Aesthetics May 2015 by Aesthetics & CCR

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VOLUME 2/ISSUE 6 - MAY 2015

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A review of vitamin A CPD

Augmenting the Buttocks

Female Adult Acne

01/04/2015 17:24 Advertising in Aesthetics

Practitioners discuss the latest methods and techniques for treating this area

Dr Anjali Mahto examines the causes and treatment of adult acne

Angela Rankin outlines the best approach for ethical advertising

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Contents • May 2015 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month 16 News Special: Awareness Campaigns We look at the latest consumer campaigns launching in the industry 18 Conference Report: AMWC Aesthetics reports on the 2015 Aesthetics and Anti-aging Medicine World Congress 21 Awards Special With the entry process officially open, we take a look at why you should enter the Aesthetics Awards 2015

CLINICAL PRACTICE 23 Special Feature: Augmenting the Buttocks Practitioners discuss the latest techniques for treating and enhancing this area 29 CPD Clinical Article Roger Bloxham and Antony Wakeford explore the role of vitamin A in aesthetics 34 Post-procedure Make-up Sarah Barker outlines the important factors to know when using make-up post aesthetic procedure 37 Aesthetics Awards Special Focus The full category list and details on how to enter the Aesthetics Awards 2015 41 Advanced Injectables Dr Emma Ravichandran and Dr Simon Ravichandran offer an anatomical insight into the use of injectables for the mid and upper face 47 Female Adult Acne Dr Anjali Mahto addresses the cause and treatment of adult acne in post-adolescent women 51 Psoriasis Dr Sadequr Rahman highlights the clinical and psychological impact of psoriasis 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 57 Electronic Record Keeping Systems We discover the latest advancements in storing clinical records digitally 60 Advertising in Aesthetics Angela Rankin outlines best practice guidelines for advertising in aesthetics 63 Vision and Finances Dr Harry Singh on the importance of ensuring your finances can support your aesthetic vision 66 In Profile: Dr Sandeep Cliff Aesthetics talks to Dr Sandeep Cliff about his journey into aesthetic dermatology 68 The Last Word: What is a ‘cosmeceutical’? Ms Rozina Ali argues for greater clarity in the definition of this term

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Special Feature Augmenting the Buttocks Page 23

Marketing Advertising in Aesthetics Page 60

Clinical Contributors Roger Bloxham is the managing director of Ferndale Pharmaceuticals Ltd and AesthetiCare, with over 28 years of commercial, technical and regulatory experience in the pharmaceutical, medical device and cosmetic industries. Antony Wakeford is a chartered chemist and Royal Society of Chemistry member. Owner and managing director of QP-Services UK Ltd., he has more than 32 years’ experience in the cosmetic, medical and pharmaceutical industry. Sarah Barker is an aesthetic nurse with more than eight years’ experience in the speciality. She owns Flawless Aesthetics and Beauty, where she offers accredited training in mineral make-up theory and application. Dr Emma Ravichandran is a general dental practitioner with a special interest in aesthetics. She co-founded Clinetix Medispa in 2010 and is actively involved in creating a national audit pathway for aesthetic practice. Dr Simon Ravichandran is a ear, nose and throat surgeon. After training in aesthetics, he co-founded Clinetix Medispa in 2010, and is now the founder and chairman of the Association of Scottish Aesthetic Practitioners. Dr Anjali Mahto is an NHS and private consultant dermatologist. Based in London, she is interested in all things skin, particularly the treatment of acne and its psychological effects. Dr Sadequr Rahman is a GP, and currently runs his own cosmetic clinics, Doctor-SR Beauty Clinics. His special interest lies in dermatology, but he also advises on nutrition, weight management and confidence building.

NEXT MONTH

• IN FOCUS: Dermatology • CPD: Social Media • Stem Cells in Skincare • VAT in Aesthetics

Entry is now open for The Aesthetics Awards 2015, until June 30. Enter now at www.aestheticsawards.com

Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228

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Editor’s letter There is never a dull moment here at Aesthetics – no sooner have we finished one event, there is another on the horizon. Now that ACE 2015 is wrapped up, and planning for 2016 in progress, I am delighted to announce that entries for the Aesthetics Awards are Amanda Cameron officially open as of May 1. Editor We are extremely proud to recall a fantastic evening of celebration last year. And this year, we promise it will be even better. So time to start thinking about your entries: we will have a larger judging panel this year, accompanied by the usual strict entry criteria, so the quality of your entry is of great importance – I would advise that entry submission is a process not to be rushed. Two new categories have been added this year to incorporate the clinic groups both large and small, so we look forward to welcoming entries from those previously unrecognised. As we have seen from previous years, the PR opportunities from winning or being shortlisted are huge, and those of you who maximise your exposure will benefit enormously from the process. December seems a long way away but will be here sooner than you think, so start planning to win!

The Aesthetics team have just returned from sunny Monaco, and the 13th Anti-Aging Medicine World Congress (AMWC). It seems a large number of our readers and contributors had a fruitful time learning about new products and new treatments – as well as sampling the gastronomic delights of the area. Read our coverage from the event on p. 18. As summer approaches patients will be thinking of exposing more of their bodies, and in this issue our Special Feature looks at the increasingly popular treatment of the buttock area (p. 23). May’s CPD article asks what exactly do we know about vitamin A as a cosmeceutical ingredient? I am sure we are all aware that vitamin A appears to maintain normal skin health, but what exactly is it, how does it work and what else is important about this widely used ingredient? Read our in-depth review on p. 29 to learn more or refresh your knowledge. I was personally saddened this month to hear of Dr Fred Brandt’s death; he was a true pioneer and a charming man who always had time for everyone. He was a great help to us in the early days of collagen treatments and he will be sadly missed. As ever, we want to hear your thoughts about #aesthetics. Tweet us @aestheticsgroup or email editorial@aestheticsjournal.com

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics Journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.

experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and also the UK lead on the BSI committee for aesthetic non-surgical medical standard. Sharon has been developing her practice in aesthetics for 25 years and has recently taken up a board position with the UK Academy of Aesthetic Practitioners (UKAAP).

and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook.

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments. Dr Sarah has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr. Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0203 096 1228 | M: 07867 974 121 chris@aestheticsjournal.com Suzy Allinson • Associate Publisher T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com Amanda Cameron • Editor T: 0207 148 1292 | M: 07810 758 401 mandy@aestheticsjournal.com Betsan Jones • Assistant Editor T: 0207 148 1292 | M: 07741 312 463 betsan@aestheticsjournal.com Chloé Gronow • Journalist T: 0207 148 1292 | M: 07788 712 615 chloe@aestheticsjournal.com Hazel Murray • Journalist T: 0207 148 1292 | M: 07584 428 630 hazel@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com Priti Dey • Customer Support Executive T: 0203 096 1228 | support@aestheticsjournal.com MARKETING Marta Cabiddu • Marketing Manager T: 0207 148 1292 | marta@aestheticsjournal.com EVENTS Helen Batten • Events Manager T: 0203 096 1228 | helen@synaptiqgroup.com Kirsty West • Assistant Events Manager T: 0203 096 1228 | kirsty@synaptiqgroup.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Sadia Rahman; support@aestheticsjournal.com © Copyright 2015 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240

DISCLAIMER: The editor and the publishers do not necessarily agree with the views

expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.

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ACE 2016

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Galderma Sharon Bennett @sharonbennettuk Fabulous being in Monaco as @galderma launch the lovely @sharonstone as their face. Safe products giving amazing results in right hands

#Aftercare Andy Millward @AndyMillward_ Just settling down after a long day & seen last client before breaking up for Easter. Just one last aftercare email to send & I’m done!

#Conference Dr Raj Acquilla @RajAcquilla Lovely pic of our UK team in #Monaco & #Cannes @Allergan #Botox #Juvederm

#Learning Nigel Mercer @NigelMercer Interesting sessions at the Korean Association Meeting. A very different spectrum of surgery driven by the very difference in skin type.

#DrFredricBrandt LaserSkinSurgCntrNY @LsscNY With heavy hearts we mourn the passing of esteemed colleague and friend, @drfredricbrandt #DrBrandt

#BookLaunch Dr Rachael Eckel @rachaeleckel Book launch celebrations in the penthouse! So proud of you @zeinobagimd & honoured 2 have been a guest editor.

#Tanning Dr Natalia @VieMedSpa Frustrating to see another tanning salon in @WinchesterCity. I see young women destroying their #skin & increasing their risk of #cancer

#Peels Dr Stefanie Williams @DrStefanieW Learnt something new #AMWC2015 today – how to use TCA chemical peel crystals to close an unwanted nose piercing hole. Fascinating!

April dates announced for ACE 2016 It has been announced that the Aesthetics Conference and Exhibition (ACE) 2016 THE BUSINESS DESIGN CENTRE / LONDON / 15-16 APR 2016 will take place on April 15 and 16, at the Business Design Centre, central London. Following a hugely successful conference in March, the prime UK aesthetics event will feature a variety of learning and networking opportunities covering the entire industry. In 2016, delegates can once again attend innovative free sessions with enriched educational content, alongside the extensive Conference agenda. According to feedback from this year, it was found that 89% of respondents rated the conference as “good” or “excellent” for the overall experience. One delegate said, “The exhibition was easy to navigate. It had seminars within the exhibition which allowed people to see and hear the presentation or demonstration.” Another added, “The team really appear to have listened to feedback on delegate experiences last year and the attention to detail was admirable.” The survey further found that 91% of attendees would recommend the event to a friend or colleague, and 98% would consider returning in 2016. With the event improving year on year, in 2016 delegates can expect an even better conference experience, with plans already underway to prepare for the event. Zain Bhojani, co-director of Church Pharmacy, who sponsored and exhibited at this year’s event, said, “ACE’s reputation really precedes itself. People know that in order to get very high quality delegates and the latest innovations, ACE is one of the best places to come.” Industry

New director of sales appointed at Medical Aesthetic Group A new director of sales has been appointed at Medical Aesthetic Group to assist the existing team with new product launches and strengthen the company profile. Jenny Claridge, who previously worked with Johnson & Johnson on their consumer products, surgery and vision care, will apply her past experience to play a key role in the launch of products such as ‘no needle’ filler Fillerina, and build the position of Medical Aesthetic Group. David Gower, managing director of Medical Aesthetic Group, said, “This is perhaps the most exciting time for the Group, which is experiencing incredible growth from its recent new product launches of V-soft lift, Fillerina and the enlargement of the unique Oxygenetix range. Long established lines such as Mene & Moy, Simildiet and Inno Aesthetics skin care continue to grow and the US brand DCL will return before the end of 2015 in revised presentation.” He added, “We are delighted that Jenny is joining the team to lead them to even greater success.”

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Aesthetics

Dermal filler

Campaign

Allergan launches Juvéderm VOLIFT Retouch Multi-speciality healthcare company Allergan has added the Juvéderm VOLIFT Retouch to its Vycross Collection of dermal filler treatments. Whilst the original Juvéderm VOLIFT contains 1ml volume, the new product contains 0.55ml volume. According to Allergan, Retouch has been designed to offer top-up treatments to refine and perfect initial treatment, whilst minimising product wastage. Following research into consumer trends, the company found that patients want natural-looking results that maintain their original facial expressiveness. Hence, the standard volume of filler may not always be required when treating patients who seek such natural results. Aesthetic practitioner Dr Tapan Patel said, “From my own clinical practice, the vast majority of my patients want to address ageing concerns whilst maintaining a natural look. I advise my patients to have small amounts of filler applied to give subtle lift and contouring to the face.” He continued, “With this kind of treatment becoming more popular, I’m looking forward to using Juvéderm Volift Retouch more on my patients to help achieve beautiful, natural-looking results. It’s also extremely beneficial at the follow-up stage when patients occasionally need a small top-up because it reduces product wastage and cost.” Juvéderm VOLIFT Retouch aims to treat deep skin depressions, restore volume and improve facial contouring. The new formulation is available now. Industry

FDA issues warning as counterfeit Botox found in US The Food and Drugs Administration (FDA) is alerting health professionals to a counterfeit version of Botox that is being distributed in the US. According to the FDA, the counterfeit version may have been sold to practitioners and medical clinics nationwide. They stress that the products are not FDA-approved and are therefore are unsafe to use, as they cannot confirm that the manufacture, quality, storage and handling of the suspect products adhere to US standards and protocols. The counterfeit versions can be identified as the vials are missing their lot number and the outer packaging is missing entries next to ‘LOT: MFG: EXP:’. The counterfeit packaging also displays the active ingredient as ‘Botulinum Toxin Type A’ instead of ‘OnabotulinumtoxinA’ as seen on the FDA-approved version. The FDA stated that, “There is no indication that Allergan’s FDA-version is at risk, and the genuine product should be considered safe and effective for its intended and approved uses.” Practitioners are recommended to check the Allergan website to ensure their distributor is authorised to distribute Botox.

Galderma launches ‘Proof in Real Life’ campaign Pharmaceutical company Galderma has launched a global consumer campaign that aims to build trust in aesthetic treatments. The news was announced at the Anti-aging Medicine World Congress (AMWC) in Monaco, where it was also revealed that actress Sharon Stone will be the campaign’s celebrity ambassador. ‘Proof in Real Life’ will promote results following treatment with Restylane fillers and Restylane Skinboosters, aiming to demonstrate that natural-looking results can be achieved with these products. Stone will host a reveal event in Germany on 28 May, where results of a group of treated patients will be unveiled. Londonbased aesthetic practitioner Dr Ravi Jain announced the news at the launch event in Monaco. He said, “The aim of the campaign is to reassure consumers that facial aesthetics is not about extremes such as huge lips or altering someone’s characteristics so that they are unrecognisable. Most of us restore or subtly enhance a patient’s appearance so that they look great for their age.” According to research conducted by Galderma, 51.1% of the practitioners they work with say their patients only want to look younger by five years or less, and almost 70% say that their biggest fear is looking unnatural. Anne-Sophie Copin, head of Skin Rejuvenation Aesthetics & Corrective at Galderma, said, “We want to shine a light on the subtle and natural-looking results of Restylane fillers and Restylane Skinboosters and, because we know it is hard for people to trust an image, we will demonstrate results people can trust in a real-life format.”

Crystalys is a new calcium hydroxyapatite-based filler with an amazing cost to benefit ratio. This new filler has long-lasting effect; it is based on synthetic calcium hydroxyapatite and is completely biodegradable. Indications for use: Crystalys is intended for deep and sub dermal tissue augmentation at the facial area. It is used for general restoration of the face, and especically for filling deep wrinkles and lines.

www.adareaesthetics.com Adare Aesthetics Ltd, 26 Fitzwilliam Square South, Dublin 2, Ireland. Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810 Email: info@adareaesthetics.com | Skype: ivanlawlor

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

Crystalys

Calcium Hydroxyapatite Sterile Gel Injectable implant for soft tissue augmentation

@aestheticsgroup Nursing

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Accolade

NMC revise Code for nurses and midwives The Nursing and Midwifery Council (NMC) has released its new revised Code, effective as of March 31. The revised Code is central to revalidation, indicating that nurses and midwives will need to revalidate every three years in order to remain on the register. With more than 2,000 nurses and midwives currently taking part in pilots across the UK, the NMC will be working to ensure that revalidation works well and will offer support to members by publishing a range of guides for more detailed instruction and information. Themes covered in the Code include prioritising people, practising effectively, preserving safety and promoting professionalism and trust. The full Code can be accessed at: www.nmc.org.uk/ standards/code/read-the-code-online Lasers

Lutronic launches multi-function laser Aesthetic equipment manufacturer Lutronic has launched its new multi-function laser, SPECTRA XT. The laser uses six wavelengths to cover a variety of indications, including skin rejuvenation, pigmentation, acne, melasma and tattoo removal. A dual-pulsed Q-switched Nd:YAG, the first of its kind to be cleared for treatment of melasma, it features extended treatments with 595 nm, 660 nm and 1064 nm. The company claim the 660 nm wavelength, RuVY Touch, is the new safest treatment for pigment removal, significantly reducing the possibility of side effects. Using the 595 nm wavelength, Gold Toning is purported to lighten post-acne redness and reduce inflammatory symptoms using photobiomodulatory effects, while the 1064 nm quasi long pulse Revital Treatment rejuvenates skin and improves wrinkles. A combination of wavelengths, 1064 nm, 532 nm, 585 nm and 650 nm, are used for tattoo removal, suitable for all tattoo colours and aiming to decrease risks of scarring with minimal pain. Dr Harryono Judodihardjo, medical director for Cellite Clinic Ltd, said, “Spectra XT’s multi-function laser with its extended platforms has provided my clinic with a very versatile machine. I’m able to offer patients tattoo removal, melasma treatments, rejuvenation results, pigmentation correction and more, with this one device. It saves my clinic valuable time and money, whilst being safe and effective.”

Mr Adrian Richards recognised with RealSelf 100 Award Plastic surgeon and Aesthetics editorial board member Mr Adrian Richards has been ranked by RealSelf.com as one of the top 100 practitioners in the world. Mr Richards is a plastic and cosmetic surgeon with more than 12 years of specialism in plastic surgery at both NHS and private clinics. The Buckinghamshire-based plastic surgeon and owner of Aurora Clinics is one of two doctors from the UK to be included in the RealSelf 100 Award, 2014. According to RealSelf.com, a US surgeon directory, the medical professionals who received this accolade are recognised for “having an outstanding record of positive consumer feedback and for providing unique, valuable insights that can’t typically be found on the social web.” Mr Richards was commended for empowering millions of patients to gain access to information they need to make informed aesthetic choices. He shares the honour with surgeons from America, Canada, Europe and Australia. Of his inclusion, Mr Richards said, “I am humbled to be included on this list. I have been fortunate in the past to have been recognised for my work inside the operating theatre, and to have something which supports the effort I’ve put into interacting with patients and enquirers online is superb.” Tom Seery, founder and CEO of RealSelf, said, “In 2014, this group of doctors collectively spent more than 3,300 hours — or 140 days — posting answers and sharing expert insights with the RealSelf community.” “For all 100 of these doctors, time is extremely valuable, yet they all make a commitment to engaging online consumers in order to build trust and help people make better decisions about potential changes to their body, face and smile.” To mark the unveiling of the new list, the faces of all the RealSelf 100 surgeons have been projected onto a screen in Times Square, New York. Awards

New sponsors announced for the Aesthetics Awards 2015 New sponsors have been announced for the annual Aesthetics Awards, taking place on December 5, 2015. Held at the Park Plaza Westminster Bridge hotel, the night will celebrate the previous year in aesthetics, with awards to be presented to clinics, manufacturers and practitioners alike. AestheticSource will sponsor the award for ‘Best Clinic Group UK & Ireland (3 clinics or more)’, while skincare manufacturer Episciences Europe will sponsor ‘Best Clinic North England’ and Church Pharmacy will support the award for ‘Clinic Reception Team of the Year’. Also announced are Sinclair Pharma as sponsors of the category ‘Aesthetic Medical Practitioner of the Year’, Dermalux as the sponsor of ‘Best Clinic South England’, as well as ‘Best Clinic Ireland’ category, sponsored by Skinceuticals. Lorna Bowes, director of AestheticSource, said, “Recognising success in the aesthetics industry is very important. So many people work so hard to offer an exemplary patient journey, so AestheticSource are delighted to be invited to sponsor the Best Clinic Group UK & Ireland (3 clinics or more).” Paul Edwards, general manager of Episciences Europe, also praised the awards. He said, “The Aesthetics Awards are a fantastic way to show recognition to outstanding achievers in the aesthetics industry. Episciences are proud to be a part of it.” As of May 1, entries are open for a variety of awards, which will celebrate roles and products across the industry. Category winners will be decided using a combination of voting from Aesthetics journal readers, and judging from a panel of industry professionals. Enter now at www.aestheticsawards.com

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Aesthetics

Vital Statistics

Clinic

Swiss Care Clinic wins Lifestyle Aesthetics Award Lifestyle Aesthetics, the UK distributor of Teoysal, has announced that the Swiss Care Clinic in London, run by Dr Ohan Ohanes, has won their Best Clinic UK award for the first quarter of this year. Lifestyle Aesthetics will be recognising one clinic per quarter with an award, chosen for the clinic’s dedication to patient safety and commitment to providing the optimum experience for patient satisfaction. Entry is open to all, and winners will be chosen based on their application and outcomes of mystery shops and cold calls, which will test the clinic’s customer service skills. With more than 40 entries for this first award, Sue Wales, co-founder of Lifestyle Aesthetics, said, “The patient’s journey is key to any successful clinic in the UK and worldwide. Lifestyle Aesthetics, in combination with Teoxane, is looking to reward clinics whose ethos is to carry out safe training and product use, outstanding clinical practise, a welcoming and supportive environment and an enthusiastic team. Swiss Care Clinic stood out as an advocate for all of these shared values. We are delighted to award Dr Ohanes, and look forward to announcing the winner in quarter two.” Rosacea

41% of women between 18-24 learn about treatments from reality TV programmes (RealSelf)

Over 50%

of all skin problems are due to diﬃculties in shedding and forming the stratum corneum (Neostrata)

In 2014, the number of liposuction procedures carried out on men and women in the UK increased by 7%

(British Association of Aesthetic Plastic Surgeons)

Galderma announces positive outcome of European Decentralised Procedure for topical rosacea treatment

Over 10 million aesthetic surgical and non-surgical procedures were performed by board-certified surgeons in the US in 2014 (American Society of Aesthetic Plastic Surgeons)

Global pharmaceutical company Galderma has announced that their SOOLANTRA Cream 10mg/g has received a positive outcome following the European Decentralised Procedure (DCP) for Approval. The once-daily topical treatment, which contains active ingredient ivermectin, has been reported to have both anti-inflammatory and antiparasitic properties and is now approved for use on inflammatory lesions of papulopustular rosacea in adults. The Marketing Authorisation application was based on three Phase III studies, comprising more than 2,300 patients. Results of two 12-week treatment vehicle-controlled studies indicated that SOOLANTRA Cream had been more effective than the vehicle cream within four weeks. A 16-week active-controlled study further suggested that the cream was also more effective than metronidazole 7.5mg/g cream twice-daily in reducing inflammatory lesion counts (ICL) of rosacea, from week three until week 16. In the final week of the study, it was found that the reduction in ICL reached 83% from baseline, which is reflected in the European prescribing information. “There are currently few effective treatments that reduce the papules and pustules of rosacea, and these may take in excess of four weeks to show results,” said Dr Jürgen Schauber of Ludwig-Maximilian University, Germany. “SOOLANTRA Cream has demonstrated a quick onset and improved efficacy over an existing reference treatment in clinical studies, making it a new therapeutic option that meets the needs of rosacea patients.” The Medical Products Agency in Sweden acted as Reference Member State on behalf of 28 EU Member states, all of which agreed that the cream could be approved.

61% of people across all age groups find the internet to be their primary source of treatment awareness (RealSelf)

One in ﬁve people in the UK would consider undergoing excess skin removal or liposuction (Mintel)

Of 1,000 UK women surveyed, 50% voted their stomach as their most hated body zone

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

(Syneron-Candela)

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Events diary 14th – 19th May 2015 American Society for Aesthetic Plastic Surgery (ASDS) Annual Meeting, Montréal www.surgery.org/downloads/microsite/ meeting2015/welcome.php

7th – 9th July 2015 British Association of Dermatologists (BAD) Meeting, Manchester www.bad.org.uk/events/annualmeeting

31st – 2nd August 2015 International Master Course on Aging Skin (IMCAS), Asia http://www.imcas.com/en/asia2015/congress

19th August – 23rd August 2015 American Academy of Dermatology (AAD) Summer Meeting https://www.aad.org/meetings/2015annual-meeting/general-information 5th December 2015 The Aesthetics Awards 2015, London www.aestheticsawards.com

Aesthetics Journal

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Psoriasis

Positive data reported from Otezla psoriasis trial Celgene has reported positive results from its ongoing phase III trial of the plaque psoriasis drug Otezla. Otezla, which is an oral selective inhibitor of phosphodiesterase 4, has been tested on a number of different patients with moderate to severe plaque psoriasis, at several different dosages. At week 16, a significant improvement was noted in patients receiving Otezla 30mg twice daily, as compared to placebo. Dr Kristian Reich, of the SCIderm Research Institute and Dermatologikum Hamburg, said the study data, “further supports the potential for this therapy to have an impact on the needs of patients suffering from this chronic and debilitating disease.” Industry

Lynton wins Training Provider of the Year award Lynton Lasers has been awarded the Training Provider of the Year award 2015, by the Chamber of Commerce and Enterprise. Over 70 UK companies competed for the award, and Lynton was recognised for its in-depth, comprehensive training courses, which cover all aspects of laser, IPL and other light-based aesthetic technologies. Lynton training courses are held at both their Manchester and Harley Street training centres, and have been developed in association with the University of Manchester, the Confederation of International Beauty Therapy & Cosmetology and the British Medical Laser Association.

