Aesthetic Medicine July 2020

INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

ON THE SPOT TREATING ACNE WITH LASER AND LIGHT

NEW TO THE GAME BUILDING A PATIENT BASE

July 2020 | aestheticmed.co.uk

STRONG CONNECTION THE NEW WAVE OF PRACTITIONER-FINDER APPS

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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

ON THE SPOT TREATING ACNE WITH LASER AND LIGHT

Contents JULY

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NEW TO THE GAME BUILDING A PATIENT BASE

July 2020

July 2020 | aestheticmed.co.uk

STRONG CONNECTION THE NEW WAVE OF PRACTITIONER-FINDER APPS

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

Vicky Eldridge, Consultant Editor 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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Aesthetic Medicine • July 2020

47 5 EDITORIAL BOARD Meet our editorial advisory board 8 NEWS The latest news from the industry

19 FULL-FACE REJUVENATION Dr Tim Eldridge presents the journey of a new patient to fullface rejuvenation using filler and threads 24 PATIENT-CONNECT APPS Looking at the benefits of signing up to three new practitioner-finder databases

15 SEO PR expert Julia Kendrick explains the crucial link between PR and SEO

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CONTENTS

IN THIS ISSUE...

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28 VIDEO CONTENT CREATION The best tools and tech to create flawless photo and video content 32 RADIOFREQUENCY AND NEEDLING Dr Patrick Treacy presents the findings of his study using a microneedle fractional RF device to for skin tightening and acne scarring.

40 CASE STUDY How a combination of laser and mesotherapy solved one patient’s skin problems 42 PRODUCT NEWS The latest product launches 44 TREATMENT FOCUS Exploring a new treatment to elongate and lift the eyes

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47 AFRO HAIR LOSS The second part of Dr Ingrid Wilson’s series on recognising, understanding and treating hair loss in Afro-textured hair 54 TIPS FOR NEW INJECTORS Dr Sadaf Hussain and Dr Simon Zokaie share their advice on building a patient base and getting started 57 INSTAGRAM FOLLOWERS Jemma Edwards’s 20 quick tips on gaining more followers for your practice 63 TREATING ACNE The options for treating acne using laser and light by Dr Firas Al-Niaimi

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Welcome to the July issue of Aesthetic Medicine 15

I, like all of us, thought we’d be starting to open up again as an industry by now.

While things are changing on a weekly, if not daily basis at the moment, at the time of writing aesthetic clinics were still not allowed to officially reopen, as per PHE legislation released on 3 July, in which the Government modified its definition of “beauty salon” to include “any premises providing beauty services including cosmetic, aesthetic and wellness treatments”.

While some clinics and practitioners have made the decision to open because they are providing medical treatments, others have stayed closed due to the lack of clarity and grey areas surrounding whether or not they would be insured. Wherever you stand with your business, I hope that the content in this issue educates and inspires, and that you’re back doing what you love and making money very soon.

Georgia – Editor georgia@aestheticmed.co.uk

Aesthetic Medicine • July 2020

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facelife™ masks

EXTRA PROTECTION FOR THOSE AROUND YOU

The FaceLife mask is designed to help protect those around you. By efficiently covering the nose and mouth it helps to minimise the spread of germs from you to others. The mask’s Copper Protection is also a powerful antimicrobial agent, which is an additional advantage over regular cotton face masks.

FOR MORE INFORMATION: email: infouk@hydrafacial.com visit hydrafacial.co.uk PLEASE NOTE: The FaceLife Masks are NOT designated by UK/EU standards as medical masks.

Therefore, they are considered in the category of personal face coverings, i.e. for lessening the spread of coughs and sneezes and the benefit of people around you – rather than protecting the wearer.

The UK government has not yet issued guidance on the level of PPE required for the delivery of HydraFacial treatments; therefore, we cannot yet assume the masks will be suitable for use in that context. However, they remain excellent for personal use.

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.

Aesthetic Medicine • July 2020

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BUILD MUSCLE SCULPT YOUR BODY TESLAFormer is a medical device using the new FMS (Functional Magnetic Stimulation) technology for muscle strengthening, toning and sculpting the body on areas of glutes, abs, hamstring and thighs, calves, arms, back and pelvic floor.

MORE THAN 50.000 MUSCLE CONTRACTIONS IN 30 MINUTES CORETHERAPY T H E O N LY S Y S T E M T H A T U S E S 4 A P P L I C A T O R S W O R K I N G S I M U LT A N E O U S LY T A R G E T I N G P E LV I C F L O O R , G L U T E S , B A C K & A B S * CO R E T H E R A PY I S CA R R I E D O UT WI T H T E S L AC H A I R + 2 B O DY A PPL I CATO R S

FULLY CLOTHED

24 PHASES NON-INVASIVE IN A CYCLE

109 Panorama, Park Street, Ashford, Kent beautyform.co.uk info@beautyform.co.uk * not a patient

FROM INCONTINENCE TO CONFIDENCE The revolutionised technology of Tesla Chair helps those who are suffering from incontinence with the Functional Magnetic Stimulation technology. This non-invasive and effective treatment helps with sexual health and wellness of women and men by strengthening the pelvic floor mus muscles.

STRESS INCONTINENCE URGE INCONTINENCE MIX INCONTINENCE INCONTINENCE AFTER RADICAL PROSTATECTOMY FAECAL INCONTINENCE REGENERATION AFTER CHILDBIRTH PROLAPSE CHRONIC PROSTATE INFLAMMATION ERECTILE DYSFUNCTION

NO PAIN

NO RECOVERY TIME

* not a patient

N E W S A N D A N A LY S I S

INDUSTRY NEWS

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Better black representation is needed in aesthetics, says new board

Dr Ifeoma Ejikeme, Dr Tijion Esho, Dr Amiee Vyas and Dija Ayodele have formed the Black Aesthetics Advisory Board (BAAB), a panel that will investigate the experiences of black practitioners within aesthetics, as well as those of black and minority ethnic patients and consumers.

BAAB was encouraged by the

resurgence of the Black Lives Matter movement to send out an initial survey which found that black practitioners face higher levels of discrimination and less progression opportunities within aesthetics.

From a patient point of view, the survey also reported that black consumers experience difficulties

in accessing practitioners confident in treating their concern safely and effectively.

BAAB aims to produce a report from the findings to provide guidance to brands and professionals in the aesthetics industry. The board’s work going forward will focus on increasing representation for black practitioners and driving a positive change in opportunities and discrimination across the board in the sector.

BAAB said in a statement: “Given the worldwide re-emergence of the Black Lives Matter campaign and the poor experience voiced by black and minority ethnic professionals as well as consumers, we were shocked at the silence from many quarters of the aesthetic industry.

“Coupled with our knowledge of BME patient experience, we want to investigate and inform change; from ensuring all practitioners understand the needs of black skin to increased representation of black professionals at all industry levels. Through this, we are also able to positively impact the experience of black patients and professionals within aesthetics.”

Small business owners predict economic recovery timescale Four in 10 small business owners believe that it will take more than five years for the UK’s economy to recover fully from the impact of coronavirus and the enforced lockdown, according to research by the #ForgottenLtd Campaign.

Only 15% of the 1,000 small business owners polled believe the UK’s economy will be back on its feet by the end of 2021, whereas more than a quarter (28%) think it will instead take up to three years to see a complete comeback, the report found.

However, 18% believe it will take at least five years for a full recovery, while the majority (39%) were of the belief that it will only be after 2025 that we will see the economy back to normality.

“The results of this snap poll sends out an unequivocal message to the Government, namely that the small business community believes it will be a very long time before the UK economy bounces back,” Gina Broadhurst, co-founder of the #ForgottenLtd Campaign commented.

“It’s these very same businesses that so many people depend on for their jobs, big companies for

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Aesthetic Medicine • July 2020

their supplies, and customers for their products and services. We are all linked, so if small businesses are in trouble, then we are all in trouble.”

This study follows recent news that coronavirus has had a “significant impact” on 92% of UK spa businesses, with 87% having to furlough the majority of their staff; and new research revealing that 29% of Brits won’t queue to buy beauty products as shops reopen.

N E W S A N D A N A LY S I S

INDUSTRY NEWS

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Transform CEO calls out “irresponsible, unethical and reckless” operators flouting lockdown rules Transform Hospital Group chief executive Tony Veverka wrote to MPs, authorities and regulatory bodies asking them to crack down on aesthetic companies who are breaking lockdown rules, particularly those continuing to claim financial support from the state in the process.

While most clinics remain closed at the time AM went to print, Veverka says that he is concerned that “not all providers have taken the necessary steps to protect public health”, branding them as “irresponsible”, “unethical” and “reckless”.

In a statement he said, “This behaviour not only puts patients’ health at risk, it also places potential unnecessary strain on the NHS at a time when we need to protect capacity to continue the fight against covid-19.

“Of course, we appreciate that the lockdown has been a challenging time for businesses and consumers alike, and we are also eager to once again open our doors. But flouting the rules by opening prematurely to the public simply cannot be condoned – the stakes are too high, and lives are at risk. “We must have consequences for these dangerous practices and offenders who break the regulations must be penalised.”

Treatment-seeking Brits concerned over safety Covid-19 is not a barrier to people wanting cosmetic procedures post-lockdown but safety is their number one priority, according to a survey by Save Face.

Out of the 2,352 members of the public who responded, 98% said that they wanted a non-surgical cosmetic treatment once lockdown restrictions were lifted, however, almost all deemed safety measures, including hand washing (99%) and PPE (100%), to be “essential” in

order for them to proceed.

As well as this, 94% said they would prefer remote online consultations to continue to reduce contact time and 95% said it was important they were treated by a healthcare practitioner who had a thorough understanding on infection control. In addition, 86% agreed that thorough health screening of patients was crucial.

Dermatologist warns of dangers of at-home pigmentation-removal pens Dermatologists are calling for a ban on sales of at-home freckle and pigmentation-removal devices. Dr Bav Shergill, president of the British Cosmetic Dermatology Group – closely aligned to the British Association of Dermatologists – has warned against the use of freckle-removal pens which can be bought for as little as £10.99 online.

The pen-like devices use thermal energy or electric currents and are advertised for removing pigmentation marks such as freckles, moles and skin tags, but cannot detect if the marks could be potentially cancerous.

The group believes the huge surge in video calls during lockdown has made people more aware of imperfections on the skin, leading to an increase in sales of the devices, which it says could inadvertently lead to skin cancer.

Speaking to The Sunday Telegraph, Dr Shergill said the pens could make cancerous melanomas harder to detect, and also cause burns, scarring and further pigmentation.

He said consumers using these devices could trigger a scar or reaction on top of the skin which could cover the pigment and a make a melanoma difficult to recognise. The melanoma could also spread as the cancerous cells remain under the skin.

“I think we have never had so much time to look at ourselves as we have at the moment,’ said Dr Shergill. “And people who ordinarily wouldn’t have more than a slight glance at themselves in the mirror before they left the house are now faced with having to look at themselves in a little box on the side of the screen for hours on end.”

Aesthetic Medicine • July 2020

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N E W S A N D A N A LY S I S

INDUSTRY NEWS

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NEWS IN BRIEF

JCCP accepts IQ Verify Level 4 in Skin Rejuvenation

GALDERMA INITIATIVE HELPS CLINICS “BOUNCE BACK”

IQ Verify’s Level 4 in Skin Rejuvenation Techniques has now been accepted as an access route to join Part B of the JCCP Practitioner Register.

This means that the UKAS-accredited certification has been developed in alignment with the latest CPSA and JCCP Cosmetic Standards. It also means that candidates who have a valid IQ Verify Level 4 Skin Rejuvenation Certificate would be able to submit it as “certifiable evidence” to apply to join and feature on the register.

The certification is suitable for anyone with a Level 3 Qualification in cosmetic practice/ beauty therapy (or above) and meets the requirements of the internationally recognised standard for personnel competency (ISO/IEC 17024:2012).

Laurence Clarke, director of IQ Verify, commented, “This is an important milestone in ensuring the visibility of those practitioners who work hard conform to the latest cosmetic requirements. IQ Verify Skin Rejuvenation now represents the UK’s first UKAS accredited personnel certification scheme in aesthetics and the first certification framework that allows therapists to gain access to the JCCP register.”

Professor David Sines, chair of the JCCP added, “The JCCP has been working with UKAS for several years now to identify and advise on the core technical standards that should be applied to UKAS accredited aesthetic certification schemes.

The JCCP Board of Trustees has now approved evidence of UKAS Accredited Certification for Level 4 in Skin Rejuvenation as an access route to Part B of the JCCP Practitioner Register. This is a welcome development.”

Galderma has launnched a new training and support programme to help customers get back on their feet once restrictions lift and clinics can open again. The initiative provides insights, tools and guidance to clinics to help them navigate their way through re-opening. “It could be a long time between patients getting a spot on the waiting list and their appointment in clinic, so we’ll be providing Restylane clinics with the tools they need to keep relationships strong,” said Katie Bennett, Restylane brand manager for Galderma UK.

INMODE ANNOUNCES NEW BRAND AMBASSADOR AND KOL

InMode has revealed it will be working with two leading names in the industry. Dr Munir Somji has been announced as a key opinion leader (KOL) for the brand while beauty and skincare expert Nilam Holmes will be a brand ambassador.

AESTHETIC SOURCE LAUNCHES ONLINE CPDACCREDITED TRAINING

Distibutor Aesthetic Source has added a new section to its website that includes CPD-accredited webinars. The courses will cover a wide-range of topics focusing on skin as well as practical and postlockdown training for those who want to refresh their knowledge before going back to clinic.

RENÉE LAPINO TO BE SECRET RF KOL

London-based medical facialist Renée Lapino has been announced as Cutera’s latest KOL. She will front the new Secret RF skin rejuvenation treatment in the UK. She said: “Secret RF is a new treatment concept that complements my integrated approach to skin health, and perfectly fulfills a niché in my treatment offerings. This microneedling-RF combo yields dramatic improvements in skin texture and appearance but with very little to no downtime.

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Aesthetic Medicine • July 2020

Most searched-for cosmetic surgery in Europe revealed Queries relating to “rhinoplasty” were the most popular cosmetic surgery search term in Europe in the last 12 months.

A report by money.co.uk into the most “Googled” cosmetic surgeries revealed 34,410 monthly unique searches for “rhinoplasty” over the past year, while “boob job” was the second most searched-for procedure, with 28,690 searches per month.

“Nose job” made the top 10 separately from “rhinoplasty”, with over 19,000 searches individually.

“Penis enlargement” had over 24,450 unique searches across Europe, most of which came from the UK, Germany, Italy and the Netherlands. Next was “Brazilian butt lift”, with over 23,000 searches, followed by “brow lift” (over 20,000), nose job (over 19,000), “labiaplasty” (over 15,000), “blepharoplasty” (over 12,000), “breast augmentation” (over 10,000); and “breast lift” (over 8,000).

The UK had the highest search volume for both surgical and non-surgical cosmetic procedures of all countries that were looked into. It was also found to be the second most expensive country to have a surgical treatment after Switzerland, where it costs on average £4,994 for a rhinoplasty, and £3,576 in the UK.

N E W S A N D A N A LY S I S

INDUSTRY NEWS

NEWS IN BRIEF WIGMORE ANNOUNCES CHANGES TO ZO TRAINING

Wigmore Medical has announced some key changes in the way it will deliver its training for ZO Skin Health.

It will be moving all theory-based learning for ZO online permanently, including the core training webinar and further tutorials on specific products, protocols and indications. Delegates will be invited to attend as many of these modules as possible, which will be launched over the coming months.

