Aesthetic Medicine June 2020 by Aesthetic Medicine

INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

LOST AND FOUND UNDERSTANDING AFRO HAIR LOSS

PROCEED WITH CAUTION ACID INTERACTIONS IN SKINCARE June 2020 | aestheticmed.co.uk

NEW HORIZONS INJECTING IN A POST-COVID WORLD

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U S E F U L I N F O R M AT I O N

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INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

4 EDITORIAL BOARD Meet our editorial advisory board

LOST AND FOUND UNDERSTANDING AFRO HAIR LOSS

PROCEED WITH CAUTION ACID INTERACTIONS IN SKINCARE

Contents JUNE

NEW HORIZONS INJECTING IN A POST-COVID WORLD

June 2020

June 2020 | aestheticmed.co.uk

EDITORIAL Georgia Seago, Editor E: georgia@aestheticmed.co.uk T: +44 (0) 20 3728 9063

8 NEWS The latest news from the industry 12 NEWS SPECIAL REPORT When is it appropriate to resume aesthetics practice, and what will be different?

Vicky Eldridge, Consultant Editor

19 FINANCE Why a sale and leaseback might be an option for struggling clinics

24 CLINIC PROFILE The owner of a Doncaster clinic on how she fell in love with aesthetics 28 AFRO HAIR LOSS The first of three articles from Dr Ingrid Wilson about treating Afro hair loss

E: vicky@aestheticmed.co.uk T: +44 (0) 7931 924 322

ADVERTISING Jack Diamond E: jack@aestheticmed.co.uk T: +44 (0) 207 349 4792

MARKETING Jennifer Shutter E: jennifer@aestheticmed.co.uk T: +44(0)203 841 7361

PUBLISHER Mark Moloney E: mark@aestheticmed.co.uk T: +44(0) 207 349 4790

DESIGN AND PRODUCTION Daniel Parker daniel@professionalbeauty.co.uk

Alex Charlton-Roberts alex.c@professionalbeauty.co.uk

Jaqui Palmer Jaqui@professionalbeauty.co.uk

PRINTING Pensord Press pensord.co.uk SUBSCRIBE Annual subscription UK: Print £44, DD £39.50, Digital £10. Europe: £59; outside Europe: £67.50. To receive your copy of Aesthetic Medicine every month call 01371 851875 or see escosubs.co.uk/aestheticmedicine The publisher accepts no responsibility for any advertiser whose advertisement is published in Aesthetic Medicine. Anyone dealing with advertisers must make their own enquiries. Professional Beauty Group 25 Allington House, High Street Wimbledon Village, SW19 5DX

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CONTENTS

IN THIS ISSUE...

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34 OPINION Dr Tijion Esho shares his thoughts on the future of injecting after coronavirus 37 DIGITAL MARKETING Part two of Alex Bugg’s look at social proof and how it can boost your business 40 SKINCARE ACIDS Aesthetic facialist Eavanna Breen breaks down the key acids and their interactions 44 CASE STUDY How Dr Pradnya Apte rid her patient of chronic migraines with toxin injections

50 PRODUCT NEWS The latest product launches 52 CASE STUDY Inside one patient’s weightloss journey with the Elipse balloon 56 HAND REVOLUMISATION Dr Nick Lowe and Mr Ali Ghanem’s findings on PCL filler for volume restoration of hands 62 PSYCHODERMATOLOGY Learning from holistic therapists about treating the mind-skin connection

48 LAUNCH FOCUS All about clinical skincare brand Exuviance’s rebrand

Welcome to the June issue of Aesthetic Medicine 19

There is a light at the end of the tunnel. Yes, uncertainty and confusion remain over how we will move forward, but know that many of our colleagues are using their brilliant minds and pulling resources together to ensure we at least have an idea about the first steps and will be able to take them as safely as possible. It has been understandably difficult for many of you to have remain closed for such a long period of time, but hopefully you’ve found positive ways to use the downtime, focusing on looking after your business, yourself and your loved ones. Before you start preparing to welcome patients back, read our special news report on pages 12 to 14 and find out how your peers are planning to approach reopening. Hear what Dr Tijion Esho has to say about tackling lip-filler treatments while clients are required to wear masks (34 to 35); and make sure you approach those first appointments with a greater understanding of how patients may be feeling mentally with our feature on psychodermatology on pages 62 to 64. Georgia – Editor georgia@aestheticmed.co.uk

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CO N T R I B U TO R S

EDITORIAL ADVISORY BOARD

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Meet the

experts The Aesthetic Medicine editorial board includes some of the leading names in aesthetics. Their clinical expertise and diverse range of specialties help ensure the magazine meets the needs of its readers

DR NICK LOWE

DR ULIANA GOUT

Dr Nick Lowe is a consultant dermatologist at Cranley Clinic, London and clinical professor of Dermatology at UCLA School of Medicine, Los Angeles. He is a Fellow of the Royal College of Physicians, American Academy of Dermatology and American Society of Laser Medicine and Surgery. He has authored more than 450 clinical and research publications, 15 scientific and five educational books.

Dr Uliana Gout is the founder of London Aesthetic Medicine Clinic & LAM Academy. She sits on the Board of the British College of Aesthetic Medicine (BCAM) and has recently been elected president. She also acts as a BCAM Appraiser for the GMC. She sits on the Board of the International Peeling Society. She has coauthored numerous medical textbooks.

DR SOPHIE SHOTTER

DR STEVEN HARRIS

DR SHIRIN LAKHANI

DR RAJ THETHI

Dr Sophie Shotter is the founder and medical director of Illuminate Skin Clinic in Kent. In 2019, she was invited to join the Allergan faculty board, having been mentored by Dr Mauricio de Maio. She is also on the board of the International Association for the Prevention of Complications in Aesthetic Medicine (IAPCAM). In 2017, she won Businesswoman of the Year at the Kent Women in Business awards.

Dr Steven Harris has been practising aesthetic medicine at his clinic in North London since 2004 and has gained an international reputation for producing natural looking results. His original approach and techniques include Facial Reshaping with Myomodulation and the Nonsurgical Lip Lift (NLL). Dr Harris is also a trainer and educator.

Dr Shirin Lakhani has an extensive background in medicine, having worked both in general practice and in a hospital environment. She is also a trained anaesthetist. In 2013 she founded Elite Aesthetics in Kent. She also practices from the renowned Cranley Clinic in London. She has a specialist expertise in intimate health and appears regularly on television and in the press as well as speaking at medical conferences worldwide.

Dr Raj Thethi graduated from Leeds University Medical School in 2013, having completed an additional BSc (Hons) 1st Class Degree in Anatomy. On completion of his surgical training in the Yorkshire Deanery he qualified as a Member of the Royal College of Surgeons (Edinburgh). He has completed a Level 7 accredited course in Aesthetic Medicine. He is an aesthetic trainer and has been published in several aesthetic industry journals.

MR ALI GHANEM

DIJA AYODELE

EMMA DAVIES

DR YASMIN SHAKARCHY

Mr Ali Ghanem is a consultant aesthetic plastic surgeon and clinical senior lecturer in plastic, reconstructive and aesthetic surgery at Barts and the London School of Medicine & Dentistry, as well as visiting professor and head of department of Aesthetic Medicine at the College of Medicine and Dentistry, Ulster University. He is qualified in Medical Law and Ethics, Surgical Science and Developmental and Stem Cell Biology.

Dija Ayodele is an aesthetician and founder of the awardwinning educational platform Black Skin Directory (BSD). With more than 10 years’ experience, her Kensington-based clinic is a go-to destination for patients of colour seeking skin rejuvenation treatments and advice for their skincare needs. She speaks regularly at both industry and consumer events and in 2019 launched a pioneering sunscreen campaign for black skin.

Emma Davies has specialised in aesthetic medicine since 1998. She was a committee member on the RCN Aesthetic Nurses Forum from 2000-2010; founder member and secretary of the British Association of Sclerotherapists (2003-2010) and founder member and past chair of the British Association of Cosmetic Nurses (20102014). She is currently clinical director of Save Face and vice chair of The Aesthetic Complications Expert Group.

Dr Yasmin Shakarchy practices dentistry and facial aesthetics in Solihull and Birmingham. Having completed her dentistry training at the University of Birmingham, she became a Member of the Faculty of Dental Surgery (MFDS Ed) and received a PG certificate in aesthetic and restorative dentistry. She was the national dental ambassador for Jamie Oliver’s Sugar Smart campaign and won Best Young Dentist 2018 for the Midlands at The Dentistry Awards.

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INDUSTRY NEWS

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Aesthetic clinics can now offer covid-19 testing through scheme Dr Martyn and Sharon King, who own Cosmedic Clinic in Tamworth, Staffordshire, have developed a covid-19 antibody testing service designed for aesthetic clinics in partnership with CST Pharma. The pair want to recruit as many clinics as possible to offer the scheme. MyCovid was developed to respond to the huge demand for covid-19

antibody testing in the UK for those who fall outside of the Government’s mass testing programme for essential workers and members of their families showing symptoms. It uses a fingerprick test to detect antibodies IgM and IgG within the sample. IgM levels become positive about seven days after the onset of symptoms, whereas IgG takes about 28

days to peak, explains a press release from MyCovid. “So, by checking both antibody levels, we can determine recent infection, infection within the last three weeks and previous infection.” The test shows a result within 15 minutes at an accuracy of more than 92.2%. The result is emailed to the patient via email and text message within the hour with a full explanation and latest Government advice regarding isolation if required. A positive result will be communicated to the patient’s GP and Public Health England. Clinics will be provided with all of the necessary policies and procedures to run the service in conjunction with their own risk assessment. The patient’s medical history and consent form are completed online and emailed to the clinic. Reporting is carried out via the clinic’s own MyCovid dashboard, where they can also add their availability for testing, as part of the MyCovid website. Clinics interested in becoming a testing centre should email clinic@mycovid.co.uk or complete an online enquiry.

Online enquiry

IQ Level 7 Certificate in Injectables for Aesthetic Medicine withdrawn Awarding organisation IQ Qualifications has been taken over by SFJ Awards after it surrendered its status as an Ofqual-recognised awarding organisation in March. IQ’s assets were bought by SFJ Awards, when it also took over all IQ training centres and registered learners. SFJ Awards is reviewing the existing suite of IQ qualifications and their long-term availability. In the meantime, the IQ Level 7 Certificate in Injectables for Aesthetic Medicine has been withdrawn with immediate effect, as of 1 May. SFJ said it has decided it no longer wishes to award the qualification as it does not meet with its wider operating remit. No further registrations can be made on the course, and the last date for certifications for previously-

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registered candidates is 31 May 2022. Industry training provider MATA (Medical & Aesthetic Training Academy), which is regulated by awarding organisation OTHM, is offering support to training academies and students affected. Training academies can contact MATA to discuss the possibility of a partnership opportunity, whereby the current IQ Level 7 Certificate would be transferred to MATA’s newer Level 7 Injectable Certificate. Students currently registered on the IQ certificate also have the option of transferring their qualification or progressing onto MATA’s Level 7 Diploma. Contact contact@matacourses.com for more information.

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INDUSTRY NEWS

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Medical device regulation delayed until 2021 The European Medical Devices Regulation was supposed to come into force on 26 May this year, but enforcement has been postponed by one year due to the coronavirus pandemic. Many aesthetic and cosmetic products will then be classified as medical devices, meaning manufacturers will have to partner with a designated Notified Body to obtain CE-Mark certification; and will be required to implement quality-management systems according to the EN ISO 13485:2016 standard. However, there has been confusion over specifically which products and devices will be affected. Aesthetic Medicine contacted the MHRA (Medical Healthcare Regulatory Authority) for clarification and asked if machines based on technologies such as radiofrequency, microcurrent and LED would be included.

We were told that while The European Commission has not yet confirmed which products will be included within each category, these devices may be covered by the following category outlined in Annex XVI of the regulations: “High-intensity electromagnetic radiation (e.g. infra-red, visible light and ultra-violet) emitting equipment intended for use on the human body, including coherent and non-coherent sources, monochromatic and broad spectrum, such as lasers and intense pulsed light equipment, for skin resurfacing, tattoo or hair removal or other skin treatment.” There is no requirement for clinics to ensure new or existing devices in use are compliant. As the new enforcement date falls after the UK’s transition period to leave the EU, the MHRA says it will provide more guidance in due course.

83% of doctors not tested for covid-19

A survey conducted by The Royal College of Surgeons of Edinburgh (RCSEd) and The Doctors’ Association UK found that at the time it was released at the beginning of May, 83% of doctors surveyed hadn’t yet been tested for coronavirus. The survey had 378 respondents from foundation year doctors to consultants, working at 151 different NHS Health Trusts and Boards across the UK. 81% said their Trust or Board was only testing staff displaying symptoms, while 68% said they had colleagues who had displayed symptoms but only 10% had gone on to be tested themselves. Professor Michael Griffin OBE, president of the RCSEd, commented: “The results of this survey show that although more testing is now available, this isn’t translating into tests being carried out on healthcare professionals. “…More tests are now available, but we need to ensure they are being used much more frequently and robustly to allow health professionals to continue their vital work and protect patient safety.” He added: “We also need consistency in how official guidance is implemented by Trusts and Health Boards. For instance, Public Health England’s official advice for the general public is to self-isolate for seven days if a member of their household displays covid-like symptoms. “However, we are aware of a number of doctors who have been advised to carry on working despite being exposed.”

Microneedling and peels most popular treatments The state of the UK beauty and aesthetics industries has been revealed in the National Hair and Beauty Federation’s (NHBF) 2020 Aesthetics Survey. It found that just under half of aesthetic treatments (49%) are happening within aesthetic practices/clinics run by medics. Microneedling and chemical peels are the most commonly provided non-invasive aesthetics treatments. Dermal fillers and botulinum toxin injections are the most popular invasive treatments, and mostly performed by medical professionals. Beauty therapists who hold a Level 3 beauty qualification as well as those with aesthetics training perform peel treatments the most, with 114 survey respondents from this group stating they perform the service. This was followed closely by nurses (95), aesthetic practitioners (45) and Level 3 trained beauty therapists (42). More experienced and qualified aesthetic therapists (Level 4) are also offering treatments such as plasma pen (said 55 survey respondents), cryolipolysis (45) and laser treatments for tattoo removal (45). Of those businesses that require medical oversight, more than half (61%) have a medic on-site, more than a quarter (28%) have a medic on call and a smaller number (11%) have a remote medic.

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INDUSTRY NEWS

NEWS IN BRIEF ABBVIE COMPLETES ALLERGAN ACQUISITION

AbbVie, a research-based global biopharmaceutical company, has completed its acquisition of Allergan following receipt of regulatory approval from all government authorities required by the transaction agreement and approval by the Irish High Court. “The new AbbVie will be a well-diversified leader in many important therapeutic categories... and our financial strength will allow us to continue to invest in innovative science and continue to serve unmet medical needs of patients that rely upon us,” commented Richard Gonzalez, AbbVie chairman and chief executive.

GC AESTHETICS INTRODUCES COMFORT PLUS WARRANTY

Silicone implant producer GC Aesthetics has announced a new lifetime warranty for its patients and practitioners, offering free, automatic and retrospective cover for treatment of late seroma (swelling which can occur after breast implant surgery) for products implanted since 1 January 2009. The new GCA Comfort Plus warranty also offers free implant replacements in the event of a rupture or capsular contracture, which was also offered on the previous warranty.