LED

Body Boost Bed launches to treat aesthetic indications A new light therapy device is claimed to be effective in treating various aesthetic indications. The Body Boost Bed, designed by Australianbased couple Vicki and Malden Jovanovic, can be used in clinic as a combination plan, or as a stand-alone treatment. Using LED lights to emit a range of frequencies with no heat, the couple claim the device will provide a variety of health and anti-ageing benefits, alleviating jet-lag and stress, as well as providing more visual benefits such as firming the skin, treating cellulite and encouraging vitamin D production. Vicki Jovanovic said, “It boosts collagen production, so you have a skin tightening and rejuvenation effect.” After undergoing more than four years of development and testing, the couple believe that the device is most effective for treating muscle and tissue disorders, by promoting regenerative metabolism at a cellular level. Dr Ahn Nguyen offers aesthetic treatments with the bed in his clinic. He said, “The Body Boost Bed is a full-sized ‘bed’ that does not emit any thermic energy. You can rest comfortably as you lay down from head to toe in our Body Boost Bed, receiving LED treatment for overall improvement of your skin, muscles and other body tissue. From dermatological benefits to healing, the Body Boost Bed is an all-encompassing treatment.” Initially launched in Australia, Laserderm International is now distributing the device in the UK.

T H E A R T O F FA C I A L R E J U V E N AT I O N

Why are Doctors and Nurses switching to VARIODERM HA Dermal Fillers?

• Made in Germany to the highest of standards • Clinical trials show that it outperforms other major brands for elasticity, longevity and performance • Dynamic product range for various indications • Very competitive pricing • Very high level of patient satisfaction Contact info@adareaesthetics.com for further info and pricing. Adare Aesthetics Ltd, 26 Fitzwilliam Square South, Dublin 2, Ireland. Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810 Email: info@adareaesthetics.com | Skype: ivanlawlor | Web: www.adareaesthetics.com

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Chemical peels

Medik8 introduces new Light Peel Global skincare brand Medik8 has launched an introductory chemical peel for the treatment of mild skin concerns. According to the company, Medik8 Light Peel is suitable for patients with fine lines, blemishes, scarring, photoageing and patches of dark pigmentation. Light Peel contains salicylic acid, to aid with the removal of dead surface skin, L-mandelic acid, an anti-bacterial AHA, L-lactic acid, a depigmenting agent, and lactobionic acid, a multi-tasking polyhydroxy acid that works as an exfoliant, antioxidant and humectant. The treatment can only be performed by a professional skincare specialist, and is recommended as suitable for all body parts, including the eye contour, hands and feet. Lasers

ABC Lasers introduces Harmony XL Pro ABC Lasers, the UK distributor of Alma Lasers, has added the Harmony XL Pro to its product range. The platform contains multiple modules, FDA-approved to address six indications: skin remodelling, vascular lesions, pigmented lesions, skin tone and texture, hair removal and acne. The modules can work independently or be combined to offer tailored treatments. “We are very excited to introduce this robust platform that opens the door to multiple generations, addressing the aesthetic concerns of patients of all ages – from teens to older adults,” said Dr Ziv Karni, CEO of Alma Lasers. “The versatility of the Harmony platform allows doctors to provide tailored, customised solutions for every age group, while also building long term relationships by meeting their needs as they change over time.” Topical

Murad launches Youth Body Builder US skincare brand Murad, founded by dermatologist Dr Howard Murad, has launched its first anti-ageing range for the body – Youth Body Builder. Formulated using glycolic acid and peptides, Youth Body Builder aims to strengthen, firm and hydrate the skin of the body, just as Murad’s other products claim to do for the face. The range currently comprises three products: Firming Peptide Body Treatment, containing Glyco Firming Complex and grape seed oil, claiming to hydrate skin quickly; Detoxifying White Clay Body Cleanser, formulated with kaolin, ginger root and glycolic acid, claiming to draw out impurities and stimulate the circulation; and Rejuvenating AHA Hand Cream, which aims to reduce the visible signs of ageing with the use of glycolic acid and botanical extracts. “By utilising the powerful technologies and ingredients that have proven so effective in our anti-ageing products for the face, Youth Body Builder formulas will provide consumers with the same proven results for their body,” said Dr Murad.

Aysha Awwad, Managing Director of Medico Beauty What are the origins of Medico Beauty? The company was formed in 1994, when both founders, Plastic and Reconstructive Surgeon Mr Awwad Awwad and Aesthetic Nurse Consultant Constance Campion-Awwad, identified that significant growth would occur in the demand for Advanced Skin Health Restoration, with no need for a doctor’s prescription. Medico acquired the exclusive distribution of American treatment systems formulated with a blend of bioavailable ingredients that are scientifically proven to correct abnormal skin function. In addition, it was obvious at this time that there was a lack of manpower and education for all professionals. A number of strategic partnerships were made, and in the process new training systems emerged that now simplify the application of treatments. What kinds of scientific innovation do you believe have made the most significant contribution to effectively resolving all skin problems? In early 2000, American Bio Chemists first discovered chemical peels, suitable for Fitzpatrick Skin Types I – VI, made with encapsulated Vitamin A derivatives that could be left on the skin overnight. Prior to this, the patent had been granted for Nobel Prize winning chemistry, Chiral Correction, and thus the formulation of skin treatment system CosMedix and Results Rx was realised. Patients happily re-invested in a series of treatments because the outcome was noticeable to them and to others. We offer a money back guarantee that the outcome from treatment is significantly noticeable, without causing discomfort. Looking at the last ten years, what do you believe defines the company’s unique treatment approach? Our expertise lies in cultivating patient relationships that are long lasting and profitable. Medico has already partnered with a large proportion of awardwinning clinics that continue to receive recognition for having the gold standard in patient care. Our company motto is to assist everyone to realise the complexion and body of their dreams. Training and certification consistently gives a phenomenal return on investment. This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Research

Study suggests women appear ‘more likeable’ following plastic surgery A new study, published in JAMA Facial Plastic Surgery, has suggested that women who have undergone plastic surgery appear more likeable. The study, which included pre and postoperative photos of 30 Caucasian women, used 170 people to rate their perceptions of attractiveness, femininity and personality traits of each image. During the survey, reviewers were only able to see one picture of each woman, to ensure they would be unaware of whether it was the before or after image. Carried out by researchers from Medstar Georgetown University Hospital in the US, the study aimed to distinguish how changes after surgery affect a person’s perceived characteristics. According to results, it was found that the women’s post-surgery photos scored better than presurgery photos on a seven point scale, with post-surgery photos scoring 0.36 points higher on average for likeability, 0.38 for social skills and 0.36 for attractiveness. “The comprehensive evaluation and treatment of the facial rejuvenation patient requires an understanding of the changes in a person’s perceived aura that are likely to occur with surgery beyond just the traditional measures of age and attractiveness,” said Dr Michael Reilly, assistant professor of otolaryngology at Georgetown University School of Medicine and co-author of the study. However, the NHS has stated on its website that while the study design seems appropriate to the question, “It has many limitations in terms of the way it was applied, including the small sample size,” – urging that the study is not conclusive and requires more research. Investigation

BBC programme investigates illegal sale of acne drug Investigative programme Inside Out, produced by the BBC, has revealed that acne drug Roaccutane is being sold illegally in the UK. On the show, the BBC reporter traced illegal online sales of Roaccutane in the UK, which was then linked to a Turkish company with a registered office in Coventry, West Midlands. The drug, which studies have suggested may have a link to serious side effects including depression and increased suicidal thoughts, is used for severe acne and can only be prescribed by a consultant dermatologist. It works by supressing the activity of sebaceous glands in the skin, which in turn reduces how much oil the glands produce. Since the investigation, the company are now taking measures to remove Roaccutane from their UK website. Lydia Scammell, senior enforcement advisor at the Medicines and Healthcare Products Regulatory (MHRA) agency told the BBC, “There are strict regulatory controls of medicines and the supplies of medicine and a medicine like Roaccutane not only needs a prescription, it needs a prescription by a consultant dermatologist.” She added, “Any supply of that medicine without a prescription is a criminal offence in the United Kingdom.” Although the distributed drug was confirmed to be genuine, Roche, the manufacturer, recommended patients always use a reliable source and seek guidance from the MHRA.

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News in Brief CoachHouse Medical announces new partnership with Sciton Medical device distributor CoachHouse Medical has announced a new partnership with Sciton for exclusive UK distribution of their Forever Young Broadband Light (BBL) laser. James Backhouse, managing director of CoachHouse Medical, said, “Working with Sciton aligns perfectly with our mission to provide pioneering technologies to our physicians. Sciton is a well-established brand in the medical laser field and the Sciton name is synonymous with innovation and quality.” Stratum C launches Complete 4 Total Hand Care Cream Stratum C has launched a new product to help reduce the visible signs of ageing on the hands. According to the company, Complete 4 Total Hand Care Cream aims to address four key issues related to ageing hands; the product contains matrixyl to boost collagen production, TEGO Cosmo to reduce age spots, keratin amino acids to strengthen skin and nails, and contains SPF 8 to protect against the ageing effects of UV rays. Complete 4 is stocked at a number of skincare clinics throughout the UK. Ecolite celebrates 20th anniversary Global IPL and laser manufacturer Ecolite is celebrating its 20th anniversary in the industry. The manufacturer launched with the Ecolite V9 IPL machine in 1995, used for treating various skin disorders such as acne and rosacea, and last year released their IR Diode Laser for hair removal and skin treatments. Susan Jaffer, legal affairs and marketing director at Ecolite, said, “As we continue to grow, we hope to provide a wide platform of products with the same emphasis on customer service, quality and economics.” Correction In the April issue of Aesthetics we printed an article by Dr Elizabeth Raymond Brown entitled ‘Advances in Lasers’. In the second column on page 42, Dr Raymond Brown wrote, ‘Some of the most recent product advances have come from the ability to produce reliable and repeatable ultrashort picosecond (ps, 10 -15 s).’ This was a typographical error and should have read ‘(ps, 10 -12 s)’. Dr Raymond Brown wishes to apologise for any confusion caused.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Psoriasis

Clinic security

Head-to-head Cosentyx trial produces positive data, Novartis reports Novartis has reported that Clear – a new head-to-head study comparing the effects of psoriasis drug Cosentyx to those of an established competitor – has produced positive data to suggest that Cosentyx is significantly superior to the alternative product. Results from the phase IIIb trial have indicated that by week 16 completely clear skin was noticeable on significantly more patients treated with Cosentyx, which also demonstrated a rapid onset of action and greater efficacy at all stages of the trial. Cosentyx, which is a secukinumabbased therapy, is the first interleukin-17A inhibitor that has been approved to treat adults with plaque psoriasis. “With Cosentyx now approved in many countries around the world, we are committed to helping psoriasis patients significantly improve their overall quality of life,” said Vasant Narasimhan, global head of development at Novartis Pharmaceuticals. Pigmentation

AestheticSource introduces NeoStrata Enlighten Pigment Lightening Gel UK distributor for NeoStrata, AestheticSource, has introduced Enlighten Pigment Lightening Gel as a new addition to the existing Enlighten range, which aims to tackle the issue of uneven pigmentation. Enlighten Pigment Lightening Gel is a targeted pigmentation corrector, formulated using a blend of AHAs and PHAs, as well as 1% kojic acid in combination with a number of other skin lightening ingredients, including butyl resorcinol, which has been proven to have an inhibitory effect on both tyrosinase and tyrosinase-related protein-1, to reduce melanin production. The gel is available in a 20g tube for home use, and the manufacturers claim it will not only diminish the appearance of existing pigmentation but also prevent new patches from developing, due to the inclusion of antioxidant chelators. Journal

Dr Maria Gonzalez joins the Aesthetics editorial board Dr Maria Gonzalez has been appointed to the Aesthetics Editorial Advisory Board this month. With 22 years of experience in the field of dermatology, and more than a decade practising cosmetic dermatology, Dr Gonzalez will bring extensive academic and clinical experience to the board, joining a team of seven other established and highly-regarded aesthetic practitioners. Her special areas of interest include dermatologic surgery, laser surgery, pigmentary disorders, hair disorders, skin cancers and the management of acne and scarring. Of her new position, Dr Gonzalez said, “I am very pleased to be joining the Aesthetics journal editorial board. Having spent 20 years in an academic teaching role, I am pleased to be able to contribute to a journal which aims to provide educational resources to practitioners in the field of aesthetic medicine.”

Doctor warns of dangers of using stolen goods following burglary Aesthetic practitioner Dr Natalie Blakely has warned of the dangers of using stolen equipment following a burglary at her clinic in April. Thousands of pounds worth of items were taken from the Light Touch Clinic in Weybridge between 9:00pm on April 12 and 7:30am on April 13. Dr Blakely shared the news on her Facebook page, saying, “All of our machinery has gone, TVs have been ripped off the wall and the whole of the retail space has been cleared out. The big issue for me is that the machinery has been stolen. This is super specialist stuff, and in the wrong hands is actually dangerous.” Detective constable Heather Francis from Surrey Police told the BBC, “This is a significant loss for a local business – both in terms of the valuable equipment and stock which was stolen and the potential impact on further earnings.” Dr Blakely urged anyone with information to come forward, and said, “Even if you’re not able to help, your good thoughts and prayers will go a long way.” Tribute

Tributes pour in for renowned dermatologist Friends, family, patients and colleagues have paid tribute to dermatologist Dr Fredric Brant, who died on April 5. Dr Brandt, often referred to as the ‘Baron of Botox’, was a board-certified dermatologist who ran successful aesthetic practices in Florida and New York. He also founded successful skincare line Dr. Brandt Skincare and is described as a ‘pioneer’ of cosmetic medicine. In her obituary to Dr Brandt, author and aesthetic business consultant Wendy Lewis claimed that he was instrumental in making Botox and Restylane household names, having conducted clinical trials for both brands and being amongst the biggest users of the products in the world. She quoted Jonah Shacknai, the founder of Medicis Pharmaceutical Corp, who said, “Fred was among the most prolific contributors to the world of aesthetic dermatology. His development of non-invasive techniques with dermal fillers and neurotoxins literally created some of the most important categories in modern aesthetics. Fred was a great and kind friend, and was deeply respected by colleagues and patients worldwide.” A private memorial service for Dr Brandt took place on April 16 in New York.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Dermal filler

Clinicminds updates patient management system Dutch software development company Clinicminds has released an update for its practice management software. The Customer Relationship Management (CRM) and Electronic Patient File software aims to address the needs of clinics, allowing practitioners to complete their invoicing, administration, marketing, patient analytics and treatment registration electronically. Clinicminds version 2.0 has undergone a complete redesign of the management system, as well as minor corrections and a general enhancement to current aspects of the system. The software is compatible with iPads and PCs, and is available on monthly subscription.

SBS-MED launches DERMAFILL range Global designers and distributors of aesthetic products SBS-MED have joined with Breit Aesthetics to release a new dermal filler range, DERMAFILL. The companies claim the range comprises safer and more effective pure monophasic injectable dermal fillers, which are made up of a three-dimensional pure gel made of hyaluronic acid. According to SBSMED, DERMAFILL falls within the advancements of cleaner manufactured homogenised viscoelastic hyaluronic gels and aims to allow for improved tissue control, whilst creating immediate visible and safe results that are consistent and long lasting. The range comprises four products aimed at specific indications; Global Xtra used for filling fine lines and wrinkles, Volume Ultra for deep wrinkles and facial volume, Lips to contour and enhance volume, and Regen for hydration of cutaneous skin tissue. Breit Aesthetics will distribute DERMAFILL in the UK. Sun protection

ZO Skin Health introduces new products to Oclipse line Dr Zein Obagi has added two new products to his Oclipse line of suncare products. The Oclipse Smart Tone Broad-Spectrum Sunscreen SPF50 and the Oclipse Sun Spray SPF50 feature fractionated melanin, which the company claims protects wearers against damaging high-energy visible (HEV) light, believed to cause premature ageing and erythema. Cosmetic dermatologist Dr Rachael Eckel said, “The new ZO Skin Health Oclipse line of suncare products provides a multimodal defense against UV light using groundbreaking science and technology.”

On the Scene

BACN Microneedling and Light-based Therapies Workshop, London The British Association of Cosmetic Nurses (BACN) held a microneedling and light-based therapies workshop for members on April 14 at the Cavendish Conference Centre in London. The event is the first time that dermal-needling expert Dr Lance Setterfield and board-certified dermatologist Dr Martin Kassir have presented together, impressing attendees with the evidenced-based clinical data they discussed. Nurse prescriber Kate Harding said, “The talks have been really interesting and we’ve all learnt plenty of new things to support us in our aesthetic practices. From pre-care to post-care, both the speakers’ knowledge bases have been impressive.” Dr Setterfield and Dr Kassir presented engaging discussions of treatments for hyperpigmentation and scars with microneedling and light-based therapies, which covered the pathophysiology of the conditions, necessary consultation processes and patient selection. The practitioners then spoke on the contraindications associated with microneedling and light-based therapies, while also sharing advice on managing potential complications. Following the event, Dr Kassir said, “The workshop has been very well attended and everyone’s been engaged and has asked very good questions – no one’s yawned yet so that’s good!” Chair of the BACN Sharon Bennett concluded, “The BACN has been really lucky to hold this event for our members – it’s been a fantastic day with a great turnout.”

Perfectha Advanced Workshop, London Aesthetic practitioners were invited to attend a Perfectha Advanced Workshop at 10 Harley Street on March 23. Hosted by Sinclair Pharma, the day began with a theory session, followed by a demonstration from aesthetic practitioner Dr Vincent Wong on the latest Perfectha techniques. The demonstrations included cheek augmentation, lip augmentation, tear trough and chin augmentation. Dr Wong said, “It’s great meeting new practitioners interested in using Perfectha. It’s such an amazing range of products, and seeing the delegates mastering the advanced techniques is just so rewarding.” Dr Wong also performed a non-surgical rhinoplasty with Perfectha Deep to demonstrate the results that can be achieved with different versions of the filler. Delegates were then invited to spend the afternoon practising advanced techniques on models. Aesthetic nurse Joolia Gilvey said of the event, “I left feeling inspired and excited, safe in the knowledge that I have gained new skills and techniques from the experts.”

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Awareness Campaigns in Aesthetics With a rising trend in industry campaigns, Aesthetics explores the need for raising patient awareness This year has already seen the launch of several industry campaigns, all with a prominent focus on raising patient awareness of the ‘real facts’ of undergoing aesthetic treatment. In what can be seen as a direct response to the Keogh report, many professional bodies, organisations and companies have since decided to tackle patient awareness head on – be this in terms of safety or by dispelling common misconceptions regarding aesthetic treatments. In November 2014, Allergan launched a consumer campaign, #THISISME, to empower women to age the way they desired. Its main focus was to help women understand more about facial filler treatments, and the campaign used images of six ‘natural-looking’ women, previously treated with Juvéderm, to encourage the idea of ageing gracefully with the aid of aesthetic treatment – but an informed approach was the underpinning message. Allergan’s vice president and managing director, Caroline Van Hove, said, “Our bold campaign, #THISISME, features women of all ages and backgrounds encouraging other women to continue to embrace the positives about getting older, but empowering them to make their own treatment choices and not be ashamed, so they can age as they want to.” The research behind the campaign showed that of 2,000 women, only 20% say they want to look five years younger – 41% would rather look fresher and more radiant, suggesting a trend towards desiring a more natural look. Galderma similarly hoped to highlight natural-looking results following their aesthetic treatments by launching a global campaign in March 2015, at the Aesthetic Medicine World Congress in Monaco, fronted by American actress and model Sharon Stone. “Almost 70% of the practitioners we work with reported that their patients most fear looking unnatural,” said Anne-Sophie Copin, global head of Skin Rejuvenation Aesthetics & Corrective for Galderma. With this campaign, the dermatology company hope to make aesthetics more publically accepted, testing their products to challenge out-dated perceptions about treatment and show that a natural look can be achieved as a result. Galderma will later

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unveil the results at a live event in May. However, dispelling myths of unnatural looking treatments is just one aspect of the campaigns currently dominating the aesthetic industry. Organisation Save Face and professional body the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) have each introduced their own campaigns to educate and increase safety awareness among current and potential patients. Save Face launched their consumer awareness campaign on the London Underground in December 2014, targeting a larger audience as people travelled to the capital from around the UK for the festive season. It utilised the image of a woman’s face with one blood-filled tear to capture attention and encourage commuters to consider cosmetic safety, guiding them to the Save Face website to learn more. “We wanted to get people’s attention, which we have been very successful in doing,” said Brett Collins, co-director of Save Face. “The campaign has driven, with no doubt, huge traffic to the website, and I think what we are still experiencing is the knock-on effect of social media,” he continued. “We were trying lots of different things to really engage with people and that’s an ongoing mechanism.” As a result, Save Face has experienced a huge rise in visitors to its website, which Collins suggests shows a growing market of better educated patients, highlighting the success of the Underground campaign. With a new advertising campaign to be featured in Elle magazine, the organisation hopes to continue educating consumers on a broad scale. Alongside the Galderma campaign, March also saw the introduction of the ‘Think Over Before You Make Over’ campaign from BAPRAS. This safety campaign aims to ensure that patients really consider their options before opting for cosmetic surgery. “We constantly see patients who go to have something done which is not really appropriate for them,” said BAPRAS president Mr Nigel Mercer. “Some of the market research we did before this said that 82% of people are unhappy with the result of the surgery that they have had done.” On the basis of this research, BAPRAS decided to outline the parameters that patients should consider. “Patients need to know what they want done, they need to do their research carefully so they know that they are seeing the right person – because there is an awful lot of bad practice going on out there – and they need to ask the right questions,” continued Mr Mercer. In March, the Supreme Court ruled that patients must be aware of all complications associated with their treatment in order to make an informed decision. This was as a result of a case in which a pregnant diabetic woman had not been informed of all risks associated with her pregnancy, therefore experienced complications where other options had been available. Mr Mercer believes this will be a gamechanger for ensuring patients are now fully informed and aware of all options from their first consultation. He said, “We now have very much better educated patients, they all have access to the internet, and therefore the surgeon or practitioner must tell the patient what their options are, what their complications are and how it will affect them.” He continued, “The ruling very clearly applies to consent for any intervention from now on.” Reflecting on the future of campaigns within the industry, Emma Davies, clinical director of Save Face, said, “The ultimate driver of any change, we’re going to have to accept, will be the consumer. We’ve got to educate the consumer, we’ve got to be consistent and we’ve got to sound unified with our messages.” Mr Mercer added, “I think the one thing that we have to live and die by is that everyone in this market has to put the patient first, not their profit first. It has to be patient before profit.”

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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AMWC 2015, Monaco We report on the highlights from Monaco’s international aesthetic conference The beautiful seafront resort of Monte Carlo in Monaco played host to the 13th Aesthetic & Antiaging Medicine World Congress (AMWC) from March 26-28, 2015. More than 10,500 aesthetic professionals from around the globe met at the Grimaldi Forum conference and exhibition centre, where delegates engaged in three days of discovering the latest aesthetic developments and learning best practice techniques from world-renowned aesthetic practitioners. Co-founders of AMWC, Catherine Decuyper and Christophe Luino, explained that in the past 13 years of organising the event, their main objective has been to encourage scientists to acquire a better understanding of anti-ageing treatment used around the world. Decuyper said, “This mission remains of fundamental importance and the scientific programme is touching on the prevention of ageing, by means of the aesthetic approach, and the use of anti-ageing medicine for the sake of inner wellbeing.” Over the weekend, delegates were invited to sessions on the updates in, and optimisation of, botulinum toxin, combination therapies, minimally-invasive body contouring, weight management, holistic approaches to aesthetics, home-use devices, and sexuality and ageing, amongst many others. Friday, saw a day dedicated to the latest Allergan developments in a symposium entitled ‘Achieving real expressions in challenging patients’. Experts in the fields of plastic surgery, aesthetic medicine and dermatology took to the stage to present to an audience of 1,200 delegates. Belgium-based dermatologist Dr Koenraad De Boulle began the proceedings at the symposium, outlining the learning agenda for the day, while CEO of Actavis Brent Saunders gave an engaging speech on the company’s recent acquisition of Allergan. He explained that Actavis shareholders are expected

to vote on acquiring ‘Allergan’ as their corporate name in the coming weeks and said, “Everyone at Actavis is looking forward to adopting the high qualities Allergan stands for.” Following the introduction, Brazilian plastic surgeon Mr Mauricio de Maio discussed the importance of patient assessment in his presentation on ‘What is a challenging case?’. Mr de Maio explained that when he began offering aesthetic treatments to patients, he didn’t always know what equated to a good result. “The results that I delivered seemed ok,” he said. “But today, I absolutely try to understand where the problems lie and achieve the best results.” As well as emphasising the need to recognise the most appropriate procedures depending a patient’s face shape, Mr de Maio noted that having knowledge of economical yet effective treatment plans, which will suit a range of patients’ financial budgets, is also very important in successful aesthetic practise. To simplify his patient assessment procedure, Mr de Maio explained it with the use of an acronym. FACT stands for Finances, Assessment, Communication and Technique, and Mr de Maio argued that each of these aspects of the treatment process were essential to a successful aesthetic outcome. For finances, he noted that practitioners should ensure patients understand the limitations of treatment with lower budgets, while for assessment Mr de Maio outlined his best consultation methods. “You should rotate and tilt the patient’s face, and always take photographs to discuss treatment options with the patient,” he said. For communication, Mr de Maio said one of the biggest challenges for practitioners is when a patient seeks one particular treatment, but the practitioner recognises that they would be better served with an alternative. “Be understanding, offer different options and show them before and after photographs of other patients you have treated,” he advised. Mr de Maio then performed a live treatment demonstration where he demonstrated his techniques for successful facial rejuvenation. Concluding the session he told delegates, “If you can ACT, then you can FACT – finance shouldn’t become a major issue.” From the UK, aesthetic practitioner Dr Tapan Patel spoke on the importance of consultation, a session well received by delegates. In his presentation he referenced research from Allergan, which claimed 45% of patients had not had a repeat treatment in the last three years. He outlined why this may be and suggested methods for improvement. Dr Patel then highlighted the importance of a strategic patient journey, which comprised another acronym – this time CASE. For him, he explained, Consent, Attitudes, Strategy and Education are essential factors for successful treatment outcomes. As such, Dr Patel shared a range of before and after photographs with the audience, while explaining the patients’ concerns, the technicality of treatment and the best methods of educating patients on procedure limitations and alternative options. “The more complex the case, the more important the consultation,” he said, adding that, “The technical part of treatment is generally easier than the consultation.” Dr Patel also engaged the audience in a discussion on the appropriate length of consultation time, presenting a study from the Journal of the American Medical Association (JAMA), which found that consultation time has been reported as an independent predictor of physician malpractice claims.1 The data recorded suggests that an average consultation period of 18.3 minutes resulted in one or fewer lifetime malpractice claims, while two or more claims were associated with an average consultation of 15 minutes. As such, Dr Patel reinforced the significance of a thorough consultation.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Across the main AMWC conference agenda, there was a plethora of interesting presentations taking place for delegates to attend. From the UK, nurse prescriber Pam Cushing spoke on mesotherapy treatments for cellulite, while Mr Dalvi Humzah discussed an anatomical approach to jaw contouring. Dr Sherif Wakil, who presented on ‘The White Box Revolution’, said, “I had a great three days at the AMWC. My presentation and demonstration went extremely well as the audience were really interactive and hungry for knowledge. Of course, being in Monaco and catching up with friends from all over the world was a delight.” On the Friday evening, global pharmaceutical company Galderma launched their latest consumer campaign, ‘Proof in Real Life’, which aims to demonstrate natural results following treatment with Restylane and Restylane Skinboosters. London-based aesthetic practitioner Dr Ravi Jain presented the news to an audience of delegates, where he revealed that actress Sharon Stone is set to be the campaign’s celebrity ambassador. He said, “The aim of the campaign is to reassure consumers that facial aesthetics is not about extremes such as huge lips or altering someone’s characteristics so that they are unrecognisable. Most of us restore or subtly enhance a patient’s appearance so that they look great for their age.” With more than 9,000 delegates in attendance, AMWC was a prime opportunity for exhibitors to showcase their latest products and scientific

ResurFACE

advancements. Doris de Beer, the managing director of needle manufacturer TSK Laboratory Europe, said, “AMWC is the biggest event in our calendar. For us, this is a great time to release new products and explain our range of equipment to delegates. Every year we seem to double our business, which is quite unique to any show in the world.” Following the event, AMWC Scientific Committee member, speaker and aesthetic practitioner Dr Sabine Zenker emphasised that the aim of the conference was to celebrate natural aesthetic results. She said, “It is important to preserve the personality of any individual through minimally invasive and safe treatments.” She believes this aim was achieved at the conference, and reiterated AMWC scientific director Dr Thierry Besins’ motto for the event – ‘Little gestures, big effects’. REFERENCES 1. Levinson W et al., JAMA. 1997 19;277(7) p.553-9.