To support the theory training, ZO Regional Sales Managers will contact remotely or visit clinics later in the year to provide further training on how to deliver professional treatments.

aestheticmed.co.uk

Most American women unaware of implant-related lymphoma Only just over half of American women with breast implants have heard of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), an immune system cancer occurring in a small percentage of women with breast implants.

According to a survey by researchers in the Division of Plastic and Reconstructive Surgery at Washington University in St. Louis, Missouri, US, only about one in seven American women overall have heard of the cancer, out of 500 who responded to their crowdsourced survey.

“Our findings can help surgeons navigate the risks of BIA-ALCL with current and prospective patients and can guide future public education efforts on BIAALCL,” said Dr Justin Sacks, chief of the Division. The full study appears in the July issue of Plastic and Reconstructive Surgery.

GET HARLEY BROADENS SCOPE OF ONLINE CONSULTATIONS

Get Harley has widened the scope of its services to allow practitioners to use the platform for a broader spectrum of online consultations. The site was originally set up to enable practitioners to sell skincare and supplements and manage repeat sales. It is now also aiming to help minimise in-clinic appointments by facilitating initial consultations for treatments online.

This will ease the burden of face-toface appointments as clinics prepare to re-open. The platform is also able to service patients paying a deposit for future treatments via the platform, at no cost.

ABIGAIL OLECK CREATES “FACIAL IN A BOX”

Celebrity facialist Abigail Oleck has created a “Facial in a Box” for clients to use at home while clinics and salons remain closed due to covid-19.

Developed during lockdown, the luxury facial provides all the products needed for a one-time-use treatment as well as bespoke products tailored to the client’s individual skin concerns.

Oleck’s clients include Lady GaGa, Holly Willoughby, Duncan James, Peter Andre and Jane Torvill.

NUTRICOSMETICS MARKET SET FOR STRONG GROWTH

The demand for nutricosmetics in the ageing population is poised to surge, according to a new report by Future Market Insights. While the analyst said that growth may be “stunted” in the post-covid era, it predicted that demand would increase due to rising awareness of the benefits of herbal supplementation.

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Aesthetic Medicine • July 2020

Dermal fillers complications course launches from Harley Academy Harley Academy has launched a new eLearning course for Preventing and Managing Dermal Filler Complications.

The six-hour online course launched on 25 June and covers in-depth anatomy and pathophysiological concepts; the latest management guidance; how to recognise side effects vs complications; the full spectrum of complications, from early infection to neural problems; and how to manage complications in both critical and non-critical scenarios.

It uses real-life case studies presented by Dr Tristan Mehta, chief executive and founder of Harley Academy, and Dr Emily MacGregor, Harley Academy’s clinical director. It also includes interactive sections to help solidify learning, downloadable protocols for in-clinic use. Delegates will be able to download a certificate of completion at the end of the course and access is lifelong, so you can return to the course time and again as needed.

Clinical education lead Dr Kalpna Pindolia added, “Causing complications in asesthetics is a challenging headspace as the treatments we deliver are a want rather than a need. We should never be afraid to learn from complications that happen to us and our colleagues, which is why we use real life case studies that we’ve encountered at Harley Academy. Doing this, you learn as the patient is managed and progresses, allowing you to embed a methodical approach to enable you to manage complications more confidently.”

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

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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

BUSINESS

SEO

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Strategy for success PR expert Julia Kendrick outlines why a PR strategy is so important when it comes to making SEO marketing support your aesthetic business WHAT IS SEO?

The purpose of SEO (search engine optimisation) is to grow the quality and quantity of traffic hitting your website by increasing the site’s visibility on search engine listings.

Simply put, if your website content is SEO optimised, it has keywords included throughout the text which will match up to frequent search engine criteria, and thus ensure that your site is included in the organic (unpaid) list of results, increasing the likelihood of people being directed to your business’s website.

Another key element which helps boost your site up the search rankings are backlinks. Backlinks are simply a link from one website to another; like if you are featured in an online article and a direct link to your website is included.

Search engines use backlinks as a ranking signal because when one website links to another, it means that the content is deemed noteworthy. High-quality backlinks linking your site to websites with a good domain authority (i.e. sites deemed to provide credible information) can help to increase your ranking position and visibility in search engine results.

Aesthetic Medicine • July 2020

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BUSINESS

SEO

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HOW PR AND MARKETING CAN HELP

MAXIMISING YOUR ONLINE MARKETING

“Many clinics are unaware of just how valuable their PR There are three key prongs to your SEO marketing is in terms of driving traffic to their website,” says Tracey strategy – the first is ensuring that your whole website is Prior, operations manager at digital agency Blow Media. properly SEO optimised and geo-tagged (which assigned a “For clinics, the backlinks generated by online press geographical location to content), which ensures that the articles not only help drive traffic to the site, but they also website is “readable” and more likely to appear in relevant deliver valuable intel to Google on the site’s authority Google search results. This will usually involve working and credibility - thus boosting you higher up the search with your website developer or a specialist digital agency rankings.” to go through the back end of the website and optimise The goal for any SEO content and marketing strategy is the content for common search terms. Use the insights to increase the site’s visibility and credibility in the search from your Google analytics to find what terms people are engine result rankings. Key factors which influence how high searching for and ensure these are seeded throughout up your site appears in these rankings include: your website.

• How much of website content is SEO The second strategy is about creating optimised and therefore visible to regular, new content on your website search engines which links into search keyword “The more your clinic • How frequently the site is updated trends. While some keywords with fresh, new content (i.e. content are perennial, people will also is featured and backlinked which doesn’t appear anywhere be searching for seasonallyinto other high-authority online else) relevant terms at certain times media outlets and websites, the • How many backlinks does your – for example “bridal”, “winter”, site have – and do these link to “summer”, “Christmas”, etc. more ‘authority’ your website websites with a high domain The easiest way to frequently generates, and search engines will authority? update your site with engaging, push it up the results listings One of the misconceptions about relevant and optimised content is PR is that it can be difficult to measure via blogs. Clinics should be aiming accordingly” and directly correlate to return on for at least two to three blogs per investment. PR is reliant on third parties month which should be optimised with to give endorsement and credibility – be relevant keywords. Blogs are a valuable that customers, media or other sources of way to provide education on available services, publicity. Measuring the outputs against business your expertise, and driving calls to action for treatment success is critical, as with any marketing investment. You’ll bookings or product purchases – all of which can also be want to see that PR is driving new patient enquiries, repeat leveraged in your patient marketing and social media bookings and press coverage across print and digital sources. activities.

Backlinks are a critical way to measure the ROI of your PR Finally, when it comes to raising your brand profile expenditure against web traffic, enquiries, and conversions. and driving traffic from other websites, this is where PR-generated backlinks come into their own. PR articles WHERE IS YOUR WEB TRAFFIC FROM? increase your visibility among wider audiences and It’s well worthwhile reviewing the top sources of your through backlinks, can help direct traffic and users to website traffic so you can understand more about your site who may never have previously found it in the how people find you and where they’re being directed organic search results. The more your clinic is featured from. Use Google Analytics to look at your site data to and backlinked into other high-authority online media understand and identify: outlets and websites, the more “authority” your website • How many users find you directly from a Google generates, and search engines will push it up the results search? Which search terms are they using? listings accordingly as a trusted source of information.

• A re users directed to your site from another web page?

SEO marketing – linked in with digital, content and PR Which ones? strategies – provides a vital support for your aesthetic • Which pages on your site are users spending the most business, with tangible outputs for your revenue, new time on? patient referrals and overall profile-building. By working • Can you map any PR activity or article publications with experts to support your business in these fields, you against resulting spikes in web traffic, enquiries or can build visibility quickly and authentically for future treatment bookings? success. AM

Julia Kendrick is an award-winning business strategy and communications expert with over 16 years’ experience. She is a regular industry author, speaker and trainer who specialises in the cosmetic surgery and aesthetic medicine sectors. She is founder of PR agency Kendrick PR and launched the E.L.I.T.E. Reputation Programme; the industry’s first online PR and marketing training programme developed specifically for medical aesthetic practitioners.

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Aesthetic Medicine • July 2020

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

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CLINICAL

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FULL-FACE REJUVENATION

Restoration project Dr Timothy Eldridge shares the journey of a 57-year-old woman undergoing facial aesthetics for the first time Aesthetic Medicine • July 2020

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CLINICAL

FULL-FACE REJUVENATION

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F

acial ageing is a three dimensional process affecting bones, muscles, adipose tissue and skin.

It is caused or sped up by a number of factors such as sun, poor diet, smoking, alcohol and gravity.

Evidence of this can be seen where convexities become concavities, the appearance of wrinkles, sagging skin, skin pigment changes, and altered facial proportions.

In this article I will discuss the treatment plan for a 57-year-old patient who I will refer to as “Patient P” who underwent facial aesthetics for the first time. She had been attending myFACE clinic for more than 10 years as a dental patient but had never considered having any aesthetic treatments before. Because she had an active outdoor lifestyle and admitted to rarely applying SPF her skin had, in her words, “taken a real battering.”

She had been conscious of premature ageing since her early 40s, when she started to show a loss in skin quality and a loss of volume in areas of her face that had previously been youthfully plump. At the time she put this down to the stress of her divorce from her first husband, but hadn’t considered the impact that sun damage had had on her skin and the ageing process. She said, “In years gone by, I didn’t understand, as I now do, the damage that the sun can have on the skin.”

ASSESSMENT When assessing a patient it is better to start from the upper third and work your way down to the lower third.

On examination, Patient P had obvious temple hollowing, flattening of the cheeks, malar fat pad descent and deepening of the nasolabial folds. In the lower third, the jowls and marionette lines are more obvious, with deepened peri-oral rhytides. The quality of the skin had reduced due to intrinsic and extrinsic ageing factors.

When assessing a patient it is important incorporate the patient’s expectations and therapeutic objectives into your treatment options, as patients have their own subjective perception of how they look. Remember it is only the symptoms that the patient can identify with and not the causes, so it is up to the clinician to explain these and demonstrate to the patient. This will ensure that when you present your treatment plan, the patient will understand why you are treating the areas that you have chosen.

With Patient P, it was important to restore the loss of volume to emphasise the features of her face and try to obtain that fuller look in her earlier photograph, by rebalancing and redistributing the volumes. Treatment outcomes were to not only restore lost volume but to also reshape the face. The skin envelope is unlikely to "lift" significantly with volumising alone and will require treatment with multiple modalities.

TREATMENT Patient P had not experienced any facial aesthetic treatments before, so she attended a myFACE training session as a model. Over several courses, Patient P had her cheeks volumised with Perfectha Subskin, jawline pre and post sulcus augmented with Perfectha Subskin and nasiolabial folds with Perfectha Deep. Patient P was pleased with the results at the time, but her main concern was still the sagging tissue. To try to correct this with fillers alone would just lead to over-inflating the face, making it appear too wide and non-aesthetic.

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Figure 1: Patient P just before treatment (above) and 10 years earlier (top). The younger face is seen encircled internally by an upside-down isosceles triangle, and the aged face encircled internally by an isosceles trapezium, the so-called “triangle of youth”.

CLINICAL

FULL-FACE REJUVENATION

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Fillers have a fundamental role in treating the lower third of the face with satisfactory results. Injecting in the pre and post jowl depression points really only achieved an optical illusion improvement. Fillers are ideal for compensating bony loss or temple hollows, but not for lifting sagging skin; they have their limitations. To complete a satisfactory 3D rejuvenation treatment in the mid and lower third on Patient P, it is necessary to use threads.

Silhouette Soft threads were the threads of choice as they perform a double action in that they reposition sagging tissue as well as stimulating the production of collagen over the following months.

Silhouette Soft threads have been a technological innovation in facial aesthetics by offering patients a treatment of repositioning and regenerating in such a simple way, with repositioning results lasting up to 18 months and regenerating results lasting up to 24 months. Silhouette Soft threads are bidirectional sutures composed of knots and cones in a resorbable material (polylactic acid and polylactic-co-glycolic acid). The threads come in different lengths and different numbers of cones (8, 12 and 16). The threads used in Patient P were eight cone threads.

After discussion with Patient P about the benefits of using a collagen-stimulating filler instead of an HA filler to address the quality of her skin, a treatment plan was drawn up. The collagen-stimulating filler of choice was Ellansé. The treatment protocol was to restore the lost volume before placing the threads to allow a better repositioning of the tissues and provide some underlying support to the tissues: • Volumise with Ellanse M • Biostimulate with Ellanse M • Reposition with Silhouette Soft eight-cone threads

Summary of the areas treated: • Temples L/R – Ellanse M 27Gneedle • Cheeks L/R – Ellanse M 27G needle and 22 gauge cannula • Peri oral rhytides/ around the mouth L/R – Ellanse M 25G cannula • Face – Five threads. Eight cones L/R • Neck – One thread. Eight cones L/R Before any treatment, the face/neck was cleansed using an aseptic technique.

Treatment was performed using both a 22G or 25G cannula and a 27G needle, depending on the area being treated.

In all areas the Ellansé was mixed with 0.2ml Lidocaine 2% to improve patient comfort without affecting the properties of the product.

The temples were volumised using gunshot technique 27G needle on the bone 0.5ml Ellansé M both sides.

The perioral rhytides and around the mouth were treated using Ellansé M and a biostimulation approach. A 25G cannula was initially used as a form of subscision in these areas to release the superficial dermis. Many passes were made depositing tiny amounts of product, approximately 0.03 to 0.05ml, in a retrograde linear technique, with a total of 1ml Ellansé M lasting 24 months. The collagen stimulation has been shown to be similar to that of hyaluronic acid skin boosters but will obviously last much longer.

The cheeks were treated with a needle and bolus technique depositing Ellansé M on the periosteum, and the submalar area was also treated with cannula subcutaneously. The pre-jowl sulcus was treated with a bolus on the periosteum. A total of 2.0mls was placed each side.

Due to the impending concern of covid-19 and possible lockdown (at the time of treatment), the threads stage of

"When assessing a patient, it is better to start from the upper third and work your way down to the lower third"

Figure 2/2a: Immediately post-treatment

Aesthetic Medicine • July 2020

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treatment was brought forward. Both patients and clinical area were draped and an aseptic technique protocol used.

The threads were placed with local anaesthetic (2% lidocaine with adrenaline) at the entry and exit points. Two threads were placed in a linear direction from the nasolabial fold towards the temple, and three threads placed from the jowls to the temple.

RESULTS Even in the immediate post treatment photograph, after placing five threads, there appears little trauma to the face, with good tissue repositioning (figure 2/2a). Patient P was very pleased and knowing that the result will continue to improve. Since this photograph an eight-cone Silhouette Soft thread was placed in the neck L/R to improve the jaw/ neck junction.

The final photo (figure 3) was taken three weeks into lockdown, by the patient at home. Unfortunately due to covid-19 we have not been able to follow up the treatment as we would like to. However due to the nature of the products used, the results will continue to improve over the next few months. It is clear that the triangle of youth appearance has been restored, with much rounder cheeks and good repositioning of tissue. A review appointment will be scheduled and depending on results, possibly another thread placed, as the patient reported she failed to follow

Figure 3: Patient P after treatment (taken at home)

the aftercare guidelines and felt some cones move.

At the end of last month, a follow-up FaceTime appointment was scheduled with Patient P. In her own words: “I’m over the moon with the results. I love it. My skin feels amazing; it is so smooth and is in the best condition it’s been in for years. My husband tells me it’s taken at least 10 years off my appearance. The results are beyond what I had thought possible." AM

Figure 4: The final outcome – before (left) and after (right)

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Dr Timothy Eldridge BDS founded myFACE dentistry and facial aesthetics in Cheltenham in 2009 and is the principal dentist. Today he spends half of his time in practice combining non-surgical treatments with cosmetic and restorative dentistry, and the other half as a clinical supervisor at Birmingham Dental Hospital. He was awarded a fellowship of the British Academy of Restorative Dentistry and was chairman of CODE for over 10 years. Dr Eldridge is also the trainer and course leader for Dr Paul Tipton’s facial aesthetic training courses.

