – Allergan t Azzalure – Galderma t Dysport t Bocoture. They all basically work in the same way.

They all claim to be either cheaper, last longer or are easier to use. In my experience, I simply buy on the basis of cost and education. Some companies contact me and my team weekly, while others I simply do not see - and they expect me to sell their product? All I can say is call them all to visit you, ask them what education, support and business planning they can provide. Choose the one that you believe is the better and review sales and support after six months. They need you more than you need them. With regards to the courses that I have been on, most are paid for but some are free and I

PRODUCTS USED Botox Allergan Azzalure Galderma Dysport Ipsen Biopharm Bocoture Merz Pharma Restylane QMed Perlane QMed Juverderm Juverderm Succeev Sanofi-Synthelabo Teosyal Teoxane

COURSES BY Wigmore Medical Bob Khanna Code Training Courses


simplest and safest products to train with are the hyaluronic acid based products such as Restylane, Perlane, Juverderm, Succeev or Teosyal. Hyaluronic acid is a natural substance found in the body. It is often used on the lips and to fill the nasolabical folds. The results last for between four and eight months, depend on the amount of product used, the type of wrinkle and the actual product. Once again training is often provided by a lot of the companies supplying these products and this is where I would begin. Following education in-house, other filler training courses can be found, but I often think that gaining basic training in-house to begin with is beneficial. Then - dependant on your experience - an open course on different fillers not related to the company may be good. Remember, facial anatomy is essential to review prior to any training or treatment, this should be provided as part of the overall training programme. A comforting, welcoming environment is vitally important in promoting good aesthetics would say they are the better. I believe that any Botox or filler course needs to provide mentoring. How? With computer technology, telemedicine and Skype, simple. You just need an understanding tutor and mentor at the end of the line. Courses that are regularly advertised are: Wigmore Medical; Bob Khanna; Cosmetic Course; and Code Training Courses. I would look at the USPs of all of the above and then make a decision. Ask friends and reps for recommendations. You should be able to inject after your first course. But remember, practice makes perfect. Invest time and products on staff to begin with, watch and video your results. I utilise a great camera called the ‘Flip Video’ which I use to record all my treatments. The patients love them, they are so easy to use, and can be placed in the patient’s computerised records or online.

FILLERS Injectable soft tissue fillers are becoming a mainstay of aesthetic medicine. The

MICRODERMABRASION Microdermabrasion involves tiny particles under negative or positive pressure being abraded against the skin, to mechanically remove the superficial epidermal layers. The treatment is a great introduction to skin enhancement, can be completed by a beautician (NVQ3) or correctly trained practitioner. In my practice, my dental nurses were trained and provided these treatments. You can purchase the equipment for as little as £300 on eBay. We did and the results are exactly the same as with a £5,000 machine we purchased five years ago. Microdermabrasion may be combined with different peeling agents and skincare, it is a great treatment to market to all of your patients who simply want a facial that exhibits results. Average cost is around £60, with treatments taking 30 minutes.

CHEMICAL PEELS Remember, not all peels are equal and I can imagine the image you have - a woman with a red burnt face leaving your surgery, skin dropping off. Well, that isn’t the case. Peels can be separated into all strengths, I would simply begin with the superficial

ones based with glycolycic, salicylic or alpha hydroxy. From my practice’s experience, once a patient has experienced a peel, felt the smoothness and softness delivered, and of course the luminosity and radiance of the skin, it is an easy way to get them asking for more. Chemical peel training is very difficult to access in the UK. One of the best three day courses I have attended is through the IAPAM in Los Angeles. The course was less than $1,000 and it covered Botox, fillers, skin, ageing and peels. It is one I still regularly recommend, even if you have to pay for a flight.

PLAN FOR GREAT PERFORMANCE If you fail to plan, then plan to fail! I’m not saying create great business plans, but let us simply think about how we are going to start. As a dentist I found this easy; I had thousands of patients on a database so I did some simple invertising (advertising internally). All I did was let my patients know by word of mouth, email and in-practice promotion on what we planned to do. It’s worth remembering this was seven years ago, when Botox and treatments were relatively unknown and expensive. If your practice is a traditional one, dedicate a room to your aesthetic centre, set the ambience – some literature, clean, calm and almost not looking like a clinical dentist room.

PLANNING A simple SWOT analysis will give you all direction. Try this:



Good patient database

No marketing experience

Good location

Nurse not interested

Established credit

Staff not used to aesthetics



New service/new treatment

Early mistakes

Staff morale

Competition nearby

Improve cash flow


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Great reception staff are imperative

and that they are understood by your team and staff. The main insurers at present who insure for malpractice are: Hamilton Fraser, Towergate and Ceart. It is important to compare all companies for pricing, procedures covered and excess premiums. The IHAS (Independent Healthcare Advisory Services) is a group that provides a quality assurance framework for practices to follow. This has been recently introduced and one which I have signed my clinics to. There has been much press about this network which at present offers the only reassurance a patient may look to to ensure that clinical standards are maintained. It is a framework of quality assurance and protocols that my team can work from. www.treatmentsyoucantrust.


A great team, good consumer focus and interaction Now what you need to do is simply set a goal. If you have no goal, you’ll get lost. The goal simply needs to be: t Time phased - set an annual or sixmonthly goal. t Monetary - track Progress, simply look at costs, profits and how to contain expenses. Believe me, expenses you need to contain. t Realistic - be realistic, don’t set goals too high. Two patients per week is a good goal to begin with. t Bought into - goals will never be achieved alone. Your team needs to understand your goal. A SWOT analysis is a great way to brainstorm with your staff and makes them feel a part of the ‘tools’, which I think is essential. From the SWOT analysis, everyone can see exactly how a strategy can be exercised in order to bring those clients through the doors. A couple of extra items for the tool bag worth explaining are insurance and IHAS registration. The correct insurance is important in this litigating society. It is vital that regulations and rules are followed

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A tool bag can be as simple or as comprehensive as you wish. The main, key ingredient however is education and knowledge. I was lucky to begin with, as I ensured that in order to gain knowledge, I worked with plastic surgeons, dermatologists

and watched other cosmetic practitioners work - simply because I was interested. I asked and they kindly agreed to share their ideas, knowledge and experiences with me. Take my advice and simply ask. It was from plastic surgeons that I learnt about procedures and from dermatologists that I learnt all about the skin. Yes, we can all read a book, but I believe that telling, showing, doing or educating, watching and knowing what to do are vitally important to understanding an ageing face, as you will see in the next article.