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Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Aesthetics Awards 2015 With the Aesthetics Awards officially open for your 2015 entries, we look at why you can’t afford to miss out Entry for the Aesthetics Awards 2015 is now open, and there’s no better way to find out why you should enter than from our latest award winners. In December 2014, the prestigious annual Aesthetics Awards were held at the Park Plaza Westminster Bridge Hotel in central London, where 500 guests came together to celebrate another successful year in the aesthetic profession. Later this year, professionals from all over the UK and Ireland will join once again to celebrate at the Park Plaza, with 2015’s most innovative companies, practitioners and groups from across the industry. Categories cover a broad spectrum of areas within the aesthetics profession, from ‘Distributor of the Year’ to ‘Training Initiative of the Year’ and ‘Medical Aesthetic Practitioner of the Year’. With an array of awards to be presented, clinic teams, aesthetic companies and individual practitioners will have the opportunity to shine in front of their colleagues and friends. Entering the awards is a chance to celebrate all the hard work that dedicated professionals contribute to the industry all year round. Emma Bedford, winner of the 2014 Janeé Parsons Award for Sales Representative of the Year supported by Healthxchange Pharmacy, said, “I think it is a great opportunity for anyone in

the industry to raise their profile and, also, with regards to the award that I received, there isn’t really any other award that recognises the work of the sales reps/product specialists and their importance within the industry.” Bedford’s award has aided in boosting her professional profile. “Winning the award has benefited my professional image and has increased interest on my professional profile on sites such as LinkedIn,” she explained. Noting the benefits for her company, she added, “It is also great for the winner’s company to state that they have the individual awarded as rep of the year as part of their team. I would highly recommend anyone entering.” Dr Johanna Ward, whose clinic won Best Clinic South England, was also thrilled with the accompanying benefits of winning the Dermalux LED Award for Best Clinic South England. As medical director of the Skin Clinic Sevenoaks, and previous winner of the Aesthetics Awards Rising Star Award in 2013, Dr Ward felt that entering was extremely beneficial in order to encourage and boost morale within clinic teams. “Winning an award is great for team spirit and encouraging all staff to continue delivering miss out levels of clinical excellence,” said Dr Ward. “It also

helps create a sense of reassurance for new patients who are interested in aesthetic treatments but don’t know who to trust and what clinic to go to – it tells them that the clinic or individual has been recognised on a national level for commitment to high standards and high clinic care.” Emphasising this growing prestige with future patients as a result of the award, she said, “It is a huge marketing point and helps make my clinic stand out from the rest. For us, having won three Aesthetics Awards is our USP and helps us communicate with potential new patients that we represent clinical excellence and first class customer care.” The awards are decided via a combination of judges scores and voting from Aesthetics journal readers. On entering the awards, both winners said they found it to be an enjoyable process. “The awards entry process is straight forward,” said Dr Ward, reiterating the benefits of entering on both an individual and company scale. “I would highly recommend entering.” Dermalux LED and the team at Aesthetic Technology Ltd were also proud winners, claiming Treatment of the Year for the second year running. “This is a very popular category due to the number of high quality aesthetic treatments in the UK,” said Louise Taylor, director of Aesthetic Technology Ltd. “Winning again has provided continued recognition for the Dermalux brand and further strengthened our position as the market leader for LED phototherapy in the UK. As a direct result we have experienced an increased awareness of the LED treatment and subsequent sales of our Dermalux systems both in the UK and in our export markets.” The awards are not just a great benefit to those who win, however, as Dr Ward concludes, “If you win it’s a fantastic achievement, but even being shortlisted is a great thing too. It shows the general public and the industry at large that you are taking what you do seriously and working with passion and excellence in mind.” Entry for The Aesthetics Awards 2015 is open from May 1 until June 30. Entries must be made via the website www.aestheticsawards.com. See pages 37-39 for the full list of categories and further details on how to enter.

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Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015 Complete start up and support package available from under £400 per month

the fat cells in the treated area die in a natural way and dissolve over the course of several months.

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Augmenting the Buttocks From implant enquiries to the treatment of cellulite, requests for procedures that enhance the appearance of the buttock area are on the rise. Aesthetics speaks to practitioners offering these sought-after treatments and investigates the growing trend sweeping the UK Bigger, smaller, tighter, tauter – aesthetic practitioners are continually challenged with an increasingly wide range of requests for augmenting the buttocks, and improving the appearance of the surrounding area. Body contouring procedures that target stubborn-to-shift areas on the abdomen, flanks, buttocks and thighs are in increasing demand, as well as remedies for what patients often regard as ‘unsightly’ cellulite. In recent years, enquiries into treatment options have soared and, at the end of 2014, the American Society for Aesthetic Plastic Surgeons (ASAPS) recorded an 86% increase in buttock augmentation treatments performed in the US since 2013.1 The president of ASAPS, Dr Michael Edwards, suggests that the technological advancements and improvements in efficacy of non-surgical fat reduction devices are encouraging people to undergo treatment. “The rise in its popularity is indicative of the public’s desire for non-surgical alternatives in lieu of their invasive counterparts,” he says, adding, “It’s not surprising that more people are opting to freeze or melt away stubborn body fat in the comfort of their surgeon’s office, as opposed to undergoing surgery.” In the UK, it’s no different. Both aesthetic practitioners and plastic surgeons have reported a rise in patient requests for treatments in this area and, while reducing the size of the buttocks has been popular for some time, some doctors have noted an increase in enquiries for buttock enhancements. In June last year, private healthcare search engine WhatClinic.com reported a 115% rise in enquiries for the ‘Brazilian butt lift’ since the previous year,2 and cites the infamous Kim Kardashian ‘belfie’ (bottom selfie) photograph as a prompt for the 136% increase in enquiries

that happened within a month of the photograph being shared on social media.2 The website also noted that within the same month, buttock implant procedures rose by 53%.2 Of the surgeons interviewed, none currently offer buttock implant surgery in their practice. Upon release of the Whatclinic.com statistics, cosmetic surgeon Dr Massimiliano Marcellino of CosmeDocs, Harley Street, did, however, highlight the risks associated with performing the surgery. He says, “For a surgeon to perform a buttock implant they need to be incredibly skilled as the procedure comes with a very high risk of infection and displacement of the implants,” adding that non-surgical buttock augmentation treatments are becoming more popular thanks to minimal downtime and no scarring. One such method increasing in popularity is VASER (Vibration Amplification of Sound Energy at Resonance) Liposuction. The Private Clinic of Harley Street claims that its staff members perform more than 1,000 procedures a year,3 with The Private Clinic practitioner and trainer Dr Dennis Wolf explaining that he treats an average of nine to 12 patients each week with VASER. And while flanks are the most common area he treats, thighs amount to approximately 30-40% of the VASER procedures Dr Wolf performs per week. He says, “By treating the areas surrounding the buttocks, you’ll make it stand out more. It’ll have a little more definition thanks to VASER treatment.” To administer VASER Liposuction, the practitioner inserts a small probe into the area requiring treatment, which is then used to transmit sound energy and liquefy fat cells prior to their removal through a suction process. Dr Wolf claims that only one treatment is needed, and it will improve the overall shape and contours of the body. He also advocates that patients should undergo Manual Lymphatic Drainage (MLD) following a VASER treatment. The specialised massage technique aims to help stimulate the lymphatic system and encourage the flow of lymph fluid. According to Dr Wolf it, “Makes a big difference to patients’ recovery and results.” In terms of patient demographics, Dr Wolf says that although 60% of his patients are women, male interest in VASER Lipo is definitely increasing. “In recent years, it’s become ok for men to have treatment. They have become more self-conscious of their appearance and are savvy in terms of what procedures are available,” he says. Managing patient expectations, however, is always of utmost importance. “Make sure they’ve got realistic expectations and understand that you’re not going to make a model out of them,” advises Dr Wolf. “We’re not striving for perfection, we’re striving for improvement.” This is reiterated by Kim Way, the managing director of Changes Clinic in Portsmouth, who says, “Don’t

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

“Quote #BTLAesth02 for our latest equipment promotion”

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overpromise and be honest. Tell patients treatment is not going to replace a surgical procedure or liposuction – but it will help. Let patients be pleasantly surprised when they see the Before After results.” In her clinic, noninvasive treatments offered to augment the buttocks include ProMax Lipo and Images courtesy of Dr Dennis Wolf Aqualyx. The first uses ultrasonic cavitation to penetrate the fat layer, which aims to cause vibrations and the formulation of microbubbles within the interstitial fluid. As the bubbles collapse, the resulting shock wave leads to a temporary change in the fat cell membrane, allowing lipids to escape the cell and be ejected by the body.4 To compliment this procedure, ProMax Lipo also utilises multi-polar radiofrequency and vacuum massage. Application of the device aims to encourage controlled waves of energy to heat the patient’s fat cells, increase their circulation, reduce the appearance of cellulite and increase fat cell metabolism.4 According to Lynton, the manufacturer of ProMax Lipo, the thermal energy from the device also results in instant collagen contraction, creating long-term improvement to collagen fibres – producing firmer, tighter skin.4 In simpler terms, Way compares it to an opera singer shattering glass. She says, “If you reach a certain pitch, it would shatter – the ProMax works in a similar way by shattering the fat cell and disrupting the membrane around it to allow the lipids inside to disperse. The second stage using the vacuum then helps draw those lipids into the lymph system so that they’re taken away by the body and not re-metabolised. Radiofrequency then aids collagen and elastin stimulation to tone the buttocks.” According to Way, patients will usually require six to eight treatments with ProMax to notice the best results, but most will see changes after just a couple of treatments. She claims that the procedure comes with little to no downtime and usually takes 30 to 40 minutes to complete. Taking regular before and after photographs significantly helps patients appreciate the gradual results, says Way, commenting that some can be very cynical of claims of good outcomes. “One of the main questions I get asked is, ‘So does it really work?’ – I think people initially assume that you have to have liposuction or surgery to remedy areas of stubborn fat. What we’re trying to do is make patients aware that there are plenty of non-surgical options available.” Another buttock Before and after treatment with Aqualyx augmentation treatment Before After offered at her clinic is Aqualyx. This fatdissolving injection has gained traction in recent years due to the publication of a range of clinical studies5 and the introduction of UK distribution in 2013. The Images courtesy of Professor P Motolese CE-marked solution is Before and after treatment with Vaser Before

After

Aesthetics

injected into localised fat deposits, aiming to liquefy the fat cells and destroy them permanently. According to the manufacturers, lipids are then eliminated naturally through the lymphatic system.6 Way explains that although she only introduced Aqualyx to patients nine months ago, her staff members have seen a significant interest in the new technology. “We’re finding it very effective for all areas of stubborn fat – patients keep coming back to have other areas treated,” she says. It is clear from each practitioner’s experience that removing fat from the buttocks continues to be popular amongst aesthetic patients. However, it is imperative to consider the earlier statistics that demonstrate an increase in requests for buttock implants and the ‘Brazilian butt lift’. Brazilian aesthetic practitioner Dr Ariel Haus offers his ‘Brazilian Beach Bottom Lift’ treatment in both his London clinic and his home city of Rio de Janeiro in Brazil. Using the Velashape III, he aims to lift the buttocks, smooth the skin and reduce the appearance of cellulite. The device combines infrared, bi-polar radiofrequency and vacuum to deep heat the fat cells, their surrounding connective fibrous septae and the underlying dermal collagen fibres. Efficient heating aims to promote an increase in circulation, lymphatic drainage, cellular metabolism and collagen depositing.7 Dr Haus notes that there has been more demand for such treatments within the past five years, and cites celebrities such as Kim Kardashian and Jennifer Lopez publically embracing their curvaceous figures as an influence on patients’ interest. “The bottom is a popular area of concern and many patients may have issues with cellulite and sagging. Other complaints relate to post-pregnancy figures, which can benefit from help toning up and firming,” he says, commenting that, “During the consultation process it’s important to establish what results patients are hoping to achieve – this allows the creation of a uniquely tailored plan with a recommended course of treatments.” According to Dr Haus, six Velashape III sessions for the buttocks are recommended, and results are visible from the first. “Following the treatment, patients are advised to drink plenty of water in order to flush out toxins from the body and ensure a healthy diet and plenty of exercise.” This notion of maintaining a healthy lifestyle pre and post buttock augmentation procedures is echoed by all of the practitioners interviewed. Dr Wolf says, “Weight management and cutting down on alcohol intake is important – patients need to engrain dietary changes and exercise into their daily routine.” Consultant plastic surgeon Mr Geoff Wilson adds that he reminds patients the work that they put in prior to surgery is very important to their recovery, the healing process and the final appearance of the buttocks following procedure. Despite the rise in less invasive buttock augmentation procedures, surgical options are still popular. The British Association of Aesthetic Plastic Surgeons (BAAPS) found that, in 2014, liposuction procedures moved from the sixth to the fifth most popular cosmetic procedure in the UK, with 7% more people opting to have the surgery compared to 2013’s statistics.8 Mr Wilson agrees that he has seen an increase in demand, especially in the last four to five years. “I think the media has perpetuated the interest with celebrities endorsing different types of procedures. People are looking to plastic surgery for a more permanent treatment,” he says. For patients presenting with buttocks they describe as ‘too big’ or ‘too small’, a lack of shape, lots of cellulite or sagging skin, Mr Wilson offers Liposculpture. The surgical process utilises traditional liposuction to remove fat, which can then be redistributed, sculpted and contoured in the body to suit a patient’s preference. He says, “Often, patients come in complaining of a banana-shaped role of fat at the top of

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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their thighs. We can remove this and replace it in another area to make a more apparent gluteal crease.” During consultation, Mr Wilson says it’s important to try to best capture why a patient wants surgery, and highlights that they must fully understand the consequences and risks associated with the procedure. “They can’t be flippant – it must be taken very seriously,” he says. “If, on the rare occasion, alarm bells do sound, such as a patient showing signs of Body Dysmorphic Disorder (BDD), we will seek a second opinion or suggest they see a psychiatrist who can offer further support and advice to that patient.” Again, Mr Wilson emphasises the need for a healthy lifestyle in order to achieve optimal results. “We work with a dietician who will offer nutritional advice to those who need it most – this could be if they have a large calorific intake or health-related issues such as diabetes,” he explains, commenting that, “Losing a bit of weight or toning the bum beforehand could improve the outcome.” Following surgery, patients are advised to wear support garments for six weeks and attend two check-up sessions. “All patients are invited to call any other time they need us,” adds Mr Wilson. Of the practitioners interviewed, none reported seeing any major complications following treatment. All did emphasise, however, that while the treatments on offer are aimed at enhancing aesthetic appearance, they should not be undertaken lightly as ‘quick-fix beauty treatments’. “With any minimally-invasive procedure, there are of course the regular risks of infection, bleeding and bruising,” says Dr Wolf, adding, “It’s important to remember with these types of treatments that there can be irregularities, pigmentation changes or a risk of lumpiness. Patients should be made aware that if they don’t want to accept those risks they shouldn’t have treatment.” It is important to also note the association between the appearance of cellulite with the thighs and buttocks. While each of the practitioners claim their augmentation methods can improve its appearance, there are other cellulite treatments available. Nurse prescriber and vice president of the UK’s Society of Mesotherapy (SOMUK) Pam Cushing offers mesotherapy to patients looking to reduce the appearance of cellulite. She says, “Mesotherapy sits very well in aesthetics for women who can’t afford other methods, and produces high-satisfaction rates.” According to SOMUK, the goal of mesotherapy is to adapt a specific treatment to each form of cellulite. Dr Philippe HamidaPisal, president of SOMUK, says, “Cellulite will appear in different forms depending on the appearance it may have when palpating. This will also match a clinicopathological form: flaccid cellulite, fat cellulite, fibrous cellulite, fibro-sclerotic cellulite, and orange skin cellulite – caused by water retention.” He explains that when a mesotherapy treatment is performed, the results will be linked to the knowledge of one of these particular states of cellulite, which often depends on the patient’s age and the age of the cellulite. He adds, “Old cellulite can indeed be found in a 25-year-old woman, which started even before adolescence and, on the other hand, young cellulite can exist in a woman of 35 or 40 years old.” Cushing explains that she pinch-tests the cellulite and uses the Nurnberger-Muller scale to classify its severity. A combination of specially prepared mixtures, which could include vitamins, homeopathic ingredients, amino acids and medication, is then personalised to the patient’s specific needs and the practitioner begins administering a course of treatment. Cushing explains that, in her clinic, patients usually undergo one treatment

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Before and after treatment with ProMax Before

After

Images courtesy of Lynton Lasers

per week for eight to 10 weeks. “For post-care treatment, I encourage the patient to increase their intake of water, wear loose clothing and avoid sunbathing as it could inflame the area,” she says. “I also advise them to massage the area following a shower to improve circulation.” As with all injectable procedures, there is the usual risk of bleeding, bruising and infection. “Practitioners should also be mindful of the risk of necrosis, which can be caused by poor injection techniques,” warns Cushing. “To reduce the risk of unevenness I grid the injection points 1cm apart and am careful not to scratch the skin with the mesogun.” Similarly to the other practitioners interviewed, Cushing emphasises the need for a healthy lifestyle, comprising a well-balanced diet and regular exercise, for patients to benefit from the most aesthetically pleasing results. Just a few of the plethora of treatments available have been covered in this article. Yet whatever method you adopt for buttock augmentation or body contouring in your clinic, it seems imperative that patients should understand that, though elective, the treatments they are undergoing are still medical procedures, which do come with side-effects and risks. Following Keogh’s recommendations,9 practitioners should explore why a patient is requesting treatment and offer impartial, evidence-based guidance on the most suitable method for managing the patient’s aesthetic concerns. REFERENCES 1. Non-surgical Fat Reduction Procedures and Buttock Augmentation Dominate in 2014 (US: ASAPS, 2015) <http://www.surgery.org/media/news-releases/non-surgical-fat-reduction-procedures and-buttock-augmentation-dominate-in-2014> [date accessed: April 13 2015]. 2. Bootylicious Britain: Butt Lifts On The Rise (Ireland: Whatclinic.com, 2014) <https://about.whatclinic.com/wp-content/uploads/2014/06/WhatClinic-Butt-lifts-June-2014.pdf> [date accessed: April 13 2015] p.1. 3. Vaser Liposuction (UK: The Private Clinic, 2015) <http://www.theprivateclinic.co.uk/treatments/lipo- body-contouring/vaser-liposuction> [date accessed: April 13 2015]. 4. ProMax Lipo Radio Frequency Facial Skin Tightening & Body Contouring (UK: Lynton, 2015) <http:// www.lynton.co.uk/promax-lipo> [date accessed: April 13 2015]. 5. Clinical Evidence (UK: Aqualyx, 2014) <http://www.aqualyx.co.uk/studies> [date accessed: April 13 2015]. 6. What is Aqualyx? (UK: Aqualyx, 2014) <http://www.aqualyx.co.uk/product> [date accessed: April 13 2015]. 7. The Science Behind VelaShape Technology (UK: Syneron Candela, 2015) <http://www.syneron- candela.co.uk/product/velashape-iii/howitworks> [date accessed: April 13 2015]. 8. Popularity of Cosmetic Surgery Declines (UK: Aesthetics, 2015) <http://www.aestheticsjournal.com/ item/statistics-reveal-decline-in-cosmetic-surgery-procedures-in-2014> [date accessed: April 13 2015]. 9. Keogh B, Review of the Regulations of Cosmetic Interventions, (UK: Gov.uk, 2013) <https://www.gov. uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_ of_Cosmetic_Interventions.pdf [date acccessed: April 13th 2015]. p.36.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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A Review of Vitamin A Roger Bloxham and Antony Wakeford explore vitamin A’s role as a treatment for ageing and photodamaged skin Introduction Vitamins are organic compounds that the human body requires to effectively function, thus they have a direct affect on our health and wellbeing. They are derived from the diet in small amounts, and, as such, are often referred to as micronutrients.1 An organic compound is considered a vitamin if a lack of it results in clinical symptoms, known as vitamin deficiency.

Summary of vitamins · Vitamin A is a term used for a group of fat-soluble compounds known as retinoids; these include retinol, retinal and retinoic acid. Their primary action is to affect gene expression and the production of Messenger RNA (mRNA), resulting in the production of proteins and the differentiation of epithelial cells and tissues, which develop from the ectoderm. Vitamin A therefore plays a key role in the development and integrity of the skin (the epidermis in particular), and the outer membranes of sensory organs such as the eye and neural membranes.1,2, · Vitamin C, or ascorbic acid, is an electron donor and is the primary and highly potent water-soluble non-enzyme antioxidant present in plasma and tissues throughout the body. It also acts as an electron donor for key enzymes involved in catecholamine synthesis (hormones involved in collagen hydroxylation) and subsequent collagen structure stabilisation as well as carnitine synthesis and subsequent mitochondrial activity.1,3 · Vitamin E describes a group of fat soluble compounds known as tocopherols. Vitamin E is a very effective antioxidant, which prevents or helps to slow down lipid oxidation and subsequent damage to cell membranes and membrane structures and lipoproteins that transport fats through the blood stream.1,3 · Vitamin D is formed from cholesterol in the skin through a photolysis reaction stimulated by exposure to UV light. This fat-soluble compound plays a role in inducing protein synthesis and calcium absorption in the intestine and associated optimum calcium levels in the kidneys and bones.1,2 · Vitamin K is involved in the carboxylation of glutamic acid in a number of vitamin K dependent proteins; during the process it is converted to an epoxide form that can be regenerated to vitamin K within the body. Many of the blood clotting factor proteins are vitamin K dependent.1,2 · The B-complex vitamins are water soluble coenzymes: Thiamine (B1) is involved in enzyme functions associated with carbohydrate metabolism.1,2 Riboflavin (B2) is a precursor of coenzymes that are involved in protein metabolism.1,2 Niacin is a coenzyme of dehydrogenases that plays a key role in the metabolism of proteins and carbohydrates.1,2 Vitamin B6, of which the most stable form is pyridoxal, is a coenzyme involved in protein metabolism.1,2 Pantothenic Acid (B5) is the main component of coenzyme-A and a key requirement for cell metabolism, the synthesis of essential fats, cholesterol and hormones, including melatonin.1,2 Biotin is the active site of five carboxylating enzymes required for the biosynthesis of fatty acids and gluconeogenesis.1,2

· Folates, including folic acid, are cofactors to enzymes that facilitate the transfer of carbon units in transfer reactions, particularly associated with the metabolism of DNA. Its effects are most prevalent in rapidly dividing cells such as red blood cells. It is also key to a process known as methylation and the associated gene expression responsible for the processing of proteins, phospholipids and cell differentiation.1,2,3 · Vitamin B12 plays a key role in the metabolism of folate and coenzyme A; it is therefore closely linked to DNA metabolism and expression.1,2 Given the primary role of vitamin A in the production and differentiation of epithelial cells, which includes the skin and in particular the epidermis, as well as the fact that a lack of vitamin A causes observable changes in skin epithelial tissue, including epidermal thickening and hyperkeratosis,2 it is no surprise that retinoids became, and still are, a topic of dermatological research for skin conditions and treatments. This is the focus of the discussion below.

