Aesthetic Medicine - September 2019 by Aesthetic Medicine

INSPIRING BEST PRACTICE IN MEDICAL AESTHETICS

WORLD VIEW GLOBAL BEAUTY TRENDS September 2019

September 2019 | aestheticmed.co.uk

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LIGHT YEARS AHEAD ADVANCES IN TECHNOLOGY AMBASSADOR FOR CHANGE TREATING LGBTQ+ CLIENTS

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lynton.co.uk/3JUVE

A Skin Solution for Every Client

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Dr Nicole Chiang Consultant Dermatologist MBChB(Hons), MRCP(UK)(Derm), PGCert Aesthetic 38 City Road East, Manchester, M15 4QN 0161 236 6500 | lumiereclinic.co.uk

As a Consultant Dermatologist, what is it that initially inspired you to move into the aesthetics industry and open the LUMIERE Clinic?

Are you happy with the clinical results you have gained with your Lynton equipment?

As a Dermatologist, I acquired experience

importantly, so are our patients. We have

in cosmetic dermatology during my

treated a large volume of Rosacea patients

training in the UK, USA and Australia.

using the Rebright IPL application, and even

My experiences from different practices

after one treatment, there is significant

around the world provided me with an

clearance. We also see a large volume of

insight into how the broad range of

patients who suffer from acne scarring, so the

cosmetic dermatology treatments can

Resurface fractional laser works perfectly in

dramatically improve a patientâ&#x20AC;&#x2122;s quality of

helping improving the texture and appearance

life. I enjoy combining both my aesthetic

of their skin. From using other IPL and laser

and specialist dermatology knowledge

devices in the past, I can say that the Lynton

to ensure that patients achieve the best

IPL is much stronger, helping us see better

possible results, and this gives me an

and faster treatment results.

Courtesy of Lumiere Clinic - Lifting & Tightening (3JUVE)

The 3JUVE treatment concept works by using varying proportions of the 3 technologies, dependent on the needs of the client; is this something you do?

What advice would you give to someone considering investing in a piece of aesthetic equipment?

We like to treat every patient on an individual

accreditations is very important. I personally

basis, so the 3JUVE is sometimes used to just

chose Lynton because I know their

treat their particular concern. For a patient

technology is medically-certified and I have

who is looking for an overall anti-ageing

seen the awards they have won in recent

or skin rejuvenation result, we may tailor a

years for the quality of their equipment and

3JUVE treatment based on what they require

the level of their customer service. I also

most. The 3JUVE actually really complements

wanted to work with a UK-based company

some of the other treatments we offer as a

and manufacturer that could offer me a

skin clinic, allowing me to focus on delivering

high-level of technical service and quick

injectable and medical treatments, and then

response times. This gives me the peace

passing a patient onto to one of my laser

of mind that if I was to occur any problems,

practitioner to finish with a 3JUVE regime.

it could be solved quickly and avoid me

We are delighted with the results we have achieved with the 3JUVE, but more

Courtesy of Lumiere Clinic - Rosacia (3JUVE)

immense sense of job satisfaction.

Why did you decide to introduce the Lynton 3JUVE into your skin clinic? As a new clinic, we needed to make an investment into one piece of equipment that would then offer us multiple treatment options, so the 3 in 1 option worked well. We have such a wide range of different skin conditions coming into the clinic, so it was important that we had a device that was versatile and that could treat our most in-demand skin rejuvenation treatments.

For me, picking a company that is well established and that has strong

cancelling any patients.

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Entrance policy: The show is open to doctors, dentists, nurses, medical professionals and qualified aesthetic practitioners. Strictly no persons under the age of 18 will be admitted.

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

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Contents SEPTEMBER

EDITORIAL Vicky Eldridge E: vicky@aestheticmed.co.uk T: +44 (0) 207 351 0536

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

NEWS AND ANALYSIS

BUSINESS

10 NEWS The latest news from the industry

24 EMPLOYMENT Victoria Vilas advises on how to deal with chronic health conditions in the workplace

16 OPINION Dr Emma Sharpe discusses the implications of the recent Cancer Research UK campaign 18 AESTHETIC MEDICINE NORTH 2019 We round up what happened at this years show

CLASSIFIED Nur Suleyman

28 MINDSET Dr Harry Singh on mindset, money and motivation 34 REGULATION Tracey Jones and Sophie SinghJagatia ask, is registration with the Government regulator a choice or a pre requisite? 38 MATERNITY LEAVE Julie Brackenbury shares her experience and advice on how you can prepare to return to a healthy business while taking maternity leave

E: nur@aestheticmed.co.uk T: +44 (0) 207 349 4796

MARKETING Chloe Skilton E: chloe@aestheticmed.co.uk T: +44 (0) 207 351 0536

26 PATIENT ACQUISITION Laura Moxham on using Google to your advantage

PUBLISHER Mark Moloney E: mark@aestheticmed.co.uk T: +44 (0) 207 351 0536

DESIGN AND PRODUCTION ICD www.icd.gb.com

PRINTING Walstead United Kingdom walstead-uk.com SUBSCRIBE Annual subscription UK: Print £44, DD £39.50, Digital £10. Europe: £59.50; outside Europe: £67.30. 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 Allington House High Street Wimbledon Village SW19 5DX

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CONTENTS

IN THIS ISSUE...

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SKIN

DEVICES

42 PRODUCT FOCUS Alto Defense Serum 44 SKINCARE SPY Sarah White shares her skincare must-haves 46 SKIN NEWS The latest product launches for the skin

INJECTABLES 50 COVER STORY We speak to Dr Vincent about becoming the world’s first LGBTQ+ ambassador 44 GLOBAL BEAUTY TRENDS We take a look at global beauty trends and the aesthetics market

59 LOCAL ANAESTHETIC Dr Sotirios Foutsizoglou on understanding local anaesthetic 70 EDITOR’S CHOICE Vicky Eldridge tries Aliaxin SR and Profhilo in the face and neck 73 INTEGRATIVE THERAPY Benedetto Cusumano discusses combining laser phototherapy and PRP for hair loss 76 Q&A Dr Zunaid Alli, key opinion leader for Vivacy Stylage, explains why he advocates the pioneering dermal filler range

OUT AND ABOUT

81 DOSSIER Advances in laser and light technology 90 INTERVIEW We speak to Professor Paolo Bonan about the benefits of C02 lasers in the treatment of children

92 VIRTUAL REALITY How Dr Sabrina ShahDesai is taking aesthetic training to the next level through virtual reality

96 OUT AND ABOUT Out and about in the industry this month

94 CLINICAL PHOTOGRAPHY Creating standardised and high quality patient images for your practice

Welcome to the September edition of Aesthetic Medicine

This month, for the first time in the magazine’s history, we have featured someone from the industry on our cov. I’m very proud to be supporting Dr Vincent Wong with his new #IAMME campaign. He has just been named as the world’s first LGBTQ+ ambassador working with Allergan and launched his campaign in a bid to explore the power of medical aesthetics to channel the inner confidence of individuals within the LGBTQ+ community in order to help overcome some of the struggles and issues they face (see pages 48-50). 48

To me this shows how many far reaching benefits our industry has for such a diverse range of patient groups. For this same reason we have decided to make the theme of our 2020 Aesthetic Medicine Live conference “diversity”, focussing on how we can best serve different patient groups who walk through the doors of aesthetics clinics, not only innovative treatments and techniques but through marketing messages, consultations and customer service too. Topics will include treating menopausal women, attracting male clients to your practice, treatments for the older demographic, the ethics around treating younger patients, offering services for a diverse range of skin types, dealing with patients with mental health issues and treating transgender patients. I look forward to announcing the preliminary agenda in next month’s magazine. Vicky Eldridge - Editor

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

INDUSTRY NEWS

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ASA rules against beauty companies offering aesthetic training following JCCP complaints An investigation by the Advertising Standards Authority (ASA) into misleading representations of qualifications and pathways to practise within aesthetics has led to rulings against three training companies. The investigation followed compalints by the Joint Council for Cosmetic Practitioners (JCCP) about advertisments by three establishments – Aesthetics Uni, Aesthetics Lounge Academy and Boss Babes Uni. In all three cases the ASA upheld the complaints stating that the companies had misrespresented or withheld the full and correct information necessary for potential students to make an informed decision. The North West of England has been highlighted as one particular problem area with exaggerated and inaccurate forms of marketing in this manner. Professor David Sines, executive chair of the JCCP, said, “With the recent significant growth in non-surgical cosmetic and hair restoration surgical procedures there has been a correspondent ‘explosion’ of education and training companies offering to train people to perform these procedures. Unfortunately, some training companies

have misrepresented the basis of the training provided, the level and type of qualification obtained, and how their programmes relate to the standards required for admittance to relevant PSA-accredited voluntary professional registers, such as the JCCP. This misrepresentation leads to trainees spending large sums of money on training programmes that have not been developed in line with required standards and regulated qualifications. We are delighted that the ASA has upheld these three complaints.”

Number of Baby Boomers seeking cosmetic procedures on the rise as they re-enter dating scene New statistics from the American Society of Plastic Surgeons (ASPS) have shown a huge spike in the number of over-55s undergoing cosmetic procedures, with nearly 50,000 more performed in 2018 than in the previous year. The rise has been attributed to the number of people in this age group now reentering the dating scene. The divorce rate among Baby Boomers has roughly doubled since the 1990s, which explains this generation’s rise in dating, with 20 million Baby Boomers thought to currently be using online dating sites. Surgical procedures like liposuction, hair transplantation, and breast augmentation have all increased in this demographic, as have minimally invasive options like Botox and fillers. This age group also accounted for nearly half of all eyelid surgeries and two-thirds of facelifts performed last year. “Baby Boomers are not looking to turn back the clock to their twenties – they just want to look as young and vibrant on the outside as they feel on the inside,” said Dr Anne Taylor, a board-certified plastic surgeon in Columbus, Ohio.

Facial plastic surgery in men enhances perception of attractiveness, trustworthiness and likeability, says study Perceptions of attractiveness, likeability, social skills or trustworthiness are increased when looking at images of men who had had facial plastic surgery, according to a first-of-its-kind study, published in JAMA Facial Plastic Surgery. A total of 24 men, who underwent one or more facial procedures with surgeons at Georgetown University Medical Center, agreed for their before and after photographs to be used for research purposes. More than 150 participants reviewed the photos and were asked to rate their perception of each patient’s personality traits (aggressiveness, extroversion, likeability, risk-seeking, sociability, trustworthiness, attractiveness and masculinity). They found that upper eyelid surgery increased likeability and trustworthiness, while lower eyelid decreased risk-taking. Browlifts gave the an improved perception of extroversion and risk-taking while facelifts increased likability and trustworthiness. Finally, necklifts increased perceived extroversion and masculinity while nose reshaping improved attractiveness.

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INDUSTRY NEWS

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Study assesses retrobulbar hyaluronidase as treatment for filler-induced blindness A study, published in Plastic and Reconstructive Surgery has examined the viability of retrobulbar injection of hyaluronidase as a treatment for blindness induced by hyaluronic acid gel fillers. The aim of the study was to determin whether hyaluronidase can diffuse through the dural sheath of the optic nerve to clear a filler-mediated occlusion of the central retinal artery. Six human cadaveric optic nerves were studied in vitro. One optic nerve was selected as a control and maintained at physiologic temperature, without any exposure to hyaluronic acid gel or hyaluronidase. To simulate a central retinal artery occlusion, this experimental nerve and additional controls were injected with hyaluronic acid gel. These hyaluronic acid gel–injected nerves were then either injected directly with hyaluronidase to establish a control for intraneural hyaluronidase exposure,

or immersed in undiluted hyaluronidase to simulate retrobulbar hyaluronidase injection. Intact hyaluronic acid gel was observed grossly and microscopically in the control optic nerves injected directly with filler and not with hyaluronidase. The control optic nerve injected with intraneural hyaluronidase exhibited partial digestion of the filler. Immersion in undiluted hyaluronidase led to no apparent gross or microscopic digestion of injected intraneural hyaluronic acid gel. The authors concluded that hyaluronidase does not demonstrate the ability to cross the dural sheath of the optic nerve, suggesting that retrobulbar hyaluronidase injection is unlikely to alleviate hyaluronic acid gel–mediated central retinal artery occlusion and blindness.

Aesthetic medicine “overwhelmingly a young and female issue” reveals latest survey of aesthetic doctors and dentists Latest data from the British College of Aesthetic Medicine (BCAM) has revealed an overwhelming 88% of patients seen by aesthetic doctors and dentists in the last 12 months are female, with 21% of women patients less than 35 years of age. The data represents analysis of more than 225,000 individual treatment episodes reported by 270 medically qualified aesthetic practitioners over the past year. The survey also showed that 64% of BCAM doctors reported treating other practitioners’ Botox issues issues, while 77% corrected other practitioners’ dermal filler complications. A further 25% of respondents reported treating laser/IPL problems, while 25% dealt with thread-lift issues.

Facial bones of black adults age differently from other races, says study

A study recently published in JAMA Facial Plastic Surgery has suggested that facial bones in black adults maintain higher mineral density as they age than other races, resulting in fewer changes to their facial structure. The study is the first of its kind and the findings could affect how plastic surgeons approach facial rejuvenation with black patients. “It is important for plastic surgeons to understand how the facial ageing process differs among racial and ethnic groups

to provide the best treatment,” said the study’s lead author Boris Paskhover, an assistant professor at Rutgers New Jersey Medical School’s Department of Otolaryngology. As people grow older, they can lose bone mineral density, which results in bone loss. In the face, this loss can affect the shape of the nose, lower jowl area, cheekbones and middle and lower areas of the eye sockets. To understand how facial bones age in black adults, researchers analysed medical records from 1973 and 2017 of 20 black patients – 14 women and six men between the ages of 40 and 55 – who had at least two facial computed tomographic (CT) images taken on average a decade apart without any surgical intervention and who reported as being black. While the comparative images showed a significant change in the facial bones over time in the black patients, these changes were minor compared to similar studies on the ageing white population. Previous studies on how facial bones age have ignored race and past studies on ethnic groups have focused on the differences in skin composition rather than bone changes, Paskhover said.

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

INDUSTRY NEWS

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36% of top YouTube videos on eczema are potentially harmful A study presented at the British Association of Dermatologists’ annual meeting in Liverpool has revealed that 36% of the most-viewed eczema YouTube videos are potentially harmful. The study analysed the quality of information provided in the 100 most-viewed eczema-related videos on YouTube. These have a combined total of 8,527,624 views and a duration of seven hours and 52 minutes. The quality of the videos was assessed using the Global Quality Scale (GQS) and the DISCERN instrument and the videos were classified into ‘useful’, ‘misleading’ and ‘potentially harmful’. The number of viewers’ ratings (‘likes’) was correlated with the scores of the GQS and DISCERN. The authors found that 46% were misleading, and 36% disseminated content that was potentially dangerous to eczema patients. Dr Simon Mueller of University Hospital Basel, Switzerland,

and lead author of the study, said, “Social media is a continually growing source of medical information for patients, particularly for young people. This information often doesn’t undergo review for scientific accuracy or quality and, as our research shows, it has the potential to be heavily biased or even harmful. We hope that our research will make people think twice about the medical information they get from social media. The internet is a powerful and often helpful research tool. We do not advise against this kind of lay research, but we clearly advise against decision making based on YouTube videos only.”

Galderma UK signs contract with Medfx as sole-preferred distributor for UK and Ireland Galderma UK has officially signed Medfx as the sole-preferred distributor for its aesthetics portfolio in the UK and Ireland. The contract will come into force on September 8 when its distributor relationships with Church and Wigmore for products marketed under the Azzalure and Restylane brands ends. Galderma announced that it had awarded Medfx the contract to act as its sole-preferred distributor for its aesthetics portfolio in June. It claims the new partnership will offer an enhanced package of customercentric support services for healthcare professionals to improve their businesses, patient outcomes, safety and overall industry standards. Paul Adams, managing director of DD (formally Dental Directory), parent company of Medfx said, “We see this partnership with Galderma as a real opportunity to improve the industry model, to offer better levels of service across the supply chain and deliver a new standard of excellence.”

UK women are cutting the number of products used in their skincare routine UK women are cutting back on the number of skincare products they use, according to research by Mintel. Its Women’s Facial Skincare Report claimed that 28% have reduced the number of products in their routine over the past year. Millennial women (aged 20–29) are the group most likely to have simplified their routines, with more than half (54%) having already removed products from their regime, the report found. Mintel predicts that the women’s facial skincare market will decline by nearly 1% this year, falling to an estimated £1.6bn from £1.17bn in 2018. Women are moving away from multi-step routines, with the number of those using one product to cleanse their face rising from 25% in 2018 to 28% in May 2019. Facial cleansing wipes have also fallen out of favour, dropping from 54% to 43% in the same time period. However, face oils and serums are immune to the shift, with 40% of women using facial caring products and associating these items with being “nourishing” and providing a healthy “glow”. As such, 20% of female skincare users think of serums as “brightening”, representing radiance and luminosity.

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INDUSTRY NEWS

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NEWS IN BRIEF ABBVIE ANNOUNCES $63 BILLION DEAL TO BUY ALLERGAN

US biopharmaceutical company AbbVie has agreed to buy Allergan in a cash and stock deal reportedly totally $63bn (£49.98bn). It is reported that Allergan shareholders will receive 0.8660 of AbbVie shares and $120.30 in cash for each share that they hold. The deal is expected to close in early 2020 and is subject to regulatory and Allergan’s shareholder approvals.

INFLAMMATORY SKIN CONDITIONS SEVERELY IMPACT QUALITY OF LIFE

Raconteur’s Skin and Dermatology Report analysed the impact a skin condition can have on mental health and quality of life. Research by the Happiness Research Institute showed sufferers of severe psoriasis had a happiness level three points below the UK average (4.2 compared to 7.2) in 2018, while 73% reported high stress and 40% said they dealt with loneliness. In addition, 44% said they had missed five or more hours of social time due to their condition, while 11% had missed more than 20 hours of work.

AESTHETIC ENTREPRENEURS’ LAUNCHPAD HELPS NEW BUSINESSES

The Aesthetic Entrepreneurs has announced the introduction of its accelerator programme for new and emerging aesthetic businesses – the Launchpad. Aimed at businesses under a year old, the Launchpad is designed to provide expert advice and support to help aspiring entrepreneurs get off the ground. Founder Richard CrawfordSmall, said “It became apparent that many new businesses were really struggling in that crucial first few months because they had no real plan and little access to support. “

VIVACY OPENS UK SUBSIDIARY WITH NEW CENTRAL LONDON OFFICE

Vivacy, the company behind the Stylage range of fillers and Desirial, the first injectable and completely biodegradable hyaluronic acid designed for intimate rejuvenation, will now be supplying products directly in the UK rather than through a distributor. The brands will also be available through Wigmore. Vivacy is a French manufacturer specialising in the design, production and distribution of injectable hyaluronic acid-based medical devices for use in aesthetic and anti-ageing medicine.

Study determines which Instagram filters are most flattering Findings from a recent study published in the Aesthetic Surgery Journal have assessed popular Instagram filters. The study, titled “What is the Ideal Instagram Filter?”, set out to determine which Instagram filters create the most flattering and youthful appearances for patients as they attempt to illustrate their desired post-op appearance. A total of 78 respondents participated in the study, which analysed standardised photos of women that were altered with popular Instagram filters. The study found the most flattering filters to be Juno, Lark, and Sierra; the most youthful to be Reyes, Rise, and Gingham; the least flattering to be Hefe, X-Pro, and Slumber; and the least youthful to be Perpetua, Crema, and Aden. The filters found to be most youthful and most flattering each made the subject’s face brighter, smoothed imperfections, and accentuated light colours. Conversely, the filters determined to be the least flattering and youthful darkened the photos and increased contrast and shadows. Dr Anthony Youn, author of the study, said, “Determining the ideal Instagram filters can give us insight into more than just the desired surgical or non-surgical cosmetic outcome, but what our society as a whole considers flattering and desirable.”

JCCP and CPSA issue a statement outlining their position on remote prescribing The Joint Council for Cosmetic Practitioners (JCCP) has issued a statement affirming that it does not endorse or permit remote prescribing of any prescription medicine when used specifically for cosmetic treatments. Alberto Costa MP, chair of the all party parliamentary group on beauty, wellbeing and aesthetics, said, “Remote prescribing for nonsurgical cosmetic procedures can be unsafe and harmful and should not be used under any circumstances. This is a great first step to further protect consumers who choose to undergo non-surgical cosmetic procedures. “This will help to close the ‘loopholes’ that currently exist in which injectables, which are prescribed by health care professionals, can be remotely prescribed and delegated to anyone without first assuring that professional face-to-face patient assessment and clinical oversight is provided in all circumstances.”

NEWS IN PICTURES Professor Bob Khanna recently held The Ultimate Thread Lifting Cadaver Course at King’s College, London. The day included theoretical lectures and practical hands-on sessions covering 3D facial anatomy and the principles of thread lifting using different methodologies. Professor Khanna said, “It’s essential that all clinicians carrying out facial aesthetic procedures be given comprehensive training and knowledge in 3D anatomy alongside detailed knowledge on techniques and concepts. This is especially important when it comes to thread lifting.”