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Consumer health and beauty shopping behaviour affected by pandemic According to new research, consumers are now more interested in factors such as brand loyalty and family recommendations when purchasing products during the pandemic, while pricing has become less of a concern. Data by The Skin Health Alliance discovered subtle shifts in consumer behaviour when it came to their health and beauty needs during coronavirus lockdown in April 2020. For example, brand loyalty experienced the greatest change at an increase of 12% compared to figures from 2019, while positive reviews from family and friends also mattered to consumers more – rising from 37% in 2019 to 44% in 2020. Meanwhile, even though price remained the top factor, its influence dropped by 2% in April 2020 to 88% (it was 90% in 2019), the data found. Other factors such as environmental friendliness and celebrity endorsement experienced slight reductions too, while the impact of allergies and the media’s influence were shown to remain the same. Hand cleanliness has also become a hot topic for 2020, with “more people seeking out products they believe work, in turn making them feel more secure, safer,” said Skin Health Alliance spokesman James Stalley. “The narrative around hand cleanliness has become one of scientific fact rather than a marketing or media driven message.”

SURGERY VISUALISATION THEATRE TECHNOLOGY DEVELOPED

Ocutrx Vision Technologies has announced plans to launch new technology that provides modern options for surgery visualisation and removes “pain” for surgeons to improve surgeries, named the Ocutrx OR-Bot Surgery Visualisation Theatre. The new ORLenz augmented-reality surgery headset features a surgery view with augmented virtual patient and operating tool information. The OR-Bot’s Lenticular Autostereoscopic 8K 3D “glasses-free” monitor allows others to view surgery in the room.

RESTYLANE UK LAUNCHES SOCIAL MEDIA

Galderma dermal filler and skin booster brand Restylane has started posting content on its social media channels, @ restylaneuk. The purpose of the page is to provide clinics with content for them to share and include in their social media calendars and campaigns, with an overall goal of educating patients on dermal fillers.

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UK has Europe’s highest number of med-tech start-ups working on covid-19 projects 11 of the 34 on-going covid-19 projects identified by an Oxford University data visualisation spin-out are based in the UK. Zegami’s research looked at med-tech start-ups in Europe and identified ongoing projects in 15 countries including Switzerland, Portugal, Poland, Iceland, Estonia and Ukraine. After the UK, Switzerland came out as home to the secondhighest number of projects, with four. Zegami is itself working on a project that uses x-rays of lungs infected with covid-19 to build a robust machine learning model to assist healthcare professionals in identifying the virus. Roger Noble, chief executive and founder of Zegami, said: “It is very encouraging to see such a positive and proactive response from Europe’s start-up med-tech sector in the fight against covid-19. Many, like us, are also providing their services for free. “There is little doubt that the industry has a huge role to play in defeating this disease.”

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AM virtual event well recieved by aesthetics industry The Aesthetic Medicine Virtual Event ran from 11 to 15 May and was a huge success. Sponsored by Inmode, the event was hosted on a dedicated Facebook Event group and featured five webinars a day for viewers to join in with, packed with engaging educational content. A highlight from the week was a session on the mind with advanced aesthetics nurse Tracey Dennison and Dr Harry Singh, owner of Botulinum Toxin Club. A little light relief was offered by focusing on the mental wellbeing essentials to help us get through these uncertain times. Another great session saw Dr John Tanquerary, ZO Skin Heath trainer representing Wigmore Medical, investigating “The science of skin health”. The session educated the audience in active ingredients, delivery systems and the fundamentals of protocol building behind Dr Zein Obagi’s ZO Skin Health system. Aesthetic nurse trainer and qualified educator Anna Baker held one of the week’s medics-only sessions, where she spoke on behalf of HA-Derma to educate the audience on understanding hyaluronic acid injectables and their correct classifications.

To view and catch up on all of the sessions from the AM Virtual Event, click here.

Singapore clinics ignoring rules Authorities in Singapore have been issuing control orders and fines to medical and dental clinics for offering aesthetic treatments deemed non-essential. The country is in a “circuit breaker” phase until 1 June, and nonessential healthcare services are not allowed during this period. A report by Channel News Asia said some of the treatments that sparked notices included skin and hair consultations, toxin and filler injections and chemical peels. One private clinic was fined $1,000 Singapore dollars (approx. £570) for failing to comply with social-distancing measures it was ordered to put in place, despite a reminder from the Ministry of Health.

INDUSTRY NEWS

NEWS IN BRIEF THERMAVEIN LAUNCHES VIRTUAL DEMONSTRATIONS AND TRAINING

Having constructed an online interactive studio in its Manchester office, ThermaVein has teamed up with Yodo to host virtual demonstrations and training and support services. The platform allows the brand to showcase its products and treatments and show treatment footage, as well as providing engaging content. Heather Dorigo from ThermaVein said: “We love meeting our clients at trade shows and this will never replace that enjoyable interaction, but does provide a fun, safe and informative environment.”

AESTHETIC TECHNOLOGY DEVELOPS VENTILATOR

Dermalux manufacturer Aesthetic Technology has completed the development and launch of a fully compliant ventilator. Due to its regulatory compliance, the Aesthetic Technology C-19 Ventilator will be available for delivery around the world. It is based on an existing fully-approved design for which the company has a worldwide permissive licence from Medtronic to manufacture for the duration of the pandemic. The ventilator is compact, lightweight and portable.

HARPAR GRACE OFFERS 30% NHS DISCOUNT

Aesthetic brand distributor Harpar Grace has introduced a 30% discount across its full iS Clinical, Codage Paris and Totally Derma ranges to all NHS employees, available through its Staff Benefits Programme E-Store with nextday delivery. The online store, which also offers a 30% discount to its partnering clinics, spas and their employees, is accessible with pre-registered details at harpargrace.com. To register, NHS employees need to upload a valid work ID as part of the registration process.

CUTERA INITIATIVE CELEBRATES AESTHETIC PROS

Aesthetic device manufacturer Cutera has announced its new Heroes Among Us initiative, created to celebrate all aesthetic professionals that have made a positive impact during the coronavirus pandemic. The initiative was established to acknowledge cases of “compassion, humanitarianism and kindness” from individuals who have gone “above and beyond” during the current global crisis. One honouree will be announced during the Virtual Cutera University Clinical Forum on October 23-25 and given a £5,000 donation to present to charity.

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NEWS SPECIAL REPORT

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Back to b What the industry is saying about returning to clinic post-lockdown

n exclusive survey by Aesthetic Medicine has revealed that 60% of aesthetic clinics and independent practitioners will offer a reduced or altered treatment menu when they reopen following lockdown. 277 industry colleagues responded to AM’s covid-19 survey – the majority of whom were clinic owners, aesthetic therapists, independent nurses or nurse prescribers, or aesthetic or cosmetic surgeons. When asked if they had undertaken a review of treatments and adjusted their menu ready to welcome patients back, the majority said they plan to do so; with lip fillers the treatment that will initially be put on the backburner for most. Responses included: “Starting back with toxin and microneedling. I’m undecided about dermal filler and have no lip treatments planned”, “I will be minimising facial peels and treatments where the patient can’t wear a mask like lip fillers, and prioritising treatments where the patient can, like upper-face botox.”, “No lip fillers to avoid aerosol dispersal”; and “I’m waiting for guidelines. I have full PPE, but I don’t think we should be augmenting lips.” Other answers that appeared multiple times included responses along the lines of minimising treatment numbers by conducting as many consultations as possible on video call, and focusing consultations on whether the patient really requires the procedure at that time. Others said they will only allow one client in the clinic at one time, won’t offer any “longer” appointments, or won’t perform laser, PRP or microneedling treatments until clearer guidelines are available on the risk presented by aerosolgenerating procedures (APGs). Around 20% will avoid facial skin treatments altogether for the time being. Most respondents (47%) said they plan to open on July 4, as per current Government guidelines [correct at the time

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NEWS SPECIAL REPORT

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business Aesthetic Medicine went to print], while 34% said they were ready to open before, and 20% answered “later”. 60% said they already had full PPE or have it on order ready for opening, while 28% said they were waiting for clearer guidelines. When asked about rearranging their premises to maximise social distancing, 65% said they plan to do so and 27% answered that it’s not necessary in their clinic or treatment space. 86% said practitioners and therapists will wear masks, gloves and any other relevant PPE during all treatments, and 69% plan to undertake refresher staff training for updated health and safety regimes with team members.

INDUSTRY GUIDANCE

After months of uncertainty, in May, some of the industry’s leading associations and members’ groups released their opinions and guidance on resuming clinical practice once lockdown lifts. Here’s what they said [information updated at the time Aesthetic Medicine went to print]:

JCCP (Joint Council of Cosmetic Practitioners)

The JCCP has produced an in-depth document designed to ensure best practice is adopted as far as is reasonably possible once clinics re-open. Covid-19 – Preparing your place of work: covid-19 & return to practice states, “There should be no compromise in safety for financial gain.” And, “We cannot support a resumption of practice during the Government-imposed lockdown or advise on specific dates for reopening (although the Government have advised that beauty salons will not open until at least the 4 July 2020). “Government advice on resumption of practice should form part of the decision to reopen, along with your ability to implement an informed risk-assessed policy, and other material factors that may impinge on your capacity to perform safely and responsibly.” The core principles behind the JCCP’s guidance has been agreed by independent and expert opinion in the CPSA (Cosmetic Practice standards Authority).

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NEWS SPECIAL REPORT

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safe practice which protects both patients and clinicians alike as well as ensuring that Members are accessing appropriate training.”

BACN (British Association of Cosmetic Nurses) The BACN has released guidance for its members in the form of a document titled Suggested Operational Plan Guidelines for

The document includes sections on standard precautions, triage, reception areas, staff, PPE and cleaning, as well as considerations such as consent, testing and risk assessment.

It can be accessed here

Covid-19: Reintegration of Medical Aesthetic Services. The document was emailed to all BACN members. It begins by calling on point 19.4 of the NMC (Nursing Midwifery Council) Code: “Take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public.” Sections covered in the document are similar to that of the JCCP guidance, and include advice on clinical rooms, treatments, payments, mobile working, insurance and tips. The BACN agrees that practitioners should follow Government announcements on a suitable reopening date, following regional guidelines if based in Scotland, Wales or Northern Ireland. On this point, BACN chair Sharon Bennett commented: “The BACN has been working to get detailed clarification from the Government. As soon as we have this clarification, it will be posted on our website. It should be stressed that any decision to reopen clinics will be down to individual members.”

The document can be viewed here

BCAM (British College of Aesthetic Medicine)

BCAM released a statement on 14 May to let members know that it had sought counsel from a QC in the field of public law in order to define an exact legal position. A full text of the opinion will be available to members, along with a suite of documents on processes relating to risk assessment, operation and protocols to support practitioners in the early-post lockdown phase. BCAM president Dr Uliana Gout said: “I am delighted the BCAM team have risen to the covid-19 challenge. There has been a focused and combined effort to obtain independent legal opinion based on the current government guidance, alongside clinical protocols for reopening. “I am certain these will be of great benefit to BCAM members as they look to re-start their practices. This is the quality of service to members that we have always prided ourselves on as the organisation leading the aesthetic medicine industry.” BCAM board member Dr Kathleen Long represented the association in a meeting with HIS (Health Improvement Scotland) on 19 May to discuss the issues facing the industry. Ahead of the meeting, an urgent virtual members’ meeting was held on 15 May to gather the views of BCAM members. Greg White, chief executive of BCAM said: “It is crucial that doctors and dentists working in aesthetic medicine have a say in its regulation and organisation. BCAM emphasises

BAS (British Association of Sclerotherapists)

The British Association of Sclerotherapists is holding a webinar on 20 June to lay out a comprehensive blueprint on re-opening after lockdown for its members and other aesthetic and dermatology practitioners alike. The three-hour webinar will bring together a body of experts with a view to laying out all information a clinic owner or manager needs ahead of re-opening. Content will include “up-tothe-minute expert advice on when it is advisable to open, risk-assessment templates, safeguarding and supporting staff, infection control, patient selection and management, how to use marketing to re-establish a client base, implementing telemedicine and diversification options to re-build a healthy cash flow.” BAS chairman Dr Stephen Tristram commented, “Whether, when and how to reopen my practice are the big questions going through my mind at this stage, and I’m certain others are in the same boat. The BAS 2020 conference has of course been cancelled for the time being, and we are excited to be supporting practitioners by putting together the definitive guide to bringing our clinics out of lockdown and rebuilding a healthy practice. This webinar will be invaluable to all aesthetic, dermatology and vascular practitioners.” AM

“Lip fillers appear to be the treatment that will initially be put on the backburner for most”

Aesthetic Medicine • June 2020

C O M M E R C I A L F E AT U R E

EM SLIM

aestheticmed.co.uk

Strengthen Your Business Using EMS technologies to reduce fat and build muscle HOW EMS WORKS

The exposure of muscles to these contractions also leads to muscle strengthening and growth as well as aiding performance and endurance levels. EMSlim focuses the electromagnetic field through all skin and fat in order to effectively stimulate the muscle, providing the most intensive continuous contractions, which is ideal for muscle growth, and inducing apoptosis, which takes place over the course of 10-14 days, rather than months. EMSLIM’s unique workout programs consists of a series of actual physical training programs, ideally designed for the maximum stimulation leading to the best result.

Electrical muscle stimulation (EMS), also known as neuromuscular electrical stimulation (NMES) or electromyostimulation, is the elicitation of muscle contraction using electric impulses. Primarily used in physical therapy for relaxation of muscle spasms, atrophy, increase of local blood circulation, muscle rehabilitation and re-education electrical muscle stimulation, maintaining and increasing range of motion, management of chronic and intractable pain, posttraumatic acute pain, post-surgical acute pain, immediate post-surgical stimulation of muscles to prevent venous thrombosis and wound healing.

EMS – THE NEW ERA

Electrical magnetic stimulation also known as EMS is a medical technology that is used in aesthetic medicine, urology and gynecology. It uses focused electro-magnetic fields with safe intensity levels. The electromagnetic fields pass non-invasively through the body and interacts with motor neurons which subsequently trigger muscle contractions. EMSlim is a HI-EMT device (High-Intensity Electromagnetic Muscle Trainer) and is designed for aesthetic purposes, with two higher-intensity applicators. This cutting-edge technology in non-invasive body contouring not only burns fat, but also builds muscle while improving strength and endurance levels. The treatment requires no anesthesia, incisions, or discomfort. In fact, patients can sit back and relax while the device performs up to 30,000 contractions. The two applicators are placed on the target muscle area, such as the abs, thighs, arms or buttocks. The applicators then generate intense electromagnetic pulses that cause involuntary muscle contractions. These contractions trigger the release of free fatty acids, which break down localised fat deposits and increase muscular tone and strength.

Before

After

EFFECT ON MUSCLE

The muscle is forced to remain in a contracted state for multiple seconds. When repeatedly exposed to these high load conditions the muscle tissue is stressed and is forced to adapt.

EFFECT ON FAT

The principle of cell apoptosis induced by increased muscle concentrations release free fatty acids that breakdown the surrounding fat.

WHY EMSLIM?

• Intensity: much higher • Durability: even stonger • Maintenance: no consumables • Convenience: easy and effective pre-set • Proven technology: patented Visit emslim.co.uk or email info@emslim.co.uk for more details and an introductory offer. AM

Before

After

Aesthetic Medicine • June 2020

Higher style. Higher power.