Vitamin A: How does our body get it and use it? The retinoid compounds that the term vitamin A describes are all lipid soluble, and are related to the preformed vitamin A compound all-trans-retinol. This is the active bioavailable form of vitamin A. There are four main physiologic functions of retinoids in the body:4 1. To ensure normal embryonic development. 2. To facilitate normalised epithelial differentiation in varying tissue types, including the skin. 3. To maintain healthy vision through the production of rhodopsin, an 11-cis-retinaldehyde containing eye pigment that enables night vision. 4. To enable adequate immune function and lymphocyte survival.

Vitamin A and nutrition Vitamin A levels within the body depend on levels of nutrition. Preformed vitamin A, predominantly in the form of retinyl esters (esterified retinol, mainly retinyl palmitate), is available from animalbased foods – liver, butter, cheese, egg yolks and oily fish are known to have a high content. It is also possible to derive vitamin A from vegetables and fruit via a relatively small sub-section of the many carotenoid compounds present in plants, particularly alpha and beta-carotenes. These are known as pro vitamin A

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compounds.3,5 In addition, some food items, such as margarine and low-fat spreads, are fortified with vitamin A. The different sources of vitamin A have different levels of potency available in food items. For example, retinyl esters are membranebound within storage cells within the animal tissue. The pro-vitamin A carotenoids are not only bound to lipids but are embedded in complex cellular structures within the plant material. Therefore the amount of the retinyl ester or carotenoid does not directly reflect the amount of vitamin A (retinol) available. Because of this, standardised units known as International Units (IU) or Retinol Equivalents (RE) are often used to express the levels available per compound, and to help provide a comparison across the different food sources.2,3 There can be a wide variability in levels contained in the different food sources, for example 100g of pork liver has been shown to have 30,000 μg RE, whereas pork muscle has 6 μg RE and oily fish has 40 μg RE.2 There are risks associated with taking too much vitamin A. The UK National Health Service (NHS) has advised that having more than an average of 1.5mg a day vitamin A, over many years, may affect bones, making them more likely to fracture.6 They point out that this is particularly important for older people, especially women, who are already at risk of osteoporosis. This is when bone density reduces and there is a higher risk of fractures. Thus, women who have been through the menopause and older men, who have a higher risk of osteoporosis, are advised to avoid having more than 1.5mg of vitamin A per day from food and supplements.6 Eating liver or liver pâté more than once a week may result in too high a vitamin A intake, and it is advised that if liver is eaten every week, supplements containing vitamin A should not be taken. Additionally, if the dietary intake of vitamin D is too low, it is possible that there will be more risk of the harmful effects of too much vitamin A.6 In addition to the osteoporosis risks associated with taking too much vitamin A detailed earlier, there are additional risks in pregnancy.6 Having large amounts of vitamin A can harm an unborn baby. It is advised that women who are pregnant, or who are thinking about becoming pregnant, should not eat liver or liver products, and should not take supplements that contain vitamin A. It is recommended that a GP or midwife be consulted for more information.6

Vitamin A and bioavailability Once the food has been consumed, digestion frees the retinol from the retinyl esters. The lipid soluble retinol is then inside a predominantly aqueous environment in the intestines and gut, with fatty acids and phospholipids and bile secretions. It then has to pass through the lipid-rich intestinal mucosal cells. Enzymes either cleave vegetable derived carotenoids as they pass through the intestinal mucosa to form retinol, or they remain as they are. Retinol is then re-esterified or is bound to a specific protein retinol

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binding protein (RBP), synthesised within the tissue, and passes into the blood stream. Any carotenoids or retinol that has become re-esterified in the intestinal cell wall is packaged in to lipoprotein particles and enters into the blood stream via lymph channels.3 The next step is storage, predominantly within the liver, in parenchymal cells. Retinol is detached from the RBP or the retinyl ester is removed from the circulating lipoprotein particle and then hydrolysed within the liver to produce retinol. The resulting retinol is then esterified for storage. The liver can also take up carotenoids from the lipoprotein particles for storage.3 Stored retinyl esters in the liver are mobilised by hydrolytic release of retinol and binding to a RBP, produced in the liver, enabling it to be transported in the aqueous environment of the plasma in the blood stream to target tissues and cells. The levels of plasma vitamin A are maintained at approximately 2μmol/L. The circulating retinol RBP combination forms a further complex with a larger protein transthyretin, to ensure the retinol is not filtered out through the kidney.7 The bound retinol enters into the tissue through the cellular membrane, where the retinol binds to an intracellular binding protein (CRBP). Within the cell, retinol can be esterified, most likely to form a localised store, and more importantly it can be metabolised to form retinal (also known as retinaldehyde) and then retinoic acid. The conversions of retinol to ester forms or retinal are all reversible which, consequently, can regulate the levels of retinol and retinoic acid in the cells.2,9

Vitamin A and biochemical activity The cellular conversion of retinol to retinal and retinoic acid is fundamental to its biological role and ultimately its role in the treatment of ageing and photodamaged skin. In ocular tissue and specifically the retina, retinol is converted to retinal and then rhodopsin – the pigment required for low light vision. For the control of cell growth and differentiation in all other epithelial tissue retinol is converted to retinal and then to retinoic acid (of which there are two primary isomers). These bind to receptors in the nucleus (known as Retinoic Acid Receptor (RAR) and Retinoid X Receptor (RXR) receptors), which in turn bind to specific elements of DNA and consequently regulate gene expression and transcription.8 As such, vitamin A is essential for the biological functions previously mentioned.4,9 Vitamin A deficiency is rare in the western world but can be a major problem in the developing world with specific symptoms including night blindness and xerophthalmia, which can lead to permanent blindness. Other significant negative effects associated with deficiency include growth retardation in children, skin disorders and impaired immune function. Deficiency in pregnancy can lead to congenital malformation of the eyes, lung, cardiovascular and urinary systems.5 In the environment of cosmetic dermatology and aesthetics, we do not usually have to deal with such issues of deficiency. The

Table 1: Table comparing pre-formed and pro vitamin A compounds: Molecule

Quantity

Retinol Equivalents (RE)

International Units (IU)

Retinol

1μg

1.00

3.3

Retinyl Palmitate

1μg

0.55

1.8

Beta-carotene

1μg

0.17

0.6

(data adapted)1,2,3

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clinical focus with respect to vitamin A is for use in the treatment of physical and anatomical impairment of the epithelial tissues and cells that occurs i.e in the skin, as part of the ageing process and photodamage, and to treat other cosmetically impairing skin conditions such as pigmentation and acne.

Vitamin A and the clinical enhancement of aged and photodamaged skin During skin ageing, the production and replacement of collagen, elastin and hyaluronic acid slows down as there are fewer dermal fibroblasts, and they operate less efficiently. Skin not damaged by photo radiation will age as a result of this, and become thinner, more lax and finely wrinkled.10,11 External factors, including UV radiation and smoking, accelerate the natural ageing process. In the 1990s, research showed that photodamaged skin had premature damage of the collagen bundles and amorphous amounts of elastotic material, which was likely due to increased synthesis of matrix metalloproteinases (MMPs) and subsequent collagen destruction.12,13 It was also demonstrated that photodamaged skin has reduced capability to produce new collagen.14 This prematurely reduces the elasticity, firmness, and smoothness of the skin, resulting in coarser lines and wrinkles. Photodamaged skin is also differentiated from naturally aged skin by a thickened and rougher appearance. With an understanding of the role of vitamin A within biological processes, and the mechanisms and effects of skin ageing and photodamage, it comes as no surprise that vitamin A is often considered an essential component of an evidence-based antiageing skin management programme.

The role of oral retinoids The consumption of vitamin A via food substances or supplements could be considered to be a logical route to try and combat the effects of intrinsic skin ageing and photodamage. However, vitamin A deficiency is rare in the western world and it is known that average daily intakes of preformed retinol within the EU are well above the recommended reference intake.5 Despite this, aesthetic consultations and treatments for skin ageing and photodamage continue to rise, implying that dietary levels of vitamin A may have little correlation with the impact of chronological or photo-induced ageing. A review of clinical studies on PubMed reveals oral vitamin A supplement studies relating to skin are relatively low in number and the data that was sourced relates primarily to skin cancer. This data is briefly reviewed here, as it can reasonably be considered to have some correlation to the impact of UV in photodamaged skin. A recently published review of vitamin A in photocarcinogenesis stated that relatively high oral doses of prescription only medicines (POMs), isotretinoin and acitretin, resulted in a significant reduction of new skin cancers in high-risk patients.15 Whilst many medical aesthetic treatments crossed over from their initial use in more clinical areas, it would be difficult (based on a risk/ benefit assessment) to attempt to adapt this approach with these medications for skin ageing treatments. One study showed daily supplementation of 25,000 IU of retinol, more than 10 times the recommended daily dose, for a median period of 3.8 years, did significantly reduce the incidence of squamous cell carcinoma.16 However a four-year follow up prospective study of 73,336 women showed that their diet, including vitamin A intake, or supplementation with vitamins including vitamin A and multivitamins, had no significant impact on the incidence of basal cell carcinoma.17

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Similarly, a study of men taking 50mg of beta-carotene on alternative days for 12 years, again more than 10 times the recommended daily intake, showed that it had no effect on the incidence of nonmelanoma skin cancer when compared to the placebo group and there was no beneficial link associated with plasma levels of betacarotene, vitamin A or vitamin E.18 Based on this, it is logical to conclude that oral intake of vitamin A is going to play a minimal role in treating ageing and photodamaged skin and, therefore, for an evidence-based approach, we need to focus on topical retinoids.

The role of topical pharmaceutical retinoids As early as 1962, the effect of topical vitamin A in the form of tretinoin (all-trans-retinoic acid) was shown to affect epidermal differentiation and keratinization, and was used clinically in the treatment of ichthyoses.19 In 1969, Kligman published the first clinical paper clearly demonstrating its clinical efficacy in the treatment of acne20 and in the early 1970s tretinoin was approved by the Food and Drugs Administration (FDA) in the USA as a prescription only medicine, the first retinoid approved as a medicine, for the treatment of mild to moderate acne.19 However, it took some time before the skin physiology-changing attributes of tretinoin were appreciated in the treatment of photodamaged and aged skin. In 1986 Kligman published a study showing that in photoaged skin, topical tretinoin 0.05% induced a normalisation of keratinocyte exfoliation and proliferation, along with improvement in keratinocyte morphology and function, extracellular matrix structure and formation, and angiogenesis.21 A review of clinical studies available for tretinoin summarised that the shorter-term studies of four to 16 weeks demonstrated physiological changes in the epidermis and significant enhancements in appearance but with minimal dermal changes. Longer-term studies of approximately six months showed that these clinically significant improvements in fine and coarse wrinkles, sallowness, hyperpigmentation, roughness and epidermal structure continued, and that these improvements were maintained after the study periods. Interestingly, it was the studies of 12 months or more that showed clinical changes in the dermis, with new collagen production and the regulation of damaged tissue.9,22 Topical tretinoin presented some potential adverse events, such as erythema and inflammation in the areas of application, as well as increased photosensitisation. It was for this reason that lower strength tretinoin was assessed and showed good results. 0.025% and 0.1% tretinoin produced statistically equivalent results after 48 weeksâ&#x20AC;&#x2122; use, with significantly less adverse events in the lower strength group.22 In the USA, the FDA review of products containing tretinoin has, to date, designated them to be POMs.24 The same is true in the UK with respect to the Medicines and Healthcare products Regulatory Agency (MHRA)25, and the EU Cosmetics Regulation26 lists tretinoin as a substance prohibited in all cosmetic products. The electronic medicines compendium (eMC) website27 shows that there are two topical medicinal products containing tretinoin available in the UK. Both are combined with an antibiotic and indicated for the treatment of acne. There are currently no forms of tretinoin suitable for use in the rejuvenation of aged and photodamaged skin with an MHRA approved marketing application (MA). If a tretinoin product is made available within the UK without an MA it must be done under the section of the Human Medicines Regulations 2012 (SI 2012 No. 1916)28 concerning unlicensed medicinal products for individual patient use. Regulation 167 of the Regulations

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requires that there is a bona fide unsolicited order, that the product is formulated in accordance with the requirement of a doctor or dentist, nurse independent prescriber, pharmacist independent prescriber or supplementary prescriber registered in the UK, and the product is for use by one of their individual patients (on the basis of ‘special need’) on the practitioner’s direct personal responsibility. In addition, guidance from the prescriber’s governing body should be considered. For example, the Nursing and Midwifery Council (NMC) provide such guidance accessible via their website.29 The most recent generation of medicinal retinoids are synthetically produced. They were developed to have a more selective mechanism of action and better tolerability. Adapalene, the first synthetic retinoid, is readily taken up by the pilosebaceous unit (hair shaft, hair follicle, sebaceous gland) and was shown to directly bind to RAR receptors and regulate keratinisation and inflammation.9 There are cream and gel formulation POMs approved by the MHRA for the treatment of mild to moderate acne.14 Their short-term use over four weeks and longer-term use of up to nine months, have shown significant improvements in photoaged skin,30 although such use is not in accordance with the approved indications, and would be considered to be ‘off-label’ with respect to the currently available and approved medicines. Tazarotene is another synthetically produced retinoid approved in the UK in a gel form for the treatment of psoriasis.14

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Specific retinoids are also available for use as cosmetic ingredients in compliance with the Cosmetic Product Regulations and the EU Cosmetic Directive. With respect to their use in ageing and photodamaged skin, retinol has had established

evidence-based cosmetic use since 1984, and is accorded ‘generally recognized as safe’ (GRAS) status by the FDA. Retinaldehyde (retinal) has generated clinical data supporting its use and the retinol derivatives such as retinyl palmitate are widely used due to their stability and ease of formulation, although less clinical evidence of their efficacy as a monotherapy is available.9 All of the retinoids referred to above require a biological conversion within the skin to form retinoic acid.9,31 The advantage of the cosmetic retinoids is that they are more widely available for use than medicinal products, and their skin tolerance has been shown to be significantly greater than tretinoin.32 The fact that they are also cosmetics allows greater flexibility with respect to formulation. The evidence of the clinical efficacy of retinol is compelling. Kang et al showed that 1.6% retinol induced similar effects to 0.025% retinoic acid, without similar measurable skin irritation.33 The retinol caused epidermal thickening and enhanced expression of retinol binding protein mRNA, similar to that of retinoic acid. However, the erythema produced by retinol application was significantly less. Interestingly, they discovered that the retinoic acid levels found in the epidermis were approximately a thousand times less in the retinol treated skin compared to the retinoic acid treated skin, despite seeing similar clinical effects and markers. They postulated that the retinol was being converted to retinoic acid in a tightly controlled manner at physiologically relevant sites; the right amount at the right location within the skin. Further studies have shown that retinol is safe and effective in the treatment of photodamaged skin.31,34,35 It is acknowledged, however, that formulation is key as retinol-based products can be unstable, particularly on exposure to light and air.9 Because of the clinical value of retinol and the fact that its efficacy

Figure 1:

Figure 2:

The role of topical cosmetic retinoids

Before

After

A 42-year-old female before (left) and after (right) eight weeks of treatment with Retinol (0.5%) aqeuous protein-rich suspension. Images courtesy of Dr Michael Gold. Figure 3: Before

After

A 69-year-old female before (top) and after (bottom) eight weeks of treatment with Retinol (1.0%) aqeuous protein-rich suspension. Images courtesy of Dr Vivian Bucay.

Visia brown spot analysis of a 41-year-old female before (left) and after (right) eight weeks of treatment with Retinol (0.5%) aqueous protein-rich suspension. Images courtesy of Dr Michael Gold.

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depends greatly on its stability and bioavailability, research and formulation developments continue. Gold et al demonstrated in 2013 the efficacy and tolerability of such a product, reporting a pilot study of a serum with retinol 1% in a novel oil-free aqueous protein rich suspension, showing improved visible signs of photodamage after eight and 12 weeks of daily use. Their subsequent study using 0.5% retinol in the same formulation showed that hyperpigmentation, telangiectasias, skin laxity, roughness and actinic keratosis showed significant improvement from baseline after four and eight weeks daily use of the formulation. Skin tolerability was reported to be good.33

Conclusion When it comes to aged skin, and skin whose ageing process, structure and appearance has been worsened by photodamage, topical vitamin A plays a key role in its treatment and visible and physical enhancement. There are robust double blind placebo controlled clinical studies regarding the use of tretinoin (retinoic acid) in the treatment of aged and photodamaged skin.21,22,23,32 Whilst clinically visible effects can be seen after four weeks, the greatest physiological effects are seen after daily use of 12 months or more, and the studies show the treatment has a good safety profile over such periods. This indicates that on-going long-term treatment is desirable, although skin tolerability issues were often reported particularly in the early phases of treatment. In the UK, the availability of tretinoin in topical formulations suitable for use in treating aged and photodamaged skin is currently limited to unlicensed medicinal products. These may only be supplied in accordance with the Human Medicines Regulations concerning unlicensed medicines for individual patient use and by prescribers able to prescribe such medicines, and in accordance with their governing body / council such as the General Medical Council. There is also compelling data for the efficacy of retinoids, available in cosmetics for the clinical improvement of aged and photodamaged skin.33, 34, 35, 36 Cosmetics containing these ingredients are more widely available and generally display better skin tolerability than prescription-only tretinoin-based topical medicines. Within this category, retinolbased formulations are supported by a high level of clinical data, although formulations need to address the inherent instability of retinol as an ingredient.9,31,33,34,36 On-going research and novel formulation enhancements means that retinol-based cosmetics can and will continue to play a significant role in the clinical management of aged and photodamaged skin. Roger Bloxham is the managing director of Ferndale Pharmaceuticals Ltd and AesthetiCare, with a BSc (Hons) in Applied Biology and over 28 years of commercial, technical and regulatory experience in the pharmaceutical, medical device and cosmetic industries. In the last 18 years, his focus has been on the dermatology sector. Antony Wakeford is a chartered chemist and member of the Royal Society of Chemistry. As the owner and managing director of QP-Services UK Ltd., an independent provider of technical, quality, safety and regulatory services to the pharmaceutical, medical device and cosmetic industry, he has over 32 years experience in the industry.

Aesthetics REFERENCES 1. Oregon Sate University Linus Pauling Institute Micronutrient Research for Optimum Health, Micronutrient Information Center (US: Oregon State University, 2015) <http://lpi.oregonstate.edu/ infocenter> [Accessed 14 April 2015] 2. Belitz HD et al. Food Chemistry, 4th Revised and Extend Version (Berlin: Springer, 2009) p. 403-419 3. Food and Agriculture Organization of the United Nations. Human Vitamin and Mineral Requirements. Report of a joint Food and Agricultural Organisation of the United Nations (FAO) and World Health Organization (WHO) Expert Consultation (Italy: foa.org, 2001) < http:// www.fao.org/docrep/004/y2809e/y2809e00.htm> [Accessed 14 April 2015] 4. Kang S, ‘The mechanism of action of topical retinoids’, Cutis, 75(suppl 2) (2005), p. 10-13. 5. European Commission, Scientitifc Committee on Food. Opinion of the Scientific Committee on Food on the Tolerable Upper Intake Level of Preformed Vitamin A (retinol and retinyl esters) (Brussels: European Commission – Europa, 2002) <http://ec.europa.eu/food/fs/sc/scf/ out145_en.pdf> [Accessed 14 April 2015] 6. NHS Choices, Vitamins and Minerals – Vitamin A (UK: NHS Choices, 2015) <http://www.nhs.uk/ Conditions/vitamins-minerals/Pages/Vitamin-A.aspx> [Accessed 14 April 2015] 7. Blomhoff, R. ‘Vitamin A metabolism: new perspectives on absorption, transport, and storage’, Physiol Revs, 71(1991), p. 951-990. 8. Allenby et al, ‘Retinoic acid receptors and retinoid X receptors: Interactions with endogenous retinoic acids’, Proc Nati Acad Sci, 90 (1993), p.30-34. 9. Mukherjee et al, ‘Retinoids in the treatmentof skin ageing: an overview of clinical efficacy and safety’, Clinical interventions in Aging, 1(4) (2006), p.327-348. 10. Fisher et al, ‘Mechanisms of photoaging and chronological skin aging’, Arch dermatolo, 138 (2002), p.1462-1470. 11. Varani et al, ‘Decreased Collagen Production in Chronologically Aged Skin:,Roles of Age- Dependent Alteration in Fibroblast Function and Defective Mechanical Stimulation’, Am J Path, 168 (2006). 12. Fisher et al, ‘The molecular basis of sun induced premature ageing and retinoid antagonism’, Nature, 379 (1996) p. 335-338. 13. Fisher et al, ‘Pathophysiology of premature skin ageing induced by ultraviolet light’, N. Engl J med, 337 (1997), p. 1419-28. 14. Griffiths et al, ‘An in-vivo experimental model for topical retinoid effects on human skin’, Bt J Dermatol, 29 (1993), p. 389-99. 15. Shapiro et al, ‘Vitamin A and Its Derivatives in Experimental Photocarcinogenesis: Preventive Effects and Relevance to Humans’, Journal of Drugs in Dermatology, 12(4) (2013), p. 456-458. 16. Moon et al, ‘Effect of retinol in preventing squamous cell skin cancer in moderate-risk subjects: a randomized, double-blind, controlled trial. Southwest Skin Cancer Prevention Study Group’, Cancer Epidemiol Biomarkers Prev, 6(11) (1997) p. 949-56. 17. Hunter el al, ‘Diet and risk of basal cell carcinoma of the skin in a prospective cohort of women’, Ann Epidemiol, 2(3) (1992) p. 231-9. 18. Schaumberg et al, ‘No effect of beta-carotene supplementation on risk of nonmelanoma skin cancer among men with low baseline plasma beta-carotene’, Cancer Epidemiol Biomarkers Prev, 13(6) (2004), p. 1079-80. 19. Zainglein A L, ‘Topical Retinoids in the Treatment of Acne Vulgaris. ‘Semin Cutan’’, Med Surg, 27 (2008) p.177-182. 20. Kligman et al, ‘Topical Vitamin A acid in acne vulgaris’, Arch Dermatol, 99 (1969) p.469-476. 21. Kligman et al, ‘Topical tretinoin for photoaged skin’, J Am Acad Dermatol, 15 (4 pt 2) (1986), p.836-59. 22. Kang et al, ‘Long-Term Efficacy and Safety of Tretinoin Emollient Cream 0.05% in the Treatment of Photodamaged Facial Skin: A Two-Year, Randomized, Placebo-Controlled Trial’, J Am J Clin Dermatol, 6 (4) (2005), p. 245-253. 23. Griffiths et al, ‘Two concentrations of of topical tretinoin cause similar improvement of photoageing but different degrees of irritation’, Arch Dermatol, 131 (1995), p.1037-44. 24. Foods and Drugs Administration, Drugs@FDA – FDA Approved Drug Products (Tretinoin), (US: Access Data, FDA, 2015) <http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index. cfm?fuseaction=Search.Overview&DrugName=TRETINOIN> [Accessed 14 April 2015] 25. Gov.uk, Medicines & Healthcare products Regulatory Agency, (UK: Gov.uk, 2015) <www.mhra.gov. uk> [Accessed 14 April 2015] 26. European Parliament, Council of the European Union, Regulation (EC) No 1223/2009 of the European Parliament and of the Council of 30 November 2009 on cosmetic products (EU: EUR- Lex, 2009) <http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32009R1223> [Accessed 14 April 2015] 27. electronic Medicines Compendium, eMC+ <www.medicines.org.uk/emc> (UK: electronic Medicines Compendium, 2015) [Accessed 14 April 2014] 28. UK Parliament, The Human Medicines Regulations 2012 (SI 2012 No. 1916) (UK: legislation.gov.uk, 2012) <http://www.legislation.gov.uk/uksi/2012/1916/pdfs/uksi_20121916_en.pdf> [Accessed 14 April 2015] 29. Nursing and Midwifery Council, Nurse and midwife independent prescribing of unlicensed medicines (UK: Nursing and Midwifery Council, 2010) <www.nmc.org.uk/globalassets/ sitedocuments/circulars/2010circulars/nmccircular04_2010.pdf> 30. Kang et al, ‘Assessment of adapalene gel for the treatment of actinic keratoses and lentigines: A randomized trial’, J Am Acad Dermatol, 49 (2003) p. 83-90. 31. Kang et al, ‘Improvement of naturally aged skin with vitamin A (Retinol)’, Arch Dermatol, 14395 (2007) p. 606-612. 32. Fluhr JW et al, ‘Tolerance profile of retinol, retinaldehyde and retinoic acid under maximized and long-term clinical conditions’, Dermatology, 199(Suppl 1) (1999), p. 57-60. 33. Kang et al, ‘Application of Retinol to Human Skin In Vivo Induces Edipermal Hyperplasia and Cellular Retinoid Binding Proteins Characteristic of Retinoic Acid but Without Measurable Retinoic Acid Levels or Irritation’, Soc Investig Drmatol, 105(4) (1995), p. 549-556. 34. Duell EA et al, ‘Unoccluded retinol penetrates human skin in vivo more effectively than unoccluded retinyl palmitate or retinoic acid’, J Investig Dermatol, 106 (1997) p. 316-320. 35. Tucker-Samaras et al, ‘A stabilized 0.1% retinol facial moisturizer improves the appearance of photodamaged skin in an eight-week, double-blind, vehicle-controlled study’, Journal of Drugs in Dermatology, 8(10) (2009), p. 932-936. 36. Gold et al, ‘Treatment of facial photdamage using a novel retinol formulation’, Journal of Drugs in Dermatology, 12(5) (2013) p. 533-510.

