Aesthetics October 2015

s tic 15 he 20 ! st ds ow Ae ar e N t Aw Vo

VOLUME 2/ISSUE 11 - OCTOBER 2015

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ONE LIFE | ONE SKIN

Male vs. Female Treatment CPD Drs Emma and Simon Ravichandran explore anatomical differences between the sexes

Understanding Thread Lifting

Treating Dark Circles

Dr Sarah Tonks details the thread lifting process and expected results

Mrs Sabrina ShahDesai shares her techniques for periorbital rejuvenation

Clinic Interiors Miss Sherina Balaratnam explains how successful interior design can benefit your business

Not all HA dermal fillers are created equal.

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The filler you’ll love 1. BEL-DOF-003 V2 Belotero® technology, June 2015. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI: 10.1159/000354384. 3. Aesthetics Awards Supplement, December 2014. Injectable product of the Year, pg 5.

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Contents • October 2015 06 News

The latest product and industry news

13 On the Scene

Out and about in the industry this month

14 Conference Reports

Reports from the joint BCAM/BACN meeting and Beyond Aesthetics conference

16 News Special: The Rise of Online Learning

Special Feature Male facial contouring Page 19

Aesthetics investigates the increase of online educational training in the industry

CLINICAL PRACTICE 19 Special Feature: Male Facial Contouring

Practitioners discuss the increase in male patients seeking treatment and techniques for successful contouring results

24 CPD Male vs. Female Treatment

Dr Emma Ravichandran and Dr Simon Ravichandran explore the anatomical differences between men and women

29 The Science Behind Mesotherapy

Dr Philippe Hamida-Pisal shares the history of mesotherapy and details the qualities of common poly-revitalising solutions

33 Understanding Thread Lifting

Dr Sarah Tonks details the thread lifting process and what results practitioners can expect to achieve

39 Sexual Dysfunction in Men

Dr Sherif Wakil advises how PRP can be used to treat a range of male-related concerns

43 Treating Dark Circles

Mrs Sabrina Shah-Desai outlines appropriate treatments for under-eye dark circles

49 Combining Surgical and Non-surgical Treatment Plans

Mr Taimur Shoaib shares advice on combining procedures to optimise aesthetic results

55 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 57 Building a Relationship With Your Sales Rep

Emma Perrett offers advice on building relationships with your sales representatives in order to boost trade

61 Clinic Interiors

Miss Sherina Balaratnam explains how clinic interior design can impact patient satisfaction

65 Practitioner to Entrepreneur

Dr Tijion Esho shares advice on how to unlock entrepreneurial potential

67 In Profile: Dr Raj Acquilla

Dr Raj Acquilla reflects on his medical aesthetic career and passion for the specialty

69 The Last Word: Are some treatments making patients look older?

Dr Kuldeep Minocha argues that practitioners must take care not to inadvertently age patients with aesthetic treatment

NEXT MONTH • IN FOCUS: Lasers • CPD: ABC of moles • Facial Resurfacing • Developing your own PR material

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In Practice Building a relationship with your sales rep Page 57

Clinical Contributors 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 is actively involved in creating a national audit pathway for aesthetic practice.

Dr Simon Ravichandran is an ear, nose and throat surgeon. He established the Scottish Advanced Aesthetic Training Programme with Glasgow University, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners.

Dr Philippe Hamida-Pisal is an aesthetic practitioner working in London and Paris. As well as being the president of the Society of Mesotherapy of the UK, Dr Hamida-Pisal is a key note speaker at major industry events around the world.

Dr Sarah Tonks is an aesthetic practitioner and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at Omniya in Knightsbridge, Dr Tonks practises cosmetic injectables and thread lifting.

Mrs Sabrina Shah-Desai is an aesthetic oculoplastic surgeon with more than 20 years’ experience in micro-precision eye surgery. Previously based at Moorfields Eye Hospital, she is now based at Harley Street and in North London.

Mr Taimur Shoaib is a consultant plastic surgeon with more than 20 years’ medical experience. He qualified from the University of Glasgow in 1992, before establishing his cosmetic surgery practice, La Belle Forme, in 2009.

Dr Sherif Wakil is the founder and medical director of Dr SW Clinics and has more than 20 years’ experience in the industry. He is a fellow of the International College of Surgeons as well as an active member of the General Medical Council.

Book your tickets now for the Aesthetics Awards 2015 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

AestheticSource are delighted to add SkinTech peels and home care to their portfolio, further supporting you and your patients.

AestheticSource distribute NeoStrata, Exuviance, Aneva Derma, SkinTech and Xxtralash.

Please see www.aestheticsource.com for information on educational opportunities such as lectures at major aesthetic and dermatology conferences, training courses, symposia and business building events.

Meeting the needs of your business, delivering high satisfaction to your patients Call us on 01234 313130 info@aestheticsource.com www.aestheticsource.com

Editor’s letter The conference season officially began in September with the first collaboration between the British College of Aesthetic Medicine and the British Association of Cosmetic Nurses at their joint regional meeting in Crieff, Scotland. Read about the highlights from this meeting, along with Amanda Cameron the first Beyond Aesthetics conference, held in Editor Manchester, on p.14 of this issue. In Scotland, delegates were keen to discuss the news that private Scottish clinics will be regulated from April 2016. Stakeholders were invited to submit their recommendations for regulation at a meeting earlier in the month, which we have covered on p.13. I’m sure you will agree that this is fantastic news for the country and I hope all our colleagues in Scotland continue to lead the way and make some of these recommendations on regulation stick!

A fast-growing segment of the aesthetic marketplace now belongs to the male patient, and successful male treatments require the practitioner to recognise the gender differences in anatomy, skin biology and ageing. To quote Medscape, “Males are an untapped patient population that could serve as an area for growth in aesthetic practices. As the number of male patients seeking treatment increases, physicians need to account for gender when evaluating

and treating a cosmetic patient.” Taking this into consideration, this month we have decided to look at the different approaches that are required for successful male treatment. Drs Emma and Simon Ravichandran have written a fascinating CPD article (p.24) on the different facial anatomy of men and women, advising practitioners on the important factors to be aware of when treating each gender. They have also shared two excellent case studies of successful treatment that I urge you all to read. The type of procedures that appeal to men seem to be those with little downtime so that they can resume their busy lives without any unwanted, probing questions.

As such, our Special Feature on p.19 hones in on facial contouring; detailing the aesthetic concerns and minimally invasive procedures that appeal to men, with valuable advice from practitioners experienced in this specialty – a great read that I recommend to any practitioners considering extending their patient demographic. I’m also delighted to tell you that the votes for the Aesthetics Awards are rolling in, but urge anyone who has not submitted their votes to do so by October 30; please don’t forget to support the companies, practitioners and products that you value most within our industry.

There are still some tables available for the ceremony – but not many – so if you would like to make the awards your Christmas celebration, please book now at www.aestheticsawards.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.

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Acne

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Patient Dr Stefanie Williams @DrStefanieW Just saw a 105 year old patient. Such a lovely gentleman. #longevity #dermatology #healthcare

#Botox Sabrina Shah-Desai @perfecteyesltd With micro-droplet Botox maestro #woffleswu #Singapore

Study claims acne treatment is growing inside human body A study published in the Journal of Investigative Dermatology has suggested that nitric oxide is an effective acne treatment that is already growing inside the human body.

The study indicated that the slow release of nitric oxide using nanoparticles was able to kill acne-associated bacteria, while the nanoparticles also suppressed the inflammation, which causes larger acne lesions to form. Dr Adam Friedman, coauthor of the study, said, “We showed that the nitric oxide nanoparticles were extremely effective in inhibiting and killing P. acnes, the bacterium which serves as a stimulus for inflammation in acne and also the nanoparticles were shown to be nontoxic in cells and a developing vertebrate model highlighting its safety.”

#Satisfaction Dr Shirin @DrShirin_ One of my patients’ biggest concerns – ‘Will everyone know what I’ve had done?’. Answer – not if you don’t want them to!

Hair Loss

#Fillers

The FDA has awarded clearance to the LCPRO female hair loss device from LaserCap Company. The hat device uses low-level laser therapy (LLLT), a non-chemical treatment which stimulates the production of energy at cellular level to reduce the occurrence of hair loss. Michael Rabin, co-founder of LaserCap Company said, “Receiving FDA clearance substantiates what we have seen in clinical studies.

There’s clearly been a strong shift in momentum towards alternative therapies for hair loss, like low-level laser therapy.”

He continued, “For the last two decades, the hair loss industry has been dominated by a few FDA-approved medications and surgery, but we’re now seeing a growing awareness within both the public and medical community about the efficacy of treatments like low-level laser therapy.”

Dr David Eccleston @DavidEccleston Demand for #fillers has risen again as the media takes more of a balanced view…

#Safety Harley Academy @HarleyAcademy “Psychological assessment is a mandatory requirement for safe, professional cosmetic practice” – Dr Patrick Bowler #safetraining

#Presentation Dr Nestor @DrNestorD Thank you Mr Paul Banwell for a highly educational and informative talk on cosmeceuticals @PEBanwell

#Patient Dr Kannan Athreya @drathreya Wow what a really busy clinic today with old and new patients but the best of all is that they are happy patients! #Essex #Aesthetics

#Meeting sharonbennettskin @sharonbennettuk Representation today on Scottish meeting for independent clinics inspectorate. Keep you updated. All a changing @aestheticsgroup

#Skin Dr Anjali Mahto @DrAnjaliMahto Evening with @SkinCeuticalsUK and the lovely @yannray #bbloggers #aesthetics #skincare

FDA approves LaserCap

Training

New training provider launches in Cheshire A non-surgical cosmetic training provider has launched in Cheshire to provide educational classes in anti-ageing treatments. Facethetics Training, launched by Private Independent Aesthetic Practices Association (PIAPA) cofounder Yvonne Senior, will train practitioners in dermal fillers, botulinum toxin, chemical skin peels, dermal rolling, PRP and PDO thread lifting, as well as the Five-Point Lift. Both foundation and advanced level courses will be available depending on practitioner experience and courses will be limited to small groups, which will take place either at the Facethetics training school in Cheshire, or privately in a practitioner’s clinic. Senior said, “We are really excited about this new venture. It is our ethos to make sure that all of our delegates are able to carry out aesthetic procedures safely and successfully.”

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Awards

Voting for Aesthetics Awards 2015 to close October 30 The voting process for this year’s Aesthetics Awards is to close on October 30. With finalists of the awards announced in last month’s issue of Aesthetics journal, the voting and judging process began on September 1, with Aesthetics journal readers able to vote in nine categories.

An expert judging panel will also assess all entries to decide a winner for 23 categories. Awards will be presented to individual practitioners, associations, manufacturers and distributors who have made an impact in the industry over the past year, through clinical excellence, customer service and product innovation. This year’s judging panel includes Aesthetics journal editor Amanda Cameron, consultant plastic surgeon Mr Dalvi Humzah, dermatologist Dr Stefanie Williams and last year’s AestheticSource Lifetime Achievement Award winner Dr Roy Saleh.

Vote for this year’s finalists at www.aestheticsawards.com Dermal fillers

Global dermal fillers market expected to grow by 13% A report has estimated that the worldwide dermal facial fillers market is expected to grow by 13% in the next four years.

The Global Dermal Facial Fillers Market Report 2015-2019 suggested the compound annual growth rate is down to key market trends; including the increasing demand for non-surgical procedures and the popularity of hyaluronic acid fillers.

It stated that North and South America were the largest contributors to the dermal filler market in 2014, followed by Europe and the Middle East. Asian Pacific (APAC) countries including Japan, Singapore, Australia and China are considered the main contributors to the APAC region, due to an increase in the middle-class population, a larger awareness of cosmetic procedures and rising incomes.

Skincare

Aesthetics

Vital Statistics A survey of 2,000 women found that 66% reported prejudice or abuse because of skin conditions (SEQuaderma)

79% of 101 women

suffering from hair loss said they think men find them less attractive (LaserCap Company)

Non-invasive procedures performed on 20-29 year olds in 2014 reached 568,000 in the US. (American Society of Plastic Surgeons)

Skin texture and discolouration was highlighted as a concern for 72% of people (American Society for Dermatologic Surgery)

A parent with psoriasis has a 1 in 4 chance of passing the condition on to their children (British Skin Foundation)

iS Clinical releases two new products Skincare brand Innovative Skincare (iS) Clinical has launched two new additions to its range of paraben-free products, which aim to stimulate collagen-synthesis and minimise pore size. The Tri-Active Exfoliant and the Hydra-Intensive Cooling Masque are both indicated for normal, dry or oily skin and, according to iS Clinical, can be used in post-procedure regimes. The Hydra-Intensive Cooling Masque aims to treat inflammation with aloe barbadensis leaf extract, sodium hyaluronate and resveratrol for protection from environmental stress and UV photo-exposure while the Tri-Active Exfoliant aims to instantly smooth and polish skin, with active ingredients including copper PCA, papain enzymes and bromelain enzymes. Alana Marie Chalmers, director of Harpar Grace, the UK distributor of iS Clinical, said, “We are delighted to be introducing two new highly effective treatment formulations.”

95%

of beauty product brands use Instagram

(Business Intelligence for Digital)

People with more than 50 moles have an increased risk of developing melanoma (American Academy of Dermatology)

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Radiofrequency

Study shows long-term lifting results in Asian skin A recent study published in the Lasers in Surgery and Medicine journal has indicated that the Endymed 3Deep applicator, The Intensif, can produce long-lasting contouring and lifting results in Asian skin.

The study, which was led by Dr Yohei Tanaka in Matsumoto, Japan, analysed results in 20 patients between the ages of 31-80 with just one single treatment using the applicator. 3D photography and histology was then used to fully assess volume changes in

the patient’s skin six months post treatment. The study recorded a significant amount of facial lifting on two-thirds of the face, as well as the cheeks, nasal and perioral areas. Six months post treatment, 90% of the patient participants reported that they were ‘satisfied’ or ‘very satisfied’ with the end results.

The applicator, which received FDA clearance in March 2014, has a penetration depth of up to 3.5 millimetres and uses a maximum power rate of 25 watts.

Research

Melanoma

Avita Medical partners with the University of Huddersfield Medical technology company Avita Medical has announced its partnership with the University of Huddersfield to research the effectiveness of Regenerative Epithelial Suspension (RES) in treating burns and skin trauma patients.

The research, which will be using the company’s CE-marked ReCell device, will aim to provide a greater understanding of the cellular interactions present in RES and the roles played to regenerate natural and healthy skin. Adam Kelliher, chief executive officer of Avita Medical said, “Our goal with this study is to further unlock understanding of the mechanism within the active suspension, so that we will be able to further discern the intricacies behind why ReCell is so effective for wound treatment.” He continued, “Our patients are at the centre of everything Avita Medical does and they will benefit from the deeper knowledge that we will achieve through this collaboration with the University of Huddersfield.”

Dr Nikolaos Georgopoulos, senior lecturer of Biological Sciences at the university said, “The collaboration is also an ideal opportunity for the Institute of Skin Integrity and Infection Prevention. We are an inter-disciplinary group whose members can pool an enormous range of expertise. This will serve us well as we investigate the full potential of Regenerative Epithelial Suspension. It is an exciting project that promises to produce real benefits.” Avita Medical and the University of Huddersfield have also announced that they intend to finalise a longer-term strategy in analysing the RES structure.

Skincare

Environ launches intensive beauty cream Skincare manufacturer Environ has released a new multipurpose beauty cream that aims to enable the restoration of collagen and improve overall skin appearance.

Developed by South African plastic and reconstructive surgeon Dr Des Fernandes, the new formula has been developed with three peptides; Matrixyl 3000, Trylagen and Matrixyl Synthé 6, which aim to enhance the skin’s effects of natural sun protectors and create overall smoothness. Clare Muir, director of training for the International Institute for AntiAgeing (iiaa) said, “The new Intensive Avance DFP 312 Cream intelligently combines a scientific formulation of three powerful super-smart peptide complexes designed to maintain the skin’s youthfulness.”

The Intensive Avance DFP 312 Cream is distributed by the iiaa and is available now.

FDA accepts sBLA review for melanoma treatment US pharmaceutical company Merck has announced that the FDA has approved a review for a supplemental Biologics License Application (sBLA) for the melanoma treatment Keytruda.

The PD-1 therapy, which was made available in the UK in October last year through the Early Access to Medicines Scheme, is seeking approval to become the first line of treatment for melanoma patients. The review is supported by the company’s phase III randomised study, KEYNOTE-006, where 834 patients from 16 countries with unresectable or metastatic melanoma were treated with Keytruda. According to the study, results proved that the treatment was superior to ipilimumab, a drug used to treat advanced melanoma, in overall survival (OS), progression-free survival (PFS) and overall response rate (ORR). OS was improved by 30% compared to ipilimumab, with 74.1% for Keytruda and 58.2% for ipilimumab, ORR was recorded at 33.7% (ipilimumab 11.9%) and the median PFS rate was 5.5 months (ipilimumab 2.8 months). Dr Roger Perlmutter, president of Merck Research Laboratories, said, “Through our clinical programme for Keytruda, we have accumulated substantial data on the role of our anti-PD-1 therapy in advanced melanoma.” He continued, “We look forward to the FDA’s review of each of these applications, and to delivering on our goal of helping patients with advanced melanoma to achieve long-term disease control and survival.”

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Awards

Book your tickets for the Aesthetics Awards 2015 With tickets for this year’s Aesthetics Awards selling fast, the entire medical aesthetics community is looking forward to a night to remember. The ceremony, which will take place on December 5 at the Park Plaza Westminster Bridge Hotel, will recognise Commended and Highly Commended finalists and Winners in 23 categories, as well as the chosen recipient of The Schuco International Award for Special Achievement. The Aesthetics Awards is the leading industry event for practitioners and other medical aesthetic professionals to network with clients and colleagues, while celebrating the achievements of the specialty in 2015. The awards will host 500 guests and the evening will commence with a drinks reception, followed by a formal dinner and entertainment from popular British comedian Simon Evans before the trophy presentation ceremony begins. To end the evening, guests will be invited to enjoy dancing and music late into the night.

To book your ticket, visit www.aestheticsawards.com Psoriasis

Pharmaceutical companies partner for psoriasis trial drug Pharmaceutical company Valeant has entered into a collaboration agreement with UK biopharmaceutical company AstraZeneca to develop and market an experimental treatment for psoriasis. Brodalumab, which aims to prevent the body from receiving signals that could lead to inflammation, is currently in development and targeted to patients with moderate-to-severe psoriasis. J. Michael Pearson, CEO of Valeant said, “We are delighted we were able to reach a licensing agreement with AstraZeneca to commercialise Brodalumab, which is potentially the most efficacious therapy yet for moderate-to-severe plaque psoriasis. We remain fully committed to dermatology and will continue to advance our pipeline of internally developed and acquired products.” The treatment is supported by research from three phase III studies involving 3,500 patients, where, at a recorded dose of 210mg every two weeks, Brodalumab was shown to be superior to a placebo and the National Institute for Health and Care Excellence accredited drug, Ustekinumab at week 12. Regulatory submission in the EU and US is due in late 2015.

Skin disease

Humira gains FDA approval for Hidradenitis Suppurativa The Food and Drug Administration (FDA) has approved the use of adalimumab (Humira) in adults with moderate to severe hidradenitis suppurativa (HS).

HS, sometimes known as acne inversa, is a painful, long-term skin disease that causes abscesses and scarring on the skin. Inflamed sweat glands and plugging of the hair follicles are linked to the condition but no exact cause has been proven.

In a clinical study, 633 patients with HS were given either adalimumab or a placebo.

Results showed that patients given adalimumab had significantly reduced signs of the condition. “Hidradenitis suppurativa is an under recognised and often devastating disease affecting women and men in their early adulthood and for years to follow,” said Dr Alexa Kimball, director of the Clinical Unit for Research Trials and Outcomes in Skin at Massachusetts General Hospital. “Having a validated treatment option with rigorous data to support its use is a major step forward for our patients.”

60

James Anderson, Managing Director of Naturastudios What do you think has contributed to Naturastudios growth within the last year?

It’s been an exciting 12 months at Naturastudios. We’ve added pioneering new products and innovative systems to our already impressive portfolio. Our growth has mainly been down to our ground-breaking equipment with the key players being our Dermapen™ skin needling device, which is the original trademark and now a very successful global brand, and our Magma Diode Laser and IPL platform, which both give outstanding results. Our Magma system is one of the few machines able to treat all skin types with results achieved in fewer treatments. All this, combined with our continued focus of providing superior results, has seen Naturastudios evolve as a company to become one of the world’s leading aesthetic suppliers. To mark this achievement, we’re sporting new silver branding, showcasing a new aesthetic brochure and launching a state of the art exhibition stand.

Our growth has also been recognised by the Aesthetics Awards 2015, with two nominations for our Dermapen device and our national sales manager, Simon Ringer.

Is your tagline ‘the pursuit of skin perfection’ something you as a company still stand by?

Yes, 100%. At Naturastudios, we pride ourselves on an ethos that centres on helping our customers and their clients in the pursuit of skin perfection.