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

OPINION

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The bigger picture Dr Emma Sharpe, lecturer in psychology at the University of Derby, discusses the implications of a recent Cancer Research UK campaign in terms of the promotion of weight bias, stigmatisation and discrimination of those who are overweight/obese

he UK’s leading cancer charity, Cancer Research UK, recently launched a campaign to highlight the problem of obesity. The overall message was clearly well-meaning, and the shock tactics used were effective in raising public awareness of the issue, but at what cost? . Globally, 39% of the world’s adult population is overweight, and 13% is obese. These rates are increasing, and it is predicted that by 2050 more than half of adults will be affected by obesity. In the UK alone, an estimated 63% of the adult population is classed as either overweight or obese. Being overweight or obese can increase the risk of developing a range of health problems and generally reduce quality of life. The chronic and acute health conditions associated with excess bodyweight also incur substantial healthcare costs and lost productivity within the National Health Service (NHS).

of the most common cancers (i.e. bowel, kidney, ovarian and liver) than smoking. Health professionals and academics alike have been extremely vocal in highlighting the potential implications of the campaign in terms of the promotion of weight bias, stigmatisation and discrimination of those who are overweight/obese. Specifically, blunt campaign messages such as these have been criticised for fat-shaming and undermining much of the previous work in the sector, which has aimed to reduce the harmful effects of weight stigma and discrimination. In fact, disapproval with the key message of the campaign has been so widespread that a number of key health professionals have now appealed to the charity to change its focus entirely. As both a psychologist and expert in the field of eating behaviour, I tend to agree with my colleagues. Using fear-based messages to tackle this issue is too simplistic and overlooks many of the factors that we know are associated with the development of obesity. In essence, this campaign promotes the message that being overweight is akin to smoking and that obesity can and should be tackled in the same way.

Using fear-based messages to tackle this issue is too simplistic

CALLS TO CHANGE THE CAMPAIGN’S FOCUS

In an attempt to reduce this growing epidemic, Cancer Research UK launched a billboard campaign which claimed that obesity plays a greater role in the development of four

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OPINION

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THE UNSPOKEN FACTORS CONTRIBUTING TO OBESITY

One reason why this message is so frustrating from an academic perspective is that to compare smoking and diet is not only inaccurate, but also extremely harmful. Unlike smoking, research has shown that a number of factors are implicated in the development of obesity, including socioeconomic status, physiology and genetics. While it is vital to educate the general public about the potential consequences of obesity, the most damaging aspect of the Cancer Research UK campaign is that the focus is on personal responsibility. Specifically, it assumes that people will see the statistics and simply stop overeating or start eating healthily as a result. Furthermore, it encourages discrimination or judgement towards individuals who are not able to do this successfully by fuelling the perception that weight gain is caused by a lack of will power. Alongside the aforementioned economic and societal determinants, research within the field of psychology has identified a number of behavioural traits and characteristics that are implicated in the development of obesity. Of these, one of the most widely researched is the link between eating and emotion. Specifically, we know that emotion can suppress or initiate eating behaviour. There are many examples in the media of people eating in response to stress, heartbreak, or even boredom. Typically, individuals viewing this type of behaviour would deem this as a relatively ‘normal’ response to negative emotion. However, research has suggested that those who are overweight or obese frequently turn to food as a way of coping with daily stress or emotion.

OBESITY AND EMOTIONS

Findings from a recent study I conducted in collaboration with colleagues at the University of Derby have shown that individuals who are overweight (as indicated by a Body Mass Index of 25kg/m2 or higher) were more likely to struggle when dealing with difficult emotions. The results of this study also demonstrated that these individuals lack access to effective coping strategies (such as problem solving and emotional acceptance), so food becomes the source of comfort. In addition, our findings revealed that these individuals are highly self-critical and display low levels of self-compassion. This creates a vicious cycle, whereby people who are overweight continue to struggle with negative emotion, overeat as a result, then criticise themselves for being unable to cope. Importantly, these individuals may lack the self-compassion to accept these negative feelings and get themselves out of this destructive cycle of behaviours. Campaigns that promote weight stigmatisation can have a damaging effect by increasing feelings of guilt and shame in those targeted, which ultimately prevents healthy eating as individuals may overeat in response to these negative emotions.

This research is important in highlighting the variety of psychological traits and characteristics which might be implicated in overeating and obesity. As such, a key issue with the recent Cancer Research UK campaign is that these factors are largely overlooked, which not only undermines the importance of this research but also promotes the idea that obesity is a simple problem that can be easily prevented by holding individuals to account for their own body size and weight.

ARE WE BEING COUNTERPRODUCTIVE ABOUT OBESITY?

In summary, it is vital that we change the way we talk about obesity. We know that campaigns based on instruction are often ineffective at promoting health-related behaviour change. The focus on weight here is therefore counterproductive and may in fact encourage unhealthy eating behaviour. For example, weight stigma has been frequently linked to poor body image, depression, anxiety, and eating disorders. Therefore, rather than framing weight as the problem, future campaigns should focus on raising awareness of the vast array of social, environmental and psychological factors implicated in the development of obesity. A more inclusive (and more accurate) campaign should therefore emphasise wellbeing rather than weight, acknowledging the fact that for many it is not as simple as eating less or choosing healthier foods. In many cases, people don’t have always have full control over their body shape and size – there are many factors that can dictate an individual’s weight and future campaigns need to be mindful of this to ensure they do not cause harm to an already marginalised group of individuals. AM

Dr Emma Sharpe is a lecturer in psychology. Her research is concerned with all aspects of eating behaviour (e.g. eating disorders, binge eating, obesity), emotion processing and behaviour change. Her PhD research focused on how emotion processing deficits may contribute to the development of eatingrelated psychopathology. Currently, she is working on a research project examining the role of emotion, compassion and personality in obesity. This work will inform the development of a diagnostic tool for obesity by focussing on the specific risk factors implicated in overeating.

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Stars of the north We give you the lowdown on what went on at our fourth annual event in Manchester

une 29-30 2019, saw the first standalone Aesthetic Medicine North event take place at Manchester Central. With some of the biggest industry brands, as well as CPD-accredited education programmes, Aesthetic Medicine North brought together suppliers, practitioners, manufacturers and industry key opinion leaders for two days of networking, education, and updates on the latest news from this fast-paced industry. Following year-on-year growth as an event held alongside Professional Beauty North, this year was the first time Aesthetic Medicine North was held as a standalone show. With 871 visitors and exhibitors in attendance, the event has become the North’s leading aesthetics event for medical professionals. The live stage saw the show’s exhibitors discussing innovative technology, treatments and the latest business queries, trends and knowledge from the aesthetics industry today. Vicky Eldridge, editor of Aesthetic Medicine, commented, “Making the decision to move Aesthetic Medicine North to a standalone event held at a different time of year was a gamble that, I’m happy say, paid off. “This was one of the best events we have held in Manchester, and I look forward to watching it continue to grow and evolve into the must-attend meeting for aesthetic practitioners in the North.

SPONSORED BY:

“Thanks to our sponsors AlumierMD (platinum sponsor) and Mesoestetic (gold sponsor), and to all our exhibitors who helped make this meeting possible.” Aesthetic Medicine North will return to Manchester in 2020 on the earlier dates of 13 and 14 June. We hope to see you there!

WHAT OUR EXHIBITORS SAID

Adam Birtwistle, managing director of Mesoestetic, said, “Aesthetic Medicine North was a very successful show for us, so successful that we have already signed up for next year! It’s an easy and friendly venue to exhibit in and attracts the right visitors who have provided us with sales, leads and new accounts. We are now looking forward to 2020.” Sandy Green from the The National Weight Loss Programme commented, “AM North 2019 delivered a fantastic opportunity to keep up-to-date within a fast-paced industry and to the show allowed us to network with the right people. If we had to describe the show in one word it would be ‘unique’, as there’s no other place like this in the North.” Lynton Lasers said, “There was a fantastic variety of talks and visitors have provided good feedback on the educational sessions. It’s a great show to have at this time of the year, it acts as a mid way point for brand visability and networking. We have also had a lot of interest in our machines too!” AM

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“Aesthetic Medicine North was a very successful show for us, so successful that we have already signed up for next year! It attracts the right visitors who have provided us with sales, leads and new accounts” Adam Birtwistle Mesoestetic

“It’s a great show to have at this time of the year, it acts as a mid way point for brand viability and networking” Lynton

“If we had to describe the show in one word it would be ‘unique’, as there’s no other place like this in the North” Sandy Green, The National Weight Loss Programme

“There’s such a quality of visitors! They are really serious about purchases of huge value. We are extremely happy with the success AM North has given us this year” John Culbert, Cambridge Stratum

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Knowledge is power Aesthetic Medicine North 2019 featured a world-class faculty of speakers sharing knowledge and insight. Here we share some of the highlights

esthetic Medicine North was founded with Delegate Dr Mohammad Nassimizadeh the philosophy of bringing a worldcommented, “The educational lecturers were class educational programme to outstanding and the clinical sessions were aesthetic practitioners outside excellent. There were live demonstrations London. Now in its fourth year, on patients and the sessions showed you the clinical conference programme at everything, from setting up the patient Manchester Central gave delegates to the injection techniques and results. access to two days of CPD-accredited It was really top quality.” learning, and the auditorium was Meanwhile, our Business packed with those eager to enhance Workshop agenda, chaired by Richard their knowledge. Crawford-Small, armed delegates with practical and implementation Sponsored by AlumierMD and with Dr Mohammed skills and strategies to grow and enhance chairs including Dr Daniel Sister, Dr Ash Nassimizadeh their businesses. Dutta, Rachel Goddard and Mr Ali Ghanem, the The interactive line-up included top business sessions covered a broad range of topics under consultants, marketing specialists and inspiring the banners Innovative Injection Techniques on entrepreneurs offering up-to-date tips and advice. Speakers Saturday and Rejuvenation and Regeneration included Dr Harry Singh, Dr Steve Harris, Sue Lumley, Nikki – Aesthetics Inside and Out on Sunday. Bringing both clinical Corrigan, Dr Arturo Almeida, Tracey Jones, Harshal Limaye, and practical education to life, our speaker faculty included Megan Foster, Chris Halpin, Alex Bugg, Mark Bugg, Danny Julie Cox, Dr Lee Walker, Dr Raul Cetto, Mr Ash Labib, Cheryl Bermant, Dr Abdul-Karim Nassimizadeh and Dr Mohammad Barton, Dr Vincent Wong, Anna Baker, Dr Steve Harris, Mr Nassimizadeh. Aesthetic nurse practitioner Tracey Arturo Almeida, Dr Olha Vorodyukhina, Dr Martyn King, Linda Dennison said, “Knowing that you’ve got people who are very Mather, Dr Raj Thethi, Dr Paul Charlson, Constance Campion, respected in the business here and having them accessible Dija Ayodele, Dr Haidar Hasan, Miriam Martinez Callejas and was a huge draw”. AM Dr Mohammed Enayat.

“The educational lecturers were outstanding and the clinical sessions were excellent. It was really top quality”

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BUSINESS

EMPLOYMENT

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Healthy practices Victoria Vilas on managing employees with chronic health issues

n your aesthetics clinic, you are likely to have a medically trained member of staff on hand to deal with any first aid issues that arise during working hours, however, as an employer, you also need to be aware of how to deal with employee health issues that are not due to accidents or acute illnesses. Chronic health issues may not cause medical emergencies at work, instead they may mean that an employee needs a little more support and flexibility from their employer. You may need to allow a team member to change their schedule to accommodate essential appointments with healthcare professionals, consider letting them change some of their duties if they struggle with particular tasks, or you may need to be understanding if your employee needs to take time off work due to a period of ill health. Although an employee with a chronic condition such as diabetes, asthma, epilepsy, or a severe allergy may be experienced in managing their own health, you should still consider what you as an employer can do to be supportive, and assess the situation to ensure that the health and safety of your employee or their colleagues is not at risk.

DISCRETION AND DATA PROTECTION

Data protection laws provide employees with the right to keep their medical history confidential. In certain circumstances an employer can ask an employee to disclose information on a health condition, for example, if it is considered to be something that could endanger the health and safety of a team member. However, you should always ask your employee to give you information with their consent. If an employee does not disclose a health issue to you, then you are unable to make provisions that would protect your workers, including the employee in question. However, many employees with a chronic condition are likely to want their employer to be aware of it, as it could put them at risk if they do not. Speak to your employee in private, record the information you collect, and follow the same data protection rules you would do for patient information. Allow your employee to check the information you have recorded if they request to. You should not disclose an employee’s condition to your team unless your employee has consented to you doing so, and even if they have, you should use discretion and only advise staff members of essential information that your employee is happy to be made public.

You should not disclose an employee’s condition to your team unless your employee has consented to you doing so

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EMPLOYMENT

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MANAGING RISKS

Use your private meeting with your employee to collect information to inform a risk assessment, and demonstrate that you have followed the correct procedures to protect your employee and their colleagues from any potential risks in the workplace. Ask your staff member questions only related to health and safety at work, as there is no need for an employee to disclose anything more to their employer. Ask your employee to advise you of any precautions you should take to safeguard their colleagues or themselves, and make sure you have details on file for an emergency contact. Ask them if there is anything in the workplace that could affect their health. After this meeting, assess your clinic for risks. If you are unsure of what to include in a risk assessment, and what to check or record, visit the Health and Safety Executive website for guidance. After you have recorded your risk assessment, address any potential risks. For example, if you have an employee with a nut allergy, you may need to set new rules on what food can be stored in communal areas. You may have experienced nurses or doctors present in the clinic, but whoever your appointed first aider is, they should be made aware if an employee has informed you of any special precautions to take regarding their condition, to save time should an emergency arise. For example, your first aider should know where to find an employee’s medication if they have a severe allergy that can cause anaphylaxis, and understand the procedure to follow.

PROVIDING SUPPORT

UNDERSTANDING THE LIMITS

There will be some instances where it may be impossible for an employee to continue to fulfil the needs of their job, even if you make reasonable adjustments to suit their needs. It may be that your employee needs to change their duties substantially, and your business cannot accommodate changing them to an entirely new role. If an aesthetic therapist suffers from chronic pain, she may need to consider a role where she no longer performs treatments, but you may not have any non-clinical roles to offer. If you dismiss someone who has a chronic condition and you have not made an effort to accommodate their needs, you could be accused of unfair dismissal, as employers are required by law to make reasonable adjustments to help an employee continue to work. In such circumstances you should always conduct assessments and ensure that you have provided the support and flexibility considered ‘reasonable’. It can be very hard to let go of an employee due to poor physical health, but business owners cannot be expected to employ people who are incapable of fulfilling the needs of their job. Just ensure that both you and your employees follow the right procedures and act responsibly. Managing employees with chronic health conditions should not cause an additional strain on your business or your team members. AM

Employers are required by law to make reasonable adjustments to help an employee continue to work

Some health issues will not require you to take any further action other than to take details of your employee’s condition and conduct a risk assessment. Many staff members who suffer from a chronic condition will be able to manage it themselves, and will require no changes to be made to their surroundings, equipment, or schedule, and will be in a perfectly fit state to work normal hours. Other conditions may require you to make changes in the workplace. You should address any potential risks in the clinic, but you should also consider if there are any changes you could make to to ensure your employee’s working week is less arduous. Small changes to schedules, tasks or equipment could make a significant difference to an employee who suffers from a medical condition, whether it manifests as pain, tiredness, a lack of mental clarity, or simply takes up time with medical appointments and treatments. For example, if an employee is struggling with their schedule, consider whether you could change rotas, allow your employee to take additional unpaid leave, or reduce their working hours. If a team member suffers from a condition that causes pain, check that they have furniture and equipment that is

comfortable and positioned correctly, and that they are not carrying out tasks that could exacerbate their condition.

REFERENCES www.hse.gov.uk/risk/

Victoria Vilas is marketing and operations manager at ARC, an aesthetics recruitment consultancy. The ARC team helps organisations in the industry grow their businesses by hiring the most talented aesthetic professionals.

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BUSINESS

PATIENT ACQUISITION

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In search of...

Laura Moxham on how you could be getting new patients on tap each month using Google Ads

hink about it. Sally, who lives in Birmingham, wants to have laser hair removal done with a local, reputable clinic. Where does she go to find this? She turns to Google of course. She gets her phone or laptop out and types in “laser hair removal treatment Birmingham”, then hits go. Now, if your clinic is based in Birmingham and offers laser hair removal and is not right at the top of Google then, sadly, she won’t be calling you to book her treatment. Sally will be calling your competitor up the road. If you’re looking to get new patient enquiries, Google reigns supreme. Advertising at the top of Google is where your potential new patients hang out. Unlike other advertising such as radio, newspapers, local leaflet drops, or Facebook, Google Ads allows you to display your advert

to prospects looking for exactly what you offer, when they need it and where they need it. Done correctly, Google Ads provides aesthetics clinics across the country with a steady flow of new patient enquiries from people looking for the treatments they offer in their local area. This guide explains what Google Ads is and how clinics are using it to receive regular new patient enquiries to grow their business.

WHAT IS GOOGLE ADS?

To create and publish search ads on Google Ads, you will need a Google Ads account (no surprises there). Advertisers then bid on keywords or phrases that they want their ads to show up for when someone searches. Ads with the highest

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bids and best solution for the searcher show while the others remain hidden. For example, a clinic offering lip fillers in Liverpool might advertise when someone searches “lip dermal fillers clinic Liverpool”. At the top of the list are the Google Ads – these are the ones with the green text box saying ‘ad’ in it to the left. There’s usually three to four at the top, then when you scroll right to the bottom of the page, there may be three or four more there too. Underneath the ads is the map which provides a listing of the clinics in the area. This is a free listing, but you need to register to appear. If you don’t currently have this listing, get your laptop out now and do so at google.com/business/. Once you’ve registered you’ll have a postcard sent to you to verify the address. Under this map section you have the ‘organic’ listings of all relevant websites for this search. This is governed by how relevant the content on your website is to that search. This is called SEO (Search Engine Optimisation.) It takes time and experience invested in your website to do this. However, Google often changes the algorithms, so your rank could easily change. If your business has many local competitors, ranking number one may be a challenge. Instead, companies can control their presence by paying to show up first in the search ads. It gives you control – where you want your ad to appear, what you want your ad to say,and which page on your website you want to take visitors to. Based on factors like intent, location, past browsing history and preferences, Google shows the ads that best match the intent of the searcher. In essence, Google does its best to answer the question: what is this person searching for?

3. Relevant Landing Page Take them to a page on your website that is specific to their search and encourages them to call your clinic to talk to you and, if they are confident, to book an appointment. Don’t take people to your home page. Take people to a page that is highly relevant to what they’ve just typed in and are looking for. For example if they type in ‘laser hair removal’ you’d want to take them to a page that talks about laser hair removal. Let people know they’re in the right place and have a very clear path of what you want them to do i.e. call for a free consultation or pop in your details to get a call back, etc. 4. Conversion Tracking and Optimisations Here’s the game changer. Whatever action you want people to do to engage with you – call your clinic or fill out an enquiry form – this is tracked as an action in your Google Ads account. From here you can see which of your ad spends is generating you the enquiries and which isn’t. You then make the necessary daily changes (optimisations) so your campaigns achieve you more enquiries. You want to spend less money on the ad campaigns that aren’t achieving the enquiries and more on the ones that do. Google Ads gives you the control to do this. This tracking is called ‘conversion tracking’. So as you can now see, Google Ads gives you the ability to propel your business onto the front page of Google’s search results. That’s huge for your visibility, and for attracting potential patients. AM

In essence, Google does its best to answer the question: what is this person searching for?

We are ofering a free 20-minute strategy session for Aesthetics Medicine readers with Laura Moxham, MD of YBA PPC. Simply email team@ybappc.co.uk quoting ‘Aesthetics Magazine Sept ’19.’

HOW DOES IT WORK?

Cutting Google Ads down to its basics is a 4-step process: 1. Kick Ass Keywords You select keywords so that when people type those in, your ad shows. Choose the right keywords and your campaign should bring in new patient enquiries. Pick the wrong keywords and you’ll either be completely ignored or, worse, your campaign will be an expensive flop. We need focused keywords when people are turning to Google with buyer intent, for example, ‘laser hair removal Birmingham’. 2. Compelling Ad Copy OK, so now we want to present them an ad that is relevant to what they’re searching for and has ad copy that is compelling and attractive to make people want to click on it. The key here is to make it relevant to the keyword (e.g. have the keyword in the headline) and make your ad more compelling than your competitors, so they click on your ad as opposed to any other. Also, have an offer or strong call to action, for example “call today”.

Laura Moxham is an expert in internet marketing for Google Ads and PPC. She is the managing director of boutique agency YBA PPC, which is recognised as being in the top 3% agencies within Europe and has been shortlisted for ‘Best for Growing Businesses Online’ category due to its highcalibre results from Google Ads.

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MINDSET

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Mindset, Motivation and Money Dr Harry Singh examines the formula for success

he formula is simple; to have success in any area of your life, whether it’s personal or business, you need the right mindset, tonnes of motivation and the correct belief about money. Each of these three pillars represents a leg of a tripod; if one is longer than the other two legs, if one leg is shorter than the other two, or if one leg is missing, the tripod will either fall or be imbalanced. This is how your success will look if you don’t have each of the legs in sync.

MINDSET – CONTROL YOUR MIND, DON’T LET YOUR MIND CONTROL YOU

Success is simply a matter of luck. Ask any failure. “I count him braver who overcomes his desires than him who conquers his enemies; for the hardest victory is over self.”– Aristotle. If you don’t master this next tool you will be doomed for failure. This critical element is learning to control your mind. Let’s say you wanted to start an aesthetics business. You may ask yourself what it takes to become a successful business owner. Most people expect some kind of quick formula that will help them to become successful overnight and they can’t wait to chew on the bone. As with anything, knowledge is essential, but knowledge has limitations without the right mindset. We can manage and control our lives if we know how our mind works, why we make certain decisions, and how to master our mind.

If as a business owner you want to go from your mind mastering you to mastering your mind, you need to understand why you make certain decisions and what the consequences of those decisions are. Would you be interested in learning to control your mind so you will always make the right choice for you in any given situation? Thinking does not happen to you, it’s something you do. For example, if you want to try to be sad, you first have to think sad thoughts; you can’t just get the result of sadness immediately. As an avid Liverpool football fan I have become a master of being sad, especially with all my wife’s family supporting Manchester United. Stick your neck out “Behold the turtle. He makes progress only when he sticks his neck out.” - James Bryant Conant. Your mindset is everything when it comes to being successful. The combination of the right knowledge and right attitude is unbeatable. For example, in 1954 Roger Bannister was the first person in history to run a mile within four minutes. Before this great achievement it was thought impossible to do this. Yet less than 12 months after Bannister’s record, other runners achieved the same feat. So what changed? It wasn’t a new diet, running shoes or technique. They had just changed their attitude and belief system.