HIGHER iQ Laser hair removal continues to be a huge market. With over 13 million treatments expected in 2020, are you ready to offer your patients the best?1

Enter Elite iQ. Featuring Skintel®, the aesthetic industry’s only melanin reader, Elite iQ enables you to customize treatments based on objective melanin measurements, giving you ultimate confidence in the safety and effectiveness of the treatment. LEARN MORE

1 2020 data. Energy-Based Ax Devices. Medical Insight, Inc. October 2019. *Compared to previous generation devices. The Elite iQ aesthetic workstation is indicated for the following, but not limited to: permanent hair reduction and treatment of veins, noncancerous pigmentation, wrinkles, warts, scars and ingrown facial hairs. Common side effects include redness, swelling, crusting and scabbing. Other side effects may include blistering, burns, hives and lightening and darkening of the skin. Like all medical procedures, not all patients are suitable for the treatment. A qualified practitioner is solely responsible for evaluating each subject’s suitability to undergo treatment and for informing those being treated about any risks involved with the treatment, pre-and postoperative care, and any other relevant information. Individual results may vary and are not guaranteed. ©2020 Cynosure, LLC. All rights reserved. Cynosure, Elite iQ and Skintel are trademarks and/or registered trademarks of Cynosure, LLC. Cynosure, LLC owns exclusive rights to photography. Use of photography without written permission of Cynosure is prohibited. PRD_3507

C O M M E R C I A L F E AT U R E

CYNOSURE

Evolution of the Elite From laser hair removal’s humble beginings to Cynosure’s Elite iQ revolution

aser has been used for hair removal from as far back as the 1960s, albeit fairly unsuccessfully due to the lack of long-term or “permanent” results achievable at the time. Laser therapy was revolutionised in the 1980s by Rox Anderson and John Parrish, postulating the theory of selective photothermolysis – the use of a specific wavelength to achieve the destruction of a target molecule and minimszing thermal damage to surrounding tissue. Perfecting the pulse duration and intensity of laser energy, Dr Rox Anderson and Dr Melanin Grossman laid the foundation of modern hair removal as we know it today, with their group out of the Wellmann Laboratory of Photomedicine at Harvard Medical School. They presented work in early 1997 at the American Society for Laser Medicine and Surgery on the use of the Ruby 695nm laser for permanent hair removal. This early work with the ruby laser, which had its limitations, then to the adoption of the alexandrite laser, with its slightly longer 755nm wavelength, more efficient for targeting the stem cells and causing miniaturisation of the terminal hair follicles. Neither of these wavelengths, however, are still the optimal choice for darker skin types because of their absorption characteristics into melanin. The neodynium-doped yttrium aluminium garnet, or Nd:YAG, is demonstrated to be safer for the higher melanin content found in the higher Fitzpatrick Skin types as its invisible infra-red light, at 1064nm, has a lower absorption into melanin that bypasses the surface colour of the skin. The alexandrite 755nm and the Nd:YAG 1064nm have become the industry standards for hair reduction, each of them optimised for treatment for a different patient population. The first alexandrite laser model that Cynosure designed was the Apogee 6200 about 20 years ago. It only carried the 755nm wavelength. In 2003, the Nd:YAG laser was added and the device was renamed Elite and included both wavelengths. The inclusion of the two wavelengths in the Elite provides optimal hair removal across all Fitzpatrick skin types from I to VI. Some years later, in 2009, proprietary technology that sequentially combines wavelengths to combine clinical effects was launched by Cynosure with the Elite MPX. With

this device, clinicians had the ability to choose treatment with a single wavelength or a combination (in a sequential mode). Combining synergistic wavelengths in the Multiplex modality allows for a safer treatment profile with lower total fluence. In addition to this, the Elite MPX had an integrated cold air system, making it more compact and additionally, an IPL handpiece for aesthetic treatments. Thereafter, a new Elite and Apogee with larger spot sizes – up to 18mm in diameter – started to be used in 2012, under the names of Elite+ and Apogee+. And then, years later in 2014, Cynosure increased the spot sizes offering larger diameters like 20, 22 and 24mm, allowing deeper penetration of energy into the tissue. This, together with a higher repetition rate, were key advantages for optimising treatments, and the Elite+ achieved industry recognition for its efficacy and treatment flexibility when it was shortlisted for device of the year at last year’s Aesthetic Awards. The most recent advancement in 2020 is the Elite iQ, which represents a real revolution in the hair removal market, since this new device incorporates the Skintel, the industry’s only Melanin Reader, which can give an accurate measurement of the skin melanin content to better guide treatment test spot settings and identify skin colouration changes throughout the course of a patients treatments. The Skintel has been an invaluable resource on other hair removal lasers in the Cynosure portfolio for over 15 years, providing clinic reassurance for the selection of safe and effective treatment parameters for each individual patient skin. The Elite iQ, builds on the legacy of our gold standard Elite laser family, now is faster, more efficacious, and smarter since it has a higher maximum energy for both Alexandrite (+19%) and Nd:YAG (+43%) laser so we can treat patients faster and more effectively and safely. The Elite iQ is cleared for hair reduction in all Fitzpatrick Skin Types, I-VI, and includes the treatment of tanned skin allowing the patients hair removal journey to continue during the summer months. It is also cleared for pseudo folliculitis barbae, and the treatment of vascular lesions, benign pigmented lesions and wrinkles, offering a comprehensive range of clinic treatment options from the one device. AM

Aesthetic Medicine • June 2020

NEW EVENT FOR MEDICAL PROFESSIONALS • Leading aesthetic brands • Clinical conference programme • Expert advice on running a successful practice • Live demonstrations

@aestheticmed_live

@AestheticMLive

#AMIreland

BUSINESS

FINANCE

aestheticmed.co.uk

To sell, or not to sell? Real estate lawyer James Polo-Richards explains the pros and cons of a sale and leaseback deal, and why it might be a viable option for struggling clinic owners

or many businesses, the financial packages offered by the UK Government in an attempt to keep the economy afloat during the coronavirus pandemic will provide much needed support and respite. Nonetheless, for many the money cannot come quickly enough, with the business secretary now acknowledging that more money needed to go out faster. The property world has been exploring alternative ideas for raising cash quickly and, in doing so, has dusted off an old favourite – the sale and leaseback.

WHAT IS A SALE AND LEASEBACK?

A sale and leaseback deal does very much what it says on the tin – the owner of a property sells the property to another party and, as part of the transaction, agrees to take a lease of the property back immediately. A sale and leaseback can provide an alternative means of raising finance for a company which may prefer to free up cash in the business rather than approaching a bank for the money. In addition, many property investors including large funds, private equity houses and smaller individual

investors, are looking at a range of opportunities at the moment. Many funds, unless they can negotiate or revise terms, may be bound by conditions to spend cash they have raised by a certain date; and individual investors may see little value in the interest rates offered by banks or not be prepared to risk the current volatility of the stock market. Accordingly, there are people in the market who have cash to spend, as evidenced by the recent deal announced by retailer Next, which has sold three logistics warehouses in the UK to Aviva Investors, through its Lime Property Fund. The three large distribution units, which are central to Next’s storage and distribution capability, were sold in total for around £110 million and immediately leased back. In this instance, it is clear the investors believe the logistics sector offers long-term resilience as retail firms improve their distribution capabilities and recognise the benefits of having a high-quality tenant who now has the funds to ensure their continuing success. If you are considering a sale and leaseback deal as an option for your aesthetic clinic, the most important advantages and disadvantages are outlined below:

Aesthetic Medicine • June 2020

BUSINESS

FINANCE

aestheticmed.co.uk

• Release of cash and existing debt For many businesses a sale and leaseback allows them to convert an asset into cash without losing control of the business. In the same way, where bank debt is secured against the asset, the sale of that asset should enable a company to repay that debt and remove the ongoing need for interest repayments. • Lower costs compared to traditional refinancing While engaging with a bank to secure debt against an existing asset may be an option, there are usually higher transactional costs associated with such deals, including being responsible for valuation, arrangement, legal and bank commitment fees. Theoretically, a sale and leaseback deal should see each party bearing their own costs. • SDLT relief Providing certain conditions are properly met, the leaseback aspects of a sale and leaseback deal may be exempt from stamp duty land tax (SDLT), meaning that the business will not need to pay any SDLT on the grant of the lease. The sale element is still likely to attract SDLT for the buyer. • But… loss of value to the business and director’s duties The sale of an asset is obviously a key consideration for directors as it could reduce the value of the business in any future business sale. It is important to remember that while directors owe a duty to the company, where a company falls into financial difficulties and the risk of insolvency is real, those duties can then extend to creditors. In exercising these duties, they need to ensure they are minimising losses.

Accordingly, any decision to enter into a sale and leaseback arrangement where the company is perceived to be struggling should always involve professional advice and a clearly documented decision-making process as to why the company took this approach. • Financial covenant and security This is key for any investor. An investor buying any asset wants to try to build in a level of certainty that the rent due under the lease they grant will be paid. In uncertain times there may be a feeling among investors that some companies looking at sale and leasebacks are struggling financially, and that a commitment to pay rent over a long term may not be realistic. In such circumstances, parties will need to consider whether any rent should be held back in escrow or in a rent deposit deed. This would give the investor certainty that an element of the rent is already held securely in the event that the new tenant does not perform. Depending on how much rent is held in this way, the seller or tenant may be quite relaxed; from a cashflow perspective they will know that they won’t actually have to pay any rent for a prescribed period if it has already been escrowed.If they have been able to negotiate a rentfree period as part of the deal, this could leave the seller or tenant with a couple of years to focus on other parts of their business. As with any transaction, particularly those involving business assets, it is important to consider a number of factors, but sale and leaseback might represent a sensible option for many commercial property owners in what is likely to be a challenging economic environment for years to come. AM

James Polo-Richards is a real estate lawyer and partner in the commercial real estate team at law firm Wright Hassall. He regularly advises property developers and property investors to help find practical solutions to their challenges so that they can achieve their goals and realise the value of their assets in a timely and cost-efficient manner.

Aesthetic Medicine • June 2020

PROVIDING EVIDENCE IN THE PURSUIT AND DELIVERY OF CLINICAL EXCELLENCE

MEDICAL DERMATOLOGY 2D & 3D IMAGING • 180° & 360° CAPTURE • BODY MAPPING • DERMOSCOPY • CLINICAL PHOTOGRAPHY SIS offers a broad range of exceptional imaging systems to enhance your practice and patient offering. This includes the most advanced whole-body imaging system, the WB360, which allows you to capture almost the entire skin surface in macro-quality resolution with a single capture. We also have a range of high resolution DERMATOSCOPES, BODY MAPPING TOOLS and MAGNIFIERS providing users with standardised image captures for superior support in skin analysis.

AESTHETIC SYSTEMS COMPLEXION ANALYSIS • VOLUME MEASUREMENTS • SIMULATIONS • 10-YEAR AGING APP • CLEAR PRECISE DOCUMENTATION SIS offers a broad range of world class image based consultative systems in both 2D and 3D applications for use across plastic and reconstructive surgery, medical dermatology and aesthetic medicine. Our range of 2D and 3D imaging services allow you to clearly assess, visualise, communicate and record throughout the entire journey. Our systems include the award winning VISIA Gen 7, which delivers superior complexion analysis, the new HairMetrix; the first AI-driven non-invasive hair consultation and the full range of VECTRA 3D imaging solutions.

Please see our website www.surfaceimaging.co.uk for our full range of products and services

READY TO TRY? Telephone: +44 (0)7774 802 409 Email: NMS@surfaceimaging.co.uk @TSIS_London

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The Worldwide leader, Medical Imaging Software, Photography Systems, Clinical Research Services

C O M M E R C I A L F E AT U R E

THE NATIONAL MEDICAL WEIGHTLOSS PROGRAMME

Join a unique community of HCPs tackling obesity… Considering setting up a private weight loss service but don’t know where to start?

hy not become part of a community of healthcare professionals (HCPs) who can help you to establish and develop a commercial business model, even in these uncertain times due to the coronavirus pandemic. By becoming a Certified Partner of The National Medical Weight Loss Programme (NMWLP), registered healthcare professionals can deliver standardised care to people living with obesity who want to achieve a healthy weight. HCPs who join us will receive a wealth of training, business and marketing support, plus benefits and discounts from our preferred partners. The NMWLP was founded by Sandy Green, INP who wanted to increase the accessibility to medical weight loss programmes where national health services are no longer available. Training on the medical management of overweight and obesity was co-authored and is part delivered by Dr Matt Capehorn, an expert adviser to the National Institute for Clinical Excellence (NICE) on obesity, a professional adviser to the Obesity Empowerment Network and part of the author group for RCGPaccredited obesity educational courses. The CPD-certified training course is also accredited by the Royal College of Nurses (RCN) and the World Obesity Federation, through the Strategic Centre for Obesity Professional Education (SCOPE).

OBESITY IS A GROWING PROBLEM

According to recent NHS data, over two thirds of the UK adult population are classed as either overweight or obese. At this rate, experts are

Aesthetic Medicine • June 2020

predicting that 90% of adults will be in this category by 2050. This is a terrifying statistic given that obesity has been found to reduce life expectancy and significantly increase the risk of cardiometabolic disease and various cancers. “Since the appearance of the coronavirus we have known that significant co-morbidities increase the risks of a more severe form of, and mortality from, Covid-19. In the UK, 73% of the first 5,500 critically ill patients were reported as overweight or obese”, explains Dr Capehorn. “The most interesting observation is that the UK population appears to be over-indulging during their period of lockdown, instead of taking the opportunity to go on a ‘health-kick’.” You may also have recognised that people are eating more and exercising less while we have restrictions on normal life. This can only increase the numbers of overweight and obese individuals, meaning that there is no better time to set up a medically-supervised weight-loss service. Using video consultations, HCPs can safely, legally and ethically

C O M M E R C I A L F E AT U R E

THE NATIONAL MEDICAL WEIGHTLOSS PROGRAMME

deliver solutions, even while their practices are physically closed, allowing you to develop a sustainable business, both during and postcoronavirus lockdown. Whilst applications like Zoom, Microsoft Teams and Skype are good for general meetings, healthcare has many considerations which are not catered for by these mainstream video platforms, including patient and HCP identification, data encryption and data storage. After reviewing the “high-level principles for good practice in remote consultations and prescribing”, PriMed Aesthetic Pharmacy built its own video consultation software which is available to NMWLP Certified Partners.

QUESTIONS

Is training available online? Training is delivered by Dr Matt Capehorn and Sandy Green via two six-hour live streamed webinars. What is included in the training? Training manuals and support materials are posted to delegates in advance of the training days. Training will cover the epidemiology and physiology of obesity, understanding fat cells, metabolism and appetite regulation, as well as weight loss interventions. The pharmacotherapy of various prescription medicines used for medically-supervised weight loss (including Saxenda and Ozempic), are covered, as well as the MHRA’s off-label use of medicines, prescribers’ responsibilities, and best practice for offering remote consultation services.

trainin. Alternatively, the NMWLP prescribing service can be used). How much does insurance cost? If you complete the NMWLP training you are guaranteed immediate cover with our preferred insurance partner, Cosmetic Insure (CI). CI use four underwriters. Two of whom cover Saxenda and Ozempic. If your existing policy is with one of the two who offer cover, then other than a £30 admin fee, there are no additional fees to add cover to prescribe these drugs (subject to annual turnover). If your CI policy is with one of the other underwriters, you will need to call them to discuss your options, with policies starting from just £585 p.a (subject to annual turnover and treatments covered). What start-up support will I get? We provide all the help you need with marketing materials and resources, including access to customisable branded documentation and social media templates. You will become part of a dedicated online clinic locator and get access to the UK’s first community of HCPs who are supporting each other to tackle obesity. Uniquely, this means that you are not alone, and Certified Partners can learn from one another, and we can grow as a community.