Aesthetic Medicine • July 2020

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F E AT U R E

PATIENT-CONNECT APPS

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Get connected

We discover the latest app launches designed to link patients to practitioners

T

he coronavirus pandemic has meant that conducting business online has become essential for survival. While clinic doors have been shut, everything has moved to a digital format and this looks set to continue while we ease out of this crisis. It may come as no surprise then that the sector is seeing the launch of a number of new digitally-focussed busineses.

Even before the pandemic, searching online was the main way patients did their research and found doctors and clinics, but the lack of regulation within the sector has meant that trying to decipher all of that information and find an ethical practitioner can be a minefield. It is no surprise then that people have started to look for a solution to this problem by developing websites and apps that bring together practitioners and enable consumers to find them more easily,.

We take a look at three recently launched examples.

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Aesthetic Medicine • July 2020

ZOOM CLINIC

ZoomClinic (zoomclinic.co.uk) is a new private clinic booking app developed by Dr Sadaf Hussain (read her advice on getting started as a new injector on pages 54 to 56).

Dr Hussain came up with the concept after noticing it was difficult to find a single platform where patients could search, find, review and book private clinic appointments quickly and easily.

“The healthcare landscape is currently undergoing phenomenal change and ZoomClinic is aiming to help revolutionise healthcare by connecting clients and clinics in just a few clicks”, Dr Hussain said.

“I launched ZoomClinic after many years as a GP. I felt there was no single private clinic directory where I could find the healthcare specialist I needed to refer patients to and even if I could find the specialist, often there was no direct booking service and not much information available about the clinician themselves.”

ZoomClinic lists almost all types of private practitioners (not just aesthetic) on its platform, including doctors, dentists, surgeons, physiotherapists, counsellors, podiatrists, chiropractors and wellbeing practitioners.

The platform provides free appointment booking software that clinicians can manage easily from their phone and clients can view and book into directly. It is built to be flexible to individual needs.

Clinicians can create as many or as few appointment slots as they wish.

For example, some clinicians may already have morning and afternoon clinics, but have a spare hour or two between. The clinician could use a spare hour to open up 15 or 30 minute private appointments on the ZoomClinic App. ZoomClinic will also be adding teleconsultations in the future, to allow practitioners to book in remote appointments and work from home.

Clinicians pay no upfront fee or

F E AT U R E

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PATIENT-CONNECT APPS

subscription fees and, as an early adopter, can benefit from a loyalty promise of no future subscription fees.

“ZoomClinic provides a fantastic opportunity to create a free profile page highlighting your training and experience, upload your photos and let the world see who you are”, adds Dr Hussain.

“Clinics are being added constantly and we have steady growth and expansion across the UK in many specialities. It is an exciting time for ZoomClinic as we have had excellent uptake by clinicians creating their free profile pages.

SAFEAP

SafeAP (safeap.co.uk), which stands for The Safe Aesthetic Practitioner, was developed by Dr Sieuming Ng and Dr Subha Punj to connect people wanting non-surgical aesthetic procedures with qualified independent healthcare professionals.

Dr Ng came up with the idea back in 2019. “I realised as a newcomer to the industry, unless you’re very socialmedia savvy, marketing yourself isn’t the easiest”, she says. “Apart from that, there is a struggle in handling mountains of paperwork that comes with it.

“SafeAP is the first mobile application marketplace founded by two medical doctors with a passion for improved safety in the medical aesthetics industry.

It is designed based on our personal experiences, both as users of medical aesthetic procedures and as practitioners ourselves.”

SafeAP serves as a dual platform for clients and practitioners.

For clients, it connects them to qualified and fullyinsured healthcare practitioners (doctors, dentists and nurses). They can filter based on treatment, price

and location to make an informed decision and able to communicate with practitioners before and after treatments using a GDPR-compliant messaging service to provide them with continuity of care. They can then review and rate practitioners.

For practitioners, SafeAP is a one-stop platform that strategically markets the practitioner, based on services, location, prices, and most importantly, ratings and reviews.

It can also be used as a client management system so practitioners are able to organise bookings, document procedures, gain consent, receive payment and generate invoices.

Practitioners can also conduct e-consultations using a GDPR-compliant messaging service.

“Our vision is to improve safety, empower clients to make informed choices and to champion practitioners by providing them with the basic tools to run their aesthetics business effectively”, Dr Ng adds. “I aim to use SafeAP as a portal to improve client awareness and educate them of the different procedures there are out there and the associated risks.”

Aesthetic Medicine • July 2020

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F E AT U R E

PATIENT-CONNECT APPS

GLOWDAY

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with the best practitioners, providing reassurance in an Launched early this month with around 150 UK clinics unregulated industry.” on board, Glowday (glowday.com) is the brainchild of Customers can find local clinics, review practitioners’ former science teacher Hannah Russell who describes the treatments, read verified reviews, compare before-andplatform as the “AirBnB for medical aesthetics”. The site after photos and book online 24/7. Software will also give aims to connect consumers with medically-qualified nonclinics a patient-management system including a diary and surgical cosmetic practitioners. scheduling software.

A patient herself, Russell was inspired to set Russell and husband Joby Russell (who, as up the business after finding it challenging chief marketing officer helped take estate and confusing trying to find a clinic for agent Purplebricks from start-up to her injectable treatments. She says, IPO), also recently secured a £3.8 “The lack of regulation “Very quickly, I identified that getting million investment deal in Glowday within the sector has information that was transparent from Horatio Investments, which meant that trying to and used non-medical language is led by entrepreneur Adam when explaining treatments was Norris, who previously built the decipher all of that really tricky. pensions division of Hargreaves information and find “I probably did about eight Lansdown and is currently working an ethical practitioner months of research before booking to transform the urban transport my first appointment and it just felt market through his electric bike and can be a minefield” a little bit cloak and dagger. Being a scooter retail business; Pure Electric. normal woman – I am not a Kensington Russell believes the investment will mum or a Love Island contestant – it kind of enable them to “hit the ground running” in felt like this wasn’t for women like me. The the post-covid landscape. She says, “Glowday whole world of aesthetics felt a little bit like is a tech-driven business for a booming market which is when you walk into a fancy clothes shop and think ‘this is still very much off-line. This will be more important postnot my club’.” covid, when practitioners will need as many aspects of Russell was looking for something that spoke to their business as possible to be digitised and automated, women like her but also allowed her to indulge in what she to enable them to treat more clients. This investment describes as the “normal consumer behaviour” of being means we’ll be ready to hit the ground running - clinics able to review, compare, contrast and inform yourself, have huge waiting lists for when their doors reopen.” “that seemed to be available everywhere else except Once the platform has 600 clinics on board the next within aesthetics”, she says. phase will be a UK-wide marketing campaign, including TV “The market is wildly fragmented with thousands of advertising. practitioners delivering a mix of quality, service and Practitioners who partner with Glowday will receive price, yet non-surgical treatments are increasingly seen 30 days commission-free. Following this, there will be a as a normal part of beauty regimes,” Russell adds. “We commission structure of 30% on treatments completed created Glowday so consumers can research and book with new clients, and 2% on treatments booked through non-surgical aesthetic treatments in absolute confidence Glowday from existing clients. AM

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Aesthetic Medicine • July 2020

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

BTL

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Smooth and tone How BTL Emtone addresses all 5 anatomical causes of cellulite

I

n order to find an effective treatment for cellulite one must understand what is happening anatomically to give the dimpled appearance. In females there is a very superficial layer of fat just under the skin. As this fat increases it bulges out, giving a lumpy appearance. As we age our skin thins and the resistance to the underlying fat bulging out is reduced. In ad-dition, the fibrous strands in the dermal layers become fibrous and twisted which pulls down, producing the dimples.

As fat accumulates in the interlobal spaces there is an increase in pressure within – this de-creases the ability of the lymphatic system to drain away lymph fluid, so this static fluid adds to the swelling in the area.

This also decreases healthy blood circulation in the affected area and good circulation is a prerequisite for neocollagenisis.

The basic anatomical causes of cellulite are: • Increase in size of fat pockets just under the skin, creating outward bulging.

• Ageing skin with less elasticity, decreasing the resistance to internal outward pressure of the fat.

• Connective strands become rigid and twisted, pulling down producing the dimple.

• Accumulation of lymphatic fluid adds to the increase in volume bulging out.

• Poor blood flow.

Emtone from BTL is a safe and effective alternative to invasive procedures that are current-ly available. The modalities used are proven over many years for different applications such a skin tightening and body contouring, resulting in many clinical peer reviewed studies for these treatments. The BTL Emtone now

combines both radiofrequency and shockwave to directly treat the anatomical causes of cellulite.

Cause: Fat pockets in the interlobal spaces dermal layers.

Solution: Emtone radiofrequency heats these fat cells to 40 to 43 degrees. The fat cells at these elevated temperatures are shown to reduce in volume.

Cause: Poor skin condition.

Solution: Emtone radiofre-quency and shockwave manipulation are both proven to increase the levels of collagen and elastin in the dermal layers.

Cause : Poor lymphatic drainage Solution: Emtone radiof-requency and shockwave manipulation effectively give a deep lymphatic drainage massage, increasing lymphatic flow and drainage.

Cause : Poor blood circulation Solution: Emtone gives a deep massage increasing blood flow. A healthy microcirculation in the affected area will encourage healthy growth of new collagen proteins.

THE TREATMENT The Emtone treatment takes around 30 minutes depending on how many areas are to be treated. Four to six treatment sessions are required at weekly intervals. Patients will see an immediate improvement because static lymph and excess fluid in the area has been mas-saged away. The full effect of Emtone radiofrequency and shockwave will take a full 12weeks. AM

Aesthetic Medicine • July 2020

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BUSINESS

VIDEO CONTENT CREATION

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Lights, camera, action Digital marketing specialist Alex Bugg’s guide to making your own professional video and photo content to show off your clinic

W

e’re all told content is king, that social media will boost us to superstardom, and how we start is by putting out regular content across multiple platforms. Professionallyshot photo and video is the gold standard, but if you can’t afford to do this regularly and reactively, with the editing time that’s involved too, then I’ve compiled some essential apps and gear that will allow you to work smarter and step up your content game.

Creating great looking and sounding content for your target audience, whether you have 150 followers or 150,000, should ultimately lead to generating more income in clinic

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Aesthetic Medicine • July 2020

– the main goal of any business social media account. Your mobile phone is a studio in your pocket, and with this guide you can get to work on your own media empire, wherever you are.

APPS

“There’s an App for that”, hailed Apple’s 2009 campaign, with the launch of the App Store. Apps, regardless of your smartphone brand of choice, are ubiquitous in modern life.

The apps I’ve chosen below will allow you to create, edit and share professional-standard graphics and videos, made up in just a few minutes.

BUSINESS

VIDEO CONTENT CREATION

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Adobe suite (Lightroom, Spark and Premiere Rush): Adobe is the number one developer of software for creatives. Thankfully, you don’t have to learn Photoshop inside out anymore to develop great-looking video and photo for social media.

Adobe Lightroom is a free photo editing app which is loved by brands, agencies and influencers worldwide. Why? It’s simple to use but you get a much more precise control of the image. You can also export at professional quality and store your images on the cloud and across your devices.

The most popular feature, however, are the pre-set filters in a much wider range than Instagram; there are 30 built in and thousands available to download online. You can transform a picture to fit your aesthetic in one tap and share across multiple channels. Don’t find a preset that you like? Save your own after playing with the sliders and cut down your editing time.

Adobe Spark Post and Video are two apps with a simple user interface that allow you to generate graphics quickly. There are hundreds of editable templates in the app, or you can start your post from scratch. Need to resize that Facebook image for Twitter? The app does it for you, ensuring the best quality and no dodgy cropping. You can also access your images from Lightroom across Spark, too.

Adobe Premiere Rush is the light version of Premiere Pro, one of the industry standards for video editing. Rush is lightweight and intuitive, and contains built-in templates, eye-catching effects and tutorials to help you get the best out of video editing.

Upgrading to the paid versions of these apps allows you to save multiple “brands”; your logo, colour schemes and fonts are saved into the app, so making a branded text post, before-andafter image or new video becomes a breeze.

Canva: A rival to Adobe Spark, Canva is known as “freemium”; you can upgrade to a pro version to unlock many more features.

Anything that is free is worth trying, in my opinion, and Canva allows you to create better social media graphics, make branded content and publish across the web.

Unsplash: Sometimes, stock imagery is required. Unsplash is an archive of beautiful, royalty-free photos, submitted by their creators. To make stock seem less dull, combine with editing, captions or animations to breathe your brand into the image.

Layout and Hyperlapse: Both free from Instagram, Layout allows you to quickly organise up to nine images in a single square for Instagram. Hyperlapse is a video app where you can shoot timelapses – videos recorded with a low frame rate, so when played at normal rate, look fast but smooth. Hours of video can be viewed in minutes.

In clinic, timelapse videos of facial treatments look great and should get great engagement. We always recommend making sure you have enough video so your timelapse is at least 30 seconds long.

Inshot: An alternative to the Adobe video editors, Inshot for phones and tablets allows you to edit video, add subtitles, music and voiceovers, and make slideshows, too. The app is comprehensive in the free version – enough to get to grips with how it works – and also offers a Pro subscription for only £11.99 per year.

Notes App (free) and Goodnotes/Evernote (paid): The best note-taking apps. These are well worth using if you aren’t a pen and paper kind of person. Always have your content plan, your hashtags and your miscellaneous scribblings to hand, separated into digital notebooks. I use Goodnotes across my phone, tablet and laptop.

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VIDEO CONTENT CREATION

EQUIPMENT

Investing in some basic photography/ videography gear will allow you to create much better-quality content, which can increase your engagement, in turn generating more bookings.

Grip/ mount: While making content in selfie mode is brilliant, going hands-free makes your video (and photography) stand out. My recommendation is Joby GripTight Mount PRO. Adjustable in portrait or landscape, the universal mount will hold any size smartphone. It’s the most secure mount we have found and can be put on any tripod or grip with a ¼ inch screw (standard in photography).

Tripod: “Buy cheap, buy twice” rings true when it comes to tripods. Manfrotto has been a leading name in photography for decades; its Compact Tripod is sturdy and can tolerate being moved around a lot, while being lightweight enough to take on public transport to clinic with you. I like the Manfrotto Compact Series; the more adjustable the better.

Mic: The biggest weakness we so often find in content production is sound. The Røde SmartLav+ is a lavalier (or clip-on) mic for smartphones which is perfect for clear, crisp audio, whether you’re talking directly to camera or talking while treating a patient. Alternatively, check out shotgun mics if you’d rather attach a mic to your phone than to yourself.

Lighting: The lighting in your clinic should already be good enough to film in, if you have set it up to get the clearest look at a patient’s skin and deliver the best results. Ring lights will be a good addition – we see a lot of ring lights in clinics and for good reason; they’re cheap, consistent and flattering. The shadow it creates brings the subject into beautiful focus.

Backdrop: Your background matters. A busy background of

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your clinic or office is usually perfect for most video. Want to create a talking head video where you are explaining?

A plain background is great for taking pictures or handson videos of products. I recommend looking for a pull-up backdrop or a traditional stand with cloth or paper. Make sure it is standing straight up and not creased, as your clean look will become distorted.