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If you can’t believe you will be successful in business, then you won’t. And without the right attitude you will miss out on some great opportunities. I always remember the T.E.A.R formula when it comes to getting the right mindset. Everything starts with Thoughts. This sparks off certain Emotions, which lead us into Action, which eventually determines our Results. We can see that our initial thoughts determine the results we achieve in life. That is why it is so critical to have the correct mindset and frame of mind, otherwise all the skills and knowledge in the world will not achieve the results you desire. Another way to look at it is to say we live in two worlds: our inner world and our outer world. The inner world controls the outer world. Whatever attitudes, beliefs, and thoughts we have will follow us in our outer world through the actions we do and the actions we don’t do, and this will produce the results we get. I have spent more time and money developing myself and learning about mind power than I have on strategies, skills and knowledge. 80% of everything we do is psychology and 20% is mechanics.

THE HARAJUKU MOMENT

I was visiting an elderly relative in hospital who did not have much more time left in this world. After chatting to them and walking back to my car, I reflected on my own life and had a Harajuku moment (an epiphany that turns nice-to-have/ do into a must-have/do). I imagined myself as an old man rocking on my chair at the front of my house and reflecting on my time on this planet. Days are expensive: when you end a day, you have one less day to spend. Therefore, I wanted to make sure I spent each one wisely. What I feared most was not having lived to the fullest extent possible, to come to the end of my life with my final words being, “I wish I had...” You listen to the older generation and I can promise you that 99% will not regret what they did, but what they didn’t do. I want to prepare to die well, having no regrets. I quote from Buddha, “Even death is not to be feared by one who has lived wisely.”

Motivation is like taking a shower, or eating it, you need it every day, otherwise it will wear away

Success is in your DNA: What are your limiting beliefs? Answer the following questions and you will discover them. When under pressure, you... You often feel guilty about... You are afraid of... You always try to... When the unexpected happens, you ... What you measure improves. Once you have found your answers, provide alternative solutions. For example, for me, ‘When under pressure I panic’ translates into ‘When under pressure I think about the situation calmly and ask for support’.

MOTIVATION – DAILY DOSES

Motivation is like taking a shower, or eating; you need it every day, otherwise it will wear away and you’ll be back to square one. However, you could spend hours watching motivational videos, reading inspiring autobiographies, attending personal development courses, but without the correct mindset, it will all be wasted. “When you want to succeed as bad as you want to breathe, then you’ll be successful.” - Eric Thomas. I have a vision board in my office which I look at daily; it represents of what I want to achieve in the next three to five years. This keeps me motivated and on track. However, the biggest motivators are the following questions: “what if?” and “what could I have done/achieved?” “The greatest tragedy in life is to spend your whole life fishing, only to discover it was never fish that you were after.” - Henry David Thoreau. We all have dreams and goals, things we love doing. However, life is filled with activities and commitments that have nothing to do with our dreams or goals. In both business and life we operate on auto pilot and live our lives in reactive mode. Sometimes we do what we think is right or what we think other people think will be right. I began to have this feeling a couple of years ago. At times it felt like I was a crosseyed discus thrower; I would never set my own personal goals, but I would definitely keep everyone else entertained.

LEAVE NO REGRETS

“The bitterest tears shed over graves are for words left unsaid and deeds left undone.” – Harriet Beecher Stowe. To leave this world with no regrets we must live with courage, moving towards what we want rather than away from what we fear. We can never guarantee success in our lives, but we can guarantee failure by deciding not to try at all. However, most of us – me included, initially – have such a great fear of failure or rejection that we die with our dreams, ideas, and aspirations inside us. Not now: we can decide our future. Now that you’re out of my life I’m so much better You thought that I’d be weak without you But I’m stronger You thought that I’d be broke without you But I’m richer You thought that I’d be sad without you I laugh harder You thought I wouldn’t grow without you Now I’m wiser Thought that I’d be helpless without you But I’m smarter You thought that I’d be stressed without you But I’m chillin’ You thought I wouldn’t sell without you, sold nine million Destiny’s Child – Survivor

THE PSYCHOLOGY OF MONEY – LEARN HOW TO WIN THE MONEY GAME

“Money won’t make you happy, but it will help you enjoy your misery in a lot of interesting places.” – Walter Hailey. Are you working too hard with little to show for it? Do you consider yourself a fairly high achiever but you are not achieving your financial potential? Are you afraid you won’t be able to retire when you plan to, or have the lifestyle you dreamed of? If you answered yes to any or even all of these questions I have the solutions for you. If you want to discover the secrets of the rich, please read on. >

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Winning the money game Before we look at money and your beliefs, let’s think about what money is to you and its importance in your life. If as a business owner you want to go from never having enough money to living with abundance, you will need to understand your beliefs about money. What is money and how important is it? What does money mean to you? Money is simply a means of exchange. Previously when we lived in the barter system, money was created to represent the value of those goods and help people exchange goods and services more easily. Money is nothing but the measure of the value that you create and deliver for people. The more value you create for people the more money will be attracted to you, therefore money flows to the people who are providing the most amount of value. For example, many of my dental patients valued the results they had from anti-wrinkle treatments and what it gave them more than maintaining optimal periodontal health. They could always find the money and would never cancel an antiwrinkle appointment, but the same patient would quite easily cancel and not value a 30-minute appointment with the hygienist. In essence, we must understand what the patient values and will be willing to pay for. If you want more money, you don’t start off with, ‘How can I make more money?’ Instead ask yourself, ‘How can I create more value?’ You create value by solving problems for people and giving them what they want. All business is solving one kind of problem or another that customers are willing to pay for.

Money is one of the most emotionally charged issues of our lives Some of us are even willing to give up things that are much more valuable than money in order to get more of it. Money by itself is neither good nor bad – it’s neutral. Money is merely a medium of exchange. It allows us to simplify the process of creating, transferring and sharing value within a society, so saving us the inconvenience of bartering. We don’t want more of this piece of paper with the queen’s head on it; we want more of what this piece of paper can provide us. Money is not everything, but it is up there with oxygen. No amount of money will ever make you wealthy. The secret to wealth is gratitude. If you think that money is the answer to all your life problems, then your problems will never go away. Money is not the answer. As rap star The Notorious B.I.G. said, “Mo money, mo problems”. Money is not everything; in fact, in my personal list it is number four, behind family, health and friends. Most people seem to have made settlements with life – settling for less than what they really believe they can have, whether it be unfulfilling relationships, or jobs that they hate going to. People constantly struggle for money or feel that happiness is only for the lucky few. These are certainly some of the feelings I have experienced. What about you? What settlements have you made? What are you tolerating in your life? My question to you is what are you putting up with it? You know you deserve better, don’t you? AM

Dr Harry Singh has been carrying out facial aesthetics since 2002 and has performed more than 3,000 cases. He is not only a skilful facial aesthetician but also a keen marketer, which he feels is vital to attract and retain patients requesting facial aesthetic services. He has published numerous articles on the clinical and non-clinical aspects of facial aesthetics and has spoken at dental and facial aesthetics conferences on these topics. He was shortlisted at the Private Dentistry Awards in 2012 and 2013 in the Best Facial Aesthetic Clinic category and was a finalist in 2012 at the MyFaceMyBody Awards for the Best Aesthetics Clinic. To find out how to turbo boost your facial aesthetics business into profitability, buy Dr Singh’s book Let Go of the Hand Brake at letgoofthehandbrake.com. Visit botulinumtoxinclub.co.uk to download his free Conversion Assessment Template.

Aesthetic Medicine • September 2019

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BUSINESS

REGULATION

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A question of choice? Tracey Jones and Sophie Singh-Jagatia ask, is registration with the government regulator a choice or a prerequisite for any business in aesthetic medicine?

roclamations have been made by promient professionals in the field of aesthetic medicine appealing for clinicians and leaders to pay more than just ‘lip service’ to the regulation of the nonsurgical cosmetic industry (Rankin 2019). But what does this mean? A professional launching an aesthetic practice may be understandably confused and overwhelmed by the dialogue related to the regulation of this specific area of medicine, particularly given the disparity in how regulation is enforced in each of the four nations of the UK. Campaigns to make dermal fillers a prescription medicines and recurrent dialogue related to non-medics and allied health professionals being endorsed to offer these treatments dominates discussion. Misperception regarding regulation is undoubtedly exacerbated for any professional transitioning from a post within the National Health Service (NHS), where there is no question that the overarching regulator in England is the government-appointed Care Quality Commission (CQC). When the changes to regulation in aesthetic medicine came into force earlier this year, Sharon King, vice chair of the British Association of Cosmetic Nurses, stated that she “welcomed the decision,” testifying that it would “bring us one step closer to protecting our patients, as well as our own practices”. However, there still seems a long way to go to engage many practitioners registered with governing bodies to view regulation in the same light. The remit of the CQC is widely understood in the medical, nursing and dentistry professions in England and, more importantly, is recognised by the general public. However, in aesthetic medicine there is not only the government regulator, but also a variety of other registers to join, all claiming to be the key stakeholder in assuring safety. So which one should a practitioner new to this field prioritise? Humzah (2019) asked: “Is there the need for new registers to bring regulations into an unregulated sector? or should we be focusing on specifically the government regulator?” A thought-provoking question. There is a dearth of ongoing discussion around the issue of regulation and it is easy to see how practitioners can become confused. Specifically when they become aware that the only legal regulator in England is the CQC and that breaching regulations of the Health and Social Care Act (2008, regulations 2014) can lead to prosecution and action against those with a professional registration. However being an industry run by independent practitioners with a financial investment makes aesthetic medicine ripe for manipulation.

IS REGISTRATION WITH THE CQC RIGHT FOR ALL?

We recently presented a workshop at Aesthetic Medicine North on the issue of regulation, questioning “if registration with the Care Quality Commission is right for all?” As part of the workshop, we asked the delegates to put forward any concerns that had caused them to question if they should register with the CQC. As a business, we recognise that this is not an easy decision to make and is one that comes with both a personal and financial cost. Every area of medicine can declare that the government regulator does not fully understand the intricacies that underpin its structure, however, all have to abide by the assurance that the one government regulator will consult specialist advisors to provide supporting advice. So who should a new practitioner register with? We have been asked if registration with the government regulator is required if a clinic has been accredited by other organisations. Our response is usually only delivered once we have explored the service provision offered by that particular clinic. Often the answer is yes, and although accreditation may be seen as beneficial to put policies and procedures in place, the clinic still requires the official registration. It is at this point that we offer the additional governance support to ensure that all areas of the service are supported by a robust governance structure. This allows for an assurance framework which supports safe practice, and it is this that the regulator is most interested in. Many questions were posed during the presentation and one in particular was related to environmental factors and the premises in which clinics are located. This is unquestionably an area where the CQC needs to widen its interpretation. The environments where aesthetic medicine services are currently offered in England has a huge scope. Some practitioners run their businesses from adapted home environments, while others operate purpose-built clinics. There is undoubtedly a diversity of services available to the general public. Inspire to Outstand Ltd has been asked what the benefits are of being registered with the CQC. After many years of experience supporting regulation within England, the idea of clinics not being registered fills us with disparity. The predominant reason for any clinic becoming registered is to assure safety and security. The industry is flooded with competitors who all strive to enhance their service by offering tailored treatments that suit the needs of their patients. However, with more media coverage of the actions taken by the regulator when things go wrong, it will only be a matter of time before the public starts to seek a clinic displaying registration with the national government regulator as a mark of assurance. >

There is a dearth of ongoing discussion around the issue of regulation and it is easy to see how practitioners can become confused

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BUSINESS

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REGULATION

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BUSINESS

REGULATION

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Nonetheless, many professionals still view regulation with the Care Quality Commission in England as an optional choice rather than one of the key strategies for both marketing and safety when launching a business in aesthetic medicine. There have been many calls for the increased regulation of unregistered professionals offering aesthetic medicine services, but shouldn’t we be leading by example? Rankin (2019) acknowledged that “safeguarding patient safety” is paramount and this can be achieved by monitoring and recognising risk. We have worked with many practitioners and one area that continues to be a low priority is having a register of risk in place. All areas of the NHS have a register that is used to highlight any potential risks and demonstrating learning from events that have occurred. However, private aesthetic practitioners often cannot distinguish what areas features as a risk in their daily practice. This is evident by the number of clinicians continuing to practice regulated procedures despite knowing that they are in fact breaking the law. The matter of previous medical experience is one that is conferred over many a forum, with professionals stating that one is superior to another. Yet until firm regulation is put in place, this will be nothing more than a dialogue to be contested. The debate continues around the capacity of training and education, however, regulation goes much further than just these topics. Interestingly, the speaker presenting before us at Aesthetic Medicine North was focused on how to increase income. It was a presentation we listened to with awe, as we learned how to increase our Google ranking and encourage the public to choose our business. Curiously, the number of delegates decreased somewhat when the presentation changed to the topic of government regulation and a commitment to governance. This sparked a question around why is it that regulation is considered a voluntary option rather than a pre requisite for practice as it is in Scotland?

Many professionals still view regulation with the Care Quality Commission in England as an optional choice

CLOSING OBSERVATIONS

Observation of a recent conversation made us ponder: a clinician posted the question “how much does it cost to become CQC registered?” The reply from another clinician was “your soul”. We have stated previously that the perception of registering with the CQC is a feeling of ‘wading through mud’; this is one of the reasons we launched Inspire to Outstand. We recognised that our wealth of experience in this field could be used to support practitioners who do not know where to start. There is both a financial and personal cost when embarking on the journey of becoming registered and, as with any change, there will be hurdles and challenges along the way. But, if as a group of professional clinicians working in aesthetic medicine you want to demonstrate safe practice, then this should mean leading by example.

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Regulation cannot be requested via a pick and mix route, it must follow the format of every other health and social care provision in the UK: government regulation. Charlson (2019) stated recently that “regulation in aesthetic medicine is long overdue”. Rather than the continual discussion about whether a clinic should be registered with the government regulator, perhaps the question should be why are all clinics offering the care provision not registered? Change in the field of aesthetic medicine is inevitable as the NHS cannot continue to pick up the cost of inadequate practice as demonstrated by the recent increase in the number of reported complications, and even deaths, as a result of cosmetic procedures (Fitzgerald 2019). How this change will take place is uncertain. However, one factor that is without question is that there will always be a government regulator in some form as this is the only watchdog that does not have a financial interest. Therefore, indisputably, this is the body that should monitor the aesthetic medicine industry, as it does in all others areas of medicine. Collier (2019) noted recently in the Journal of Aesthetic Nursing to state that there is a risk that if regulation is not taken seriously that “aesthetic medicine will be completely demedicalised”. This, we can presume without hesitation, is not what any medical professional working in the arena of aesthetic medicine would ever want to prevail. AM REFERENCES 1. Charlson, P. (2019) What we need is light touch, high trust appropriate regulation. The PMFA Journal, June/July 2019. Vol 6 No 5. 2. Collier, H. (2019) The need for regulation grows ever more urgent. Journal of Aesthetic Nursing, May 2019. Volume 8 Issue 4, P;180-181. 3. F itzgerald, B. (2019) Government campaign to tackle ‘botched’ procedures. Journal of Aesthetic Nursing Editorial, May 2019, Vol 8 No 4. 4. H umzah, D. (2019) Regulation in the aesthetics industry. Journal of Aesthetic Nursing, June 2019, Vol 8 No 5. 5. King, S. (2019) Hanging by a thread: legislation and protecting the public. 6. Rankin, A. (2019) Why it’s time to pay more than lip service to regulating the non-surgical cosmetic industry. The PMFA Journal, June/July 2019. Vol 6 No 5. 7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Tracey Jones (pictured) and Sophie Singh-Jagatia are directors of Inspire to Outstand, a team from Cheshire who support businesses moving forward with becoming regulated. The pair has more than 35 years’ experience in healthcare and regulation, and their backgrounds have seen them on both sides of the regulatory process. Since launching in 2019 they have predominantly worked with businesses from the world of aesthetics.

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BUSINESS

MATERNITY LEAVE

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Leave and return

Balancing a growing aesthetics practice and preparing for a new baby is a major test for any self-employed practitioner. Aesthetic nurse practitioner Julie Brackenbury shares her first-hand knowledge and advice on how you can prepare for maternity leave and ensure you return to a healthy business 38

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BUSINESS

MATERNITY LEAVE

aestheticmed.co.uk

aving a baby and running a business are two of the biggest challenges any woman faces, and getting the right balance between the two can be a juggling act. From navigating through complex maternity leave rules and concerns about the future of the business to worrying about how to retain a client base built up over years, let alone planning for the nine-month mark – it’s all a bit of a minefield. But with careful planning, it can be done. For some aesthetic practitioners, their business is referred to as “their baby”, and there is some truth in this. It can be difficult for women who run their own aesthetic practice to step away from all the aspects that come with the responsibility of running a business. Some may feel leaving the helm of their team is akin to abandoning their responsibilities. Nevertheless, despite looking forward to motherhood, it is important not to lose any entrepreneurial spirit as this is the driver for any successful business. Research by Gregory 1 has shown that more and more women are delaying pregnancy to achieve life goals such as starting their own business or building their careers.

HOW MUCH TIME SHOULD I TAKE OFF?

This is one of the toughest decisions to make. The reality is that if you take a year off, you are quite likely to lose clients unless a practitioner can cover treatments in your absence. However, there is a lot at stake in this particular scenario. The harsh reality is that, sometimes, business trust can be broken when a practitioner decides to take your client base. So, what is the least amount of time to take off? It’s entirely your choice, but I personally took three months maternity leave. The cycle in my practice for repeat treatments is around three to four months, so my regular clients were able to see me on my return. I didn’t go back full-time and it took a while to get the routine right, but one of the advantages of being self-employed is the ability to have flexible working hours to fit your lifestyle.

It can be difficult for women who run their own aesthetic practice to step away

PLANNING FOR MATERNITY LEAVE

First and foremost, practitioners should take time out of the day-to-day running of their business to plan for both their maternity leave and their return. DeMorrow2 advises women to write a maternity business plan before the birth, a simple one page document that outlines how they will support themselves and the business financially while on leave. Many businesswomen feel apprehensive about taking time out of their business, worrying that they may lose clients or that their business may no longer be viable. There may feel concern at missing out on training, conference or networking events and their ability to keep up-to-date with what’s happening in the industry. In addition, they may also worry that they will miss out on the valuable information shared during informal conversations with colleagues, as well as opportunities to strengthen working relationships. Maternity leave can also be a time for other members of their team to l earn new skills and take on more responsibility. It can be helpful to treat it as part of the team’s training and development rather than simply a time to delegate tasks because the leader is absent. It is vital that time is built into the diary for antenatal care, as well as running a health and safety check on products and equipment to ensure that they can be used safely during pregnancy.3

TAKE A STEP BACK

While self-employment offers women obvious benefits, such as the flexibility to work the hours that suit them, it also has drawbacks. For example, women who are their own boss have to claim their own Maternity Allowance (MA)1, the equivalent of Statutory Maternity Pay (SMP).4 They also have to work out how to keep their business afloat while they take some time off to be with their baby.

INFORMING YOUR CLIENTS

Advising clients about the maternity plans and keeping them in the loop is important. It is recommended not to take on any new clients three months before going on maternity leave. In addition, be prepared to lose clients through this process. If this does happen, try and view this with positivity and see it as an opportunity for a fresh start. Women should look at their maternity leave as an opportunity to define their target clients. This will help them develop more effective marketing strategies and strengthen their business in the longer term. Losing a few clients can help practitioners identify their most loyal customers and discover the kind of client base with whom they want to work with.

INTRODUCE YOUR PATIENTS TO THE COVERING PRACTITIONER

Many patients will be loyal to their favourite aesthetic practitioner and may be afraid of change, so be sure to introduce your patients to the practitioner taking over for >

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BUSINESS

MATERNITY LEAVE

aestheticmed.co.uk

TIPS In the month before you go on maternity leave, only treat regular clients so there is enough time for review Avoid administering invasive treatments Communicate with your clients Use social media for updates Hire a virtual PA to answer calls, texts, and emails Plan a proper routine for your return Remember, the most committed clients will stay. the maternity period so clients can feel comfortable. In addition, allow the practitioner to take the time to understand the results your patients want to achieve. Regular patients are not going to enjoy being surprised at the last minute by an unknown person entering the treatment room. Patients will feel more at ease if they know their procedure is to be performed by an equally experienced practitioner, and one who understands what they want to achieve.

to practice, they can offer ongoing support, something which does not have to be restricted to the period of maternity leave.

MATERNITY LEAVE RULES

Women who claim MA are entitled to work for 10 keepingin-touch days during their maternity leave. They can use this time to keep in touch with clients and colleagues, to take part in training, or to attend conferences. These days will help practitioners stay connected to their business and remind people they won’t be away for long. However, practitioners shouldn’t work for more than 10 days or their MA payments will stop. Another good piece of advice is to review tasks that are important to help promote and build the business that don’t involve meeting clients. For example, it could be a good time to overhaul the website or refresh the marketing plan. Practitioners should attend conferences or take part in training to refresh their skills. This will help them get back into a work mindset so they can return feeling confident. Industry events like training, CPD, and conferences will also help practitioners build a network of support they can turn to, and who can turn to them.7,8 AM

Women are entitled to work for 10 keeping-in-touch days during their maternity leave

MANAGING PATIENTS’ FEELINGS

Aesthetic practitioners build a long-term relationship with their clients based on trust, so it’s understandable that clients may be reluctant to let anyone else treat them. Some may even feel panicky at the thought of another practitioner injecting them. However, you can help reassure clients and maintain their loyalty if, as early as possible, clients are introduced to the covering practitioner who is going to overseeing their care while you are away. You should be in the room when their client meets the new practitioner and talk about their client’s treatment preferences and routine.