Ferndale Pharmaceuticals Ltd / AesthetiCare market products containing vitamin A ingredients and QP-Services UK Ltd are technical and regulatory service providers to Ferndale Pharmaceuticals Ltd.

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what cosmetics and make-up your patients use. It is also imperative to look at the evidence supporting the ingredients contained in the make-up and cosmeceuticals that we advise patients to use, or that we sell to them.

Patient education Below is an overview of some ingredients found in make-up, which can cause skin issues, and, if possible, should be avoided by patients who have recently undergone an aesthetic procedure:

Using Make-up Post-Procedure Sarah Barker examines the important factors to understand when using make-up post-aesthetic procedure Day in, day out, most of our patients wear make up. These products often contain preservatives, chemical dyes, fillers and numerous fragrances – all potentially detrimental to the skin, particularly after aesthetic treatments. Following most treatments, skin can be left sensitive and penetrable. Because of this, make-up has the potential to be damaging to the skin, either by increasing the risk of further irritation, instigating an allergic reaction or causing acne. Advice on post-treatment make-up varies, depending on the product and treatment used. In the case of dermal fillers, it is advised that light makeup can be applied immediately to hide redness.1 Botulinum toxin requires a minimum of four hours2 before application. Other treatments may require a longer waiting period before products of this kind can be applied. With chemical peels, it is advised that the patient should avoid make-up on the day of the peel,3 whilst patients who have undertaken derma-rolling treatments should avoid the use of cosmetic products for 12 hours post treatment. However, radio frequency treatments allow the patient to ‘put make up on as desired.’4 Abiding by these guidelines will enhance good results, and, as advised after a derma-rolling treatment, it may also be beneficial for the practitioner to supply the patient with specialist mineral make-up, in order to avoid potential irritation.5 As professionals in aesthetics, we should have an understanding of how patients’ lifestyles influence their health and wellbeing, and take every opportunity to promote health, prevent illness and support patients to make lifestyle changes where appropriate.6 Most of our female patients, and some male, wear make-up or use some form of cosmetics on a daily basis. To follow on from the care that they receive in-clinic, it follows good and thorough practice to find out

••

•• •• ••

•• ••

Methyl, propyl, butyl and ethyl parabens are used as inhibitors of microbial growth, and to extend the shelf life of products. They are widely used, even though they are known to be toxic and can cause allergic reactions and skin rashes in individuals with paraben allergies,7 hence they should only be used in small quantities (less than 0.8%). With other paraben ingredients, such as isopropylparaben, isobutylparaben, phenylparaben, benzylparaben and pentylparaben, the human risk could not be evaluated because of a lack of data.8 Petrolatum is found in most lip products, and is usually advertised as protecting the lips from sunburn, chapping and so forth. Petrolatum is mineral oil jelly, and mineral oil causes a lot of problems when used on the skin, such as photosensitivity (i.e. promotes sun damage). It tends to interfere with the body’s own natural moisturising mechanism, leading to dry skin and chapping – therefore, resulting in a product that creates the very conditions it claims to alleviate.9 Imidazolidinyl urea and diazolidinyl urea are the most commonly used preservatives after parabens. They are found in many cosmetics, skin care products, shampoos and conditioners, as well as bubble baths, baby wipes and household detergents. Both preservatives are well established as a primary cause of contact dermatitis.10 Neither has a good shelf life and must be combined with other preservatives, with imidazolidinyl urea releasing formaldehyde, which can induce allergic reactions.11 These chemicals have been found to be toxic to the skin and body system.10 Propylene glycol, which is recognised as safe for use in food as well as cosmetics,12 is a vegetable glycerin mixed with grain alcohol, both of which are natural (so consumers often assume this is safe), but both can cause skin sensitivity and eye irritation.13 Sodium lauryl sulphate is a synthetic substance used in shampoos for its detergent and foam-building abilities. It can cause eye irritations, skin rashes, hair loss, scalp problems and allergic reactions.14 Stearalkonium chloride is largely used in hair conditioners and creams. This can cause allergic reactions, eye irritation and even hair loss. Stearalkonium chloride was developed by the fabric industry as a fabric softener, and is a lot cheaper and easier to use in hair conditioning formulas than proteins or herbals.10 Synthetic colours, which aim to make a cosmetic ‘pretty’, should also be used with caution due to skin irritation. Many artificial colours are now banned due to their carcinogenetic effects.15 Synthetic fragrances used in cosmetics can have as many as 200 ingredients. There is no way to know what the chemicals are, since on the label it will simply say ‘fragrance’. Some of the problems caused by these chemicals are headaches, dizziness, rash, hyperpigmentation, violent coughing, vomiting and skin irritation.10 Triethanolamine (TEA) is used to adjust pH, formulated with fatty acids to convert acid to salt (stearate), which then becomes the base for a cleanser. TEA causes allergic reactions including eye problems, dryness of hair and skin, and could be toxic if absorbed into the body over a long period of time.16 A natural mineral derived additive, bismuth oxychloride, has been used in make-up for centuries. It gives a pearly shimmer and is usually found in foundation. This can potentially cause irritation and, in many cases, cause or worsen cystic acne and rosacea.17

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Conclusion It is best to advise patients to look out for make-up that contains as few additives as possible, is fragrancefree and made with natural ingredients. Patients prone to acne should also seek non-comedogenic products. Preservatives are in almost any product that contains water, and the most common preservatives have been linked to skin allergies. However, it is important to remember that this doesn’t mean they will cause allergic reactions in everyone. Mineral make-up, because of its nature, cannot harbor bacteria and therefore does not need a preservative. Recommending this kind of product or approach to a patient following an aesthetic procedure, as is suggested after a derma rolling treatment, (where it is advised that a practitioner may provide a patient with mineral make-up),5 is encouraged as a clinically sound, and realistic, approach to post-procedure cover up. Sarah Barker is an aesthetic nurse and owner of Flawless Aesthetics and Beauty. She is a BACN and PIAPA member, as well as an associate member of BABTAC. Sarah has recently launched her own UK Mineral Makeup Brand and offers accredited training in both theory and application.

Aesthetics

REFERENCES 1. Galderma, Post Treatment Advice – Restylane, Emervel, (Galderma UK Ltd, July 2013: Available on request). 2. Allergan, A Guide for patients being treated with Botox, (Allergan UK Ltd, /1164/2013a p.7: Available on request). 3. Medica Forte, FAQs, (UK: The Perfect Peel, 2014) <http://theperfectpeel.co.uk/faqs/> 4. Weisman T, ‘Endymed The Three Deep Company – Endymed Medicals Innovative RF Fractional Skin Resurfacing Applicator Proven Effective and Safe for Wrinkle and Acne Scar Improvement’, Endymed Medical Ltd, 2011. 5. Dermaroller, After Procedure Skincare, (UK: Genuine Dermal Roller Clinic, 2014) <http://genuinedermarollerclinic. co.uk/dermaroller-aftercare.html> 6. Nursing and Midwifery Council, The Code: Standards of conduct, performance and ethics for nurses and midwives, (London: Nursing and Midwifery Council, 2008) <http://www.nmc-uk.org/Publications/Standards/The- code/Introduction> 7. Nagel et al, ‘Paraben allergy’, Journal of the American Medical Association, (1997) p.1594-5. 8. Scientific Committee on Consumer Safety, SCCS OPINION ON Parabens Updated request for a scientific opinion on propyl- and butylparaben COLIPA n° P82 (Europe: European Commission, 2013) <http://ec.europa.eu/health/ scientific_committees/consumer_safety/docs/sccs_o_132.pdf> 9. Aubrey Hampton, Ten Synthetic Cosmetic Ingredients to Avoid (US: Organic Consumers Association, 2001) <www.organicconsumers.org/bodycare/toxic_cosmetics.cfm> 10. Marla E Rendall, ‘Do early skin care practices alter the risk of atopic dermatitis? A case-control study’, Paediatric Dermatology, 28 (2011), p. 593-595 11. DermNet, Formaldehyde Allergy, (New Zealand: DermNet, 2013). <http://www.dermnetnz.org/dermatitis/ formaldehyde-allergy.html> 12. Lush, Propylene Glycol (UK: Lush Retail, 2015) <https://www.lush.co.uk/propylene-glycol> 13. European Chemical Industry Council, Guidelines for the Handing and Distribution of Propylene Glycol USP/EP (Pharmaceutical Grade), Revision 2.2, May 2013 – English (Belgium: European Chemical Industry Council, 2013) <http://www.propylene-glycol.com/uploads/documents/GuidelinesUSP_2013_UK_HR.pdf> 14. Sue Bedford, Choosing A Healthy Diet and Lifestyle, ebook <http://www.pulsescreening.co.uk/EBook/ Choosing_A_Healthy_Diet_Lifestyle_web.pdf> 15. International Agency for Research on Cancer, Agents Classified by the IARC Monographs, Volumes 1 – 112. (France: International Agency for Research on Cancer, 2015). <http://monographs.iarc.fr/ENG/Classification/ ClassificationsGroupOrder.pdf> 16. J Levin, ‘How Much Do We Really Know About Our Favourite Cosmeceutical Ingredients?’ Journal of Clinical Aesthetic Dermatology, 3(2) (2010), p. 22-41. 17. My Sensitive Skincare, Best Mineral Makeup (US: My Sensitive Skin, 2015) <http://www.mysensitiveskincare.com/ best-mineral-makeup.html#axzz3XqfyW8Za>

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Aesthetics Awards Special Focus

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Entry for The Aesthetics Awards 2015 is now open The Aesthetics Awards bring together the best in medical aesthetics and leaders in the profession to celebrate the achievements of the past year. 23 prestigious awards categories have been designed to recognise finalists and winners for their services to the profession and industry. Awards are presented to those who have worked hard to represent the highest standards in clinical excellence, product innovation and practice achievement and have truly excelled in the field of aesthetic medicine, from clinics and individual practitioners to manufacturers and suppliers. Following the success of last year’s awards, the 2015 Aesthetics Awards will be held on Saturday December 5 at the Park Plaza Hotel in Westminster. The evening will play host to 500 guests, new award categories and fantastic entertainment. Beginning with a drinks reception and followed by a performance from a top comedian and formal sit down dinner, the evening will culminate in the award presentations recognising winners in 23 categories, before guests will be able to enjoy music and dancing late into the night.

Why should I enter? Entering The Aesthetics Awards is an excellent opportunity to celebrate the successes and achievements of your business. Being shortlisted as a finalist or chosen as a winner in the awards is a great marketing tool, enabling you to show potential and existing clients why you stand out from your competitors in this competitive sector. Entry will be open until June 30, with finalists announced on September 1 in the Aesthetics journal

T H E

A EST HE T I C S

AWA R D S

20 15

• Cosmeceutical Range/ Product of the Year This award will be given to the manufacturer or UK distributor of the best Cosmeceutical product or product range, retailed in UK medical aesthetics clinics. The judges will select finalists who show evidence that their product is effective, safe, easy-to-use and well accepted by patients.

• Treatment of the Year This award will be given to the manufacturer or supplier considered to offer the best medical aesthetic treatment in the UK. The category is open to any treatment offered in UK medical aesthetic clinics. Finalists will be able to demonstrate a wide range of indications, evidence of good safety and efficacy, optimum duration and tangible benefits over similar treatments on the market.

• The Sterimedix Award for Injectable Product of the Year This award will be given to the manufacturer or UK distributor of the injectable product deemed to be the best-in-class available on the UK market. Finalists will be chosen from products that support a wide range of indications and can show evidence of good safety and efficacy, optimum duration and tangible benefits over similar products on the market.

• Equipment Supplier of the Year Finalists for the award for Equipment Supplier of the Year will be chosen from those suppliers who offer an up-to-date range of equipment and can demonstrate excellent customer service and ongoing support for practitioners using their product. • Distributor of the Year This award acknowledges the vital role played by UK distributors who bring new, international products and treatments to the UK medical aesthetic market. Finalists Aesthetics | May 2015

CATEGOR I E S

will be selected on the basis of their customer service, product range and services to the industry. • Best Customer Service by a Manufacturer/Supplier This award acknowledges the manufacturer or supplier that has offered outstanding customer service and aftersales support in the last 12 months. In choosing finalists, the Aesthetics team will look for specific examples of outstanding customer service, as well as initiatives aimed at improving and maintaining customer service, consistent supply and aftersales support. • The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy This category is designed to recognise the valuable contribution that sales representatives make to their industry, their 37

Aesthetics Awards Special Focus

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Aesthetics Journal

customers and ultimately patients. Finalists will be able to show outstanding levels of support for their customers, a strong commitment to their industry and a proven ability to assist clinics in supporting patients and growing sales of their product. • The Neocosmedix Award for Association/Industry Body of the Year This award recognises the important role that professional associations and industry bodies play in supporting the development of their members and the profession as a whole. In selecting finalists, the Aesthetics team will look for tangible member benefits, and evidence of strong activity designed to support members and the profession/industry as a whole.

duction Fat Re

• The 3D-lipomed Award for Best New Clinic, UK and Ireland The award for Best New Clinic is open to any clinic in the UK and Ireland which was established after January 1 2014. The best new clinic will be judged on initiatives designed to promote growth, evidence of commitment to customer service, patient care and patient safety, as well as good feedback from customers/patients. g

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• The Epionce Award for Best Clinic North England

• The Dermalux Award for Best Clinic South England

• The SkinCeuticals Award for Best Clinic Ireland

• Best Clinic Scotland

• Best Clinic London

• Best Clinic Wales

Best Clinic Group Awards New for 2015 are the Best Clinic Group categories. These awards are open to any clinic group in the UK and Ireland with either more than three clinics (but less than 10), or 10 clinics or more. The group will be judged as a whole on commitment to excellence in customer service, patient care and patient safety and evidence of good feedback from customers/patients. • The AestheticSource Award for Best Clinic Group UK & Ireland (3 clinics or more) • Best Clinic Group UK & Ireland (10 clinics or more) • The Church Pharmacy Award for Clinic Reception Team of the Year This award is open to reception teams of any size working in a clinic in the UK or Ireland. In selecting finalists and a winner for this award the judges will look for evidence of ongoing, outstanding customer service, a continuous training programme, strong practitioner support and effective teamwork for benefit of the clinic and it patients. • Training Initiative of the Year This award will be presented to the training provider or individual trainer whose training programme is considered to have advanced the education of medical aesthetic professionals most effectively during the last 12 months. Judges will look for engaging methods of delivery, a high-quality, relevant, generic programme, a continuous development and improvement programme and achievement of measurable outcomes by delegates.

Aesthetics | May 2015

Aesthetics

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How will winners be selected? Entries will close on June 30, with the finalists selected by the Aesthetics judges announced in the September issue of the Aesthetics journal. A process of voting and judging will take place to select the winners. Aesthetics journal reader votes will constitute a percentage of the final score for each finalist in the following categories: • Cosmeceutical Range/Product of the Year • The Sterimedix Award for Injectable Product of the Year • Treatment of the Year • Equipment Supplier of the Year • Distributor of the Year • Best Customer Service by a Manufacturer/Supplier • The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy • The Neocosmedix Award for Association/Industry Body of the Year The results of these votes will be combined with scores from an expert judging panel, selected by Aesthetics, to decide the winner. Winners in the following categories will be decided by assessment from the judging panel alone: • The 3D-lipomed Award for Best New Clinic, UK and Ireland • Best Clinic Scotland • The Epionce Award for Best Clinic North England • The Dermalux Award for Best Clinic South England • Best Clinic London • Best Clinic Wales • The SkinCeuticals Award for Best Clinic Ireland • The AestheticSource Award for Best Clinic Group UK & Ireland (3 clinics or more) • Best Clinic Group UK & Ireland (10 clinics or more) • The Church Pharmacy Award for Clinic Reception Team of the Year • Training Initiative of the Year • The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year • The Sinclair Pharma Award for Aesthetic Medical Practitioner of the Year • Product Innovation of the Year The winner of The Aesthetics Award for Special Achievement will be selected by the Aesthetics team and will be announced on the night.

@aestheticsgroup

Aesthetics Journal

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• The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year This award will recognise the Aesthetic Nurse who is deemed to have contributed most to the profession and/or has provided the most outstanding care and treatment to their patients in the last 12 months. The winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole. • The Sinclair Pharma Award for Aesthetic Medical Practitioner of the Year This award will recognise the aesthetic doctor, dentist, dermatologist or surgeon who is deemed to have contributed most to the profession and/ or has provided the most outstanding care and treatment to their patients in the last 12 months. The winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole. • Product Innovation of the Year This award recognises the most innovative and dynamic products on the market. Eligible products must have been launched into the UK market after 1 January 2014. The judges will look for genuine innovation or product advancement leading to treatment for new indications, quicker or easier treatments, better treatment outcomes, enhanced patient safety, backed up by sound evidence. • The Aesthetics Award for Special Achievement This award recognises an individual who has made a significant contribution to the medical aesthetics profession and industry, either through a long and distinguished career and/or a great achievement in recent years. The winner of this category will be selected by the Aesthetics judges from within the profession. Individual entries are not accepted for this category.

Enter now! www.aestheticsawards.com

Aesthetics Awards Special Focus

How to enter All entries must be made via the Aesthetics Awards website. You can enter in as many categories as you wish but you may only enter yourself, a company you work for, an employee who works for your company or a product made or distributed by your company. Entries made on behalf of a third party will not be accepted. You may only enter each category once. Multiple entry forms for the same clinic, company, individual, treatment or product will be disregarded. All entries must be accompanied by the supporting evidence requested in the entry form. This information will be used to choose the lists of finalists and by the judges when voting on a winner.

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Background The patient was a 45-year-old woman, who was medically fit and well, was not receiving any current medication and had no history of allergy. She previously had toxin treatment to the upper third of her face and a hyaluronic acid (HA) filler injected into her lips more than three years ago. Her expectation was to achieve a natural rejuvenation of her face with minimal downtime. Our assessment identified areas of subtle volume change in the forehead, temple, eyebrow, malar, perioral and jawline that were contributing to early signs of ageing.

Anterior midface

Advanced Injectables Dr Emma Ravichandran and Dr Simon Ravichandran share their anatomical approach to mid and upper facial rejuvenation, as presented at ACE 2015 Introduction There is no doubt that a thorough understanding and respect of facial anatomy, combined with an understanding of the rheologic behaviour of modern injectable products will lead to more effective and safer dermal filler treatments. The aesthetic practitioner should also be familiar with a variety of techniques that can be employed to place the products in the correct tissue planes with minimal risk and downtime to the patient, and to produce maximal benefit. In March, we presented a pan facial rejuvenation treatment using botulinum toxin and dermal fillers at the Aesthetics Conference and Exhibition (ACE) 2015. The aim of this article is to provide a review of the techniques that were employed for our patient at the conference. We will discuss the anatomic considerations and product rheology to support the technique choice.

The anterior midface, from an aesthetic perspective, will differ slightly from the true anatomical description,1 which has the midsagittal plane as its medial border and the transcanthal line as the superior border. As we are concerned with cheek fat rejuvenation, we can lower the superior boundary to the orbital retaining ligament, and the medial border to the lateral edge of the nasolabial fat. The lateral border should remain as a line connecting the lateral orbital rim and the oral commissure. Its floor is the surface of the maxilla and roof is the overlying skin. Its contents of note are the infraorbital foramen and the structures that run through it, the deep fat, and the subcutanous fat. Anterior maxillary resorption, reduction in volume of the deep investing fat, and loss of volume and descent of the subcutaneous fat all contribute to deflation and descent of this subunit, and thus contribute to flattening and hollowing of the lower eye. This area can be rejuvenated with dermal filler implants in both the deep fat and the subcutaneous fat. Belotero+ Volume is suitable for both planes of injection and was the product used in this demonstration. It has a lower G Prime (gel hardness) but a high cohesivity, giving it the characteristics of lifting, however, it is also soft enough to mould and contour in the subcutaneous. JuvĂŠderm Voluma is also used in this area with good results, as is Radiesse. A 25g cannula with an entry point over the maxillary process of the zygoma was used at ACE (Figure 1). This approach protects the infraorbital foramen, which opens inferiomedially, making it virtually impossible to cannulate from the superiolateral direction. Bolus deposits of 0.4cc or greater can be placed with obvious immediate result. The cannula was then withdrawn to just beneath the skin, re-angled and introduced into the subcutaneous, with product deposited using a fanning technique. We believe this to be one of the most useful and effective techniques in restoring the appearance of an aged midface.

Lateral midface Whereas the anterior midface is related to the medial portion of the lower lid and orbit, rejuvenation of the lateral midface by revolumisation will lift the lateral portion of the cheek and provide an aesthetic improvement to the hollowing of the lateral tear trough. The lateral midface can be defined as being a triangle, with one limb running from the lateral canthus to the upper part of the tragus, another limb running from the lateral orbital rim to the corner of the mouth, and a third limb from the corner of the mouth to the lower part of the tragus.1 A line drawn from the alar groove to the mid part of the tragus separates this unit into upper and lower parts, and volumetric rejuvenation typically concentrates on the upper part, particularly with reference to perioccular rejuvenation. As with the anterior midface there is volume loss in the deep compartment, above the periosteum, as well as subcutaneous thinning. Deep injections, perpendicular to the skin, can be performed directly onto the zygoma laterally, and the malar mound anteriorly to place lifting

Reproduced from Aesthetics Aesthetics | Volume May 20152/Issue 6 - May 2015

aestheticsjournal.com Figure 1:

Before

@aestheticsgroup Mid cheek revolumisation The lateral boarder of the nasolabial fat compartment, the orbital retaining ligament, and the position of zygomaticus major are identified. The red star signifies the entry point of the cannula and the red dotted line shows the direction of cannula placement.

Aesthetics Journal

Aesthetics Upper third rejuvenation The red dots show supraperiosteal depots of the filler, whilst the blue dots represent placement of toxin in periocular depressor muscles. Red lines represent position of the supraorbital and supratrochlear vessels.

Figure 2:

After

fillers in small depots. Belotero Volume+ was again the product of choice for our patient, this time with a 30G 1.5 inch needle. Injecting perpendicular to skin minimises the amount of tissue that the needle will traverse, thus reducing the risk of vascular injury, and allows direct placement onto the superperiosteum, a safe plane of injection. A 25G cannula was used with an entry point lateral over the zygoma to place the moldable and cohesive HA filler (Belotero Intense in this case) into the subcutaneous plane for contour and definition. Single entry point and the use of blunt cannula allows for a large area to be treated with a reduced risk of haematoma.

Temple The treatment of the midface is the first step in addressing an aged appearance to the perioccular area, and is often all that is required. In patients with more pronounced stigmata of ageing, however, we need to start moving superiorlaterally to address the ageing concerns of the upper face. One of the most noticeable ageing signs in this area is laxity and descent of the lateral brow, with the development of dermatocholasis. The traditional surgical approach is an upper blepharoplasty and a brow lifting procedure, however we can now address moderate lateral brow ptosis with toxins and fillers. If we look at the anchor points of the upper face above the zygoma, we see that the skin and subcutaneous tissues are firmly adherent to the underlying structures at the frontotemporal crest.2 Laxity below this area is noted due to volume loss in the superior and anterior temple area. This can be demonstrated in patients with a sunken temple appearance by placing a finger over the skin about 1cm posteriosuperior to the zygomaticofrontal suture, and elevating the skin in a superio-lateral direction. If the position of the lateral brow elevates, then revolumisation in this area will contribute to the perioccular rejuvenation. The structures that cause us concern in this area are the frontal branch of the facial nerve, and the

As we are concerned with cheek fat rejuvenation, we can lower the superior boundary to the orbital retaining ligament, and the medial border to the lateral edge of the nasolabial fat temporal arteries, superficial and deep. If you chose an injection point 1cm superiolateral to the zygomaticofrontal suture, you will likely be superior to the position of the nerve, which typically runs a little closer to the zygoma before running under the tail of the brow. The superficial temporal artery is simple to avoid, both by identifying its location by palpation, and by injecting in a deeper tissue plane. The deep temporal arteries arise from the maxillary artery and run deep to the zygoma and deep to the temporalis muscle before investing and supplying the bulk of the muscle. They are found posteriorly and inferiorly to the chosen injection point for this technique.3 Belotero+ Volume was used with a 30G needle and injected perpendicular to the skin, straight down until the tip of the needle made contact with bone. The advantage of a 30G needle in this area is that the bevel length on a larger needle is more likely to cross tissue planes and cause more intramuscular deposition of product. Aspiration was demonstrated to enhance injection safety as anatomical variants do exist. Depots of between 0.2 and 0.4cc of product were used to restore volume and create the desired elevation of the brow.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

@aestheticsgroup

Flattening and ptosis of the eyebrows is a feature of ageing that can be addressed in its early stages with both toxins and fillers The Forehead Bossing of the forehead in the supra-brow region in itself may be a cause of aesthetic concern. Just as temporal volume loss will result in laxity and lateral ptosis, a very small amount of mid and medial brow ptosis can be seen from volume loss in this area. Careful placement of small amounts of a softer dermal filler can often improve the overall rejuvenating effect of a treatment. The anatomical structures of concern are the supratrochlear and the supraorbital arteries. The supraorbital artery enters the forehead from the supraorbital foramen, which is found in the supraorbital ridge in the mid pupillary line. The supratrochlear artery runs in the orbit and pierces the orbital septum to cross onto the forehead about 1cm medial to the supraorbital. Both arteries are deep structures for the first centimetre or so of the forehead, running on the epicranium, they then run more superiorly within the frontalis muscle which they supply.3 The suprabrow forehead volume loss is typically more than 1cm above the orbital rim, so small depots can be safely placed in the superperiosteal plane. We use a 30G needle and a soft product, such as Belotero+ Balance, and place a series of depots of less than 0.05 in six areas (Figure 2).