AESTHETICS TOOL BAG CHECKLIST Education of staff and practitioner A room for completing procedures – with the correct ambience Botox - educational materials / injections / products / sharp bins / gauze / good before and after images Fillers - educational materials / products / sharp bins / good before and after images / patient aftercare advice Peels - and a microdermabrasion Skin care - do not invest heavily if you are not confident to begin with Team - a team who believes, loves and understands facial aesthetics Follow up - constant contact Relationships with reps and suppliers are extremely important; they can help with education, marketing and planning

A good injecting technique and patient trust is crucial

Insurance IHAS registration

To ask a question or comment on this article please send an email to: External promotion and good staff are important




AN INTRODUCTION TO THE PROCESS In her third article on becoming an aesthetic practitioner, Tracey Bell explains what you need to know about how the face ages


hy do we age? How do we age? What are the implication of ageing? And how do we recognise what the problem is? All important questions that should be considered by an aesthetic practitioner. This month’s article is a simple overview. Books have been written on the subject and this article is intended to be a simple illustration of the key points an aesthetic practitioner would need to know, understand and comprehend. From botox, fillers, lasers, super charged skin care and state of the art wrinkle creams,

the choices for treating ageing faces are greater than ever before. However, to the new practitioner this can be extremely daunting. It is so easy to assume a little bit of botox, or the odd syringe of filler can treat every single aspect of ageing - but unfortunately it’s not true. Opting for the wrong treatment can be disappointing to the new client and even more of a disappointment to you when they fail to return and tell 10 friends just how much they paid for so little. And, believe me, they will! So what does this teach us? Primarily, ageing is multifactorial. In the face it involves the skin, muscle, bone and fat, and the dental substructure. It is important that as a practitioner we understand why a face has aged, how we can treat this and the best options involved. Education and diagnosis in aesthetic medicine therefore go hand in hand.

the skin lose its luminosity, radiance and makes it more susceptible to UV damage, sun spots and wrinkles. The second is extrinsic ageing, referring to the environmental factors that influence the way we age. The sun, smoking, alcohol, pollution and food - all are key environmental factors that influence this part of ageing. There are certain habits that can slow down extrinsic ageing of the skin, most significantly wearing sun screen and giving


Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

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There are two ways the skin shows the ravages of time. The first is what ‘mother nature intended’. It is the natural biological process which occurs in the skin. This includes hormonal changes such as a decrease in oestrogen - which makes the skin drier, decreases in collagen and elastin production, resulting in loss of plumpness and less melanin. This in turn makes

Figure 1: Intrinsic (on left) and extrinsic (on right) ageing


Figure 2: Static wrinkles at rest up smoking. Other studies have also shown evidence that nutrition and sleep can also influence extrinsic ageing, hence their greater understanding of trying to prevent it. We must also understand that as we age, muscles contract, bone atrophies and the skin simply sags. Figure 1 is a beautiful ‘hypothetical’ diagram comparing intrinsic and extrinsic ageing. The woman’s face on the left shows intrinsic ageing, while on the right extrinsic ageing is shown.

HOW AGE SHOWS ON THE SKIN The most important thing to remember about ageing is that it is simply not just about wrinkles. Ageing is a combination of loss of volume (fat, muscle, bone) as well as changes in skin texture and tone. t Texture: As we age the skin loses its luminosity. This is normally due to the increase in dead skin cells which accumulate with age. t Tone: Flushing, pigmentation and redness can all be attributed to tone. As we age the skin in general loses melanin, making sun spots more common, additionally veins and telangiectasia can appear in the cheek and nose area. t Wrinkles: Lines I classify as static or dynamic. Static wrinkles (Figure 2) come

Figure 4: Triangle of youth, pointing downwards

Figure 3: Dynamic wrinkles, those produced on expression


with gravity, loss of volume, loss of fat, bone and muscle - many factors which aggravate. Dynamic wrinkles (Figure 3) are caused by animation and movement. Typically, these are forehead, crow’s feet and around the mouth. As we age these muscles become large, causing lines and wrinkles in these areas. Botox is the best solution for ‘dynamic’ wrinkles. Volume: As we age loss of volume in the mid part of the face leads to deep nasolabial folds, loss of jaw definition and inversion of the ‘triangle’ (Figures 4 and 5). I believe that the recognition and understanding of the fat pads in the malar, submental and temple areas are the most important landmarks to recognise, understand and try to correct in facial cosmetic treatments. Figure 6 shows the common signs of ageing.

Figure 5: Triangle of despair, note the triangle with base at the bottom of the face

t Epidermis: The outer part of the skin is

A REVIEW OF ANATOMY The skin is a specific organ containing many cells, layers and structures. It acts as a protective barrier to the environment and is also involved in maintaining body temperature and function. The skin is divided into three layers:


0.05mm - 1.5mm thick and contains five layers: stratum basale; stratum spinosum; stratum granulosum; stratum licidum; stratum corneum (dead flat skin cells). Dermis: This varies in thickness, 3 - 8mm and is composed of three types of tissue: collagen, elastic tissue and reticular fibres. The dermis contains two layers: reticular

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Figure 6: The common signs of ageing

Figure 8: Facial muscles and their actions are imperative to understand in facial aesthetics


lower, which is thicker and contains collagen; papillary upper, which contains a thin layer of collagen fibres. Subcutaneous tissues: This is a layer of fat and connective tissue that houses larger blood vessels and nerves. It varies in thickness dependent on the part of the body and from person to person.

CONCLUSION In diagnosis and treatment planning it is vitally important that the basics of facial anatomy is understood. The ageing process varies from individual to individual and is determined by numerous factors involved in intrinsic and extrinsic ageing. How we age should be divided into canvas (skin), lines (static and dynamic) and

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Figure 7: Important facial landmarks - arteries/vessels volume. If the practitioners can classify and understand at what condition each of these factors exhibits treatment, planning becomes easier. When diagnosing, I consider each factor separately: t The canvas: What are the presenting problems? Can I correct these? Are they an issue to the patient? t Lines: Are the lines static or dynamic? Are they in the upper, mid or lower part of the face? How can I correct them? Is it an issue to the patient? t Volume: This is the most important factor to consider in facial ageing. It generally exhibits in the mid third of the face to begin with; however, its effects are visible in the lower third.

All of the contributing factors should be understood: how they appear visually, comprehended, and whether you should treat them primarily separately and then combine to produce the ideal treatment plan. Facial ageing, diagnosis and treatment planning is key to any successful aesthetic practitioner and is the evaluation of an ageing face, one that needs to be understood.

To ask a question or comment on this article please send an email to: ppd



AESTHETIC USE OF BOTULINUM TOXIN Tracey Bell gives an introduction to botulinum toxin, an important product for aspiring facial aesthetic practitioners


otulinum toxin treatment for wrinkles has become a hugely popular treatment in America and Britain in the past decade. It can be used alone or is increasingly combined with cosmetic surgery, laser treatments, chemical peels or fillers. The treatment itself has no downtime, produces high patient satisfaction and is a treatment that certainly can be offered in a dental surgery. The questions I am most often asked are ‘What Botox do you use?’ ‘Where did you begin?’ ‘What are the current regulations with regards to prescriptions, insurance

Botulinum toxin is most commonly used in reducing dynamic lines in the upper third of the face and advertising? and most importantly, ‘Do patients want this treatment?’ This article will simply review the action of Botox, the products available and their overall use.


Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

132 May 2011 PPD

Botulinum toxin is a potent neurotoxin produced by the bacterium Clostridium botulinum. Commonly referred to as Botox (though the name is a registered trademark of Allergan Inc) it works by preventing the release of acetylcholine at the neuromuscular junction. By preventing the production of acetylcholine no message is transmitted from

the nerve to the muscle and hence the muscle becomes temporarily inactive. By producing a decreased activity cosmetic improvement is noted as the dynamic winkles decrease and the muscle which is prevented from moving starts to atrophy. Clinical studies of the synaptic vesicles producing acetylcholine show they do not start to work again, but instead new synaptic connections are produced. Botox in general shows to have an effect for between 12-16 weeks and then treatment is required. Both you and your patient will notice a progressive improvement in the facial appearance with repeated treatments as the muscles atrophy producing smoother skin


Botulinum toxin can also be used to treat hyperhydrosis or excessive sweating

The effects of botulinum toxin in smoothing facial lines clinically. Botulinum toxin was originally used in medicine for treating cerebral palsy, torticollis and blepharopasm. The practitioners who were using Botox in blepharopasm patients noted the decrease in glabella lines in these patients and hence the boom of Botox cosmetics began.

PRODUCTS AVAILABLE At present there are numerous Botox products that are available. Differences in formulation and the way every unit test is performed, results in ‘units’ varying in potency. It is therefore important to understand that a dosage of ‘one unit’ cannot necessarily be



Botox (Allergan)


Vistabel (Allergan)




Xeomin (Merz)


Dysport (Ipsen)


transferred to different types of Botox. For example it is reported that a unit of Botox equates to three or four units of Dysport. This will become more clear when training on the products is completed and dosage units are discussed. In addition, the neurotoxin protein load in each product differs. Botox (Allergan) is reported to have a lower protein content and it is this protein content that may cause immune response that can lead to formation of antibodies. At present, research shows that 5% of Botox users may show antibody formation in the long term.

RECONSTITUTION AND HANDLING With all neurotoxins it is recommended to dilute with bacteriostatic saline. Recent reports show bacteriostatic (or preserved) saline to be less painful during injection and from experience it certainly is. Volume dilution varies but the most common dilution per vial is 2.5cc. It is recommended that botulinum toxin should be used within four hours on reconstitution and stored prior to dilution in freezers at -5°C.

Simple diabetic syringes can be used to administer Clinical experience and recent studies suggest that potency can be maintained for up to six weeks with proper storage at 4°C. Xeomin is a botulinum toxin which isn’t dependant on storage at -5°C and may be useful to those practitioners who may travel or not have the facility for a freezer.

TREATMENT As with any treatment, informed and written consent is essential. It is important to inform the patients about the toxin - it’s ‘off the label’ use of the drug in alternative therapies.

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can certainly be used alone or integrated with other non-surgical modalities to begin to build a non-surgical business. It’s best to start off simple, stay safe and of course get as much practice as possible. Good training courses are available, and remember it’s very natural to feel apprehensive about your first injections. However, with good clinical practice, experience and mentoring, administering this revolutionary treatment will become second nature.

Different brands of botulinum toxin will have different strengths Vistabel is the only botulinum toxin in Britain to be licensed for use in the glabella. Complications may include bruising, non response of the muscles, headaches etc. Once mixed botulinum toxin is usually delivered using a 0.5ml - 1ml gauge 30 needle (simple diabetic syringe). Typically anaesthetic is usually not necessary. However, it may be beneficial in those patients who are extremely nervous. Botox is most commonly used in reducing dynamic lines - those produced in facial expression in the upper third of the face. The most common areas treated are: 1. Glabella 2. Forehead lines 3. Crow’s feet. It can also be used in areas such as the perioral, naso-labia, nasalis, dimpled chin and the bands of the neck. The glabella or ‘legs eleven’ lines are due to the hyperactivity of the muscles procerus, corrugators and orbicularis oculi. The development of horizontal forehead lines is associated with the elevation of the brow by the frontalis muscle. Good Botox treatment should be to partially relax the muscle evenly and avoid complete paralysis. The brow position may

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be altered by balancing toxin treatments between the glabella, forehead and crow’s feet dependant on the individual result required. Bunny lines appear on the side of the nose as a result of the transverse portion of nasalis. This may appear when the crow’s feet are treated and hence a small dose in the nasalis will prevent this. Perioral lines are vertical lines which may appear around the mouth as a result of ageing, smoking or loss of teeth. Botox may be used in small doses to decrease muscle activity and hence cause atrophy. If this is repeated every three months fantastic results can be produced long term. Platysmal bands on the neck occur with ageing and laxity. Botox can be utilised to reduce unevenness and appearance. Hyperhydrosis or excessive sweating can be treated successfully using Botox. It works at the end organ level where it prevents the sweat glands from secreting by blocking the release of acelychldrine.

CONCLUSION Botox is an effective treatment with results which are normally seen in three to five days. Patient satisfaction is high and with a low rate of adverse effects it is a treatment that

FACTFILE: BOTULINUM TOXIN Advertising As a prescription-only medicine, Botox or botulinum toxin may not be advertised to the public in any form under the CAP code rule 12:12 stating, ‘Prescription - medicines or prescription only medical treatments may not be advertised to the public.’ A lot has been written about advertising of Botox on websites etc but basically it is not allowed. In my opinion simply find another term ‘anti-wrinkle treatment, anti-wrinkle injection etc’. The consumer is savvy - they know what it refers to and I feel as always it’s better to comply with the authorities. Supply and Administration Botulinum toxin is a licensed medicinal product for specific medical conditions. The MHRA has not licensed these products for general cosmetic procedures. An excellent resource on who can prescribe, who can administer and use these products can be found at

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BOTULINUM TOXIN TREATMENT IN THE UPPER FACE Continuing her series on getting started in facial aesthetics, Tracey Bell looks at botulinum toxin treatments in the upper face


he use of botulinum toxin in aesthetic medicine is the most common cosmetic procedure currently undertaken. Clinical studies show high patient satisfaction and therefore it’s an ideal treatment to provide to your patients in a dental surgery. This article reviews the general principles of botulinum toxin A and specific guidelines for each potential treatment area in the upper third of the face. The majority of Botox that you will provide in clinical practice lies in the upper face. This area includes the glabella, horizontal lines on the forehead and the crow’s feet.

This article will educate the reader in the target muscles, the total starting doses (by gender per injection site) patient assessment and potential retreatment intervals. This article is a simple overview and I would encourage all readers to continue with practical education and continued reading and research on the subject. In this business practice makes perfect and of course all patients are individuals.