We’re passionate about searching for the latest, innovative technologies and travel the world to bring the best, high-grade systems to the UK. Regardless of age, gender or ethnicity, we have a complete range of products and treatments to suit all desires and needs.

What can we expect from Naturastudios in the future?

I can reveal that we’re very excited to be launching our new Mesotherapy range, Ameson, and our tattoo removal system in the near future. As well as launching new systems, we’ll be promoting our existing portfolio of aesthetic equipment at exhibitions in 2016. We’re also keen to open more training clinics in the UK, alongside our flagship centre in Chichester, where we can showcase our products and services. Last but not least, we’re looking forward to continuing our partnership with Dr Sherif Wakil as brand ambassador for Dermapen™, and working alongside other prestigious clinics on London’s Harley Street.

This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Events diary 3rd October 2015 British Association of Cosmetic Nurses Conference, Birmingham www.bacn.org.uk/events/bacn-annualconference-exhibition

15th - 17th October 2015 12th Annual Anti-Ageing Conference, London www.antiageingconference.com

23rd - 24th October 2015 AMEC 2015 European Congress www.euromedicom.com/amec-2015

5th December 2015 The Aesthetics Awards 2015, London www.aestheticsawards.com

28th - 31st January 2016 IMCAS World Congress 2016 www.imcas.com/en/attend/imcas-worldcongress-2016

15th - 16th April 2016 Aesthetics Conference & Exhibition, London www.aestheticsconference.com

Thread lifting

Silhouette Soft gains SNCH approval for neck and eyebrows An EU regulatory body has given its approval to Silhouette Soft being used in more areas of the face. The Socièté Nationale de Certification et d’Homologation (SNCH) – that conducts tests to verify a product’s efficacy, quality, reliability and safety – has given certification and endorsement to the re-absorbable surgical threads treatment being used in the neck and eyebrows. The approval means that practitioners are now allowed to treat a greater number of areas of the face as, up until now, it had only been possible to treat the mid-face area with the threads. Aesthetic practitioner Dr Kuldeep Minocha said of the approval, “These are two really exciting areas for which the licence has been extended for Silhouette Soft. The brow is so often an area that we can improve only slightly with the use of botulinum toxin or dermal fillers. Silhouette Soft can now be added as a proven modality of treatment to lift and shape the eyebrow and reduce the appearance of hooding and tired-looking eyes – without the need for surgery.”

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Technology

Leo Pharma leads investment in melanoma app Global pharmaceutical company Leo Pharma has invested $3.4 million into the dermatology app company SkinVision for the app to move beyond analysis of melanoma and investigate other skin conditions. The agreement will see LEO Pharma collaborate with the SkinVision leadership team to aim to expand the reach of SkinVision’s technology solutions, allowing for focus on other areas of skin analysis. Kim Kjoeller, senior vice president of global development at Leo Pharma said, “We are very pleased to collaborate with SkinVision as we will gain unique insight into the convergence of digital technologies with medical applications. This is a huge opportunity for the European technology and pharmaceutical industries to become world leaders.” The app, which initially launched in 2011 as Skin Scan, allows users to upload images of any suspicious moles and provides a risk rating for melanoma to highlight any abnormalities. Dick Uyttewaal, CEO of SkinVision, said, “The new funding round will be used to expand geographically and broaden the scope of the offering to customers with other serious skin conditions. We will also look to establish a stronger link with national health systems in our chosen markets to enable our users to engage online with the health system.” Awarded a European CE mark in 2013, assessment of risk level is rated on a scale of red (indicating a developing melanoma), orange (further analysis of the mole may be needed) or green (no further analysis is needed).

Skincare

Skinceuticals releases anti-photoageing cream Skincare manufacturer Skinceuticals has launched the Metacell Renewal B3 cream to treat the early signs of photoageing. According to a 12-week study conducted by the company, there was a 24% increase in skin barrier function and 18% improvement in hydration of the 56 participants. A 20% increase in the barrier repair protein involucrin was recorded and a further 20% decrease in tyrosinase, an enzyme which is responsible for melanin production. Professor Jim Krol, global scientific director of SkinCeuticals who led the research, said, “For us as a brand, this is a revolutionary product as it is targeted to the younger consumer. Concerns that we see in younger people are not as advanced compared with older consumers, therefore we had to develop the right texture which can address early signs of photoageing.”

He continued, “This did prove a challenge, and it was incredibly important to get the right texture, with the speed which you mix the ingredients, the size of the blades, the heat transfer – everything matters as it will completely change the texture of the product.” The product consists of three key ingredients; niacinamide, which strengthens the skin’s moisture barrier and reduces localised discolouration, tri-peptide concentrate to enhance skin firmness and support natural hyaluronic acid synthesis, and glycerin which aims to penetrate the skin for intense hydration without disrupting the barrier. Further research is currently being conducted for combining an IPL treatment with Metacell Renewal B3.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Conference

Aesthetics Psoriasis

More details announced for ACE 2016 programme

The Aesthetics Conference and Exhibition (ACE) steering committee has revealed further details of the educational programme for the 2016 event. To be held on Friday 15 and Saturday 16 of April in central London, ACE is set to remain the UK’s leading medical aesthetics conference and exhibition through its comprehensive clinical and business agendas, vast networking opportunities and high quality exhibitors.

Chair of the steering committee consultant plastic surgeon Mr Dalvi Humzah, along with international speakers Dr Raj Acquilla and Dr Tapan Patel and chair of the British Association of Cosmetic Nurses, Sharon Bennett have joined with ACE conference programme organiser Amanda Cameron to provide 2016 delegates with an even more engaging agenda, packed full of CPD accredited education.

The steering committee has announced that the premium content Conference agenda will comprise eight modules, each centred on one key anatomical area. Sessions will include those focused on the peri-orbital area, forehead and temple, lower body, and peri-oral region, amongst others. Each module will feature multiple presentations from leaders in the field and will include discussions on relevant anatomy, assessment, treatment options with live demonstrations, and complication case studies. ACE 2016 will again feature the extremely popular live demonstration Expert Clinic agenda. With sponsored sessions already announced by Syneron Candela, Healthxchange, AestheticSource, Aestheticare, Skinceuticals, Rosmetics, BTL Aesthetics, Lynton Lasers and Fusion GT, the programme will also feature more than a dozen nonsponsored treatment technique insights from the most successful practitioners. Also included in the Free Exhibition Pass will be in-depth sponsored Masterclass presentations showcasing best practice methods with the latest products, as well as invaluable guidance from experienced consultants in Business Track workshops. New for 2016 will be the Treatments on Trial sessions, to be held on Saturday 16, where delegates will have the unique opportunity to directly compare products and treatments with similar indications, in supplier head-to-head demonstrations and debates. With respected speakers including Dr Maria Gonzalez and Dr Daron Seukeran already confirming their participation in the clinical agenda, ACE will once again deliver unrivalled education for medical aesthetic professionals and those involved in aesthetic practice. Practical demonstrations will be mixed with anatomical video exploration along with presentations and discussions, covering the breadth of the specialty.

To register your interest and keep up to date with the latest developments and announcements, visit www.aestheticsconference.com

Study claims psoriasis and acne respond to the change in seasons A study published in the Journal of the American Academy of Dermatology has indicated that the symptoms of psoriasis and acne clear up in the summer and worsen in the winter.

Researchers found 20% of participants’ psoriasis cleared up in the summer, compared to 40% who flared up in the winter. Of patients with acne, 17% noticed an improvement in summer compared to 46% who flared-up in winter. The researchers said, “Winter flaring of psoriasis may be caused by the season’s cold temperature, darkness and low humidity, which can increase skin permeability, epidermal thickening, and stimulate inflammatory mediator production.”

They continued, “Its summer improvement may be attributed to the sun’s known immunomodulatory and bactericidal effects. Similarly, acne’s summer/autumn improvement may be caused by decreased inflammation from ultraviolet light-induced immune suppression and/or decreasing Langerhans cell reactivity.”

Complications

Aesthetic nurse launches emergency treatment bags Aesthetic nurse Jacqueline Naeini has launched Managing Complications Emergency Bags for practitioners, which include essential tools in dealing with possible complications post procedure. The British Association of Cosmetic Nurses member, who runs the Face Training Company in South Yorkshire, initially created her own emergency bag due to travelling between locations and fear of forgetting necessary items. Naeini said, “In the past, I have shown delegates my own emergency bag and its contents. Because of this, I received many requests to create additional emergency bags, so I decided it would be a good idea to allow all delegates the chance to purchase one on completion of the course.”

She continued, “We now receive independent requests from nurses in the specialty, who say that they feel much safer having all emergency supplies in one organised bag.” The emergency bag contains; a copy of Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment by Mr Christopher Inglefield, Fiona Collins and Marie Duckett, guidance and consent forms on the use of hyaluronidase, a guidance document on the possible event of an anaphylactic reaction, syringes and needles, heat pads, a respiratory support mask, aspirin, antihistamines and sterilising materials.

Practitioners are also advised to add prescription drugs such as adrenaline and hyaluronidase. Practitioners who have not completed a training course with the company are still able to request an emergency bag.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Topical

Murad launches Collagen Support Body Cream Skincare manufacturer Murad has added a new product to its Youth Builder body range that aims to lock in moisture and nourish the skin. The Collagen Support Body Cream intends to reduce the visible signs of ageing for a more youthful appearance and triple skin’s moisture levels upon application. Dr Murad, founder of the company, said, “Citrus aromas of lemongrass, vetiver and bergamot are designed to provide a therapeutic experience to help ease nerves and combat stress-induced cellular ageing. This light and refreshing aroma helps revitalise the body and unwind a busy mind.” As well as the key ingredients of hyaluronic acid and anti-ageing peptides, the collagen cream also includes shea butter, sunflower seed oil, jojoba extract and vitamin E. PDT

Daylight PDT an effective solution for actinic keratosis New evidence presented at the American Academy of Dermatology summer meeting, suggests daylight photodynamic therapy (PDT) to be an effective treatment for large disseminated areas of actinic keratosis. A presentation from Dr Emily J Fisher, director of Mercy Health Physicians in Ohio, suggested that PDT is as effective as topical treatments such as 5-fluorouracil and imiquimod.

According to the presentation, most aspects of daylight PDT are the same as conventional PDT. The skin is first prepared by removing scales and crusts to improve penetration of the photodynamic agent, using aminolevulinate acid (ALA) or methyl aminolevulinate (MAL). Before light exposure, the occlusion time with the photodynamic agent is three hours. In addition, light exposure in both cases should begin within 30 minutes. Dr Fisher said, “I think that over the next few years, this is going to have a big place in patient treatment. It is more convenient and better tolerated.”

Industry

Tributes paid to Oxygenetix founder The founder and developer of Oxygenetix post-procedure foundation, Barry Knapp, has sadly passed away following a house fire on August 23. With a career in the beauty and cosmetic industry spanning 25 years, Knapp achieved international success with the creation of Oxygenetix. He successfully created the foundation’s Ceravitae formula, which aims to proliferate collagen cell and connective tissue growth in ageing or wounded skin to enhance beauty and promote optimum skin health.

David Gower of Medical Aesthetic Group – the distributor of Oxygenetix in the UK, said, “Barry Knapp rushed into our life in March 2014 when we began representing the unique post-procedure product Oxygenetix that he had formulated and is now sold in more than 40 countries worldwide. Those who met Barry recognised his passion and deep knowledge for his subject. In the short period of our relationship we became firm friends.

We had great plans for the future, which will be delivered. I will miss him.”

According to Medical Aesthetic Group, Knapp leaves behind children, three brothers and a loving mother and father, who inspired and influenced his commitment to the beauty and wellness industries.

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News in Brief North east clinic re-launches to link with training company Aesthetic clinic Skincare Rejuvenation Aesthetics is rebranding to Face Cosmetic Clinic to coincide with its training company Face Cosmetic Training. The clinic offers a range of anti-ageing treatments in six locations including Huddersfield, Wakefield and Barnsley, and will open a seventh clinic in 2016.

Fusion GT partners with Oxygenetix Aesthetic supplier Fusion GT has partnered with Oxygenetix to promote the use of its healing foundation post-treatment. Fusion GT, the supplier of the non-invasive soft surgery treatments Plexr and Vibrance, aims to ensure that patients receive the best coverage post treatment. The company recommends the use of Oxygenetix to proliferate collagen cell and connective tissue growth in ageing or wounded skin.

Scandinavian Skincare Systems UK named distributor of Hyabell dermal fillers Hyabell hyaluronic acid dermal fillers with lidocaine are to be distributed by Scandinavian Skincare Systems in the UK. The new Hyabell filler, which will also be distributed in Norway through Scandinavian Skincare Systems, aims to offer safe, gentle and effective results. The filler uses monophasic particle technology (MPT) during the production process, which aims to give Hyabell a much gentler extrusion force.

Murad launches new Exfoliating Collection Skincare brand Murad has launched an exfoliating range with a product for every complexion. The three exfoliators aim to safely ‘buff and polish’ different skin types. The Skin Smoothing Polish targets dull, uneven skin texture, the AHA/BHA Exfoliating Cleanser aims to help combat dehydrated and the Transforming Powder aims to keep blemishes at bay in oily skin.

Cosmetic Facial opens in Marylebone Cosmetic treatment group Cosmetic Facial has announced the opening of a new clinic on Cleveland Street in Marylebone.

Operated by managing director Janna Tobit and clinical director Dr Fara Didar, the branch is set within the Maple Dental Clinic and will provide aesthetic and dermatology treatments including; facial peels, lip fillers, micro-needling, facial contouring and platelet-rich plasma treatment.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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SkinCeuticals Preview Evening, London SkinCeuticals invited aesthetic practitioners to a preview evening of the Metacell Renewal B3 at the Rosewood London Hotel on September 14. The evening began with a networking and drinks reception, followed by a presentation from Professor Jim Krol, global scientific director of SkinCeuticals, who discussed the science behind the new product, and presented case study images of the average result recorded. SkinCeuticals said that they decided to take this approach as they wanted to present overall outcome, which greater reflects the average results patients can expect. Following six years of research and development, Metacell Renewal B3 has been specifically created to treat the early signs of photoageing in younger skin. Dr Martin King, aesthetic practitioner and co-founder of the Cosmedic Clinic in Tamworth said, “I thought the presentation was very good and it’s nice to see new products coming along that are backed up by good clinical studies. One of the best things I heard this evening was the term ‘pre-rejuvenation’, as it is quite refreshing for SkinCeuticals to release a product which is targeted to the younger market.”

Aesthetics

Ellansé ‘Train the Trainer’ event, Manchester Aesthetic practitioners and trainers were invited to an Ellansé two-day training course at the Healthxchange Academy in Manchester on September 9 & 10. The first day began with a welcome reception and presentation from Chris Spooner, CEO of Sinclair Pharma, on the company history and focus for 2016, followed by a champagne and canapé reception and group dinner. Board certified plastic surgeon, Dr Pierre Nicolau, led the second day with an introduction and masterclass presentation. A live demonstration and discussion session then followed, which was presented by Dr Gareth O’Hare, medical director of Skinfinity Cosmetic Clinic in Leeds. The course rounded off with a question and answer session. Dr O’Hare said, “The two day event was fairly informal, and meeting the CEO of Sinclair was really interesting as he gave an overview of the history of the company, and insights into his plans for the future. Training courses such as this are always very important for highlighting the difference between different products.”

Independent clinics’ stakeholder meeting, Edinburgh The planning and quality division of the Scottish Government Health and Social Care Directorates held a stakeholder meeting to discuss the regulation of independent clinics in Scotland on September 1.

The meeting, which took place at St Andrew’s House in Edinburgh, hosted a number of groups and representatives from the aesthetic specialty, as well as other independent clinic sectors that will be affected by the regulation when it is implemented in April 2016.

Members of the Scottish Cosmetic Interventions Expert Group (SCIEG), which was established by the Scottish Government in January 2014 to make recommendations for the implementation of independent healthcare regulation, were also present. Stakeholders discussed how the initial regulation framework for independent clinics had been put together so far, the recommendations of the SCIEG report published in July, and the intention to start implementing the regulation next year.

Suzanne Armstrong, nurse prescriber and BACN representative in the High Quality Care (HQC) group, a subgroup of SCIEG, explained that stakeholders discussed the SCIEG’s plans for a three-phase regulation programme that would aim to protect consumers from potentially unsafe practice. The SCIEG report explains that the first phase will allow the inspection of independent clinics providing services by regulated healthcare professionals, while the second phase will allow for the regulation of independent cosmetic practitioners who are not members of a statutory register (e.g. beauticians, hairdressers or similar therapists). The third phase will consider the voluntary or legislative options for any additional healthcare professionals who provide services and wish to be accredited. Armstrong explained that while the first phase will be implemented in April, as of yet, there has been no dates set for the implementation of phase two. She said, “I feel proud that the uniqueness of Scottish law has prevailed and finally a degree of protection will be put in place to try to ensure the public receives

safe, effective and high quality aesthetic healthcare. However, I am still concerned about who may be delivering care in Scotland. If things go ahead as planned, all our efforts will focus on those already regulated by their professionals bodies and untrained or insufficiently-trained people can continue to purchase dermal fillers on the internet and inject them into patients who do not realise the risks that they are laid open to.” Jackie Partridge, nurse prescriber and BACN representative at the meeting, added that concerns were raised in the meeting that tighter regulation may force rogue traders underground, which would not be beneficial to the independent clinic sector as a whole.

Aesthetic nurse Helena Collier said, “The independent clinics are actually the minority, they are low risk providers and there is a very high likelihood that these practitioners are delivering safe and effective care, and meeting the criteria expected of an independent private clinic. I am concerned about inappropriate people injecting the public in inappropriate environments.” Other concerns suggested that the public might actively seek the services of non-regulated individuals, as regulation may impact on treatment costs within independent clinics. While the stakeholder meeting only served as an opportunity for discussion, Partridge said it has formed the foundations for the Health Improvement Scotland (HIS) meetings that will take place from now until April. Partridge will sit on the Independent Healthcare Programme Board as the BACN representative, alongside Dr Nestor Demosthenous on behalf of the British College of Aesthetic Medicine, and other independent clinic representatives. Members will meet with HIS to discuss and decide upon the final regulations to be implemented in April 2016. Speaking on behalf of the BACN, Partridge concluded, “There will be many practitioners feeling uncertain at this time, however it is important to remember that the main aim of regulation is to improve standards, and this is certainly what the board will endeavour to do.”

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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BACN and BCAM Joint Regional Scottish Meeting 2015 The British Association of Cosmetic Nurses (BACN) and British College of Aesthetic Medicine (BCAM) held their first combined meeting in Scotland on September 5. The one-day event, which took place at the Crieff Hydro Hotel in Perthshire, Scotland, opened its doors to an array of medical professionals, including surgeons, doctors, nurses and dentists interested in or practising medical aesthetics. BACN board member, and one of the main event organisers, Frances Turner Traill, said the meeting had a fantastic turnout, with even more delegates attending than those who had originally registered. The varied agenda included a masterclass demonstration of injection techniques by Dr Raj Aquilla; a presentation on the Galderma ‘Proof In Real Life’ campaign by Dr Kuldeep Minocha, who also conducted a patient demonstration using Restylane Skin Boosters; and a discussion on managing complications with Mr Taimur Shoaib, which generated plenty of audience participation.

Mr Paul Banwell also presented on how certain cosmeceutical ingredients work well for specific indications, while Dr Uliana Gout spoke on skin peels, advocating them

as a widely growing treatment request within medical aesthetics.

Dr Sam Robson and Turner Traill then co-presented on appraisal and revalidation for doctors and nurses, which provoked much discourse from the floor.

Also presenting was Dr Sara Davies, a public health consultant for the Scottish government and member of the Scottish Cosmetic Interventions Expert Group (SCIEG), which has recently published recommendations for the regulation of independent clinics in Scotland. Together with the BACN representative for SCIEG, Suzanne Armstrong, they discussed Scotland’s plans for successful regulation of clinics and updated the attendees with its progress.

Dr Nestor Demosthenous, one of the meeting’s organisers, ended the educational agenda by thanking all of the delegates for their participation and attendance. Speaking after the meeting he said, “The conference in Scotland between the BACN and BCAM was a first of its kind for many reasons. It brought together, for the first time in the UK, two institutions whose core values are patient safety and education. Crieff Hydro Hotel was the perfect venue, and provided excellent conference facilities for delegates.”

Dr Kuldeep Minocha added, “The quality of internationally renowned speakers was second to none, covering a range of topics including skincare and lasers as well as the latest use of dermal fillers. This inaugural event was really well received and appreciated by the delegates who are not always able to travel far to receive this quality of education.”

The meeting drew to a close with an informal networking dinner.

Beyond Aesthetics Conference, Manchester The first Beyond Aesthetics conference made its way onto the Aesthetics calendar this year, taking place at the Hilton Hotel in Deansgate, Manchester. The two-day conference, which took place on September 17-18, had a full and varied itinerary, with delegates enjoying talks from Dr Maria Gonzalez, Mr Dalvi Humzah, Dr Daron Seukeran and Mr Sultan Hassan. Using state-of-the-art audio and visual equipment, live injectable sessions were carried out from the HealthXchange Academy by injectors Dr Tapan Patel and Dr Marian Landau, which were very well received by the audience.