The Eyebrow Flattening and ptosis of the eyebrows is a feature of ageing that can be addressed in its early stages with both toxins and fillers. Careful relaxation of the depressor muscles is the first line of treatment and usually proves effective (Figure 2). Treatment with volume replacement presents the risk of embolisation of the supraorbital or supratrochlear vessels and must be undertaken with considerable care and attention. The position of the vessels is identified by surface landmarks and may also be checked with a Doppler ultrasound test.5 Definition and contouring can be achieved using a 27G 1.5 inch cannula in the subcutaneous fat, approached from a lateral entry point. The cannula has the

Aesthetics Journal

Aesthetics aestheticsjournal.com

advantage of presenting a reduced risk of vascular injury but must still be performed gently. Belotero+ Balance was used with great success for contouring the lateral brow of our patient.

Conclusion The lower third of the face was also injected, which will be discussed in a separate article. The patient experienced mild swelling for a couple of days post treatment and no bruising. The patient will be reviewed in four months for toxin revision and in 12 months for filler maintenance. Dr Emma Ravichandran qualified as a general dental practitioner in 2000, before establishing an interest for aesthetics in 2007. She co-founded Clinetix Medispa in 2010 and, alongside teaching and training commitments; she is actively involved in creating a national audit pathway for aesthetic practice. Dr Simon Ravichandran is as an ear, nose and throat surgeon, specialising in rhinology. He trained in aesthetic medicine in 2007 and co-founded Clinetix Medispa in 2010. Dr Ravichandran has established the Scottish Advanced Aesthetic Training Programme with Glasgow University, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners. REFERENCES 1. Mendelson BC, Jacobson SR, ‘Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments’, Clin Plast Surg, 2008;35(3) p.395-404. 2. Moss CJ, Mendelson BC, Taylor GI, ‘Surgical anatomy of the ligamentous attachments in the temple and periorbital regions’, Plast Reconstr Surg, 2000 Apr; 105(4) p.1475-90. 3. Correa MB, Wafae GC, Pereira LA et al, ‘Arterial branches to the temporal muscle’, Ital J Anat Embryol, 2008 Apr-Jun;113(2) p.109-15.  4. Erdogmus S, Govsa F, ‘Anatomy of the supraorbital region and the evaluation of it for the reconstruction of facial defects’, J Craniofacial Surg, 2007 Jan;18(1) p.104-12. 5. Ugur MB, Savranla A, Uzun L et al, ‘A reliable surface landmark for localizing supratrochlear artery: medial canthus,’ Otolryngol Head Neck Surg, 2008 Feb;138(2) p.162-5.

FURTHER READING Hema Sundaram, Jean Carruthers (2013). ‘Glabella/central brow’. In: Carruthers, J. and Carruthers A. Soft Tissue Augmentation. 3rd ed. New York: ELSEVIER. p.88-100. VaL Lambros (2013), ‘Volumetric treatment of the brows’ In: Carruthers J, and Carruthers A. Soft Tissue Augmentation. 3rd ed. New York: ELSEVIER. p.100-104. Jason Sneath, Massimo Signorini (2013), ‘Eyebrow height/ shaping’, In: Carruthers,A. and Carruthers J Botulinum Toxin. 3rd ed. New York: ELSEVIER. p.85-93.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Dr Anjali Mahto details the prevalence and pathophysiology of acne in post-adolescent women, with an overview of the treatment options available

Adult Acne Introduction Acne is one of the most common skin disorders amongst the general population, with research estimating that it affects up to 80% of people at some point during their lives.1 It is well-recognised that acne can cause both long-term physical and mental scarring, making it imperative that a treating practitioner assesses disease severity and psychological distress in individual patients, while creating a tailor-made treatment plan to suit their requirements. Within the past decade, scientific data, in addition to anecdotal evidence, has suggested that acne has become an increasing problem in one particular group – namely, the post-adolescent female.2 What causes acne? Acne is a disorder of the pilosebaceous unit in skin which is composed of a sebaceous gland, hair follicle and hair. These are found all over the body except the palms, soles, top of the feet and the lower lip, while the face, neck and upper chest contain the largest number of pilosebaceous units. Sebum is produced by sebaceous glands and functions to keep skin well-lubricated and waterproof. During adolescence, under the influence of hormones (particularly androgens), sebaceous glands enlarge.3 The pathophysiology of acne is complex and multifactorial but a number of factors are thought to play a role, including interplay between hyperkeratinisation, excess sebum production and colonisation of the hair follicle by Propionibacterium acnes (P acnes).4 Hyperkeratinisation is a disorder of the cells lining the hair follicle. Under normal circumstances, these cells desquamate every 21 days. The growing hair usually pushes these cells out of the follicle. With hyperkeratinisation, this process fails and excess keratin is produced. Keratin is a sticky protein, which will cause dead skin cells to adhere to each other. This in turn can block the follicle or sebaceous gland in a process known as comedogenesis. Comedones (blackheads or whiteheads) can then develop.5 If a comedone continues to grow under the skin surface, its contents of keratin and sebum will expand. Eventually, this will lead to rupture of the comedo wall and its contents will be extruded resulting in inflammation.6 This is visualised as pustular or papular acne. P. acnes can also proliferate at this stage contributing to the problem. Depending on the severity of inflammation, deeper, more painful nodules and cysts can develop which leave a risk of skin scarring.5 Epidemiology of female adult acne Outpatient visits for patients with acne over the age of 25 are increasing, and women seem to make up the majority of patients with adult acne.7 The spectrum of acne as a disease is also showing some interesting trends. Cases are developing both earlier and later than what has previously been seen.7 There are also a large number of people in whom acne is continuing for longer, beyond the teenage years.7 Two distinct subtypes of adult female acne may be defined according to onset: ‘persistent’ and ‘late-onset’. Persistent disease is that which develops in the teenage years and fails to spontaneously resolve by the third decade of life. Patients who suffer from persistent acne have lesions intermittently or continuously during this time. They make up about 80% of cases of female adult acne.8 Lateonset disease is defined as acne that initially begins after the age of 25 years and has been reported to occur in about 18.4% of women.1 Most patients with postadolescent acne present at 24 years of age.1 Some studies suggest that acne in

later life is associated with a strong family history of the disorder. Data from one study has shown that 50% of patients had a first-degree relative with post-adolescent acne.9,10 There appears to be no link for the development of female adult acne with exogenous factors such as cosmetics, skin care products or occupation.2 Androgens Androgens are steroid-based hormones present in both men and women. In women, they are produced primarily in the adrenal glands and ovaries; however, peripheral tissues such as skin and fat also play a role in converting weak androgens into their more potent counterparts. Women with high androgenic states are more likely to have acne, due to increased size of their sebaceous glands in addition to increased sebum production.7 Androgens are thought to be a major causative factor in female adult acne. The majority of women with acne in their post-adolescent years are likely to have a hormonal component to their disease.7 However, interestingly, most adult women will have normal circulating androgen levels upon blood tests.11 The possible explanation for this observation is that androgen levels are higher at the local cutaneous or skin level, rather than in the bloodstream. Certainly, data is consistent with this hypothesis and studies have shown increased levels of tissue-derived androgens acting locally on target tissues, promoting acne in females.11,12,13 One also needs to consider, however, the possibility of disorders causing excess circulating androgen in women. Of these, polycystic ovarian syndrome (PCOS) and congenital adrenal hyperplasia (CAH) are most common.2 PCOS affects how a woman’s ovaries work and is one of the most common endocrine disorders in women of a reproductive age, with a prevalence of 6%.14 It can be associated with irregular menstruation, weight gain and hirsutism. Approximately 25% of women with PCOS will have acne.15 One review of data indicates severe acne or resistant acne in women is highly suggestive of PCOS and the discerning clinician should think about screening for this.12 CAH is a genetic disorder characterised by enzyme deficiencies that is much more rare, but important to consider in refractory cases.1 Patients may have precocious or failure of puberty, excessive facial hair, ambiguous genitalia, or menstrual irregularities. It may be diagnosed by blood tests and occurs more frequently in those of Eastern European Jewish descent.16 If there is any concern about these conditions, then suggest your patient sees their GP and is referred appropriately to a specialist (dermatologist, endocrinologist, gynaecologist). Clinical features Late onset acne has usually been associated with a distinctive clinical pattern, however, not all studies have confirmed this finding and many report that

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late onset disease may be similar to that in adolescence.17-18 Adult women often have a cyclical pattern to their disease, with peri-menstrual flares of acne. There can often be deep, tender, inflammatory lesions concentrated along the lower half of the face, jawline, chin and neck. Female adult acne sufferers have been reported to have comparatively low number of comedonal lesions compared to teenagers, although this finding is variable.7,17,18 Psychological aspects There is no doubt that acne can have a significant impact on a patientâ&#x20AC;&#x2122;s emotional and psychological well-being. A recent study of approximately 2,000 acne sufferers, commissioned by the British Skin Foundation, revealed that 63% of respondents felt that the condition had affected their self-confidence and 20% had considered or attempted suicide.19 Adults may be more self-conscious of their disease, and experience more social anxiety and isolation, as acne is still largely considered a disease that primarily affects teenagers. It is important to assess how a patientâ&#x20AC;&#x2122;s acne is affecting their quality of life and ask pertinent questions relating to this. A specialist should review disease that is causing severe psychological distress. Treatments Female adult acne patients seem to exhibit higher treatment failure rates with traditional acne therapies. One study showed that 82% of persistent acne sufferers failed therapy with multiple courses of antibiotics, and 32% had relapsed after treatment with one or more courses of isotretinoin.20 Bearing this in mind, if your patient falls into this category, has nodules or cysts, evidence of scarring, or post-inflammatory change in pigmented skin, it is prudent to refer them to a dermatologist early. In my experience, these patients are much more likely to have resistant, unresponsive disease where treatment delay is likely to result in unnecessary further scarring. Acne therapies for the adult woman are likely to involve a combination of conventional therapies in association with adjunctive cosmetic treatments. Specifically this will be influenced by factors such as the predisposition of older skin to irritation, whether they are of child-bearing age, psychosocial impact, possible slow response to treatment and high likelihood of good adherence.2

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Common treatment options for acne will now be discussed, but please note that this does not aim to be an exhaustive list. 1) Comedo extraction21,22 Physical removal of comedones has been popular with dermatologists and aestheticians alike. It can be carried out in a number of ways including use of a comedone extractor, steam extraction, or electrosurgery (using a hyfrecator). It will cause a reduction in the number of future inflamed lesions and can create an immediate sense of improvement. The procedure is also a useful adjunct prior to treatment with isotretinoin. There is a risk that it can cause tissue damage and make cystic lesions worse,21 so it is important that the practitioner is properly trained. Open comedones (blackheads) reappear clinically after 20-40 days and closed comedones (whiteheads) within 30-50 days.22 The treatments therefore need to be repeated on a regular basis for optimum results. 2) Topical preparations A number of topical therapies are available, including those containing benzoyl peroxide, antibiotics (e.g. clindamycin), salicylic acid, retinoids and azelaic acid. These agents work in a number of ways aiming to reduce comedone formation and inflammation, or decreasing the activity of P. acnes. They are suitable for the treatment of comedonal or mild to moderate inflammatory acne. 3) Chemical peels23,24,25 The most commonly used agents are salicylic and glycolic acid-based products but there is a much wider range of acid-based products available on the market. The chemical peel is applied to the skin surface to induce an accelerated form of exfoliation. Light peels will cause sloughing of the cells in the top layer of the skin or stratum corneum, while deeper peels can penetrate the dermis. Peels are useful to treat active comedones, post-inflammatory change and superficial scars. They are not suitable for inflammatory cystic acne, as they are unlikely to provide long-term control of disease. 4) Intralesional steroid This is a useful method for treating large, stubborn, solitary acne cysts, or if a rapid response is required by the patient. Concentrations of 5mg/ml or less of triamcinolone acetonide can be injected directly into the acne lesion until subtle blanching is observed. This results in flattening of the nodule within 42-72 hours.26 There are risks of skin atrophy and pigmentary change with this procedure, and caution is advised.27 5) Photodynamic therapy (PDT)28,29,30 This is a developing area where a light source is combined with the application of a photosensitising agent to the skin. It is safe and effective but there is no consensus regarding which photosensitising agent should be used, the type of light source, or the optimum dosing schedule.28 Blue light can improve acne temporarily due to its antiinflammatory effects but red light may provide the best long-term results. Side effects that can be a problem include pain, redness lasting 3-5 days, swelling or oedema, and pigmentation change. The data is still lacking for best practice.29,30 6) N-lite31,32 This is a type of pulsed dye laser that uses yellow light at 585 nm. It is thought to increase TGF-beta production in skin. TGF-beta is a potent stimulus for neocollagenesis and also reduces inflammation. Anecdotal evidence suggests that it may have a role in mild to moderate acne but may not be as efficacious as PDT.31,32 It can be of use in conjunction with other agents. 7) Oral treatments If a patient has moderate to severe active acne with scarring, they should see a dermatologist. A dermatologist is likely to use one of a number of oral systemic agents such as antibiotics, spironolactone and isotretinoin for treatment. Spironolactone has anti-androgenic properties and is an effective drug for female adult acne that has failed to respond to other treatments. It has been used for more than two decades in a dermatological setting and is generally well tolerated.7 Isotretinoin is a retinoid drug of great value for nodulo-cystic acne. Despite its well-publicised side-effect profile, it is an extremely safe and effective drug when prescribed by a specialist.33

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Dr Anjali Mahto is an NHS and private consultant dermatologist. Her NHS base is in North West London and she privately works out of Highgate Hospital and the Cadogan Clinic. She is interested in all things related to skin and has an avid interest in the treatment of acne and its effects on the psyche. REFERENCES 1. Collier CN, Harper JC, Cafardi JA, et al. ‘The prevalence of acne in adults 20 years and older’, J Am Acad Dermatol. 58(1) (2008), p. 56-9. 2. Goulden V, Clark SM, Cunliffe WJ. ‘Post-adolescent acne: a review of clinical features’, Br J of Dermatol, 140 (1999), p. 672-676. 3. Friedlander SF, Eichenfield LF, Fowler JF et al. ‘Acne epidemiology and pathophysiology’, Semin Cutan Med Surg 29(2 Suppl 1) (2010), p. 2-4. 4. Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al. ‘New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group’, J Am Acad Dermatol, 60(5 Suppl) (2009), p. 1-50. 5. Zaenglein A, Thiboutot D. Acne vulgaris. In: Dermatology (Bolognia J, Jorizzo J, Rapini R, eds) (USA: Elsevier Ltd, 2003) p. 531-544. 6. Norris JF, Cunliffe WJ. ‘A histological and immunocytochemical study of early acne lesions’, Br J Dermatol 118(5) (1988), p. 651-9. 7. Kim G, Del Rosso J. ‘Oral spironolactone in post-teenage female patients with acne vulgaris’, J of Clin Aesthet, 5(31) (2012), p. 37-50. 8. Dreno B, Layton A, Zouboulis C, et al. ‘Adult female acne: a new paradigm’, J Eur Acad Dermatol Venereol 27(9) (2013), p. 1063-70 9. Cunliffe W, Gould D. ‘Prevalence of facial acne vulgaris in late adolescence and in adults’, BMJ, 26 (1979), p. 931-935. 10. Gouden V, McGeown CH, Cunliffe W. ‘The familial risk of adult acne: comparison between first- degree relatives of affected and unaffected individuals’, Br J of Dermatol, 141(2) (1999), p. 297-300. 11. Carmina E, Lobo RA. ‘Evidence for increased androsterone metabolism in some normoandrogenic women with acne’, J Clin Endocrinol Metab, 76 (1993), p. 1111-1114. 12. Lookingbill DP, Horton R, Demers LM et al. ‘Tissue production of androgens in women with acne’, J Am Acad Dermatol, 12 (1985), p. 481-487. 13. Thiboutot D, Harris G, Iles V et al. ‘Activity of the type 1 5-alpha-reductase exhibits regional differences in isolated sebaceous glands and whole skin’, J Invest Dermatol, (1995), p. 209-214. 14. Azziz R, Woods KS, Reyna R, et al. ‘The prevalence and features of the polycystic ovary syndrome in an unselected population,’ J Clin Endocrinol Metab, 89(6) (2004) p. 2745-9. 15. Lowenstein EJ. ‘Diagnosis and management of the dermatological manifestations of the polycystic ovary syndrome’, Dermatol Ther, 19(4) (2006), p. 210-223. 16. O’Brien RF, Emans SJ. ‘Polycystic ovary syndrome in adolescents’, J Ped Adolesct Gyn, 21(3) (2008), p. 119-128.

Aesthetics 17. Lucky AW. ‘Quantitative documentation of a premenstrual flare of facial acne in adult women,’ Arch Dermatol, 140 (2004), p. 423-424. 18. Dréno B, Thiboutot D, Layton AM, et al. ‘The Global Alliance to Improve Outcomes in Acne. Large- scale international study enhances understanding of an emerging acne population: adult females’, J Eur Acad Dermatol Venereol,Oct (2014). 19. British Skin Foundation. Over half of acne sufferers experience verbal abuse from friends &family due to their condition (UK: British Skin Foundation, 2015) <http://www.britishskinfoundation. org.uk/LinkClick.aspx?fileticket=i2bE2n4c8m0%3D&tabid=172> [Accessed 15 April 2015] 20. Goulden V, Stables G, Cunliffe W. ‘Prevalence of facial acne in adults’, J Am Acad Dermatol, 41(4) (1999), p. 577-580. 21. Lowney ED, Witkowski , Simons HM et al. ‘Value of comedo extraction in treatment of acne vulgaris’, JAMA, 189 (1964), p. 1000-1002. 22. Plewig G. ‘Follicular keratinisation’, J Invest Dermatol, 62(3) (1974), p. 308-320. 23. Lee HS, Kim IH. ‘Salicylic acid peels for the treatment of acne vulgaris in Asian patients’, Dermatol Surg, 29(12) (2003), p. 1196-1199. 24. Kaminaka C1, Uede M, Matsunaka H, et al. ‘Clinical evaluation of glycolic acid chemical peeling in patients with acne vulgaris: a randomized, double-blind, placebo-controlled, split-face comparative study’, Dermatol Surg, 40(3) (2014), p. 314-22 25. Dreno B, Fischer TC, Perosino E, et al. ‘Expert opinion: efficacy of superficial chemical peels in active acne management--what can we learn from the literature today? Evidence-based recommendations’, J Eur Acad Dermatol Venereol, 25(6) (2011), p. 695-704 26. Levine RM, Rasmussen JE. ‘Intralesional corticosteroids in the treatment of nodulocystic acne’, Arch Dermatol, 119(6) (1883), p. 480-481. 27. Callen JP. ‘Intralesional corticosteroids’, J Am Acad Dermatol , 4(2) (1981) p.149-151. 28. American Academy of Dermatology. Photodynamic therapy for acne, a work in progress (US: American Academy of Dermatology, 2011) <https://www.aad.org/dw/monthly/2011/march/ photodynamic-therapy-for-acne-a-work-in-progress> [Accessed 15 April 2015] 29. Kim RH, Armstrong AW. ‘Current state of acne treatment: highlighting lasers, photodynamic therapy, and chemical peels’, Dermatol Online J, 1(3) (2011), p. 2. 30. Smith EV, Grindlay DJ, Williams H. ‘What’s new in acne? An analysis of systematic reviews published in 2009-2010’, Clin Exp Derm, 36(2) (2011), p. 119-122. 31. Seaton ED1, Charakida A, Mouser PE, et al. ‘Pulsed-dye laser treatment for inflammatory acne vulgaris: randomised controlled trial’, Lancet, 25;362(9393) (2003), p. 1347-52. 32. Seaton ED1, Mouser PE, Charakida A, et al. ‘Investigation of the mechanism of action of nonablative pulsed-dye laser therapy in photorejuvenation and inflammatory acne vulgaris’, Br J Dermatol, 155(4) (2006), p. 748-55. 33. Goodfield M, Cox N, Bowser A et al. ‘Advice on the safe introduction and continued use of isotretinoin in acne in the U.K. 2010’, Br J Dermatol, 162 (2010), p. 1172-1179.

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submammary areas and is often confused with candidal intertrigo rashes. A rare but more severe pustular psoriasis can cause a systemic illness and may even be lifethreatening.1

Psoriasis Dr Sadequr Rahman details the physiology of psoriasis, and shares advice on managing its psychological effects Introduction Psoriasis is a common skin disorder, with several clinical patterns. About 2% of the population will suffer from psoriasis, distributed equally between males and females and with all skin types and ethnicities affected.1 It presents mainly on the limbs, but can also be found on the trunk and scalp. The latter can be particularly distressing due to risk of hair loss and a flaking scalp, similar to the visible effects of dandruff. Nails can also be damaged with pitting and discoloration. Pathophysiology The mechanisms of the visible effects of psoriasis are relatively well established, although the aetiology is unknown. Skin biopsies have been found to reflect

increased skin turnover – in fact the hyperproliferation is up to 10 times the normal rate.1 Triggers may include stress or poor nutrition although, again, these are not necessarily well documented. The age of onset is variable with a ‘young’ peak between 16-22, and a later-onset peak in the mid-50s. In 5% of cases multiple joints can be affected by pain and stiffness, a condition referred to as psoriatic arthropathy.1 Presentation The most common type, chronic plaque psoriasis, presents with scaly plaques on the extensor surfaces. Guttate psoriasis (Latin guttata meaning ‘droplet’) forms as widespread circular lesions over the trunk. Flexural psoriasis presents in the groin or

About 2% of the population will suffer from psoriasis, distributed equally between males and females and with all skin types and ethnicities affected

Treatments Psoriasis is usually dealt with in primary care, depending on the severity. Emollient creams remain the mainstay, though require patience from the patient and encouragement from the practitioner. Add-on treatment includes calcipotriol, a vitamin D derivative which acts by promoting normal skin cell growth and development, and preventing the excessive growth rate of skin. Dovobet and Silkis are the most commonly prescribed from this group. Dithranol and, in the past, coal tar have also been used with similar effects, although the latter were often poorly tolerated due to the strong tar odour.2 More severe cases may require secondary care. The role of sunlight has long been recognised as beneficial in treating psoriasis, due to its effect at reducing skin inflammation. The most effective rays have been isolated to UV-A and UV-B.2 Because phototherapy is of a very narrow band and in controlled bursts, it is erroneous to believe that exposure to sun lamps, which emit mostly UVA light, would have a similar effect, although many patients will try this.3 In more extreme and resistant cases, the patient may require immunosuppressants which work by blocking TNF-alpha, a ‘chemical messenger’ that signals to other cells in the immune system to create inflammation. People with psoriasis have too much of this chemical in their body, and adalimumab helps to lower this to a more normal level, leading to an improvement in symptoms.2 Patients taking immunosuppressants are more at risk of infection, and the most common side effects are upper respiratory and urinary infections, as well as abdominal pains and headaches.2 Patients will also require regular blood test monitoring. The psychological component So far, we have discussed the condition much as how a medical student is introduced to any dermatology disease. What has not been covered is how deeply our patient may be affected by psoriasis and how much their confidence can be impaired. As the condition does not affect the face, it may not be immediately