Facial muscles The most popular syringes utilised for Botox treatment are insulin syringes. These syringes are generally 30 gauges, 8mm at either 0.3ml or 0.5ml capacity. Important considerations are to always inject with the bevel up and to calculate the ‘units’ per ml before commencing. Preparing the toxin: 1. Utilise bacteriostatic saline as your diluent 2. Draw up the correct amount of saline to dilute the toxin 3. A vacuum should pull the diluent into the vial 4. Remove the metal sealer and rubber bung to allow your Botox to be drawn up into your syringe. Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

down - planning is important. t Work under good lighting in order for you to be able to diagnose vessels and avoid bruising t Cleanse the site with alcohol prior to injection t Examine the patient at rest and making facial expression - mark where you plan to inject

ITEMS REQUIRED Gloves Gauze to apply gentle pressure to any site that bleeds


Sharps bins for disposal of sharps

It is important that before injecting the patient’s skin is cleaned, diagnosed and your treatment plan for the individual written

Multiple needles – replace needle after every six injections to ensure comfort for patient Ice before and after may prevent bruising and reduce pain.

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t Depressor supercilii - these pull the brow

Figure1: Injection points in the glabella

Figure 2: Glabella showing lines at rest and heavy eyes

Figure 3: A glabella in dynamic movement

Figure 4: The frontalis has four injection points, and should be treated in conjunction with the glabella

t Identify any facial asymmetry or ptosis - inform the client and take good preclinical photographs.

GLABELLA The glabella is the smooth elevation of the frontal bone just above the bridge of the nose. The complex of muscles works to produce lines between the medial aspects of the eyebrows. The glabella consists of a group of muscles known as ‘depressors’, so called as they pull the brow down and in. The muscles of concern within this area are: t Procerus - this pulls the brow in infer medially

infer medially t Corrugators and orbicularis oculi - these move the eyebrows medially and infer medially. The strength and size of the glabella complex varies from patient to patient dependent on the size and strength of the muscles. This can affect the dosage of Botox provided, a person with stronger or larger muscles may require a larger dose of Botox. Other factors to consider include brow symmetry, brown ptosis, muscle mass. For all injection techniques we are to assume that a 100 unit vial of Botox has been mixed with a 2.5ml of Bacteriostatic Saline resulting in each 0.1ml of solution being four units. Please refer to Table 1 for treatment, dosage and injection sites. Figure 1 shows injection sites for the glabella complex in women. Consensus normally recommends five injection points, one centrally into the procerus muscle and the other four into the corrugators and supercilii muscles. The total dosage is normally 20 units in women and men to begin with. It is important that when we treat the glabella we diagnose the patient at rest and frowning. Remember that patients who attend for Botox in this area who have large vertical lines at rest – Botox will not remove this on the first treatment and it is important that the patient is told. How I explain this to the patient is that the ‘muscles have gone to the gym for many years and built bulk’; this bulk of muscle then forms lines at rest. Botox works to inhibit muscle movement so if we stop movement the muscle will ‘thin and waste’. Therefore if regular treatments are performed at intervals of three to four months then this line or lines will rejuvenate over time. The patient then understands, becomes involved and of course returns to your practice regularly. If the patient is adamant that the vertical lines at rest are not acceptable I would then look at combination treatments such as Botox and fillers on a primary visit. Diagnosis and facial analysis are the key to good aesthetics, patient management and overall result. Other points to remember are

that males require larger doses (larger muscle mass), eyebrow droop below the orbital margin may indicate ptosis and never inject the toxin below the orbital rim.

HORIZONTAL FOREHEAD LINES These lines are raised by the contraction of the frontalis muscle, which is responsible for ‘elevating’ the eyebrows and skin in the forehead. It is important when treating the frontalis muscle that correct patient assessment is completed. In practice I never treat the elevators alone as if this is done without weakening the glabella complex then brow ptosis (heaviness of the lids) can occur. The dosage utilised in the frontalis is again dependent on gender, muscle mass and anatomy. 16 units of Botox is often utilised at the same time as treating the glabella. As a rule of thumb I would inject within two fingers above the brow to avoid ptosis and a heavy brow. The frontalis has four injection points, which receive four units each (Figure 4). Special considerations when treating this area are: t Always treat the glabella complex with the frontalis t Assess the patient carefully. Those patients who use the frontalis muscle at rest to elevate the brow must be informed of this and treated with caution t With those patients who may have had surgery such as surgical brow lift, always consider the anatomy may have changed t A conservative approach is needed t Aim for weakening rather than total paralysis t Avoid the area immediately above the eyebrow t Examine for existing brow ptosis, which may contraindicate treatment.

CROW’S FEET Botulinum toxin can dramatically reduce the appearance of crow’s feet or periorbital lines. The muscles that are responsible for crow’s feet are that of the obicularis oculi. The muscle is a sphincter surrounding the eye and moves the brow inferiomedially.


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TABLE 1  BOTULINUM TOXIN TREATMENTS Treatment of glabellar frown lines Client positioning: Seated with chin slightly down Curved eyebrow in females: muscles here are not strongly developed, therefore it’s possible to inject lower doses here. Inject into the procerus muscle, the medial aspect of the corrugator muscle and the orbicularis muscle Typical dose: 20 units Botox Injection sites: One injection site is located just above the root of the nose and two others are situated below the line connecting the medial ends of the eyebrows. These sites can be gently massaged after injection

The effects of botulinum toxin on the forehead

Treatment of crow’s feet will vary depending on the pattern of lines The folds extend radically from the lateral epicanthus at right angles to the direction of contraction of the obicularis oculi muscle. The fibres of the muscle are arranged in a circular pattern around the eyes. The folds are also affected by the elevators of the corner of the mouth zygomaticus and risorius. The treatment of periorbital lines or crow’s feet may require a slight variation dependant on the pattern. In general three injection sites are used depositing four units in each site. Things to consider when injecting Botox here are: t Always palpate and inject outside the orbital rim t Always ensure that injection sites are above

Treatment of periorbital region Client positioning: Seated Typical dose: 12 to 16 units of Botox per side distributed between 2-4 injection sites Injection sites: Ask the client to smile or squint to contract the muscles in the periorbital region fully. A dose of 3-4 units of Botox to be injected into central part of the folds, 1cm lateral to the orbital margin. Repeat injections approximately 1-1.5cm above and below the first injection site. It is possible to inject around to the mid papillary line if appropriate. Complications: Drooping of the lower eyelid if injecting too close to the lateral canthus. In rare cases injections can accentuate excess fat under lower eyelids. Diplopia can occur from significant overdosage or injecting within the orbital margin or below the zygomatic bone Post treatment: Advise client to remain upright for approx 4 hours, encourage client to use the injected muscles as much as possible for an hour following treatment - frowning and smiling. Do not press or manipulate the treated area. Follow-up schedule: Clients should return in two weeks for assessment and clinical photos. Re- injection is necessary at 3-4 months following treatment for the first year, following this less frequent or client dependent. Treatment of horizontal forehead lines Client positioning: Client seated or slightly reclined Young clients Typical dose: Dose 14-20 units of Botox Injection sites: Inject in an imaginary line between eyebrows and hairline. 4-5 units of Botox injected into midpupillary line, and two additional sites injected at equal distances between them. Massage gently after injection Elderly clients (or brow ptosis) If the client has deeper eyebrows, mild brow ptosis or is over 50 years of age, most practitioners also treat the eyebrow depressor muscles Typical dose: 14-20 units of Botox. For procerus inject 8 units for a female or 12 for a male. Injection sites: As in young clients, inject in a straight line across the mid forehead in 4-10 divided doses. Assess the lateral eyebrow depressor muscles by observing the lateral canthus during maximum contraction of the orbicularis muscle. If muscle activity is present, treat lateral part of orbicularis with 2 units (female) or 3 units (male). Inject directly above the lateral canthus, slightly above the orbital margin

Care and follow-up is important when providing botulinum toxin treatments

t t t

the zygoma (to avoid the insertion of zygomaticus and weakening) Instruct the client to smile to identify individual variation Mark blood vessels to avoid bruising Inject superficially.