WHAT DELEGATES SAY

“Amazing product. Amazing training. Amazing support. I would gladly recommend it to any of my colleagues.” – Dr Xavier Goodarzian “I’m proud to be a Certified Partner of the NMWLP. Comprehensive education backed by excellent support.” – Susan Young. “The training is in-depth, clinically evidenced and presented by experts in obesity. One of the best training I have attended, and I highly recommend it. The after-support is second to none from the whole NMWLP team.” – Lou Sommereux. AM Find out more: nmwlp.co.uk

Can dentists and nonprescribing nurses train with you? Training is available exclusively to registered HCPs including doctors, dentists, prescribing pharmacists, nurse prescribers and nurses (who must work with a prescriber who attends the

Aesthetic Medicine • June 2020

CLINIC PROFILE

KL AESTHETICS

aestheticmed.co.uk

PERSONAL GROWTH

Aesthetic Medicine â&#x20AC;¢ June 2020

CLINIC PROFILE

aestheticmed.co.uk

KL AESTHETICS

Kirsty Whitworth, owner of KL Aesthetics in Doncaster, tells Georgia Seago how she grew to fall in love with aesthetics, despite getting off on the wrong foot

irsty Whitworth’s journey into aesthetics isn’t the usual story. She admits she didn’t have a passion for the specialism when she started her training in 2011 – rather, it was through traumatic personal circumstances that she ended up embarking on the career she now loves. “My dream was always to be an oncology nurse,” says Whitworth. I qualified in 2003, and by 2010 I was a haematology nurse specialist. In 2011 I had a baby boy and at six weeks old he had a spontaneous intraventricular brain haemorrhage. Miraculously, he made a full recovery after two weeks in intensive care and through close observation on a neuro-science ward.” Her son’s illness meant Whitworth was unsure if she’d be able to return to the NHS as a nurse; doctors told her she’d likely need to be his full-time carer. So, she began to think about what she could do to work for herself and around his needs, and that’s where aesthetics entered the picture. “I actually tried to cancel the course the night before because I booked it spur of the moment and didn’t really think about what I was doing, but they wouldn’t let me cancel at such short notice,” she says. “I hated every minute of the training because I went into it for the wrong reasons.”

CAREER CHANGE

In 2012 and while still on maternity leave, Whitworth’s son was developing amazingly well. She was performing aesthetic treatments for friends and family but decided to

return to her job as an oncology nurse, as it was where her lifelong passion lay. However, not long after she returned Whitworth’s mother was diagnosed with bowel cancer, and this combined with days and nights spent on the oncology ward quickly became too much. “It became awful. I remember walking into work and thinking, ‘I hate this’,” she says. “My passion just drained from me all of a sudden with my mum being diagnosed. In about nine months, I went from being full-time to three days, and I started to put everything into aesthetics.” Whitworth says her passion “transferred overnight”, realising she had the skills to make people feel happier and better about themselves and help to improve their confidence. "I wanted to be making people happy. My view on aesthetics shifted and I realised how much treatments affect people’s lives. It’s so much more than lines and wrinkles; it makes such a difference psychologically and, as I’ve developed as a practitioner, I understand the emotional side of aesthetics,” she says. When she left the NHS after she wasn’t able to reduce her working days beyond three, Whitworth began slowly building up her client base, treating patients in the outhouse she had converted into a treatment space for family and friends on the side while she was still working. “Because I’d worked behind the scenes for a couple of years, just on people close to me, I learnt slowly. I didn’t rush. A lot of people complete their training and then the next day they’re offering treatments to patients. But I took my time

Aesthetic Medicine • June 2020

CLINIC PROFILE

KL AESTHETICS

aestheticmed.co.uk

and was slowly starting to enjoy it, and that really helped me. I had a client base big enough to justify me working fulltime about nine months after qualifying ,” she says.

NEW HOME

Her mum and son now both recovered and healthy, in 2017 Whitworth decided to move into a proper space and open her own clinic. Based in Armthorpe, Doncaster, KL Aesthetics is housed in a large, semi-detached house which Whitworth noticed one day on her way back from viewing other premises. “We bought the house and converted it into a three-room clinic. It was on the market for about two years because it has a huge front garden on a main road but no back garden,” she says. “This was perfect for us though, as it meant we could offer lots of parking for patients in the walled front garden.” Whitworth admits that with no previous experience in renovating a property for business purposes, the project ended up costing a lot more than she originally thought. “When we looked into the regulations to pass for inspection – fire doors and alarms, disabled access, emergency lighting, etc. – everything had to be redone, it all had to go back to the bare brick and it’s basically a new house inside. But it’s up to the standards it needs to meet, and that’s the most important thing,” she says. In terms of the clinic’s interior, Whitworth says she knew exactly what she wanted. “I want patients to walk in and to feel like they’re walking into a luxury hotel, and not be intimidated by a hyper-clinical

Aesthetic Medicine • June 2020

atmosphere,” she says. “I’m a very relaxed person and we’re a family-run business, which I actually think is partly why my client retention rate is so high.”

SOLID FOUNDATIONS

The KL Aesthetics team consists of Whitworth, her sister, who is a skin therapist, and one other full-time aesthetic nurse. When the UK went into lockdown in March, Whitworth was looking to hire an additional nurse to work from the third treatment room and help manage the (then) waiting list of over six weeks, which is sure to have grown during lockdown. As a top Allergan account in the north, Whitworth says she received a lot of help from her business consultant when she was recruiting her existing aesthetic nurse. “They get to know new practitioners in the north, so they recommended some new nurses to the industry. I needed help with the recruitment and management side, which Allergan gave me,” she says. Whitworth performs the more advanced injectable treatments such as non-surgical rhinoplasty, temples and full-face rejuvenations, while for the time being, nurse Hannah injects lips, cheeks and jawlines while she continues to be mentored by Whitworth in other procedures. In addition to Allergan, KL Aesthetics also works with ZO Skin Health for skincare, sales of which Whitworth says have really taken off during lockdown. “People are just loving it. I’ve started using it – I’m on the brightening programme for pigmentation – and I’ve been posting my progress on our social channels, so people can see how quickly and effectively it’s transforming my skin.” Alongside promoting and processing skincare sales, Whitworth has used the downtime to focus on achieving CPD certification for the training courses she plans to launch when the time is right; one or two-day courses for fully-qualified nurses and doctors where she will teach foundation toxin and/ or dermal filler. The clinic’s double garage will be converted into a training space. “I was hoping to start the training around September time, but we’ll have to see, and with social-distancing measures it will probably now just be one to one,” she says. Despite the uncertainty cast by the pandemic, Whitworth has a positive outlook and is keen to start seeing the patients on her lengthy waiting list when it’s safe to reopen the clinic’s doors. For someone who had a shaky start in aesthetics, it certainly seems like smooth sailing from here. AM

C O M M E R C I A L F E AT U R E

1023

What is skin biorevitalisation? Biorevitalisation is a preventive and corrective method of skin imperfections with injections of hyaluronic acid. It’s a way of returning life back to skin and it’s a nonsurgical and widely applied way to fight skin ageing and various skin problems in aesthetic medicine. Biorevitalisation can significantly improve your skin condition on any part of your body. For example, face, décolletage, arms, neck, inner arms. After the procedure with with non-crosslinked hyaluronic acid skin regains elasticity and a healthy glow, both attributable to young skin. Rejuvenation is the best way to preserve your skin’s youth.

Indications + Increased dryness caused by free radicals such as stress, sun exposure, smoking… + Skin ageing + Prevention of premature signs of ageing

+ Wrinkle correction + Flaccidity on face, neck and décolletage + Dull skin

Discover the new biorevitaliser TKN HA 3 TKN HA 3 is the latest addition to our portfolio of products with hyaluronic acid. This biorevitaliser is an injectable syringe gel composed of 9mg/ml of non-crosslinked hyaluronic acid. It has the highest molecular weight in the market (3.000 kDa), that is, the most similar to the skin physiological one. Having a larger molecule, its degradation is slower and its effects last longer providing a filler effect. TKN HA 3 can be used on the face, neck and décolletage to prevent and correct signs of ageing.

BEFORE

AFTER 1 treatment

Actions: + Participates in wound healing, allowing cells to migrate to the injured area + Slows down the ageing process, especially the formation of wrinkles + Maintains skin moisture levels as it retains up to 1,000 times its weight in water, improving the moisture content in the skin and strengthening the skin barrier + Stimulates the production of collagen and improves the morphology of fibroblasts + Provides a powerful nourishing action and a lifting and firming effect on flaccid skin + Provides a preventive effect on young skins + It’s the perfect complement to prepare the skin before fillers and Botox and after for a perfect finish Post written in collaboration with Dr. Nima Ostovari

Discover more on toskani.com | Distributed in UK by mabeautyaesthetics.com Ph. 01293 441909

CLINICAL

HAIR RESTORATION

aestheticmed.co.uk

THE ROOT CAUSE In the first of a three-part series, Dr Ingrid Wilson explains hair loss in patients with Afro-textured hair, and her approach to examination and consultation

Aesthetic Medicine â&#x20AC;¢ June 2020

CLINICAL

HAIR RESTORATION

aestheticmed.co.uk

understood by the public. Although aesthetic practitioners may have access to the tools to help address some of these concerns, such as PRP therapy or mesotherapy, they may feel less confident in diagnosing hair loss conditions which aren’t due to common causes such as androgenetic alopecia (balding). Practitioners may feel even less confident in diagnosing and managing hair loss in patients with skin of colour with afro-textured hair. This is potentially a lost opportunity to cater for a segment of the market which has a significant need.

AFRO-TEXTURED HAIR

full head of hair is an important contributor to the aesthetic ideal of looking young and rejuvenated. Hair loss can be emotionally devastating, and as such aesthetic practitioners may wish to address hair loss concerns. There are a wide range of causes of hair loss and hair thinning, including nutrition, genetics, disease, medications and haircare practices. At present the available alternatives to surgical restoration of the hair and associated costs are not widely

Human hair has commonly been classified according to three conventional ethnic human subgroups; African, Asian and European. This broad classification doesn’t factor in the high complexity of human biological diversity resulting from both multiple and past or recent mixed origins. For example, indigenous African hair varies from very curly in the southern part of the continent to nearly straight in northern areas. This article will focus on the needs of black, tight curly African hair, hereafter referred to as Afrotextured hair, which does have significant diversity. The classification of hair will be covered more thoroughly in article two of three. There is little data about the epidemiology of hair loss in people with Afro-textured hair in the UK, but data from the US indicates that hair loss is the fourth most common reason for African-Americans to see a dermatologist.1 A US-based survey conducted at predominantly AfricanAmerican churches in 2014 found that more than 50% of African-American women reported excessive hair loss. 28% percent had visited a physician to discuss hair issues, but only 32% felt their physician understood AfricanAmerican hair. 2 The perceived lack of understanding of black hair and hairstyling practices can lead to delays in seeking help. 3 Ophelia Dadzie’s study was the first UK epidemiological study exploring hair loss in women with “Afro-textured” hair and concluded that hair loss in black women should be considered a public health issue, as it found that around 50% of its sample of women of African descent experienced some form of hair loss.4 This suggests that a different approach is needed so that this patient group feels able to come forward with hair loss concerns. Patients with Afrotextured hair often report how their hair loss concern was dismissed by some GPs and dermatologists, and they were simply told to get a wig.

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CLINICAL

HAIR RESTORATION

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Professional expertise

The clinical management of hair loss has traditionally been the realm of the dermatologist. However, there are only a handful of dedicated NHS hair-loss clinics – even fewer specifically for “ethnic” hair, and a recognition that higher specialist training may result in a lack of confidence in managing ethnic skin and hair conditions.5 A survey of dermatology trainees and junior consultants in 2013 indicated that only 38 out of 78 respondents (49%) thought they were/would become competent in treating conditions pertinent to the UK’s ethnic population following completion of the training programme. Extrapolating this finding to hair loss conditions, the pool of expertise is likely to be even smaller. In the NHS, patients will have been referred by their GP, who themselves is likely to have received minimal training in hair loss conditions before they qualify.6 This was my personal experience as a GP; I struggled to find a course that would help to meet my educational needs for hair loss. So, between 2010 and 2012 I completed a course of training with the Institute of Trichologists which helped to broaden my knowledge of diagnosing hair loss conditions in Afrotextured hair. To compound the situation there is a lack of UK studies pertaining to hair loss in women of African descent. Most of the current published data originates primarily from the US and South Africa. There will of course be differences in genetics and environmental factors when this data is applied to patients in the UK.

Figure 1. Advanced hair loss. Patient should have been referred much earlier for a biopsy from a dermatologist

APPROACH TO CONSULTATIONS

Regrettably, a significant proportion of patients may be seeking help late on in the hair-loss process, but an overall positive approach should be taken in terms of advising about the cosmetic as well as medical approaches. Practitioners should develop an awareness of dermatologists specialising in Afro-textured hair loss, as well as hair stylists who are able to safely style and care for natural Afro-textured hair. Patients will be prepared to travel for a good quality service. Patients may have already seen a variety of high street or holistic practitioners or trichologists, after perhaps not feeling confident to approach their GP. They may feel relieved that they now have permission to discuss their hair loss, so additional time needs to be factored into the consultation to allow for this discussion. Relationships should be developed with good-quality wig suppliers or hair-replacement system suppliers if this is not supplied in clinic. Clinics should also develop knowledge about the common methods of scalp camouflage.

Figure 2. Hair pull test. Evidence of hair loss at the vertex/ crown

consultation. A significant advantage to this approach is that hairstyles which can be used to cover hair loss can take up to several hours to remove at the clinic. As with all clients, photography is essential to monitor progression of the hair-loss condition.

The consultation environment should be private and free from interruptions, away from the view of the public and other clients. Patients are likely to feel self-conscious about their hair-loss condition and may have taken a long time to prepare to go out. It can also be helpful for the clinic to carry stock of stylish head coverings for women with alopecia, and to ensure that a large, well-lit mirror is available to enable clients to adjust their hair after the appointment. It is important to conduct a general assessment of the hair loss to include: • The duration and progression of hair loss – Is the hair loss progressing or has it become stable? • The history, pattern and site of hair loss and thinning –

“Hair loss is the fourth most common reason for African-Americans to see a dermatologist”

Photography

Since covid-19 social restrictions were introduced in the UK in March 2020, remote consultations have become more commonplace. As part of this, it is helpful for patients to send in photographs from the front, back, side and top views of their head (frontal, occipital and parietal). Most patients have smartphones that can take good-quality photographs that can be helpful to review before the

Aesthetic Medicine • June 2020

Clinic environment

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In particular ask about hair breakage or hair loss at the vertex (CCCA) or temples (traction alopecia) • Changes in hair fall – It is worth noting that there is more natural breakage in the kinkier curl pattern naturally, however there can be treatable reasons • Change in rate of growth and hair texture changes • Associated symptoms – Including itching, burning, pain or tingling of the scalp, or scalp scaling • Past Medical History – Medication history including supplements, plus nutrition history • Family history – Important in central centrifugal cicatricial alopecia and androgenetic alopecia • Previous treatment – Patients may have seen other professionals in the past such as a trichologist or hair transplant surgeon. It can be helpful to find out more • Hair care practices – Including bleaching or processing • Hair-maintenance products used – Figures reported by Black Hair Magazine in 2018 revealed that in the UK, £5.25 billion is spent annually on hair care. Spending by black women accounted for 80% of total hair product sales, and black women reportedly spend six times more on their hair compared with white women.7 Women with

curly and coily hair are more likely to purchase products specifically for textured hair rather than general market products, according to the 2018 TextureTrends Report from NaturallyCurly. 8 It is also important to assess the psychological state of the patient, and a questionnaire completed before the consultation can be helpful.