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evident to the examining practitioner unless it has been noted in the medical history. Indeed, the patient may go to great lengths to hide the offending areas from prying eyes. This will include covering up the limbs even in warm conditions. The plaques are considered almost as scars and, cruelly, become more prominent in warmer weather as the blood vessels of the skin vasodilate. This means that the exposure to sunlight, which would most greatly benefit the psoriasis plaque, can often be reduced because of the patient’s cosmetic embarrassment. Let us consider a hypothetical patient called Jenna, a healthy 18-year-old woman who has developed psoriasis on the knees and elbows. Her GP tells her that she will have to use creams, probably for the rest of her life, and that this will be a recurring condition. This may not seem a particularly serious issue, but Jenna will avoid t-shirts and swimwear, thus denying herself a pleasurable or social activity, leading to further isolation and loss of confidence. Other minor ailments or skin conditions become magnified, and she considers herself ugly or disfigured even though, fully clothed, no-one is aware of her psoriasis. Worse still is the knowledge that although we have an opportunity to improve the texture of the plaques, the skin discoloration will almost certainly remain to some extent. Imagine the immense anxiety and self-conscious feelings Jenna may have in the presence of a potential partner. How can this be overcome? A self-fulfilling prophecy Any condition that persists longer than a few months with only temporary remission, or none at all, has to be considered a chronic condition. With no obvious cure or knowledge of a trigger factor, Jenna’s outlook on life becomes consumed with both the psychological and physical effects of her psoriasis. It is at the forefront of her thoughts daily, reminded as she is by the repeated topical treatments that must be applied, the possible odour from those treatments, the limitation on clothes that may or may not be worn, and the staining of the clothes that she does wear from the creams. Itchiness may be a constant reminder, as is damage to the hair of the scalp. As aesthetic clinicians, we are faced daily with patients who are concerned, possibly over-concerned, about blemishes, skin quality, lines and minor age-related changes that, when combined, affect their confidence enough to bring them to our door. The psoriasis patient may feel ugly, and has to deal with their skin routinely affecting their social life. They may become more isolated for fear of rejection. Often they will not venture outdoors and will not receive the sun exposure that would improve the appearance of the plaques, hence worsening the condition further. Hair and nails make up a significant part of the cosmetic identity of our patients and the market continues to grow for services and products related to this need. Now our patient has to contend with not wanting to display their hair or hands due to psoriatic involvement. How to approach the psoriasis patient Now imagine our hypothetical patient Jenna is sitting in front of you in your clinic. She may have come for some light filler treatment, but you have noticed the psoriasis in her medical history. I start with an assessment of when and where the psoriasis presents and how long it has been a problem. My patient will have discussed this with their GP prior to starting their treatment. What they may not have discussed is how it impacts on other parts of their life. I recommend using a few questions to help establish their attitude towards the psoriasis, such as:

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1. Do you remember to apply your creams daily, and are they having the desired effect? 2. Are you avoiding any activities or socialising because of your psoriasis? 3. How confident would you feel, day-to-day, if you had to expose your skin regularly either in front of strangers or to your partner? 4. If there were a better treatment but with possibly more side effects, would you consider it? 5. On a scale of 1 to 10, how big a problem do you find dealing with your psoriasis? I find that assessing avoidance of enjoyable situations is a much more effective tool than simply asking if it bothers them or not. Do not underestimate the changes in body language that develop when a psoriasis patient discusses their condition. A patient who shifts about more, closes in on themselves or acts to cover areas which are affected (particularly if they are already clothed) are likely to be struggling to come to terms with their condition. They may not wish to make eye contact as much, or be as responsive to answering, unless, and this is vital, your demeanour is that of someone who cares whether they are happy or not. It may be the first time anyone from a professional viewpoint has suggested that their mental state may be affected by the psoriasis. If you show interest in that, they may open up a whole lot more about their real fears and concerns. Developing the patient/clinician relationship I believe it has never been more important than it is today to try and understand a patient’s viewpoint. If you are that one person who has shown an interest in how they are and exhibit a genuine desire to help, more than helping your patient your stock sales should also improve and you may have gained a lifelong patient. Therefore you need to be comfortable with these kinds of conversations. GPs, or at least good GPs, will be very used to assessing a patient’s psychological state and where they may be open to avenues of improvement. As aesthetic practitioners, we should aim to adopt this helpful and understanding approach to consultation. Once trust is established, different treatment approaches can be discussed more easily, and you, the clinician, will have been the one that opened the door for your patient, helping them to regain their confidence. Think now of Jenna, who has lost a lot of her confidence. You could choose to simply treat what she has requested and send her on her way, or back to her GP. However, this is an opportunity to assess what has or hasn’t worked for her so far and advise possible next steps in her treatment regime. Jenna may have read about other treatment options but has not had the opportunity to discuss her thoughts with her GP, or may be receiving conflicting answers from friends, other patients, or online resources. Remember that without a clear understanding of treatments from a professional, a patient will likely believe whatever they come across. This is an opportunity to gain trust by being that professional. You may have access to, or are aware of practitioners offering cognitive behavioural therapies or hypnosis. In recent years, these kinds of approaches have yielded more scientific and robust evidence for their use in anxiety and depression disorders.4 Possessing a more than passing knowledge of the benefits of such treatments will encourage patients such as Jenna to seek treatment for their emotional state. By simply reflecting

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on your observation that she has such a problem can in itself catalyse your patient into self-awareness. It may be that she requires medication in the form of antidepressants – I can state from my own practice that at least 33% of my patients over the age of 40 are taking an antidepressant, some of whom are doing so following a suggestion from myself to seek treatment for their anxiety. I also encourage non-pharmacological means as indicated above. Goyal et al have recently advised that, “Despite the limitations of the literature, the evidence suggests that mindfulness meditation programs could help reduce anxiety, depression, and pain in some clinical populations. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress.”5 Roger Neighbour, in his book The Inner Consultation, discusses the five stages of a consultation from start to finish, the first being, “Connecting with the patient and developing rapport and empathy”.6 A great many of my surgical colleagues indicate that they have little time or use for such skills. I would happily argue that developing rapport and empathy is the cornerstone of communication with practically any person, be it friend or stranger, young or old, if the desired outcome is an effective transaction of any sort. When it comes to it, our professional desire is for the patient to recognise our value as a clinician and our ability to generate a result, then to provide that result for a financial outlay. The patient’s desire is for an improvement mostly (but not exclusively) to their physical appearance, with the final

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result being an improvement in mental well-being which will hopefully be sustained by you, the clinician, for a financial outlay. More succinctly, you make them feel better and provide ongoing betterment, and they will pay you for it. If we consider that our business is skin care and beauty, we must be awake to the physical and emotional concerns of a common skin condition that strikes fear and anxiety into its sufferers. We must not shy away from these conversations. We can help hypothetical patients such as Jenna, and others like her, simply by being prepared to listen. Our ears can be as valuable as our best filler products, and we must use them wisely. Dr Sadequr Rahman studied medicine at King’s College London. He has been a practicing GP since 2003 and has run his own cosmetic medicine clinic, Doctor-SR Beauty Clinics, in South Wales since 2010. Dr Rahman has a special interest in dermatology, and offers patient advice on nutrition, weight management and confidence building. REFERENCES 1. Parveen Kumar, Michael Clark, Clinical Medicine 8th ed. (London : Saunders Ltd, 2012) p. 1287-9. 2. The Psoriasis Organisation, Psoriasis Treatments (UK: The Psoriasis Organisation, 2014) <https:// psoriasis-association.org.uk/pages/view/about-psoriasis/treatments> [accessed 3 April 2015] 4. 5. 6.

Alladin A, Alibhai A, ‘Cognitive Hypnotherapy for Depression: An Empirical Investigation’, International Journal of Clinical and Experimental Hypnosis, Special Issue: Evidence- Based Practice in Clinical Hypnosis—Part I, 55 (2007), p.115-130. Goyal M. et al, ‘Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis’ JAMA Intern Med., (2014) 174(3) p.357-368. Roger Neighbour, The Inner Consultation (UK: Radcliffe Publishing Ltd; 2nd Revised edition 2004) p. 17.

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Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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A summary of the latest clinical studies Title: Basics of dermal filler rheology Authors: S Pierre, S Liew, A Bernardin Published: Dermatologic Surgery, April 2015 Keywords: Dermal fillers, rheology, facial contouring Abstract: Hyaluronic acid injectable fillers are the most widely used dermal fillers to treat facial volume deficits, providing long-term facial aesthetic enhancement outcomes for the signs of aging and/or facial contouring. The purpose of this article was to explain how rheology, the study of the flow of matter, can be used to help physicians differentiate between dermal fillers targeted to certain areas of the face. This article describes how rheological properties affect performance when filler is used in various parts of the face and exposed to mechanical stress (shear deformation and compression/stretching forces) associated with daily facial animation and other commonly occurring external forces. Improving facial volume deficits with filler is linked mainly to gel viscoelasticity and cohesivity. These 2 properties set the level of resistance to lateral and vertical deformations of the filler and influence filler tissue integration through control of gel spreading. Selection of dermal filler with the right rheological properties is a key factor in achieving a natural-looking long-lasting desired aesthetic outcome. Title: Functional safety assessments used in a randomized controlled study of small gel particle hyaluronic acid for lip augmentation Authors: SR Smith, HM Vander Ploeg, M Sanstead, CD Albright, MJ Theisen, X Lin Published: Dermatologic Surgery, April 2015 Keywords: Hyaluronic acid, lip augmentation, safety Abstract: Dermal fillers are commonly injected in the lips for aesthetic treatment. Small gel particle hyaluronic acid (SGP-HA) is the only filler approved by the US Food and Drug Administration for this indication, based on a pivotal trial of effectiveness and safety. The objective was to assess multiple measures of tolerability and lip function in a randomized controlled trial of SGP-HA (without lidocaine) for lip augmentation. Patients were randomized to SGP-HA (n = 135) or no treatment (n = 45) at baseline; all could receive SGP-HA after 6 months. Assessments for tolerability and lip function at clinic visits throughout the study included lip texture, firmness, symmetry, movement, function, and sensation; device palpability; mass formation; and ease of repeat injection. Many assessments were normal (lip function, sensation) or unremarkable (movement, mass formation, ease of reinjection) in most patients. Nearly all abnormalities with other assessments (texture, firmness, symmetry, device palpability) were mild and transient (<4 weeks). Lip augmentation with SGP-HA showed excellent safety with the assessments used in this study. Further study should be conducted to validate these assessments with the goal of developing a comprehensive scale for measuring potential functional complications and risks. Title: A prospective, split-face, randomized study of the efficacy and safety of a novel fractionated intense pulsed light treatment for melasma in Asians

Authors: WJ Yun, SM Lee, JS Han, SH Lee, SY Chang, S Haw, JB Lee, CH Won, MW Lee, JH Choi, SE Chang Published: Journal of Cosmetic Laser Therapy, March 2015 Keywords: Fractionated IPL, melasma, safety Abstract: Intense pulse light (IPL) has been reported to effectively treat melasma in previous studies, but an aggravation of pigmentation was noted. Fractionated IPL is a novel technique in which microsecond-domain fractionated pulses are delivered to the target area. The objective was to compare the safety and efficacy of low-fluency, frequently scheduled fractionated IPL and conventional IPL for melasma treatment. This was a 14-week, split-face study in which 30 Asian women were treated with weekly fractionated IPL on one side of the face and biweekly conventional IPL on the other side. The non-inferiority of a weekly fractionated IPL regimen to a biweekly conventional IPL regimen was verified by a lower margin of the 95% confidence interval for the difference in the Melasma Area and Severity Index (MASI) change from baseline of 2.61 for each side. This value was greater than the previously determined non-inferiority margin of -2.68 (P < 0.025). On the fractionated IPL side, the modified MASI score decreased continuously, but in the conventional IPL group, the MASI score rebounded during the treatment course. Fractionated IPL shows moderate efficacy as a melasma treatment and is therefore a good alternative to conventional IPL as there is no indication of melasma exacerbation. Fractionated IPL can also be used as a maintenance treatment for melasma. Title: Retinoic acid and glycolic acid combination in the treatment of acne scars Authors: BS Chandrashekar, KR Ashwini, V Vasanth, S Navale Published: Indian Dermatology Online Journal, April 2015 Keywords: Acne scars, glycolic acid, retinoic acid Abstract: Acne is a prevalent condition in society affecting nearly 80-90% of adolescents, often resulting in secondary damage in the form of scarring. Retinoic acid (RA) is said to improve acne scars and reduce postinflammatory hyperpigmentation while glycolic acid (GA) is known for its keratolytic properties and its ability to reduce atrophic acne scars. There are studies exploring the combined effect of retinaldehyde and GA combination with positive results, while the efficacy of retinoic acid and GA (RAGA) combination remains unexplored. The aim of this study remains to retrospectively assess the efficacy of RAGA combination on acne scars in patients previously treated for active acne. A retrospective assessment of 35 patients using topical RAGA combination on acne scars was done. The subjects were 17-34 years old and previously treated for active acne. Case records and photographs of each patient were assessed and the acne scars were graded as per Goodman and Baronâ&#x20AC;&#x2122;s global scarring grading system (GSGS), before the start and after 12 weeks of RAGA treatment. The differences in the scar grades were noted to assess the improvement. At the end of 12 weeks, significant improvement in acne scars was noticed in 91.4% of the patients. The RAGA combination shows efficacy in treating acne scars in the majority of patients, minimizing the need of procedural treatment for acne scars.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Electronic Record Keeping Systems We explore the advancements in digital record keeping and discover what methods three aesthetic practitioners are using to store patient notes safely and securely As technology increasingly seeps into every aspect of our lives, from digital apps that monitor our sleeping pattern to faceless banking conducted via smart phones, aesthetic record keeping is also evolving in light of the digital revolution. Electronic record keeping has gained traction within the industry over the past decade. By 2015, practitioners are now utilising technology in a way that many would have never considered possible before the turn of the 21st century. And it seems there are countless benefits to these digital systems. Dr Askari Townshend, advanced trainer and aesthetic practitioner, agrees. “There are all sorts of ways that these technologies can help us minimise emissions and deviations of protocol. They can enable practitioners to run reports to ensure your auditing is robust, you are following protocols, or identify staff or staff groups that are not adhering to certain protocols.” He continues, “Being able to flag all of that up at the touch of a button is invaluable, and it should help drive standards in everything that we do.” Upon opening his aesthetic practice in May, Dr Townshend intends to ‘go paperless’ immediately, and is currently working with Customer Relationship Management (CRM) developers Pabau to create a personalised record keeping system. “I think the software and technology are up to standards that we can manage [ourselves] usefully,” he says. “The real value in using technology lies in making sure that processes are improved, and where things are going wrong they can be highlighted.” With a variety of systems currently available, founder of iConsult Richard Crawford Small explains why he believes his technology was a front runner in developing electronic record keeping systems. “iConsult was designed initially around the needs of the peripatetic, or mobile injector, who would need to carry patient medical records around from site to site. We gave them a database, and a simple way to capture patient notes, images and consent,” he says. Crawford Small hoped that this would also aid insurance issues, where keeping track of thousands of individual pieces of paper can be challenging. “I have been told many times that the majority of malpractice cases are settled before liability is even established, because of incomplete or missing paperwork,” he says. Consultant plastic surgeon Mr Taimur Shoaib reiterates this aspect of legality.

As a medicolegal expert, he emphasises that standards of record keeping are set by our fellow colleagues and peers, and when a practitioner is under investigation for a malpractice case, he says, “If that peer doesn’t feel that the standard of record keeping was as comprehensive as it could have been, then there is a higher chance of a successful medical negligence claim.” Managing director of clinic management software company e-clinic Mark Lainchbury believes that electronic record keeping systems, including e-clinic, are versatile not just from a medical and legal perspective, but also for business needs. “Some clients are very focused on the clinical data aspects, whereas others are more focused on the very powerful business tools such as marketing and reporting,” says Lainchbury. “I think the most important facet of e-clinic is that it offers a much broader range of features that generally go deeper than most of the other systems which are available.” e-clinic allows users to design their own clinical workflows, scan records, save images and keep patient information online through a patient management system that allows you to text and email patients directly. However, Lainchbury says, “The downside of such a rich feature-set is you sacrifice a degree of simplicity, which is why we introduced a less sophisticated version, e-clinic Standard, last year.” Plastic and cosmetic surgeon Mr Adrian Richards uses e-clinic in each of his UK clinics. “We’re now up to now our 25th album of patients, so we store 25,000 records on e-clinic,” he explains. “You can imagine how many notes and files 25,000 would be – they would fill a room. It would also be hard to find them and a hassle for my staff, so I would definitely say electronic is the way to go.” Mr Richards says he finds the system easy to use and it allows him to set up multiple clinics on one system. However, he says, “Some of our nurses are still very keen on paper. Some people are reluctant for change, so you really have to show them the benefits of using an electronic system.” His own reasons for going digital were focused on a desire for simplicity. The lack of needing to store paper records, and the ability to easily access records from several years ago, has significantly improved the efficiency of his work both in clinic and on the move.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Though incorporating an electronic record keeping system for the very first time in your clinic could seem daunting, those using these digital systems contend that it creates better efficiency long-term. “This is what technology is made for,” emphasises Dr Townshend. “To make life easier, to keep things more precise, to make sure people are accountable – that’s really what we should be doing.” He believes that using digital systems is a logical progression, noting that the ability to read medical notes is an on-going clinical issue. He exemplifies the problem, saying, “I sometimes pick up notes that I wrote in a rush when I was tired at the end of the day and I’m not quite sure what one or two of the words say – how on earth is anyone else going to read it if I can’t?” Mr Shoaib opened his clinic nine years ago and immediately downloaded several 30-day trials of record keeping systems to decipher what would be the most effective system for his new clinic. He now uses a system called ClinicOffice. “It turned out to be the most versatile of a lot of packages because it comes with different modules,” he says, explaining that its multiple facets enabled him to use its document module for scanning and saving documents, store records in its financial section, log demographic information and patient contact details, as well as providing a function to allow patients to log in and book their own appointments. Although his record-keeping methods haven’t changed drastically since his clinic opened, Mr Shoaib finds that his staff now use ClinicOffice to its potential better than they did initially; making use of its online diaries and automatic texts/emails to patients. With its differing functionality, this kind of software is flexible to the user’s needs. Users also have different levels of access depending on their job role. One issue he has discovered, however, is the hindrance of a slower internet connection when sending out information, due to the volume of practitioners using the software in clinic, therefore causing it to slow it down. This, he says though, is down to his own broadband speed, which could be improved with a different internet provider. So what is the real crux of effective record keeping? In light of his experience of having to record very precise, detailed notes as a consultant in the NHS, with the resources to record them, Mr Shoaib considers the effects of electronic systems being thrust upon a practitioner not previously familiar with them. “Most hospital consultants are used to dictation systems because we learnt how to use them in the NHS,” he says. “Hospital consultants, I think, are in a privileged position. For the regular aesthetic practitioner, this is not going to be the case, but that doesn’t mean to say that medical record keeping can fall below the standards that we expect from the standard that is set.” He highlights that it is crucial that medical records reach a high standard, whether digitally or on paper. “You cannot compromise on any particular aspects of the medical record keeping process,” says Mr Shoaib. “Even if the medical record keeping process is done with paper it has to be stored for seven years,1 and if it is done electronically, then there is no reason to ever delete them.” Dr Townshend agrees, stating that if a digital system is effectively designed, there is no excuse for producing low standard medical records. Of the different systems available, he says, “If you have a great idea, but you implement it and design it poorly, it’s not going to help you and it can actually make it worse,” adding, “You have to get it right so people can understand what the benefits are.”

One of the key concerns that may cross the mind of those undecided on adopting an electronic record keeping system is security. Many systems use the Cloud, a system of servers that store and back up information with secure access. “Our Cloud platform [for e-clinic] is very secure with robust data backup and replication across two UK data centres. That infrastructure does come at a cost but I think most people understand the need for that level of security and resilience,” says Lainchbury. Online security in this way also means more accessibility. “With iConsult, all of the records are stored securely online, ready for access either through the iConsult app, or the website,” says Crawford Small. Mr Shoaib adds, “Security is of course exceedingly important and there are BSI standards for security, and all clinics who used any form of electronic storage need to register themselves with the Data Protection Act.”2 He continues, “The Data Protection Act also states that we have to back-up the data and, ideally, the information should be stored offline as well. This is to ensure that if there is a physical catastrophe in the clinic, our patient’s notes are still accessible.”3

What does the future hold? Toby Makmel, co-founder of patient management system Clinicminds, is confident that the future of medical record keeping is digital. Though his own system is yet to incorporate the function of medical records into its own software, Makmel believes this will change as the Dutch-based company becomes more popular in other countries and is required to follow country specific protocols. “I think the future is a very clean desk – a tablet with a keypad and a stylus [pen-like device for touch screen electronic devices] is all that’s needed. I think working on the Cloud will be the future because you don’t want to have the trouble of continuously getting out your work – you want full mobility,” he says, adding that this will be a crucial factor for growing clinics who hope to make a mark in the aesthetics world. Dr Townshend agrees, “The negative points that are made will come from the kind of people who don’t want change. I don’t say that in an insulting way – Lots of people don’t want change because things that are new are sometimes difficult, you have to learn new things – but if we fast forward five years or 10 years, there is no way on earth we’re going to have little scraps of paper floating around that people can lose, damage, take home, or leave on the train.” REFERENCES 1. DH/Digital Information Policy, Records Management: NHS Code of Practice (2nd Edition) (UK: gov.uk, 2009) <https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/200139/Records_Management_-_NHS_Code_of_Practice_Part_2_ second_edition.pdf> p. 4 2. Information Commissioner’s Office, Register of data controllers (UK: Information Commissioner’s Office, 2015) <https://ico.org.uk/about-the-ico/what-we-do/register-of- data-controllers/> 3. Information Commissioner’s Office, Information security (UK: Information Commissioner’s Office, 2015) https://ico.org.uk/for-organisations/guide-to-data-protection/principle-7- security/

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

Syneron Candela Launches Breakthrough Technology. Again. Introducing PicoWay. PicoWay is a remarkably innovative dual wavelength picosecond laser from Syneron Candela, the most trusted brand in lasers. With both 532nm and 1064nm wavelengths, PicoWay can treat a very broad range of pigmented lesions and tattoo types and colors on any skin type. PicoWay has the highest peak power and the shortest pulse duration of any picosecond laser for superior efficacy, safety and comfort. Proprietary PicoWay technology creates the purest photo-mechanical interaction available to most effectively impact tattoo ink and pigmented lesions, without the negative thermal effects of other lasers. And, PicoWay has the reliability physicians want.

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Advertising in Aesthetics Business and marketing consultant Angela Rankin outlines the importance of ethical advertising in aesthetics Arguably, the close of the Keogh and Health Education England (HEE) chapter heralds the approach of a new era in medical aesthetics. Standards, professional accountability and visible practice subject to regulatory scrutiny mark the way forward. This article focuses on a narrow area of practice, but one with far reaching implications – advertising and marketing. As the joint owner and practice manager of an aesthetic clinic, part of my daily routine is to be responsible for all of the marketing and advertising requirements to run a successful business. However, even with a strong marketing background of 15 years prior to entering the aesthetic arena, little can prepare anyone for the ethical and moral issues surrounding the advertising of aesthetic procedures to the general public. The dilemma aesthetic practices face is governed largely by the necessity to operate within strict advertising regulations that do not contravene the standards of the Advertising Standards Agency (ASA) and the Committee of Advertising Practice (CAP), while at the same time promoting what are, essentially, medical procedures to the general public. Here are just a few of the questions we should be considering before committing to any advertising or marketing campaigns: Are we acting ethically as advertisers? Are we using subliminal messages to gain more business from our competitors? And most importantly – are we acting with a sense of responsibility to the consumer when we prepare our marketing material? A subliminal message that is positive, transparent and reassuring to the patient regarding our services is far more preferable and professional compared to undermining our competition in a negative manner. To begin, it must be decided what the differences between ethics and morals are. One definition describes how, “Ethics and morals relate to ‘right’ and ‘wrong’ conduct. While the terms are sometimes used interchangeably, they are different: Ethics refer to rules provided by an external source (e.g. codes of conduct in the workplace), while morals refer to an individual’s own principles regarding right and wrong.”1 When considering the best approach to marketing clinical procedures we should not be placing the emphasis on the services we offer, but rather on how these treatments can be offered ethically and responsibly to the consumer. The CAP offers guidance to help advertisers interpret the UK Code of non-broadcast advertising.2 This guidance covers the marketing of surgical and non-surgical interventions. Nonsurgical interventions include treatments such as botulinum toxin injections, dermal fillers, chemical peels and non-ablative laser treatments, amongst others. The CAP Code is explicit in defining what constitutes an advertising statement (i.e. claim). This can be

implied or direct, written, spoken or visual – the name of a product can constitute a claim. Therefore, at each stage of the marketing process, every communication we use must be “prepared with a sense of responsibility to consumers and to society.”2 So, how do we implement these principles into the daily running of our aesthetic practice? From my own experience as the first point of contact both on the telephone and front of house, a number of issues arise that highlight the need to apply these principles. Members of the public are at their most vulnerable when calling a clinic for the first time. Recent market research from Allergan UK on the timeline from first considering a non-surgical procedure to calling a clinic to book a consultation had a surprising result – it can take a patient up to 10 years to make the decision.3 The manner in which we deal with potential customers in this first instance is key to building trust and confidence prior to the consultation process. At this stage, transparency of service is vital; we should be listening to each individual’s needs and expectations and not focusing on promoting specific treatments – even if this is inevitably part of the process. Patients often ask about the credentials of the practitioner who will be performing their treatment, and, according to the CAP Code (11.9):2 “If we are to include a statement about a practitioner in our marketing material we must be able to provide suitable credentials – for example evidence of relevant professional expertise or qualifications, systems for regular review of skills and competencies, suitable professional indemnity insurance covering all of the services we provide, accreditation by regulatory bodies that has systems for dealing with complaints and taking disciplinary action, and has registration based on minimum standards for training and qualification.” This information should be made readily available to patients when they speak to clinic managers or members of staff when booking consultations. Current indemnity insurance certificates should be on display in all clinics for the patient’s reassurance, as should current membership of regulatory bodies such as the Nursing and Midwifery Council (NMC), General Medical Council (GMC) and General Dental Council (GDC). Professional bodies Professional associations such as the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS), the British Association of Dermatologists (BAD), the British Association of Aesthetic Plastic Surgeons (BAAPS), the British College of Aesthetic Medicine (BCAM) and the British Association of Cosmetic Nurses (BACN) together represent the vast majority of medical clinicians within the industry. As members of these associations, practitioners will have access to much of the information they require to run an ethical and

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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professional clinic. Implementing this information and communicating this association clearly in your clinic will assure patients that you practice within the remit of a professional association that is committed to patient safety and wellbeing. Displaying logos/kite-marks of professional associations both in the clinic and on websites with links attached, as well as on advertising material, gives the general public a point of reference to research when selecting a clinic for treatment. Promote the ‘consultation’ – not the product There are some exceptions for websites, principally, those for clinics and pharmacies offering consultations for the treatment of lines and wrinkles. Such websites may provide information about a prescription only medicine (POM), such as botulinum toxin, in the context of the product being a possible treatment option following a consultation. Marketers offering botulinum toxin may for example, include the claim “a consultation for the treatment of lines and wrinkles”. The CAP says “The offering of a ‘consultation’ in the first instance is paramount because the name of the POM should not be referenced in the initial advert. No reference to a POM should be made on a sponsored ad link, a home page of a website, logo, testimonial or hover text, and any small print at the bottom of a home page should not refer to POMs or directly link consumers to a page where it is referred to. Price lists included on a website should not include product claims or encourage viewers to choose a POM based on the price. Marketers should ensure that the casually browsing consumer does not come across information relating POMs with ease.”4 The ASA recently upheld a complaint about an advert where Botox was the subject of the website, not the consultation itself.5 Promoting the ‘consultation’ and not the product when speaking to customers is very important. The ASA considers that the information on a website “has to be balanced and factual and must be presented in the context of an advertisement for the service i.e. the consultation.”4 Another important factor to remember is that, when producing marketing material, botulinum toxin can only be mentioned to treat areas for which the product is licensed. Marketers should not include information in their adverts that suggest botulinum toxin can be used to treat areas other than those areas for which the product is licensed.6 Advertisers should look for information and specific advice on the advertising and promotion of medicines in the UK on the Medicines and Healthcare Products Regulatory Agency (MHRA) website.7 One area of marketing which is often open to abuse is the misleading claims of results post treatment for the average patient. We often see advertisements including visual claims that exaggerate the effect that the cosmetic intervention is capable of achieving. The ASA states that it, “Expects marketers to ensure they retain appropriate material to be able to demonstrate whether any re-touching has been carried out. This might include ‘before’ and ‘after’ images showing the effect of both pre- and post- production techniques as appropriate.”8 If we decide to include before and after photographs to demonstrate the possible outcomes of treatment, it is preferable to include photographs of patients that have been treated by the practitioner, rather than generic photos from manufacturers’ websites. These photographs should relate specifically to the treatments that have been performed by the practitioner and, if necessary, the eye area may be blocked out at the request of the patient. It is important to note that all parties concerned must sign a consent form prior the use of any photographs. From the patient’s point of view, it reinforces the professionalism and transparency of practice of the practitioner who will be performing their treatment. In summary, our ‘ethics’ in advertising and marketing our services to

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the general public should be based on the guidelines available from organisations such as CAP and ASA, and our ‘morals’ should be selfgoverning. As an industry, we are obligated to move towards a stance of moral integrity, putting the general public’s safety as our first priority. We should constantly ask the question, “How would you expect to be treated as a patient?” If we don’t sell, but advise on the basis of need, we are fulfilling our moral objective because we are focussing on the patient’s perspective of need and expectancy, and using our medical expertise to analyse the best treatment programme, rather than being influenced purely by the services we offer in the first instance. Often patients come to us expecting a specific treatment which may not necessarily produce the best results based on a full consultation and analysis of a problem area. All aesthetic practitioners should take these points into consideration. Making claims about our services and products according to the CAP Code should be based on “documentary evidence and adequate substantiation.”8 In a competitive market place and a rapidly growing industry, public awareness of our services is key to successful and on-going business development. Therefore, moral obligation and responsibility to the patient should be pervasive throughout the whole process.