Talks included: assessment of the aesthetic patient (Dr Humzah); skin rejuvenation with laser technology (Dr Sean Lanigan); and case presentations on difficult or interesting aesthetic cases. Dr Landau also performed a live demonstration using chemical peels alongside nurse prescriber and director of AestheticSource Lorna Bowes, while Dr Roberto Pizzamiglio and Mr Humzah. presented a session on thread lifting integrated with injectable treatments.

According to Dr Gonzalez, one of the

Beyond Aesthetics organisers, the conference aimed to provide a platform for in-depth, simple and straightforward education on treatments offered by today’s aesthetic practitioner. She said that this had been achieved, explaining, “The event was a great success with the standard of speakers and informative educational talks; it has made for a fantastic couple of days!” Conference delegate and aesthetic nurse prescriber Jacqueline Naeini said, “I thoroughly enjoyed the conference with fantastic speakers and the event stood out for being so intimate.

The live video feed from the HealthXchange academy was brilliant and really made the event. I hope to attend the next one.” Bowes added, “It was such a fantastic event with great content and very impressive mediated sessions with several experts on-hand to discuss their personal approaches. What a great learning opportunity for

the delegates, many who are new to the industry and moving from dermatology to aesthetics.” Alongside thanking the delegates for their attendance and support of Beyond Aesthetics, Dr Gonzalez said she would also like to thank the conference’s exhibitors for their support; Sinclair IS Pharma, Merz Aesthetics, Allergan, Syneron Candela, Lumenis, Aesthetic Source, Cynosure, Cutera, Consulting Room, Church Pharmacy and Swiss Code.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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As many now look to online training as a major source of professional education, Aesthetics investigates the increased use in our industry

The Rise of Online Learning A 2014 survey from the Learning and Performance Institute (LPI), an organisation for workplace learning professionals, showed organisations’ selfpaced e-learning had risen by 59% in just one year; compared to classroom-style training, which had dropped by 29%.1 The response, which came from 320 individuals, including chief executives, general managers and managing directors, showed online learning was growing substantially.2 So why is e-learning on the increase, and can it benefit trainee aesthetic practitioners and those wishing to expand their skillset?

Moving with the times There are many training companies that have introduced online learning within the last few years; the Harley Academy, Cosmetica Training and the Medical and Aesthetics Training Academy (MATA) are just a few aesthetic training organisations that now offer e-learning modules. As well as aesthetic training companies, a number of individual practitioners who provide training are also delivering more webinars and online tutorials to their trainees.

“Innovation is the currency of progress,” says academic technology coordinator, Aran Levasseur who writes for MindShift, an organisation that examines the future of learning. Lavasseur argues, “The social and economic world of today and tomorrow requires people who can critically and creatively work in teams to solve problems. Technology widens the spectrum of how individuals and teams can access, construct and communicate knowledge.”3 Dr Tristan Mehta, managing director of the Harley Academy, agrees the increase in online learning is a positive step. “The main benefit is that it’s flexible. People are very busy nowadays and need to work around existing commitments and at their own pace. E-learning provides a platform for useful tools such as online lectures,

videos, diagrams and more.” Dr Mehta believes that the use of online learning is the only way to adhere to the new guidelines published by Health Education England (HEE), aimed at improving training standards in the industry. Commissioned by the Department of Health, HEE has made recommendations on regulations for the non-invasive cosmetic specialty.

“The new guidelines state training must be delivered at higher education standard, which now means students need anywhere between 50 and 100 hours of teaching time to be able to reach these standards. This is something that can’t be done in a one-weekend training course,” explains Dr Mehta, adding, “the guidelines published by HEE specify that students must pass a rigorous assessment, which takes into account a portfolio of evidence including online learning.”4 Pros and Cons Aesthetic practitioner and trainer Dr Raj Acquilla explains that, although he still spends a significant proportion of his time presenting at congresses, the use of webinars has made it much easier for him from a teaching perspective; “I was working in 40 countries doing big conferences and would sometimes have an audience of up to 3,000 people. At the end, people would come up to me and ask ‘when can I learn from you?’ Unfortunately I can’t be everywhere at the same time, so I created a series of webinars. They have been hugely successful and really compliment my teaching.”

While the use of available resources online can enhance modern-day learning, there are some legitimate concerns. “I could potentially empower bad practitioners who could then go on to do terrible work,” says Dr Acquilla. “I have to purely rely on the integrity of the individual.” There are also limitations, as Dr Mehta explains, “Students will need to have the dedication and

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commitment to do well – that’s key.”

Last year, 74% of companies around the globe used learning management systems (LMS), virtual classroom, webcasting, and video broadcasting.5 This shouldn’t come as too much of a surprise, given that e-learning can half a business’ training costs.6 However, Annequa Bhatti, marketing and model coordinator at the Medical and Aesthetic Training Academy (MATA), said online learning isn’t just about cost cutting, “The online programme at MATA was created to improve the standard of training in the medical aesthetic industry and adhere to the new HEE guidelines.”

Bhatti explains, “We’ve tried to make it ‘fun’; so whilst it’s very informative and rich in content, we’ve tried to make it as interactive and engaging as possible to keep people’s attention.”

An additional concern is that the transparency of learning online could cause some practitioners to feel vulnerable; worrying their techniques and treatments are been given away too freely. “If you’re a Michelin star chef and you share the recipe for your signature dish, someone could copy it, open a restaurant next door and become a competitor – that might be a worry for some,” explains Dr Acquilla. His belief, however, is that through sharing best practice techniques and treatment, practitioners are improving both the standards and aesthetic results within the industry.

Looking to the future Despite some disadvantages, it is predicted that this year, 98% of organisations will use e-learning courses as part of their learning strategy.7 “E-learning is becoming big in every industry; we’re such a digital generation now,” says Bhatti, concluding, “you don’t need the classroom setting to take part in non-practical learning; industries are moving forward.”

REFERENCES 1. Martin Belton, ‘A comprehensive review of the workplace learning sector’, Learning Survey 2014, (2014) 33 (p.8) 2. Martin Belton, ‘A comprehensive review of the workplace learning sector’, Learning Survey 2014, (2014) 33 (p.3) 3. Aran Levasseur, Does our current system support innovation? (2012) <http://ww2.kqed.org/ mindshift/2012/07/17/does-our-current-education-systemsupport-innovation/> 4. Harley Academy, New Guidelines (2015) <http://www. harleyacademy.com/new-guidelines/> 5. Christopher Pappas, The top eLearning statistics and facts for 2015 you need to know (2015) <http://elearningindustry. com/elearning-statistics-and-facts-for-2015> 6. Christopher Pappas, Top 10 e-Learning statistic for 2014 you need to know (2013) <http://elearningindustry.com/top-10-elearning-statistics-for-2014-you-need-to-know> 7. Aurion Learning, 15 E-Learning statistics you need to know for 2015 (2015) http://www.trainingzone.co.uk/blogs-post/15e-learning-statistics-you-need-know-2015/188198

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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seeking more surgical procedures as well. Despite trailing off last year,2 numbers of men having facial cosmetic surgery soared in previous years, peaking in 2013. At that time, according to the British Association of Aesthetic Plastic Surgeons (BAAPS), there was a significant rise compared with the previous year. Most notably, there were increases of 9% in rhinoplasty, 17% in blepharoplasty, 18% in brow lifts, and 19% in face and neck lifts.3 (Figure 1).

This trend is mirrored abroad, where aesthetic and cosmetic procedures have climbed in popularity among male patients over the last five years. In the US, the number of blepharoplasty and face lift procedures has risen by 34% and 44% respectively since 2010, while non-surgical treatments have drastically increased in the same period: botulinum toxin by 84% and hyaluronic acid by a staggering 94%.4 (Figure 2).

On the Face of It: Men in Clinic

Figure 2: US trends in male aesthetic procedures4

With men increasingly opting for facial contouring, Allie Anderson speaks to practitioners about the reasons behind the growth and how male patients are changing the face of aesthetics Oscar Wilde once said that “a man’s face is his autobiography; a woman’s face is her work of fiction”. His words appear to represent a traditional view of gender stereotypes: women present a façade to mask their true appearance, while a man’s visage shows his unaltered, natural self. This view is largely outdated, not least in the context of the aesthetics industry, which is no longer the domain solely of women.

The growth of male treatments There has been a boom in men undergoing cosmetic and aesthetic procedures over the last decade or so, as more and more men succumb to the desire to emulate the looks of celebrities or to retain a youthful appearance.1 Botulinum toxin has emerged as a particular favourite with male patients, with clinics reporting a year-on-year upsurge of up to 40% in the wrinkle-busting treatment.1 This is perhaps unsurprising, owing to the non-invasive nature and relative low cost of botulinum toxin injections, but men in the UK have been Figure 1: UK trends in male surgical procedures3

1200 UK trends for surgical procedures in men 2013 and 2014

1000 800 600 400 200 0000

Rhinoplasty

Blepharoplasty

Otoplasty 2013

Face/neck lift 2014

Brow lift

Procedure

Increase from 2010 to 2015

Blepharoplasty

34%

Face lift

44%

Botulinum toxin

84%

Hyaluronic acid

94%

A different canvas In the UK, practitioners find that men now make up a larger proportion of their total patient cohort than ever before. “I’d say around 20 to 25% of our patients are men these days,” says Maria Phillips, director, nurse prescriber and lead aesthetic practitioner at Beautifil Aesthetics. “We recognise that this is quite a large number, and it’s growing all the time. They come in looking for rejuvenation, to look fresher and more youthful, and they tend to opt for botulinum toxin treatments.” Gender is an important factor not only in what treatments men seek and the outcomes they require, but also in how effective the treatments are, Phillips adds. She reports that men require more botulinum toxin treatments than their female counterparts, as the toxin doesn’t last as long in male patients. “That’s partly because of the physiological differences in the facial anatomy, but also, because men’s metabolisms are faster, so they break the product down more quickly.”

Indeed, their larger skulls, greater muscle mass, higher density of facial blood vessels, and deeper rhytides (compared with women)5 affect how men respond to botulinum toxin injections. A 2013 review of clinical studies in the treatment in men – in which men represented 11.1% of patients overall – reported that botulinum toxin is generally less effective in males and that higher doses are needed to achieve desired results than are typically used to treat women.5 It is also suggested that more injections are needed when treating the frontalis muscle in

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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particular (on account of men having larger foreheads than women), using a flat injecting technique to prevent a feminine-looking arched brow and instead maintain a flat brow position.6 Desired outcomes According to Dr Dan Dhunna, aesthetic practitioner and founder of Skin Etc., male patients are well-informed and decisive about the treatments they want and the outcomes they hope to achieve.

“Men have already made up their minds when they come to see me. They rarely walk in shrugging their shoulders; they usually have a clear idea about what they want,” he comments. “It might be enhancing the jaw or chin, or botulinum toxin in the upper face – but they are after something that’s relatively subtle. They want to be able to see a definitive change themselves, and for others to see an improvement in them, but without people knowing they’ve had work done or being aware of what they’ve had done.”

Likewise, male patients at Revivify London are looking for naturallooking results, says clinical director Dr Souphiyeh Samizadeh. “In general, men want to look fresher, healthier and less tired. They don’t necessarily want to look beautiful, have high cheek bones, soft silky skin and high-arched brows,” she says. “Men prefer to have lines and wrinkles, but shallower and less evident.” Dr Samizadeh suggests that the best candidates for facial contouring are middleaged men and athletes, the former able to achieve a fresh, rested appearance and the latter seeking to correct the loss of facial fat.

Many practitioners categorise male patients by the factors that motivate them to have facial contouring; broadly, to compete in the workplace, to attract a partner, and to boost their self-esteem. “Male patients generally seek to become more handsome or younger,” explains Dr Dogan Tuncali, who practices in Turkey. “The former seek attention from their female counterparts, and the latter mainly seek to prolong social and professional acceptance, trying to show society that he is still dynamic and full of energy.” Phillips agrees, adding that major life events – such as relationship breakups or divorce, or looking for a new job – can leave men feeling deflated and in need of a lift, metaphorically and literally. She suggests, “It’s a great confidence boost and can greatly benefit self-esteem.”

This notion is supported by research: a RealSelf survey revealed that of 700 men and women exploring cosmetic surgery options, 76% wanted to feel confident after their procedure.7

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Many practitioners categorise male patients by the factors that motivate them to have facial contouring; broadly, to compete in the workplace, to attract a partner, and to boost their self-esteem

natural-looking results, maintaining the person’s individual look but bringing the nose more in balance with the rest of the face.

Notwithstanding men who seek to correct perceived or actual anatomical flaws they were born with, many more are driven by social norms, perceptions and patterns. “In the modern world in which we live, appearance is very important, whether it’s professionally, socially, or when it comes to looking for a partner,” Dr De Silva adds. It’s generally accepted that in many aspects of life, attractiveness is directly proportional to success and achievement; for example, attractive people have more dates, are perceived to have positive personality traits, and are more likely to be successful in job interviews.8 Attractiveness is largely a subjective measure, and this is reflected in what male patients request. Dr Dhunna suggests that younger male patients often seek “outcomes more skewed towards a feminine look”, because they are influenced by metrosexual imagery and social media. However, practitioners report that a key factor when treating men is to avoid over-feminising the face, often preferring to masculinise features. “There are certain parts of the face that are more masculine, and men who are considered handsome and good looking tend to have very strong jawlines,” says Dr De Silva. “In patients with a weak jawline, you can make real improvements and give a stronger jawline with better facial Social and professional pressures balance and harmony.” The aim would be to sharpen the angle of Dr Julian De Silva, a specialist in facial plastic and cosmetic surgery, the jaw, which Dr De Silva says is “more like 90 degrees” in youth, points out that there are a number of factors that influence how but becomes looser with age. It can be claimed that this typically satisfied men are with how they look. “For example, people with wide-jawed face has implications, with wider-faced men reportedly large noses often were teased about it when they were younger, achieving greater professional success9 and earning more money10 and as a result they might feel that it’s holding them back,” he than their slimmer-faced, narrower-jawed peers. says. On such patients, he would perform a rhinoplasty and aim for With the male nose, Dr De Silva adds, it’s important to keep it in proportion and avoid making it too Before After small, giving it a feminised look.

The final element of a masculine face is the eye area, which needs to be carefully addressed – again, to prevent feminising the face if this is not the desired outcome.

“Blepharoplasty needs to be more conservative in a man, and this can be quite challenging because you could otherwise really change someone’s appearance.”

Before and after chin, jawline and neck augmentation. Images courtesy of Dr Julian De Silva

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Before and after treatment using dermal fillers for mild mid-facial volume loss, minor lip enhancement and jaw-angle enhancement. Images courtesy of Dr Souphiyeh Samizadeh.

Equally important is to avoid excessively masculinising the face, which can produce unnatural results and elicit unwanted reactions, driven by social ideals and perceptions. Dr Samizadeh highlights the need to counsel male patients so they understand the consequences of a procedure. “The perception of dominance, social boldness and physical strength is related to anatomical features that demonstrate high masculinity, such as strong cheekbones and jaw prominence,” she comments. “These can be enhanced in male patients but need a thorough consultation and understanding of the changes. Overdoing male facial contouring, such as creating an excessively large chin, check bones and jaw angles, can result in poor aesthetic results and harsh features – features that are linked to aggressive behaviour.”

In this way, Dr Samizadeh adds, maintaining a balance between slightly feminised and hyper-masculinised features produces optimal results. Interestingly, a recent study into ideals of male attractiveness found differences between what men and women desire: women actually prefer a softer jaw, slimmer face and fuller lips in men, while men tend towards a traditionally masculine look.11 Scientific research supports these findings, suggesting that morphological masculinity bears less influence on men’s attractiveness than has historically been presumed.12 Products and treatments The outcomes men hope for often determine what procedures and treatments are prescribed, and what products the practitioner uses.

When employing non-surgical methods, Dr Tuncali provides a threepart solution, comprising: · Botulinum toxin around the eyes or as part of a Nefertiti lift to contour the jowls and jawline · Short-lasting hyaluronic acid fillers and fat grafting · Mechanical interventions, mainly involving a fractional CO2 laser and high-intensity focused ultrasound (HIFU) “The HIFU system I use has 1, 1.5, 2 and 4mm probes to reach the subcutaneous or muscle tissue,” Dr Tuncali explains, adding that more power is often needed when treating men as they tend to have thicker skin and subcutaneous tissue. “The ultrasound has the ability to focus its energy at a desired depth using different probes, thus the name ‘focused ultrasound’. “After the ultrasound session, I use the in-built 635nm laser to achieve faster healing and drainage, and smoother, brighter skin,” says Dr Tuncali, explaining that the best results are achieved through combining the HIFU and fractional CO2 laser systems. Despite a minority of patients experiencing increased swelling, postoperative recovery and side effects are comparable with those seen when each of these treatments is performed individually, yet overall results are significantly improved.13 Dr Dhunna, conversely, often uses fillers to contour the male face. Here, men’s anatomy and physiology dictates the type of product used. “Men’s skin is thicker,

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hairier and oilier, so when using facial contouring products I tend to use less in volume, but something with a stronger uplift potential,” he explains. “The product must have a good G prime (a measure of the product’s stiffness), but give a sharper result. You need a product that is robust and malleable, which can be good if you want to exaggerate anchor points and widen the bigonial distance.”

Risks and complications The potential for complications is typically no greater among male patients than female patients, practitioners state; but men are often less compliant when it comes to aftercare and general skin care, which can optimise results. “Men of a certain age tend to wash their face with soap and water and very little else. They often think that when they come to see me, they get their treatment with 12 months’ effect, and they’re done. To convince them otherwise can be tricky,” explains Dr Dhunna. Overcoming this barrier involves consulting with each patient to glean an understanding of his lifestyle and to encourage him to embrace the often-new concept of skincare. Crucially, all of the practitioners interviewed said this should always involve high-factor sun protection year-round to prevent further photodamage. Smoking is a particular risk factor for patients of both genders undergoing surgery, Dr Dhunna adds, as it strongly correlates with postoperative pulmonary, cardiovascular and cerebrovascular complications, delayed wound healing and tissue ischemia, particularly in elective facial aesthetic procedures.14, 15, 16 Male and female patients undoubtedly have diverse needs when it comes to facial contouring. Their aesthetic concerns and desired outcomes are driven by different influences, and as a result, practitioners must approach the genders accordingly.

Whatever an individual wants to achieve with facial procedures and treatments, the overarching principle is to manage their expectations appropriately – regardless of gender.

REFERENCES 1. Vicki-Marie Cossar, The rise of Brotox: Plumbers and businessmen copy Simon Cowell’s Botox look (London: Metro.co.uk, 2013) <www.metro.co.uk/2013/02/25/the-rise-of-brotox-plumbers-andbusinessmen-copy-simon-cowells-botox-look-3510335/> 2. The British Association of Aesthetic Plastic Surgeons, Tweak not tuck. New statistics show extreme surgery’s gone bust – surgeons welcome more educated public (London: Baaps.org.uk, 2015) <www.baaps.org.uk/about-us/press-releases/2039-auto-generate-from-title> 3. The British Association of Aesthetic Plastic Surgeons, Britain sucks. Over 50,000 cosmetic surgery procedures in 2013 – Liposuction up by 41% (London: 2014) <www.baaps.org.uk/about-us/pressreleases/1833-britain-sucks> 4. The American Society for Aesthetic Plastic Surgery, The American Society for Aesthetic Plastic Surgery reports Americans spent more than 12 billion in 2014; procedures for men up 43% over five year period (New York: 2015) <www.surgery.org/media/news-releases/the-american-societyfor-aesthetic-plastic-surgery-reports-americans-spent-more-than-12-billion-in-2014--pro> 5. Keaney TC, Alster TS, ‘Botulinum toxin in men: review of relevant anatomy and clinical trial data’, Dermatological Surgery, 39(10), (2013), pp.1434-43.

6. Keaney T, ‘Male aesthetics’, Skin Therapy Letter, 20(2), 2015.

7. Kramer E, Why get plastic surgery? 76% of people say they want to feel… (Seattle: 2015) <www. trends.realself.com/2015/06/25/why-plastic-surgery-confidence-survey/> 8. Little A et al., ‘Facial attractiveness: evolutionary based research’, Philosophical Transactions B of The Royal Society, 366(1571) (2011), pp.1638-1659.