GOOD MEDICAL PRACTICE

When choosing a practitioner to delegate to while on leave, you must be satisfied that the individual has the appropriate qualifications, skills and experience to provide safe care for the patient.5 In addition, the GDC states that patients must be informed if a treatment plan changes, and are provided with an updated version in writing.6

REFERENCES 1. Gregory (2012) Why Women Are Embracing the New Later Motherhood. Ingram Publisher Services USA 2. DeMorrow (2016) https://www.theguardian.com/small-businessnetwork/2016/sep/06/how-juggle-babies-and-business-entrepreneur 3. Information for expectant mothers from the Health and Safety Executive (HSE): http://www.hse.gov.uk/mothers/faqs.htm 4. Information from the government on maternity allowance: https://www.gov.uk/maternity-allowance 5. (GMC 2013) https://www.gmc-uk.org/ethical-guidance/ethicalguidance-for-doctors/good-medical-practice (2.3.8 GDC 2019) 6. https://www.gdc-uk.org/professionals/standards/st-scope-of-practice 7. Information from the government on your rights while you’re on maternity leave: https://www.gov.uk/employee-rights-when-on-leave 8. Maternity Action: https://www.maternityaction.org.uk

HOW PRACTITIONERS CAN CREATE A STRONG NETWORK OF SUPPORT

An experienced support network is vital, and it is important that practitioners connect with other businesses to gain valuable insights into how to keep running a business while taking some time out to have a baby. In addition, if relationships haven’t already been built, it is advisable to reach out to other aesthetic practitioners in the area. If they share the same ethics and approach

>> 40

Julie Brackenbury RGN, INP is a non-surgical nurse practitioner in the South West and South Wales. She sits on the editorial board for the Journal of Aesthetic Nursing and the Dermatological Nursing Journal and is the author of more than 30 published peer-reviewed articles.

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PRODUCT FOCUS

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In defence

Alto Defense Serum was found to deliver a significant capacity to reduce oxidative stress

We take a look at the results of a new study analysing the effectiveness of Alto Defense Serum by skinbetter science

recent study published in the Journal of Aesthetic and Clinical Dermatology has shown the efficacy of skinbetter science’s Alto Defense Serum. The product is an advanced antioxidant serum formulated with WEL-DS, an exclusive technology that deploys a combination of 19 powerful antioxidant ingredients, designed to work together to provide a new level of comprehensive and dynamic defence against free radicals. As part of the study, which was funded by skinbetter science, investigators sought to evaluate the antioxidant capacity of WEL-DS, its ability to protect skin against the oxidising effects of UVA/UVB radiation, and to assess the effectiveness and tolerability of WEL-DS for visible improvements in facial photodamage. In-vitro testing utilised a hydrogen peroxide assay to detect activity in human skin explants following the application with WEL-DS, a leading antioxidant serum (L-AOX), and a saline control. Clinical studies included a minimal erythema dose (MED) trial in female subjects, aged 35 to 60 years. Skin was initially irradiated to determine each subject’s MED. WEL-DS was applied for four days to one site on the lower back of subjects; the other site remained untreated. Both sites were irradiated with 1x, 2x and 3x each subject’s MED, digital images were obtained, and punch biopsies were collected from the 3x MED irradiated areas for histological analysis. A second

clinical study evaluated the efficacy and tolerability of a twicedaily application of WEL-DS in female subjects, aged 25 to 65 years with mild-to-moderate photodamage. Changes in fine lines/wrinkles, dyschromia, erythema, skin tone, pores, and tolerability were assessed at baseline and weeks four, eight and 12. A subset of subjects were evaluated through week 16. Alto Defense Serum was found to deliver a significant capacity to reduce oxidative stress over time, compared to a top-selling antioxidant competitor. Skin treated with Alto Defense Serum encountered 53% less oxidative stress versus a top-selling antioxidant in test one and 41% in test two. Treatment with the serum also showed statistically significant reductions in UV-induced redness as demonstrated via MED assessment. It also demonstrated cellular protective effects versus untreated irradiated skin. WEL-DS demonstrated average improvements from baseline of 37%, fine lines/wrinkles; 17%, skin tone; 13%, dyschromia; 18%, erythema; and 4%, pores (N=21; week 12). In a 12-week study, 100% of subjects agreed that Alto Defense Serum was cosmetically elegant with a light texture and feel, absorbed well and worked well with make-up. Continued improvements were demonstrated in all parameters in an extension study (n=14; week 16). WEL-DS was well-tolerated.The study can be read by visiting jcadonline.com/antioxidants-april-2019 AM

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SKINCARE SPY

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Skincare Spy Sarah White from Sarah White Aesthetics shares her skincare must-haves SKINCEUTICALS GLYCOLIC 10 RENEW OVERNIGHT

Product description: Glycolic 10 Renew Overnight is an innovative night cream that works at a true active acid level of 10%. This delivers maximum efficacy for dissolving cellular cohesions and promoting skin cell turnover, while maintaining tolerability for nightly use. It restores skin’s lustre and improves its texture to bestow a healthy, radiant complexion. Sarah says: “Glycolic 10 Renew Overnight is my night-time face cream. I am a fan because it provides a long-lasting glow and leaves skin looking refreshed. It is an effective solution in treating dull, photodamaged skin, which we know is a common skin concern for many of our patients today. More importantly, Glycolic 10 Renew Overnight tackles the key signs of skin ageing, such as rough texture, fine lines and dullness, by promoting cellular turnover for a healthy stratum corneum and improved skin tone and smoothness. It leaves the skin feeling nurtured, soft, and renewed. After cleaning my face, I apply a small amount of cream with my fingertips. In the morning my skin radiance is restored and I am ready for a day in the clinic. Our clients love it!”

SKINCEUTICALS C E FERULIC

Product description: C E Ferulic is a daytime triple antioxidant that delivers advanced environmental protection and improves the appearance of fine lines, wrinkles, and loss of firmness. C E Ferulic actives comprise 15% L-Ascorbic acid, 1% Alpha-Tocopherol and 0.5% Ferulic acid. The synergistic formulation of ingredients provides robust protection against UV-induced erythema, free radical formation and cellular damage that results in premature skin ageing, and it also aids skin’s renewal process to prevent further adverse effects. Sarah says: “I am passionate about skin protection. I believe that a good antioxidant serum should be used every day to protect the skin against environmental aggressors and premature ageing. SkinCeuticals C E Ferulic is very much the cornerstone of my skincare regimen. The combination of vitamins C and E combined with Ferulic acid delivers eight times the skin’s natural protection against environmental

Sarah White, Sarah White Aesthetics Sarah White is an advanced medical aesthetic nurse practitioner, independent prescriber and trainer with more than 30 years medical experience. She uses the highest quality clinically proven products to ensure safe treatments that will achieve the best possible results for her patients. She believes that a quality cosmeceutical skincare regime is in her patients’ best interests as it can enhance areas not addressed by dermal fillers or toxins. A dedicated commitment to skincare is essential to achieving a global improvement in appearance, particularly in areas of skin tone, texture, and pigmentation. She believes passionately in “skin health for all”. She says, “Ultimately, when patients experience the amazing results, they remain loyal that helps build and maintain business.”

aggressors while helping the skin renewal process. It leaves my skin looking and feeling firmer and smoother. I also apply C E Ferulic immediately post procedure to my non-ablative and ablative laser patients to reduce downtime and prevent new damage from reoccurring.”

SKINCEUTICALS MINERAL RADIANCE UV DEFENSE SPF 50

Product description: Mineral Radiance UV Defense SPF 50 is a lightweight, ultrasheer tinted formula that is best suited to Fitzpatrick skin types I-IV, making it ideal for daily use to prevent visible signs of ageing and photodamage. Sarah says: “I use Mineral Radiance UV Defense SPF 50 daily. It is beautifully lightweight and easy to use. I apply it on top of C E Ferulic to provide powerful protection against photodamage. Its translucent spheres evenly disperse within the fluid to provide a sheer surface coating, repelling oil to minimise sebum appearance while enhancing natural skin tone and radiance.” AM

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S K I N / D E R M AT O L O G Y

SKIN NEWS

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skinbetter science launches AlphaRet® Exfoliating Peel Pads Aesthetic Source has announced the UK launch of AlphaRet® Exfoliating Peel Pads – the latest addition to award-winning clinical skincare brand skinbetter science. Designed for the improvement of skin smoothness and clarity, alongside reduction of lines and wrinkles, the AlphaRet® Exfoliating Peel Pads harness a patented, triple-acid formulation. Key ingredients include AlphaRet®, a patented ingredient that combines a retinoid and lactic acid, to create a revolutionary doubleconjugated retinoid as well as lactic acid, glycolic acid and salicylic acid. In a trial conducted by skinbetter science, 100% of patients experienced noticeable results after three weeks of three times per week use, reporting that their skin was healthier looking, its overall appearance was improved and it was brighter, more radiant and smoother looking.

Proto-col introduces Collagen and HA supplement Proto-col has added Collagen and Hyaluronic Acid Capsules to its clinical range of high-grade collagen, results-led products. Harnessing the powerful technology of VERISOL® Bioactive Collagen Peptides® (2,500mg) and the moisture-binding benefits of hyaluronic acid (50mg), this innovative formula is scientifically proven to reduce the appearance of lines and wrinkles, improve the skin’s elasticity and promote cell proliferation in fibroblasts, resulting in healthy cells in as little as four weeks. It also helps improves wound healing after surgical intervention, reduces the appearance of cellulite and improves brittle nails.

IMAGE Skincare adds I CONCEAL to I BEAUTY collection

Pharmacies to stock Derma-Seal Derma-Seal is now a registered trade mark in the UK and Europe and is available at Wigmore, John Bannon and Church Pharmacy. Derma-Seal is a disinfectant product which applies an impervious barrier over a puncture wound that has been created by a needle or cannula. It can be used in conjunction with other disinfectants and applied as a last step in a patient’s injectable treatment. The product can help reduce the risk of post-treatment infection by creating a clear film skin covering the puncture wound and protecting the injection points from unintentional accidental contact with hair, make-up and other environmental contaminants.

IMAGE Skincare has relaunched its I CONCEAL flawless foundation SPF 30 in the I BEAUTY collection. The I CONCEAL collection has the same shades and formula but is now packaged in rose gold easy-to-use tubes at the lower price of £45.00. The range also includes I PRIME flawless blur gel, a botanically boosted primer; I BEAUTY refreshing facial wipes; I BEAUTY flawless foundation brush and I BEAUTY brow and lash enhancement serum. AM

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Beyond skin deep Proto-col Clinical - a new professional-only ingestible wellness range to complement aesthetic treatments.

Discover more by calling Rebekka on 07399 475259 or visit www. proto-col.com/clinical

I N J E C TA B L E S

COVER STORY

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Ambassador for change We speak to Dr Vincent Wong about becoming the worldâ&#x20AC;&#x2122;s first LGBTQ+ ambassador for a global pharmaceutical company, his new #IAMME social media campaign and treating LGBTQ+ patients

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COVER STORY

Aesthetic Medicine: Explain the current landscape for the LGBTQ+ community and the access that patients currently have to treatments? Dr Vincent Wong: Currently, there is no specialism for the LGBTQ+ community in medical aesthetics despite the needs of the community being very different from the more “traditional” target audience for aesthetics procedures (i.e. anti-ageing and more targeted towards women). I believe that the approach is very different as the aim is to match the outer appearance to their inner identity, and you need to be very open-minded to achieve that. Furthermore, there are also very sensitive issues that are unique to the community. AM: How did you get into specialising in this work? VW: Throughout my career, I have found sexual dimorphism extremely intriguing when it comes to facial appearance. When I wrote and published a guide on injecting the male face with dermal fillers, I did a lot of research into the differences between male and female faces, which then led to a special interest in feminisation and masculinisation in faces, and I treated a number of trans patients. AM: What do you most enjoy about it? VW: Building the confidence of my LGBTQ+ following seeing the impact medical aesthetics has on self-confidence and self-acceptance is extremely rewarding. AM: What are the challenges, barriers and fears for patients coming to a clinic from the LGBTQ+ community? VW: Sadly, there are many people from the LGBTQ+ community who fear that they may be botched by practitioners who have a phobia against the community. From the conversations I have had, this seems to be one of the biggest barriers. Others are worried that the practitioner may not fully understand their needs and how they feel, which in turn creates an awkwardness that inhibits good rapport. I believe those that identify themselves as non-binary would face the biggest challenge as they may want to keep both feminine as masculine features and this can be quite difficult to explain to the practitioner. >

The #IAMME campaign explores the power of medical aesthetics to channel the inner confidence of individuals within the LGBTQ+ community to help overcome the struggles and issues the community faces. Among the celebrities supporting the #IAMME campaign are former Blue singer and actor Duncan James and Talulah-Eve, the first transgender contestant on Britain’s Next Top Model, both of whom are patients of Dr Wong. James said, “Speaking from my own experience as a gay guy, I prefer to go and and see a doctor or a physician who is LGBTQ+ friendly, somebody who understands my needs. I think, for me, it makes me feel a little more comfortable and more confident in talking about what I’m looking for. “It’s not just about putting filler or Botox in your face, it’s also about building inner confidence within yourself to wake up every day and feel happy with the way you look. I think this #IAMME campaign can embody that and really help people.” Talulah-Eve said, “I’m 25 now and I started transitioning when I was 19. When I first started transitioning, I didn’t have a clue what I was doing. I was literally walking around looking like a man in a wig. There’s no problem with that, but I just didn’t have a clue on how to be or how to portray myself as a woman. “I knew how I felt in the inside, but I didn’t know how to project that on the outside. My journey into things like aesthetic medical science, finding Dr Vincent Wong, makeup, fashion, modelling, all that kind of stuff, has helped me in becoming the woman that I am today. And, if anything, we’re stronger because we have to go through so much to be the women that we are. So I try and be vocal about that in the work that I do.”

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COVER STORY

medical aesthetics can play a big role, for example, those with HIV or eating disorders. Scar reduction is also popular within the community as the self-harm is more prevalent in this group of patients. AM: Can anyone offer these treatments? VW: No. The approach is very different, especially when treating a trans patient. More so in this group, we have to assess and treat the entire face rather than selected areas, while respecting facial balance and harmony.

AM: What are the considerations practitioners need to make when treating patients? VW: Firstly, you have to have an open mind as some of the requests may go against what we would recommend or what is traditionally deemed as “aesthetically pleasing”. The key here is to try and understand why a particular request is important to that patient. Many members of the LGBTQ+ community have undergone major trauma when it comes to acceptance, self-confidence and other sensitive issues. Therefore the psychological state is more important with this group and it is vital to look for red flags when it comes to mental health.

AM: Where can people find an experienced LGBTQ+ practitioner? VW: There needs to be a register or a website, hence why I started the #IAMME campaign. Colleagues in the industry who are interested are more than welcome to contact me directly to make this a bigger success!

Seeing the impact medical aesthetics has on self-confidence and selfacceptance is extremely rewarding

AM: Where can practitioners get training in treatments for the various needs of the LGBT+ community? VW: I’m in the process of putting together training courses, so for those who are interested, please get in touch! AM

AM: I imagine treating transgender patients is quite specialised. What additional training would you recommend? VW: At this point in time, there is no specialised training available. Having extensive experience treating both men and women would definitely be beneficial alongside training in mental health screening. AM: Do some patients choose medical aesthetic treatments over surgery? VW: Not many people from the community know about what can be achieved with medical aesthetics. For those that do, they choose non-surgical treatments as they can pace it with their journey and “grow” into their looks rather than having a dramatic change immediately. There is such a wide but clear variety within the LGBTQ+ community, which makes it a very unique market. If we narrow it down to treatment modalities, muscle relaxing injections and dermal fillers would be at the top. This is because these treatments can achieve so much, from gay men who want to look more masculine, lesbian women who want to look more feminine, those who identify as nonbinary who may want a more androgynous look, to the trans subgroup who want full feminisation or masculinisation of their faces. In addition, there are certain conditions where

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Dr Vincent Wong has won a number of awards for his work and has been shortlisted as one of the Ultimate 100 Global Aesthetics Leaders. Dr Wong regularly runs training courses and workshops for other healthcare professionals and mentors junior doctors and specialises in feminisation and masculinisation of faces within the LGBTQ+ community. He is actively involved in research and presents his work and research at national and international conferences.

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OUR EXPERT RANGE ALLOWS YOU TO RESHAPE, REGENERATE AND REDEFINE

Silhouette Soft®: 3D cone technology suspension sutures

Ellansé®: Collagen stimulating dermal filler

Perfectha®: Full range of Hyaluronic Acid fillers

WORKING WITH YOU TO DELIVER NATURAL LOOKING RESULTS

For more product and training information visit www.sinclairpharma.com Sinclair Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. 0207 467 6920 Date of preparation: January 2019 COR04 Rev A

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TRENDS

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World view

We take a look at global beauty trends and the aesthetics market

he UK has become a magnet for diversity and there are more nations represented here than in many other countries. It is unsurprisingly, therefore, that there is a burgeoning trend towards the treatment of an increasingly disparate and diverse range of ethnicities. According to the Office for National Statistics, there are approximately 67.5 million people living in the UK. Of these, 87.2% are white British. The most recent Census highlights that in England and Wales, 80% of the population were white British. Asian (Pakistani, Indian, Bangladeshi, other) groups made up 6.8% of the population; black groups 3.4%; Chinese groups 0.7%, Arab groups 0.4% and other groups 0.6%. Eighty-seven percent of those in England and Wales were born in the UK. Of those not born in the UK, 9% were born in India, 8% in Poland, and 6% in Pakistan.And this is just the people who are resident in the UK. Visitors from all over the globe converge on Britain for treatments because of its worldclass medical reputation. We have spoken to a number of aesthetic doctors who are riding this trend and are using products from the Sinclair Pharma portfolio to address the the diverse ethnicities of their patients, their skin types, their anatomical differences, and their treatment requests/requirements.

“African Americans are protected from developing UV-induced wrinkles, which are commonly visible in the Caucasian population, however, given the increased melanin in their skin, they develop mottled pigmentation and a texturally rough skin. Their skeletal ageing leads to pronounced sagging of the malar fat pads with soft-tissue laxity and jowl formation. “Similar to African Americans, the Hispanic population has enhanced protection against photoageing due to an increased melanin content in their skin. However, Latinos develop skin mottling, jowl formation, and tear trough hollows, too. “A commonality in aesthetic treatments for African-Americans, Hispanics and East Asians, is the use of combination treatments to reposition sagging tissues of the mid-face (with threads) with volume restoration (with fillers) to address structural ageing while preserving ethnic features.”

There is a burgeoning trend towards the treatment of an increasingly disparate and diverse range of ethnicities

DIVERSE FACIAL ANATOMIES

Mrs Sabrina Shah-Desai, a leading consultant ophthalmic plastic reconstructive surgeon, comments on how important it is to develop an understanding of the diverse facial anatomies and skin types, as there is no longer a single standard of beauty and the ageing process has ethnic variability. She says, “The ideal facial proportions of a Caucasian patient (oval face, prominent cheekbones, tapered jaw line, narrow nasal base, and thin lips) and the concept of universally applying the mathematical proportions of ‘phi’ (the golden ratio) to calculate beauty, are not valid across all ethnic groups and ages. “When it comes to aesthetic concerns, patients differ in terms of their unique anatomical structure, skin physiology and mechanisms of ageing, as well as the cultural perceptions of beauty that are dependent on ethnicity. “The facial structure and soft tissue of East Asians is similar to that of an infant, including a wider and rounder face, fuller upper lid, lower nasal bridge, flatter midface, more protuberant lips, and a more receded chin. Studies suggest that the Asian facial skeletal framework is weaker centrally, which results in greater gravitational soft-tissue descent of the midface, leading to sagging of the nasolabial folds and a tear trough hollowing due to malar fat pad ptosis.

ARABIC DESCENT

Dr Saleena Zimri from Skin Doctors Clinics in Leeds, treats a number of clients of Arabic decent. She explains that: “Most clients of Middle Eastern descent come to me to treat genetic hollows under the eyes. It’s a common problem that affects this population due to anatomical variance. They like to look glamorous so aren’t afraid of volume, but also like to look more contoured and have a ‘slimmer’ looking face. Generally, they have good cheeks and lips, but the eye and temple region is where they tend to have most concerns. “I use Silhouette Soft to help them achieve a lifting effect on heavy skin, but I combine this with Ellansé and Perfectha to give them volume in areas of defect, such as the temples, lips, and tear troughs.”

Before

After

Before

After

ASIAN SKIN

Mrs Sabrina Shah-Desai, who is also an expert in facial rejuvenation, comments: “Asian skin is made up of higher levels of melanin, the pigment that provides skin with natural protection from sun damage.

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TRENDS

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As a result, signs of ageing around the eye zone show up much later in life. However, melanin also makes skin more prone to pigmentation problems. Most East Asians are born without an upper eyelid crease, which can cause the lashes to droop or give rise to a sleepy appearance. Also, loss of elasticity and a weaker skeletal support leads to under eye hollows and cheek flattening. “Hollowness under the eyes and flatter cheeks can be padded out with hyaluronic acid and Ellansé around the mid face. Asian blepharoplasty, also known as double eyelid surgery, can give a higher crease and remove excess skin, muscle, and fat, while maintaining ethnicity. Pigmentation around the eye zone can be addressed with skincare containing ingredients such as vitamin C and kojic acid.”

HISPANIC DESCENT

According to dermatologist Dr Gabriel Aribi, “My Brazilian patients have specific skin changes related to increased sun exposure, so they often have more intense collagen loss and more blemishes than women in the UK. More and more patients are seeking treatment with biostimulators, as well as lasers to address these complaints. “The most popular facial aesthetic treatments in Brazil are: botulinum toxin for the treatment of dynamic facial wrinkles; pre-packing with hyaluronic acid to improve facial contours, loss of volume, and sagging; biostimulators for the treatment of sagging and skin tone; lifting threads to improve flaccidity and provide a lifting effect; laser, intense pulsed light and peelings for the treatment of melasma, rosacea and facial rejuvenation; microrelief with drug delivery for the treatment of various aesthetic complaints and for rejuvenation. Another trend is the treatment of body complaints, especially ‘sad navel’ and buttocks (volume increase and cellulite treatment) with biostimulators.”