HAIR-CARE PRACTICES AND THEIR SIGNIFICANCE

People with natural Afro-textured hair wash their hair approximately once every one to two weeks. This is partially due to lower levels of sebum on the hair shaft, as the hair grows away from the scalp with resulting dryness and breakage if shampooed too frequently. Afro-textured hair in its natural state free from chemical processing is the healthiest option for hair. Certain haircare practices and hairstyles are unique among women (and some men) of African descent, which may contribute to specific types of hair loss. A variety of hair-care practices may have been engaged in throughout life. It is important to get as much detail about the practices and products that are used and how often. Natural hair may have been straightened, or its texture altered using heat or chemical means. In general, consumers will tend to buy brands with product formulas specifically made for them in mind. Haircare regimes designed to maintain and style natural hair are growing in popularity, with chemical product use declining (in the US). 9

Styles that can cause tension

Afro-textured hair can be manipulated into various styles including braids, twists, cornrows, dreadlocks and weaves. If too much tension is used, this can accelerate hair loss. In all of these styles (except dreadlocks), human or synthetic hair may be added for increased length and volume. • Braids and twists: Where the hair is parted into sections and two or three strands are repeatedly crossed over • Cornrows: Formed by braiding the hair into the scalp in rows • Hair weaving: The hair is cornrowed, and additional hair is sewn or glued to the cornrows • Locks (also known as dreadlocks, locs or dreads): Where the natural hair is sectioned into small areas that are then twisted, braided or coiled using the finger, palms or tools. The new hair growth is re-twisted after six to eight weeks and allowed to mat. Figure 3. Fringe sign in traction alopecia

Figure 4. Traction alopecia before applying keratin fibres

Figure 5. After camouflage fibres

Styles that can cause thermal damage

High temperatures applied to the hair cause the expulsion of water from the hair, which leads to deficits in the cuticle (outer hair layer) which then becomes fragile and more susceptible to breakage. • Hot combing or pressing: The hair is coated with a lubricating oil and then combed with a hot metal comb heated to 300 to 500°F • Flat iron: The hair is placed between two hot, smooth, ceramic plates with temperatures ranging from 180 to 450°F • Silk press: Flat irons are used with products containing silicones, such as dimethicone and cyclomethicone, which are applied prior to heat application to create a lighter, less weighed-down straightened look compared to the

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hair using the comb and your hand. This is very important – unfortunately patients with Afro-textured hair often report a reluctance by the clinician to actually examine the hair, which is needed to help to assess dryness, fragility and how easily the hair comes away from the scalp (hair pull test). If sufficiently skilled, trichoscopy or dermoscopy can be useful, particularly in areas of scarring. Scarring may not always be appreciated clinically. For this reason, there should be a low threshold for performing scalp biopsies, preferably by a pathologist or dermatopathologist trained in the histopathological interpretation of scalp biopsies.15

SUMMARY Figure 6. Hair loss patient with hair thinning at the front diagnosed by dermatologist as lichen planopilaris

traditional press • Brazilian keratin treatments/ formaldehyde-based straightening: The hair is washed and then the formaldehyde/ keratin solution is applied throughout the hair with a comb. The hair is then blow-dried and flatironed at elevated temperatures of 400 to 450°F which helps to seal the cuticle after straightening. Formaldehyde treatments are now banned in the EU, but it is possible that these products may have been used.

Styles that can cause chemical damage

• Chemical relaxers: These produce permanent hair straightening by rearranging disulfide bonds within the shaft; using sodium hydroxide in lye relaxers, and guanidine hydroxide in no-lye relaxers. These often result in irritant contact dermatitis, trichorrhexis nodosa, and fragile, easily-damaged hair.10 It may be worthwhile asking where the relaxer was purchased as incorrect formulations11 are associated with alopecia. When used improperly they can also cause local irritant contact dermatitis and chemical burns to the scalp and hairline that can potentially lead to a scarring alopecia.12 Relaxers are associated with reduced cystine content consistent with fragile, damaged hair. 13 The use of relaxers has been steadily declining. In the US the black hair-care market has evolved to include protective styling where the ends of the hair are tucked away to protect against wear. 14

Physical examination

The hair and scalp should be examined under good lighting. Sometimes when people attend clinic they have covered their hair with wigs or hair pieces, which can affect the ability to make a full assessment. It is helpful to ask before the consultation that they send in good quality photographs of their hair from the vertex, parietal, occipital and frontal views, as mentioned earlier. Part the hair using a wide-tooth comb, as this will be kinder to the hair and minimise breakage. Examine the

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There is an unmet need for the care of patients with skin of colour experiencing hair loss in the UK, so it is important that a non-judgemental approach is taken which acknowledges that. Thorough assessment and knowledge of hair care practices will help to improve the confidence of practitioners. However, if unsure about assessment it is important to ensure that the patient is assessed by an appropriately knowledgeable professional. AM REFERENCES 1. A lexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis. 2007;80:387–394. 2. Gathers RC, Mahan MG. African american women, hair care, and health barriers. J Clin Aesthet Dermatol. 2014;7(9):26-29. 3. A kintilo L; Hahn EA; Yu JMA; Patterson SSL. Health care barriers and quality of life in central centrifugal cicatricial alopecia patients. Cutis. 102(6):427-432, 2018 Dec. 4. Dadzie OE; Salam A. Correlates of hair loss in adult women of African descent in London, U.K.: findings of a cross-sectional study. British Journal of Dermatology. 173(5):1301-4, 2015 Nov. 5. S alam A, Dadzie O. Dermatology training in the U.K.: does it reflect the changing demographics of our population? Br J Dermatol. 2013 Dec;169(6):1360-2. 6. T he King’s Fund, How Can Dermatology Services Meet Current And Future Patient Needs While Ensuring That Quality Of Care Is Not Compromised And That Access Is Equitable Across The UK?, 2015. <https://kingsfund.blogs.com/health_management/2015/05/how-candermatology-services-meet-current-and-future-patient-needs-whileensuring-that-quality-of-ca.html> 7. h ttps://blackhairmagazine.co.uk/hair/opinion-why-black-women-beingvocal-is-imperative-in-driving-diversity-in-the-hair-industry 8. T extured hair care retail squeeze. Globa cosmetic industry, 2019, 187, Daily newsletter, February 10 9. M intel report. Black Haircare – US – August 2019 10. K humalo NP; Stone J; Gumedze F; McGrath E; Ngwanya MR; de Berker D.’Relaxers’ damage hair: evidence from amino acid analysis. Journal of the American Academy of Dermatology. 62(3):402-8, 2010 Mar. 11. Swee W, Klontz KC, Lamber LA. A nationwide outbreak of alopecia associated with the use of a hair-relaxing formulation. Arch Dermatol 2000;136:1104-8 12. Richardson V, MD, Agidi A, Eaddy A, Davis L. Ten pearls every dermatologist should know about the appropriate use of relaxers. Journal of Cosmetic Dermatology, 16, 9--11 13. K humalo N, Stone J, Gumedze F, McGrath E,. Ngwanya M, de Berker D‘Relaxers’ damage hair: Evidence from amino acid analysis 14. August 2019 Mintel report 15. S alam A, Aryiku S, Dadzie O. Hair and Scalp disorders in women of African descent: an overview. British Jornal of Dermatology (2013) 169 (Suppl 3). Pp19-32

Dr Ingrid Wilson is a portfolio GP and trichologist in Cheshire and has been on the Specialist Register for Public Health since 2006. She is also director of Crewe Hair and Skin Clinic. She gained a distinction in both years of study at the Institute of Trichologists between 2010 and 2012 and won the John Mason Memorial prize. She is a Member of the International Association of Trichologists and affiliate trichologist Member of The British Association Of Hair Restoration Surgery.

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OPINION

FUTURE OF INJECTING

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BEHIND THE MASK Dr Tijion Esho explores what the “new normal” might look like for lip-filler procedures post-pandemic

any of us are preparing to reopen our clinics next month [in July – as Aesthetic Medicine went to print], and with planning underway for the secure covid-19 guidelines we will have to employ, clinicians and patients alike are starting to see what a new normal could look like for clinics, with measures including screens and PPE across the board. But in a world now full of protective face masks, how will we as injectors approach administering lip fillers; the UK’s most popular dermal-filler procedure?

MINIMISING RISK

As we know, treating the lips has always carried a high risk due to the vast blood supply to the area. Risks include infection, bleeding and tissue necrosis, but we will now have to be aware of the additional risk of covid-19 transmission. Potential transmission of the virus through the air between patient and injector is a real concern for many. The risk is reduced when treating the upper face as patients can still effectively wear their masks while toxin and/or filler is

Aesthetic Medicine • June 2020

injected anywhere above the nose. Because of this, upperface treatments are likely to be the first procedures to return on a near-full scale when clinics re-open. However, below the nose the mask must come off and for the time being at least, all bets are off, as the risk of spread despite the injector wearing PPE isn’t yet truly known. Treating the lip area isn’t a true aerosol-generating procedure (AGP) – to be so it must be one that activates the gag reflex and enters into the oral cavity – but there is still the risk of the patient coughing, sneezing or simply breathing to contend with. The race to reduce risk for both injector and patient is now on, and the good news is there are already sensible suggestions of how to make one of our most popular procedures safe in a post-covid world. Having performed multiple lip-filler procedures in almost a decade’s worth of aesthetics practice, I have also been looking at ways to reduce risk to myself and my colleagues, as well as our patients. But, it is important to note that there will never be no risk, and that should form part of the consent process. Here are my suggestions:

OPINION

FUTURE OF INJECTING

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4. Ventilation

1. Virtual lip assessment

Before the appointment, as much assessment of the lips and the dynamics of the peri-oral area should be done via video as well as standardised photos from the patient. This will help you build an accurate treatment plan, so you can prepare as much as possible before the patient enters the treatment room.

2. Mask on/ mask off

“ In a world now full of protective face masks, how will we as injectors approach administering lip fillers; the UK’s most popular dermal-filler procedure?”

The best masks for a clinic setting are FFP2, while FFP3 masks are considered most appropriate for true AGPs. They should be worn by both patient and injector at all times where possible. The patient should remain wearing their mask all the way up to the point you are ready to clean and prep the area, in order to reduce droplet spread. It should be placed back onto the patient immediately post-procedure (once they have seen their results).

3. Decontamination

As clinicians we’re all aware of how crucial cleaning of the treatment area is pre-procedure, but now, with the more we understand about how coronavirus colonises in the nasal and mouth cavities, additional cleanses of these areas using nasal swabs and mouthwash will be a prerequisite for pre-procedure preparation.

A lip-filler procedure can take anywhere from five to 15 minutes to complete, so even when wearing PPE, this is a long time for an injector to be close to a patient without social distancing. Reducing aerosol/ droplet spread during this time is crucial and, there are a number of devices now becoming available to help. Some use specific filters that the patient places in their mouth, while others use suction devices that sit in front of the patient’s face during the procedure to promote extraction. In my clinics, we have opted for Radic8; an airflow-extraction system that filters and eliminates the virus in the air throughout the entire clinic.

5. Post-procedure care: delayed-onset reactions

One of the rare but known complications of dermal fillers is delayed onset nodules. This is where – normally after a viral illness – an immune reaction is triggered, with the body causing the filler to form hard and painful lumps. As of yet we don’t know how covid-19 could interact in patients with dermal fillers, so it is crucial to make this part of the consent process and follow up with patients not just at two weeks post-treatment, but further down the line too, in order to collect data and ensure the continued safety of our patients in this new landscape. Taking these steps will help reduce risk, but, as mentioned above, will never remove it altogether. We must be realistic and accept that we will be living with the risk of coronavirus until we find a cure. Ultimately, aesthetic procedures like lip fillers are wants and not needs, and patient and injector safety must always come first. AM

Dr Tijion Esho is a multi award-winning UK cosmetic doctor, with clinics in London, Newcastle, and Dubai, attracting a global clientele. Dr Esho Is the resident cosmetic doctor on ITV's This Morning and E4's Bodyfixers. He heads up the Esho charity initiative, which provides free corrective treatment to victims of botched surgery, trauma or those born with congenital defects.

Aesthetic Medicine • June 2020

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BUSINESS

DIGITAL MARKETING

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More to say Following her introduction of social proof in the May issue, Alex Bugg shares more tips on working it into your website

our website is your 24-hour shop window, and social proof should be woven into its fabric. Firstly, your homepage should be rich in social proof to show visitors that they’re in good hands when they choose to undergo a treatment with you. You want to kill any scepticism that people who access your site via organic (search engine) traffic may have when they click on. So, present them with higher-level social proof such as affiliations, impressive numbers and media appearances right on your homepage.

Moving to your treatments and conditions pages, these are prime real estate for video testimonials, case studies and reviews from real patients who have had great results – this is the kind of authentic and tailored social proof that can really convert browsers to patients. Answering the questions that website visitors (or potential patients) have is the minimum you should be doing; those answers coming from a patient of yours hold even more power. As practitioners look to set themselves apart from the crowd, aesthetic treatments are becoming ever more

Aesthetic Medicine • June 2020

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bespoke. Use “the wisdom of crowds” by noting on your treatment pages that patients who had X treatment also had Y to complement, and take-home skincare Z to maintain results. This is similar to algorithmic recommendations from services such as iTunes or Netflix, where users are shown things they may like based on what they’ve already shown interest in. Getting patients themselves to talk about this in reviews or videos is more trustworthy and feels less like a sell, while hopefully boosting add-on or follow-on sales.

website, and reprint or link to the coverage there. Check for permissions first, but posting articles and video clips allows you to kill any scepticism as to their authenticity. Visitors can then decide for themselves if you are trustworthy, rather than be left wondering if you were a key feature in a big-time publication or programme, or if you actually barely received a mention. Most consumers find it easy to spot fake affiliations and reviews these days, likewise a suite of 100 fake five-star reviews for a small business. Faking social proof via reviews is not only a red flag to consumers, but using the Google platform to exploit the system can get your business removed or even blacklisted. Even worse, paying for reviews breaks UK Consumer Protection from Unfair Trading Regulations (2008), as well as advertising codes, and you would be breaking the law.

IF YOU’RE NEW TO THE INDUSTRY…

Congratulations on starting out in aesthetics. If you’re new to the industry or your clinic hasn’t been open long and you don’t have “impressive” treatment numbers or consented before-and-after photos yet, you can still employ social proof in your marketing. Make reviews your priority and hold onto them like gold when you receive them. Then, you should use social proof from product partners as if they are your own. For example, Allergan recently celebrated having shipped over 100 million vials of Botox, so if this is your toxin of choice, shout about it, and drive home the message of why you use the products you do. You may also want to think about starting to build relationships with the media to help introduce your business and boost your profile. Whether you know it or not, you are influenced every day by social proof. There are lots of resources online that discuss social proof in marketing – you may find you’re using one or two tactics already. If you’re not, try to integrate social proof across your website, social media and other marketing activities, and see what results you achieve. AM

“Your treatments and conditions pages are prime real estate for video testimonials, case studies and reviews from real patients”

AUTHENTICITY

Operating your aesthetics business authentically factors greatly into your use of social proof as marketing. For example, are you actually a member of that professional organisation, or have you just got a certificate from a CPD event they ran five years ago? To consumers that hold these affiliations in high regard, it is often possible to check credentials on linked registers. Organisations are also looking to protect the integrity of their membership, so expect contact from them if you are in fact being dishonest and attempting to mislead the public with the use of their logo. If you’ve featured in any print, online or TV media, back up the logos on your homepage with a media section on the

Alex Bugg works for Web Marketing Clinic, a family-run digital agency, which specialises in medical aesthetics. They build websites and deliver award-winning marketing campaigns for doctors, nurses, dentists, distributors and aesthetic brands. Contact her on alex@webmarketingclinic.co.uk or follow her on Instagram: @webmarketingclinic

Aesthetic Medicine • June 2020

C O M M E R C I A L F E AT U R E

BEAUTYFORM MEDICAL

ESLA Former is a medical device using the new FMS (Functional Magnetic Stimulation) technology for muscle strengthening, toning and sculpting the body on areas of the glutes, abs, hamstrings, thighs, calves, arms, back and pelvic

floor. TESLA Former provides pulsed magnetic fields, contracting the muscles through its effect on motor nerves of the muscles on the target site. Tesla Former delivers more than 50,000 pulses in 30 minutes with constant changes in frequency, waveform, and contraction type. This doesn’t allow the targeted muscles to adapt to the treatment, therefore higher muscle growth is achieved and no plateauing effect will be seen.