Our ‘ethics’ in advertising and marketing our services to the general public should be based on the guidelines available from organisations such as CAP and ASA, and our ‘morals’ should be self-governing Angela Rankin is joint owner of Regenix Medical Aesthetics Clinic in Malvern, Worcestershire. Prior to setting up her clinic, she worked for Newsquest Media as a sales manager and has won many awards and competitions in advertising, working with companies and manufacturers across all sectors. REFERENCES 1. Diffen, Ethics vs. Morals, (US: Diffen, 2013) <http://www.diffen.com/difference/Ethics_vs_Morals> 2. The Committee of Advertising Practice, The CAP Code: The UK Code of Non-broadcast Advertising, Sales Promotion and Direct Marketing (UK: TSO, 2010) <http://www.cap.org.uk/~/media/Files/CAP/ New%20Codes/New%20CAP%20Code.ashx> 3. Allergan Medical Combined DOF 003 Key Insights Aug 2014, Allergan data on file [available on request] 4. The Committee of Advertising Practice, Anti-ageing: Botulinum toxin products (UK: The Committee of Advertising Practice, 2015) <http://cap.org.uk/Advice-Training-on-the-rules/Advice-Online-Database/ Anti-ageing-Botox.aspx#.VRwO-L6R8yE> 5. The Advertising Standards Agency, ASA Adjudication on HB Health of Knightsbridge (UK: The Advertising Standards Agency, 2014) <http://www.asa.org.uk/Rulings/Adjudications/2014/1/HB-Health- of-Knightsbridge/SHP_ADJ_237714.aspx#.VRwPer6R8yE< 6. The Advertising Standards Agency, ASA Adjudication on Dermaskin Clinics (UK: The Advertising Standards Agency, 2014) http://www.asa.org.uk/Rulings/Adjudications/2014/1/Dermaskin-Clinics/ SHP_ADJ_237709.aspx#.VRwQG76R8yE 7. Gov.uk, Medicines & Healthcare products Regulatory Agency (UK: Gov.uk, 2015) <https://www.gov.uk/ government/organisations/medicines-and-healthcare-products-regulatory-agency> 8. The Committee of Advertising Practice, Help Note: Committee of Advertising Practice (CAP) Broadcast Committee of Advertising Practice – Marketing of Cosmetic Interventions (UK: The Committee of Advertising Practice) http://cap.org.uk/~/media/Files/CAP/Help%20notes%20new/ CosmeticSurgeryMarketingHelpNote.ashx

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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Aesthetics Journal

Aesthetics

Answering the ‘why’ question Ideally, you must be able to answer these questions and plan for every eventuality before you start building an aesthetic practice: • • • •

Vision and Finances Aesthetic practitioner Dr Harry Singh explains the importance of ensuring your finances can support your aesthetic vision This article will detail and advise on the two most important concepts that have made the biggest difference to my aesthetic practice. The first point is the need for a crystal clear vision for your business, and the second is how to carefully consider the financial aspects of making this vision successful.

Vision Imagine you are trying to complete a jigsaw. You have all the pieces, however, you’re unsure of what the jigsaw will look like once completed. In these circumstances, you would struggle to complete the jigsaw and, even if you did manage to complete it, it would take longer, causing much frustration along the way. So why do so many practitioners not have a clear vision of what their business should look like before they embark on this exciting journey? Most practitioners spend hours evaluating what services to offer, what training they need to undertake and who to employ. Yes, these are necessary, but they are all ‘how’ aspects of running an aesthetic practice – you need to establish why you want to do this. I would argue that your business success will be increased if you were to spend 80% of your time on the ‘why’ and 20% of your time on the ‘how’. I find many that embark on this journey will lose motivation at difficult times as they did not have a clear ‘why’ vision at the start.

Think about your Unique Selling Point (USP). The aim of identifying a USP is to draw attention amongst a sea of competitors. Why should patients choose you?

Why do you want to open an aesthetic practice? Do you want to create extra income? Do you want to replace your current income? Do you want to integrate services within a dentistry/medical clinic? • Do you want to offer a mobile aesthetics service? If you have answered these questions confidently, you should be primed to continue with the hard work that accompanies starting a business. Discovering ‘how’ your business will work Once you have established why, you should then look at how your business will operate: • What will your business look like? Will it be a clinical setting, a spa feel? Will it be a single treatment room or multi-roomed practice? • Will you work solely, or with a team of specialists? A sole practitioner will have tighter and less overheads but, with the responsibility of providing all the treatments, would only earn when they work. A specialist team will have higher overheads but allow you to be more flexible with your time in clinic. • What strategic goals do you have for your business? Consider whether these will be financial goals in terms of turnover or profit, or a high number of patients undergoing aesthetic treatments per week. Consider how you want your clinic to be perceived. This could be in the press or by patient recommendations to friends and family. How others perceive your business will have a profound impact on referrals and patient turnover. Consider what will make your business stand out from others Think about your Unique Selling Point (USP). The aim of identifying a USP is to draw attention amongst a sea of competitors. Why should patients choose you? Is it your experience, qualifications, location, unique services? Note how you will market this to prospective patients; consider advertising spend, setting up a website, potential costs of running social media – will you do this or employ someone else to do so? Align your vision with accessible resources • Find out what tools are available to you in terms of time, money and skillset. When employing staff, consider the candidate’s skillset and qualifications. A nurse may be particularly skilled

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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at injecting, whilst an aesthetic therapist has the essential qualifications and experience to conduct laser treatments. Hire enough staff members who are capable and qualified to provide your offered services. • Do you need to undergo any further training? This could be clinical training or relate to business needs. It’s important you are competent in both the treatments you offer and the business aspects of running a clinic.

Finances Most business owners consider lack of patients/customers, poor marketing or poor customer service as the main reason for failure. I agree; these are important pieces of the jigsaw puzzle. However, in my opinion, the majority of businesses fail due to misunderstanding the financial aspects of the business. It’s imperative to establish the level of capital required to set up and successfully run your clinic. Once established, you must monitor your key performance indicators (KPIs) regularly. You should also consider optimisation strategies to implement increased annual turnover. KPIs Like your business vision, you need to determine your targets to record and assess how you are progressing. There are numerous KPIs you could analyse, but I find the following to be the most beneficial to my business, and study these figures on a monthly basis: • Turnover total: How much did you make that particular month? In my practice, I also like to separate this figure into the different treatment modalities I offer such as toxins, fillers and skin products. • Number of paying patients per month: How many patients did I see that month that paid for a treatment or service? • Average spend per patient: This is critical to determine if any paid marketing activity was profitable. Compare your average patient spend to marketing costs and how many new patients visited as a result to determine which strategy has worked, and therefore should be continued, or what didn’t and therefore should be reconsidered. • Time blocked for appointments: How many clinical hours did you allow for patients? Compare this with the number of actual hours worked seeing patients to discover the percentage of capacity utilised. This way you can measure if there is space for more new patients, or, if you were over booked, whether you need more practitioners. • Turnover per hour: Total turnover divided by number of hours worked. Use this figure to compare it against the operating costs per hour, and also as a benchmark when considering introducing a particular new service, to see if this service will match or better your current turnover per hour. • Operating costs per hour: Don’t just look at your turnover, examine how much it costs you to run the business and establish the profit you make each month. • Number of new patients per month and percentage of referral sources: We’re all going to lose some patients, so therefore you need a regular source of new patients to sustain your business. If you aren’t getting regular referrals from existing patients, look into ways of improving this. Ask patients to give testimonials for your marketing, or share their positive experiences on social media. • Percentage of enquiries/assessments compared to

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paying patients: How effective are your conversions? If your conversion rate is low, try new methods of improving this crucial service. Ensure your staff members are following up on all enquiries, offering high standards of consultation and, most importantly, excellent customer service. Managing the financial aspects of your business may seem daunting, but it’s easy to get used to, and if you digitally store data these figures are easily extracted. In my experience, spending extra hours analysing my finances is much more beneficial to my business in the long run.

Optimisation Now we know what figures to record, and what our intended target for each KPI is, to improve these baseline figures I use optimisation, which can be broken down into: Increasing your lead generation There are numerous lead generation techniques you can undertake. I normally divide this between internal and external lead generation. Internal lead generation will include activities such as producing newsletters, birthday cards for patients, holding open evenings, and sending promotional email shots. External lead generation strategies include newspaper advertising, direct mail, internet marketing and search engine optimisation. Increasing the effectiveness of the consultation Monitoring this KPI on a monthly basis will trigger you to improve on your consultation process. Follow up with patients who have had a consultation but not proceeded with treatment because they have forgotten, or if they have decided not to go ahead with your suggested treatment and find out why. You can then consider offering a different or more personalised service to that patient. Increasing sales and transactions Ask satisfied patients to refer you to their friends or family. You can also send out regular newsletters, which will ensure you are a constant reminder to those that are considering, or have delayed, treatment. Moreover, whenever a patient undertakes a consultation, you can explore three other options to increase the transaction value. This includes: downselling (by offering them alternative products or treatments if they cannot meet the original treatment price); cross selling (by offering an extra service to compliment their original treatment); and upselling (such as offering a discounted combined package rather than just selling one treatment). It is important, however, to remember that we must only offer treatments and services that would be appropriate for the patient and add value to their purchase.

Conclusion Returning to the jigsaw, it should now be clear that there are many pieces required to complete the puzzle of establishing your own aesthetic practice. Having a clear understanding of your vision for your business, as well as for the financial considerations that should be undertaken, are vital aspects for achieving business success. Vision and finance are, to me, the pivotal corner pieces of the jigsaw and the very first starting points to completing the rest of the puzzle. Dr Harry Singh qualified as a dentist in 1996 and completed his facial aesthetic medicine training in 2002. He is also a keen marketer, a skill he believes is vital to attract and retain patients requesting aesthetic services.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

COMPOSED • CONFIDENT • MY CHOICE

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Now approved for crow’s feet lines Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,

dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualiﬁcations and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1183/BOC/DEC/2014/DS Date of preparation: December 2014

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Botulinum toxin type A free from complexing proteins

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“Securing a reputation as a thorough and honest practitioner is the key to success” Consultant dermatologist Dr Sandeep Cliff recalls his journey into the world of aesthetics Following a successful beginning as a consultant dermatologist in the NHS, aesthetics wasn’t a career choice that Dr Sandeep Cliff had considered until patients began requesting treatments for their photo-damaged skin. “This fuelled an interest in pursuing more aesthetic treatments, but from an evidence-based perspective,” he explains. Dr Cliff’s family emigrated from Uganda to London in 1971 when he was four. After attending a North London state school, Dr Cliff studied medicine at University College London followed by a paediatric fellowship at Harvard Medical School. Dr Cliff completed his dermatology training at St George’s Medical School in London and, in 1999, was appointed as a consultant dermatologist and Mohs surgeon at East Surrey University Hospital and St Helier Hospital where he still practises today. He also serves as the clinical sub dean for Brighton and Sussex Medical School. “I enjoy my work for its variety and case-mix; I still feel the need to continue in dermatologic research and development,” Dr Cliff explains. Enthused by the advancements of HIV medicine in the 1990s and fascinated by the cutaneous manifestations of HIV, Dr Cliff decided to pursue a career in dermatology, and has never looked back since. “I was debating whether to leave medicine to go into pharma and become a company medical advisor,” he explains. “But being able to help very sick people motivated me to pursue my passion for clinical medicine in dermatology.” Following his training in Mohs micrographic surgery, treating skin cancer has become Dr Cliff’s passion. “Many skin cancer patients come back to me after treatment and say their skin has lost its quality, lacks lustre and looks scaly and dry,” he says. “Helping these patients improve their skin texture and condition is very satisfying. I aim to provide advice based on good clinical data not on hearsay; something my patients continue to appreciate.” When first contemplating aesthetic medicine, Dr Cliff confesses, “Initially, I felt very sceptical. Then I realised dermatology bridges aesthetics. I have patients who are bothered by their rosacea, their erythema and their acne but they also want to protect their skin from early signs of ageing and attain optimal skin quality. So I find that clinical management of skin often dovetails with the cosmetic aspects of skin management, such as photoageing. Today there are aspects of cosmetic dermatology which are now on the curriculum of dermatology registrars in the UK.” Dr Cliff advises newcomers to medical aesthetics to focus on improving treatment techniques, have a keen eye for patient safety and be realistic in terms of what can be achieved. He recommends budding medical aestheticians to keep their eyes open for the latest trends and to keep abreast of the latest techniques. “If practitioners don’t, we’ll never move forward,” he says, adding, “When practising aesthetic medicine you have to balance the need to be careful and cautious with the natural inclinations of an inquisitive mind to push the boundaries.” Staying up-to-date

is essential for future development, affirms Dr Cliff, however he is passionate that practitioners shouldn’t be ‘cajoled’ into using products or devices unsupported by robust clinical data. A regular speaker at conferences and events on behalf of pharmaceutical and skincare companies, he says, “I cannot possibly feign interest in a product that hasn’t got strong clinical evidence to prove it works and is safe. I advocate the ‘family test’ where I ask myself, ‘Would I be happy to use this on a close family member?’” Dr Cliff urges that beginners to aesthetic medicine should attend meetings and observe peers in practice. He says, “Whilst it’s important to learn how things should be done, it’s crucial to be aware of potential complications. In medicine, unfortunately things do go wrong and the skill lies in recognising and treating complications.” He adds, “It’s important to be transparent when communicating with your patients. Securing a reputation as a thorough and honest practitioner is the key to success. If you follow best practice and do it properly, carefully and skilfully, you will find your practice will grow and everything else will follow naturally.” What treatment do you enjoy giving the most? Giving dermal fillers is the most enjoyable, because you can see the results immediately. What technological tool best compliments your work? The cannula, as it has a multitude of uses and allows treatments to be delivered with minimal downtime for the client – a definite plus. What’s the best piece of career advice you’ve been given? Approximately 20 years ago Professor Brian Gazzard, who was a professor of HIV medicine at Chelsea and Westminster Hospital, took me aside and said, “You need to pursue a career in medicine which is expanding. With an ageing population there will be more skin diseases, in particular skin cancer and skin surgery will expand; you will never be bored.” I thank him for his advice and guidance; his sage words inspired me to pursue a career in dermatology. Do you have an industry ‘pet hate’? I don’t like the promises everyone seems to be able to offer. I think you’ve got to be absolutely transparent. Patients are often drawn-in by incredible pictures. Expectations are raised when, in reality, the results can’t always be achieved and disappointment follows, which is not good for the reputation of the aesthetic medicine industry. What aspects of aesthetics do you enjoy the most? I enjoy the meetings, the social aspects and the constant learning. I also love to teach and lecture on dermatology, in particular discussing cosmetic ingredients that have real evidence behind them. I am looking forward to some talks coming up soon where I will be discussing different approaches to skin health with my colleague and friend, consultant plastic surgeon, Mr Paul Banwell.

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015

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The Last Word Ms Rozina Ali argues for greater clarity in the definition of the term ‘cosmeceutical’ In 1984, Dr Albert Kligman coined the phrase ‘cosmeceutical’ to describe, “A topical preparation that is sold as a cosmetic but has performance characteristics that suggest pharmaceutical action.”1 At the time, Dr Kligman was conducting clinical studies to confirm the efficacy of topical vitamin A in improving ageing skin, whilst at a similar time, Dr Eugene Van Scott and Dr Ruey Yu were working on developing alpha hydroxy acids (AHAs) for skincare.1 According to Oxford Dictionaries, ‘Cosmeceutical’ is a blend of the words ‘cosmetic’ and ‘pharmaceutical’, and is a cosmetic that has or is claimed to have medicinal properties. The American version adds an extra definition to medicinal properties, stating, ‘especially antiaging ones.’2 However, contrary to popular use, the US Federal Food, Drug, and Cosmetic Act (FD&C), states clearly that ‘cosmeceutical’ is not a recognised term. They claim a product can be a drug, a cosmetic, or a combination of both, but the term ‘cosmeceutical’ has no meaning under US law.3 There is therefore an evident mismatch between the terms commonly used within the industry and the strict definition of the regulatory authorities. With the global cosmeceuticals market estimated to increase at a compound annual growth rate (CAGR) of 8.62% from 2014 to 2019,4 a clear definition is crucial. What, therefore, classifies as a cosmeceutical? A ‘cosmetic’ product is any substance or mixture intended to be placed in contact with the various external parts of the human body with a view exclusively or mainly to clean them, perfume them, change their appearance and/or correct body odours and/ or protect them or keep them in good condition.5 In the UK, the legal implications of this are that cosmetics are governed by The EU Cosmetics Directive. The fifth recital of the directive, ‘the Cosmetic Directive’, foresees cosmetic products having a secondary preventative (but not curative) purpose.6 Pharmaceuticals, on the other hand, are prescription-only medicines (POMs) designed and rigorously proven to cure, treat and improve a described condition. As such, they must be prescribed for use, and are governed by The Medicines and Healthcare Products Regulatory Agency (MHRA), which is an executive UK government agency,7 regulating both medicines and medical devices nationally. Interestingly, like the FD&C, neither the European body nor the MHRA uses or refers to the word ‘cosmeceutical’. In short, the term ‘cosmeceutical’ is not recognised as a legal category, yet it has become an accepted term in the industry. The original definition by Kligman has been lost in the world of free-markets, margins and promotions; companies have realised that there is no legally-binding definition of the word, therefore anyone may call their product or brand a ‘cosmeceutical’. The dermatology-based research and development companies established during the 1980-1990s that used the term ‘cosmeceutical’

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to describe their newly discovered active ingredients and synergistic formulations, such as alpha hydroxy acids and vitamin A, now find themselves with patents expired and generic ingredients flooding the market. Newcomers are now able to use any ingredient, at any dose, in any formulation – as long as the EU Cosmetics Directive has approved the ingredient. This, in my mind, has caused confusion, and requires an urgent and incisive move for clarity. One of the ways of doing so, aside from legislation, is to discuss with patients the claimed versus proven benefits of skincare. Many practitioners may ‘prescribe’ a skincare regimen, but this does not necessarily mean that they are prescribing POMs, and this must be understood by the patient. ‘Prescribing’ skincare implies to them that they are getting something that is clinically proven to be effective, when in fact the practitioner may simply be supplying goods under the EU Cosmetics Directive. This requires only that they be deemed ‘safe’ with the manufacturer responsible for product safety. All products do, however, need to be registered in the Cosmetic Products Notification Portal (CPNP).5 In order to clarify this, I strongly believe it would be beneficial to have a specific category classifying ingredients or formulations that are clinically proven to exert a positive effect on the epidermis, dermis or components of either. Cosmeceuticals may then be further subdivided into those exerting effects on skin health, skin rejuvenation or skin healing. Reproducible, reliable clinical evidence is key. As medical practitioners familiar with clinical studies and levels of evidence, we will find remarkably few randomised, double blind, placebo-controlled (or even better vehicle-controlled) studies on cosmetic ingredients and formulations. Marketing material tells me nothing useful professionally – it’s only when I am offered scientific and/or clinical data that my antennae is alerted and I am primed to investigate an ingredient, product or range more closely. I am, however, heartened by the increasing number of single ingredient and formulation studies now being conducted. The serious players in the industry have recognised the value of an evidence-based unique selling point. As we fast approach the oncoming ‘cosmeworld’, we need to make sure we understand the terminology used by manufacturers, and take the time to decipher, by reading the studies and verifying exactly what ingredients, and in what strengths, we are delivering in the product choices we recommend to our patients. Ms Rozina Ali is a consultant reconstructive and aesthetic surgeon with an interest in facial aesthetic surgery. Graduating from St Thomas’ Hospital Medical School with first class Anatomy BSc honours, she later undertook additional postgraduate surgical training at the cranio-facial unit at Great Ormond Street Hospital. REFERENCES 1. Patricia Farris, A critical look at the term cosmeceutical: Descriptive or deceptive? (US: Dermatology Times, 2013) <http://dermatologytimes.modernmedicine.com/dermatology-times/content/tags/ cosmeceutical-products/critical-look-term-cosmeceutical-descriptive-o?page=full> [Accessed 9 April 2015] 2. Oxford Dictionaries, Cosmeceutical (UK: Oxford University Press, 2015) <http://www. oxforddictionaries.com/definition/english/cosmeceutical> [Accessed 9 April 2015] 3. The Food and Drugs Administration, Federal Food, Drug and Cosmetic Act (FD&C Act) (US: The Food and Drugs Administration, 2010) <http://www.fda.gov/RegulatoryInformation/Legislation/ FederalFoodDrugandCosmeticActFDCAct> [Accessed 9 April 2015] 4. RNR Market Research, Global Cosmeceuticals Market to Grow at 8.62% BAGR by 2019 (US: WhaTech, 2014) <http://www.whatech.com/market-research-reports/press-release/consumer/37005- global-cosmeceuticals-market-to-grow-at-8-62-cagr-by-2019> [Accessed 9 April 2015] 5. The Cosmetic, Toiletry & Perfumery Association (CTPA) Information Centre (UK: The Cosmetic, Toiletry & Perfumery Association, 2015) <http://www.ctpa.org.uk/content.aspx?pageid=233> [Accessed 9 April 2015] 6. European Union, Regulation (EC) No 1223/2009 of the European Parliament and of the Council of 30 November 2009 on cosmetic products (EU: Official Journal of the European Union, 2009) <http://eurlex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:342:0059:0209:EN:PDF> [Accessed 9 April 2015] 7. Gov.uk, The Medicines and Healthcare Products Regulatory Agency (UK: gov.uk 2015) <https://www. gov.uk/government/organisations/medicines-and-healthcare-products-regulatory-agency> [Accessed 9 April 2015]

Reproduced from Aesthetics | Volume 2/Issue 6 - May 2015