Gaffer tape: Knowing where to put a patient against a background to create uniform before and after shots is as simple as using four strips of gaffer tape made into an eight-point star, and another to set your tripod on.

Have your patient set their feet on each line of tape. My recommendation: Duck Tape. It comes in pink.

Gimbal: Now, we’re verging away from essential, but have you ever wondered how live sports are filmed so smoothly at such a fast pace? A gimbal allows you to shoot stable footage when moving, thanks to a 3-axis pivot, motors and a chip which knows when you are moving your camera intentionally and when you aren’t. No more shaky hands! My recommendation: DJI Osmo Mobile 3. Ergonomic, versatile and lightweight enough to use in one hand, you can add movement to your videos without the shakiness Finally, if you want to pick up a camera to shoot your own video, I would recommend going to a specialist such as London Camera Exchange to find a model to fit your needs. “Vlogging” cameras are now specially built by manufacturers to meet the needs of fast content creators, and could suit your clinic perfectly. The Sony ZV-1, Canon Powershot G7 MKIII and Fujifilm X-A7 are all compact cameras with flappable screens for “selfie” viewing and Wi-Fi connection to share footage straight to your phone.

You should expect to spend between £600 and £800 on a camera. AM

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

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Aesthetic Medicine • July 2020

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CLINICAL

RADIOFREQUENCY

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RF AND READY Dr Patrick Treacy reviews minimally-invasive radiofrequency options for skin tightening and acne scarring with a microneedle fractional RF device, with case studies by Rebecca McMahon

P

atients are increasingly seeking minimallyinvasive methods to tighten lax skin and remodel acne-scarred tissue. Multiple energy-based technologies, including fractionalised CO2 laser (FLRS), high-intensity focused ultrasound (HIFU), micro-needling (MN), and radiofrequency (RF) have evolved to meet this rising demand.1 More recently, other treatments, including fractional radiofrequency micro-needling (FMR), have become popular, as patients can achieve favourable results without extensive downtime. In contrast to laser, RF is chromophore independent and has a better safety profile for all skin types in terms of pigmentation changes. 2 In this study we tested a multi-frequency fractional RF microneedling device (Onix, SHE Co., Korea), during treatments for facial and neck skin tightening and acne scarring to evaluate its safety and efficiency.

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Aesthetic Medicine • July 2020

THE DEVICE

The multi-frequency fractional RF micro-needling device has a disposable single-use treatment cartridge tip consisting of 36 golden 0.3mm non-insulated 30g microneedles. These electrode pairs are contained within the area of 10 mm2, with the exposed electrodes extending from 0.5-6mm below the skin surface. These bipolar electrode pins form a closed circuit through the irradiated skin, delivering between 0.5MHz- 2MHz of conducted RF current to the skin.

An adjustable RF power up to a maximum of 220w can be delivered, in relation to the intensity (1-5) and a dwell time up to a maximum of seven seconds can be obtained. Since RF flows along the least resistance path, bipolar RF will usually be superficial and will heat the upper part of the dermis. The Onix uses a water chiller and a thermoelectric cooling (TEC)

CLINICAL

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plate in order to prevent epidermal burns and to minimise pain.3 This thermal electric Peltier plate enables the cooling plate to maintain constant temperature and is detachable for sterilisation between treatments.

There is also a Chevron circuit board, which spreads RF evenly inside both the epidermis and dermis, avoiding bulk heating and providing an optimal RF emission flow for effective treatment. A further coolant-cooling system inside the handpiece controls and maintains the temperature of the Peltier.

The Onix device uses TEC modules to bring the refrigeration source directly to the tissue to be treated, thereby achieving significant improvements in control of the applied therapeutic temperature. TECs function via the Peltier effect in which a voltage differential applied across the device generates an orthogonal temperature gradient.4,5 The efficiency by which heat can be removed at a high temperature to the environment is a major factor determining the magnitude of refrigeration load that the TEC can produce. Safety is optimised through this unique multi-system temperature control mechanism, resulting in a high predictability of treatment results.6-7 The needles are inserted into the skin by a step motor that is electronically controlled, enabling smooth insertion that minimizes patient discomfort. The non-insulated technology enables heating of both papillary and reticular dermis in order to encourage the skin to produce new collagen.8,9 The epidermis remains intact due to its high impedance.10-12

RADIOFREQUENCY

Acne scarring after needle depth 2.0-3.0 Level 5

SKIN LAXITY AND NECK-TIGHTENING STUDY

Radiofrequency micro-needling (FMR) allows for subdermal adipose remodelling and skin tightening. It achieves this by thermal heating of the reticular dermis to 50–52°C, which triggers a healing cascade stimulating the formation of new collagen and elastin fibres.13

EXCLUSION CRITERIA

Patients who are/have: • Artificial bone, silicosis, collagen or synthetic materials in the treatment areas • Metal materials in body (including metal teeth) • Uncontrolled disease such as asthma, diabetes, hypertension, hyperthyroidism or hypothyroidism.

• A history of immunosuppressive deficiency disorders (including HIV infection or AIDS) or currently using immunosuppressive medications (e.g. Azathioprine, Belimumab, Cyclophosphamide, Enbrel, Imuran, Humira, Stelara, methotrexate, prednisone, Remicade and/or undergoing any sort of radiation treatment • Pregnant, ready to become pregnant or are lactating • Any form of cancer (need to be one year free of disease) • Any prior intralesional treatments or surgery in axilla • Significant mental health disorders, drug, alcohol or other substance abuse.

• Known history of secondary hyperhidrosis • Currently enrolled in an investigational drug or device study • Soft tissue augmentation within the previous six months.

Acne scarring before needle depth 2.0-3.0 Level 5

Acne scarring patient after session 3 depth 2.0-3.0 RF Level 4-5

Aesthetic Medicine • July 2020

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CLINICAL

RADIOFREQUENCY

Acne scarring patient e needle depth 2.5-3.0 RF Level 4-5

The bipolar RF also tightens the skin by contraction of the underlaying reticular ligaments and fibroseptal network.

This leads to induction of neocollagenesis, elastogenesis, and angiogenesis.14 The Onix device handpiece uses noninsulated gold-plated microneedles for deep dermal remodelling. Ultrasound gel was applied to all treatment areas. The handpiece was then gently applied to the treatment area to create constant, uniform coupling and circular movements were enacted to match the area of the retaining ligaments. Three treatment areas were identified for patients:

34

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had skin type Fitzpatrick I–III. The treatment areas were cleansed with alcohol prior to the treatment. The treatment parameters were set as follows: treatment target temperature of 43.0°C and energy of RF 3-4. Each treatment area was heated to a temperature of 43.0°C, and maintained at that temperature for at least five minutes. The patients underwent a series of four to six weekly treatments with these settings. Any side effects of treatments were noted. Clinical photographs of the face and neck were taken using a digital camera before treatment and at approximately two weeks after the final treatment. All treatments were performed under the direction of a single research technician.

After initial assessment of the photographs, the series of photographs were revaluated by both the patient and two clinical staff to determine clinical improvements in skin laxity. Based on the primary endpoint for efficacy of skin tightening, all the subjects were judged to have some level of clinical improvement. 27 of the 35 sets of patient photographs (81.81%) were determined to have achieved significant clinical improvement over four to six sessions.

ACNE-SCARRING STUDY

1. The cheek, platysma auricular fascia, nasolabial fold and masseteric cutaneous ligament 2. The lower eyelid, zygomatic cutaneous ligament and the area of the orbicularis retaining ligament, 3. The jowl, neck submental area and the buccomaxillary ligaments 35 patients who were interested in undergoing FMR agreed to participate in this case series. The mean age of the patients was 56.9 (range: 42–71) years, and the patients

Acne vulgaris is a common condition experienced by up to 80% of people between 11 and 30 years of age and by up to 5% of older adults. It is characterised by non-inflammatory open or closed comedones, inflammatory papules, erythematous papulopustular lesions and cysts, which often leave behind residual scarring and pigmentation. Its onset in adolescence may lead to significant psychological distress and low self-esteem and add to the emotional and psychological challenges experienced during this period.15-16 Although commonly encountered it remains a challenging problem to treat for the dermatologist. Despite the advances in pharmacology and technology, scar treatment remains suboptimal and has several adverse effects.17 Laser resurfacing was introduced in the 1980s with continuous wave carbon dioxide (CO2) lasers; however, because of a high rate of side effects, more specific lasers, including the erbium-doped yttrium aluminium garnet lasers were developed. Ablative fractional lasers

Before treatment

After two treatments (six weeks later)

Aesthetic Medicine • July 2020

CLINICAL

RADIOFREQUENCY

aestheticmed.co.uk

can effectively treat acne scars and enlarged pores, but cause considerable pain and downtime for patients, as well as potentially causing post inflammatory hyperpigmentation (PIH), especially in Asian skin.18-19 Nonablative resurfacing produces dermal thermal injury to improve rhytides and photodamage while preserving the epidermis. Fractional resurfacing thermally ablates microscopic columns of epidermal and dermal tissue in regularly-spaced arrays over a fraction of the skin surface. 20 The therapeutic approach to the treatment of acne scars and photoageing varies according to the type of lesion.

Traditional carbon dioxide (CO2) laser is associated with long healing times, persistent erythema, and high risk of post-inflammatory

hyperpigmentation. The drive to attain cosmetic facial enhancement with minimal risk and rapid recovery has inspired the field of nonsurgical skin rejuvenation. Fractional radiofrequency (FRF) is renowned for its use in cosmetic dermatology, especially in the treatment of rhytids, striae, and cellulite but its use in acne scars has been more recent. 21 Postinflammatory hyperpigmentation can be managed successfully with topical agents such as azelaic acid and hydroquinone.

The therapeutic approach to the treatment of acne scars and photoaging varies according to the type of lesion.

Traditional carbon dioxide (CO2) laser is associated with long healing times, persistent erythema, and high risk of post-inflammatory hyperpigmentation. FRF

"Our clinical experience has shown that the combination of bipolar RF and RF micro-needling can achieve substantial skin tightening and collagen remodelling"

(ONIX) TREATMENT GUIDELINES Table 1 – Neck Neck

Treatment area

Needle depth

RF level

Pulse duration

Thin

1.0-1.5

4-5

Medium

1.5-2.0

Thick

Passes

MHz

LED

0.3-1.0

2

Red

4-5

0.3-1.0

2

Red

1.5-3.0

4-5

0.3-1.0

2

Red

Table 2 – Acne scars Acne scars

Treatment area

Needle depth

RF level

Pulse duration

Passes

MHz

LED

Thin-thick

Forehead

1.0-1.5

4-5

0.3-1.0

1-3

2

Blue

Thin-thick

Eyes, Nose

1.5-2.0

4-5

0.3-1.0

1-3

2

Blue

Thin-thick

Cheek

2.0-3.0

4-5

0.3-1.0

1-3

2

Blue

Thin-thick

Periorbital

1.5-2.0

4-5

0.3-1.0

1-3

2

Blue

Thin-thick

Jawline

1.5-2.0

4-5

0.3-1.0

1-3

2

Blue

Table 3 – Skin rejuvenation Skin rejuv

Treatment Area

Needle Depth

RF Level

Pulse Duration

Passes

MHz

LED

Thin-thick

Forehead

1.0-1.5

4-5

0.3-1.0

1-5

2

Red

Thin-thick

Eyes, nose

1.5-2.0

4-5

0.3-1.0

1-5

2

Red

Thin-thick

Cheek

2.0-3.0

4-5

0.3-1.0

1-5

2

Red

Thin-thick

Periorbital

1.5-2.0

4-5

0.3-1.0

1-5

2

Red

Thin-thick

Jawline

1.5-2.0

4-5

0.3-1.0

1-5

2

Red

Aesthetic Medicine • July 2020

35

CLINICAL

RADIOFREQUENCY

is renowned for its use in cosmetic dermatology, especially in the treatment of rhytids, striae, and cellulite, but its use in acne scars has been more recent. 21-22 Fractionated RF induces deep dermal heating and leaves the epidermis less affected. 23 13 patients who were interested in undergoing FMR for deep acne scarring agreed to participate in this case series.

The mean age of the patients was 25.3 (range: 22–37) years, and the patients had skin type Fitzpatrick I–IV.

EXTRA EXCLUSION CRITERIA OF ACNE SCARRING STUDY:

• History of keloid or abnormal scarring • Patients with metal materials in body (including metal teeth) • Active systemic or local infections • Recent ablative or non-ablative laser rejuvenation procedures • Roaccutane within the previous six months • Soft tissue augmentation within the previous six months.

After initial assessment clinically and by use of photographs, the patients were revaluated by both the patient and two clinical staff to determine clinical improvements in acne scarring. Based on the primary endpoint for efficacy of results being based on an endpoint of patient satisfaction, almost all the subjects were judged to have some level of clinical improvement.

One patient who was rather psychologically disturbed by her scarring didn’t feel she got the result she thought she would get. 12 of the 13 sets of patient photographs (92.3%) thought they achieved significant clinical improvement four to six sessions, comparable to CO2 laser and much better than microneedling alone.

CONCLUSION

Fractional microneedle radiofrequency (FMR) devices deliver energy to the deep dermis through insulated microneedles without destroying the epidermis. This article reviews minimally invasive radiofrequency options for skin tightening and acne scarring, focusing on safety and efficacy by use of microneedle fractional RF device (Onix, SHE Co., Korea).

Our clinical experience has shown that the combination of bipolar RF and RF micro-needling can achieve substantial skin tightening and collagen remodelling in patients who are not candidates or prefer to not undergo surgery. The results with acne scarring were comparable in the author’s opinion to similar cases with fractionalised CO2 laser and a definite improvement to multiple sessions of microneedling alone. We didn’t experience any complications in any of our patients using this method and a literature search confirms this when the method is properly applied in appropriate patients. AM

aestheticmed.co.uk

REFERENCES 1. F ritz K, Salavastru C. Ways of noninvasive facial skin tightening and fat reduction. Facial Plast Surg. 2016;32(3):276-282 2. Alster TS, Lupton JR. Nonablative cutaneous remodeling using radiofrequency devices. Clin Dermatol. 2007;25(5):487-491 3. G oldsmid, H. J., 2009, Introduction to Thermoelectricity, Springer, New York 4. Potekaev N, Zhukova1 O. Evaluation of safety and efficacy of the maximus™ system for facial wrinkles. J Cosmet, Dermatol Sci Appl.

2013;3:151–156 5. Elman M, Vider I, Harth Y, Gottfried V, Shemer A. Non-invasive therapy of wrinkles, lax skin using a novel multi-source phase-controlled radiofrequency system. J Cosmet Laser Ther. 2010;12: 81–86 6. Hantash BM, Ubeid AA, Chang H, Kafi R, Renton B. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Lasers Surg Med. 2009;41 7. K aplan H, Kaplan L. Combination of microneedle radiofrequency (RF), fractional RF skin resurfacing and multi-source non-ablative skin tightening for minimal-downtime, full-face skin rejuvenation. J Cosmet Laser Ther. 2016;18(8):438-441 8. H arth Y, Elman M, Ackerman E, Frank I. Depressed acne scars – effective, minimal downtime treatment with a novel smooth motion non-insulated microneedles radiofrequency technology. J Cosmet, Dermatol Sci Appl.

2014;4:212–218 9. H arth Y, Elman M, Ackerman E, Frank I. Depressed acne scars – effective, minimal downtime treatment with a novel smooth motion non-insulated microneedles radiofrequency technology. J Cosmet, Dermatol Sci Appl.

2014;4:212–218 10. Z ip C. The impact of acne on quality of life. Skin Ther Lett.

2007;12(10):7–9.