9. Sarah Knapton, Successful male leaders have wider faces than average man. Wider faces make men appear more dominant, ambition and powerful and so better business leaders, a study suggests (London: 2015) <www.telegraph.co.uk/news/science/science-news/11806360/Successfulmale-leaders-have-wider-faces-than-average-man.html> 10. Kevin Short, The shape of your face may affect how much money you make (2014) <www. huffingtonpost.com/2014/08/06/work-success-study_n_5635227.html> 11. Julian Robinson, Most beautiful faces in the world? Scientists use e-fits to create the most attractive man and women – and David Gandy and Kendall Jenner are the closest to real life examples (London: 2015) <www.dailymail.co.uk/femail/article-3017464/Are-perfect-faces-Scientistsmap-features-world-s-beautiful-men-women-asking-100-people-attractive.html> 12. Scott I et al., ‘Does masculinity matter? The contribution of masculine face shape to male attractiveness in humans’, Public Library of Science One, 5(10), (2010).

13. Woodward JA et al., ‘Safety and efficacy of combining microfocused ultrasound with fractional CO2 laser resurfacing for lifting and tightening the face and neck’, Dermatological Surgery, 40(12) (2014) pp.190-193.

14. Coon D et al., ‘Plastic surgery and smoking: A prospective analysis of incidence, compliance, and complications’, Plastic and Reconstructive Surgery, 131(2), (2013), pp.385-391.

15. Rohrich R et al., ‘Planning elective operations on patients who smoke: Survey of north American plastic surgeons’, Plastic and Reconstructive Surgery, 109(1), (2002), pp.350-355.

16. Krueger J and Rohrich J, ‘Clearing the smoke: The scientific rationale for tobacco abstention with plastic surgery’, Plastic and Reconstructive Surgery, 108(4), (2001).

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Male vs. Female Facial Rejuvenation Dr Emma Ravichandran and Dr Simon Ravichandran explore the anatomical differences between men and women and how this can affect aesthetic treatment Introduction In current non-surgical aesthetic practice, we are seeing a steady increase in the number of male patients presenting for aesthetic rejuvenation treatments. The number of men in the United States seeking botulinum toxin injections increased by 268% between 2000 and 2011.1 There has been a range of suggested explanations for this rise, including a growing desire for men to appear more youthful and, therefore, competitive in the workplace, as well as an increasing social acceptability for such procedures.2 Whilst the trend is ongoing, the majority of patients in aesthetic practice are still female.1 This means that busy practitioners who frequently see large numbers of aesthetic patients become very familiar with the female aesthetic, whilst remaining less familiar with the male aesthetic.

Unfortunately this shift in skill to the female side means that male patients can receive sub-standard or inappropriate treatments, as it is clear that the male form differs from the female, and, accordingly, an approach to female rejuvenation and beautification will not result in a satisfactory outcome when applied to a male face.

In todayâ&#x20AC;&#x2122;s competitive aesthetic market, where practitioners find themselves competing with less-trained and non-medical service providers delivering the same treatments over and over again, it is vital that the expert stands above the rest and differentiates his or her practice with high-quality techniques that deliver outstanding results based on superior knowledge.

In order to develop the skills required to provide excellent aesthetic rejuvenation treatments to both men and women, an understanding of sexual dimorphism is required, coupled with a profound appreciation of both male and female beauty. This article aims to outline the differences between male and female facial anatomy, and their relevance to aesthetic rejuvenation procedures. It is intended as a guide rather than a set of instructions, to allow the reader to subtly alter their approach between male and female patients, and modify their techniques accordingly. The article is split into segments detailing specific areas, which, when taken as a whole, will allow a holistic appreciation of the subtle differences in anatomy and, accordingly, treatment. We will not, on this occasion, address the issues of feminisation of a male face. The knowledge and skills required for such outcomes not only encompass prior understanding of the anatomy of both the male and female face, as outlined in this text, but also detailed specialist understanding of the psychology of the patient requesting such treatments. We therefore consider it to be outside the scope of this article.

The Forehead Often the last approached area in non-surgical facial rejuvenation,3 the forehead is actually one of the most important areas for rejuvenation where marked differences are noticeable between the sexes. Anthropologists studying skulls use the skeletal

structure of the forehead as a significant indicator as to the sex of the skeleton4 (Figure 1). The forehead begins at the supraorbital ridge inferiorly and runs superiorly to the hairline. The female skeleton characteristically has a flat supraorbital ridge with a smooth convexity running up to the hairline, while the male skeleton has a prominent and more projected supraorbital ridge, above which is a concavity before it flattens and becomes concave again.5 This convexity gives rise to the appearance of supraorbital bossing in males. The prominent supraorbital ridge is medially continuous with the glabella, giving rise to a more pronounced and projected glabella region in males.5 This skeletal difference gives rise to three important sexually-defining characteristics; the prominent glabella and supraorbital bossing as described, and also the skeletal structure that influences the overlying soft tissues, and thereby the position of the eyebrows.

The male eyebrow sits along the supraorbital ridge and is generally flat,6 whereas the female brow starts medially in the same position, but arches superiorly at an angle of between 10 and 20 degrees with the tail more superior to the head.7 The goal of medical aesthetics is to restore a youthful and, most importantly, natural appearance. As such, the techniques that we apply to a female patient, such as forehead revolumisation or brow lifting with neuromodulation and revolumisation, may result in a feminised and unnatural appearance if used injudiciously on a male patient. Our guide when approaching the male forehead is to elevate a ptotic brow with neuromodulation and fillers if required, but endeavour to lift no more than the supraorbital ridge.

An extensively bossed forehead is an indicator of volume loss and should be corrected; however there should remain a small element of bossing that corresponds to a natural contour. The female brows are more amenable to lifting techniques, and the forehead should be revolumised, when required, to achieve a smooth and natural looking convexity to the hairline.

The Cheek The cheek is an extensively covered area with regards to aesthetic rejuvenation, and medical literature is awash with descriptions of the female contour and the female rejuvenation process, however very little is said of the male cheek.7,8 Even with the availability of literature and advice on female cheek rejuvenation, we all frequently see poor treatment outcomes; seemingly from the repetition of the same cheek inflation treatment over and over again, with a consequent deformed and overinflated appearance. The cheek, from an injectable perspective, is largely a soft tissue structure, overlying the maxillae medially, the zygoma laterally and the deep fat and buccinator muscle inferiorly.9 Whilst some maxillary and zygomatic resorption does occur with age, more so in males than females,10 it is the overlying soft tissue contours that give rise to the characteristic differences in

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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surface contours between the male and female cheek. Overall, the ideal female cheek is believed to be rounder and fuller, whereas a male cheek is flatter and more angular.11 Two studies using MRI to quantify the differences in subcutaneous facial fat in men and women and their changes with age showed that, overall, the male face has a thinner layer of subcutaneous fat.12,13 They also indicated that whilst the distribution of fat in the male cheek is uniform, the female cheek has a thicker fat compartment in the medial area as compared to the lateral area, with a ratio of 1.5 to 1. This uneven distribution explains why the female cheek is rounder and fatter, and the male cheek is flatter, conforming more to the contours of the underling structures.

The anatomic approach to a natural rejuvenation should respect the relative anatomy and thus, for a male, the subcutaneous should be filled uniformly, replacing the lost volume and maintaining the flatter and more angular cheek contour. For a female rejuvenation procedure the volume replacement technique should be the same, however the volume of product used should vary, with more placement medially to mimic the naturally slightly-thicker fat in this area and provide a feminine, rounded appearance. Dr Arthur Swift and Dr Kent Remington have beautifully described the ideal contour and surface landmarks for identifying the cheek area, based on the mathematical concept of PHI.7 The techniques utilise a triangle drawn on the face with points at the lateral canthus, ipsilateral oral commisure and ipsilateral tragus, and drawing an oval with three points contacting the lines of the triangle tangentially (Figure 2). This generally corresponds to an ideal cheek position for soft tissue volumisation in both the male and female face, the significant difference being the point of greatest projection.

Figure 2

Dr Arthur Swift and Dr Kent Remington’s technique for identifying the cheek area, based on the mathematical concept of PHI. The triangle shows the points at the lateral canthus, ipsilateral oral commisure, and ipsilateral tragus, while the oval meets the three points tangentially.

The Nose The nose is one of the areas of the face where particularly subtle differences occur between the sexes. There are many angles and measurements to define an ideal nose shape, position and proportion,14 however for the purposes of the sexually dimorphic traits that can be effected, we will discuss two main angles. The nasolabial angle (Figure 3) is the angle between a line drawn from the lip border to the base of the columella, and a line drawn from the base of the columella to the nasal tip. This angle describes the degree of rotation of the nasal tip.15 The ideal male angle has been described as 97 degrees and the ideal female angle as 105.9 degrees.16 The same study identifies different preferences in different ethnicities, with Native Americans and African Americans preferring a more acute angle. A similar, more acute nasolabial angle preference was found in a study in the Asian patient population.17 It is therefore important to bear in mind the cultural preferences of the patient being treated. As a general rule, however, the angle should be more obtuse in a female patient, and slightly upturned in a female Caucasian patient. The other angle of significance is the naso-frontal angle. This is the angle of the radix, the lowest point on the nasal bridge and is formed by a line running from the radix to the glabella, and from the radix along the dorsum on the nose.16 The angle is greater in females than males, with one study identifying an average

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female angle of 138 degrees and a male angle of 130 degrees.18 The position of the radix is also of importance; in the female it should be at the level of the lash line, in the male it tends to be higher, at the level of the tarsal fold, and more confluent with the glabella. When performing rhinomodulation with toxins or fillers it is important to respect these angles, as beautification does not typically involve masculinisation of a female feature or vice-versa.

Figure 3

N

Frankfurt plane

PRN

AL BN

Naso-labial angle

Outline of the measurements made in the basal vision of the nose of 180 males and females between 18 and 30 years old. Green: Nasion projection; Red: nasal length (N-PRN); Yellow: nasal wing to proposal distance (ALPRN); Black: nasolabial and nasofrontal angles.

The Jawline and Chin The consensus of what constitutes an attractive jaw line in both males and females tends to vary with ethnicity,19 and in today’s multicultural society, the practitioner must not just be aware of the local norms, but also be open to a wide range of expectations from treatment. The gonial angle is the angle formed by the mandibular line (a line running tangentially to the two lowest points on the anterior and posterior mandible) and the ramus line (a line running through the two most distal points on the ramus).20 This angle has been shown to be lower in males than in females.20 Additionally, the male mandible is wider at the gonion, due to eversion of the bone caused by masseteric attachment, and the bulk of a larger masseter muscle.20 The male chin is generally larger than a female chin, with a more widely-set trigon.20 The underlying anatomy matches the Hollywood ideal of a male having a wide, sharply-defined jaw, sharply angled and with a wide flat chin. The female counterpart has a narrower, softer chin, gently sloping from auricle to a narrower, more pointed chin. We can employ both masculinasation and feminisation techniques to the jawline and chin, using toxins to narrow down the masseter or curve a chin, and fillers to widen a jawline, increase definition, add a sharper gonial angle or flatten and enlarge a chin.

Perioral area Perioral rejuvenation is a very common patient request amongst females but not so common in the male population. After appropriate lip rejuvenation there is often not much else required in a male patient, but female patients tend to suffer more from perioral smoker’s lines, as well as much more severe perioral wrinkling,21 which may require resurfacing treatments in addition to toxins and fillers. The underlying reasons for this difference are not clearly understood, however it is thought to be related to the male skin being thicker and more seborrheic, with thinner underlying fat and a greater vascularity.22 Interestingly, one study has shown that the female obicularis oris attaches 1.5 times closer to the skin in female patients than in male patients,22 which provides a reasonable explanation for the greater tendency to smoker’s lines in females. Where it would be common to address a perioral female case with toxins, fillers and CO2 pulsed laser, a similar approach to the male perioral area may result in a feminisation of the skin and should be performed with caution.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Case Studies In June 2015 we delivered a live demonstration of the differences in the assessment and injection techniques for male and female rejuvenation at a conference. Our male patient (Patient A) was 40 years old and had previously received mid-facial volumisation with Radiesse and upper-face toxin treatments two years previously. The female patient (Patient B) was 45 years old and had previously had mid-facial hyaluronic fillers and upper-face toxin treatment more than two years previously. We discussed the outcomes desired by each patient and found that Patient A wanted a result that was not obvious to his peers, made him look less tired and younger, whilst maintaining his masculine, rugged appearance. Patient B was less specific, however noted that she wanted to look fresher and more attractive. A comprehensive assessment of the male face of Patient A identified global volume loss, particularly evident at the temples causing an hourglass deformity with loss of the tail of the eyebrow. There was moderate bossing of the central forehead and significant mid-facial cheek sagging.

The lips were both thinned, and the upper lip inverted causing a lengthening of the philtrum. The jawline was fairly strong but had a slight softening curve along from the gonion to the chin (Figure 4). The temple was treated with superperiosteal Figure 4

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depots of Belotero Volume, 0.8cc each side placed approximately one centimetre superolateral to the superolateral bony rim of the orbit (Figure 5). Further treatments in this area should be repeated at intervals until sufficient revolumisation is achieved.

The central forehead bossing was softened but not completely corrected with supraperiosteal deposits of Belotero Balance. The cheek was volumised with supraperiosteal Belotero Volume anteriorly in a single deposit of 0.5 cc with a needle, then a uniform deposition of Belotero Volume 0.5cc in the subcutaneous fat of the anterior cheek area using a 25G microcannula. The lips were both volumised and the upper lip everted with Belotero Intense 1cc using a 25G cannula. The jaw line was sharpened with subcutaneous threads of Radiesse, injected with a 27G needle. Results of Patient A’s treatment are shown in Figure 6.

For Patient B, a full assessment highlighted signs of ageing as a result of loss of volume associated with the temples, cheeks, jaw, maxilla and chin (Figure 7). The temples were augmented using the same technique as the male with 0.4ml of volume. The female temple remained concave, but helped blend the contour of the forehead smoothly into the lateral cheek prominence. The apex of the cheek is located at the intersection of the alar tragal line and a vertical line dropped vertically from the lateral canthus

Figure 5

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of each eye. A bolus of 0.2 ml of volume was injected supraperiosteally at this point with a 30G 0.5mm needle to widen the bizygomal distance. Small boluses of volume were deposited across the lateral and mid-cheek to lift and project the mid-face. Finally, lateral cheek contouring was defined as described by Dr Swift and Dr Remmington7 using a 25G 1.5inch cannula subcutaneously, depositing more filler medially. The lower third of the face showed the most marked signs of ageing, and perioral rejuvenation included restructuring the vermillion boarder by injecting Belotero Balance intradermally along the vermillion boarder. The ‘white lip’ was also injected directly intradermally using a blanching technique described by Patrick Micheels.23 The chin was injected supraperiosteally with several boluses of standard dilution Radiesse at the pogonion to lengthen and project the chin. Radiesse was also injected in the menton area to reduce the mental crease and smooth the contour between the lower lip and the chin.

Results of Patient B’s treatment are shown in Figure 8.

Figure 7

Figure 6

Figure 8

Figure 4: Note the low-brow position on a prominent supraorbital ridge with central forehead bossing. The patient also has significant anterior mid-facial volume loss with subsequent mid-facial ptosis. The upper lip is thin and inverted and the jaw line slightly soft and curved. Figure 5: TC stands for Temporal Crest, while FP stands for the Frontal Process of the zygoma. The purple dot shows the position of Belotero Volume placement. Figure 6: Male patient immediately after treatment to forehead, temples, lips, cheeks and jawline.

Summary Medical aesthetics is still a new and evolving field of medicine.

In order to achieve excellence it is not enough to simply keep on top of the evolving products and techniques. If we truly want to achieve excellence we also need to stay ahead of

Figure 7: Female patient immediately before treatment Figure 8: Female patient immediately after treatment

the changing markets. With the increasing number of males presenting for rejuvenation treatments, it is imperative that the expert practitioner extends his or her expertise to the matter of male rejuvenation. What constitutes a beautiful female face, and the techniques to non-surgically make a female face beautiful,

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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will not translate onto the typical male patient.

An understanding of the different anatomical characteristics, as well as the different expectations for treatment, will, however, assist in providing the best treatment outcomes for male and female patients.

Dr Simon Ravichandran is an ear, nose and throat surgeon, specialising in rhinology. He trained in aesthetic medicine in 2007 and co-founded Cinetix 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.

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; Dr Ravichandran is actively involved in creating a national audit pathway for aesthetic practice.

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REFERENCES 1. American Society of Plastic Surgeons, 2011 Cosmetic Surgery Gender Distribution (US: American Society of Plastic Surgeons, 2012) <http://www.plasticsurgery.org/Documents/news-resources/statistics/2011-statistics/2011_Stats_Male_Procedures.pdf> 2. Rossi AM, ‘Men’s aesthetic dermatology’, Seminars in Cutaneous Medicine and Surgery, 33 (2014) pp.188-196.

3. Sundaram H, Carruthers J, ‘Procedure in Cosmetic Dermatology: Soft Tissue Augmentation’, Elsevier, pp.88-99.

4. Snow CC, Gatliff BP, McWilliams KR, ‘Reconstruction of facial features from the skull: An evaluation of it’s usefulness in forensic anthropology’, Am. J. Phys. Anthropology, 33 (1970) pp.221.

5. Douglas K, Ousterhout DDS, ‘Feminization of the forehead: Contour Changing to Improve Female Aesthetics’, Plastic and Reconstructive Surgery, 79 (1987), pp.701-711.

6. Goldstein SM, Katowitz JA, ‘The Male Eyebrow: A Topographic Anatomic Analysis’, Ophthalmic Plastic and Reconstructive Surgery, 21 pp.285-291.

7. Swift A, Remmington K, ‘BeautiPHIcation™: A Global Approach to Facial Beauty Clinics in Plastic Surgery’, Elsevier, 38 (2011) pp.347-377.

8. Sundaram H, Carruthers J, ‘Procedure in Cosmetic Dermatology: Soft Tissue Augmentation’, Elsevier, 2012.

9. Ulrike Pilsl, Friedrich Anderhuber, Berthold Rzany, ‘Anatomy of the Cheek: Implications for Sort Tissue Augmentation’, Dermatologic Surgery, Special Issue: Fillers, 38 (2012), pp.1254-1262.

10. Mendelson B, Wong C, ‘Changes in the Facial Skeleton with Aging: Implications and Clinical Applications in Facial Rejuvenation’, Aesthetic Plastic Surgery, 36 (2012) pp.753-760.

11. Scheib JE, Gangestad SW, Thornhill R, ‘Facial Attractiveness, symmetry and cues of good genes’, Proc Biol Sci 199; 266(1431) pp.1913-1917.

12. Wysong A, Kim D, Joseph T, MacFarlane DF, Tang JY, Gladstone HB, ‘Quantifying soft tissue loss in the aging male face using magnetic resonance imaging’, Dermatol Surg, 40 (2014) pp.786-793.

13. Wysong A, Kim D, Joseph T, Tang JY, Gladstone HB, ‘Quantifying soft tissue loss in facial aging; a study in women using magnetic resonance imaging’, Dermatol Surg, 39 (2013) pp.1895-1902 14. Prendergast, PM, ‘Facial Proportions. In: A. Erian and M.A Shiffman Advanced Surgical Facial Rejuvenation’, Springer-Verlag, (2012), pp.15-21.

15. Sino HH, Markarian MK, Ibrahim AM, Lin SJ, ‘The ideal nasolabial angle in rhinoplasty: a preference analysis of the gneral population’, Plast Reconstr Surg, (2014).

16. Steele N, Thomas JR, ‘Surgical Anatomy of the Nose’, In: ‘Schick, B Rhinology and Facial Plastic Surgery’, Springer, pp.5-12.

17. Choi J Y; Park JH; Hedyeh J, Sykes JM, ‘Effect of Various Facial Angles and Measurements on the Ideal Position of the Nasal Tip in the Asian Patient Population’, JAMA Facial Plast Surg, 15 (2013) pp.417-421.

18. Ferdousi M A, Mamun AA, Banu L A, Paul S, ‘Angular Photogrammetric Analysis of the Facial Profile of the Adult Bangladeshi Garo’, Advances in Anthropology, 3 (2013), pp.188-192.

19. Kane M A, ‘“Is there a double standard of beauty”? Or can common/ general beauty be applied to Asian and Caucasian Patients?”’, World Congress of Dermatology, 2011.

20. Chole HC, Patil RN, Chole SB, Gondivkar S, Gadbail A, Yuwanati MB, ‘Association of Mandible Anatomy with Age, Gender and Dental Status: A Radiographic Study’, ISRN Radiology, 2013.

21. Wojnarowska F, ‘Clinical aspects of ageing skin’, In Fry L., ‘Skin problems in the elderly’, Churchill Livingstone, (1985) p.28-46.

22. Paes EC, Hans J, Teepen M, Koop W A, Kon M, ‘Perioral Wrinkles: Histologic Differences between Men and Women’, Aesthetic Surgery Journal, 29(2009) pp.467-472.

23. Micheels P, Sarazin D, Besse S, Sundaram H, Flynn TC, ‘A Blanching Technique for Intradermal Injection of the Hyaluronic Acid Belotero’, Plastic and Reconstructive Surgery, 132 (2013) pp.59-68.