SUMMARY Botox is a fantastic offering to both the practitioner and the patient. With years of experience at the ‘coal face’ I would recommend anyone new or old to the business to keep your practice safe and profitable by providing Botox in the common sites requested. It can be provided at a relatively low cost, with minimal outlay and if done correctly can bring your practice good financial gain and very happy patients who are eager to recommend your business. Again I would always remind you that of course results matter, but to the customer the care and follow-up you provide will be the deciding factor that could make you a winner in the ‘Botox bonanza’ that appears at present in the UK.

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FACIAL AESTHETICS: CHEMICAL PEELS Continuing her introduction to facial aesthetics, Tracey Bell looks at the different types of chemical peels available and the results they achieve excellent results no matter what skin types and conditions.



hemical peels have become extremely popular over recent years as patients become more educated on their benefits and understand the dramatic results they can achieve. All peels are different and contain alphahydroxy acids (AHAs), betahydroxy acids (BHAs), trichloroacetic acids (TCAs) and combinations of the above (Jessner’s solutions, blended peel solutions). Much of the information given on chemical peels is attached to the marketing of a particular product or product line. Some of the information and claims are correct, yet spun in favour of the marketer, so it’s important that we learn to read the information we are given on products with a critical eye and most of all that we understand the effect an acid can have on the skin. This article will help the professional make the best product choice and achieve Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

CITRIC ACIDS These come from citrus fruit and are considered the mildest of the AHAs. The end result is a smoother, thicker, more hydrated skin with reduced stratum corneum. Research also shows that citric acids do not create irritation or inflammation in subjects who used the acid over a three-month period. Other research shows that citric acid is effective in smoothing fine lines and wrinkles and can correct uneven photo damage.

Image: thinkstock

Tracey Bell

Alphahydroxy acids sourced naturally come from sugars found in plants and fruits, which is where the term ‘fruit acids’ comes from. Others are produced from dairy sources, or synthetically. I believe that it is often better to use AHAs that are formulated from a pure and natural source. AHAs include: t Citric acids (citrus) t Glycolic (plant sugars) t Lactic acid (sour milk) t Malic acid (apples) t Mandelic acid (almonds) t Tartaric acid (grapes) AHAs work by dissolving the glycoprotein and desmosomes that bond keratinocytes

and corneocytes. This loosens the stratum corneum, which encourages faster cell turnover and helps stimulate collagen. Medical research supports this belief that AHAs can stimulate the skin’s building blocks, collagen and elastin, which in turn strengthens the matrix that comprises the skin.

Citric acid comes from citrus fruit and is considered the mildest of the AHAs

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skin tightener and antimicrobial. It is therefore an excellent choice for treating ageing skin, smoothing and brightening it, while keeping the skin plump, moist and hydrated.

MALIC ACID This acid is comes from apples and has been shown, not only to exfoliate, but also moisturise and hydrate.


Image: thinkstock

This acid is derived from bitter almonds and is relatively new to the aesthetic market. However, it hasn’t been tested in many clinical studies to date, although it is used in the successful treatment of melasma and other pigmentary conditions.

Beautiful skin can be achieved with mild chemical peels

GLYCOLIC ACIDS These acids are derived from plant sugars, such as sugar cane, beetroot and rhubarb. The acid has the smallest molecule size and therefore although rapid acting as it strips through the stratum corneum it also causes erythema, inflammation and irritation. These acids are the most commonly used in aesthetic medicine but must be used in higher concentrations. The higher the concentrations however, the higher the risk of side-effects. Studies have shown that glycolic acids have a long-term drying effect on the skin. A recent study in

TARTARIC ACID the Dermatology Times has also shown a link between glycolic acids and an increased risk of skin cancer and sun damage.

This acid is derived from grapes. Although ‘grapes’ have been utilised for marketing purposes in aesthetic medicine, tartaric acid is still not commonly used.



Lactic acid is a natural AHA constituent of the skin. It is produced in the muscles and then resides in the perleche acid mantle covering the skin. Due to the size of the molecule, penetration into the skin is slow, which helps to reduce oedema and redness during treatments. Lactic acid has many benefits for the skin, acting as a moisturiser, lumectant, exfoliant,

Peel type

AHA peels

Salicylic acid peel

TCA peels - low concentration-35%

TCA peels - high concentration

Phenol peels

Trichloroacetic acid or TCA as it is also known, is a keratolytic and can be used in levels between five and 50% and are most commonly used in damaged and aged skins to reduce wrinkles. TCA percentages higher than 50% are exceedingly risky and are therefore generally avoided. Combinations of TCAs and AHAs have recently been brought to the market and show promise. Indications: t Ageing skin t Photo damaged skin t Lines and wrinkles

Fine Lines

Some improvement

Little improvement

Little improvement

Moderate improvement

Good improvement



Good improvement

Good improvement

Little improvement

Little improvement

Good improvement

Acne scars

Little improvement

Little improvement

Some improvement

Moderate improvement

Good improvement

Deep wrinkles

Little improvement

Little improvement

Little improvement

Moderate improvement

Good improvement

Age spots

Some improvement

Some improvement

Moderate improvement

Good improvement

Good improvement

As a practitioner, you may have heard of Jessner’s Solution, developed in the 1950s by a German doctor, Max Jessner. It is made up of a blend of AHA lactic acid, salicylic acid and resorcinol in an alcohol carrier base. However, because of the high alcohol content, it can have quite a drying effect on older skin.


1 to 3 months

1 to 3 months

3 to 6 months



BLENDED ACIDS These acids are combinations of the above and are generally the safer of all acids to use on aesthetic medicine. The addition of lighting






High Risks

High (including Cardiac Risks)

Recovery time



Generally Short



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Image: thinkstock

I would recommend utilising peels in their superficial form, which over a course of treatment, allow the patients to return to your practice over a period of months. Peels that are deeper can result in hypopigmentation, damage to melanocytes and I feel should be avoided by practitioners who have just started out in their career. Choosing the most appropriate peel and adding this to your treatment list will enhance your medical aesthetic practice and produce a synergistic end result.