CELTIC ORIGIN

According to Dr Vincent Wong, “Celtic people of Irish or Scottish origin are associated not only with red hair but also thin, fair skin (which burns easily in the sun) and freckles.” He adds, “The more melanin present in your skin and hair the slower most people will appear to age. If you have thicker skin, the signs of ageing are less noticeable. When the dermis layer of the skin is thicker, cells are more densely packed together and more compact. You don’t see fine lines and wrinkles as much. Conversely people with fair, thin skin appear to age earlier.” The women who consult him are universally concerned with the signs of ageing; which typically sagging skin, drooping jaw and jowl lines with a lack definition, and loss of facial volume. They also complain of a loss of their youthful bloom and that their complexions look duller as they have aged. >

Before

After

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His answer to their concerns is invariably collagen stimulating treatments, and as a leading treatment provider for both Silhouette Soft and Ellansé, he extolls their versatility to address all these concerns: correcting hollowing, adding volume, creating definition, improving skin quality, and, of course, for the long-lasting effects. “Collagen stimulation is the holy grail” adds Dr Wong. “Rather than plumping up the face inauthentically in places nature never intended, it is now possible to replace lost volume by kick starting the body’s natural collagen production once more. This is the future of beauty.”

CHINESE PATIENTS

“Over the past three years, I have seen a significant increase in the number of Chinese patients requesting cosmetic treatments at Harley Street Skin,” says Dr Aamer Khan. “One of the things I have noted is that the Chinese population commonly start having aesthetic procedures as early as their twenties. This view is supported by the statistics: China ranks third in the world behind the United States and Brazil for the number of plastic surgeries performed, according to industry officials.” 1 “Chinese patients typically have specific anatomical differences from other ethnic groups. The shape of their skull, muscle and tendon insertions are such that they have flatter faces and short, backward sloping foreheads, which can start to look square as they age. “Their noses tend to be small, with a low or flat bridge, and a short tip. They have strong and prominent masseter muscles,

and shorter chins that accentuate the wideness of the jawline and roundness of the face, with fat under the chin. “The Chinese features have an absence of the upper eyelid crease, so we receive a lot of requests for ‘double eyelid’ surgery to surgically create an upper eyelid crease. Upper blepharoplasty is one of the most common aesthetic procedures for East Asians. 2 Chinese Asian patients who want to change the flat bridge of their nose and make it longer, can have their nose reshaped with a collagen stimulator such as Ellansé. A concave forehead and sunken temples also cause concern. “Chinese skin can be more prone to large pores, acne, scarring, and hyper-pigmentation. Skincare, peels, IPL, and facial sculpting and tissue remodelling with fillers, such as hyaluronic acid and Ellansé give the best results in many cases. “I have found that many of my patients have already had jaw shaving surgery in South Korea and Vietnam in order to give them sharper features. This type of surgery is being sought by, and being provided to, very young women in their early thirties, without a good idea of the long-term consequences of such procedures. We find that remodelling the face with sutures, fillers or fat transfer, while reducing the masseter size using botulinum toxin, can give the desired result as a safer alternative. “Within this patient group, facial ageing is one of the most common concerns I find in my practice. Collagen and volume loss to the midface and temples coupled with the ‘slide’ of the tissues in the mid and lower face are all typically accentuated by the squarer jaw line and flatter, round face. “I use a thread treatment with Silhouette Soft collagenstimulating polyactic acid sutures to lift sagging tissues, Ellansé as a collagen stimulator to correct volume loss, and

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subdermal criss-cross Ellansé as a redermaliser to tighten and restructure the skin.

CAUCASIAN FACES

Dr Joanna Christou, who practices at The Cosmetic Skin Clinic in London shares her observations on beauty trends in patients from Caucasian descent. She comments “Facial augmentation leading to overfilled or over frozen results, I believe, is becoming a thing of the past and people now seek to avoid that one-size-fits-all approach; especially in my 35+ patients. As such, any treatment should enhance your natural features, not erase them. Lost volume skeletonises the face as we age producing hollowing that collects shadows on the face rather than reflecting light. Typically, with many of my Caucasian patients, loss of elasticity causes a soft tissue ‘slide creating nasolabial folds, marionette lines, and jowling. A combination approach is needed, using dermal filler to strategically replace lost volume and threads placed in vectors to realign the elasticity loss, lifting the soft tissue back to restore the smoothly lifted outline to the face.”

Before

After

AFRO CARIBBEAN DESCENT

Dr Ifeoma Ejikeme, medical director of Adonia Medical Clinic in London, comments: “Black-African and Caribbean skin is generally much thicker and contains more melanin than other skin

types. However, these higher levels of melanin mean the skin is more prone to pigmentation. In addition, dark circles and hollowness under the eyes are common in this group, conditions that often worsen with age.”

SOUTH EAST ASIAN DESCENT

Dr Tahera Bhojani-Lynch from The Laser and Light Clinic, shares her observations about beauty trends in her patients of East Asian descent. She comments: “There are two main areas of concern that patients of East Asian descent typically wish to address: dark circles and increasing definition of the jawline. Typically, Asian patients do not have a significant level of medial fat under their tear troughs, meaning that very early, even in their late teens, many patients are turning to under eye concealers to hide dark circles. This concern can be addressed relatively easy using an HA filler in the area, taking careful consideration to treat not only the tear trough, but also balance proportions around the cheekbone and outer lid cheek junction. Results are instant and patients are keen to maintain the results as the HA filler wears out. “Genetically, most Asian patients do have smaller, softer, delicate jaw lines and many patients I see are keen to create more definition in this area. For me, collagen stimulation,rather than ‘filling’ is critical to treat the jawline, and Ellansé is therefore an ideal choice. Clinicians can, and do, use HA filler for jawlines; however, we must be mindful of HA filler’s properties. HA is a gel that can attract water, and therefore weight, to the area where it is placed. In the jawline particularly, results with HA may look heavy, which many patients are keen to avoid. For Asian patients particularly, who do not tend to develop wrinkles to the same degree as western/Caucasian patients, collagen stimulating treatments like Ellansé are ideal. Collagen itself does not carry weight, and Ellansé, with its principle component of polycaprolactone microspheres, does not attract water. It offers a defining lift without giving too much of the added projection of HA fillers.” AM

REFERENCES 1. h ttp://factsanddetails.com/china/cat11/sub75/item136.html 2. A sian Journal of Surgery. Comparison of aesthetic facial criteria between Caucasian and East Asian female populations: An esthetic surgeon’s perspective. https://www.sciencedirect.com/science/article/pii/ S1015958416301798

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

GALDERMA AND MED-FX

Preferred partners On 8 September, Galderma and Med-fx will operate under a sole-preferred distributor model for Galderma’s Azzalure and Restylane brands in the United Kingdom and the Republic of Ireland. Here Toby Cooper, Head of Galderma’s Medical Solutions Business in UK & Ireland, explains what the change means for customers and what they can expect Why did Galderma decide to change its distribution model? The increasing demand for aesthetics treatments in recent years has led to higher numbers of active injectors and products. Now more than ever, healthcare professionals and their patients need to have full confidence in the safety and quality of the product and treatment they’re receiving. We are committed to excellence in patient safety and customer care, and our new distribution model with Med-fx has been designed to help raise industry standards by improving how we meet these demands. How will the new distribution model better meet demands for the safety and quality of treatments? On September 8, Med-fx will become the sole-preferred distributor for all Galderma Azzalure and Restylane products in the UK and Ireland, and will operate under a ‘Raising Standards in Aesthetics’ principle. This means Med-fx will only supply Galderma products to qualified healthcare professionals, reflecting guidelines provided by the Joint Council for Cosmetic Practitioners (JCCP). To support safety and quality standards further, Galderma and Med-fx will provide a market-leading Customer Care Service package, including specialist training, to its customers. What else can customers expect from the Galderma and Medfx partnership? In addition to our commitment to improve the safety and quality of patient outcomes, we are focused on delivering a truly market-leading experience to our customers that will improve their businesses. Customers will benefit from a new customer care service package, which will include a training and education platform available nationwide and for all experience levels. We look forward to sharing more detail about this in the coming months. What other detail is available about the delivery of products under the new model, and Galderma and Med-fx’s commitment to market leading customer service? Together we are committed to providing excellence in customer service. In addition to a continued, reliable supply of products, we are working hard to improve Med-fx’s existing and impressive customer service performance, which includes an ‘on time in full’ rate of 99.3%, a Net Promoter Score of 65 (where 50 is considered ‘exceptional’) and a record of answering customer calls in an average of six seconds.

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What was the process to appoint Med-fx and why was it selected? We appointed Med-fx as our sole-preferred distributor following a rigorous review and selection process. Med-fx’s commitment to high quality standards and customer service and its innovative ideas impressed our team, and the business shares our ambition to improve the safety and quality of patient outcomes under the ‘Raising Standards in Aesthetics’ principle. We look forward to implementing our new model and to further developing our Customer Care Service package. We would also like to thank all the distributors who took part in the process, both for their submissions and for their partnership under the previous model. What is the impact of the appointment on other distributors? Following September 8, other distributors who have an active account with Galderma will still be able to purchase products under the Azzalure and Restylane brands. This will be under our standard terms and conditions. However, as our preferred partner, Med-fx (or their appointed partners) will have priority supply of products. It’s been reported that there have already been changes to some distributors, what does that mean? The contracts with some distribtuors have ended early but they are still able to sell stock which they have already purchased, and therefore may be able to fulfill orders until that runs out. Med-fx are on standby to assist any customers seeking an alternative supplier during this time. How can customers continue to get Azzalure and Restalyne? How should they sign up to Med-fx? Products sold under the Azzalure and Restylane brands will only be available to qualified healthcare professionals eligible to join the JCCP register. Existing Med-fx customers don’t need to do anything, and we’re inviting all other customers who fit those criteria to contact Med-fx online or by phone. Opening an account is a simple process – after completing a short form, your account will be running within one working day.

Galderma Customer Services 01923 216 000 Med-fx med-fx.co.uk | 01376 532 800

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MEDICINE

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LOCAL ANAESTHETIC

Local knowledge Dr Sotirios Foutsizoglou on understanding local anaesthetic

he expanding field of aesthetic medical treatments and procedures requires the proper selection and administration of anaesthesia to maximise patient safety and comfort. Topical application of anaesthetics is particularly effective for mucosal surfaces because of their enhanced absorption. For more invasive procedures, intradermal or subcutaneous infiltration are the most commonly used techniques, the former being more immediate in onset and more prolonged, but also causing more tissue distortion and pain. To anaesthetise a large area of skin, a nerve block may be more appropriate, injecting a small amount at the major cutaneous nerve trunk that supplies the area (e.g. infraorbital or mental block for lip treatments), therefore avoiding the use of potentially toxic amounts of anaesthetic. Several local anaesthetics with various methods of delivery are now available for cutaneous surgery or invasive treatments. Their safety and efficacy depends on the correct choice of compound, understanding its

pharmacological properties, and employing the proper technique of administration.

STRUCTURE & PHYSIOLOGY OF ANAESTHETICS

Most local anaesthetic agents have similar chemical structures, consisting of three components: an aromatic portion, an intermediate chain, and an amine portion (Fig. 1). Modifications of any of these components can affect the pharmacological properties of the anaesthetic agent. The aromatic end provides most of the lipophilic properties and facilitates the diffusion of the anaesthetic through membranes, which correlates to the potency of the anaesthetic.1 The hydrophilic end, usually consisting of a tertiary amine, is involved in binding within the sodium channel.2 These two domains are linked with an intermediate chain, consisting of either an ester or amide, and having a length between 3 and 7 carbon equivalents is necessary for local anaesthetic activity.2 Disruption of this chain initiates the drugâ&#x20AC;&#x2122;s metabolism and allows for the reversible nature of the anaesthetic.2 >

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LOCAL ANAESTHETIC

a lower pKa correlates to a higher concentration of base and a faster onset of action.2 Alkalinisation of the anaesthetic solution increases the amount of base and the anaesthetic’s onset of action.8 In addition, the pH of the tissue can also affect the action of local anaesthetics. Infected tissues tend to be acidic and impair the effectiveness of local anaesthetics.9

MECHANISM OF ACTION

Fig. 1. Basic structure of local anaesthetics The differences in the intermediate chain linkage (ester vs amide) classify local anaesthetics into two groups (Table 1). Ester-type compounds tend to have a shorter duration of action because they are rapidly hydrolysed by plasma pseudocholinesterases to form metabolites excreted by the kidneys.3 Individuals with decreased levels of pseudocholinesterase may be prone to the toxic effects of these agents,3 and PABA, which is a major metabolic product, is responsible for the higher incidence of allergies with ester-type anaesthetics.4 Amide derivatives meanwhile are not readily hydrolysed; they are metabolised by microsomal enzymes in the liver and excreted by the kidneys.3 Individuals with compromised liver function are more susceptible to the toxic effects of amide anaesthetics.5 The pharmacological properties of common ester and amide anaesthetics are outlined in Tables 2 and 3. The molecular structure and dissociation constant (pKa) of local anaesthetics affect their potency and toxicity.6 In general, lipid solubility determines the potency of the agent, while protein binding dictates its duration of action.6 For example, the addition of a 4-carbon group to procaine creates tetracaine, which is more lipid soluble and potent. Highly protein-bound agents, such as bupivacaine, are tightly associated with the neural membrane, leading to a longer duration of action.2 The pKa influences the onset of action of local anaesthetics.6 For the most part, the shorter-acting anaesthetics tend to have a faster onset of action and less toxicity. However, peak plasma concentrations depend on various factors, including the concentration of anaesthesia, the duration of infiltration, the site of injection, and the rate of metabolism of the agent.7 The pKa of local anaesthetics and the hydrogen ion concentration (pH) of the solution and tissue influence the pharmacological activity of local anaesthetics.2 Local anaesthetics are weak bases, with a pKa between 7.7 and 9.1. They are usually prepared as solutions of hydrochloride salts with a pH of 5.0 to 6.0 to enhance their solubility and stability.4 In tissue, they exist either as an uncharged base or as a cation, with their relative proportions determined by the pKa of the anaesthetic and the pH of the solution.6 The non-ionized base form can readily diffuse across lipid nerve sheaths and cell membranes, while the ionized form can diffuse through the extracellular space and intracellular cytoplasm.6 In general,

Local anaesthetics act by reversibly interrupting the propagation of impulses and blocking nerve conduction.6 During conduction of an impulse, sodium channels open and allow sodium ions to move across the membrane and generate an impulse or action potential. By interfering with the influx of sodium ions into the cells, local anaesthetics prevent the depolarisation of peripheral nerves and subsequent nerve conduction.6 The exact mechanism of action by which local anaesthetics interfere with the movement of sodium ions is unclear. One postulated mechanism involves the local anaesthetic binding to receptors in sodium channels, and when enough sodium channels within an axon are blocked, conduction is interrupted.10 The binding site of local anaesthetics may be at the channel’s pore or on the protein subunits within the channel.11,12 Nerve fibres are divided into three main categories: A, B, and C fibres.4 A and B fibres are myelinated and C fibres are unmyelinated. The A fibres are the largest and are subdivided into four types: alpha, beta, gamma, and delta. The A-alpha fibres conduct motor impulses, the A-beta fibres primarily conduct light touch and pressure, the A-gamma fibres are responsible for joint proprioception, and the A-delta fibres, which are the smallest of the A fibres, conduct pain and temperature. The B fibres are preganglionic sympathetic fibres. The C fibres are the smallest and, like the A-delta fibres, conduct pain and temperature. In general, smaller myelinated fibres are easier to block than larger myelinated fibres; therefore, pain and temperature sensation may be eliminated before the loss of vibration and pressure.4 This translates clinically as locally anaesthetised patients may not feel pain and temperature, but still feel a pressure sensation during a procedure.4

Local anaesthetics act by reversibly interrupting the propagation of impulses and blocking nerve conduction

ADDITIONS TO LOCAL ANAESTHETICS

Substances are frequently added to local anaesthetics to augment analgesia and enhance the ease and safety of the surgery. Some of these products are commercially available pre-mixed by the manufacturer. VASOCONSTRICTORS Vasoconstrictors are commonly added to local anaesthetics to decrease bleeding and thereby facilitate the ease of surgery. In addition, they retard the absorption of anaesthetics, which in turn minimises the amount of drug injected and decreases systemic toxicity. By localising the drug to the field injected, vasoconstrictors also prolong the duration of the anaesthesia. Epinephrine or adrenaline is the most common vasoconstrictor added to local anaesthetics to enhance efficacy. Although the anaesthetic may have an immediate onset of action, full vasoconstriction with epinephrine typically requires seven to 15 minutes.4 Epinephrine is commercially available pre-mixed

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at concentrations of 1:100,000 and 1:200,000 with lidocaine. The optimal dose of adrenaline has been debated,13,14 but in clinical practice, concentrations greater than 1:100,000 are associated with an increased risk of side effects.15 The maximum dose of epinephrine for local anaesthesia injected in healthy individuals should generally not exceed 1mg (100ml of 1:100,000 solution) over approximately eight to 10 hours, which is the equivalent of five half-lives. However, these parameters can be significantly influenced by patient age and concomitant health issues which may affect metabolism.4 To prevent the degradation of epinephrine in an alkaline pH, commercially prepared lidocaine with epinephrine contains acidic preservatives, such as sodium metabisulfite and citric acid.17 The resulting acidic solution tends to cause more pain on injection.18 Freshly mixed solutions of lidocaine with epinephrine result in a less acidic solution and therefore less discomfort on injection.17 A freshly prepared anaesthetic solution with a 1:100,000 concentration of epinephrine can be made by adding 0.5ml of 1:1,000 epinephrine to 50ml of lidocaine. Adding half as much epinephrine in this mix would give a concentration of 1:200,000 epinephrine. SODIUM BICARBONATE The addition of sodium bicarbonate to commercially available lidocaine with epinephrine reduces the pain on infiltration.19 The pH of lidocaine is around 5.0-7.0. However, the addition of acidic preservatives lowers the pH of commercially prepared epinephrine and lidocaine solutions to around 3.3-5.5, thus causing more discomfort on injection. Buffering with 8.4% sodium bicarbonate at a ratio of 1 sodium bicarbonate to 10 epinephrine (1:100,000) or 1 sodium bicarbonate to 15 epinephrine (1:200,000) increases the pH, bringing it closer to physiologic pH, and reduces pain.20 Adjusting the pH of the solution can affect other pharmacological properties of these agents. Adrenaline is chemically unstable in anaesthetic solutions alkalinised by sodium bicarbonate. Neutralising lidocaine and bupivicaine solutions containing epinephrine with bicarbonate decreases the duration of action of epinephrine and decreases the shelf life of the mixture.21 In addition, alkalinisation of local anaesthetics allows for increased amounts of uncharged, lipid-soluble base, which more readily crosses the nerve membrane, leading to a faster onset of action. Clinically, alkalinisation of mepivacaine and lidocaine for use in peripheral nerve blocks leads to more rapid nerve blockade.2 HYALURONIDASE Hyaluronidase is an enzyme that depolymerises hyaluronic acid, one of the acid mucopolysaccharides present in intercellular ground substance. It is typically prepared in 1,500 unit vials. Its addition to local anaesthetics facilitates diffusion of injectable solutions through tissue planes, thereby increasing the area of anaesthesia and minimising tissue distortion by fluid infiltration.22 It facilitates undermining in the subcutaneous plane by hydrodissection of fatty tissue.23 Clinically, hyaluronidase may be a useful adjunct in surgery in the periorbital region to minimise the number of anaesthetic injection sites and potential ecchymoses. It may also be helpful in harvesting split-thickness skin grafts when wider areas of local anaesthesia can be attained with minimal loss of anatomic contour.24 Uniform dosage recommendations for cutaneous surgery are not available, but 150 units in 20-30ml of anaesthetic have been used.23

Hyaluronidase has disadvantages that limit its use in cutaneous surgery. It decreases the duration of anaesthesia and potentially increases the risk of anaesthetic toxicity as a result of increased absorption.23,25 Hyaluronidase contains the preservative thimerosal, which is a contact allergen.24 Because rare allergic reactions have been reported, preoperative skin testing has been recommended.23 Hyaluronidase is not recommended for tumescent liposuction because it does not augment the degree of anaesthesia with the tumescent technique and increases the rate of absorption of lidocaine, and therefore the potential for systemic toxicity.25

TOPICAL ANAESTHESIA

Topical application of anaesthesia has been particularly effective on mucosal surfaces, but caution must be taken regarding increased systemic absorption leading to toxicity. The stratum corneum presents the major barrier to the delivery of topical anaesthesia on intact skin. 26 However, the development of novel delivery systems has allowed for increased penetration and greater efficacy of newer topical agents. 27 COCAINE Cocaine is an ester anaesthetic that, unlike other local anaesthetics, possesses vasoconstrictive properties. Available as a 4% and 10% solution, it is primarily used for intranasal surgery.28 Anaesthesia occurs within five minutes of application and lasts up to 30 minutes; the maximum recommended dose is 200mg/kg. Potential toxicity, including hypertension, tachycardia, and arrhythmias, can result from blocking the reuptake of norepinephrine. In addition, decreased coronary blood flow can occur, leading to myocardial infarction.28 Dopamine reuptake blockade results in central nervous system stimulation.28 The risks of adverse events and the potential for abuse limit cocaineâ&#x20AC;&#x2122;s anaesthetic use over safer alternative agents. BENZOCAINE Benzocaine is a topical ester anaesthetic available as an aerosol spray, gel, ointment, or solution ranging from 5-20%. It is commonly used for achieving rapid anaesthesia on mucosal surfaces. Although topical benzocaine can cause contact sensitisation, it is still widely used. The anaesthetic effect lasts for about 12 to 15 minutes. Available as a spray and liquid, cetacaine is a mixture of 14% benzocaine, 2% butyl aminobenzoate, and 2% tetracaine hydrochloride that produces rapid mucosal anaesthesia that lasts for approximately 30 to 60 minutes.28 Benzocaine-containing preparations should be avoided in infants because of the risk of methemoglobinaemia.30 LIDOCAINE Lidocaine, available in a 2-5% gel and topical and viscous solutions, has been used reliably for topical anaesthesia on mucosal surfaces. However, these compounds are formulated in conventional vehicles that often do not provide adequate and consistent anaesthesia for intact skin surfaces. Over the past decade, topical anaesthetics in more sophisticated vehicles have become commercially available that allow for better efficacy in reducing pain. >