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Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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The Science Behind Mesotherapy Dr Philippe Hamida-Pisal shares the history of mesotherapy for aesthetic treatment and details the qualities of common poly-revitalising solutions History and usage Mesotherapy is a technique developed in France in the 1950s by the renowned practitioner Dr Michel Pistor. It was recognised as a medical treatment by the French Academy of Medicine in 1987 and has since successfully been used in many countries all around the world.1 The treatment can be used for pain management as well as aesthetic rejuvenation; studies have found that it can alleviate rheumatism, arthritis, muscle pain, and sports injuries, amongst numerous others.

Mesotherapy can also treat smoking cessation, allergies and ophthalmological pathologies.2,3 In the aesthetic field, mesotherapy can be defined as a non-surgical technique aimed at diminishing difficult areas in the skin such as cellulite, stretch marks and alopecia, while also offering a treatment for body contouring and face, neck, and hand rejuvenation. Mesotherapy is administered via several microinjections, either manually or using a mesotherapy gun, which contain a polyrevitalising solution that contains various medicines, vitamins and minerals. The solution can be injected into the epidermis and the dermis using four different injection techniques. Different techniques are used depending on the aesthetic concern and the depth of injection required to treat that concern. The intraepidermal technique, popular for facial rejuvenation, reaches a depth of 1mm; the papular technique reaches a depth of 2mm and can be used to treat wrinkles; the nappage technique, which can be used on the scalp and as a cellulite treatment, reaches between 2 - 4mm; while the point-by-point technique reaches a depth of 4mm in the skin and is used mainly for fat reduction.3 While interesting, a discussion of treatment techniques is outside the scope of this article. I will instead use this opportunity to provide a detailed overview of each of the different substances employed in poly-revitalising solutions and explain how the skin reacts to them. Doing so will hopefully help and support practitioners incorporate mesotherapy treatments into their aesthetic clinics.

What happens to skin during ageing?

Before discussing the effects and reactions in the skin when we perform mesotherapy, it may be worth having a closer look at the developments that occur in the skin during the ageing process. As I’m sure we are all aware, there are internal and external factors that influence ageing: internal factors include a person’s genetics, age, evolution and expression; while external factors are caused by smoking, sun exposure, lifestyle and pollution. It is a fact that when we age, the epidermis thins and the rate of skin cell renewal decreases. Photoageing leads to thinning of the epidermis with abnormal keratinocyte differentiation and dryness of the stratum corneum, which is partly due to the lack of hyaluronic acid. We know that the junction between the dermis and epidermis also becomes thinner.4,5,6 One of the reasons for the epidermis thinning taking place is a quantitative and a qualitative change in collagen types I and III, and changes to the fibroblasts. Fibroblasts combine the extracellular matrix and collagen – the structural framework

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for human tissue.4,5,6 Consequently, it can be said that understanding the ageing process and the importance of fibroblasts is the key to a sound understanding of how mesotherapy works.

Fibroblasts and the ageing process Fibroblasts are concerned with many aspects that give our skin its youthful look. They are primarily involved with maintenance and tissue metabolism and their correct functioning is responsible for structural and biochemical modifications, changes in sensitivity, permeability and capacity of scar formation. Fibroblasts make collagen, glycosaminoglycans, reticular and elastic fibres, glycoproteins found in the extracellular matrix, and cytokine thymic stromal lymphopoietin (TSLP). They also represent the major skin type in the dermis and are responsible for producing and maintaining the extracellular connective tissue.7 As time passes, however, fibroblasts cease to be able to maintain the skin’s youthful look. The exact reason for this change remains unclear – studies have suggested an age-related increase in oxidative stress, due to alteration in the balance between production and elimination of reactive oxygen, is responsible for the physical changes in the aspect of dermis.4,6 How do the medicines, vitamins and minerals used in mesotherapy actually work in the skin?

Our main concern in medical aesthetics is the effectiveness of the so-called poly-revitalising solutions employed in mesotherapy and how they affect our skin when we apply them. Each of the components used in mesotherapy solutions, such as the New Cellular Treatment Factor Hyaluronic Acid (NCTF HA) that has been used in numerous clinical studies into the efficacy of poly-revitalising solutions, has a physiological effect on the skin cells. The main principle is that ageing skin is supplied with various substrates that are key to the adequate functioning of the fibroblasts. These include vitamin, mineral elements, amino acids, nucleotides, coenzymes and antioxidants, as well as hyaluronic acid. Fibroblasts work more efficiently if provided with the nurturing environment in which they can function properly,4,7 and the substances used in those components aim to create such an environment. Both young skin and aged skin can be targeted with mesotherapy. In young skin it aims to keep the fibroblasts active and maintain a patient’s youthful appearance, tonicity and hydration, while in aged skin the treatment aims to aid hydration, reduce the anti-radical action and fight against the effect of oxidative stress. The results of mesotherapy are progressive and accumulative and the advantage is that it is noninvasive and non-traumatic. We usually recommend patients undergo five sessions of mesotherapy, two to three weeks apart, but some patients, who may have time available and the funds to pay for it, want to have quicker results. For such patients we can perform one session per week and, usually, within three sessions we will notice an enormous difference. After completing the five sessions, we always recommend two sessions per year to maintain the results. It is also worth mentioning that mesotherapy is a treatment that will provide the best results when combining it with other treatments such as peels and fillers. Short-term side effects such as mild pain, redness, swelling, and bruising are relatively common and an expected consequence of the injections themselves, but serious complications are rare.8 Disinfecting the skin before the treatment is important to avoid possible infections.

Main components of poly-revitalising solutions used in mesotherapy Through a thorough understanding of a patient’s concerns, medicines, vitamins and minerals can be used individually or in combination to create a tailor-made poly-revitalising solution for your patient.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Figure 1: Table of qualities of main components used in mesotherapy poly-vitalising solutions7

Vitamin A (retinol)

An important vitamin with antioxidant effects that regulates epidermis regeneration and melanocyte activity. Vitamin A also controls oil gland activity and, together with vitamin C, assists in the synthesis of collagen and other intercellular matrix components.

Vitamin C (ascorbic acid)

An important antioxidant that speeds up DNA synthesis and is essential for collagen synthesis.

Vitamin E (tocopherol)

Vitamin E has a high level of antioxidant activity. It controls skin physiological regeneration and starts repair processes in the case of skin damage.

Inositol

A vitamin-like substance used by cells as a signaling molecule and contributes to maintaining the capacity of the cell membrane.

Vitamin B1 (thiamine)

Vitamin B1 plays a key role in producing energy from carbohydrates and in obtaining ribose and deoxyribose from glucose, which are used for DNA and ribonucleic acid (RNA) synthesis. It also catalyses the decarboxylation of alpha-keto acids (lactic and pyruvic), easing the cells’ fight with metabolic acidosis.

Vitamin B2 (riboflavin)

This vitamin and its derivatives are involved in the delivery of energy from carbohydrates and fat, as well as supporting redox cell metabolism and the activation of vitamins B6 and B9.

Vitamin B3 (nicotinamide)

Vitamin B3 is incorporated into two coenzymes (NAD and NADP), that play a crucial role in many reactions involving energy production from carbohydrates, fats and proteins, and in the biosynthesis of various molecules, such as fatty acids.

Vitamin B5 (pantothenic acid)

This vitamin is a key part of the CoA molecule and is also essential in the generation of energy from carbohydrates, fats and proteins, and the synthesis of various biomolecules.

Vitamin B6 (pyridoxine)

Vitamin B6 is converted to a coenzyme (PLP) that is key in the cellular metabolism of amino acids, including their transfer through the cell membrane and intracellular transformation.

Vitamin B7/B8 (biotin)

Used in four carboxylase enzymes that take part in regulating the metabolism of protein, fat and carbohydrates, and also has high anti-seborrheic activity.

Vitamin B9 (folic acid)

This vitamin is necessary for cell division, and also contributes to the mutual transformation of amino acids.

Vitamin B12 (cyanocobalamin)

Vitamin B12 contributes to the metabolism of carbohydrates, proteins and fats, and participates in the formation of coenzyme forms of folic acid (ie: activation of vitamin B9).

Amino acids

These represent the relevant substrates required to build dermal extracellular matrix proteins, mainly collagens.

Minerals

The three main minerals found in mesotherapy solutions are calcium, phosphorus and magnesium. Calcium is the main iron used to regulate cell homeostasis. Phosphorus is essential for cell wall regeneration and all the biological membranes, while magnesium is required to maintain more than 180 normal enzymatic reactions.

Nucleosides

Five nucleosides are necessary to replicate DNA for fibroblast fission and RNA generation in the process of protein synthesis.

Coenzymes

Coenzymes are biochemical reaction catalysers. A cell is able to synthesise the majority of these coenzymes independently using vitamins. However, since a cell will have to spend a considerable amount of its own substrates and energy at the initial stages of synthesis, it is useful to include ready-made primary coenzymes in a formula to make fibroblast metabolism easier.

Other antioxidants

Tripeptide glutathione ranks among the most efficient endogenous antioxidants. There is an opinion that premature cell ageing is very closely related with a reduction in glutathione intracellular concentration.7

Hyaluronic acid

Hyaluronic acid can accumulate and retain 1000 times its weight in water, which may help the skin remain hydrated. It also has anti-inflammatory, antibacterial, antifungal and antioxidant properties. In aged skin, hyaluronic acid production by fibroblasts is attenuated. It also helps to maintain human skin fibroblast cell proliferation.

The table above (Figure 1) summarises the qualities of the various components that we commonly find in poly-revitalising solutions such as NCTF HA. Further information can be found in a research study produced by Sergey Prikhnenko.7

to support the effectiveness of mesotherapy treatments,4,6,7,8,9 as well as long-term international experience in the clinical use of such preparations. We should not forget, though, that our knowledge of the skin is constantly evolving and we should adapt our treatment methods to reflect this.

Conclusion The goal of the poly-revitalising solutions is to create a favourable microenvironment to optimise the activity of fibroblasts. In my opinion, if performed appropriately mesotherapy is one of the safest existing techniques for aesthetic treatment, as it uses natural components in little quantities. There is preclinical and clinical trial evidence available

Dr Philippe Hamida-Pisal is an aesthetic practitioner working in London and Paris. As well as being the president of the Society of Mesotherapy of the UK, the society partner of Euromedicom and IMCAS Paris, Dr Hamida-Pisal is a key note speaker at major industry events around the world; discussing the concept of beauty, the ageing process and ethnic skin.

REFERENCES 1. What is it? History, (France: French Society of Mesotherapy, 2009) <http://www. sfmesotherapie.com/en/What-is-that/?MenuActive=2&CatRef=101> 2. ‘Atlas de Mesotherapie’, CERM de Paris Edition SFM, (2001).

3. Maya Vedamurthy, Mesotherapy, (India: Dermatol Venereol Leprol, 2007), <http://www.bioline. org.br/pdf?dv07021> 4. Reygagne P, ‘Cheveu, vieillissement et environnement: aspects cliniques (Hair, ageing and environment, clinical aspects)’,Ann Dermatol Venereol, 136 (2009), S22-S24.

5. Arck PC, Overall R, Spatz K, Liezman C, Handjiski B, Klapp BF, et al, ‘Towards a “free radical theory of graying”: melanocyte apoptosis in the ageing human hair follicle is an indicator of oxidative stress induced tissue damage’, FASEB J, 20 (2006) p.1567-9.

6. Le Coz J, ‘Mesotherapie et medecine esthetique (Mesotherapy and cosmetology)’, Editions Solal, (1998).

7. Prikhnenko S, ‘Polycomponents mesotherapy formulations for the treatment of skin aging and improvement of skin quality’, Clinical, Cosmetic and Investigational Dermatology, 8 (2015) p.151-157.

8. Sivagnanam G, Mesotherapy – The French Connection, (J Pharmacology and Pharmacotherapeutics, 2010) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142757/> 9. Blume-Peytavi U, ‘Cheveu, vieillissement et environnement: aspects fondamentaux (Hair, ageing and environment: fundamental concepts)’ Ann Dermatol Venereol, 136 (2009) S25-S28.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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medical aesthetic practitioners. Indeed, the Contour Threadlift system (Surgical Specialities Corp; Reading; Pennsylvania), which was approved by the FDA in 2005, has since lost its FDA approval due to the high incidence of post-operative complications,6 although new cogged suture variations are now available.7 When reviewing the literature regarding threads, it is important to note that although early data showed inconsistent results and early relapse, as new devices were developed and the indications for each technique were refined, the incidence of complications has decreased correspondingly in later studies.8 When performed properly, thread lifting is associated with minor and infrequent complications.

Understanding Thread Lifting Dr Sarah Tonks explains the process of thread lifting, selecting patients, and the risks and complications involved Age-related changes in the facial skeleton, musculature, connective tissues, fat and skin manifest with universally-recognised patterns.

Advancing laxity in the soft tissues leads to a ptotic brow, jowl formation, nasolabial fold prominence and malar flattening. The appearance is further compromised by hyperpigmentated and wrinkled skin.1 A variety of procedures are available to rejuvenate the ageing face.

The most commonly used options in the non-surgical aesthetics clinic are botulinum toxin, dermal fillers and chemical peeling.2 Non-surgical procedures have become popular in recent years as they allow for a faster turnaround time and can be performed outside the theatre environment, making them convenient for patients and practitioners alike. According to the review of the regulations of cosmetic interventions by the Department of Health in 2013, the value of UK cosmetic procedures was worth £2.3bn in 2010 and is estimated to rise to £3.6bn in 2015.3 The history of threads There has been a renewed interest in thread lifting over the past couple of years in the UK, perhaps because both practitioners and patients are looking for alternative ways of rejuvenating the face for those who do not wish to have injectables, or because they wish to utilise suspension threads in order to create lift. Threads have been marketed as an alternative to more invasive procedures such as a facelift due to the long recovery time or cost associated with a surgical facelift. Russian surgeon Mr Marlen Sulamanidze introduced the use of the barbed suture thread to lift ptotic facial tissues in the late 1990s.4 Variations of this original antiptosis suture (APTOS) have been used, which involve placement of cogged threads along a planned trajectory; the threads are then pulled to lift the skin, secured and trimmed at the entry point.5 Thread lifting is viewed with a degree of suspicion amongst some

Look at the indication It is perhaps better to consider thread lifting as a preliminary procedure, which combines well with other non-surgical procedures, rather than a surgical alternative. Threads can also be used to good effect post-surgery on a patient who has had a facelift and would like to lift the skin again, but is not ready for a second surgical procedure.

It is important to distinguish initially between threads that are used for skin rejuvenation and threads that are used for lifting ptotic skin.

These are both free-floating threads and not anchored to any point.

Those for skin rejuvenation are used to give an overall improvement in the texture and tone of the skin and are monofilament threads, which are used in a lattice-work arrangement, inserted into the dermis.

Usually around 10-120 threads are inserted at one time depending on the indication. These straight and smooth threads are mounted on a 25G-31G needle, inserted into the skin, where due to the folding of the thread on the needle mount, it becomes a ‘V’ shape and remains in the skin.9 These threads are most usually made of polydioxanone (PDO). If histology is performed, a foreign body reaction can be found from the middle dermis to the subcutaneous layer, and there is a fibrosis and lymphocyte clustering. After monofilament insertion there is a subtle but immediate lift evident.10 Threads for lifting can be either cogs or barbs, which mechanically lift the skin. The usual number of threads can be from one to five per side depending on what is being treated. Evidently, the type of thread to use is important – think about the treatment indications; is lift required or skin rejuvenation?

Combined treatments All types of threads can be used together or in conjunction with other treatment modalities for the best effects. Indeed, using barbed and cogged threads in combination with dermal fillers or fat grafting will give superior results by addressing the issue of volumetric change.

Use of threads in conjunction with radiofrequency or microneedling for superficial rhytids will give improved results, as it may help to tighten excess skin to a limited degree.11 Thread lifting cannot address the

It is important to distinguish the difference between threads that are used for skin rejuvenation and threads that are used for lifting ptotic skin

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Patient selection Thread procedures often result in more downtime than that experienced when using injectables alone. For monofilament threads, the number of needle insertions necessary will inevitably result in bruising. For cogs and barbs, the entry point of the cannula or needle can be 16G, resulting in a visible entry area, and there can be irregularity of the skin over the thread tract for a couple of days.

Patients differ with the amount of downtime they can tolerate, and what they perceive as downtime. Some patients will happily accept bruising and puckering for a number of days as being part of the procedure, whilst others will suffer a lack of confidence about their appearance if there are any visible signs of a procedure having taken place immediately after the treatment. Before discussing the possibility of using threads, it is important to know where your patient falls on this spectrum. Patient management post-thread procedure can be difficult if they do not fully grasp the risks of bruising, swelling and puckering following treatment.

Unlike hyaluronic acid dermal fillers, the procedure cannot be easily reversed. It is important that all the possible complications and expected side effects are discussed, and the patient is given adequate time to weigh-up the information before deciding to go ahead. This is not a procedure suitable for consultation and treatment on the same day.

It is essential that the patient is able to tolerate the procedure. Pain thresholds and acceptance of treatment varies widely from person to person. As threads are more invasive than injectables, it is important that the patient is able to tolerate a modicum of discomfort during the procedure. The sensation of having the barbed and cogged threads tightened can be uncomfortable, and for some a distressing experience.

Realistic expectations are obviously essential. From my experience, the maximum amount of lift that can be achieved using barbs and cogged threads is around 1cm. If the patient has more to lift than this, then it may not be appropriate. If the patient does not want or cannot have surgery, a staged approach may be appropriate – using multiple threads in conjunction with other treatment modalities, which will result in an improvement but a compromised treatment outcome in comparison with a surgical outcome.

Threads for lifting do not work well on those with excessively lax skin, a large body habitus, thick skin and those with unrealistic expectations. Conversely, monofilament threads can be used to promote collagen stimulation in those with lax and crepey skin to promote skin tightening and texture improvement.14

issue of excess skin or volumetric change alone, although multiple monofilament threads can also give a degree of skin tightening.12 Treatment indications • A patient may not want dermal filler treatment but would like to see an improvement in their appearance: Threads can provide a viable alternative to those individuals who would like improvement without use of dermal fillers. Spring threads can be used as an easy alternative in the nasolabial, malar and marionette regions. Spring threads are monofilament threads, which have been coiled around the introducing needle to make a spring shape. Monofilament threads can be used as an alternative to dermal fillers used for hydration and collagen stimulation.

• A patient has had dermal fillers to lift the skin and would like more of a lift: There is a limited amount of lift achievable using dermal fillers alone because they are only capable of adding volume and give lift as a secondary effect by redistributing the volume in the face. For those patients who have undergone augmentation using the ‘8-point lift’ or ‘Tower technique’,13 a method of depositing dermal filler in a perpendicular depot, cogged and barbed threads can provide a further improvement of the appearance by giving additional lift.

Risks and complications · Asymmetry: A patient will often examine their appearance in great detail after a cosmetic procedure so it is important to point out any pre-existing asymmetries. In the case of barbs and cogs, precision when inserting the threads and tightening when the patient is seated vertically, with patient participation so they can view the process in a hand mirror, is helpful in avoiding any potential problems with perceived asymmetry later on. · Rippling and puckering: This is a complication seen when using barbs and cogs. If the thread is tightened too much then the

·

·

·

·

skin will ripple over the thread and cause visible folding. If the thread has been placed in the correct tissue plane then this will typically resolve itself in a few days. Sometimes slight ruching can be caused by oedema and the placement of local anaesthetic, swelling the tissues.15 It is important to be realistic when manipulating the thread and not to over tighten as this will not only lead to rippling, but also the tissues will drop again very quickly after a couple of days, thus leading to dissatisfaction for the patient and practitioner alike. Persistent dimpling can usually be corrected with manual manipulation several days post procedure.

Infection: From what I’ve seen, reported infection rates post-thread insertions are extremely low. All types of threads should be placed using an aseptic technique to reduce the risk of infection, which, practically speaking, translates as use of betadine or chlorhexidine preparation, use of a sterile field such as surgical drapes for cogs and barbs (although this is not necessary for monofilament and springs) and use of a sterile dressing pack and gloves.

Granuloma: Threads placed in a more superficial plane can lead to higher incidence of granuloma formation.16 In a study of 100 patients receiving either PDO or Prolene after minor breast biopsy, a buried knot eroded through the skin in 17% of PDO patients due to positioning and granuloma formation.

Thread loss: It’s essential when placing threads that when the thread is cut, the end will tuck back into the skin – protrusion of a thread through the skin is an infection and granuloma risk and may cause distress to the patient. In the case of monofilament, if there is a protruding thread, the end should not be cut as with barbs and cogs, but grasped firmly and removed. It’s easy and cheap to remove a monofilament thread thus removing the risk of granuloma if the thread is placed too superficially. Barbed and cogged threads can only be removed with difficulty, if at all. If the end of a thread is left in a superficial plane then there is increased likelihood of granuloma formation.

Thread breakage: When first learning how to place cogs and

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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barbs, breakage can be an issue. Typically this occurs during tightening of the PDO cogs and barbs as during placement the thread is protected by the needle or cannula. In the case of Silhouette Soft threads, the thread is not protected in this way and so the tissues must be carefully manipulated in order to avoid breakage during insertion and tightening.