One other benefit of Tesla Former is although it doesn’t target the fat directly, when the target muscles are contracting they use up the low amount of energy that is stored within them in a short period of time and they start to draw on fat in the targeted area. This allows muscle building and natural, non-invasive body sculpting.

UNIQUE FEATURES:

• More than 50,000 contractions in 30 minutes • Six applicators available (four body applicators and two built into the TeslaChair) • TeslaChair for core muscle strengthening targeting the pelvic floor, back and abs • 24 different phases of muscle contractions in one cycle, constant change of frequency, waveform and type of contractions • 200 treatment protocols (aesthetics, physical therapy, sports rehabilitation and gyneacology) • Alternating applicators using higher energy levels • Three Tesla Power and four Channels Tesla Former comes with the TeslaChair if required. This combination allows targeting of the pelvic floor + back + abs, with four applicators for core therapy. The TeslaChair also helps with Pelvic floor issues such as incontinence problems with two built-in applicators in the chair. AM

Aesthetic Medicine • June 2020

CLINICAL

SKINCARE ACIDS

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CHEMICAL REACTION Aesthetic facialist and skincare expert Eavanna Breen on what to be aware of when treating patients with acids

Aesthetic Medicine â&#x20AC;¢ June 2020

CLINICAL

SKINCARE ACIDS

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e use acids in skincare as superficial peeling agents to treat acne, scarring, pigmentation and ageing. Alpha hydroxy acids and beta hydroxy acids (better known as AHAs and BHAs) are the two main classifications of hydroxy acids, though in recent years polyhydroxy, L-ascorbic and retinoic acids have seen an increase in popularity. In skincare products, acids act on both dermal and epidermal levels. Overuse or improper application can be dangerous and sensitising to the skin, resulting in immediate stinging and burning sensations; while prolonged overexfoliation compromises the skin’s acid mantle, disrupts the microbiome, and can increase inflammation and irritation in a detrimental way. The phenomenon of social media “skincare gurus” has spawned a new type of client – the “skintellectual” expects results-driven skincare that achieves visible changes to their skin in a short space of time. While these clients pride themselves on being obsessed with their skin and may use skin-science terms and understand how ingredients work on a basic level, they do not have formal training, and their eagerness to see results can lead to skin problems. They are encouraged to exfoliate their skin to achieve a much sought-after glow, which means that our clients are buying products containing acids that often aren’t suitable for their skin. I have seen this on numerous occasions in my own practice, whereby a very well-marketed consumer skincare product was causing multiple clients to develop compromised lipid barriers and skin sensitivity. Eventually, I only had to look at a skin and I was able to tell the client that they had used this particular product. It is up to us as professionals to educate our clients on the appropriate use of these acids and instil proper guidance when using active ingredients.

AHAS

AHAs improve subcutaneous barrier function by increasing proliferation and thickness, as well as restoring hydration by increasing the skin’s level of hyaluronic acids. They interact with the water in the upper layers of the skin, reducing the superficial pH of the skin’s surface. This weakens the ionic bonds of the lipids that hold the dead cells together, resulting in the sloughing of dead cells. The most commonly used AHAs are glycolic, lactic, mandelic, malic and citric. Glycolic acid has the smallest molecule that can easily penetrate the skin. It is derived from sugarcane, as well as synthetic sources. It can be used at 3% upwards, but anything over 10% should be used at night only and under supervision of a professional. Combining AHAs with retinol should be advised with caution. As these actives are both known for effectively increasing cell turnover, it is not recommended to use them together in the same night routine. If a patient’s skin responds well to both of these then at most, alternating nights would be the way to go.

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SKINCARE ACIDS

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BHAS

While AHAs are water-soluble, BHAs are oil-soluble. This means they can penetrate the sebaceous follicles, making them a better choice for patients with oily skin and comedones. BHAs are exfoliants and are effective at reducing the appearance of fine lines and wrinkles, improving overall skin texture without the irritation often associated with AHAs. Derived from aspirin, salicylic acid is the most common BHA. It has both anti-bacterial and anti-inflammatory benefits to the skin. 2% is recommended for targeting acne, while 0.25% helps control the oil and inflammation associated with ageing. Mixing AHAs and BHAs in a skincare routine should be approached with caution, but since everyone’s skin is different, the combination could be safe and even beneficial for some, like those with particularly oily skin, for example. This is one of the reasons why it is so important that patients come to skin professionals for guidance before embarking on any new regime or introducing a new product into their routine.

is also a hydrating antioxidant ingredient with soothing properties, which makes it good to use alongside retinol – as found in AlumierMD Retinol –as it gently exfoliates to allow the retinol to penetrate while soothing skin at the same time.

“It is up to us as professionals to instil in patients proper guidance when using active ingredients”

HYALURONIC ACID

HA is a complex sugar molecule that occurs naturally in the body. It is renowned for its ability to hold 1000 times its own weight in water. HA has a large molecule and hydrates the skin by drawing moisture to the surface. More of a support ingredient rather than anti-ageing, it does not have the ability to stimulate the body’s own HA or collagen production. It works well alongside other acids to help in the anti-ageing process because of its incredible ability to hydrate and plump the skin.

RETINOIC ACID

Retinoic acid is a morphogen derived from retinol (vitamin A) that plays an important role in maintaining skin health. It is known as the gold-standard skincare ingredient because it has so many functions that help the skin. It is capable of reducing fine lines and wrinkles by stimulating collagen, it treats pigmentation and is an antioxidant capable of protecting the skin from UV-induced free-radical damage. Retinoic acids combined with other acids such as L-Ascorbic is one of the best combinations for an anti-ageing skincare routine. The use of L-ascorbic in the morning and retinol at night makes a winning combination in the fight against signs of ageing.

L-ASCORBIC ACID

The most bio-available form of vitamin C, L-ascorbic is found in skincare from 5-15%. It helps the skin in a variety of metabolic ways, including helping hyperpigmentation, post-inflammatory hyperpigmentation and signs of ageing. It is involved in the production of collagen and protects the skin from oxidative stress by fighting free radicals. The combination of vitamins A (retinol), C and E are vital in skincare and will lead to healthy skin.

PHAS

Polyhydroxy acids are naturally-occurring compounds that have efficacy levels similar to AHAs but are larger molecules and therefore less sensitising. Popular PHAs include gluconolactone and lactobionic acid, which are chemically and functionally similar to their AHA counterparts (glycolic acid and lactic acid, respectively), but given their larger molecular structure, they are not able to deeply penetrate the skin and cause the same level of damage while reaping similar benefits. Gluconolactate

>> 42

For clients who are at risk of damaging their skin due to acid use, gentler acids are ideal to promote skin cell renewal without the harmful side effects. Less aggressive, time-released products, such as AlumierMD Acne Balancing Serum, which contains 2% encapsulated salicylic acid, are ideal for helping to treat skin without any harmful side effects. However, the use of acids in skincare is well documented, and even high levels can be safe and beneficial to the skin if understood in terms of ther indications and interactions, and applied correctly. AM

Eavanna Breen has been an aesthetic therapist since 1991. She has worked alongside cosmetic surgeons, doctors and naturopaths and specialises in diathermy, advanced skin care and laser treatment. She opened the first Akina Beauty Salon in Dublin in 2006. Eavanna also works with clinical skincare brand AlumierMD.

Aesthetic Medicine • June 2020

C O M M E R C I A L F E AT U R E

VINDOC AESTHETIC ACADEMY

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VinDoc Aesthetic Academy Let’s talk training with Dr Vincent Wong of VinDoc Aesthetic Academy

he brand has seen amazing progress within just one year but we expected nothing less, as the academy is the ran by leading aesthetic practitioner Dr Vincent Wong and Alexandra Cutler, the names behind brands such as plasma pen Jett Medical and TruCryo Kaasen Life advanced cryo body and facial sculpting. Known for “creating the faces of the future”, Dr Vincent is an expert in facial balancing and harmony, and well-known for his 360-degree vision of aesthetics. His innovative approach to the face is loved by all his clients who include a long list celebrities and influencers. “I launched the company 2019 and we have grown quickly, already having been acknowledged as a name for quality training by the aesthetic community. We have many amazing brands and training partnerships including Allergan, AQ Skin Solutions, Fillmed and many more,” says Dr Vincent Wong. VinDoc Aesthetic Academy offers a range of training to suit all levels of practitioners. Training is clearly split between medics and non-medics, with all injectable courses run for medical practitioners only, and the huge range of skin treatments and technology training courses available to both medics and nonmedics. Our team is focused on quality in both the product range and training to offer the peace of mind that all practitioners trained by us are trained to the highest level. In these unprecedented times we are seeing a lot of online training popping up that concerns us for customer safety and practitioners alike, such a seen IV vitamin infusion courses and even a lips masterclass fully trained online in just one day during these strange times. We know it is hard for all training facilities and practitioners during this time but please think before you train. We would ask insurance companies to consider what they are covering when someone can train online to deliver Vitamin D injections with no blood testing in place and no medical training. This is a fat-soluble vitamin that could potentially cause damage to patients. Similarly, we ask educational providers and practitioners to think before they train online in any form of injectable treatments and invasive technologies. We have ourselves opened an online training portal to deliver non-invasive treatment training and the home study sections of our classroom-based courses. We thought long and hard about the courses that could be delivered online. We will be offering discounts for courses booked during lockdown to help our clinics with their self-development and home study prior to attending live training. We have launched our CPD-accredited Complications course for only £99 (normal RRP £695), and we have a large range of courses at 50% discount. We hope you all keep safe and prepare for the boom in trade when our patients leave lockdown and turn to us to help them look and feel their best. AM For further information please contact Info@vindocaestheticacademy.com 020 8050 1684

Aesthetic Medicine • June 2020

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MIGRAINE TREATMENT

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Head’s up Dr Pradnya Apte explains how she used Botox injections to bring relief to a patient suffering from severe migraines

hy toxin injections help with migraines is not fully understood. Sensory nerves carry pain impulses and secrete chemicals such as CGRP (calcitonin gene related peptide) – a neuropeptide. Neuropeptides are small protein-like molecules (peptides) used by neurons to communicate with each other. They are neuronal signalling molecules that influence the activity of the brain and the body in specific ways. CGRP has been shown to be strongly implicated in the cascade of migraine symptoms. When botulinum toxin enters the muscle, the muscle acts as a container to keep the Botox around the sensory nerve, allowing it to be absorbed into the nerve. Once in the nerve, it decreases the release of CGRP and other chemicals involved in migraine. CGRP is also a vasodilator which dilates the blood vessels, and this can sustain a migraine. When Botox is used cosmetically, it works specifically on the muscle. For a muscle to contract, the nerve releases a chemical messenger called acetylcholine. Acetylcholine is a neurotransmitter which sends signals from one neuron to another. In this case, acetylcholine attaches to cells in the muscle, which causes

Aesthetic Medicine • June 2020

them to contract. When Botox is injected, the release of acetylcholine is blocked, preventing the contraction of the muscle. Abnormal muscle contraction is reduced by toxin, which allows the muscle(s) to become less stiff. This aspect of toxin might help with neck muscle stiffness, which is commonly seen in patients with chronic pain such as migraine.

CONSULTATION

Patient Hayley Smith, who is 34 and lives in Exeter with her partner and two young children, had suffered for most of her adult life with chronic migraines, however over the last two years these had been increasing in intensity. Sometimes a migraine could last as long as two weeks for Hayley. When visiting the clinic for an aesthetic procedure, Hayley mentioned her fluctuating migraines and I suggested that treatment with Botox could help in reducing them. I have treated a number of male and female patients with botulinum toxin for their migraines with

C AS E ST U DY

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MIGRAINE TREATMENT

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MIGRAINE TREATMENT

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great success and was incredibly keen to help Hayley. Her experience was more on the extreme end of the migraine spectrum as she had sensitivity to light during her attacks, but I was confident that treatment would be successful. BoTX A injections do not affect any other medications the patient may be on for migraine, but this would need to be approved by their GP. If they suffer from other conditions such as myasthenia gravis for example, this treatment is contraindicated. Botox has not been proven to work for the treatment of migraine headaches that occur 14 days or less per month or for other forms of headache. Results can vary and may require a couple of rounds of treatment to see if it works. There are some patients that will get a headache after treatment and potentially neck pain, but this subsides after a few days.

•C orrugators: 20 units divided into four sites •P rocerus: five units in one site •O ccipitalis: 30 units divided in six sites • Temporalis: 30-40 units in six to eight sites as this can vary. I tend to do more here if there are vision issues •T rapezius: 30 units divided in six sites • Cervical muscle group: 20 units divided into four sites • About 155 units in 31 sites and more if I carry out more in the temporalis muscle.

“...This aspect of toxin might help with neck muscle stiffness, commonly seen with chronic pain such as migraine”

Treatment plan

I have tailored my treatment plans following the PREEMPT (evaluating migraine prophylaxis therapy) for the last five years in which I have been treating patients with migraine. There are 31 sites with 5U injections, but this can sometimes vary. I have only treated one patient with more than 31 sites. I use Onabotulinumtoxin-A ( Botox ®) and dose the following way: • Frontalis: 20 units divided into four sites, but 30 units in men for six sites

Within two days Hayley had noticed a difference. She told me: “Before I was treated I used to have a permanent heavy-feeling head, even when I wasn’t experiencing a migraine. It’s now three months since I had treatment and I’ve not had a migraine since. I feel like I have my life back – I’m so much happier, I’m not fighting a permanent discomfort and I am loving that I can enjoy my time with my kids so much more. “Before, when I was experiencing a migraine, even simple things like reading a story with them took so much out of me, and now I read with them all the time. I have a new lease of life, an increase in energy and my migraines have gone. I will definitely keep up the treatment.” I have treated patients with this method and so far, have had a 100% success rate. Their lives are so debilitating with this condition and they have had relief for up to six months or so. AM

Dr Pradnya Apte qualified as a dental surgeon in 1993, but since 2007 she has focused on her passion, facial aesthetics. She opened her first clinic in Exeter in 2015 and her second clinic in London in 2019. She is best known for her ability to achieve a natural-looking rejuvenation of the face based on her knowledge of the jawline and facial muscles.