11. M oretti M. Skin tightening: Softening demand in a weak economy.

Medical Insight Inc; 2008 12. Dierickx CC. The role of deep heating for noninvasive skin rejuvenation.

Lasers Surg Med. 2006; 38:799–807.

13. L olis MS, Goldberg DJ. Radiofrequency in Cosmetic Dermatology: A Review: Dermatol Surg. 2012;38(11):1765–1776.

14. M ulholland RS. Radio frequency energy for non-invasive and minimally invasive skin tightening. Clin Plast Surg. 2011; 8:437–448 15. Cameli N, Mariano M, Serio M, Ardigò M. Preliminary comparison of fractional laser with fractional laser plus radiofrequency for the treatment of acne scars and photoaging. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2014;40(5):553–561.

16. L evy LL, Zeichner JA. Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches.

Am J Clin Dermatol. 2012;13(5):331–340.

17. Jacob CI, Dover JS, Kaminer MS. Acne scarring: A classification system and review of treatment options. J Am Acad Dermatol. 2001;45(1):109– 117.

18. A lexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin resurfacing: Nonablative, fractional, and ablative laser resurfacing.

J Am Acad Dermatol. 2008;58(5):719–737.

19. K im JE, Lee HW, Kim JK, Moon SH, Ko JY, Lee MW, Chang SE. Objective evaluation of the clinical efficacy of fractional radiofrequency treatment for acne scars and enlarged pores in Asian skin. Dermatol Surg Al. 2014;40(9): 988–995.

20. B rightman L, Goldman MP, Taub AF. Sublative rejuvenation: experience with a new fractional radiofrequency system for skin rejuvenation and repair. J Drugs Dermatol JDD. 2009;8 (11 Suppl): s9–13.

21. F ractionated radiofrequency (RF) induces deep dermal heating and leaves the epidermis less affected Single-center study on the efficacy and safety of fractionated radiofrequency on active acne and deep acne scars (with histology analysis). J Am Acad Dermatol. 2015;72(5): AB11.

22. Chantes A, Antoniou A, Leontaridou I. Clinical improvement of striae distensae in Korean patients using a combination of fractionated microneedle radiofrequency and fractional carbon dioxide laser.

Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2014;40(6):699.

23. F O’Shaughnessy, Dermatol Surg. 2012 May; 38(5): 728–735.

Dr Patrick Treacy is chairman of the Royal Society of Medicine (London) Aesthetic Congress and of the Irish Association of Cosmetic Doctors. He is also the Irish representative of the British Association of Cosmetic Medicine. He founded The Ailesbury Clinic in Dublin anc Cork.

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Aesthetic Medicine • July 2020

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The NMWLP was developed exclusively to support and train registered HCP’s belonging to the following Bodies GMC, NMC or GPhC (i.e. doctors, nurses or pharmacists).

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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).

Training is delivered over 2-days via live streamed, interactive webinars.

Guaranteed insurance All Partners are guaranteed cover through Cosmetic Insure, and will also enjoy a preferential rate on their annual premium. Partners can also spread the cost of payments over ten months.

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Everything you need to set up a private weight loss service miums, all Partners will receive exclusive pricing from our official Pharmacy Partner PriMed Aesthetic Pharmacy.

Business support

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continued support, advice and supervision.

Marketing support

* Access to pre-made branded marketing material which can be customised.

* Templates for eblasts and social media. * Advice on of how to run a successful event to introduce this service into your practice.

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C AS E ST U DY

LASER AND MESOTHERAPY

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Combined approach Ai Beauty Clinic in London shares the results of a combination of laser and mesotherapy to treat pigmentation and pore size CONSULTATION

Patient Grace Zhang, 30, presented with discolouration and pigmentation on her face, having inherited a genetic pigmentation issue from her mother, coupled with sun damage later in life. After understanding her desired results, daily routine, skincare and any previous aesthetic procedures (she had six sessions of laser previously), treatment plan combining PicoSure laser and mesotherapy was recommended. As the clinic’s approach is to begin by treating the patient’s biggest concern first, it was decided that Zhang’s sun damage and pigmentation spots would be addressed first, followed by pore size. The PicoSure sessions were carried out by laser therapist Chelsea Hull, while mesotherapy was done by aesthetic doctor Dr Mark Fellows.

CHOICE OF TREATMENT

In order to replace the loss of water caused by photo-ageing, the combination of PicoSure and mesotherapy would help the skin replenish and lock in moisture in a shorter time. Mesotherapy was chosen alongside the laser to help shrink pores, makes the result of PicoSure treatment last longer. Based on Ai Beauty’s clinical experience: this combination treatment works well to: • Reduce fine lines, improve dull skin and replenish moisture • Shrink pores, increase elasticity and tighten, hydrate and soften skin • Lighten stains and improve pigmentation.

TREATMENT PLAN

A course of three PicoSure treatments and three mesotherapy treatments was decided upon. In the first PicoSure session, the PicoSure fixed handpiece was used to scan the entire face once, and again to focus on the dark spots on her cheeks in the second pass. In the

40

Aesthetic Medicine • July 2020

Grace Zhang before and after

second and third PicoSure sessions, the Zoom handpiece was used to work on the local area around the cheeks, near the eyes.

Zhang was recommended to complete a PicoSure treatment every four to six weeks with mesotherapy interspersed, again at four-to-six-week intervals, with two to four weeks between any two sessions depending on how quickly her skin recovered.

Patients are usually advised to undergo a PicoSure treatment first to speed up the skin’s metabolism, followed by mesotherapy to make moisture replenishment more effective.

Homecare advice was as follows: • Cool the skin post-treatment as needed with cold gel packs, masks, aloe vera gel, or cool air • Wash the treatment area gently with soap and water; do not soak the treated areas • Apply moisturiser for sensitive skin • Do not shave the treated area if crusting is evident • Avoid sun exposure between treatments.

If sun exposure is unavoidable, use a 30+ sunblock to protect exposed, treated areas • Because the skin is particularly sebaceous, consider waiting 24 hours before applying any topical products post-treatment. AM

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PRODUCTS

PRODUCT NEWS

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CUTERA

Aesthetic device manufacturer Cutera has launched a new fractional radiofrequency microneedling device, Secret RF. The device targets radiofrequency energy into deep layers of the skin without causing damage to the surface.

The amount of energy released is customised to each patient and delivered at targeted depths, ranging from 0.5mm to 3.5mm. Practitioners can effectively remodel collagen at levels which are usually only accessible through more aggressive, ablative technologies and instead comes without any of the risks or downtime.

MESOTECH

CombO3 is the new air sanitiser and purifier from Mesotech, designed to control odours and infections in enclosed spaces by destroying viruses, bacteria, mould and fungi to ensure that all exposed surfaces are hygienic. The machine produces controlled ozone that attacks the various organic compounds by oxidising and deactivating them.

With the device, ozone undergoes a process of conversion into oxygen at the end of the cycle, making the ambient air healthy and breathable. The device is built with a touchscreen-programmable operating system.

PROVIZAGE

PPE manufacturer Provizage has introduced its visor technology, designed for dentists, into the aesthetic industry. The visor rests on the chest and provides a liquid repellent with a continuous barrier that protects the neck and face, and is made from material used in the nuclear industry.

Designed not to fog up, the visor is built to British standard EN166, and has an estimated return on investment versus a disposable visor of less than four weeks. It is designed for use with an FFP2 mask and can be cleaned with a virucidal wipe.

42

Aesthetic Medicine • July 2020

LYNTON

Lynton Lasers has released a new Smart Handpiece for the Onda device, in partnership with manufacturer DEKA. The new, ergonomic handpiece is designed to treat the submental area using Coolwaves technology for a controlled wavelength on the microwave spectrum of 2.45GHz to target unwanted deposits of subcutaneous fat and skin laxity. By guiding the electromagnetic field to the lipocytes, fat cells are destroyed while also stimulating cellular metabolic processes and collagen production.

WAGNER INTERNATIONAL

To help aesthetic practitioners protect themselves and their patients from potential exposure to covid-19, Wagner International has created the Universal 690 Flexio Sprayer. The disinfecting machine is designed for interior and exterior use, is suitable for waterbased disinfectant, provides uniform coverage on all conventional materials, and has variable air-volume regulation for the handling of materials of different viscosities. This product also comes as a separable gun for fast spray attachment changes and simple cleaning.

4T MEDICAL

Aesthetic product supplier 4T Medical has launched SKINrePEN in the UK, made for precision microneedling with a specially-shaped needle cartridge which makes linear, non-overlapping needle insertions. This design allows for increased patient comfort, a significant reduction in downtime and a controlled, efficient treatment by stimulating collagen and elastin synthesis. No lacerations or overlapping needle insertions are produced, allowing for wound closures 12 to 15 minutes after the treatment, reducing the visibility of redness and swelling. Additionally, the high insertion frequency (150Hz) means topical anesthetic is unnecessary in most cases.

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FOX EYES

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EYES WIDE OPEN Exploring a new-to-the-UK procedure to alter the lift of the eyes with Dr Mahsa Saleki

Both left and right: Before treatment (top) and after treatment (bottom)

P

opularised by Hollywood celebrities and influencers, the “Fox Eyes” treatment is a fresh take on using threads to create a more typically feminine elongation of the eyes with an almond shape. The minimally-invasive, non-surgical procedure is in demand at SAS Aesthetics in London, where founder Dr Mahsa Saleki is a specialist in the procedure. She describes Fox Eyes as “a versatile treatment, designed and meticulously developed for modern, busy women wanting to achieve a lifted brow and upper eye lid lift without the big spend and long downtime... of surgery.”

The treatment is typically performed with dissolvable sutures to lift the outer eye corner but can also be tailored so that the brow itself is minimally changed, she explains. Dr Mahsa performs the procedure using three different techniques depending on a patient’s desired end-result, lifestyle and longevity they are looking for:

longevity; with results reported to last between two and three years. For both semi-permanent and PDO threads, Dr Mahsa advises patients a downtime of seven to 10 days for bruising and swelling to settle. Any skin folds in the hairline will relax after two to three weeks.

3. The hybrid mini surgical technique – Performed under local anaesthetic via a single hairline incision and combined with lifting sutures, this technique has the highest longevity, with results that can last up to five years. There is a slightly longer downtime with this option – healing is expected 10-21 days after treatment.

Dr Mahsa explains that the lift will relax by around 50%, which needs to be taken into consideration during consultation when exploring the patient’s desired positioning. For those who don’t wish to lift the brow itself, she says this is particularly difficult as the skin vectors and the end brow are so closely associated. “In these cases, I tend to opt for the most lateral point possible to minimise the disturbance to the brow tail and ensure it remains somewhat undisturbed,” she says, adding that the laxity of the skin and the strength of the underlying temporalis muscle bulk are the most important factor in determining the best position for a lift. A lift can be dropped within the first two weeks after treatment if a little too high for the patient, while the procedure can be repeated after six to eight weeks to achieve a more dramatic result. AM

“A versatile treatment, designed for modern, busy women wanting to achieve a lifted brow and upper eye lid lift without the big spend and long downtime... of surgery”

1. PDO threads – The most commonly-used and most cost-effective technique, where lifting, dissolvable sutures are inserted under the skin to create a lift lasting six to 12 months. This technique allows patients to build up the effect of the lift over time.

2. Semi-permanent threads – PLLA threads are inserted using a similar technique to PDO but offer a much higher

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HAIR RESTORATION

STRONG GROWTH Dr Ingrid Wilson explores hair growth and the biological differences of Afro-textured hair, along with important hair-loss conditions and how they present

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ndigenous African hair varies from very curly in the southern part of the continent to nearly straight in northern areas. The term “Afro-textured hair” is used in this article to refer to the very curly hair type. African hair, even without chemical processing, has a tight, coiled spring-like structure. It is important to remember that patients with Afro-textured hair will experience the same hair loss conditions as other hair types. This article will focus on the intrinsic differences between this and other hair types, the types of hair loss that are more commonly experienced or underdiagnosed by people with this hair type, and the resources available for practitioners to find out more.

This is important because misdiagnosis can lead to the wrong management, which in the worst cases actually has the potential to hasten hair loss, e.g. by performing a hair transplant in active frontal fibrosing alopecia. There is evidence that people with Afro-textured hair present later in the history of their hair loss, which can lead to less satisfactory results. In cases of scarring alopecia, once the hair follicle is lost, it will never regrow hair.

Both intrinsic hair qualities and hair care practices play a role.1 Lower baseline tensile strength, hair density, and growth rates, as well as certain hair care practices, may contribute to alopecia in this group. Certain types of alopecia, such as traction alopecia, discoid lupus erythematosus, and central centrifugal cicatricial alopecia, occur more commonly in people with Afro-textured hair than in those of other ethnicities. Recognising and differentiating these alopecic subtypes clinically and histopathologically is important for prompt diagnosis and treatment.1

INTRINSIC QUALITIES OF AFRO-TEXTURED HAIR COMPARED WITH OTHER HAIR

All human hair types have the same basic structure, but it is acknowledged that further work needs to be done on understanding the key structural differences between hair types. The three-dimensional shape (In 2007 a method was

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proposed to use three easily accessible descriptors of hair shape: curve diameter (CD), Curl index (i) and number of waves (w)) of the entire fibre varies considerably depending on ethnicity and geography, with examples from very straight hair with no rotational turn about the long axis, to the tightly sprung coils of African races. 2 It is thought that asymmetry of hair bulb follicle differentiation and follicle shape are likely to be responsible for Afro-textured hair: • The shape is not a simple wave or crimp. It is flatter in crosssection than other hair types. Its wider axis twists along the length of the fibre, helping to create a tighter curl. The crimp varies along the fibre, tending to increase where the fibre twists. Fibres can twist in opposite directions along the length of the hair. Its shape is more elliptical than other hair types and there is a slightly greater average diameter than other hair types.

• There is a tendency to knot more than other hair types; and scanning electron microscopy shows features consistent with repeated breaks of the shaft. The shape also creates internal stresses when hair is unbent, untwisted or stretched that lead to fracture. There is more interlocking of hair shafts than in other (Asian and Caucasian) hair types.3 • Hair is difficult to comb and breaks easily4, which may explain the observed shorter lengths of combed natural African hair even after many years without a haircut.5 The higher the degree of curl, the higher the likelihood of it is to be vulnerable to stress.

Conventional mechanical testing on virgin, singlesource African hair suggests a dry state break stress that is around 10% lower than virgin Caucasian hair.

Fatigue S/N curves show that at all stresses, very curly hair breaks roughly 10x easier than straighter hair. Other data show that relaxed very curly hair breaks 10-20x easier again.5 The unbending, untwisting and stretching of tightly curled hair probably leads to internal shear forces that lead to crack formation. Scanning electron microscopy and tomographic studies suggest that cracks form between

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cortical cells and between the cortex and cuticle.

• The thinner cuticle layer in African-textured hair contributes to a higher levels of breakage. The cuticle is the outermost layer of the hair shaft and is composed of the protein keratin. It protects the underlying cortex by providing a barrier to chemical and water.6 A healthy, intact cuticle has a smooth surface and low friction in the root-to-tip direction.

• Afro-textured hair tends to be dry, and the water content is lower than in Caucasian hair.7 • There is thought to be increased sebum on the scalp in Africans8, but because of the structure of the hair the sebum is not able to travel down the hair shaft. This is likely to be one of the reasons why Afro-textured hair is prone to dryness.

HAIR GROWTH PATTERNS

Compared with Asian and Caucasian hair, Afro-textured hair tends to break rather than shed.3 African hair is characterised by both low growth and low hair density compared to Asian and Eurasian hair types.9 The rate of hair growth has been documented to be, on average, 0.3 to 0.4mm a day.10,11 According to literature hair grows: • Six inches per year for Asian hair • Four inches per year for African hair • Five plus inches per year for Caucasian hair.