Other potential side effects include: • Haematoma formation17 • Nerve damage17 • Sensory impairment18 • Chronic pain18 • Palpability (more common in cogged threads but usually settles after several days)18 • Hypersensitivity18 Conclusion The use of threads provides the aesthetic practitioner with another potential treatment modality and can give more flexibility to reach patient expectations. It is important to select the correct patient before performing a thread lift and to be realistic about the potential treatment outcomes and potential complications of this versatile procedure.

Dr Sarah Tonks is an aesthetic practitioner and previous maxillofacial surgery trainee, dually qualified in medicine and dentistry. Based at Omniya in Knightsbridge, she practices cosmetic injectables and thread lifting.

Aesthetics REFERENCES 1. De Maio, M. & Rzany, B. Botulinum Toxin in Aesthetic Medicine. (2007).

2. ASAPAS, Cosmetic Procedures Increase in 2012 (2013) <http://www.surgery.org/media/newsreleases/cosmetic-procedures-increase-in-2012> 3. Department of Health, ‘Government Response to the Review of the Regulation of Cosmetic Interventions’ (2014) p.1 https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/279431/Government_response_to_the_review_of_the_regulation_of_cosmetic_interventions. pdf 4. Sulamanidze, M. A., Fournier, P. F., Paikidze, T. G. & Sulamanidze, G. M. Removal of facial soft tissue ptosis with special threads. Dermatol. Surg. 28, pp.367–71 (2002).

5. Abraham, R. F., DeFatta, R. J. & Williams, E. F. Thread-lift for facial rejuvenation: assessment of longterm results. Arch. Facial Plast. Surg. 11, pp.178–83 (2009).

6. Aston, S., Steinbrech, D. & Walden, J. Aesthetic Plastic Surgery. (2009).

7. Abraham, R. F., DeFatta, R. J. & Williams, E. F. Thread-lift for facial rejuvenation: assessment of longterm results. Arch. Facial Plast. Surg. 11, pp.178–83 (2009).

8. Sulamanidze, M., Sulamanidze, G., Vozdvizhensky, I. & Sulamanidze, C. Avoiding complications with Aptos sutures. Aesthet. Surg. J. 31, pp.863–73 (2011).

9. Shimizu, Y. & Terase, K. Thread Lift with Absorbable Monofilament Threads. J. Japan Soc. Aesthetic Plast. Surg. Vol. 35 No.2 (2013). <http://www.mesothread.com/filebox/[JSAPS]Dr. Yuki Shimizu_LFL. pdf> 10. Shimizu, Y. & Terase, K. Thread Lift with Absorbable Monofilament Threads. J. Japan Soc. Aesthetic Plast. Surg. Vol. 35 No.2 (2013). <http://www.mesothread.com/filebox/[JSAPS]Dr. Yuki Shimizu_LFL. pdf> 11. Abraham, R. F., DeFatta, R. J. & Williams, E. F. Thread-lift for facial rejuvenation: assessment of longterm results. Arch. Facial Plast. Surg. 11, pp.178–83 (2009).

12. Guerrerosantos, J. Evolution of technique: face and neck lifting and fat injections. Clin. Plast. Surg. 35, pp.663–76, viii (2008).

13. Bartus, C. L., Sattler, G. & Hanke, C. W. The tower technique: a novel technique for the injection of hyaluronic acid fillers. J. Drugs Dermatol. 10, 1277–80 (2011).

14. Shimizu, Y. & Terase, K. Thread Lift with Absorbable Monofilament Threads. J. Japan Soc. Aesthetic Plast. Surg. Vol. 35 No.2 (2013). at <http://www.mesothread.com/filebox/[JSAPS]Dr. Yuki Shimizu_LFL. pdf> 15. Kalra, R. Use of barbed threads in facial rejuvenation. Indian J. Plast. Surg. 41, S93–S100 (2008).

16. Aitken, R. J., Anderson, E. D., Goldstraw, S. & Chetty, U. Subcuticular skin closure following minor breast biopsy: Prolene is superior to polydioxanone (PDS). J. R. Coll. Surg. Edinb. 34, 128–9 (1989).

17. Kalra, R. Use of barbed threads in facial rejuvenation. Indian J. Plast. Surg. 41, S93–S100 (2008).

18. Della Torre, F., Della Torre, E. & Di Berardino, F. Side effects from polydioxanone. Eur. Ann. Allergy Clin. Immunol. 37, 47–8 (2005).

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Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Radio Frequency (Skin Tightening) Focus Fractional RF is the 3rd generation of RF technology.

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Sexual Dysfunction in Men Dr Sherif Wakil details the use of PRP for effective outcomes in a range of male-related indications Introduction There has been plenty of research over the years on erectile dysfunction (ED) as we aim to better understand the causes and how to treat it. Although ED can happen to men at any age, a study in 2004 showed that as men get older, it is likely to become worse, especially after the age of 60.1 According to the UK Health Centre, which provides access to health and medical information, men over the age of 75 have a staggering 77.5% chance of suffering from erectile problems,2 and smokers, diabetics, those with heart disease, hypertension and cerebrovascular disease are all at a massively increased risk.3 For others who are fortunate enough to not experience ED, I believe it is fair to assume that many will still suffer in silence when it comes to insecurities about the look, feel and size of their penis. For many, these insecurities will continue to increase with age and can dramatically impact on their sexual performance and confidence.4 Treatment There are, however, treatments available that aim to enhance the appearance and performance of the penis, along with its overall function.

Different treatments of ED include:5 • Psychological support, e.g counselling.

• Pharmacological, e.g.

Phosphodiesterase type 5 (PDE5) inhibitors that are usually the recommended first-line treatment for ED. • Testosterone replacement therapy for

cases of androgen insufficiency.

• Vacuum constriction devices.

• Vasoactive drug injection therapy.

• Surgical treatment: surgical implantations of penile prosthesis, which can either be inflatable or malleable.

Most of these treatments have their own risk factors and complications, as well as often limited benefits. These may include side effects from PDE inhibitors such as headaches, flushing, dyspepsia, nasal congestion and dizziness during treatment.6 Vacuum constriction devices (VCDs) don’t always satisfy the majority of men7 and surgical intervention can carry a much bigger risk.8 A recent advancement in treating erectile dysfunction, as well as the look and size of the penis, is plateletrich plasma (PRP) therapy. The treatment works by stimulating the body’s natural ability to heal and rejuvenate itself. By injecting PRP into the penis, it stimulates a regenerative process that aims to treat a

range of indications, including a number of health issues, in particular Peyronie’s disease, which is a development of fibrous scar tissue inside the penis that causes curved and painful erections.9 Following assessment of each of the procedures available, I have personally found PRP to be the safest option, which also showed the best potential in treating the wide range of male sexual dysfunction issues. PRP has been used in various fields in medicine with satisfactory results, including cardio surgery, plastic surgery, sports injury, wound healing and rejuvenation.10 A study, involving a rat model, showed that an injection of PRP into the cavernous nerve that facilitates penile erection was a safe and effective treatment for improving sexual function.11 PRP Treatment The PRP method involves applying a topical anaesthetic to the patient’s arm, (where the blood will be taken from) and the penis. A small amount of blood is then taken and placed in a high-speed centrifuge where the plasma is harvested. Different centrifuges produce varying qualities of PRP, which is why after trying most of the centrifuges on the market, I realised that not all devices achieve the same quality PRP for so many reasons.

For example, I discovered that using a dual spin system can have advantages compared to other systems on the market.12 After the plasma has been harvested, it is placed in a separate vessel where a few drops of activator (calcium chloride solution) are added, to trick the platelets in the plasma into thinking the body has been injured, (by initiating fibrinogen cleavage and fibrin polymerisation) so that they release growth factors. Once the activator is added, you have about 10-12 minutes to inject the solution before it solidifies into a fibrin clot.15 The resulting plasma generated contains cell-regenerating growth factors, which, when injected into the penis, trigger stem cells to increase blood flow and generate healthy

Centrifuge – Single Spin vs. Dual Spin This can also be described as ‘Separation’ versus ‘Concentration’. In order to truly concentrate the platelets I would advise that you use a dual spin centrifugation system.13 The initial spin removes the red blood cells from the plasma. However, if you stop there, the result is simply a mixture of Platelet Rich Plasma (PRP) and Platelet Poor Plasma (PPP) that contains a relatively small number of platelets. It is during the second spin that a finer separation takes place; removing the PPP and leaving you with a fraction that contains a higher concentration of platelets which results in a PRP that falls within beneficial levels (6 times baseline).14 In order for it to be the most effective, it really needs to be no less than six times the concentrate.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Aesthetics Journal

• Increased firmness of erection Corpora Cavernosa Superficial dorsal vein • Increased sexual stamina • Healthier appearance • Increased length and Arteries Deep dorsal vein girth • Increased blood flow and Urethra Corpus Spongiosum circulation With regards to increase in Figure 1: Cross-section of the penis showing the corpora cavernosa size, the immediate difference tissue growth.15 The PRP is injected into the is initially noted in girth, due to the plasma two sponge-like cylinders of tissue that form fluid that has been injected. This can slowly the ‘shaft’, known as the corpus cavernosum reduce over the next week as the plasma is (Figure 1). This is where most of the blood in absorbed by the body, but will increase again the penis is during erection.17 The procedure over the next three to four weeks, due to takes approximately 40 minutes to conduct. the growth factors starting the regeneration Patients that I have injected with PRP report process. Firmness and strength of erection minimal pain or discomfort associated with is also noted after three to four weeks and the procedure, with some patients reporting this usually continues improving over the no pain at all. Feedback reported to the next three months. Smokers have the least Peyronies Society Forum, an online forum amount of growth as the tar from cigarettes where the procedure is discussed among inhibits growth factor production. 19 While this 18 patients, reflects this. is a very new procedure, some patients have said a second injection four to eight weeks Downtime and aftercare after the first causes another growth spurt, From my personal experience, there are potentially further regenerating the tissue. typically no side effects or downtime required There is yet to be any research on this theory. with this procedure, with the exception of a As for sexual function, some men report few drops of blood from the injection site and immediate results, however, realistically, mild soreness, which tend to quickly resolve most men should expect about four weeks themselves. As the patient’s own plasma and to pass before they notice any significant growth factors are used, no allergic reactions improvements. In my experience, almost all have been reported, to my knowledge. patients who have had PRP treatment enjoy From what I have seen, patients can return an increase in their sexual response, and to work as normal, exercise and even have for many, they have reported a dramatic sexual intercourse on the same day as the increase. The effects of the treatment procedure if they wish. Just one treatment continue to improve for up to three months can make a difference, but some patients and may last for 12 to 18 months.20 may require two or three, due to the severity of the issue or the ageing level of tissue.

Conclusion For example, a 40-year-old man is likely to To my knowledge, none of the PRP respond much better than a 60 or 70-yeartreatment providers have reported any old man. side effects following treatment for sexual dysfunction. With many patients reporting The Results instant improvement after one treatment, When patients are treated with PRP, the the procedure offers a safe and effective results we aim to deliver are: method of improving sexual function as • Increased erection quality well as men’s sexual confidence. It was • Heightened sensation and pleasure important to me, as it should be to all aesthetic practitioners, that I underwent the official training to provide this treatment safely and correctly to my patients. It is important that we as practitioners share with one another the right knowledge and skills, in order to ensure the safety and the satisfaction of our patients. Without the correct understanding and education, there is a potential to seriously damage the patient – it just takes one injection in the wrong spot. I urge any of my

Firmness and strength of erection is also noted after three to four weeks

Aesthetics aestheticsjournal.com

fellow colleagues wanting to add sexual rejuvenation treatments to their clinic to seek out the best possible training.

Dr Sherif Wakil is the founder and medical director of Dr SW Clinics and has more than 20 years’ experience in the industry. He is a fellow of the International College of Surgeons as well as an active member of the General Medical Council, American Cosmetic Cellular Medicine Association and British College of Aesthetic Medicine.

Disclaimer: Dr Wakil trained with Dr Charles Runels, the inventor of these techniques, and is the official UK trainer for this procedure.

REFERENCES 1. R Shiri, J Koskimäki, J Häkkinen, TL Tammela, H Huhtala, M Hakama, A Auvinen, Effects of age, comorbidity and lifestyle factors on erectile function: Tampere Ageing Male Urological Study (TAMUS), (2004) <http://www.ncbi.nlm.nih.gov/ pubmed/15082206> 2. UK Health Centre, Statistics on Erectile Dysfunction (2015) <http://www.healthcentre.org.uk/pharmacy/erectile-dysfunctionstatistics.html> 3. Smart Choice, Erectile Dysfunction, (2015) <http://www. smartchoicestemcell.com/conditions-treated/erectiledysfunction.aspx> 4. David H Barlow, Causes of sexual dysfunction: The role of anxiety and cognitive interference. Journal of Consulting and Clinical Psychology, Vol 54(2), (1986) pp.140-148.

5. NHS, Erectile dysfunction (impotence) – Treatment, (2015) <http://www.nhs.uk/Conditions/Erectile-dysfunction/Pages/ Treatment.aspx> 6. Brian Wu, Will Zialin Z-Strips Treat My Erectile Dysfunction?

(2015) <http://www.healthline.com/health/erectile-dysfunction/ zialin-z-strips-and-ed> 7. J Yuan, A N Hoang, C A Romero, H Lin, Y Dai, R Wang, Vacuum Therapy in Erectile Dysfunction 0 Science and Clinical Evidence, (2010) <http://www.medscape.com/ viewarticle/725873_2> 8. Kenneth R Hirsch, Erectile Dysfunction Complications, (2014) <http://www.healthline.com/health/erectile-dysfunctioncomplications#Treatments2> 9. Drogo K. Montague, James H. Barada, Arnold M. Belker, Laurence A. Levine, Perry W. Nadig, Claus G. Roehrborn, Ira D. Sharlip, Alan H. Bennett, Clinical Guidelines Panel on Erectile Dysfunction: Summary Report on the Treatment of Organic Erectile Dysfunction, (1996) <http://www.ncbi.nlm.nih.gov/ pubmed/8911378 > 10. V Cerveli, I Bocchini, C Di Pasquali, B De Angelis, G Cervelli, C B Curcio, A Orlandi, M G Scioli, E Tati, P Delogu, Pietro Gentile, P.R.L Platelet Rich Lipotransfert: Our Experience and Current State of Art in the Combined use of Fat and PRP (2013) <http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3804297/> 11. X G Ding, S W Li, X M Zheng, L Q Hu, Y Luo, The effect of platelet-rich plasma on cavernous nerve regeneration in a rat model, (2009) <http://www.ncbi.nlm.nih.gov/pubmed/19151738> 12. Maria J H Nagata, Michel R Messora, Flavia A C Furlaneto, Stephen E Fucini, Alvaro F Bosco, Valdir G Garcia, Tatiana M Deliberador and Luiz G N de Melo, Effectiveness of Two Methods for Preparation of Autologous Platelet Rich Plasma: An Experimental Study in Rabbits (2010) <http://www.ncbi.nlm.nih. gov/pmc/articles/PMC2948740/> 13. P Borrione, A D Gianfrancesco, MT Pereira, F Pigozzi, Plateletrich plasma in muscle healing (2010) Am J Phys Med Rehabil 89 (10): pp. 854–61 14. Pamela Ellsworth, Penis Anatomy, (2015) <http://emedicine. medscape.com/article/1949325-overview> 15. Peyronies Forum, Priapus Shot, (2015) <http://www. peyroniesforum.net/index.php?topic=4639.0> 16. S Yilmaz, G Caker, S D Ipci, B Kuru, B Yildrim, Regenerative treatment with platelet-rich plasma combined with a bovinederived xenograft in smokers and non-smokers: 12 months clinical and radiographic results, (2010) <http://www.ncbi.nlm.nih. gov/pubmed/20096066> 17. Charles Runels, Official Priapus Shot Home Page, (ND) <http:// priapusshot.com>

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

Fat Reduction

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Why choose 3D-lipomed?

A complete approach to the problem

Face and Body skin tightening

Prescriptive

Highly profitable

Multi-functional

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Inch loss

National PR support campaign

Cellulite

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Before Treatment of the Year 3D Lipomed

After

Before Equipment Supplier of the Year 3D Lipo Limited

Cavitation (Overall Circumference Reduction) Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss.

Duo Cryolipolysis (Superficial Targeted Fat Removal) Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months.

Two areas can now be treated simultaneously.

Radio Frequency (Skin Tightening) Focus Fractional RF is the 3rd generation of RF technology.

It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

After The Pinnell Award for Product Innovation 3D Lipomed

3D Dermology RF (Cellulite Reduction) The new 3D-lipomed incorporates 3D Dermology RF with the stand alone benefits of automated vacuum skin rolling and radio frequency.

What the experts say...

‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients. 3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

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LIFT, CONTOUR & REJUVENATE 1,2

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RAD/7/SEP/2015/DS Date of preparation: September 2015

Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

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1. Sundaram H. J Drugs Dermatol. 2012 Mar; 11(3): S44-S47 2. Yutskovskaya Y, et al. J Drugs Dermatol. 2014; 13(9): 1047-1052

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Aesthetics

Treating Dark Circles Sabrina Shah-Desai examines the treatment methods that are beneficial for the common concern of dark circles in the peri-orbital area Introduction Under-eye dark circles are a common aesthetic concern and can give the face a fatigued appearance, making them difficult to conceal with cosmetics. Dark circles, along with puffy eyelids, remain challenging to treat, both surgically and non-surgically due to their strong genetic influence and multifactorial nature.1 Recent anatomical studies have ascertained that a primary factor contributing to the development of a tear trough deformity, such as a dark circle under the eye, is an age-related unmasking of the tear trough ligament.2 As this is a true osseo-cutaneous ligament2, it tethers both eyelid skin and orbicularis muscle to the orbital rim.

Deflation and descent of the sub orbicularis oculi fat pad (SOOF) affects the deep plane of the tear trough ligament,3 and loss of subcutaneous fat, accompanied by a change in thickness between the eyelid and cheek skin, are

Traditional non-surgical treatments using hyaluronic acid fillers are focused at filling the depth of the hollow by placing volume supraperiosteally or subcutaneously, in an attempt to smooth the tear trough deformity

felt to be contributory factors in the subcutaneous plane of the tear trough ligament.3 Factors that affect treatment outcomes are the breadth of the hollow, prolapse of orbital fat and skin quality changes that include thinning and pigmentation.2 Lambros4 noted that there appeared to be a thinning of tissue just superior to the lid cheek junction. The thin pigmented eyelid skin, scant in subcutaneous tissue sits just superior to the usually lighter coloured, thicker and subcutaneous-rich cheek skin, which is more visible as a contributing factor in younger patients, before the overlying fat bulge enlarges and masks this intrinsic loss of tissue in older patients.4 Patients often want a quick fix with a single procedure, however they can sometimes have a restricted budget. Accurate assessment of the main treatable causative factor, which will give patients the most for their money, and management of unrealistic expectations is critical in obtaining successful outcomes.

Consultation To be able to identify potential contributory factors, a detailed patient history is key to understanding the possible causes of dark circles. Special note should be made of thyroid or renal disorders, systemic allergies, atopic skin conditions, use of eye make up, eye drops, caffeine intake, smoking and alcohol consumption, and other lifestyle factors. Patients with systemic conditions like underactive thyroid and allergies may swell much more post procedure and it is better to avoid fillers that tend to have increased swelling capacity for this reason.5 During consultation, I also enquire about the patientâ&#x20AC;&#x2122;s current skincare preferences and their commitment to improving their skincare regime. This is vital as eyelid skin is unique, being the thinnest in the body and highly pigmented,6 and patientâ&#x20AC;&#x2122;s need to understand that they have to invest in treating and protecting their skin to improve and maintain results.

If they have had previous treatment(s), I take note of the type of filler used, any concerns they may have and satisfaction with results, so that I can better manage patient expectations.

I prefer to examine the patient with no facial makeup, in a room illuminated with natural light, as this allows a more accurate assessment of relevant anatomy and superficial blood vessels. The patient sits upright viewing his/her face in a large handheld mirror, whilst pointing out areas of concern. I like to review previous photographs of patients in their 20s and 30s as a blueprint to plan rejuvenation treatment.

Clinical examination I rate the tear trough based on Sadickâ&#x20AC;&#x2122;s Tear Trough Rating Scale7 as it allows an evidence-based clinical evaluation of the tear trough with regard to depth of the trough, hyperpigmentation, volume of prolapsed fat, and skin rhytidosis.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients.

In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis.

Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection.

Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions.

Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

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 Galderma (UK) Ltd.