Aesthetic Medicine • June 2020

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L AU N C H FO C U S

EXUVIANCE REBRAND

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HIT REFRESH

Clinical skincare brand Exuviance unveils its market repositioning, along with new packaging, products and treatments

ver the coming months, distributor Aesthetic Source will reveal a new look for clinical skincare brand Exuviance in the UK. In order to bring the brand in line with presence in the US, products will soon be split into Exuviance Professional (treatment and take home) – exclusive to clinics and salons, and a new retail range, simply called Exuviance. “This new split of the existing product line is the first step to help Exuviance create exclusive professional products in the future,” explains Aesthetic Source chief executive Lorna McDonnell Bowes. “The professional has always been at the heart of the Exuviance brand, and together we want to develop as [a clinic] partner and help grow [our partners’] businesses. The professional market continues to be an important part of expanding the Exuviance Professional brand worldwide.” Exuviance Professional products will feature refreshed packaging with a marble look, with the design theme carried through to POS and backbar materials. Clinic accounts will be provided with tools to successfully incorporate the brand refresh, including online learning, protocol

Aesthetic Medicine • June 2020

videos, newly-designed treatment menus and digital promotion assets. The first phase of the brand refresh includes the launch of three new products in the Exuviance Professional division: • Glycolic Polish (back bar and take home) is a dual physical and chemical exfoliant to resurface skin instantly and clear impurities from pores, with glycolic and lactobionic acids and alumina crystals. • Retinol Serum (take home) combines stablised retinol with hyaluronic acid and neoglucosamine to enhance skin’s hydrating matrix, smoothing and firming. • Retinol Eye Crème (take home) uses time-released retinol, a dualpeptide blend and neoglucosamine to target wrinkles, crepiness and dark circles around the eyes. Some products will be available in a direct-to-consumer range exclusively from online retailer Skincity UK, in new rose-gold packaging. Exuviance Professional take-home products on the other hand, will only be available for clients to purchase in clinic. “Exuviance Professional and Professional homecare will be exclusive to in-clinic use only, administered by trained aestheticians,” says McDonnell Bowes. AM

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PRODUCTS

PRODUCT NEWS

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ALUMIERMD

AlumierMD has launched the Home Renewal Kit, containing four homecare products to rejuvenate skin during lockdown, as well as a complimentary AlumierMD skincare bag and headband. Included is AHA Renewal Serum, with 8% lactic acid and sodium hyaluronate; Bright and Clear Solution, containing a combination of 3% lactic acid and 0.25% salicylic acid; Retinol Eye Gel, with a 0.1% concentration of encapsulated retinol; and Hydraboost Cleanser. For every kit sold, AlumierMD will donate £10 or €10 to the NHS or HSE in Ireland.

GOODPOINT CHEMICALS

Aesthetic product supplier 4T Medical is now distributing Goodpoint Chemicals exclusively in the UK. The brand’s range of antiseptic and disinfectant products include both alcohol and non-alcohol-based options, such as hand and skin antiseptic gels and sprays, wipes and rapid disinfectants for surfaces. Goodpoint has been awarded ISO certificates 9001 Quality Control System and ISO 14001 Environment Control System. 4T Medical’s portfolio also includes PPE such as type IIR masks, protective fullface shields, KN95 masks and gloves.

SKINCEUTICALS

There are three new Skinceuticals Skin Concern Kits for 2020, including the Age Renewal System, which includes powerful triple-antioxidant serum C E Ferulic, corrective serum H.A. Intensifier, and Retinol 0.3 Refining Night Cream. The Clarifying Skin System includes salicylic enriched Blemish + AGE Cleanser Gel, Blemish + AGE Defense, and soothing gel-serum Phyto Corrective. The Brightening Skin System includes the daytime serum Phloretin CF, corrective serum Discoloration Defense, and Retinol 0.3 Refining Night Cream.

SKINGEN

SkinGenuity Hair Restoration Home Kit is a new collection from SkinGen utilising growth factors and inter-cell messenger technology to specifically target the regrowth of hair follicles. Providing the necessary growth factors and cytokines that are used to increase hair regrowth, the kit contains four 5ml bottles which have 11 growth factors, a 0.2mm Micro-Fusion Applicator to deliver growth factors to the scalp, and a brush with hollow needles to deliver over 30 botanicals to support the hair condition.

ZO SKIN HEALTH

ZO Skin Health latest launch is Sunscreen and Powder SPF30, offering free-radical, blue-light and environmental protection through a formula billed as barely detectable on the skin. The products are infused with colour-enhancing pigments and are designed to maintain skin hydration and absorb surface oil. Available in three universal shade, Light has cool undertones, Medium gives a natural look or a sheer base, and Deep is for a more bronzed, defined look.

Aesthetic Medicine • June 2020

111SKIN

Cosmeceutical skincare brand 111SKIN has released 111AROMATICS under its 111SPA/CLINIC line, a collection of massage oils with aromatic blends to accompany its new body treatments of the same name. Bringing wellness experiences into the clinic setting, there is the Vitality Oil, blending bergamot, marjoram, coriander and wild mint; Serenity, with ylang ylang, clove bud, sandalwood and vanilla; Performance, a tangerine, nutmeg, ginger and eucalyptus blend; and Metropolitan, with elemi, frankincense, basil and amyris.

C O M M E R C I A L F E AT U R E

ELÉNZIA

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Midas touch

elénzia’s nano gold technology can improve both treatment results and clinic profits

t elénzia, a brand emcompassing health, beauty and wellness, our mission is to bring exclusive, innovative and efficacious science to our customers to improve their lifestyles and benefit their lives for the future. Our aesthetic range by Spanish brand Endor Technologies brings true innovation to the aesthetics industry to not only provide clinically-proven results, but to also boost clinics’ existing treatments, making them more effective and profitable. After over a decade of medical research, Endor Technologies brings its new, patented active ingredient to the aesthetics world. Gold Thioethylamino Hyaluronic Acid (Nano), better known as nano gold technology, is clinically proven to increase the body’s natural production of hyaluronic acid, collagen and elastin – the three key components to healthy skin.

HOW?

Activating specific cell receptors in the skin naturally produces hyaluronic acid, collagen and elastin, forming healthy, firm skin. Firm skin is lustrous, wrinkle-free and resists fat pods, avoiding the orange-peel effect known as cellulite. Our nano gold technology that is present in all Endor Technologies skincare products boosts the natural revitalisation of skin. The nano gold technology is made by uniting tiny fragments of hyaluronic acid with tiny particles of gold that are so small they are able to enter the dermis and activate the cell receptors.

WHY DOES THIS MAKE AESTHETIC TREATMENTS MORE EFFECTIVE?

Within the Endor Technologies collection we have our hero products specifically for aesthetic professionals – the Celltense and Hyalgen Serums, clinically proven to improve radio frequency treatments, making them 18 times more effective. The serums use the same innovative nano gold technology that is present in all of the Endor products, however when applied directly before radiofrequency (RF) treatments, the heat and the wavelength from the RF stimulates the particles of the nano gold technology,

Before

After 5 sessions of RF + Celltense Serum using Alma RF machine

allowing it to activate multiple cell receptors at one time, resulting in an increased biological effect and therefore better results from your RF treatments. This effect works for both face and body treatments, in particular for cellulite reduction when using the Celltense serum.

HOW WILL THIS IMPROVE MY CLINIC?

Not only will the Celltense and Hyalgen serums improve treatment results by up to 18 times, but adding boosters onto your treatment prices will improve the return on investment for your RF machines. The serums also work well across multi-treatment platforms, and the aftercare range continues the results of the treatments for clients at home.

CLINICAL TRIAL

Efficacy test of a serum with gold nanocomplex combined with radiofrequency to reduce the cellulite effects. Endor Technologies S.L., Instituto de Fotomedicina, Dr. Joaquin Querol, Gabriel Buendía Bordera M. Sc., Dr. Jorge Gaviria, Dr. Juan Bascones. AM

Aesthetic Medicine • June 2020

C AS E ST U DY

WEIGHT LOSS

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A weight off We take a look at the case study of a patient who underwent weight-loss treatment with the Elipse gastric balloon from Allurion 52

Aesthetic Medicine â&#x20AC;˘ June 2020

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WEIGHT LOSS

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ASSESSMENT

Patient Rich Jones, 35 years old and from Bristol, began weight-loss treatment with the Allurion Elipse Balloon in August 2019 at Nuffiled Health in Bristol. His treatment was overseen by Mr Dafydd Wilson-Evans, a private practice specialist dietitian and lead dietetic practitioner within the bariatric surgery team at North Bristol NHS Trust. The patient presented for treatment with the swallowable gastric balloon after seeing it advertised on TV and being attracted because of its simplicity. “I am an ex-competitive rugby player and have struggled with my weight for a number of years after leaving the Armed Forces,” said Jones. “I have been very active in the past, however, for the past few years I have lived a sedentary life due to work. I always kidded myself and tried a diet and exercise every now and again, but like a lot of people, I found excuses to fall off the wagon.” The patient was given full support and information about

the procedure and its placement, the treatment programme and what could be expected post-placement. He was also consulted on the lifestyle changes it would be necessary to make for the best chances of weight-loss success.

TREATMENT JOURNEY

The Elipse balloon is placed when the patient swallows a capsule containing a deflated balloon attached to a thin tube. Placement is confirmed with an x-ray before the balloon is filled with 550ml of water using a catheter. A second x-ray is performed to ensure the balloon is filled. Of the placement of the balloon, patient Jones said: “I struggled slightly with the placement of Elipse, and so the doctor used a stylet [to stiffen the catheter and aid navigation of the tube]. The first few days after the balloon were uncomfortable, with some stomach pains and nausea, but after the initial phase passed, I did not suffer any further side effects and nearly forgot I had the balloon in place. I was able to carry on

“The Elipse Balloon is favoured in our practice to other intragastric balloons because there is no need for anaesthesia or an endoscopy”

Rich Jones before

Rich Jones after

Aesthetic Medicine • June 2020

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WEIGHT LOSS

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PRACTITIONER Q&A

Mr Dafydd Wilson-Evans, lead dietetic practitioner in the bariatric surgery team at North Bristol NHS Trust and private practice specialist dietitian, weightloss and DWE nutrition. How many patients have you treated with the Elipse balloon? 22 What is the cost to the patient? From £4,000

with normal life.” Using the Elipse programme’s connected portable Smart Scale and smartphone app, Jones “weighed in” every few days. To help adapt his eating habits to maximise success, part of the treatment plan involved telephone calls between the patient and Mr Wilson-Evans every few weeks to discuss Jones’s nutritional progress. He was also instructed to keep a food diary, which was sent to Mr Wilson-Evans weekly. The patient was supported throughout the treatment programme by clinical psychologist Dr Vanessa SnowdonCarr, “who helped me identify some bad eating habits that probably led to weight gain in the first place,” said Jones. “I received great support from the clinic and they stayed in touch with me all throughout the placement journey. When I started to lose weight and muscle mass, I decided to increase my frequency at the gym.”

RESULTS

In the eight months from August 2019 when the balloon was placed to April 2020, when the patient’s case study was released, he had achieved a weight loss to date of 25kg (3.9 stone). The balloon was passed in December 2019. Commenting on his results, Jones said: “The balloon has focused my mind again and made me want to live a healthier life. It has got me back into the gym and making better choices about what I’m eating.” The patient’s weight loss plateaued around two to three months after the balloon was passed, fluctuating by 1-2kg up and down. However, he said, “It is fair to say I have maintained the weight loss. I’ve certainly not been gaining fat.”

Total weight loss: 28kg (4.4 stone) Heaviest weight: 156kg (24.6 stone) Weight when the balloon passed: 134kg (21.1 stone) Weight now (April 2020): 131kg (20.6 stone) Weight loss to date: 25kg (3.9 stone) Date balloon swallowed: August 2019 Date balloon passed: December 2019

Aesthetic Medicine • June 2020

How do you manage patients’ expectations? All potential Elipse Balloon patients will have a full assessment with an obesity consultant and specialist dietitian. Discussing the patient’s expectations is part of the assessment process and is managed on a case-by-case basis. Topics include; expected weight loss, health improvements, managing possible side-effects and life afterwards. Who is an ideal candidate and who wouldn’t be suitable? The Elipse program can help a number of different patient groups. There are many reasons why patients may want to lose weight; this might be for aesthetic reasons, to improve related health conditions or as a way to reduce their weight to be eligible for other medical interventions. A patient is eligible for an Elipse Balloon if they have a BMI >27kg/m2 and have tried different lifestyle interventions in the past. Are there any risks once the patient has ingested the balloon? As with any medical procedure, there are always risks to consider. However, the Elipse Balloon is very low risk in comparison to other weight-loss procedures and favoured in our practice to other intra-gastric balloons because there is no need for anaesthesia or an endoscopy. How likely is it that patients maintain a reduction in weight after passing the balloon? We discuss the possibility of weight regain after the balloon has passed at the assessment consultation. The factors that will influence weight regain are multifactorial but include biological and behavioural elements. We aim to help patients during this transition phase and focus on weight maintenance initially. Supporting patients with their diet and exercise regimes at this time can help achieve this. AM

TITE TRIM TONE

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W H I T E PA P E R

HAND REVOLUMISATION

Helping hand An edited extract from “Volume restoration of hands with polycaprolactone by cannula delivery; a prospective single centre consecutive case series evaluation” by Dr Nick Lowe and Mr Ali Ghanem

Aesthetic Medicine • June 2020

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W H I T E PA P E R

HAND REVOLUMISATION

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ABSTRACT

Background: Dorsal hand volume loss results in the perception of ageing appearance. Several volumising fillers have been used for this correction. Objective: To report restoration of dorsal hand volume using cannula delivery of polycaprolactone (PCL) microspheres and to assess efficacy, duration, and safety up to three years post-treatment. Method: 15 patients with volume loss of their hands were evaluated by clinical examination, photography and a handvolume grading scale. PCL was injected by 25G cannula after locating dorsal veins using a viewing laser to avoid intravascular injections. Patients’ satisfaction and grade of severity were re-evaluated at early (three to six months) and late (12 to 18 months) timepoints following the procedure. A second treatment was offered if desired by the patient. Results: Eight participants required one treatment session to achieve satisfaction. Five had two treatments. Patients requiring a second treatment were reassessed after 12 months. All patients had improvements on the severity score by the end of the evaluation period. Side effects were minimal and transient. No patients developed bruising.

Conclusion: PCL injections are a reliable method for hand volumisation. Results persisted for up to three years in some patients. Laser vein viewer and cannula delivery ensure uniform injections and avoid intravascular injuries.

INTRODUCTION

Loss of subcutaneous volume in the dorsal hands are a visible sign of ageing, resulting in interphalangeal hollows and “bony” appearance of the hands. Veins become more visible with this loss of dorsal hand volume.1-5 Hands also exhibit ageing as a result of photodamage with loss of skin elasticity, rhytids, skin laxity, and dyspigmentation. There has been increased use of injectable hyaluronic acid and hydroxyapatite fillers for hand re-volumisation.1–6 Polycaprolactone microsphere (PCL) injections were introduced in Europe for skin volumising approximately seven years ago.9 A pilot study of hand volumisation in five patients treated with PCL filler has been reported.10 The PCL microspheres are 25–50μm size, suspended in a vehicle of carboxymethylcellulose (CMC), consisting of gel carrier and PCL filler. PCL microspheres are smooth, spherical, and

Aesthetic Medicine • June 2020

W H I T E PA P E R

HAND REVOLUMISATION

bioresorbable.9 PCL hydrolyses to hydroxycaproic acid and water, which is reabsorbed and excreted via a variety of metabolic pathways. CMC gel is absorbed by macrophages over several weeks.15 A CMC-based filler has been shown to effectively correct nasolabial hollows for up to six months in a bilateral period comparison study against an HA filler).16 PCL microspheres are not phagocytised but are thought to stimulate neocollagenesis via fibroblast activation, perhaps by cytokine release during microsphere resorption in the skin. Studies in animal model showed initial deposition of type-3 collagen with later deposition of type-1 collagen.9 Clinical observations have confirmed that PCL-based microspheres are well tolerated for facial treatment. One previous pilot study of hand rejuvenation in five patients showed improvement of patient and physician reported Global Esthetic Improvement Scale (GAIS) for six months.10 Comparative studies have shown that PCL-based fillers, when compared with a hyaluronic acid filler, showed greater persistence.7

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DURATION OF IMPROVEMENT

The assessment of hand volume was based on the hand severity scale reported (6,17) and is summarised in Table 1. Four patients with severe volume loss (grade 3) achieved improvement to moderate (grade 2) severity. Ten patients with moderate severity (grade 2) improved to mild severity (grade 1). One patient with moderate volume loss did not show improvement on clinician’s grade scores four months after the first treatment but was slightly satisfied with improvement. She elected to receive a second treatment.