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EMLA A widely used agent over the past decade, EMLA (eutectic mixture of local anaesthesia) cream is a 5% eutectic mixture composed of 2.5mg/ml of lidocaine and 2.5mg/ ml of prilocaine in an oil-in-water emulsion cream. EMLA’s formulation contains emulsifiers that enhance skin penetration and increase the anaesthetic concentration to 80% in the oil droplets while maintaining a low overall concentration of 5%, thereby minimising the risk of systemic toxicity. 29 Several clinical trials have shown its efficacy in alleviating pain during various aesthetic and dermatological procedures, including laser surgery, chemical peels, harvesting split-thickness skin grafts, skin biopsies, and curettage and electrosurgery. 27,29 EMLA is available as a 30g tube in retail pharmacies and a 5g tube in the hospital setting for inpatient use. EMLA is also packaged as an anaesthetic disc, which contains 1g of EMLA emulsion, with an active contact surface area approximately 10cm2. Generally, a 60-minute application period under an occlusive dressing is needed before the procedure; however, this may vary depending on the location of the treatment. Effective anaesthesia after 25 minutes of EMLA application to the face and after five to 15 minutes on mucosal surfaces has been reported. 27 Increased duration of application over two hours has been shown to correspond to enhanced depth of analgesia. The depth of analgesia after 60 minutes is 3.0mm and after 120 minutes, 5.0mm. 29 Because of the risk of methemoglobinaemia associated with prilocaine, EMLA should be used with caution in infants.31 Alkaline injury to the cornea has been seen with EMLA, so the use of EMLA close to the eyes should be avoided.32

TETRACAINE Tetracaine, a long-acting ester anaesthetic, is available in a 0.5% solution and is used most commonly for ophthalmic procedures. It can provide anaesthesia to the mucous membranes for up to 45 minutes. A formulation of 0.5% tetracaine, 0.05% adrenaline (1:2,000), and 11.8% cocaine in normal saline – termed TAC – has been compounded by pharmacists for more than 20 years for anaesthesia and vasoconstriction before repairing superficial lacerations, especially in children.31 Its limited absorption on intact skin limits its utility for other cutaneous procedures. One study found EMLA cream to be superior to TAC solution for anaesthesia of lacerations on the extremities.38 Concern over the potential systemic absorption of cocaine led to the substitution of 4% lidocaine for cocaine (LAT formulations).29 Tetracaine 4% gel in a lecithin gel base (the lecithin is thought to enhance penetration of the tetracaine) is available in the US from compounding pharmacies. Studies are still needed regarding its efficacy and safety compared to other available compounds.27 One study showed its effectiveness in reducing laser-induced pain after a 60-minute occlusion period.37 Amethocaine 4% gel, a preparation with 4% tetracaine currently not approved for use in the US, is marketed in Europe as a topical anaesthetic that provides more rapid and longer duration of action than EMLA and can be safely used in children and adults. 27 A study comparing 4% amethocaine and EMLA for pain relief during pulsed-dye laser treatments found amethocaine superior to EMLA.39 Adverse events tend to be transient and include erythema, oedema, and pruritus. 27

LMX LMX (originally named ELA-Max) is a more recently developed topical anaesthetic containing lidocaine encapsulated in a liposomal delivery system that is available without a prescription. The liposomal vehicle facilitates penetration and provides sustained release of the anaesthetic. In addition, liposomes may enhance the anaesthetic’s duration of action by protecting it from metabolic breakdown. 27 LMX 5% is labelled as an anorectal cream indicated for the temporary relief of local discomfort associated with anorectal disorders. It tends to have a faster onset of action; a 30-minute application time before the procedure is recommended. In studies comparing EMLA and LMX 5% used for dermatological procedures, both were effective in reducing pain; however, LMX 5% had a longer duration of action.33 It has been used, without the need for occlusion, to decrease pain induced during medium-depth chemical peels and laser hair removal.34,35 Its use on mucosal or conjunctival surfaces is not recommended because of the risk of increased absorption and the potential for irritation of the cornea. 29 Moderate amounts – 30–60g – of occluded liposomal 4% cream in adults showed no signs of clinical or serum toxicity in a study of eight healthy adults.36 In a child weighing less than 20kg, a single application of LMX should be limited to an area of less than 100cm2. 27

Table 1 Local anaesthetics

Concern over the potential systemic absorption of cocaine led to the substitution of 4% lidocaine for cocaine

TYPE

GENERIC NAME

SOME TRADE NAMES

Esters

Procaine

Novocain

Tetracaine

Pontocaine

Benzocaine

Hurricane

Chloroprocaine

Nesacaine

Cocaine

(None)

Lidocaine

Xylocaine

Bupivacaine

Marcaine

Mepivacaine

Carbocaine

Prilocaine

Citanest

Amides

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Table 2 Ester local anaesthetics Maximal recommended dose (mg/kg) for adults

Duration (min) ANESTHETIC Procaine Chloroprocaine Tetracaine

ONSET (min)

pKa

WITHOUT EPINEPHRINE

WITH EPINEPHRINE

WITHOUT EPINEPHRINE

WITH EPINEPHRINE

8.9

15–30

30–90

5–6

30–60

N/A

8.6

120–240

240–480

Table 3 Amide local anaesthetics

ANESTHETIC Lidocaine

Maximal recommended dose (mg/kg) for adults

Duration (min)

TabDuration (min) ONSET (min)

pKa

WITHOUT EPINEPHRINE

WITH EPINEPHRINE

WITHOUT EPINEPHRINE

WITH EPINEPHRINE

7.7

30–120

60–400

Bupivacaine

2–10

8.1

120–240

240–480

2.5

Mepivacaine

3–20

7.6

30–120

60–400

Prilocaine

5–6

7.7

30–120

60–400

Etidocaine

3–5

7.7

200

240–360

4.5

6.5

Ropivacaine

1–15

8.2

120–360

Not yet defined

3.5

Not yet defined

Levobupivacaine

2–10

8.1

120–240

Not yet defined

2.1

Not yet defined

CRYOANAESTHESIA Applying cold agents to the skin can be useful in reducing the pain associated with minor surgical procedures. The placement of ice cubes on the skin is a rapid, inexpensive, and easy method to minimise the discomfort during needle injections.40 Topical freezing agents or vapocoolants rapidly cool the skin and provide enough anaesthesia for injections or brief superficial surgical procedures. Held 10-30cm from the skin, the refrigerant is sprayed toward the lesion just until the area turns white. Various topical freezing agents are available.41 Care should be taken to protect the eyes and to avoid the inhalation of vapour when using these agents. Cryoanaesthesia has the potential to cause pigmentary alterations and scarring. In addition, some vapocoolants, such as ethyl chloride, are flammable.41,42 Various cooling methods to the skin are used with several laser procedures. These include the application of a cooled gel, a cold glass window, and other contact cooling devices to the skin being treated. The delivery of refrigerated air onto the skin, such as Zimmer air cooling, has also been used successfully for many aesthetic procedures, including fractional photothermolysis and pulsed-dye laser. Some laser devices are equipped with dichlorodifluoromethane and tetrafluoroethane cryogen sprays that deliver transient cooling to the epidermis.42 These cooling methods provide some anaesthesia and protect against laser-induced epidermal thermal injury.

INFILTRATIVE TECHNIQUES

LOCAL INFILTRATION Local infiltration of anaesthesia that involves the injection of the anaesthetic into the surgical site is the most commonly used technique in cutaneous surgery. This is administered either intradermally and/or subcutaneously. Intradermal injection results in an immediate onset and prolonged duration of anaesthesia compared to deeper injections. However, it tends to cause more tissue distortion and pain. Subcutaneous injection of anaesthetics produces less tissue distortion and pain, but has slower onset and duration as a result of diffusion and increased absorption. >

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Various techniques can diminish the pain and make local infiltration of anaesthesia better tolerated.44 Providing a calm and comfortable environment with the patient reclining, and reassuring the patient, can diminish fear and anxiety as well as the perception of pain. The use of smalldiameter needles, such as the 30-gauge needles commonly used in cutaneous surgery, minimises the pain associated with the initial puncture of the skin.16 The application of topical anaesthetics, ice, or other cooling devices before the initial injection may be helpful for children and extremely anxious individuals.40 Warming lidocaine to body temperature may also help attenuate the pain with infiltration.30 Providing counter-irritation by pinching the skin around the needle entry point can diffuse the pain stimulus.16 As multiple needle punctures can be painful, re-entering at previously anaesthetised areas can further reduce discomfort, especially when working on larger areas. Tissue distension with infiltration of the anaesthetic produces pain. Injecting slowly and using only the volume necessary to achieve adequate anaesthesia can attenuate the pain associated with tissue distension.16 The use of smaller-diameter needles also lends to a decreased rate of infiltration with slow tissue distension and less pain. These systems have been marketed primarily for dentistry, and their practical utility in decreasing pain during various cutaneous procedures is yet to be determined. FIELD BLOCK Field or ring block involves the placement of anaesthesia circumferentially around the operative site (Fig. 2). It is useful when direct infiltration into the surgical field is undesirable. Examples include cyst excisions because injection directly into the cyst can lead to rupture of cystic contents, and working with inflamed or infected tissue when local infiltration may not produce as effective anaesthesia in an acidic environment.3 This technique can also minimise the total amount of anaesthetic required, which is beneficial for procedures involving larger areas that would usually require more anaesthesia via local infiltration.16 To obtain optimal anaesthesia using ring blocks, the anaesthetic should be injected into the superficial and deep planes.16

Fig. 2. Field or ring block. TUMESCENT ANAESTHESIA The tumescent technique involves the delivery of large volumes of dilute anaesthesia (usually 0.05-0.1% lidocaine with 1:1,000,000 epinephrine) into subcutaneous fat until the tissue distends. It has been widely used for liposuction in which as much or more dilute anaesthesia is administered as fat is removed. The anaesthetic is typically delivered through 0.5-1.5mm multiport infiltration cannulas or 18-20-gauge blunt-tipped spinal needles. To administer the large volumes typically necessary for liposuction, special pumping devices aid infiltration. Although the basic tumescent solution described by Klein48 contains 0.05% lidocaine, the concentrations of lidocaine and epinephrine can be tailored, depending on the site and nature of the procedure. The safe upper limit of lidocaine dosage with this technique is estimated to be 55mg/kg.49 Warming of the tumescent solution before infiltration to 40Â°C and slowing the rate of infiltration have been shown to reduce pain in liposuction patients.50 Although best known for use during liposuction, the tumescent technique is helpful whenever large areas are to be treated to obtain adequate and safe anaesthesia. Examples are endovenous ablation with lasers or radiofrequency devices, ambulatory phlebectomy, and face lifting.

Although local infiltration remains the most commonly used method, other techniques of drug delivery have expanded the use of local anaesthetics

NERVE BLOCKS Knowledge of the anatomic distribution of sensory nerves of the head, neck, and hands and feet enables one to anaesthetise large areas of skin by using a nerve block. >

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REFERENCES 1. Covino BG. Local anesthesia. N Engl J Med 1972;286:975–983. 2. Tetzlaff JE. The pharmacology of local anesthetics. Anesthesiol Clin North Am 2000;18:217–231. 3. Covino BG. Local anesthesia – second of two parts. N Engl J Med 1972;286:1035–1042. 4. Grekin RC, Auletta MJ. Local anesthesia in dermatologic surgery. J Am Acad Dermatol 1988;19:599–614. 5. Selden R, Sasahara AA. Central nervous system toxicity induced by lidocaine: a report of a case in a patient with liver disease. JAMA 1967;202:908–909. 6. Covino BG. Pharmacology of local anesthetic agents. Br J Anaesth 1986;58:701–716. 7. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248–263. 8. Catchlove RFH. The influence of CO2 and pH on local anaesthetic action. J Pharmacol Exp Ther 1972;181:298–309. 9. Bieter RN. Applied pharmacology of local anesthetics. Am J Surg 1936;34:500–510. 10. Fink BR. The long and short of conduction blockade. Anesth Analg 1989;68:551–555. 11. Butterworth JF, Strichartz GR. Molecular mechanisms of local anesthesia: a review. Anesthesiology 1990;72:711–734.

The smaller volume of anaesthetic required not only reduces the risk for toxicity, but also decreases tissue distortion at the operative site. If wide undermining is planned and haemostasis is needed, a more dilute lidocaine with epinephrine mixture can be infiltrated painlessly in the field following the block. In general, nerve blocks cause less discomfort for the patient given the limited number of injections, especially during a mucosal approach. They can also avoid the need for additional sedation or general anaesthesia. In dermatological surgery, nerve blocks are commonly used on the face and digits, but can be used to anaesthetise other areas, such as the ears, feet, hands, penis, and lateral thigh. Because of their usefulness in cutaneous surgery, it is important to carefully learn the proper technique for peripheral nerve blocks to minimise potential adverse effects. For optimal results, administering nerve blocks requires technical skill and knowledge of local neuroanatomy. Once analgesia is obtained, an infiltration of vasoconstrictor at the surgical site or use of a tourniquet is often necessary because nerve blocks do not usually provide sufficient haemostasis. Risks include direct nerve injury leading to dysesthesias and paresis, as well as vessel trauma causing ecchymoses and haematoma formation.46 Amide-type anaesthetics are most commonly used for nerve blocks. As smaller volumes are injected, higher concentrations of anaesthetic, such as 2% lidocaine, may be used to enhance diffusion of the anaesthetic around the nerve.46 Vasoconstrictors, such as epinephrine (1:200,000), may be added to the anaesthetic agent. Epinephrine can have the advantages of slowing absorption of the anaesthetic from the injected site, prolonging the duration of anaesthesia, decreasing the amount of anaesthetic needed, and improving haemostasis.51 The use of epinephrine in digital blocks has been avoided given the potential risk of vasoconstrictor-induced ischemia; however, some debate this risk as theoretical when a proper technique is employed.51,52 >

12. Ragsdale DS, McPhee JC, Scheuer T, et al. Molecular determinants of state-dependent block of Na+ channels by local anesthetics. Science 1994;265:1724–1728. 13. Siegel RJ, Vistnes LM, Iverson RE. Effective hemostasis with less epinephrine: an experimental and clinical study. Plast Reconstr Surg 1973; 51:129–133. 14. Fante RG, Elner VM. The use of epinephrine in infiltrative local anesthesia for eyelid reconstruction. Plast Reconst Surg 1998;102:917. 15. Moore DC, Bridenbaugh DL, Thompson GE, et al. Factors determining dosage of amide-type local anesthetic drugs. Anesthesiology 1997; 47:263–268. 16. Auletta MJ, Grekin RC. Local anesthesia for dermatologic surgery. New York: Churchill Livingstone; 1990. 17. Moore DC. The pH of local anesthetic solutions. Anesth Analg 1981;60:833–834. 18. Howe NR, Williams JM. Pain on injection and duration of anesthesia for intradermal infiltration of lidocaine, bupivicaine, and etidonate. J Derma- tol Surg Oncol 1994;20:459–464. 19. McKay W, Morris R, Mushlin P. Sodium bicarbonate attenuates pain on skin infiltration with lidocaine with or without epinephrine. Anesth Analg 1987;66:572–574. 20. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local anesthesia. J Dermatol Surg Oncol 1989;15:1081–1083. 21. Robinson J, Fernando R, Sun Wai WY, et al. Chemical stability of bupivacaine, lidocaine, and epinephrine in pH-adjusted solutions. Anesthesia 2000;55:853–858. 22. Lewis-Smith PA. Adjunctive use of hyaluronidase in local anesthesia. Br J Plastic Surg 1986;39:554–558. 23. Clark LE, Mellette JR. The use of hyaluronidase as an adjunct to surgical procedures. Dermatol Surg 1994;20:842–844. 24. Dinehart SM. Topical, local, and regional anesthesia. In: Wheeland R, ed. Cutaneous surgery. Philadelphia: WB Saunders 1994; 105–110. 25. Klein JA. Pharmacology of lidocaine. In: Klein JA. Tumescent technique, tumescent anesthesia and microcannular liposuction. St Louis: Mosby 2000; 127. 26. Adriani J, Dalili H. Penetration of local anesthetics through epithelial barriers. Anesth Analg 1971:50:834–841. 27. Friedman PM, Mafong EA, Friedman BS, et al. Topical anesthetics update: EMLA and beyond. Dermatol Surg 2001;27:1019–1026. 28. L atorre F, Klimek L. Does cocaine still have a role in nasal surgery? Drug Saf 1999;20:9. 29. H uang W, Vidimos A. Topical anesthetics in dermatology. J Am Acad Dermatol 2000;43:286–298.

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I N J E C TA B L E S

LOCAL ANAESTHETIC

aestheticmed.co.uk

30 Chen BK, Eichenfield L. Pediatric anesthesia in dermatologic surgery: when hand-holding is not enough. Dermatol Surg 2001;27:1010– 1018. 31. Rincon E, Baker RL, Iglesias AJ, et al. CNS toxicity after topical application of EMLA cream on a toddler with molluscum contagiosum. Pediatr Emerg Care 2000;16:252–254. 32. Eaglstein NF. Chemical injury to the eye from EMLA cream during erbium laser resurfacing. Dermatol Surg 1999;25:590–591. 33. B ucalo BD, Mirikitani EJ, Moy RL. Comparison of skin anesthetic effect of liposomal lidocaine, nonliposomal lidocaine and EMLA using 30-minute application time. Dermatol Surg 1998;24:537–541. 34. Altman DA, Gildenberg SR. High-energy pulsed light source hair removal device used to evaluate the onset of action of a new topical anesthetic. Dermatol Surg 1999;25:816–818. 35. Koppel RA, Coleman KM, Coleman WP. The efficacy of ELMA versus ELA-Mac for pain relief in medium-depth peeling: a clinical and histopathologic evaluation. Dermatol Surg 2000;26:61–64. 36. Friedman PM, Fogelman JP, Nouri K, et al. Comparative study of the efficacy of four topical anesthetics. Dermatol Surg 1999;25: 950–954.

Nerve blocks involve injecting anaesthesia adjacent to a nerve or within the same fascial compartment as the nerve to be anaesthetised. Typically, a 1-inch 30-gauge needle is selected; the smaller-calibre needle tends to be less painful and allows a slower and more controlled delivery of anaesthesia.52,53 As vessels tend to travel along sensory nerves, care must be taken to avoid injecting into a vessel by aspirating before injection. Some advocate the use of a 25-gauge needle for nerve blocks because the smaller-calibre needles may be less reliable in aspirating blood during inadvertent intravascular placement.4 After the needle is placed into the desired area, a small volume of anaesthetic is injected and allowed to diffuse around the nerve. One should take caution not to inject into the nerve itself, which can cause a neuropraxia resulting in paraesthesia in the distribution of the nerve. Rarely this can be permanent.53 Peripheral nerve blocks require diffusion into larger-sized nerves, and thus require a longer onset of action than local infiltrative anaesthesia. Usually the block is effective after five to 10 minutes. The duration of anaesthesia depends upon the anaesthetic chosen.4

37. Zempski WT, Karasic RB. EMLA versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med 1997;30:163–166.

SUMMARY

47. True RH, Elliott RM. Microprocessor-controlled local anesthesia versus the conventional syringe technique in hair transplantation. Dermatol Surg 2002;28:463–468.

The use of local anaesthesia is ideal for most cutaneous procedures and aesthetic treatments. Knowledge of the pharmacological properties, potential adverse effects, and different applications and techniques of administration is crucial to the practice of cutaneous surgery and aesthetic medicine. With proper use, the available anaesthetic agents provide safe and effective anaesthesia and analgesia. Although local infiltration remains the most commonly used method, other techniques of drug delivery have expanded the use of local anaesthetics. As the use of local anaesthesia broadens with the emergence of new laser technology, new surgical techniques and more invasive aesthetic treatments, the impetus will hopefully be present to develop novel agents and delivery systems with even greater safety, efficacy, and ease of administration profiles AM

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38. M cCafferty DF, Woolfson AD, Handley J, et al. Effect of percutaneous local anaesthetics on pain reduction during pulsed dye laser treatment of portwine stain. Br J Anaesth 1997;78:286–289. 39. Kuwahara RT, Skinner RB. EMLA versus ice as a topical anesthetic. Dermatol Surg 2001;27:495–496. 40. P lotkin S. Clinical comparison of preinjection anesthetics. J Am Podiatr Med Assoc 1998;88:73–79. 41. Nestor MS. Safety of occluded 4% liposomal lidocaine cream. J Drugs Dermatol 2006;5:618–620. 42. W hite J, Siegfried E, Boulden M, et al. Possible hazards of cryogen use with pulsed dye laser. A case report and summary. Dermatol Surg 1999;25:250–253. 43. G reenbaum SS, Bernstein EF. Comparison of iontophoresis of lidocaine with a eutectic mixture of lidocaine and prilocaine (EMLA) for topically administered local anesthesia. J Dermatol Surg Oncol 1994;20:579–583. 44. DeCou JM, Abrams RS, Hammond JH, et al. Iontophoresis: a needlefree, electrical system of local anesthesia delivery for pediatric surgical office procedures. J Pediatr Surg 1999;34:946–949. 45. Ke M. Pain inhibition with pneumatic skin flattening in permanent diode laser hair removal. J Cosm Laser Ther 2007;9:210–212. 46. Hawkins JM, Moore PA. Local anesthesia: advances in agents and techniques. Dent Clin N Am 2002;46:719–732.