HAIR RESTORATION

Cause: This is hair loss due to repetitive tension on the hair that produces a continuous pulling force on the hair roots. Common haircare practices that involve tension are ponytails/ pigtails, chignon, braids, cornrows, twists, sister locks, dreadlocks, weaves, extensions and curlers.12-14 Scalp pain from braids is a bad sign, and along with tight braids that cause pimples, will also increase the risk of traction alopecia.15 Traction alopecia is preventable and with appropriate education could be eliminated.16-18 Clinical findings: TA typically manifests with hair loss usually along the marginal hairline (frontal, temporal, or occipital) with decreased retained follicular markings and the presence of a “fringe” of finer or miniaturised hairs. The characteristic finding is the retention of hair follicles of lesser diameter along the frontal and/or temporal hairline.

This sign is called the “fringe sign”, and it correlates with the presence of vellus hairs seen in the histology.19 The other findings that may also occur include folliculitis, hair casts, reduction in hair density and replacement with vellus hairs; and the occasional presence of broken hairs in

HAIR LOSS CONDITIONS MORE COMMON IN AFRO-TEXTURED HAIR Traction alopecia (TA)

Presentation: Hair loss at the temples

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the affected areas, which finally proceeds to alopecia that leaves scars. The hair casts due to traction alopecia are nonadherent, white or brown in colour, cylindrical in shape and tend to encircle the proximal hair shaft. 20, 21 It can be associated with a headache, relieved when the hair is loosened. The pattern of the alopecia is characteristic and reflects the distribution of the traction.

Dermoscopic findings: The “flambeau sign” is where multiple linear, white tracks over the scalp at the base of the shaft of terminal hair are seen, especially in the area posterior to the fringe formed in the direction of pull of hairs. These linear tracks in continuation with the shaft of hair at one end give the appearance of a flame or lit torch. 22 The severity of traction alopecia is assessed by using the Marginal Traction Alopecia Severity Score (M-TAS). This is a validated photographic scale used to ascertain the

severity of marginal TA. Anterior and posterior hairlines are localised using anatomic landmarks and are graded on a scale of zero to nine. The scale has been used in clinical studies to correlate disease severity with potential risk factors for TA. Potentially, the M-TAS may be a useful tool used to monitor response to treatment.

"Misdiagnosis can lead to the wrong management, which in the worst cases actually has the potential to hasten hair loss"

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Central centrifugal cicatricial alopecia (CCCA)

Presentation: CCCA typically starts to cause symptoms and signs in the mid to late 30s. Unexplained hair breakage at the vertex may be an early sign of CCCA. It is then followed by hair thinning, mostly involving the vertex scalp. Hair loss progresses centrifugally.

Cause: The exact cause of CCCA is unknown and likely to be multifactorial. However, traumatic haircare practices have been associated, though studies have not shown a consistent link. 23, 24 There is a genetic

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component to CCCA. Mutations in PADI3, which encodes a protein that is essential to proper hair-shaft formation, were associated with CCCA.13 It has been observed to affect women in families in a manner that suggests an autosomal dominant trait, with partial penetrance and a strong modifying effect of hairstyling and gender. 26 Clinical findings: Most patients with CCCA present with a seemingly non-inflammatory disease resembling androgenetic alopecia. On examination a scarring alopecia is typically seen involving the vertex of the scalp. There is loss of follicular ostia leading to a smooth, shiny surface with minimal inflammation. Within this area residual terminal hairs may also be seen. The Central Scalp Alopecia Photographic scale has been validated to assess the severity of CCCA. 26 Dermoscopic findings: The presence of a peripilar white halo is a dermatoscopic feature that suggests the diagnosis of CCCA in AfricanAmerican patients with mild central thinning, and it is an optimal site from which to obtain a biopsy specimen. 28 A disrupted pigmented network and loss of follicular openings can also be seen.

Dermoscopic findings: Absence of follicular opening, absence of vellus hair, minor perifollicular scaling and perifollicular erythema.

Ophiasic alopecia areata

Presentation: This type is often underdiagnosed in black women because there is a tendency to diagnose it as traction alopecia. You would tend to see a horizontal band of hair loss at the back and sides of the hairline.

Cause: Stress can be one of the triggers.

Clinical findings: The prognosis is less favourable so if this form of hair loss is suspected, a prompt referral to a dermatologist is recommended, as they will have access to a greater range of therapies.

Dermoscopic findings: Dermoscopy may show yellow dots, dystrophic hairs and short, miniaturised growing hairs.

"African hair is characterised by both low growth and low hair density compared to Asian and Eurasian hair types"

Trichorrhexis nodosa

Presentation: Hair breakage at any point in the hair shaft.

Cause: Trichorrhexis nodosa (TN) is a common hair-shaft disorder that stems from the loss of cuticle cells on the hair shaft. Without the protective cuticle, the cortical fibers of the hair shaft become fragile and fray longitudinally. In contrast to the rare congenital form of TN, acquired TN is induced by traumatic hair care practices – both chemical and thermal.

Clinical findings: Broken hairs of varying lengths are revealed, along with hair fragility. Repeated trauma to the hair shaft ultimately results in dry, brittle hair with whitish spots along the shaft. These whitish spots (also called nodes) represent the location of fraying and ultimate shaft breakage.

Dermoscopic findings: The shaft will display numerous areas of swelling, representing the weakening at the nodes.

Frontal fibrosing alopecia

Presentation: Gradual receding of the frontal hairline over time with a smooth, band-like appearance.

Cause: There is an ongoing debate about the cause of frontal fibrosing alopecia (FFA). It is likely to be multifactorial.

Clinical findings: This may well be underdiagnosed in women of African descent due to misdiagnosis as traction alopecia. 29 Particularly when examining a female patient in the post-menopausal age group who presents a smooth, symmetrical and atrophic area, linear frontotemporal hairline recession with enlargement of the forehead accompanied by alopecia of the eyebrows, the diagnosis of FFA should be suspected. Patients with FFA should be evaluated for additional cutaneous features including facial papules, glabellar red dots, and depressed frontal veins.30

Discoid lupus

Presentation: Discoid lupus erythematosus (DLE) on the scalp is usually associated with the DLE of the face and other exposed parts of the body like beard, v-area of the neck, upper back and ears, etc. It can present as red, scaly plaques with soreness and itchiness. The affected scalp shows erythema, scaling and oedema with follicular hyperkeratosis, atrophy and telangiectasia. More than one half of patients present with scalp lesion. In skin of colour patients it can present as hyperpigmented, scaly plaque without area of hypopigmentation.

Cause: DLE is a chronic form of cutaneous lupus, which can cause scarring.

Clinical findings: Examination of the scalp reveals atrophic alopecic patches. The affected area may be oedematous in the initial stage and is often associated with follicular plugging, erythema, scaling and telangiectasia. The patch may look white due to loss of pigment and fibrosis due to scarring.

Dermoscopic findings: Loss of pigmentation and disruption of honeycomb pattern; follicular keratotic plugs, red dots, giant irregular capillaries (thick arborizing vessels), periand inter follicular blue gray dots, loss of follicular opening (a common trichoscopic feature of all the scarring alopecias).

LEARNING RESOURCES

The UK’s black population is a minority and to date there are limited opportunities for those working in the field of hair restoration to equip themselves to adequately serve this group. Many conditions could be treated by a GP, but unfortunately the resources for education and updating in the field of diagnosing and managing Afro-textured hair conditions is limited. Opportunities for learning about hair loss in people with Afro-textured hair in the UK are limited in primary care, dermatology and aesthetics.

The majority of education takes place through societies such as the Primary Care Dermatology Society, which is primarily aimed at GPs and the wider primary health care team; The British Hair and Nail Society, whose membership

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comprises dermatologists; and the British Association of Hair Restoration Surgery, whose membership mainly comprises hair transplant surgeons. There will be other sources such as the St John’s Derm Academy events and occasionally the Nottingham Centre for Evidence-Based Dermatology. Resources for hair loss can be found on its skin of colour resource: nottingham.ac.uk/research/ g roups/cebd/resources/skin - of- colour/ hair- scalp disorders.aspx Hair-loss clinicians who want to better service POC patients should develop relationships with hairdressers and trichologists who will have their finger on the pulse of the latest hair fads. Industry events that may be worth attending include the International Ethnic Skin and Hair Conference, SCS (Society of Cosmetic Scientists) and REFERENCES 1. Raffi J; Suresh R; Agbai O. Clinical recognition and management of alopecia in women of color.

International Journal Of Women.s Dermatology. 5(5):314-319, 2019 Dec. 2. Westgate G, Ginger R, Green M. The biology and genetics of curly hair.. Experimental Dermatology.

2017;26:483–490.

3. K humalo N, Doe P, Dawber R.Ferguson D What is normal black African hair? A light and scanning electron-microscopic study. J Am Acad Dermatol 2000;43:814-20.

4. B ryant H, Porter C, Yang G. Curly hair: measured differences and contributions to breakage.

Internationla journal of dermatology 51(s1): 8-11 (2012) 5. Evans TA. Fatigue testing of hair-a statistical approach to hair breakage. Journal of cosmetic science. 2009;60(6):599-616.

6. Robbins C. Chemical andphysical behavior of human hair.4th Ed New York: Springer 2013 7. Q uaresma MV; Martinez Velasco MA; Tosti A. Hair Breakage in Patients of African Descent: Role of Dermoscopy. [Review] Skin Appendage Disorders. 1(2):99104, 2015 Sep. 8. P ouradier F; Liu C; Wares J; Yokoyama E; Collaudin C; Panhard S; Saint-Leger D; Loussouarn G. The worldwide diversity of scalp seborrhoea, as daily experienced by seven human ethnic groups.

International Journal of Cosmetic Science. 39(6):629-636, 2017 Dec. 9. L oussouarn G, El Rawadi

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C,Genain G, Diversity of hair growth profiles. International Journal of Dermatology 2005,44(Suppl. 1), 6–9 10. B arth JH. Measurement of hair growth. Clin Exp Dermatol 1986;11:127-30.

11. M yers RJ, Hamilton JB. Regeneration and rate of growth of hairin man. Ann N Y Acad Sci 1951;53:862-5.

12. A ncer-Arellano J, Tosti A, Villarreal-Villarreal CD, Chavez-Alvarez S, OcampoCandiani J. Positive Jacquet's sign in traction alopecia. J Eur Acad Dermatol Venereol. 2018 Dec;32(12):e446-e447.

13. W aśkiel A, Rakowska A, Sikora M, Olszewska M, Rudnicka L. Trichoscopy of alopecia areata: An update. J. Dermatol. 2018 Jun;45(6):692-700.

14. A kingbola CO, Vyas J. Traction alopecia: A neglected entity in 2017. Indian J Dermatol Venereol Leprol. 2017 NovDec;83(6):644-649.

15. K humalo NP, Jessop S, Gumedze F, Ehrlich R. Determinants of 16. m arginal traction alopecia in African girls and women. J Am 17. Acad Dermatol 2008;59:432-8.

18. Goren A, Wei L, Tan Y, Kovacevic M, McCoy J, Lotti T. Frontal pattern hair loss among Chinese women is frequently associated with ponytail hairstyle. Dermatol Ther. 2019 Jan;32(1):e12784 19. Al-Refu K. Clinical Significance of Trichoscopy in Common Causes of Hair Loss in Children: Analysis of 134 Cases. Int J Trichology. 2018 Jul-Aug;10(4):154-161.

20. Billero V, Miteva M. Traction

EHRS (European Hair Research Society). There will be a one-day symposium in London on Multi-Ethnic Hair by TRI Princeton and the International Trichology Congress on 5 October 2020.

SUMMARY

All practitioners providing hair-loss services should be aware of the important scarring hair loss conditions such as CCCA, frontal fibrosing alopecia and lupus, which need prompt referral to a dermatologist to slow down the progression.

Traction alopecia should only be diagnosed if the clinical signs are certain. If there is any doubt about the diagnosis, the patient should be referred to a GP who will be in a position to refer on to a dermatologist. AM alopecia: the root of the problem.

Clin Cosmet Investig Dermatol.

2018;11:149-159 21. S amrao A, Price VH, Zedek D et al. The, “fringe sign” A useful clinical finding in traction alopecia of the marginal hair line.

Dermatol. Online J. 2011; 17.

J; Gat A; Isakov O; Rabinowitz T; Shomron N; Adir N; Simon M; McMichael A; Dlova NC; Betz RC; Sprecher E. Variant PADI3 in Central Centrifugal Cicatricial Alopecia. New England Journal of Medicine. 380(9):833-841, 2019 02 28.

22. Polat M. Evaluation of clinical signs and early and late trichoscopy findings in traction alopecia patients with Fitzpatrick skin type II and III: a single-center, clinical study. Int. J. Dermatol. 2017 Aug;56(8):850-855

28. D lova NC; Jordaan FH; Sarig O; Sprecher E. Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black South Africans. Journal of the American Academy of Dermatology. 70(4):679-682. e1, 2014 Apr.

23. X u L, Liu KX, Senna MM. A Practical Approach to the Diagnosis and Management of Hair Loss in Children and Adolescents. Front Med (Lausanne). 2017;4:112

29. O lsen EA1, Callender V, Sperling L, McMichael A, Anstrom KJ, Bergfeld W, Durden F, Roberts J, Shapiro J, Whiting DA. Central scalp alopecia photographic scale in African American women.

24. A grawal S; Daruwalla SB; Dhurat RS. The flambeau sign - A new dermoscopy finding in a case of marginal traction alopecia. Australasian Journal of Dermatology. 61(1):49-50, 2020 Feb. 25. Shah SK; Alexis AF. Central centrifugal cicatricial alopecia: retrospective chart review.

Journal of Cutaneous Medicine & Surgery. 14(5):212-22, 2010 Sep-Oct. 26. Gathers RC; Jankowski M; Eide M; Lim HW. Hair grooming practices and central centrifugal cicatricial alopecia. Journal of the American Academy of Dermatology. 60(4):574-8, 2009 Apr. 27. Malki L; Sarig O; Romano MT; Mechin MC; Peled A; Pavlovsky M; Warshauer E; Samuelov L; Uwakwe L; Briskin V; Mohamad

30. D ermatol Ther. 2008 Jul-Aug;21(4):264-7. doi: 10.1111/j.15298019.2008.00208.x.

31. M iteva M; Tosti A. Dermatoscopic features of central centrifugal cicatricial alopecia. Journal of the American Academy of Dermatology. 71(3):443-9, 2014 Sep. 32. Miteva M; Whiting D; Harries M; Bernardes A; Tosti A. Frontal fibrosing alopecia in black patients.British Journal of Dermatology. 167(1):208-10, 2012 Jul. 33. K rueger L; Svigos K; Brinster N; Elbuluk N Frontal fibrosing alopecia: cutaneous associations in women with skin of color. Cutis. 102(5):335-338, 2018 Nov.

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 medical Member of The Trichological Society.

Aesthetic Medicine • July 2020

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BUSINESS

NEW INJECTORS

strong start Dr Sadaf Hussain and Dr Simon Zokaie answer some of the most pressing questions for newly-qualified practitioners

S

tarting out as a newly-qualified injector in aesthetics can be a daunting prospect.

While you are embarking on an exciting career that can make a huge, positive impact on people’s lives, there are also many different factors to consider.

The first step is to build your skills, techniques and knowledge of the procedures that you are starting out with. This is your foundation, which you will build upon with time and experience. The rest will come.