It’s important for practitioners to evaluate different products themselves, and learn about the effects which acid has on the skin agents, tyrosinase inhibitors, for example, minimise post-inflammatory pigmentation and risks involved in most peels. These blended types can also be utilised on darker skin types.

POSITIVE RESULTS Chemical peels play an important role in aesthetic medicine and if utilised appropriately can produce excellent results. As a practitioner,

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FACIAL AESTHETICS: PLASTIC SURGERY Continuing in her series on practising aesthetics, Tracey Bell gives an overview of some of the more common facial surgery procedures available BLEPHAROPLASTY Blepharoplasty is an operation designed to remove excess skin and wrinkles from the upper and lower eyelids. It can be carried out under local or general anaesthetic and may involve fat removal also. It is commonly known as ‘eye bag’ removal and can be utilised along with Botox.


Tracey Bell

A facelift is a term used to describe a wide range of surgical procedures aiming to rejuvenate certain areas of the face, particularly to lift sagging skin and rejuvenate the mid

and lower face, as well as the neck area. It is commonly used alongside other surgical procedures, such as blepharoplasty. There are many ways of carrying out a facelift with each tailored to the individual. For example, the scar may run from the temple behind the hairline, along the preauricular crease and tucked behind the ear, while in some cases, an incision is made under the chin. Facelift incisions and techniques vary depending on the presenting condition and which surgeon is carrying out the treatment. General anaesthesia is mainly used and recovery normally involves wearing a facial


Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

Image: thinkstock

ith more information, carrying out medical aesthetics becomes easier. This is why I consider myself lucky to have watched various facial surgical procedures being carried out in the operating theatre. Not only did it teach me that a collaborative approach is essential, it also gave me a more thorough knowledge of anatomy and understanding of surgical facial treatments available. This in turn allows me to feel more confident in discussing further treatment options with my patients. In this article, I will give an overview of some of the more common facial surgical procedures to be aware of, so you can inform patients presenting for non-surgical solutions of any surgical solutions, should they be considering it.

There are many ways of carrying out a facelift with each technique tailored to the individual

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Image: thinkstock


The face can be plumped using fat taken from another part of the body support garment for a number of days. Swelling and bruising in normal after treatment, which is reviewed around six months after it is carried out.

BROW LIFTS A brow lift can be achieved using a number of techniques. The aim of the procedure is to elevate the brow and remove unwanted wrinkles in the forehead and glabella, open the eye area, reduce the appearance of excess skin in the upper lid and is often combined with blepharoplasty. During an endoscopic brow lift, small incisions are made behind the hairline in the scalp. This is a more intense technique but can produce very pleasing results, without having to make large incisions that are traditionally used during an open brow lift.

RHINOPLASTY Surgery to reshape the nose is a common procedure and can be used to increase or decrease the size of the nose, reshape, straighten or rebuild any aspect of the nose. The shape of the tip or bridge can be changed, but the procedure is technically very demanding in terms of aesthetics and function of the nose. The operation is normally carried out under general anaesthetic and

can be completed by an internasial (closed rhinoplasty) or via a small scar across the central base of the nose (columella) - (opened rhinoplasty). Normally an external splint is placed post-surgery and black eyes and swelling is common. Patient satisfaction of rhinoplasty is normally excellent as long as skilled surgeon is involved.

face, most commonly the midface over the cheekbones and in the hollow of the cheek itself. It is also beneficial in filling nasolabial lines. When fat is transferred, it needs new blood vessels to grow and provide nourish for cells, and despite refinements to the technique, it is still impossible to accurately predict how much fat will survive some say 50-60%, which means that over-correction is necessary.

OTOPLASTY This is a surgical and non-surgical procedure for correcting position, deformities and defects of the external ear and is one of the most common cosmetic surgery operations. Generally, the operation is performed through an incision on the back of the ear so no scars are visible and is designed to produce an entirely normal-looking ear. The ridge within the cartridge is generally recontoured and recreated.

FAT TRANSFER As the face ages, the skin becomes lax due to the loss of tissues beneath the fat pads, contraction of the muscles and thinning of bone. Fat transfer involves taking fat from one part of the body, for example the buttocks or abdomen, and transferring it into the

COMMON FACIAL SURGERY PROCEDURES 1. Face lift and neck lift 2. Blephroplasty 3. Brow lift 4. Fat transfer 5. Rhinoplasty 6. Otoplasty 7. Facial liposuction

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Continuing her introduction to facial aesthetics, Tracey Bell looks at products which contour and add volume to the face


or years I was taught to fill and chase lines and wrinkles with hyaluronic acids, fillers and other materials. But for deeper wrinkles and furrows these products offered little value when trying to volumise and contour the face. And with years of experience, practise and the ability to look subjectivity at patients, the key to rejuvenation and sculpting is simply that - volumisation and contouring. By replacing and restoring the fat, bone and muscle that is lost in the mid part of the face, any problems in the lower part will minimise and true reinvention or rejuvenation of the face starts to become easier. These products should not be used by a novice (some, such as fat transfer, I don’t do myself) but as a clinician you should

know about them. Once you have mastered the art of the cheek enhancement, then temple restoration, the main factors when treating a whole face will be contouring and volumisation. There are two important factors to consider when restoring a face. 1. Canvas (the skin). Improve the texture, tone tonicity of the skin and all of your work will look better. 2. Are lines static or dynamic? Static lines are those present when assessing the patient at rest. These lines are best treated with fillers, volumisers or peels. Dynamic lines appear with facial expression, they normally occur in the upper part of the face, forehead and crows feet, these lines are best treated with Botox (botulinum toxin).

THE IMPORTANCE OF VOLUME Many of the changes we see in facial ageing result from the shrinkage of the underlying dermal tissues, shifts and atrophy of fat pads, alterations in bone and cartridge and muscle contraction. When we are young it is the robust, heartshaped fat pads which sit directly over our cheek bones which give our faces fullness. As we age they suffer from atrophy and sink downwards and inwards towards the nose, causing the tell tale signs of ageing. When this happens we see eyelids which are hollow, darkened and crinkly or bulging, as well as pronounced smile lines on the side of our nose and drooping ‘marionette’ or sad lines, at the corners of the mouth and chin. The weight of the fall accentuates the unsightly

Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

Clinical diagnosis is the key to good aesthetic treatment

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Figure 1: Pretreatment

Figure 2: A slow natural result following two Sculptra treatments

jowls along the jawline. The key aim of volumisation is to replace this. Here’s a look at some products to consider in volumisation. 1. Hyaluronic fillers (Juvederm Voluma, Restylane SubQ) 2. Sculptra - a product of poly-lactic acid that works deep in the dermis to produce collagen. Normally a course of three sessions is required. 3. Fat transfer - fat is removed through other parts of the boy and later used for facial rejuvenation in areas such as the cheeks.

excellent and long lasting. The main benefits are: • it restores the facial volume loss • it has a smooth consistency, thicker product can last up to 15 months • the results are instant, long lasting and natural • it produces an instant lift to the lower part of the face.