AZZ/021/0313

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Figure 1

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Figure 2a

Figure 3

Figure 4

Figure 1: Patient before treatment, Figure 2: Patient one week after receiving two-combination treatment, Figure 3: Patient one week after three-combination treatment, Figure 4: Four weeks after treatment completed

Assessing depth of trough and volume of prolapsed fat Loss or descent of fat underneath the eye and cheek manifests in a more pronounced under-eye groove (unmasking of the tear trough deformity). Protruding fat creates an illusion of a deeper tear trough deformity due to shadowing, and a globe malposition results in a dark shadow over the lower eyelid.4 Palpate the lid-cheek junction to assess the amount of eyelid tissue overlying the bony infra orbital rim. Mid-face ptosis will bare the tear trough and hypoplasia of the infra orbital malar complex can worsen an under-eye hollow.8 Tip: Define the extent of the hollow to estimate the amount of required filler; this is important to plan whether patients need cheek filler in addition to tear trough filler and can help you provide quote on price.

Figure 5

Figure 6

Figure 2 & 2a: Brown discolouration from sun damage can worsen with age, skin conditions such as eczema and hormonal changes

Hyperpigmentation & skin rhytidosis Eyelid skin is naturally more pigmented than the surrounding paler facial skin. This brown discolouration from melanin worsens due to sun damage as we age and can get worse with hormonal changes such as pregnancy or an allergic reaction to makeup or eczema.9 (Figure 5 & 6) However there can also be a deeper pigmentation due to visible blood products leaking from damaged capillaries, which causes a blue/ violet discoloration.10 The VISIA complexion or Stratum Skin analysers may be useful to demonstrate areas of skin hyperpigmentation and wrinkles. The pictures often give patients a visual understanding of the quality of their skin, and can help engage them in improving skin care, to achieve better results. Use the VISIA complexion analysis to demonstrate to the patient areas of skin hyperpigmentation and wrinkles, as this allows the patient to be able to appreciate the role of good skin quality to achieve better results. It also allows a better patient understanding of the various factors at play, so that they have realistic expectations of the outcome.

Quality of skin (thick or thin, smooth or wrinkled) and skin pigmentation (colour of the overlying skin) is crucial, as filler may improve shadowing but will not alter pigmentation or correct laxity.11 Tip: To differentiate brown discoloration from a purple/blue tint in the dark circles, pull the eyelid skin sideways and if the darkness improves, the problem is caused by excess skin pigment in the area.

Patients with a history of thyroid or renal dysfunction, allergic rhinitis, hay fever or

seasonal allergies, associated with puffy eyelids, often have violet/blue pigment due to venous congestion or leaking blood products.10 Ocular examination Document when the patient last visited an optician for a sight test and if there are any ocular issues. Amblyopia or the presence of only one good seeing eye, are better treated by expert injectors, to minimise the risk of permanent sight loss from cosmetic filler treatment. Measure the globe position as deep-set eyes or prominent eyes can worsen the dark circles by creating a shadow.

Tip: Highlight the rare risk of irreversible sight loss with all facial fillers, (risk of blindness is 1 in 5 million treatments and skin necrosis 1 in 1 million treatments).12 Lazzeri et al conclude that a number of precautions could minimise the risk of embolisation of filler into the ophthalmic artery following facial cosmetic

Patients with systemic conditions like underactive thyroid and allergies may swell much more post procedure and it is better to avoid fillers that tend to have increased swelling capacity for this reason injections: Intravascular placement of the needle or cannula should be demonstrated by aspiration before injection and should be further prevented by application of local vasoconstrictor. Needles, syringes, and cannulas of small size should be preferred and replaced with blunt flexible needles and

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Figure 8

Figure 9

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Figures 7, 8, 9 & 10: Before and after using Restylane Light to reduce shadows and boost skin from venous pooling. Figures 9 & 10. Four weeks post-treatment from three-combination technique.

microcannulas when possible. Low-pressure injections with the release of the least amount of substance possible should be considered safer than bolus injections.13 Volume loss affecting skin and/or deeper tissues Hyaluronic acid fillers have become the mainstay of treating most under-eye dark circles. Traditional non-surgical treatments using hyaluronic acid fillers are focused at filling the depth of the hollow by placing volume supraperiosteally or subcutaneously, in an attempt to smooth the tear trough deformity. The tear trough hollow, however, in particular its medial aspect, can be extremely unforgiving of any overfilling and can actually exaggerate the deformity.4 I prefer to use a combination of fillers that have a reduced swelling capacity in a layered manner in the tear trough to give a more natural result, and avoid overfilling. Once the causative factors are assessed, I suggest treatment(s) based on two broad categories.

Combination Filler Technique Place deep filler with a lifting capacity (i.e Restylane Perlane, Emervel Deep, Juverderm Ultra) at the lid cheek junction using a needle and inject small aliquots of the product in a retrograde fashion. The product is placed in the supra-periosteal plane (deep to the orbicularis muscle). The second layer is placed between the orbicularis and periosteum at three points a softer product (i.e Restylane Lidocaine, Volbella, Emervel Classic). The product is gently massaged to smooth the tear trough depression. (Figures 1 & 2).

In patients with loss of volume in the lower eyelid (i.e due to thin skin or loss

of underlying subcutaneous fat), I inject Restylane Vital Light into the thin eyelid.

(Figure 3 & 4). This is a new treatment modality, and as yet there are no peerreviewed publications regarding this technique.

Pigmentation: Brown or Blue Brown pigment: benefits from an adjunctive skincare regime with topical eye creams that contain vitamin C, retinol, kojic acid and resveratrol to brighten and thicken the skin.14 Blue pigment, due to leaking blood products is thought to be improved by eye creams that contain vitamin K (to improve the damaged capillaries).12 When blood vessels are visible as dark purple or blue under-eye circles, intense pulsed light therapy (IPL or Photofacial) may be suggested to reduce these dark circles.9 There are many skin boosting treatments to choose from for this indication, such as Belotero Balance dermal filler, however I prefer to use Restylane Vital Light to help reduce the shadows from dark brown pigment and by plumping the skin to mask some of the blue discoloration from venous pooling.

(Figures 7, 8, 9 & 10).

Tips to avoid complications and maximise outcomes A thorough knowledge of relevant anatomy to avoid injecting fillers in the wrong location is vital, as overfilling the medial tear trough and the lid cheek junction can worsen appearance of under eye dark circles.4 It is important to inject the correct hyaluronic acid filler, in the correct plane, in small aliquots to avoid the Tyndall effect, overfilling and migration. Assess various causative

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factors; educate the patient to better manage their expectations so that they appreciate the fine nuances of tear trough rejuvenation with an emphasis on natural looking results.

Conclusion In addition, as with any aesthetic procedures I perform, I encourage patients to address contributory lifestyle factors (smoking, eye rubbing, sleeping with make up on) and recommend combination filler treatments to correct volume loss, improve shadows from pigmentation and improve overall skin quality.

I also advocate sunscreens, UVA & UVB protective sunglasses, and advanced eye creams to improve the appearance of skin pigmentation.

Images courtesy of Mrs Sabrina Shah-Desai.

Mrs Sabrina Shah-Desai is an aesthetic oculo-plastic surgeon with over two decades of experience in micro-precision of eye surgery, with the aesthetic concepts of facial plastic surgery. Previously based at Moorfields Eye Hospital, she is now based in Harley Street and in north London.

REFERENCES 1. M.Cane, ‘Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid’, (Aesthetic Plastic Surgery, 2005), (29), pp.363-367.

2. Wong CH et al, ‘The tear trough ligament: anatomical basis for the tear trough deformity’, (Plastic Reconstructive Surgery, 2012), (6), pp. 1392-402.Haddock NT, et al, ‘The tear trough and lid/ cheek junction: anatomy and implications for surgical correction’, (Reconstr Surg, 2009), (4), pp.1332-42.

3. Lambros, ‘Hyaluronic acid injections for correction of the tear trough deformity’, (Plastic and Reconstructive Surgery, 2007), (6 Suppl):74S-80S. 4. Park KY,et al, ‘Comparative study of hyaluronic acid fillers by in vitro and in vivo testing’, (Journal of the European Academy of Dermatology and Venereolgy, 2014), (5) pp.565-8.

5. Ha RY, et al, ‘Analysis of facial skin thickness: defining the relative thickness index’, (Plastic and Reconstructive Surgery, 2005),115, (6), pp.1769-73.

6. Sadick NS, et al, ‘Definition of the tear trough and the tear trough rating scale’, (Journal of Cosmetic Dermatology 2007), (4), pp.218-22.

7. Mendelson BC, Jacobson SR, ‘Surgical anatomy of the midcheek: facial layers, spaces, and the midcheek segments’, (Clinics in Plastic Surgery, 2008), (35), pp.395–404.

8. Veronica A. Russo, Lisa E. Maier, ‘Allergic Contact Dermatitis of the Eyelid’ (The Dermatologist, 2012), Volume 20, (4). <http:// www.the-dermatologist.com/content/allergic-contact-dermatitiseyelid> [accessed 1st September 2015] 9. Obraien K. ‘What causes dark circles under the eyes?’ (Free article directory, 2010).< http://www.articlepdq.com/healthfitness> [accessed on 1st September 2015] 10. Stutman, Ross L., and Mark A. Codner. ‘Tear trough deformity: review of anatomy and treatment options’ (Aesthetic Surgery Journal) 32.4 (2012), pp.426-440.

11. Inglefield, C et al, ‘Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment’, (Aesthetic Medicine Expert Group, 2014) 12. Ahmadraji, et al, ‘Evaluation of the clinical efficacy and safety of an eye counter pad containing caffeine and vitamin K in emulsified Emu oil base.’ (Advanced Biomedical Research, 2015), (4) <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4300604/> [accessed 1st September 2015] 13. 13. Lazzeri D, et al, ‘Blindness following cosmetic injections of the face’, (Plastic and Reconstructive Surgery, 2012), (130), (5) <http://journals.lww.com/plasreconsurg/Fulltext/2012/11000/ Blindness_following_Cosmetic_Injections_of_the.40.aspx> 14. Mitsuishi T, et al, The effects of topical application of phytonadione, retinol and vitamins C and E on infraorbital dark circles and wrinkles of the lower eyelids, (J Cosmet Dermatol, 2004), (2) pp.73-5.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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Forming an Alliance: The benefits of combining surgical & non-surgical treatment plans Consultant plastic surgeon Mr Taimur Shoaib shares advice on incorporating both surgical and non-surgical procedures to complement aesthetic results Introduction As aesthetic practitioners, we are all aware that facial rejuvenation treatments include surgical options as well as non-surgical options. Most patients want to look fresh and less tired, and a thorough consultation will of course determine the most suitable approach to treatment. Although there are variations in the results that can be achieved with surgical and non-surgical options, many practitioners, such as myself, believe that a combined, holistic treatment approach can produce superior results.

From facials to facelifts In 2014, my staff and I performed an audit of patients who attended our practice during the whole of 2013. I run a surgical and a non-surgical practice, so we considered these as two separate modalities. We looked at all our appointments over a calendar year and determined the crossover rate of treatment modality in patients who had more than three treatment appointments. These had to include at least two non-surgical appointments and one appointment for a surgical procedure. We found that 22% of patients who started off having non-surgical treatments subsequently underwent surgery, and that 80% of patients who

started off having a surgical procedure subsequently underwent multiple nonsurgical treatments.

The patients who began by having nonsurgical treatments waited, on average, 18 months before they underwent a surgical procedure, and the patients who started off with surgery waited, on average, only four months before undergoing multiple nonsurgical procedures.

The study had its limitations; the most significant was the fact that practitioners from other clinics referred a number of non-surgical patients to me for surgery. The patients then returned to their non-surgical practitioners for continued treatments after surgery, meaning that the 80% figure may be significantly higher.

These results clearly suggest that there is a noteworthy crossover between surgical and non-surgical treatments, further supporting my view that there is a need for more combination procedures.

In my opinion, surgeons and non-surgical aesthetic practitioners should work together to recognise how their work can be complemented by the alternative treatment method, and produce enhanced results for all our patients. Although there is some crossover in what each of the two different techniques can obtain, there is a wide variation in indication for different modalities of treatment. As such, I have detailed the considerations to bear in mind during your patient’s aesthetic journey.

Consultation Many patients tell us that when they look in the mirror, they don’t see a reflection of someone who has the life, vitality, energy and freshness that they feel within themselves.

Most patients who come in with these concerns are, therefore, looking for aesthetic treatments that will help them achieve those aims; they want to look as fresh on the outside as they feel on the inside.

When these patients attend our clinics, we should start with a thorough and in-depth consultation to assess the patient’s wants and needs. In my opinion, the aesthetic consultation needs to follow a specific order: • • • • • • •

History Examination Investigation Diagnosis Discussion of treatment plan Delivery of treatment Follow up

As we become more skilled, the examination and history can sometimes take place simultaneously, but the principles still apply; practitioners should understand a patient’s medical history to ensure they are

While there are some things that surgery will do that cannot be achieved through non-surgical treatments, there are many treatments that are best performed non-surgically

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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In practice Figure 1 Figure 2 Case Study: Patient A As part of our patient assessment, we ask patients how much of an improvement they are hoping to see, and attempt to quantify the magnitude of their facial ageing examination findings. In the example below, we can see that Patient A has signs of facial ageing: descent and atrophy of the mid-face fat pads, unwanted fat deposits in the submental region, a prominent jowl and hooding of the upper eyelids (Figure 1). The patient wanted quite a considerable improvement, so I suggested that the best approach to treatment was surgery. After taking time to consider this route, Patient A decided she was keen to go ahead. I informed her that she would need to maintain her results with non-surgical treatments, beginning approximately six months later.

Before treatment Four weeks after Patient A’s facelift (before her upper-lid Patient A underwent a facelift, followed by an upper-lid blepharoplasty. I elevated blepharoplasty) the malar fat pads and performed liposuction to the cervical and submental region (Figure 2). At the consultation I asked Patient A how she wore her hair, as she would have a prominent scar for a few weeks after surgery. Although this did not concern Patient A, it is important to prepare patients for all eventualities post surgery.

Although the scars are visible, they are likely to mature over a period of approximately one year. We can see the reduction in the prominence of her jowls, the improved definition of the jawline and the elevated cheek fat pads. We can, however, still see thinning of the lips, a marionette line, and nasolabial lines. While the facelift has improved her appearance, Patient A will benefit from further aesthetic treatment to enhance her results. Rather than recommending she undergo another facelift, which may be not indicated, it is worthwhile offering non-surgical treatments to further improve her aesthetic outcome. In this case, I would offer Patient A lip filler, laser skin treatments (CO2 fractionated resurfacing, green or yellow light IPL) and skincare products to help improve the appearance of her skin, the marionette and nasolabial lines, as well as the volume loss in her lips. Even after surgery, examination of the patient shows mild volume loss and persistent skin ageing. A multifactorial approach to facial ageing, combining surgical and non-surgical treatments, will therefore give her the best results.

Figure 3 Case Study: Patient B One of the side effects of fat injections into the fat pads of the face is that stem cells are imported to the tissues. These stem cells rejuvenate the surrounding tissues,5 and patients often report an improvement in the quality of the skin of the face. Apart from this, a facelift (and associated ancillary procedures) will do nothing to improve the skin. There are, however, many non-surgical options available to enhance skin quality.

Patient B sought treatment for her moderately sun-damaged skin, fine lines, loss of elasticity, and Before treatment heterogeneous patches of pigmentation (Figure 3). Following three sessions of laser treatment we can see a significant improvement in the appearance of her skin (Figure 4). While Patient B was happy with Figure 4 her results, there is more we could do to improve the signs of ageing, using a combination of surgery and non-surgical treatments. For maximum results for the jowls, I would advise that Patient B undergo a facelift. For more subtle results, however, I would recommend CO2 laser treatment, Ultherapy and radiofrequency tightening. Although these treatments will not give as powerful a result as a facelift, the combination of treatments will all help to lift and tighten the skin and muscle layers of the face in this area. In Patient B, we can see she has loose skin and moderate jowls. The treatment plan should therefore be aimed at addressing the main salient features of the patient’s facial ageing, including her After three sessions of laser loose skin and jowls. Although non-surgical treatments will deliver a more modest result, when we treatment ask the patient what they are hoping to achieve, and when we examine them, we can advise on the magnitude of effect likely to be delivered from the different treatment modalities, and suggest a plan accordingly. As with all patient counselling for facial surgery, we would also advise Patient B that she would need to continue with non-surgical treatments after surgery, such as regular radiofrequency and occasional laser treatment.

suitable for treatment before recommending any procedure.

While patients often come to us requesting a particular treatment, many will not understand what they actually need to improve their aesthetic concern. In the past I have had patients say “I would like some Botox to make my lips bigger” or “I think I need collagen injections in my

lines”. However, the patient is starting the consultation at the bottom of the journey and, clearly in these examples, they can sometimes be misled in what they believe to be the best treatments for the concerns that they have. Therefore, it is our job to guide them onto the correct path for a successful patient journey.

To do this, I believe the two most important

questions to ask at the beginning of the consultation are: • What do you not like about yourself?

• What is it you’re hoping to achieve?

By asking these questions, and subsequently examining the patient, we can establish the starting point for treatment and formulate a

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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plan that takes the patient from where they are currently, to where they want to be.

The treatment plan Once you are confident that you understand your patient’s requests and have discussed appropriate options with them, it’s time to examine the patient and agree on an appropriate treatment plan.

How to examine the ageing face Facial ageing is a complex process. If we want to simplify something that is complex, we break it down in to different components.

Facial ageing is no different, and we should look at different parts of the face and tissue layers separately. Accordingly, our examination should break down the face into the upper third, the middle third and the lower third.1 We should also look at the face in its tissue component layers – the skin, the fat, the muscles and the bones – remembering that the layers do change in different parts of the face (for example, here there is skin and oral mucosa at either extremes of the tissue layers).2 It is very important for all aesthetic practitioners to understand that facial ageing takes place in all tissue layers. We must realise that even though we see, for example, dynamic glabellar lines, the reasons for them appearing lie in the skin, the fat, the muscles and the bones. When we see lateral brow ptosis, the reasons for this lies in changes that have occurred in the skin, the fat, the muscles, and the bones. Facial ageing occurs at all tissue levels and treatment must therefore be directed to all the tissue layers. Naturally, the tissue layer that shows most signs of ageing must be the first tissue layer to be treated (for example it is usually highly appropriate to use botulinum toxin for overactive muscles that are causing dynamic lines). Sometimes patients will be disappointed with results and the best

Avoiding the ‘done’ look is possible with multimodality treatment

Aesthetics Journal

solution to this is to address a different tissue layer. When we can see the effects of facial ageing and we know the reasons why the effects are being seen, we can treat the underlying cause and, hopefully, give our patients the best possible results.

Multimodality treatment At a simple level, we can perform multimodality treatment using multiple non-surgical techniques. For example, if someone dislikes the lines they have around the crow’s feet region, which worsen when they smile, we can treat these in many different ways. We get dynamic crow’s feet lines because our skin and fat layers become thinner and our muscles become stronger with repeated use.3 Additionally, the inferolateral aspect of the orbital rim undergoes recession posteriorly and inferor displacement laterally.4 To treat dynamic crow’s feet lines we can therefore reduce the power of the muscles with a neuromodulator, we can thicken the fat layer with a relatively thin and forgiving filler, we can thicken the skin with a CO2 laser, and we can address the bony loss with bony structural augmentation using fillers at the orbital rim, placed deep to orbicularis but inferior to the eyelid and orbital rim.

Fat or fillers?

If you have a surgeon based in your clinic, or work closely with a local colleague, the treatment plan will often take the form of surgical and non-surgical treatments. Both treatment types will work together not only to deliver the results we are hoping to see, but also to maintain surgical results with continuous non-surgical treatments. The best results from our aesthetic treatments are the ones where other people cannot tell that the patient has had significant treatment and avoiding the ‘done’ look is possible with multimodality treatment. For example, if a patient wants to achieve fuller cheeks and a lifted face, we might wish to recommend a facelift and fat injections (if these are indicated) and we may want to maintain the results with pre-jowl fillers, malar fillers and high intensity focused ultrasound treatment to the SMAS (the facial muscle that is tightened in a facelift).

For the volume loss that we see in the lips and mid-face there are two options: fat injections or fillers. How should we decide what is best for the patients? As with most treatments, there are advantages and disadvantages to both. Fat is autologous tissue, which gains a blood supply, and so

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any infection can be treated with antibiotics.

Fat injections are also permanent, however approximately half of the fat will fail to obtain a blood supply and will therefore disappear over a period of a few months.

Surgery, however, has a longer recovery time and is usually more expensive. On the other hand, fillers are temporary but the recovery time is usually quicker and, until a certain volume is used they are usually cheaper. With fat versus fillers there is usually a tipping point at which fat becomes more desirable. The tipping point may relate to the financial issues associated with having repeated large volumes of filler injected versus the single treatment of a similar amount of fat, the magnitude of the clinical result desired, or the desire to use autologous tissue rather than a foreign material. However, even with fat injections I advise patients that they will inevitably want to have volume restoration into the fat-filled areas again at some point in the future. We can therefore, in some patients, consider fat injections to give us a better starting point for subsequent filler injections.

Summary To be regarded as a trustworthy and reliable aesthetic practitioner, it is imperative that we be honest and keep our patient’s best interests in mind. While there are some things that surgery will do that cannot be achieved through non-surgical treatments, there are many treatments that are best performed non-surgically. As such, surgeons and non-surgical aesthetic practitioners should endeavour to work together to provide patients with the best possible outcomes and long-term, sustained results.