BUILDING A CLIENT BASE

One of the first questions people often ask is, “How do I start building up a client base?”

Remember that everyone, even the most successful injectors, started out without an established client base for these treatments. You may initially be reluctant to promote yourself, but we recommend that you start doing so to help you build your client base straight away. Don’t leave too long between completing your training course and picking up a syringe, as you may lose confidence. Of course, or those who trained just before lockdown and have been unable to inject patients yet, this is a particular challenge. It may be worth considering a refresher course once face-to-face training ensues to build your confidence back up. The main ways to do this are: Word of mouth – Landing your first few clients often comes by word of mouth through referrals from friends and family.

Taking care of these first few clients and delivering an excellent service will most likely result in those patients

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recommending you to their friends and family too. Word of mouth has always been one of the most effective ways of building a client base, so don’t underestimate it.

Build relationships – Speak to other established practitioners. Don’t be afraid. You are likely to find that they are quite happy to answer your questions and they may be a great source of support for you. They may even enlist you to work in their clinic where you can build up some experience. Building relationships with your patients is also paramount. Being technically great at what you do is important, but patients must also like and trust you. When a patient feels safe with you, they will come back to you and often introduce other new clients.

Online presence – Having your own website will help capture client interest.

Make sure it is easy to navigate and have an enquiry form so that you can capture enquiries and feedback. Having a profile on social media platforms is also crucial for clients to find you.

You should be on as many platforms as you can manage. In our experience, Instagram is one of the best platforms to build a following, but it is saturated. It will take time to become established and build a following.

Stay committed and regularly feature new informational or interesting posts. You can support this with paid ads on social media platforms and Google ads if you have the budget for it. You can also create a free profile page on apps like ZoomClinic.

Patients can view your availability and book appointments with you directly. You will soon also be able to offer video consultations to clients increasing your potential client base across the UK. Remember, often things do start off slowly, but keep going and you will start to see the rewards.

LOCATION, LOCATION, LOCATION

The next question people often ask themselves is where to practice from and whether or not they should rent their own treatment space. Most newly-qualified practitioners are still working in their primary professions and may want to build up their client base by starting to work on their aesthetic business part time.

Many start out by renting a treatment space somewhere to begin with. As your business grows, you may then be able to consider working full time in aesthetics and setting up your own practice.

There are pros and cons in each situation – consider the overheads and profit margins involved with running a full clinic versus a room alone.

In general, full clinics with staff and support tend to do better than a solo, oneperson service from a rented room. However, you may have limited options when you are first starting out. So, you really need to balance out and assess where you are right now and work towards your goals.

“Don’t leave too long between completing your training course and picking up a syringe, as you may lose confidence”

PRICING

How should you work out your pricing at first? Should you offer discounts on what you plan to charge when you’re more experienced and communicate this to potential patients?

You can look at prices set by other clinics, but this may not relate to your client base or area so keep that in mind.

Carry out your own patient survey regarding the prices your patients are willing to pay for treatments. Make sure that your prices allow for all your overheads and ensure your business can grow. This is one of the reasons discounts on services are generally not a great way to start. You want to attract the right clientele from the offset.

MAKING YOUR PATIENTS FEEL COMFORTABLE

Another concern many practitioners have when starting out is how to handle it if potential clients are wary of being treated by someone without much experience. Be honest about your training and be prepared to answer questions.

Patients will appreciate this and it will build trust between you. If you have a profile on ZoomClinic, you can tell patients that the service only registers doctors, dentists or nurses as aesthetic practitioners. So, although you may be new to aesthetics, you have strong grounding in patient care, practising safely and clinical experience which will support your aesthetic practice.

CHOOSING YOUR TREATMENTS

The most sensible treatments to start with are the simpler, such as anti-wrinkle injections (glabella, forehead, and

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crow’s feet) or dermal fillers (lips, cheeks, nasolabial folds).

Monitor and audit how many procedures you carry out rather than use a timescale to try and upskill yourself. Try to perform as many simple treatments as you can, perhaps even a thousand if that is what it takes for you to be a confident and competent injector, before doing more complex techniques. This will reduce the risk of possible complications further down the line when you may work within higher risk areas such as tear troughs, as you will have a firm grounding in injecting safely. When you start off, gentle lasers and skin rejuvenation treatments can also help bring you patients.

and if possible, take their email address or PA’s contact number. Throughout your training you will meet trainers who will be happy to remain in touch with you to support you. When you do refer clients, make it clear why you are referring and ask when they expect to review the patient again.

Stay in touch with your colleague and your client.

“Discounts on services are generally not a great way to start – you want to attract the right clientele from the offset”

REFERRALS

It is a good idea to have other contacts you can refer patients to if they want a treatment you don’t offer. Reach out to other more experienced colleagues such as dermatologists and plastic surgeons. You often meet other colleagues at educational events, so speak to them

Dr Sadaf Hussain is a GP with training in aesthetic treatments and founder of ZoomClinic, a private clinic directory and appointment booking service for clinics across the UK.

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COMPLICATIONS

It is incredibly important to learn about prevention, recognition and management of complications.

Be prepared and ready to manage complications that may occur. Remain calm, manage the complication, talk your patient through and speak to another senior colleague who can support you both.

It is a good idea to join bodies such as the British Association of Cosmetic Nurses (BACN), or British College of Aesthetic Medicine (BCAM), who can provide advice and guidance to aesthetic practitioners. Joining the Aesthetic Complications Expert (ACE) Group is also a good idea. AM

Dr Simon Zokaie is a consultant dermatologist and founder of The Linia Skin Clinic. He is also a key opinion leader for ZoomClinic.

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Follow the leader Get more followers for your clinic on Instagram with these 20 quick wins, says Jemma Edwards

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ith over 1 billion active users who spend an average of 53 minutes per day on the app, Instagram is an essential tool in your marketing plan. It’s a highly visual platform so you can show off your transformations, videos and treatments and the results are usually interesting enough to catch people’s attention. Along with Facebook, it’s where you should be concentrating your social media marketing efforts.

But, as the average person on Instagram follows 822 other profiles, you’re competing for attention. Here are 20 quick wins to boost your popularity with followers on Instagram:

1. TAKE BETTER PICTURES

You don’t need a special camera or photography degree; you just need a smartphone and to learn a little bit about lighting.

Maybe invest in a ring light to film your videos or for taking before-and-after pictures. You can now easily edit photos using filter software on your computer or with specific apps.

[See Alex Bugg’s advice on the best editing apps on pages 28 to 30.] If you are using a filter, try to use the same on all of your images. Save the settings so it remembers for each picture.

2. USE INSTAGRAM LIVE

Videos get great social media engagement and live videos are even better, so both Instagram and Facebook Live are well worth starting to use. People start to feel like they know and trust you and can interact with you and ask questions directly. This is especially good for aesthetic practitioners when it’s all about building trust with patients.

Also, if you save your “Live” to your “Story” you will be one of the first posts to show up on a user’s home screen.

Instagram favours videos and live videos over regular posts, so they will always show up higher in the feeds. Just make sure your videos aren’t too long and prepare what you want to say in advance. You could even do a trial run to keep your timing in check.

3. POST VIDEOS

If you want to upload a video onto your Instagram account’s feed and have it show up like a normal photo on your grid, it needs to be up to 60 seconds long. You could post quick videos of treatments in progress (time lapse) or a patient’s reaction when they look in the mirror and see their transformation.

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WOW FACIAL

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The WOW factor WOW Fusion mesotherapy is now available as a standalone treatment

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OW Facial is finishing its first year of trading, proving its success by celebrating three award wins. WOW Facial was awarded Advanced Facial Treatment of the Year 2020

by Lux Life, 2020’s award for Excellence and Innovation by Global Health and Pharma Magazine and the Aesthetic Entrepreneurs award for innovation and creativity within the industry. The team at WOW Facial have been working hard to make sure customers and their clients get the very best results from their treatments.

WOW Facial are experts in hyper-personalised skin solutions – this is why the facial gives such transformative results.

Claire Williams, CEO and founder of WOW Facial, set about helping support smaller businesses by providing an effective, personalised range of skin treatments, including WOW Fusion. WOW Facial launched WOW Fusion in February 2019 with advanced training for medics only, following strict protocols while teaching how to hyperpersonalise the system for patients. The combination of the high-quality ingredients and the novel delivery method with the WOW Fusion device has seen our customers get exceptional results when treating clients’ skin.

The WOW Facial is a six-stage protocol that is personalised at four of the six stages and uses carefullyselected active ingredients to help improve issues such as acne, pigmentation, open pores, oiliness, rosacea, fine lines

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and wrinkles, dehydrated skin and dullness.

WOW Fusion is the mesotherapy element of the full WOW Facial. Due to its popularity and successful results it is now marketed as a standalone treatment. Highly-effective techniques and protocols have been developed using highlyefficacious solutions. Protocols have been developed to improve rosacea, acne, oily skin, open pores, pigmentation, sun damage, hair loss and general skin rejuvenation.

The WOW Fusion device and solutions are now available to purchase from John Bannon Pharmacy, Wigmore Medical and Church Pharmacy or direct from the team at WOW Facial.

The team at WOW Facial is growing rapidly and they will soon be a team of six full time employees. They are excited to announce the arrival of a new skincare range comprising of four systems. The Intradermology range is due to launch in September 2020, with next-generation active ingredients with novel delivery systems.

Prior to the launch of the full range in September, WOW Facial is launching its Intradermology SPF in August. Synergy 6 NX-Gen SPF represents a new era in sun protection and damage prevention and will be the first new product to launch from the Intradermology range.

For any enquiries or further information, the team at WOW Facial would love to hear from you. Please visit wowfacial.co.uk or email info@wowfacial.co.uk AM

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4. ADD TO YOUR STORIES

Instagram prioritises “Stories” in user feeds, meaning you’ll get more recognition from your existing followers. The platform also favours people who are active and use all of its features, increasing your chances of your posts being favoured above others. You can also use Instagram Stories to post videos; they’re a great way to share smaller parts of your day with your followers without having them posted on your actual feed.

Stories expire after 24 hours, making this feature great for videos that are less important than the ones you want to be displayed permanently. You will need to be concise as videos on Instagram Stories can only be 15 seconds long.

Any videos longer than 15 seconds will be split into separate segments that can be uploaded in one go.

5. ENGAGE WITH PEOPLE

In the algorithm-driven world of social media, posts that have greater engagement are more likely to be shown to more people. Interact with people and comment on other users’ posts and images – not just a word or an emoji but a well thought out and positive comment. And when you post something, they are more likely to engage with your post in return.

6. LINK IN WITH LOCAL INFLUENCERS

The highly visual nature of Instagram is great for influencer marketing and free exposure. Instagram users are more likely to actively look for product recommendations on the platform, as opposed to Facebook, where they actively ignore them. So, try using Instagram influencers or even people in your local area with a large number of followers to spread the word about your treatments or business by offering them a free service. Just make sure any freebies are clearly declared as such on any posts.

USE HASHTAGS

7. Unlike Facebook, you can use up to 30 hashtags. And the more you use, the better, so use them all. Using 11 or more relevant hashtags means 442% more engagement compared to using none.

8. POST CONSISTENTLY

“Instagram favours videos and live videos over regular posts, so they will always show up higher in the feeds”

Aim for a maximum of one to three posts per day for Instagram. Don’t worry if you don’t have the time to post every day; try at least every other day.

9. SWITCH TO A BUSINESS ACCOUNT

your audience is most engaged.

• Ability to add a contact button to your profile: You can edit the button to be contacted directly by email or phone or provide customers with a map showing your location.

• Ability to add links to Instagram Stories: The only clickable link you are allowed with personal accounts is restricted to your profile. This restriction is lifted for business accounts.

• Add a URL to an image you post, and someone can click directly on that picture to be taken to wherever you want them to go.

• The ability to advertise on Instagram and create promoted posts: If you want to advertise on the platform you will need to operate a business profile. You can boost posts and run ads on Facebook and it will give you an option to also run the ad on Instagram.

An Instagram business account allows you to do much more, such as: • Access Instagram insights: When you switch to a business account you can access more data about the performance of your account such as the best time to post and when

10. SET UP YOUR SHOP

Instagram Shop allows brands or business accounts to turn their Instagram posts into “shoppable posts”, allowing them to buy the products in real-time directly from these posts. This feature is for physical products, so if you are talking about products you in clinic, you can tag them and lead users to your online shop.

11. RUN ADS

When you run ads, you are putting your business in front

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of thousands of people who wouldn’t usually see your posts. Instagram was bought out by Facebook founder Mark Zuckerberg in 2012, giving it immediate access to Facebook’s capabilities. Facebook’s highly advanced social media advertising platform lets you target people by age, interests, behaviour and location.

All this is now available on Instagram.

12. FOLLOW PEOPLE MOST LIKELY TO BE INTERESTED IN YOUR TREATMENTS

One of the best ways to attract a new following is by seeking out your closest competitors’ Instagram accounts and engaging with their audience. The three types of engagement on Instagram are following a user, liking a photo, and commenting on a photo. Shopify ran a test to see what engagement makes users follow other accounts: • Follow: 14% follow back • Follow and like: 22% follow back • Follow, like, and comment: 34% follow back

13. THINK ABOUT YOUR PROFILE PICTURE

Your profile picture on Instagram is tiny, so you want it to represent you and your business well. Professional images of you or a nicely-designed logo work well.

17. TAG PEOPLE OR COMPANIES IN YOUR IMAGES

Next time you post, think about who you can tag to open your posts up to a wider audience, such as a relevant brand or product and perhaps something related.

18. MENTION TRENDING TOPICS

Such as International Women’s Day, St Patrick’s Day, etc., but only if and when relevant to what you’re posting.

19. TAG LOCATIONS

Here you want to quickly let people know who you are, what you do and why you’re different, with a link to your website.

Sounds obvious, but a lot of businesses don’t utilise the space effectively and with potential customers in mind.

Besides hashtags, you can also make your Instagram posts and Stories discoverable by tagging your location, either the city your clinic is in or the venue where the photo or video was taken. Local businesses get the most value out of location tags by posting regularly to these feeds and also engaging with posts from prospective customers who are physically in the vicinity.

15. PROMOTE ON OTHER CHANNELS

20. DON’T “BUY” FOLLOWERS

14. OPTIMISE YOUR BIO

Give your Facebook, Twitter and LinkedIn followers a reason to head over to your Instagram account – announce that you’ll be doing an Instagram Live at a certain time, for example. If you can, do something like this once a month.

You might not get a ton of followers straight away but you’ll pick up a few here and there.

16. PUT YOUR SOCIAL MEDIA LINKS ON YOUR WEBSITE

Have your social links everywhere; your website, email footer and on appointment cards. You can also embed your Instagram and Facebook feeds to your website. As well as expanding your reach, it will also help with your SEO, pushing you higher up the ranking pages of Google when people search for your services.

Building a good following or reputation online takes time.

Some might be tempted to just buy followers, mainly for vanity. You can get a large number of followers very quickly for a relatively small cost, but there are some genuine downsides that will, in the long run, cause more problems for your business. The main issue is these paid-for followers are most likely fake accounts. They will not interact with you and most importantly not become patients or be interested in your services.

Instagram or Facebook will recognise that your large following isn’t engaging and will subsequently shrink the audience that views your posts, meaning your genuine followers won’t see your posts, making it harder to acquire potential new followers. Take it too far and Instagram and Facebook might simply ban you altogether. AM

Jemma Edwards is the owner of deliveringdemand.com, helping aesthetic professionals and cosmetic surgeons get more patients and grow their practices.