JUVEDERM VOLUMA In my practice Voluma is a key to any part of my treatment planning and it is one of my ‘true loves’. Voluma is an injectable hyaluronic acid produced to restore volume to the chin, cheeks and cheekbones. Its main effects are to: • restore deep volume loss and smooth the mid face  • restore sunken areas around the cheek bones and cheeks  • restore and produce youthful contour in the jaw and chin. The product is part of the Juvederm family and produced by Allergan. Experience is required to inject and the product is inserted using a cannula or needle. I prefer a cannula to minimise bruising and to ensure the product is deposited evenly. The product is provided in 2ml syringes. The results are

RESTYLANE SUBQ This product is very similar to Voluma in terms of clinical indications placement and results. My preference always comes down to the support of the company, training/ education and follow-up, not only for myself but also my team. SubQ is inserted into the skin using a cannula and creates beautiful long-term results. It can also be combined with Q-Med’s other products such as Restylane, Perlane, or Syno Vital.

SCULPTRA Sculptra is an injectable volumising treatment that stimulates the regeneration of the body’s own collagen to smooth out wrinkles and restore lost facial volume to give a fuller, younger-looking face. Sunken cheeks, temple, indentation and hollows under the eyes regain lost volume over time by Sculptra’s ability to produce collagen. Sculptra provides a gradual and significant increase in skin thickness improving the appearance of the folds and sunken areas with volumising effects which

have been clinically proven to last 23 months. Sculptra is a synthetic injectable known as poly-l-lactic acid. Poly-l-lactic acid is biocompatible (a material that does not harm the body) and has been used in medicine since 1999. In 2004 the product was approved in the United States for large volume corrections for facial fat loss and was subsequently approved for restoring volume for cosmetic purposes. Training is very important in Sculptra; generally the product is mixed at least 72 hours before use and the product is injected deep over a period of three months at monthly intervals. The treatment regime I commonly use on a first consultation is five vials over three appointments.


So many people have wished the proportions of their body were different, wanting to move fat from one area to another. In a way this is what fat transfer does. The procedure involves the removal of fat from one part of the body separation preparation and then effectively it is transferred into the facial volume loss on the face. There are advantages and disadvantages to this procedure. The advantages I would say are a natural result in the longer term. The disadvantage is that over correction is often needed due to ‘fat death’ and that is obviously a surgical operation.

CONCLUSION In my practice facial volumisation is part of my core business. Whatever age the patient, in general they all present with some form of facial fat loss and devolumisation. I do believe that a clinician with a good eye who bears in mind canvas, lines and volume can crack the art of volumisation. To ask a question or comment on this article please send an email to: ppd

118 October 2011 PPD




Once new aesthetic practitoners have the equipment and training to practice, they will need patients. In her latest article Tracey Bell offers advice on going into the business of aesthetics


ver the last few articles I have given you a basic overview of the non-surgical treatments that can be integrated into a dental practice. Utilising and using: Botox, fillers, peels, a little microdermabrasion, and retailing skincare. But how do you begin to market? Aesthetics has had a wonderful honeymoon period, particularly in the last three years. As the recession hit the cosmetic surgery market hard, people have realised that incredible results can be achieved with Botox and cosmeceuticals. In the future I think we will see fewer simple skin clinics, but dental practices are the perfect environment to be able to offer a ‘one stop shop’. How do you do this? On a small-scale, measurably and with passion.

Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

Happy staff who have benefited from treatments themselves make great ambassadors

THE SCENERY In my practice I have always believed that Botox and non-surgical treatments should not be offered in a dental chair. Not in the literal sense of a dental chair, but I believe it would be bad practice to offer a completely separate procedure alongside a filling or root canal treatment. I have always kept my appointments and clinical rooms separate for both businesses. In this type of case, it would be advisable to dedicate a room or area and time where non-surgical procedures, consultations and treatments are provided. You can also instruct the practice to dedicate a specific time period to deal purely with non-surgical treatments. Ensure that the room is clinical, inviting, the staff are educated and it looks like a nonsurgical environment. Personally, having a skin treatment does not go hand in hand with the smell of the dentist; the sound of a drill or a pair of extraction forceps in sight. Therefore, I would ensure that a room is dedicated and decorated to provide non-surgical information and procedures. The room should: • be warm and inviting with a medical couch • have surroundings that reinforce the practice

Have information and pricing details available to all patients

brand and values • be looked after by properly trained staff • contain information on non-surgical treatments. • have a dedicated appointment book.

PATIENTS A dental practice will normally have a great number of patients that already know, trust and eagerly love the practice. These are the ideal patients to market at: with little cost, minimal disruption and an easy to track follow up which enables you to assess the strategy. The simplest ideas are usually the most successful. Simply tell them what you are doing. A strategically placed poster in the waiting room or clinical areas will allow patients to read about

104 November 2011 PPD



the new services and probes them to ask about the services available. The reading material can be placed in many forms: posters, newsletters, practice badges that the employees wear, anything that will stir an inquisitive nature.

BRAND AMBASSADORS The practice team needs a solid foundation of knowledge and passion when it comes to understanding exactly what your non-surgical business is. They need to love it the same way they love your dental skills. They are your brand ambassadors and they must live the dream. In my practice, which was originally purely dental, I encouraged the involvement by offering them complimentary treatments - yes, I gave them it! They looked fresher, brighter and more youthful. This in turn caused a butterfly effect. The procedures they had had done would be directed towards the patients and they were talking case studies. Remember, the patients like a friendly face and the practice receptionist, dental nurse often become their dental confidants, and in turn their non-surgical confidants. The patients will often say: ‘Wow, you look well’, and you want your team to reply: ‘Well, it’s all down to doctor x, not only did he whiten my teeth, but he also rolled out my wrinkles.’ Promote your services to your existing dental patients first

Treatment rooms should be welcoming and dedicated to aesthetics

EMAIL MARKETING Email addresses are an invaluable and an effortless route to contact your patients. Please ensure that you have permission from the patient to contact via e-mail. I simply inquire this on a medical history form. The use of a website such as Mailchimp. com is a free service that allows you to manage e-mail lists free of charge. You can then create newsletters or offers and send on mass (with the avoidance of spam files) to all your patients at the touch of a button. The system allows you to monitor how many actually opened the e-mail, how many actually read it, how many were undelivered and how many opted out from not receiving any more e-mails from you. Mondays and Fridays are not good days to send emails and remember to be strategic and think about occasions like payday, Christmas party season and so on.