MATERIALS AND METHODS

15 female patients aged between 48 and 72 years of skin type 2 and 3 were evaluated for PCL filler injections to their hands because of dorsal hand volume loss (Ellansé typeM, Sinclair Pharmaceutical). They were provided with informed consent at least five days prior to treatment. They all had a minimum rating of three on a previously reported hand aging severity scale.17 Their hands were photographed before and following treatment with consistent photography. Clinical examination of dorsal hand skin quality recorded severity of rhytides, skin laxity, and elasticity.

METHODS OF INJECTIONS OF PCL

PCL (Ellansé M) was selected for treatment based on past personal experience with Ellanse products for facial volume loss (Lowe, NJ personal data and a pilot study).10 Hands were cleansed with chlorhexidine gluconate 4%. Local anesthetic (0.1 ml of 1% lidocaine) was drawn into a 1ml syringe and mixed with PCL filler by luerlock connection with 20 transfers between the syringes. Entry points for cannulas were selected to avoid dorsal hand veins and entry areas injected with 0.3ml of 1% lidocaine with adrenaline. 25G (50mm) cannula with introducer (SoftFil) was used for all patients. The cannula was inserted through an introducer to mid to upper subcutaneous depth and PCL injected using a retrograde technique while slowly withdrawing the cannula. A total of 1cc PCL was injected to the dorsal of each hand. The injected area was then massaged to smooth the area. Side effects and severity of pain and swelling were noted over the following five days. Presence of bruising and swelling was documented.

RESULTS

Results are summarised in Tables 1 and 2. Severity scores improved in all patients and were recorded as the degrees of improvements using the scales previously reported.6,17 This improvement was statistically significant (Fisher exact test 0.0002. p < .05). Seven of the patients elected to have a second treatment between the two evaluation timepoints following their first treatment.

Aesthetic Medicine • June 2020

Figure 2. Pre and six months post-polycaprolactone

W H I T E PA P E R

HAND REVOLUMISATION

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Nine patients were evaluated between one and three years after their first treatments. They had maintained one grade severity of improvement at that time. Seven patients received second treatments and had improvements of one to two grades on the severity score. These patients had maintained improvement between six and 24 months after their second treatment. Patient satisfaction scores are summarised in Table 2, at the same time points as their severity grades following the first treatment. There was slight improvement in two, good satisfaction in seven and six patients were extremely satisfied.

DISCUSSION

compared to using needles (personal observations of Lowe, NJ). The avoidance of vein puncture and bruising was also assisted by observation of the veins prior to injection using a laser vein imaging device as previously reported.18 In the dorsal hands, it is important to obtain a smooth result with an absence of nodules and irregular surface. One of the problems with using, for example, poly-L-Lactic acid (PLLA) in areas such as the hands, is the risk of the formation of nodules, which are often visible and difficult to reduce and remove.8-19 One disadvantage of PCL filler is that it cannot be dissolved, unlike a hyaluronic acid filler which can be reduced using hyaluronidase injections. For this reason, slow injection with cannula to avoid over-volumising and vascular injection is essential. PCL filler has been injected in patients at our clinic – with over 400 PCL treatments for the last four-plus years with injections to the face for volume replacement and atrophic scars without serious adverse effect or allergy (Lowe, NJ, unpublished data). Three of our patients developed transient small nodules, which resolved without intervention over three months. Local swelling has been transient and usually clears within two to five days. If persistent nodules or allergic reactions occur, intralesional injections with corticosteroids would be an option for treatment as with other non-HA fillers. 20 Physician and patient evaluation of their treatments showed significant improvement of the hand-ageing changes immediately post-injection, which persisted during the observation period. Side effects were short lived, but edema lasted longer than that reported and personally

“PCL filler was determined to be effective for improvement of dorsal hand volume loss with minimal side effects”

PCL is currently approved in numerous countries outside of the US. Further controlled studies are desirable to compare PCL with other volumising injectables including HA. All patients reported received 1ml of PCL per hand, however our current clinical practice is to inject larger volumes of PCL (1.5 and 2mls per hand) where there is severe volume loss. This is achieving greater improvement, possibly resulting from the reported PCL-induced neocollagenesis9, which may be the reason for the prolonged duration of improvement of hand volume. That said, these patients need to be followed for longer to determine whether there is any difference in duration of improvement. There may be several advantages of cannula delivery dorsal hand injection of injectables over needles. It is a minimally-traumatic procedure with reduced risk of vascular injections of filler. The use of 25G (1 1∕2 inch) cannula-assisted delivery reduced bruising, number of entry points and reduced risk of intravascular injections

Figure 5. Pre and post polycaprolactone injecton with self-limiting edema lasting for five days

Aesthetic Medicine • June 2020

W H I T E PA P E R

HAND REVOLUMISATION

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TABLE 1. Dorsal hand severity scales before and after first PCL treatment

observed for HA fillers. Hand edema can persist for up to five days (Figure 5), but no other side effects were noted.

CONCLUSION

PCL filler was determined to be effective for improvement of dorsal hand volume loss with minimal side effects. It would be of interest to perform comparison studies of dorsal hand treatment to explore the duration of PCL filler volume correction with hyaluronic acid or calcium hydroxyapatite fillers. Further comparative studies with larger numbers of patients and comparisons with other fillers used for dorsal hand volumisation are suggested. AM

Dorsal Hand Severity Scale Pre-treatment

Post 1st – treatment 3 to 6 months

0 – No Volume Loss 1 – Mild Volume Loss 2 – Moderate Volume Loss 3 – Severe Volume Loss 4 – Very Severe Volume Loss

0/15 10/15 5/15 0/15 0/15

TABLE 2. Patients’ satisfaction score after first and second treatment Patient Satisfaction Scale

1st Treatment 3 to 6 months (n = 15)

Extremely Satisfied Satisfied Slightly Satisfied Dissatisfied Extremely Dissatisfied

6/15 4/7 7/15 3/7 2/15 0/7 0/15 0/7 0/15 0/7

Laser Ther. 2008;10:237–41.

REFERENCES 1. Fabi G, Goldman MP. Hand rejuvenation a review and our experience. J Dermatol Surg. 2012;35:1978–1984. 2. Brandt FS, Cazzaniga S, Strangman N. Long term effectiveness and safety of small gel particle hyaluronic acid for hand rejuvenation. Dermatol. 2012;1524–1525. 3. Marmur ES, Al Quaran H, de SA, Earp A, Yoo JY. A five patient satisfaction pilot study of Calcium Hydroxyapatite injection for treatment for ageing hands. J Dermatol Surg. 2009;35(12):1978– 84. 4. Busso M, Moers-Caprim SR, Storck R, Ogilvie P, Ogilvie A, et al. Multicentre randomised trial assessing the effectiveness and safety of Calcium Hydroxyapatite for hand rejuvenation. J Dermatol Surg. 2010;36:790–97. 5. Sadick NS, Anderson D, Werschler WP. Addressing volume loss in hand rejuvenation: a report of clinical experience. J Cosmet

0/15 0/15 11/15 4/15 0/15

6. Bertucci V, Solish N, Wong M, Howell M. Evaluation of theMerzHand grading scale after Calcium Hydroxylapatite hand treatment. Dermatol Surg. 2015;41:S389–S396. doi:10.1097/ DSS.0000000000000546. 7. Galadari H, Abel DA, Neuvami KA, Al Faresi F, Galadari I, et al. A randomised, prospective, blinded, split-face, single-center study comparing polycaprolactone to hyaluronic acid for treatment of nasolabial folds. J Cosmet Dermatol. 2014;14:27–32. 8. Lowe P, Lowe NJ, Patnaik R.Three-dimensional digital surface imaging measurement of volumising effect of poly-L-lactic acid for nasolabial folds. J Cosmet Dermatol. 2007;13(2):87–94. 9. Nicolau PJ, Marijnissen-Hofste J. Neocollagenesis after injection of a Polycaprolactone based dermal filler in a rabbit ear. Euro J Aesthetic Med Dermatol. 2013;3:19–26. 10. Figuerido VM. A five patient pilot study of a polycaprolactone based dermal filler for hand

rejuvenation. J Cosmet Dermatol. 2013;12:73–77. doi:10.1111/ jocd.12020. 11. Woodruff MA, Hutmacher W. Return of a forgotten polymer - Polycaprolactone in the 21st century. Progress Polymer Signs. 2010;35:1217–56. doi:10.1016/j. progpolymsci.2010.04.002. 12. Middleton JC, Tiptan AJ. Synthetic biodegradable polymers as orthopedic devices. Biomat. 2000;21:2335–46. doi:10.1016/ S0142- 9612(00)00101-0. 13. Hutmacher D, Hurzeler MB, Schliephake H. A review of material properties of biodegradable and bioresorbable polymers and devices for GTR and GBR applications. Int J Oral Maxillofac Implants. 1996;11:667–78. 14. Sinha VR, Bansal K, Kaushik R, et al. Poly e caprolactone spheres, nanospheres: an overview. Int J Pharm. 2004;278:1–23. 15. Falcones S, Doerfler AM, Berg RA. Novel synthetic dermal fillers based on sodium carboxymethylcellulose: comparison with crosslinked

2nd Treatment 12 to 24 months (n = 7)

hyaluronic acid-based dermal fillers. J Dermatol Surg. 2007;33:136–43. 16. Lowe P, Falcone S, Berg R, et al. Synthetic fillers: carboxymethylcellulose, polyethylene oxide dermal fillers. In: Carruthers J, Carruthers SA, editors. Soft tissue augmentation. Philadelphia, USA: Elsevier; 2008. Chapter 12. p. 161–165. 17. Carruthers A, Carruthers J, Hardas B, et al. A validated hand grading scale. Dermatol Surg. 2008;34:179–83. 18. Lowe NJ, Halliday D. Vein imaging laser reduces bruising in bruise-prone botulinum toxin injected patients. J Cos Laser Ther. 2018;3:162–64. 19. Butterwick K, Lowe NJ. Injectable poly-L-lactic acid for cosmetic enhancement, learning from the European experience. J Am Acad Dermatol. 2009;61:281–93. 20. Lemperle G, Gauthier-Hazan N. Foreign body granulomas after all injectable dermal Fillers: part 2. Treatment

Dr Ali Ghanem is a consultant aesthetic plastic surgeon and clinical senior lecturer in plastic, reconstructive and aesthetic surgery at Barts and the London School of Medicine & Dentistry, and head of department of Aesthetic Medicine at the College of Medicine and Dentistry, Ulster University.

Aesthetic Medicine • June 2020

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Outside in Eleanor Vousden finds out what aesthetic practitioners can learn from holistic therapists about addressing the mind-skin link

n his book Skin Deep, psychologist Dr Ted Grossbart writes: “Shut anger or sadness or frustration out the door and it comes through in the window, or often enough, through the body. Your heart ‘attacks’. Your asthma ‘gasps’. Your eczema ‘weeps’.” If we’re unable to process stress or emotion, it can show up in the form of acne, eczema, psoriasis, rosacea or even disorders such as dermatillomania, which manifests as repetitive and compulsive skin picking. This can affect our emotions and self-esteem. In fact, a study published in the British Journal of Dermatology found that those who suffered with acne were 63% more likely to develop depression in the first year of being diagnosed.1 “The link between mind and skin has been known for centuries, dating as far back as Hippocrates,” says

Aesthetic Medicine • June 2020

Dr Alia Ahmed, a consultant dermatologist who runs a psychodermatology service at Eudelo Skin Clinic in London, and practises in the NHS. “Psychodermatology considers both the mind and the skin together when seeing a person with a skin problem.” These patients are often facing a breadth of skin problems or body dysmorphia disorder, coupled with emotional distress. Neuroscientist Dr Claudia Aguirre, who specialises in the mind-skin link, explains that our negative thoughts can affect the skin far more than we may realise. A term in psychology called rumination, which is when someone has a recurring stream of negative thoughts, can wreak havoc on the skin. “This can hinder our healing, since it can lead to depressive thoughts or feelings of defeat about a recurring condition,” she says. “So, we can get stuck in

F E AT U R E

PSYCHODERMATOLOGY

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“It’s not just about applying things topically, it’s about looking at lifestyle and where the stress is coming from to treat the stress as well as the skin”

a negative thought pattern, which is a form of stress and anxiety, and can maintain the body in an inflammatory state – this can even trigger or worsen inflammatory skin conditions like eczema and acne.” As a result, this stress can make the issue worse, and so the vicious cycle begins. “Feelings of emotional distress lead to the release of stress hormone cortisol, which is known to affect the immune system (making the skin less able to defend itself), drive allergic responses, delay healing and disrupt the skin’s natural barrier,” she says. “I believe addressing the interaction between the brain, skin and mind is key to achieving healthy skin.”

Aesthetic Medicine • June 2020

F E AT U R E

PSYCHODERMATOLOGY

ACHIEVING CONNECTION

With the rising acknowledgement of psychodermatology and the popularity of mindfulness, the emphasis on the mind-skin link is now trickling into skin treatments performed by holistic facialists. One practitioner paving the way is Beata Aleksandrowicz, founder of the Aleksandrowicz System. Her latest treatment, Face Cure, addresses the client’s connection to their appearance and the emotions that can be held in the face. “If there is a preponderance of the negative emotions, the muscles will remain contracted, which will restrict the flow of oxygen and nutrients to each cell and will be manifested by a lack of radiance and tone,” says Aleksandrowicz. Combined with mindfulness and massage, her treatment focuses on the client reconnecting with their facial appearance. “I see so many clients who are unhappy with their face. Many have had aesthetic treatments and in some cases they become disconnected with their face,” she says. “It is as much about inner work on the conscious and subconscious as outer work on the facial muscles and skin.” The skin can be a barometer for what’s going on underneath and tapping in to this mind-skin link is becoming increasingly important to deliver a tailored treatment. “More clients are coming in with stressed skin, whether that is redness or rosacea, eczema or psoriasis, or general extremes on the skin,” says Katie Light, a holistic wellness coach and facialist, who treats clients at her treatment rooms in Brighton and London.

Aesthetic Medicine • June 2020

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WELLBEING PERSPECTIVE

Light often sees these skin issues going hand-in-hand with mental health problems. “If people are having anxiety, panic attacks or depression, which I see a lot more of now, it affects the skin, and everyone is supressing it because they think it’s the norm; no one is dealing with it,” she explains. “It’s not just about applying things topically, it’s about looking at everybody’s lifestyle and where the stress is coming from to treat the stress as well as the skin.” Light says the initial consultation is vital to fully understand her clients’ needs. “It’s an essential part of what I do to treat the physical, mental and emotional; whether it’s anxiety or eczema, they all need to be treated from a whole wellbeing perspective,” she says. In her treatments, Light uses a range of techniques. “I do affirmations and visualisations that are personal to that client, so I would ask: ‘How do you want to look? What is your ideal?’ and we make that in to a storyboard or a visual board of something to aim for,” she says. Neurolinguistic programming is another technique she uses, and between sessions she will also set “homework” for clients, so they have a toolbox of techniques to hand to keep both the skin and mind healthy. AM REFERENCES Vallerand, I.A., Lewinson, R.T., Parsons, L.M., Lowerison , M.W., Frolkis, A.D., Kaplan, G.G., Barnabe, C., Bulloch A.G.M., Patten, S.B. (2018) “Risk of depression among patients with acne in the U.K.: a population-based cohort study”, British Journal of Dermatology, 2018 (Feb 07)

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