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

MEDIRA

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Advanced option PRP treatment for patients who present with a known low platelet count of 135K /µl

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hile much is made by PRP systems of an increase in platelet concentration over baseline, what is likely more relevant is the total number of platelets that are injected.

Total number of platelets is also likely to show greater correlation to the quantity of growth factors and with Cellenis PRP, the enrichment of monocytes and subsequent anti-inflammatory cytokines released at the site of injection.

Whereas platelet concentration depends on the volume of plasma that the platelets are suspended in, total platelets is a more accurate way to quantify the dose of platelets injected.

µl or more. 2 • For hair regeneration a platelet count of 1.4mil /µl can be considered ideal. 3 How can this patient’s low platelet count per microlitre be increased to a level considered clinically efficacious?

Very simply, if Cellenis PRP’s unique physical gel separation technology is used. Let’s assume a platelet count in the region of 1mil/µl is desired: • Cellenis PRP provides an average platelet harvest of 80%.

If the client platelet count is 135K/µl, 135 x 80% = 104K/µl platelets will be produced using Cellenis PRP. • To increase this to the 1mil/µl range, a nine-fold increase of this number is required. 104 x 9 = 936K/µl.

This is easily achieved with Cellenis by removing 90% of platelet-poor plasma immediately after centrifugation.

Re-suspend the platelets which have settled on top of the gel barrier into the remaining plasma – this step is critical with gel separation technology. Without this key step after centrifuging, any PRP platelet counts of plasma will be hopelessly inaccurate.

It’s not practical for most clinics to have an expensive cell count machine. To ensure high platelet counts per microlitre with every treatment, Cellenis PRP 22ml blood draw tubes enable an increase in platelets/µl while retaining an adequate volume of PRP for treatment. With an average client platelet count of 300K/µl, removal of 50% of plateletpoor plasma will ensure a platelet count in the region of 1mil/ µl within 6ml Cellenis PRP. Not only can a high platelet count per microlitre be simply obtained, but Cellenis technology ensures the depletion of neutrophils and erythrocytes as well.

Finally and importantly, is PRP a stem-cell treatment?

While it is true that today, peripheral blood is used as a stemcell source post-oncology treatment, it involves taking medication to mobilise haematopoietic stem cells with their CD34+ markers from bone marrow into the blood stream.

1500ml of blood is then drawn to isolate enough stem cells.

PRP should never be advertised as a stem cell treatment – there are simply too few stem cells in peripheral blood. AM

11ml

22ml

Individual platelet counts can vary between 150,000 and 400,000-450,000 per microlitre.

A literature review provides some guidance on what is an ideal, efficacious number of platelets per indication:

REFERENCES

• Orthopaedic and sports medicine favour 1,000,000/µl. 1 • For skin rejuvenation it’s between 800,000 to 1000,000/

3. G entile et al. Stem Cells Translational Medicine 2015;4:1317–1323

1. J Phys Ther Sci. 2017 May; 29(5): 896–901 2. A nn Derma. Can Platelet-rich Plasma Be Used for Skin Rejuvenation 2011 Nov;23(4):424-31

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TREATING ACNE

On the pulse Dr Firas Al-Niaimi looks at the options for using laser and light to treat acne vulgaris

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cne vulgaris is a common inflammatory skin disorder occurring often in adolescent years and can have a profound impact on the patient’s wellbeing. In addition, it has the potential to cause scarring which can further compound the psychological burden.1 Increasingly, acne is seen and reported in different age groups and with varying clinical presentations.

There are a large number of laser and light-based therapies available to patients for “common” acne, also known as acne vulgaris. However, these are not without side effects and in many cases the disease can be resistant to treatment, with relapses are relatively common. Current

treatment options available include topical therapy (both over the counter and prescriptive), chemical peels, and systemic therapy in the form of tablets. The choice of treatment depends on a number of factors such as the severity grade, type of lesions present, anatomic location, and patient preference. 2 Of late, interest in lasers and other light-based treatments has increased, with some authors reporting encouraging findings. One of the main advantages of the use of lasers in acne is the high degree of compliance and the negligible rate of potential systemic adverse events.3 It is therefore an attractive choice to many patients who are either unwilling to commit to prescriptive therapies or have

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experienced undesirable side effects.

It must be noted that while lasers certainly play a role in the management of acne, it is not the first-line choice of treatment, and in my opinion, works better synergistically in combination with other treatments. It is suitable for mild-to-moderate severity acne and is not recommended for severe acne.

MODE OF ACTION

Prior to explaining the mode of action of lasers in acne it is useful to briefly revisit the pathogenesis of acne and the main factors involved in its prognosis and treatment. Acne is a disease arising from the pilosebaceous unit, which comprises of the hair follicle with the attached sebaceous glands and the follicular openings often referred to as pores. Four key mechanisms play a role in acne and include: overactivity of the sebaceous gland, often manifesting itself with oily skin, follicular hyperkeratinisation, manifesting itself with blockage of pores, overgrowth of a commensal gram-positive bacteria cutibacterium acnes (formerly known as p.acnes); and lastly an inflammatory response mediated largely by the innate immune system secondary to the presence of the bacteria and the excessive sebum production.1 It is well known that the innate system plays a key role

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in acne, when pattern recognition receptors called T-like receptors-2 are activated with mediators such as AP-1 and NFĸB eliciting an inflammatory response.4 Successful treatment of acne therefore should target as many of these mechanisms as possible, and therefore combination therapy is often recommended.

Lasers and light-based therapies such as lightemitting diodes (LED) and intense pulsed light (IPL) work predominantly through a combination of photochemical and photothermal mechanisms. That is, the heat generated from the light can have beneficial effects on acne through effects on sebaceous gland activity, bactericidal killing and anti-inflammatory actions through heat shock proteins.

Photochemical effects are largely aimed at the c.acnes bacteria through a phototoxic reaction, with further modulations of the inflammation through the biological interaction of light and tissue.3 Endogenous porphyrins produced by c.acnes are thought to absorb light at specific wavelengths which then produce phototoxic effects, resulting in bacterial death with, as result, a reduction in the secondary inflammation partly initiated by the overgrowth and presence of the bacteria.

Another example of the photochemical effect is the alteration in the TGF-beta following the use of pulsed-dye laser (PDL) in acne.5 In general, all lasers and light-based

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therapies have shown a preferential benefit in inflammatory acne compared to non-inflammatory comedonal acne and as such, lasers should not be recommended if the acne is predominantly non-inflammatory.

fewer studies and comparative trials. Nevertheless, it has been used with success in acne and like the PDL works preferentially in the inflammatory type of acne.3

MAIN MODALITIES

Infrared lasers penetrate deep into the dermis, targeting water as their main chromophore with a predominantly photothermal effect on the sebaceous glands in addition to the generation of heat-shock proteins that can lead to bacterial killing. A previously used laser with 1450nm was specifically designed for acne with good efficacy, although this is no longer being manufactured.8 The 1540nm erbium glass laser is a mid-infrared laser; its wavelength is absorbed primarily by water and thus targets the sebaceous glands and dermal matrix. There is minimal absorption by melanin, making it a safe option in dark-skinned patients. While it is predominantly used for scars and rejuvenation, there are few studies supporting its benefit in acne.9 The 1064nm Nd:YAG is probably the best studied and used infrared laser in acne, which similarly to the other modalities, has shown superiority in the inflammatory component with overall satisfactory results following few treatment sessions. Comparative studies have demonstrated comparable results to the PDL with few side-effects. The mode of action is predominantly photothermal and both the long-pulsed in millisecond as well as the microsecond modes have been used with equivocal efficacy.3

Each of the main laser or light-based modalities will be presented with regards to its role in acne:

LED (blue and red light)

Although blue light has poor skin penetration given its short wavelength in the range of 400-420nm, it exhibits the strongest porphyrin photo-excitation co-efficient and thus is the most effective wavelength to photo-activate the endogenous porphyrins produced by c.acnes.

Pulsed blue light is not used in clinical practice hence LED is the preferred choice for this wavelength. The difference is that LED contains a band of wavelengths within the blue light spectrum, emitting continuous low-level energy light in a non-collimated fashion. There are several studies on blue light in acne as monotherapy or in combination, with most studies showing an improvement with photodynamic therapy (PDT) and blue light showing the strongest level of evidence.6 Red light penetrates the skin at a deeper level – down to the sebaceous gland – and is thought to have anti-inflammatory properties. Its deeper penetration is also clinically relevant in targeting the sebaceous glands and the micro-vessels around them.

Currently the evidence of red light is the strongest in combination with blue light, topical therapy, or with a photosensitising drug as PDT.7

Infrared lasers

"I prefer to combine the laser or IPL treatments with appropriate topical therapy and use at intervals of two to three weeks"

Pulsed dye laser (PDL)

The 585/595nm PDL targets oxyhaemaglobin and results in selective photothermolysis of vessels. It is largely considered the gold standard laser in vascular malformations and disorders largely owing to the vast level of evidence behind it. In acne the PDL has been used with overall good level of success both as monotherapy and in combination. The mechanisms are a combination of photothermal effects and in particular the microvessels that form part of the inflammatory process in addition to photochemical effects and bactericidal killing, as described earlier in the article.

This is because of the absorption spectrum of endogenous porphyrins with their peak in blue light and a second lower peak in the soret band between 500 and 600nm, hence the effect of the PDL. There are different parameters used with inconclusive evidence for one particular range and both purpuric and non-purpuric settings in acne showed comparable efficacy.15

Potassium titanyl phosphate (KTP)

This 532nm laser emits green light which penetrates deeper than blue light but less so than PDL for the same spot size. Given its wavelength within the soret band it exerts similar mechanisms to the PDL although with

Photodynamic therapy (PDT)

Photodynamic therapy includes the use of a photosensitiser, which is taken up by the pilosebaceous unit and undergoes metabolism through the haem-synthesis pathway, resulting in the production of protoporphyrin IX. The activation of this pathway leads to the production of free radicals and singlet oxygen which are cytotoxic, thus destroying the pilosebacoues unit and killing c. acnes itself.10 For PDT to be effective, light, oxygen and a photosensitiser are required. A light source can be an LED or fluorescent lamp, laser, sunlight, xenon flash lamp, arc lamp or filtered incandescent lamps. C. acnes photoinactivation can be altered depending on the concentration of porphyrins, which is governed by the type of acne lesion, effective fluence, wavelength of the photons emitted, exposure time and the temperature. Currently, most of the PDT is used in the setting of blue and red light with the highest level of evidence.11 Studies on PDT with IPL and PDL have however shown good results, albeit less compared to LEDs.12

Intense pulsed light

An IPL device delivers an intense source of light, the wavelengths of which can be modified via the use of filters.

It is different to lasers in that the light is non-collimated and a band of wavelengths are used instead of a single wavelength. The theory of treating acne lesions with IPL is based on the photochemical and photothermal effects

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on both the c. acnes as well as the inflammatory process, sebaceous glands, and small vessels associated with the process.

Different filters are used either in the blue light range, soret band (500-600nm), or infrared. Some IPL machines have a dedicated “acnefilter” handpiece, emitting shorter wavelengths in blue and visible light with longer wavelengths in the infrared range to allow for maximum dual effect of both photochemical and photothermal effects at different depths. IPL is generally effective in acne and can be used in combination with other treatments.13

Photopneumatic therapy

Photopneumatic therapy combines pneumatic energy in the form of suction and broadband light (400-1200nm), encompassing the short blue light wavelengths and the longer infrared wavelengths with the advantages explained above. The suction acts to lift the contents of the dermis, bringing it closer to the skin’s surface, thus making energy transfer more effective. There is also an element of comedone clearance through the mechanical suction. This treatment is relatively safe with few studies supporting its efficacy in mixed inflammatory and comedonal acne, the latter in particular secondary to the pneumatic function.14

COMBINATION THERAPY

As mentioned, while light-based therapies are largely effective in acne they are best used in mild-to-moderate severity cases, and preferably in combination. Appropriate skincare products suitable for acne such as salicylic or glycolic acid exfoliators or cleansers with topical niacinamide or retinoids can be combined with lasers for enhanced efficacy. Systemic drugs can be combined, although in most cases caution is required, and this would be limited to the experienced practitioner.

My preferred method is the PDL in lighter skin types (or the IPL) and the Nd:YAG in darker skin types to maximise safety. I prefer to combine the laser or IPL treatments with appropriate topical therapy and use at intervals of two to three weeks, with the exception of LED therapy, which is more frequent.

Lasers and light-based therapies appear to work better on the inflammatory component and require several treatment sessions based on the severity. They are a suitable choice for patients unwilling to or unsuitable for standard medical therapy and are generally safe. The main advantage is the lack of systemic side-effects, which is increasingly requested by patients. AM

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REFERENCES 1. Z aenglein AL. Acne Vulgaris. N Engl J Med. 2018;379(14):1343-1352.

2. Nast A, Dréno B, Bettoli V, et al. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol.

2012;26 Suppl 1:1-29.

3. T ong LX, Brauer JA. Lasers, Light, and the Treatment of Acne: A Comprehensive Review of the Literature. J Drugs Dermatol.

2017;16(11):1095-1102.

4. D reno B, Gollnick HP, Kang S, et al. Understanding innate immunity and inflammation in acne: implications for management. J Eur Acad Dermatol Venereol. 2015;29 Suppl 4:3-11.

5. S eaton ED, Mouser PE, Charakida A, Alam S, Seldon PM, Chu AC. Investigation of the mechanism of action of nonablative pulsed-dye laser therapy in photorejuvenation and inflammatory acne vulgaris [published correction appears in Br J Dermatol. 2007 Feb;156(2):409.

6. S cott AM, Stehlik P, Clark J, et al. Blue-Light Therapy for Acne Vulgaris: A Systematic Review and Meta-Analysis. Ann Fam Med. 2019;17(6):545553.

7. P osadzki P, Car J. Light Therapies for Acne. JAMA Dermatol.

2018;154(5):597-598.

8. D arné S, Hiscutt EL, Seukeran DC. Evaluation of the clinical efficacy of the 1,450 nm laser in acne vulgaris: a randomized split-face, investigatorblinded clinical trial. Br J Dermatol. 2011;165(6):1256-1262.

9. P oliti Y, Levi A, Enk CD, Lapidoth M. Integrated cooling-vacuum-assisted 1540-nm erbium:glass laser is effective in treating mild-to-moderate acne vulgaris. Lasers Med Sci. 2015;30(9):2389-2393.

10. P ollock B, Turner D, Stringer MR, et al. Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action. Br J Dermatol.

2004;151(3):616-622.

11. B oen M, Brownell J, Patel P, Tsoukas MM. The Role of Photodynamic Therapy in Acne: An Evidence-Based Review. Am J Clin Dermatol.

2017;18(3):311-321.

12. Rojanamatin J, Choawawanich P. Treatment of inflammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study. Dermatol Surg. 2006;32(8):991-997.

13. T aylor M, Porter R, Gonzalez M. Intense pulsed light may improve inflammatory acne through TNF-α down-regulation. J Cosmet Laser Ther. 2014;16(2):96-103.

14. O mi T. Photopneumatic technology in acne treatment and skin rejuvenation: histological assessment. Laser Ther. 2012;21(2):113-123.

15. Forbat E, Al-Niaimi F. Nonvascular uses of pulsed dye laser in clinical dermatology [published online ahead of print, 2019 Apr 19]. J Cosmet Dermatol. 2019;10.1111/jocd.12924. doi:10.1111/jocd.12924

Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser expert with over 15 years’ experience.

He is currently in full-time private practice in London alongside a lecturing and research post at a Danish university involved in scientific research. Dr Al-Niaimi has published over 180 publications in dermatology and lasers.

Aesthetic Medicine • July 2020

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