COLLABORATION Going forward I see collaborations between businesses and services as great opportunities for the future. Local beauticians, hairdressers, women’s groups and high-end retailers may be happy to advertise your services; but always remember that people will want a favour or business in return. I have worked with beauticians, retailers, gyms and personal trainers by ensuring that I

promote their services as they promoted mine. Bear in mind that the most important part of any business relationship is contact. A monthly phone call, a thank you or a catch up is often what the collaborating business simply needs. With all business, word-of-mouth, whether it be verbally or online, is still the core source of any decent business growth. I see recommendations from the media and peer groups playing an increasingly important role in market growth. There are various studies in magazines and online about the side effects and forums where people ask others for their experiences of a treatment or product and in the future. I can see maybe dentists and doctors becoming less important in that decision as the media becomes more integral and efficient at providing a rounded view. To begin with keep your patient happy and your aesthetics business will grow, the internet will come next. To ask a question or comment on this article please send an email to: ppd

PPD November 2011 105




Smile design is a combination of science and technique


merican perception that the British care nothing for the state of their teeth still exists. In comparison to America’s obsession with perfectly white, straight teeth, the British tend to take a more functional view of dentistry, and are seen as being less preoccupied with the aesthetics and more interested in the health of our – some would say – more ‘characterful’ teeth. However, although wonky, gappy, sallow teeth can be perfectly healthy, it is my belief that an askew smile can affect your inner confidence. It is all very well being told that as long as your teeth are healthy, it doesn’t matter what they look like, but to me, it really does. Whether someone has good teeth or bad teeth, we all notice what they look like,

Tracey Bell, BDS (Hons) Manchester, has aesthetic centres in the Isle of Man and Liverpool, which specialise in facial aesthetics and cosmetic dentistry.

In the final article of her series on aesthetics, Tracey Bell takes a general look at the benefits of a perfect smile and ways of achieving it which is why having nice straight teeth is so important. A beautiful smile contributes to a person’s overall attractiveness and helps them feel better about themselves. The smile is the most attractive expression of human nature; it shows, physically, our inner self. People enjoy being smiled at as it brightens their day which will positively benefit wellbeing.

THE SCIENCE OF SMILE DESIGN Smile design is a craft; a piece of art that through science and technique can create the perfect, individual smile design. Proper aesthetics is a highly individual goal, softer features or a vigorous dominant demeanour will be reflected in a smile, displayed through size and shape of a patient’s teeth. The same basic rules apply when making someone’s smile look good. The front teeth should be dominantly displayed to create a harmony with the rest of the face – this is where science meets art. Divine Proportion was recognised by Phidias, a Greek Sculptor, for being a commonality in size and shape for spirals and patterns found in nature. This became know as the Fibonacci Series, and has a beauty and magic that is found in many of nature’s most beautiful creations, from butterfly wings to the Pyramids of Egypt. When it comes to teeth, the theory of Divine Proportion is used as a guide for dentists to determine the amount of tooth that should be seen through a smile. Questions are raised: the eyes – do they smile too? The corners of the mouth – how much do they lift up when we smile? How much tooth and how much gum show when we smile? How do our

teeth look when we are talking? How does age affect our smile? The ratios of smile display to full smile; the proportion of gum to tooth; the amount of tooth display at rest or upon full smiling; the soft tissue cosmetics of lip size to nose size or upper facial height to lower facial height – are more than any patient needs to know, but a complete trust in their dentist to utilise this guide for the creation of a cosmetically pleasing smile framework is crucial.

THE SMILE DESIGN FACELIFT Cosmetic dentistry is all about improving the smile: tooth whitening, straightening, crowns, veneers, cosmetic dentures, etc. However, the smile is not just about teeth, but improving the muscle tone and the slackness of the face that can come with age or with poor tooth structure. Smile design is essentially a dental facelift. Facial rejuvenation through dentistry has an amazing anti-aging effect. Teeth are vitally important when it comes to smile design, but the gums and the lips need to come into consideration when dealing with the overall ‘frame’. When designing a smile, there are extra dimensions we need to consider to achieve the perfect results. When you look at the bigger picture, for example the face, we have to consider the other aspects. Botox and fillers help to rectify a crooked smile, make thin lips fuller and help to lower those gummy smile lines. Botox is also transferable in its dental uses: it can relax the jaw muscles of bruxists which in turn eases wear of teeth, headaches and any head or neck pain. Facial volume is also a major key to looking younger, with the focus today having moved from traditional

78 December 2011 PPD



TOP TREATMENTS This has certainly been a year of change in dentistry with minimally invasive dentistry a hot topic and I believe that 2012 will see a huge growth in this area. The patients want it, and as healthcare professionals we should be providing it, so let’s hear what our patients said:

ENLIGHTEN WHITENING Andrew was on the verge of giving up on achieving pearly whites, but Tracey Bell opened his eyes to the ultimate Vita B1 Shade guarantor. ‘With nothing to lose, I took the plunge and I’ve never looked back – or better!’

NOBEL BIOCARE IMPLANTS Chrissy had a cracked upper tooth which had to be extracted. Having heard of dental implants, she decided to seek her dentist’s advice and was referred to Tracey Bell. ‘I am delighted with the finished result and my smile has been restored to full glory, for life.’

facelifts to ‘injectables’. Prepare for another seismic shift, which has revolutionised the dental and aesthetic industry: the answer to staying youthful could now lie with the teeth. A youthful face has a three-dimensional quality, veneers can help to create and maintain this, and each one is individually tailored to flatter the face, relieving many of a ‘horsey’ appearance. The veneers are crafted like fine pieces of jewellery to the upper and lower teeth, helping to boost the cheeks, plump the lips and restore any lost facial volume. Building out the upper sides of the teeth causes the arch to widen and also lifts the cheeks. The lips appear fuller with a slight lengthening to the top two front veneers; the corners of the mouth are also subtly lifted, pushing the lips back up and out.

The overall result is a fuller, younger face and no one will know why. It takes a certain artistry to know where to build up and reduce but small, simple changes can really cause a transformation: one millimetre to the surface of the back teeth translates into three millimetres in the front of the mouth: instant age rejuvenation.

THE BEST RESULTS For a perfect, well-designed, smile, the teeth and the eye line should be on the same plane and parallel. Facial symmetry is an essential role in attaining the ‘vision’ of perfection so many people demand. Having a beautiful smile imparts self-confidence; it endears you to others and can help with that dream job which you have been aspiring to. Celebrities

INVISALIGN Christine is currently receiving her Invisalign treatment; she is guaranteed the perfect smile on Christmas morning. ‘I am halfway through my Invisalign treatment and am so pleased with the visible process – all of my friends and family inundate me with compliments about how good they are looking – and I haven’t even finished the treatment yet!’ and mere mortals alike are undergoing smile-design treatments. Everyone deserves to have a bright, confident smile, and those seeking it now have several modern dentistry and orthodontic options available to them, each with its own series of aesthetic, age rejuvenating and confidence building benefits. This is the message that should always be sent to your patients.

To ask a question or comment on this article please send an email to: ppd

PPD December 2011 79


Trace Bell Premium Practice Dentistr  

An compilation of educational articles by Dr.Tracey Bell for Premium Practice Dentistry.

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