48. Klein JA. Anesthetic formulation of tumescent solutions. Dermatol Clin 1999;17:751–759. 49. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg 1996;22: 921–927. 50. Kaplan B, Moy RL. Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction. A randomized doubleblind study. Dermatol Surg 1996;22:707–709. 51. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg 2001;108:114–124. 52. Eaton JS, Grekin RC. Regional anesthesia of the face. Dermatol Surg 2001;27:1006–1009. 53. Cohen SJ, Roenigk RK. Nerve blocks for cutaneous surgery of the foot. J Dermatol Surg Oncol 1991;17:527–534.

Dr Sotirios Foutsizoglou developed a particular interest in anatomy during his time working in plastic and reconstructive surgery in the NHS. He became heavily involved in teaching anatomy and physiology to medical students and junior doctors and has worked as an anatomy demonstrator for Imperial College. He is currently completing his last year of training in plastic and reconstructive surgery at Evangelismos General Hospital of Athens. Since 2012, in his role as the lead trainer of KT Medical Aesthetics Group, he has been training practitioners in facial anatomy and advanced non-surgical treatments and procedures. He has written and lectured on facial anatomy and complications associated with injectables both nationally and internationally.

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TISSUE REMODELLING IMPROVEMENT OF SKIN QUALITY

EVERYONE IS A MASTERPIECE

www.ha-derma.co.uk

hadermauk

@ha_dermauk

0208 455 4896

I N J E C TA B L E S

EDITOR’S CHOICE

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Profhilo and Aliaxin SR Vicky Eldridge tries out a combination treatment for the face and neck with Dr Shirin Lakhani at Elite Aesthetics

first tried Profhilo back in 2017 and I absolutely loved the natural results it provided. I wanted to look a bit fresher without looking like I’d had anything done, and I was keen to address some of those telltale signs of ageing, particularly volume degradation, fine lines and wrinkles, and the general dulling of my complexion. Profhilo definitely delivered. This year I turned 40 and, suddenly, as well as noticing the signs of ageing on my face, I’d started to become more and more conscious of the creases and bands around my neck. I spend a lot of time at my computer, like so many of us do, so it’s no wonder the term “tech neck” is increasingly bandied about. I’d always laughed at my mum for doing neck exercises and lifting her neck up like a swan, but whenever I was on a video call or FaceTime I would find myself doing the same. I went to see Dr Shirin Lakhani who runs the Elite Aesthetics Clinic in Kent and she suggested a combination of Profhilo and Aliaxin SR (Shape and Restore) in the face and neck. I was excited to have Profhilo again and try it in my neck, but I have always been a bit nervous about having fillers. However, having had a consultation with Dr Lakhani, someone who I know and trust, I decided to go ahead with the treatment. During my first appointment, both products were injected in my neck and Profhilo was used on my face. A small amount of Aliaxin SR was injected in my temples. Dr Lakhani used a cannula, which I have never experienced before, and I found the sensation quite odd. However, the treatment was quick and I could see an immediate difference in the temporal region. Aliaxin, like Profhilo, is distributed in the UK by HADerma. Aliaxin SR utilises a combination of three different molecular weights of ultrapure hyaluronic acid with the ability to seamlessly integrate into the skin. The Shape and Restore product is ideal for dermal remodelling, thanks to the dual action of lifting and bio-restructuring. A month later, I came back for my second Profhilo treatment. Profhilo is the first product developed with NAHYCO® technology, which is what makes it so unique. It is the only stabilised HA on the market without the use of BDDE and is designed for bio-remodelling. And this is what I love most about Profhilo. About a month after the second treatment,

Before and after treatment with Profhilo and Aliaxin SR

you just wake up one day, look in the mirror and realise you look better but you are not sure exactly what has changed. I never thought I would had filler in my temples, but the Aliaxin SR has made a real but subtle difference and the results in the neck from using both products together are great. The most prominent band has significantly faded and the other is virtually non-existent. Dr Lakhani said, “I really like the Aliaxin SR for areas where you’ve got mobility and you want to do some superficial filling because it integrates really nicely with the tissues. I love it, in particular, as a neck treatment because it lifts the bands and then the Profhilio intensely hydrates the area. It stimulates the collagen and elastin and improves that turkey neck appearance.” AM

Aesthetic Medicine • September 2019

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I N J E C TA B L E S

HAIR LOSS

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The perfect pairing Consultant trichologist Benedetto Cusumano discusses an integrative therapy for the successful treatment of hair loss

t is safe to say that a sizable portion of the cosmetics industry is aimed at treating clients suffering from hair loss conditions; a bright and clear complexion, coupled with a lion’s mane of hair, is the ideology of “being youthful”. Hair Loss affects people all around the world and of all ages, gender and background. Moreover, while genetics has a role to play, trauma, hormones, an inadequate diet or an underlying medical condition are all common causes of hair loss. Hair loss in itself is not hazardous to a person’s health.

However, it can have a devastating effect on a person’s life and self-esteem, leading to emotional suffering, depression and feelings of being socially unaccepted. Natural remedies are gaining more ground in the world of science and, since these types of treatments promote healing from within, there are rarely any side effects. In the cosmetic industry, one such integrative therapy is Platelet-Rich Plasma (PRP) and Laser Phototherapy (LPT) – quickly becoming a powerful combination in the treatment of hair loss. >

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I N J E C TA B L E S

aestheticmed.co.uk

HAIR LOSS

PLATELET-RICH PLASMA (PRP)

Platelet-Rich Plasma, otherwise referred to as PRP, is a concentration of platelets, a component of the blood which plays a vital role in blood clotting. Platelets also play a critical role in the regeneration of cells. As such, PRP is a widely used tool in surgical procedures to promote recovery and healing. Indeed, studies have suggested that a significant quantity of proteins are released by platelets, which are responsible for the rejuvenation of damaged tissue. Platelet-Rich Plasma is produced by taking a sample of the patient’s blood and, using a centrifuge, separating the platelets from other cells within the patient’s blood. Once the PRP is collected, it can be administered to the injured area by way of a syringe. Since the 1970s, PRP has been used for a wide array of treatments, including orthopaedics, ophthalmology, dermatology and cosmetic surgery. How Platelet-Rich Plasma (PRP) is used in the treatment of hair loss Clinical studies have shown encouraging results; studies have demonstrated both an improvement in damaged hair follicles and new hair growth. In addition, a reduction of hair loss, accompanied by an increase in hair density, has also been observed. Studies have also shown an increase in blood vessels and thickness of the skin around the hair follicles, improving the function of the follicle itself. Currently, there is no consensus as to how often PRP injections should be administered, although results have shown that injections at between one and three-month intervals are enough to stimulate new hair growth. To achieve optimum results, the platelet concentration should be a minimum of four times the normal count found in whole blood. Using Platelet-Rich Plasma for treating hair loss conditions is a successful and straightforward solution, without any side effects, for both men and women, and is currently used worldwide in the treatment of alopecia.

that he discovered the hair grew back much more quickly on the exposed group than that of the control group. Stimulating tissue with the energy emitted from a low-level laser increases the manufacture of an organic chemical called adenosine triphosphate (ATP), which is a primary source of energy in cells, generated by the cell’s powerhouse, the mitochondria. Consequently, low-level lasers accelerate the healing process, increase circulation and is an effective therapy to reduce inflammation and discomfort. It is effective as a treatment in an impressive array of treatments, which include but is not limited to, nerve injuries, gingivitis and lumbar disc herniation. Laser Phototherapy, abbreviated as LPT, is a new, state of the art technology for successfully treating hair loss, and is available both in-clinic and as an affordable “treat at home” device. LPT provides a source of energy, which nourishes hair cells that may have been cut off from nutrients it would otherwise benefit from in the patient’s blood. Studies have shown that, by using LPT, hair follicles are shifted into their growing phase, known as the ‘anagen phase’, promoting stronger follicles, hair growth and increased tensile strength. There have been extensive clinical studies globally, many of which focus on the use of LPT to treat hair loss conditions, including androgenetic alopecia, alopecia areata and chemotherapy-related hair loss. Moreover, with an array of scientific papers published in reputable journals for the dermatology, cosmetology, hair restoration and plastic surgery industry, it is safe to say that the use of LPT is quickly becoming a mainstream procedure in the treatment of hair loss.

Platelet-Rich Plasma and Laser Phototherapy are both clinically proven to be efficient tools for combating hair loss

LASER PHOTOTHERAPY (LPT)

The first case of using light as a treatment dates back to the early 20th Century by Danish physician and scientist Dr Niels Ryberg-Finsen, who was awarded the Nobel Prize in Medicine and Physiology in 1903 for his pioneering work on the treatment of disease with concentrated light radiation. Later, it was Hungarian physician Endre Mester who took over the mantle to become a pioneer of laser medicine and is credited as the innovator behind discovering the positive natural effects of low-level laser therapy. It was while experimenting with low-level laser therapy on shaven mice

>> 74

USING PRP AND LPT AS AN INTEGRATIVE THERAPY FOR TREATING HAIR LOSS

Due to the individual success of both Platelet-Rich Plasma with Laser Phototherapy, clinical studies have begun to investigate the additional benefits of using Platelet-Rich Plasma in conjunction with Laser Phototherapy as an integrative treatment and, so far, the results have been very positive. One observed benefit in the use of Platelet-Rich Plasma with Laser Phototherapy is that LPT is proven to reduce inflammation, which can be caused as a result of a series of PRP injections. In fact, many reputable clinics are beginning to promote LPT alongside PRP as a means to optimise treatment and increase the effectiveness of PRP as a standalone treatment. Platelet-Rich Plasma and Laser Phototherapy are both clinically proven to be efficient tools for combating hair loss, increasing hair density, promoting new hair growth and minimising hair shedding. Combined, they are fast becoming the most potent and effective treatment in the fight against hair loss today. AM

Benedetto Cusumano is a consultant trichologist and founder of TrichologistsUK and the TrichoCentre. He set up the clinic in 2015 because he wanted to do more to help people suffering from hair loss and scalp conditions. He qualified at The Institute of Trichologists in London and was awarded the John Firmage Certificate of Distinction in recognition of his work in this field. He is a registered member of The Institute of Trichologists, the International Association of Trichologists, an affiliate member of the British Association of Hair Restoration Surgery (BAHRS), and was shortlisted for the Outstanding Trichologist Newcomer Award at the Hair Science Awards in 2018.

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I N J E C TA B L E S

Q&A

aestheticmed.co.uk

Led by innovation Dr Zunaid Alli, key opinion leader for Vivacy Stylage, explains why he advocates the pioneering dermal filler range AM: How did you get into aesthetics? Dr Zunaid Alli: I started out as a medical doctor in an incredibly busy GP practice in Johannesburg, South Africa. We performed a lot of minor surgery, such as bump removal, circumcision, and toenail removal, and the clinic also offered aesthetics. About eight years ago, the owner of the practice encouraged me to get involved in the aesthetics side so I did my foundation course and was introduced to the Stylage range. Then I got married and moved to the UK and found I

had to retrain for insurance purposes. This turned out to be the biggest blessing because I gained a lot more skills in the UK and eventually became a trainer myself. AM: Why did you choose the Stylage products for your own practice? ZA: Stylage was the chosen range in the South African GP practice where I started out. I had great respect for the doctor whoâ&#x20AC;&#x2122;d selected it so it was a natural choice.

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I N J E C TA B L E S

Q&A

aestheticmed.co.uk

As I did more research on the company, I became even more assured that it was the right one for me for several reasons. The company is highly established worldwide and the product line is safe and very extensive; the range covers everything from skin boosters to volumising and contour agents. So if I’m working on the tear trough, for example, I can reach for a box of trusted product or if I’m doing non-surgical rhinoplasty I have a go-to product. Stylage also has a fantastic UK-based team now and the quality of the training is outstanding. Due to its reputation, I get international clients asking for Stylage when they come to the UK – particularly patients from Hong Kong and Korea where it is widely used and, for my patients, the price point is competitive. Stylage also puts a huge emphasis on research and development, which results in the most cutting-edge products. AM: What do you like most about the results you can achieve with the range? ZA: When I first started out, the product’s longevity attracted me. All of the products in Stylage range contain the antioxidant mannitol, which is a simple sugar. This boosts the activity of hyaluronic acid via a synergistic mechanism and prevents a degradation of the product ensuring results last for a long time. The product also injects really, really well and creates a natural result. When it comes to dermal filler the rheology is important. You need this to be excellent, especially when working on areas where tissues are quite soft, for example the lips, because you really need the product to flow beautifully. The moment you stop-start, you create lumps. The range is extensive and versatile, so there’s something for all indications.

is slightly cross-linked so I use it in areas where I need a very minimal lift, such as the perioral lines and areas adjacent to the mouth. It’s quite nice to use in the hands as well. For fine lines and wrinkles, Stylage S is my go-to filler. I use it in the tear trough as it’s soft and very moldable. The product contains 16 milligrams of hyaluronic acid, so you can also use it in the lip contour and I find it excellent for defining the vermillion border. I also use it for the glabella frown lines. A lot of patients don’t like the effect of a toxin there, so this is a really good alternative. If the lines are really deep you can you can combine it with toxin. I have done this on a few patients and it makes for a really lovely finish. For contouring work, I use the XXL product.

When it comes to dermal filler the rheology is important. You need this to be excellent

AM: What are your thoughts on Stylage’s patented IPNLike technology? ZA: It’s an exciting innovation. The IPN-Like Technology involves the interpenetration of two cross-linked monophasic hyaluronic acid networks. The crosslinking stage aims to stabilise the hyaluronic so as to increase the product’s duration once it has been injected. AM: Which products do you use for which indications? ZA: The Hydro product is a skin booster and, in my opinion, is incredibly underutilised. It only injects four millimetres into the skin and can be used all over the face, chest and décolletage, as well as in the hands for a hydration boost and to smooth the skin. The HydroMax is slightly different but is also a lovely product to use; it’s really good for crepey skin. The product

AM: What do you think about the new Bi-SOFT technology in the new syringe? ZA: The previous syringe was very robust. I never had a situation where a syringe broke or was dislodged, but what I like about the Bi-Soft technology is the fact that the winglets have been extended and they are now ergonomically designed. This is great for teaching when the course delegates have different sized hands and may be less steady. The broader winglets are perfect for both tiny hands and for someone with larger fingers. The design means that the physician can perform an aspiration test, if necessary, without dislodging the plunger from the syringe thanks to the special marks located on the surface of the grip plate. This is important and it’s where the safety aspect comes in. The patient may not appreciate the fact that it’s a fantastic syringe but the injector definitely will because it makes for more harmonious, easy injections. AM

Dr Zunaid Alli is a renowned medical aesthetics doctor and trainer in the UK teaching various topics such as basic, intermediate and advanced Botulinum and dermal filler. He is key opinion leader for Vivacy Stylage and the lead medical aesthetics and skincare trainer for Glow Aesthetic Training in the UK.

Aesthetic Medicine • September 2019

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DEVICES

DOSSIER

aestheticmed.co.uk

Light years ahead One of the most exciting things about working in a sector like medical aesthetics is the development and evolution of the technologies available to provide cutting-edge treatments for patients. In this monthâ&#x20AC;&#x2122;s dossier we take a look at some of the most recent advances in technology and the most new and innovative devices on the market.

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DEVICES

www.aestheticmed.co.uk

DOSSIER

3D-HYDRO2 FACIAL (3D-LIPO)

Launching this month, the 3D-HydrO2 Facial is one of the newest pieces of technology on the market. The multi-technology facial device is designed to target universal facial concerns including hydration, oxygenation, anti-ageing, brightening, skin tightening and congestion by utilising seven different technologies. During a 3D-HydrO2 facial, you may choose from one or all of the available technologies to create completely bespoke treatment packages. The Hydro Peel function can use a combination of three solutions to cleanse and smooth, hydrate and nourish and help with bacteria and inflammation. The Deep Cleanse creates ‘the Bohr effect’, allowing oxygen to be drawn into the skin. The active ingredients used are kojic acid and retinol, which deliver hydrating and brightening results. The Oxygenation spray creates a Venturi

effect, breaking down the molecules within the product to encourage product penetration and hydration. The oxygenation capsule attached to the neo-oxygen handpiece exfoliates and removes dead skin cells. The Skin Lifting treatment uses electroporation to increase the absorbency of the cell for product penetration. This, in turn, revitalises and ‘wakes up’ dull and lifeless skin. Skin Tightening uses radiofrequency technology to increase collagen reproduction in mature skin, making it ideal for incorporating into an anti-ageing facial. Hydration, using an ultrasound technology, is also helpful for product infusion. Lastly, the Cryo Facial handpiece reaches both hot and cold temperatures. The hot setting opens pores, increases blood to the area and evens out skin tone, while the cold setting tightens pores following product penetration.

ACCUTITE (INMODE)

AccuTite is the latest handpiece to be added to the InMode BodyTite system. It delivers precision heating in addition to the science and safety recognised with the Radiofrequency-assisted liposuction (RFAL) family of technologies, which all sit within the BodyTite platform. AccuTite is the smallest minimally-invasive radiofrequency contraction device with clinical studies and peer-reviewed publications backing its safety and efficacy. Indications for the face include brow, periorbital, nasolabial folds, lower face and neck. Body indications include axilla bra fat, upper arms, hands, abdomen etching, inner thigh, knees and women’s health and wellness. It offers patients who need precision contouring

BYONIK (PURE SWISS AESTHETICS)

The Byonik Pulse Triggered Laser is one of the latest advancements in the slowing of the ageing process, repairing skin cells and locking in hydration without causing trauma. It uses 658nm red light, which is antibacterial, antiinflammatory and supports the cell absorption of antioxidants, as well as 806nm near infrared light, which increases cell metabolism, helps cellular repair and detoxification of collagen and elastin fibres. This combination ensures that the process is not only non-thermal, non-invasive and non-ablative, but it's also not cytotoxic, ensuring that there is no downtime, redness or side effects. During the process, the cell lipid biolayer allows certain molecules to pass through its open channels and the pulse laser light forces the cell to extrude its cytoplasm, releasing toxins. At the end of the pulse cycle, the cell re-expands and absorbs hyaluronic acid and antioxidants from its

at the subcutaneous level with skin tightening a new solution. The procedure can be performed in a clinic setting under local anaesthetic in less than 20 minutes, removing the need for excisional surgery. The cannula is no bigger than a dermal filler cannula and targets those previously harder to reach areas such as eyelids, for a non-surgical blepharoplasty and nasolabial folds. The dual sensor temperature control and bi-polar radiofrequency eliminates the risk of burns and hot spots. Inmode has also recently added the Morpheus8 handpiece for RF microneedling to the system too. The depth of the (coated) pins can be set to 2mm, 3mm or 4mm and used on the face and body for fat contraction, remodelling and skin tightening and neocollagenisis.

surroundings. By preserving the DNA, protecting telomeres from shortening and re-energising dormant cells and fibroplast, the Pulse Triggered Laser prolongs the healthy cell life cycle. Also improved is the colour and contour of fresh scars from collagen induction and cell protection, in which the skin’s immunity and barrier function is boosted Through light-induced transmembrane convection, in which a pulse oximeter informs the laser when to be triggered within milliseconds through a complex algorithm, a patient’s individual cell-breathing cycle can be uniquely adapted to. The process is safe for those with Fitzpatrick skin types I-VI and treats lines, wrinkles, dehydrated and dried skin, as well as dermatitis, psoriasis, eczema and rosacea. Additionally, the process assists recovery following invasive treatments such as surgical procedures, ablative lasers, CO2, deep peels and skin needling. >

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DOSSIER

COOL LASER (NOVUS MEDICAL)

Following its success in the US, Novus Medical has recently launched Cool Laser in the UK. Through the use of a dual-mode, high-definition, fractionated Erbium laser that targets the water in the skin, the device improves skin tone, smoothes fine lines, and evens out skin discolouration by treating small sections at a time. Cool Laser is able to reach deep layers of the skin, causing carefully targeted damage that triggers healing and regeneration with a significant degree of precision that can be measured in microns. This is a safe and clinically effective treatment for white stretch marks, epidermal pigmentation, fine

DERMAFRAC (EDEN)

lines, wrinkles and acne or surgical scar removals, as well as age spots and fractional or ablative skin resurfacing. It is also suitable for all skin types. It is the use of cryogenic technology that separates the Cool Laser from other devices. Delivering minus 35 degrees Celsius cryo-air, the process simultaneously cools the skin while emitting laser light. This means that there is a quicker healing timeframe than other laser resurfacing techniques. Another significant feature is its short pulse duration, which facilitates coagulation and leaves surrounding skin conditions unharmed, as well as a thermal mode that mitigates bleeding.

Combining microneedling with simultaneous infusion and crystal free microdermabrasion, the DermaFrac Compact is a new portable system that improves the texture and luminosity of skin with no pain or downtime. The handpiece improves fine lines and wrinkles, UV damage, ageing skin and enlarged pores. Other targeted areas include brown spots, pigmentation and acne scarring, as well as improving epidermal density and strength, skin health and barrier function. Operating under vacuum occlusion, the handpiece creates micro-channels that dramatically increase absorption rates of topical serums, as well as using micro-needles that create

DERMALUX (AESTHETIC TECHNOLOGY)

Aesthetic Technology, manufacturer of the multi award-winning Dermalux LED systems, has recently achieved Medical CE Certification for its new Dermalux MD range. The MD range offers the most advanced LED Phototherapy treatments available in the global aesthetic market, according to the company. LED Phototherapy and Medical CE Medical CE is a certification that indicates conformity with health and safety standards within the European Union. With the forthcoming changes in industry regulations, it also ensures compliance with the new Medical Device Regulation (MDR) which comes into force in May 2020. From this time, all LED devices will need to be reassessed as a medical device. It allows Dermalux MD professionals to state medical claims for the treatment and management of acne,

pathways of uniform depth to allow better penetration of topicals. The viscosity and molecular structure of the solutions included are specifically designed for optimal delivery through the DermaFrac Compact handpiece. Ingredients included in these formulations are vitamin C with two percent ethyl absorbic acid, an antioxidant that slows unstable, collagen-damaging molecules, Kojic acid, a non-toxic lightening ingredient which suppresses melanocyte activity and the pigmentation process; and Growth Factor Rejuvenating Complex, a rich blend of growth factors, moisturisers, peptides and vitamins. Also included is the HylaSponge System, which is compromised of proprietary levels of small and large hyaluronan molecules that retain water to aid its delivery to the deeper layers of skin.

psoriasis, musculoskeletal pain and wound healing. Cosmetic indications include rejuvenation, pigmentation and sensitive skin conditions. In addition the Dermalux MD range are the only LED devices medically certified for the treatment and management of psoriasis. The new devices include the TriWave and Flex. Tri-Wave is a free-standing LED system with an ergonomic light weight design which offers full treatment coverage for the face and body. Innovative Tri-Wave technology enables three clinically proven wavelengths to be delivered as single or multi-wavelength treatments for powerful and lasting standalone results. Flex is targeted as an entry-level device that is fully portable and ideal for in-clinic and mobile use. It delivers the same three wavelengths as the Tri-Wave MD and can be used for the face and the body. >

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DOSSIER

EMSCULPT (BTL AESTHETICS)

BTL Aesthetics has recently announced its latest addition for the EMSCULPT device. EMSCULPT is a non-surgical contouring treatment that uses an electromagnetic field to simultaneously build muscle and cause fat cell disruption. The FDAapproved procedure reduces the abfat layer by 20% and increases the muscle layer by 18%, which can give transformative, non-invasive results in just 30 minutes with no side effects or bruising. The procedure involves lying down while a paddle device, which channels an electromagnetic field, is placed on the abs or buttocks for 30 minutes, stimulating 20,000 rapid contractions during that time – the equivalent of 20,000 sit ups or squats. The device also bypasses the brain’s

neurones and enables 100% use of the muscle, as opposed to using only 40% if the muscle was exercised consciously. Building upon the existing clearances for the abdomen, buttocks, and thighs, BTL Aesthetics has launched its new Small Contour Applications for the arms and calves; bringing the unrivalled EMSCULPT results to even more key muscle groups and making it the only non-invasive treatment that is safe to tone and strengthen the arms and calves. Four 20-minute treatments, over the course of two weeks, represent the shortest procedure currently available for non-invasive muscle strengthening and fat reduction in combination. The new Small Contour Applicator and the EMSCULPT Large Applicator possess the highest intensity and highest amount of energy available.

MEDIOSTAR (BEST BROTHERS)

Launched in February 2019, the new MeDioStar Monolith comes with dual handpieces that can do a full body treatment in less than 30 minutes. The high-powered diode laser (5,000w) can also perform skin tightening, skin lightening, acne treatments and skin rejuvenation and is upgradable to do vascular treatments. The new Monolith handpieces were completely redeveloped and are now more ergonomic, lighter and stronger. A more flexible cable for better ease of use has also been introduced. The 360° contact skin cooling system cools the epidermis very efficiently,

MOTUS AY (DEKA/LYNTON)

Motus AY provides a leap into the future of hair removal and vascular treatments for all skin types. The new system, which combines Alexandrite with Nd:YAG laser sources, covers all applications in dermatology. Due to the exceptional melanin absorption capabilities of a primary Alexandrite laser, it is widely considered as only safe to use on skin types I-III – that is until now. The Motus AY uses Moveo Technology for faster, painless hair removal treatments, using a

protects the skin from burns and enables treatment in any direction. Ascelpion's TAPER technology not only ensures even distribution of energy over the entire spot area, but it also prevents the formation of hot spots, thereby reducing the risk of side effects. The sapphire tip provides optimal protection of the fibre bundle for maximum reliability, while the two-handpiece port system ensures that multiple treatment methods can be offered.

20mm integrated sapphire contact cooling tip combined with optimum peak powers. This unique feature offers laser practitioners the advantages of ‘pain-free’ laser hair removal but with the unsurpassed clinical efficacy and results associated with the Alexandrite, on all skin types. The double sources system of Alex (755nm) and Nd:YAG (1064nm) broadens the range of possible treatments, while the Moveo technology drastically reduces the reflected energy loss by keeping the Alexandrite laser in constant contact with the skin. >

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DOSSIER

PICOSURE FOCUS (CYNOSURE)

The PicoSure® is the world’s first and only picosecond aesthetic laser. This unparalleled breakthrough in laser technology delivers ultra-short pulse bursts of energy to the skin in trillionths of a second. Picosecond pulse width is 100 times shorter than nanosecond technology, enabling unmatched photomechanical impact for better clearance with fewer treatments and less

fluence. The addition of the Focus™ Lens Array harnesses the powerful photomechanical effect of the device and microscopically concentrates the PicoSure® pulse to a precise depth, offereing a skin revitilisation treatment unlike any other. This is accomplished by exposing less than 10% of the skin to areas of high fluence, embedded in a low fluence background. PicoSure Focus treatments are ideal for patients seeking dramatic results with minimal downtime.

STRATUM 8 (CAMBRIDGE STRATUM)

Stratum 8 is an eight-function medical CEapproved machine. Each head is automatically recognised by the machine as it is plugged in and the software adapts accordingly, making the Stratum 8 a very flexible modular system that can expand as your business grows. Technologies include the Active Q Switch NdYag laser at 1064nm with 532nm frequency doubling tip as standard. for tattoo removal and pigmented lesions; Long Pulse NdYag laser at 1064nm with chilled sapphire tips for patient comfort and to reduce the risk of hyperpigmentation; Er: Glass Fractionated 1545nm Laser for skin resurfacing and the improvement of hypotrophic scars such as acne

SOPRANO TITANIUM (ABC LASERS)

The new Soprano Titanium Hair Removal System is a clinically proven method of laser hair removal that is safe on all skin types, including dark and tanned skin, and is virtually painless. Thanks to its large 4cm2 spot size and advanced cooling system, the Soprano Titanium treatment is much faster and pain free, offering a significantly improved solution for patients who are always on the go and require fast and ef-fective treatments. It’s unique gradual heating and rapid/fast pulse delivery method effectively damages the hair follicle and hinders re-growth, while preventing injury to the surrounding tissue.

V BEAM PRIMA (CANDELA)

The device combines four proprietary technologies including 3D, simultaneous lasing of the three most effective laser wavelengths for hair removal (755nm, 810nm and 1064nm); Quattro™, an extra-large spot size covering an enormous grid of 600-900 cm2, shortening treatment time by 40%; ICE Plus™, the most advanced cooling system, combining TEC and Inverter cooling technologies to offer an unparallel treatment experience for the patient; and Smart Clinic, a cloud-based business development tool, enhancing management processes, reflecting real time platform status and productivity, driving optimisation and standardisation and empowering business decisions with genuine data and statistics.

The latest addition of Candela’s Vbeam, the Prima, is an evolution on its already successful formula. In addition to the proprietary 595nm wavelength, which is absorbed by oxyhemoglobin to coagulate and clear vessels with more tolerability and fewer instances of melanin absorption, the Prima now has a 1064nm wavelength, which treats blue veins, venous lakes and wrinkles. With a larger maximum treatment spot and a greater maximum energy, the Vbeam Prima offers a more efficient treatment. Thanks to the patented cryogen-based Dynamic Cooling Device scales and EverCool contact cooling, vascular and pigmented lesions can be treated at the same time, offering increased

and stretch marks, and ErYag Fractionated 2950nm Laser with 2950nm. The device also includes monopolar and bipolar radiofrequency which both benefit from chilled treatment tips to enable more power to be delivered without overheating the epidermis; and IPL and IPL with radiofrequency (RF) for full control and built in protocols for easy and safer operation by less experienced users. IPL is a great treatment for acne, and its large head size of 50mm by 15mm often makes it the treatment of choice for telangiectasia matting and age spots. It is also useful for hair removal in skin types I to IV. The addition of RF can make the more intense treatments less uncomfortable and help to reduce the risk of pigment changes.

versatility and epidermal protection. Usage is streamlined with additions such as a once-daily system calibration, which auto-calibrates on start-up, and a smart dye life management, in which the dye life meter provides real-time data to avoid unexpected interruptions due to dye loss. As well as this, the Vbeam Prima’s versatile zoom handpiece allows for precision targeting within an accuracy of 0.5mm, and a guided user interface provides quick access to saved, favourite treatment settings. The Vbeam Prima can be used for vascular lesions, haemangiomas, angiomas, leg veins, inflammatory acne, benign pigmented lesions, striae, warts, port-wine stains, rosacea, poikiloderma, scars and wrinkles. AM

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DEVICES

INTERVIEW

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Smart thinking Professor Paolo Bonan discusses the benefits of C02 lasers in the treatment of children with the SmartXide from DEKA, which is distributed in the UK by Lynton Lasers AESTHETIC MEDICINE: Which paediatric skin conditions can C02 lasers successfully treat? PROFESSOR PAOLO BONAN: Many skin conditions can be treated in the paediatric field and the improvements in C02 laser technology by companies such as DEKA have given practitioners the opportunity to achieve safe, efficacious results. When it comes to treating children, the toleration of the various types of treatment depends on the type of procedure, the protocols, and so on. But with C02, we can treat warts, viral warts for example, scars and vascular anomalies such as a port-wine stain. This can be treated in combination with other vascular-selective lasers such as the pulsed dye laser. AM: Could you talk specifically about how you might treat a child’s port-wine stain? PB: We follow specific protocols and employ a pulsed dyed laser in the first instance for three or four sessions, depending

on the thickness of the port-wine stain. We can then use the SmartXide Touch with a surgical handpiece and a 7-inch spot size to vaporise the nodular and hypertrophic areas of the lesion before using the device’s fractional modality with the Hi-Scan DOT/RF scanner. Fractional CO2 allows us to remodel and to complete the procedure in this kind of anomaly. AM: What are the main benefits of the SmartXide Touch? PB: The device not only offers a practitioner the ability to achieve results quickly while maintaining the safety profile, but they can also be very selective in the procedure. It’s possible, for example, to target a lesion without damaging the apparently healthy skin surrounding it. I would say that the SmartXide Touch is like a gorgeous Ferrari. If you are capable of driving a Ferrari, you will just enjoy your machine; but if you’re not, the likelihood is that you will crash. You need the appropriate training to understand the full benefits of the device. AM: Are there are special considerations a practitioner should take into account when it comes to treating a child? PB: Yes, and this point is valid whether you are treating children or adults: it is very important to know not just the physics of the laser and the laser tissue interactions, but the entire protocol of treatment needs to be carefully considered, from the preliminary interview with a young patient to post-treatment care. AM: What treatment parameters would you follow when treating children with darker skin types? PB: For younger skin, we try to find the best combination of parameters by reducing some parameters and increasing others. However, it is important to recognise that we have to treat children with darker skin types or children of colour differently. There are specific protocols to follow and DEKA offers the possibility of modulating the laser tissue interaction by combining different options and parameters, many of which are unique to the company. So if we modulate carefully and treat over a number of sessions, we can achieve the same results, maintain safety, and mitigate the risk of instances of post-inflammatory hyperpigmentation (PIH) in darker skin types. AM: Are there any post-procedure complications that need to be taken into consideration? PB: As mentioned, PIH is a risk factor for some skin types, but this can be mitigated to a certain degree by using an imaging

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INTERVIEW

I like to involve the children I treat in a bit of fun, exploiting their fascination with the light, and pointing out that the laser resembles something out of Star Wars

system that allows you to study the skin before treatment. I personally use a system by QuantifiCare, which complements a clinical assessment by allowing me to analyse the skin and document the depth of the melanin pigment. PIH is quite unpredictable – it is always lurking around the corner – but if you follow the procedure and make a preliminary study, you can reduce the risk. AM: How useful is fractional CO2 laser therapy in the treatment of acne scars? PB: The first point to note is that inflammatory acne scars are completely contraindicated for this kind of treatment. On the contrary, depressed scars, or atrophic acne scars, are perfectly remodelled by the fractional modality, the Hi-Scan Dot/RF. We have studied this a lot – we’ve published papers on this topic – and have discovered that you can stimulate collagen fibres, creating new collagen fibres that stimulate the process of remodelling the skin. We normally need two months for neocollagenesis, but there are different processes that happen in the skin. Normally new collagen fibres are formed, but even the matrix, the so-called extracellular matrix, is modified, so it’s a cascade of events, alongside the release of a lot of substances called cytokines, that can contribute to this important remodelling of the skin.

AM: How would you approach the consultation process when treating a child? PB: The exact approach to the consultation process depends on the age of child, of course, but my personal approach is to adopt maximum empathy for the patient, especially when it is a young child. I like to involve the children I treat in a bit of fun, exploiting their fascination with the light, and pointing out that the laser resembles something out of Star Wars. I find that this is one of the best ways to reduce any tension or anxiety they may have.

AM: What advice do you offer parents regarding post-procedure aftercare? Does this advice for children differ from that given to adults? PB: The post-treatment procedure is very important and there aren’t any differences in the advice given, whether the patient is an adult or a child. It is very important to keep the wound hydrated and protected from the sun, and to apply moisturising cream, antibacterial cream and wet gauzes soaked with thermal water in the immediate days following the procedure. It is simple advice, but I would say it’s crucial for getting the best results. Avoiding crusting of the wound is incredibly important. AM

Professor Paolo Bonan qualified as a physician and surgeon in 1986 before specialising in the fields of dermatology and venereology. He is a member of the European Academy of Dermatology and Venereology, the European Society of Dermatological Research and the Italian Society of Dermatology and Venereology, and is an author and co-author of a number of books and research papers on the topic of light sources in dermatology. Holding professorships at a number of universities in Italy, Professor Bonan heads up the cosmetic, plastic and laser demo surgery unit at the Villa Donatello clinic in Florence. He is a key opinion leader for DEKA, leading the Academy sessions that the company hosts at the clinic.

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VIRTUAL REALITY

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Virtual reality We find out how Dr Sabrina Shah-Desai is taking aesthetic training to the next level through virtual reality

eading the way through innovation in medical aesthetic teaching, Dr Sabrina Shah-Desai’s new Oculo-Facial Aesthetic Academy (OFAA) Virtual Reality App will bring aesthetic training into the 21st century. For the very first time, medical practitioners from across the world will be able to watch live training procedures through the eyes of Dr Shah-Desai without leaving home. Renowned for her bespoke eye and face restoration and rejuvenation, Dr ShahDesai is utilising the latest innovations in technology to make it easier then ever to access leading industry training. By using the app, practitioners, especially those based overseas, can save time and money by avoiding lengthy and strenuous travel. Wearing the headset, medical practitioners will learn holistic facial assessment, advanced filler injection techniques, detailed cadaver anatomy, and gain practical knowledge on how to use hyaluronidase to manage complications. This will enable trainees to access valuable and up-to-date, relevant knowledge all at the their fingertips. It’s not just for overseas or remote practitioners, however. Providing unrivalled flexibility, the new technology also enables medical practitioners to maintain continuous professional development following their initial formal training and, in the event of a vascular emergency, skills can be refreshed within seconds. By accessing techniques on a handheld device, a practitioner who might be managing a catastrophic emergency alone has access to instant support. “I want to unleash the potential of aesthetic training by fusing it with modern technology, to give practitioners the best possible learning experience,” says Dr Shai-Desai. “We have come a long way from traditional classroom lectures and paper-based learning, and more and more practitioners are looking to update their knowledge using modern technology. Delegates want to learn in their own time, without the

expense and challenges of attending conferences, and this is exactly what the OFAA Virtual Reality App offers.” As an avid educator, Dr Shai-Desai has become aware that a one-or-two day training course, without access to scientifically relevant updates, was failing in upskilling or reskilling practitioners, something she feels can be resolved through the app. “Ongoing CPD assessments allow learning to be conscious and proactive rather than passive and reactive,” comments Dr Shah-Desai. “Aesthetic practitioners will find this app extremely beneficial in enhancing and maintaining their skills and proficiency throughout their careers.” “I have a strong passion for teaching and I want to carry on contributing to raising the bar in our specialty.”

I want to unleash the potential of aesthetic training by fusing it with modern technology

Here’s what delegates had to say:

“It’s the first device to see everything in a 3D way and everything is so clear, as if you are in a real situation in the room.” Dr Aou Nuttapol, aesthetic doctor, Bangkok

“Everything is so clear; it literally feels like you’re in the cadaver lab, you feel like you’re genuinely in that room and you’re watching everything. It was surreal actually, wasn’t it?” Dr S Sall and Dr R Brady, dental surgeons, London

“It goes through the details of how the injections were done and complications and the different tissue layers.” Dr Maryam Helai Osmani, aesthetic doctor, London

“It’s educationally phenomenal. I’m definitely getting it when it comes out.” Dr Deok– Kyu Han, aesthetic doctor, South Korea

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PHOTOGRAPHY

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Image conscious We find out about the Clinical PhotoPro system and how it can help you to create standardised and high quality patient images for your practice

aking before and after photographs is an important factor in running an aesthetics practice, not just for insurance reasons but also as a tool for marketing and demonstrating your results to perspective patinets. Despite this, many clinics struggle to take good consistent images that accurately reflect the quality of their work. Launched in January, Clinical PhotoPro is a system that helps clinics standardise their photography and solves the problem of poor and inconsistent quality with before and after images. Founder Clint Singh says, “Most clinics use their mobile phones or tablets to take before and after images, which presents a security risk if images are stored on these devices. These devices all operate on algorithms that automatically adjust four variables: shutter speed, aperture, ISO, and the colour temperature. If pre-and-post procedure images are taken at different times of the day and the ambient light in the room changes, the algorithm will adjust the settings of the camera to accomodate for the changing light. As a result, before and after images look different. The Clinical PhotoPro system overcomes these problems by replacing every variable that causes inconsistencies with static values. This ensures that every image taken will always have the same exposure, depth of field, and colour.”

BENEFITS

Clinical PhotoPro allows clinics to standardise their photography procedure by maintaining consistent quality with before and after photos. It provides clinics with the

highest quality images to document their clients, protect their reputation and to showcase their results. The system doesn’t use mobile phones to take photos, so all the issues with inconsistent lighting have been overcome. And because all the equipment is preconfigured, a practitioner doesn’t need years of experience as a photographer to get professional results. It’s as easy as turning on the equipment, positioning the client, and taking a shot. Social media is the driving force for today’s marketing campaigns, so you need to be posting quality content to keep your audience engaged. Fortunately, Clinical PhotoPro comes with training on digital workflow to help practitioners produce professional social media content. This enables clinics to not only prepare their own marketing and social media content, but also become self-sufficient by bringing professional professional skills in-house. And, with access to professionally presented and branded before and after images, a clinic’s reputation is protected. AM

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OUT AND ABOUT

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skinbetter science press event, Selfridges, London A mix of trade and consumer press attended an event in the Pegasus Room at the Brasserie of Light, Selfridges, London to learn about skinbetter science. The event featured three key speakers: Dr Benji Dhillon, Dr Sophie Shotter and Dr Sabrina Shah-Desai. Dr Dhillon provided an overview of the range and what makes it different; Dr Shotter spoke about the two main technologies at the heart of skinbetter science – InterFuse and AlphaRet; and Dr Shah-Desai revealed her hands-on experience of the brand to date.

Out and about Out and about in the industry this month

PERFECTHA FACTORY VISIT, LYON, FRANCE A group of 10 leading aesthetic practitioners were invited to visit Sinclair Pharma’s Perfectha production facility, 30 minutes from the centre of Lyon in France. During a guided visit, the clinicians were able to observe the Perfectha manufacturing process in detail from start to finish. All of the world’s production of the product is made on site; enough to fill 30,000 syringes per week. Currently only the filler itself is made on site. The filling of syringes and sterilisation is carried out at a separate facility. However, plans are in underway to see 100% of the production process in one place within the next five years. The practitioners were also given a glimpse into the future at plans for new product developments which will be announced later in 2019 and 2020. Sharon Bennett, aesthetic nurse and chair of the British Association of Cosmetic Nurses, said, “We have had a fabulous time learning and discovering the complicated process of making hyaluronic acid gels for facial aesthetics. We gained an understanding how fillers are made, what is unique about each one, and what gives them all different capabilities in the skin.”

Lynton 25th birthday celebrations, Great John Street Hotel Rooftop Lounge, Manchester Lynton kicked off its 25th birthday celebrations with its annual summer staff conference, which took place at the Manchester Marriott Victoria & Albert Hotel in Manchester. Every year Lynton staff meet to discuss new developments and opportunities for the ever-growing business, with this year focusing on plans for the future, including upgrades to the company’s product portfolio. The team moved on to the Great John Street Hotel Rooftop Lounge where they enjoyed drinks, shared laughter and reminisced about the past 25 years together. To add to the quarter of a century of success in the aesthetics industry, Lynton is running the campaign – #weuselynton – to celebrate its customers’ successes. It also commissioned a project to commemorate its heritage by presenting a surprise custom-designed ‘Manchester Bee’, which has been named the ‘Lynton Bee’ by staff. The Manchester Bee is an iconic symbol that best summarises the city’s reputation for hard work and tenacity. Jon Exley, managing director of Lynton said, “We are delighted to be celebrating Lynton’s 25th anniversary this year. The Lynton Bee captures a chapter in Lynton’s long history and reminds us of how far we’ve come since the development of our first tattoo removal lasers back in the science lab. I welcome any of our many customers and course delegates to come and see the Lynton Bee, which now takes pride of place in our prestigious training centre.”

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