Mr Taimur Shoaib is a consultant plastic surgeon with more than 20 years’ medical experience. He qualified from the University of Glasgow in 1992, before establishing his cosmetic surgery practice, La Belle Forme, in 2014. Mr Shoaib is an honourary senior clinical lecturer at the University of Glasgow and a faculty member of the Allergan Medical Institute.

REFERENCES 1. Zimbler MS, Kokoska MS, Thomas JR, ‘Anatomy and pathophysiology of facial aging’, Facial Plast Surg Clin North Am, 9(2) (2001) pp.179-87.

2. Wayne F Larrabee Jr, ‘Surgical Anatomy of the Face’, Lippincott Williams and Wilkins, (2004), pp.31-75.

3. Kane, Michael, ‘Classification of Crow’s Feet Patterns among Caucasian Women: The Key to Individualizing Treatment’, Plastic & Reconstructive Surgery, 112 5 (2003), pp.33S-39S. 4. David M. Kahn and Robert B. Shaw, Jr., ‘Aging of the Bony Orbit: A Three-Dimensional Computed Tomographic Study’, Aesthetic Surg, 28 (2008) pp.258–264.

5. Coleman, Sydney R, ‘Structural Fat Grafting: More Than a Permanent Filler’, Plastic & Reconstructive Surgery, 118 (2006) pp.108S-120S.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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A summary of the latest clinical studies Title: The attractive lip: A photomorphometric analysis Authors: Penna V, Fricke A, Iblher N, Eisenhardt SU, Stark GB Published: Journal of Plastic, Reconstructive & Aesthetic Surgery, July 2015 Keywords: Attractiveness, lip aesthetics, perioral region, photomorphometry Abstract: This study was conducted to clarify what it is that makes lips attractive - and whether there are gender-related differences of an attractive lip and lower third of the face. Pictures of the lip and chin region of 176 patients were photographed in a standardised way and evaluated by 250 voluntary judges through an internet presentation by means of an analogue Likert scaling system. We found a significant higher ratio of upper vermillion height/mouth-nose distance in frontal-view images of attractive compared to unattractive female (p < 0.001) and male (p < 0.05) perioral regions. Furthermore, the ratio of upper vermillion height/chin-nose distance was significantly higher in attractive than in unattractive female (p < 0.005) and male (p < 0.05) lip and chin regions. The nasolabial angle was significantly sharper in attractive compared to unattractive female perioral regions (p < 0.001). Moreover, attractive female lip and chin regions showed a wider mentolabial angle compared to unattractive female lip and chin regions (p < 0.05). Comparing men and women, we found that attractive female perioral regions showed a higher ratio of lower vermillion height/chin-mouth distance (p < 0.05) and lower vermillion height/chin-nose distance than attractive male perioral regions (p < 0.05). We were able to define certain parameters of the lip and lower third of the face that seem to add to the attractivity of female and male individuals.

Title: Evaluation of the efficacy and safety of fractional bipolar radiofrequency with high-energy strategy for treatment of acne scars in Chinese Authors: Qin X, Li H, Jian X, Yu B Published: Journal of Cosmetic and Laser Therapy, October 2015 Keywords: Acne scarring, fractional photothermolysis, radiofrequency, post-inflammatory hyperpigmentation Abstract: Fractional technology overcomes several problems of ablative lasers such as a high incidence rate of post- inflammatory hyperpigmentation (PIH). A new technology fractional radiofrequency, which induces deep dermal heating and leaves the epidermal less affected results in less adverse effect in Chinese. To evaluate the efficacy, safety and tolerance of fractional bipolar radiofrequency (RF) in the treatment of acne scars in Asian people with the strategy of high energy. Twenty-six healthy Asian patients with acne scars received four monthly high energy (85-95mj/pin) treatments with a fractional bipolar RF device. Improvement and tolerance were evaluated at each treatment and a 4-week and 12-week follow-up visit. Twentythree patients completed the study. Acne score showed a significantly decrease at 4-week and 12-week follow-up visits. Patients’ evaluation of global improvement and satisfaction increased at the 12-week visit compared with baseline. Side effects were limited to transient pain, erythema, dryness and low risk of PIH. Treatment with high energy of fractional bipolar RF is safe and effective for acne scars in Asian people.

Common side effects such as PIH, eschars are less than fractional lasers.

Title: Enhancing the efficiency of 5-aminolevulinic acid-mediated photodynamic therapy using 5-fluorouracil on human melanoma cells Authors: Tahmasebi H, Khoshgard K, Sazgarnia A, Mostafaie A, Eivazi MT Published: Elsevier LTD, August 2015 Keywords: 5-Aminolevulinic acid, 5-fluorouracil, Photodynamic therapy, Protoporphyrin IX (PpIX), Mel-Rm cell line, melanoma Abstract: This in-vitro study attempted to know whether the killing effect of ALA-PDT on the human melanoma cells (Mel-Rm cell line) could be increased by the presence of 5-fluorouracil (5FU). To evaluate the effect of ALA-PDT in combination with 5-FU on viability of human melanoma Mel-Rm cells, the cells incubated with 5-ALA and 5-FU for 3h in nontoxic concentrations, and subsequently illuminated with a 630nm light-emitting diode array.

The cells viability and cytotoxicity determined by mitochondrial activity and lactate dehydrogenase assays. Combination of ALAPDT and 5-FU (FU-ALA-PDT) showed a considerable growth inhibition according to the results of MTT assay compared to ALA-PDT. The results of LDH assay also showed a cytotoxicity effect in ALA-PDT; however, the FU-ALA-PDT showed no significantly enhancement in cytotoxicity compared to ALA-PDT using LDH assay.

Title: Genetic vs Environmental Factors That Correlate With Rosacea: A Cohort-Based Survey of Twins Authors: Aldrich N, Gerstenblith M, Fu P, Tuttle MS, Varma P, Gotow E, Cooper KD, Mann M, Popkin DL Published: JAMA Dermatology, August 2015 Keywords: Rosacea, environmental, NRS, twins Abstract: To study a cohort of identical and fraternal twins to determine whether genetic factors contribute to rosacea development and, if genetic factors are present, quantitatively estimate the genetic contribution, as well as to identify environmental factors which correlate with rosacea by controlling for genetic susceptibility.

Identical and fraternal twins were surveyed regarding risk factors implicated in rosacea. Faculty dermatologists determined a rosacea score for each twin participant according to the National Rosacea Society (NRS) grading system. Data was collected at the annual Twins Days Festival in Twinsburg, Ohio, on August 4-5, 2012, and August 2-3, 2013. Analysis was conducted for several months after each meeting. A cohort of 550 twin individuals participated. The NRS score and rosacea subtype were assessed using the NRS grading system and physical examination by board-certified dermatologists.

Among the 275 twin pairs (550 individuals), there were 233 identical twin pairs with a mean rosacea score of 2.46 and 42 fraternal twin pairs with a mean rosacea score of 0.75. We observed a higher association of NRS scores between identical vs fraternal twins (r = 0.69 vs r = 0.46; P = .04), demonstrating a genetic contribution. Using the ACE model (proportion of variance in a trait heritable secondary to additive genetics [A] vs the proportions due to a common environment [C] and unique environment [E]), we calculated this genetic contribution to be 46%. A higher NRS score was also significantly associated with the following factors: age (r = 0.38; P < .001) and lifetime UV radiation exposure (r = 0.26; P < .001).

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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the latest clinical studies, or training team members on how products work. Equally important is setting goals for future meetings and agreeing expectations going forward.

How to Make the Most of Your Sales Rep National sales manager Emma Perrett offers advice on building a valuable relationship with your sales representatives for the benefit of your business and your patients Introduction Being a salesperson in the aesthetics industry means I’m able help to transform new clinics into successful ones and watch existing clinics make changes and develop in ways they didn’t know were possible. I work hard to build strong relationships through determination, being reliable and understanding my clients’ needs. To a certain extent, there is always a need to utilise the experience of a professional sales representative when selecting a new treatment, product or device for your clinic. These days, however, we realise that clients usually already know what they want by the time they get in contact with us, so it is our job to back that decision up with the details, provide vital further information, form a relationship, and stimulate thinking by offering new ideas. This article outlines what I think should be the key things to expect from your sales representative and how to get the best out of their services.

What skills should you be looking for in your sales rep?

Although the level of resources at their disposal may differ depending on whether they work for a small or large supplier, you should reasonably be able to expect the following from your sales rep: • Reliability • Availability and time • Knowledge • Inspiration • Training • Collaboration • Improved results – whether that’s for the patient or the business

As busy practitioners, your time is precious, so any sales representatives wishing to meet with you should plan a suitable date and time in advance to give the most effective return on your invested time. You should always enter a meeting with an objective in mind; this could include introducing a new product, exploring

How do you keep up in a world that is changing so fast?

The market has shifted in recent years so both practitioners and sales reps also have to be able to adapt effectively. As such, it’s important practitioners stay informed of the latest developments so they can offer their patients the very latest treatments; keeping up with, and sometimes ahead of the market. Although the sales person will be conveying a lot of information, a marketing team is often supporting them by sending e-shots (email updates) about the latest products, training dates and educational events. It’s important that you and your clinic staff sign-up for e-shots or regular e-newsletters to ensure that you don’t miss any crucial information or developments within the industry.

Always ask for more information A key element for business owners is to choose a product line or piece of equipment that comes recommended by colleague testimonials; supported by the company’s clinical evidence and data. Watch out and try not to be drawn into any ‘shiny new products’ that may be endorsed by a name but hold little to any evidenced substance, or cost the earth and fail to deliver results.

Choosing products for a new or existing clinic isn’t easy but your sales rep should have enough experience to steer you in the right direction. Ask about results, studies and medical data – ask where the proof is. However, clinical evidence speaks for itself, and when provided with this data you will be able to make informed decisions and understand for yourself if a product is worth your investment.

Ask your rep what will happen after you have placed your first order, who you will see for training and if there will be consistent visits to support your clinical team. This should help you to make the right decisions. Your rep should be able to provide you with a detailed plan for customer support following your purchase, which will show you exactly what you can expect from the company.

What should you expect from your sales rep once you have chosen to proceed?

I believe that it is imperative I am there to support my clients, especially in the early days when they might need extra guidance.

As time passes, this level of support may not be as frequent as in-clinic confidence grows, but support should never completely disappear. Once clients are confident with the products, they can expect to be contacted around every six to eight weeks to see how things are progressing, so that their rep can provide marketing materials and see if they, or any other members of staff, need a refresher in product

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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If you feel your rep provided offers and services that didn’t benefit you, discuss these and suggest what you would like to see in the future instead knowledge. Whether it’s with a phone call or an email, you should always contact your sales rep with any queries. Their job is to support their clients and they should be replying to your query within 48 hours.

Don’t be afraid to tell your rep what you want and what you need from them. If you feel your rep provided offers and services that didn’t benefit you, discuss these and suggest what you would like to see in the future instead. Your rep will be drawing on their product knowledge to try to get the best out of your investment for you, but nobody knows your patient demographic better than you do, so by working together you can achieve greater results.

What level of training should you be looking for from your sales rep?

Training programmes are essential to understanding the products or devices you hope to incorporate into your clinic. On top of this, your sales rep should provide you and your team with all the knowledge and techniques you need to confidently and successfully sell products to your patients.

The type and quality of training can vary; so always look out for training that includes reference to clinical data, facts and figures.

Sales reps should work alongside qualified healthcare professionals to deliver more thorough training too. Quite often, a practical demonstration is offered as part of the training – these are important so practitioners can get a feel for how the treatments work with patients, as well as gain valuable handson experience in any specialised techniques.

Some providers have a dedicated team who support sales people, so ask if they have a clinical educator or medical team with competent doctors who review the materials.

Finally, continued professional development (CPD) is now part of the vernacular of being a doctor or nurse, so ensure you ask your sales rep if their courses are CPD certified in order to use your learning to count towards

any professional validations and get the best value from your time. Consult days are an effective way to ensure positive footfall but also educate your clinical team at the same time. A product specialist coming in on an agreed date will increase sales and drive education whilst doing so. For example, injectable technique training improves patient results, keeps your team abreast of new information and raises confidence.

Make the most of marketing materials provided for your clinic Providing marketing material should be one of the main roles of your sales rep, as it is these materials that help you promote and sell the products. It is important, however, that you make sure you use these materials to drive sales in your own clinic, not to arm patients with data to take elsewhere for treatment. Building a package of treatments to take place over the coming months, or a calendar with regular patient-review meetings, ensures your patients stay with you and increases compliance with any treatment protocols you’ve set out. Ensure you find out what marketing materials will be available to you when looking to invest. This could be anything from product banners, stands and posters, to counter cards and DVDs. You should expect to receive these in the first instance to help launch your new product, and then subsequently inform your rep when you are running low so that they can replenish these next time they visit.

From a general marketing aspect, your sales rep will have done many launches in other clinics. Draw on their experience and ask them what has worked well before; they will be able to suggest marketing ideas that will ensure a successful launch, maximise exposure to patients and support you where possible in any events you run. To get the most from your sales rep, it’s best to work with them on a plan for your business development and how you want to grow

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your clinic. Some may have more time than others to help you with development advice, so agree a suitable plan in advance to ensure each party is aware of their commitment and responsibilities. You will, of course, remain in control of running your business, while they can support you when necessary and in the way agreed according to your plan.

Will you be able to combine products with what you already sell in your clinic?

Just because you are taking on a new product, doesn’t mean you necessarily need to remove others. Your sales rep should be able to work with you to combine the brands that you already work with. Your sales rep should be there to assist you with the most practical advice for your business, ensuring you provide the best patient care. Ask them about combination treatments: what works for optimum patient outcomes, and how could you link products to your existing offering to enhance the commercial results for your practice. If you have patient queries on how a product works, or possibly even a team member who isn’t quite sure how to use a product in combination, it is essential you have the support of a product specialist. They will be on hand to answer any queries and, as mentioned above, many companies will have a medical team and clinical educators to give you the very best advice.

Conclusion If you are considering going into a partnership with a supplier in such an unregulated industry, do your research, choose a trusted supplier, ask the business what they will provide to you as a client, how long they have been around and, where possible, aim to find out if their products will be here for the long-term.

If you find a sales rep that you can build a great relationship with and who can provide you with all the support discussed in this article, then this should make incorporating and marketing new products a more straightforward process. The training, sales and marketing support they provide you with lay the foundations for your success, while your hard work and determination enables your business to flourish.

Emma Perrett is the national sales manager for Healthxchange and has been with the company since 2013. With more than 20 years’ experience in software and IT, she completed the Miller Heiman Complex Sales Course in 2009 before moving to the aesthetics industry.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

COMPOSED • CONFIDENT • MY CHOICE

PURIFIED1• SATISFYING2 • CONVENIENT3

Approved for glabellar and 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. Imhof, M & Kühne, U. A phase III study of incobotulinumtoxinA in the treatment of glabellar frown lines. J Clin Aesthet Dermatol 2011; 4(10):28-34.

3. Data on File: BOC-DOF- 012 Bocouture® - Convenient to use August 2015.

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/6/SEP/2015/LD Date of preparation: September 2015

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Botulinum toxin type A free from complexing proteins

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The Importance of Clinic Interiors Miss Sherina Balaratnam explains how the interior design of your clinic can have an impact on patient satisfaction Introduction Having recently refurbished and launched my new clinic this year, I have enjoyed the experience and opportunity of creating a personalised and unique environment for patients seeking medical aesthetic treatments.

The interior and décor of an aesthetic clinic is integral to the overall patient experience. From the lighting and colour scheme, to the layout of furniture and display materials, it is essential to create a welcoming environment for patients to feel instantly at ease and reassured by the calibre of their surroundings.

The creation of functional, aesthetically-pleasing spaces, will in turn improve the patient experience, comfort and overall satisfaction, and may even increase employee productivity. In this article, I shall be detailing how to create the ideal environment for patients and outlining points to consider when choosing interiors for an aesthetic clinic.

Where to start?

The process begins well before choosing furniture and equipment. First, it is crucial to research and consider how the clinic space will function: • Look for inspiration: Many clinics showcase themselves visually via their website and social media. Take a look at a few different sites and consider what aspects of design you like, what works well and what could translate into your own clinic environment.

• Evaluate: Look at the layout and floor space of your clinic and consider how the space should function. How can the layout operate at maximum efficiency to allow patients and staff to interact as seamlessly as possible?

• Put pen to paper: Create mood boards and scrapbooks of images, colours and textures. These will help you capture the aesthetic you are aiming for and also communicate to third party trades and others what you envisage it to look like.

In addition to the treatment and consultation rooms, a whole host of other areas and aspects of your clinic will require consideration. Some of those are: • Payment processing Ideally transactions are made with as much discretion as possible.

• Secure storage of products Important not only from a security perspective, but also considering botulinum toxin is a prescription medication that needs to be securely stored.

• Waiting room How many patients can wait at any time? Consider that some patients may bring a friend or family member.

• Before and after photography Designate an area with good lighting, not too much shadow and a black, non-reflective background that won’t bounce flash photography.

• Office(s) Lockable storage of all clinical records, storage of marketing materials and associated materials for the day-to-day clinic operations.

• Marketing materials What type of display(s) will be implemented? How will literature be displayed so it is visible and readily accessible?

• Laundry How will dirty towels and associated items be washed, dried and stored?

• Staff areas Where can your staff go during break times?

• Privacy If a patient has to apply numbing cream, is there somewhere they can sit in private during this phase of a treatment?

After following the above method, I created a twodimensional floor plan to provide an aerial view. I would advise that this is a valuable method to adopt as it enabled every single item of furniture to be planned in, and associated elements such as door clearance, walkway space and the location of product displays to be accurately captured in advance of ordering furniture.

It is important to also consider how flexible these spaces can be. For example, if your clinic will be hosting talks or training sessions, can the space be reconfigured and is the furniture moveable to enable different activities to take place in a particular room? First impressions begin with the clinic exterior. In my personal experience, patients undergoing medical aesthetic treatments typically seek and expect a certain level of discretion. As such, I opted for frosted glass on the exterior of the building to showcase both the clinic branding and website, whilst also protecting patient’s privacy and having a more functional purpose by directing patients to the discreet side entrance.

The waiting room Televisions in reception areas can be a divisive topic.

A constantly repeating, short loop is more likely to create irritation amongst customers and staff than encourage sales. Smart TVs, however, can easily stream content from a variety of sources and ensure a diverse, regularly changing,

Figure 1: S-THETICS ‘floating acrylic boxes’ for easy accessibility for patients

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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yet targeted range of content reflecting a clinic’s treatment and product portfolio. If waiting rooms are separate to a clinic reception, for security, stock may need to be secured in lockable units, with testers being part of the consultation and treatment process. Space constraints can mean the typical large, floor-standing display units are not practical.

Instead, I opted for a streamlined look of wall-mounted ‘floating acrylic boxes’, all open-fronted to help with accessibility (Figure 1) These were strategically positioned within arms reach and eye-height. This has encouraged patients to interact with and try products, and has in turn helped drive both product awareness and retail sales.

Lighting and ambience Given the importance of the clinic ‘atmosphere’, having the right lighting in place can greatly enhance the appearance and feel of a clinic and also shape first impressions. A room with limited light would likely appear claustrophobic and Figure 2: S-THETICS treatment room unwelcoming to patients. designed with stronger lighting for Before creating a detailed patients to feel comfortable during lighting plan, sources of treatment natural light should be identified and their impact on each room mapped out. Wherever possible, available natural light should be maximised. As well as for patients, it is more beneficial for clinic staff to not spend their entire working day under artificial light. A study by the Swiss Federal Institute of Technology in Lausanne found that people who spend more time in natural lighting compared to those in artificial lighting have increased productivity and alertness.1 Consider if there are particular features such as furniture or product displays you wish to highlight. For example, ceiling spotlights would not be suited to treatment rooms where body treatments are undertaken, where a patient may spend the majority of time lying flat and looking up. A room that is designed for injectable treatments, however, requires stronger lighting, so ceiling spotlights would work well in this environment. For instance, injectable procedures require precise technique and identification of facial anatomy such as visible veins, hence they require strong lighting (Figure 2). I added an LED shadow gap light to my main reception, as a cool white or multi-coloured LED lighting enables the creation of either a more clinical environment or a very different ambience for events and presentations.

Who are your target patients?

Throughout the process, the needs and expectations of future patients should always be kept in mind. Designing your clinic links closely to your marketing plan; you will have already identified your target customers, so you should take into account the most suitable environment for these patients. An example of this could be a city centre clinic that is used for busy city workers visiting in their lunch hour or pre and post-office hours. The focus will be on efficient and rapid patient processing, as many patients will have limited time for treatments. For instance, multiple payment terminals could be a solution to effectively process transactions during busy periods of the day. With men now accounting for nearly 14% of all cosmetic procedures and with that trend predicted to steadily increase,2 the clinic interior and decoration should have a unisex appeal to accommodate this ever-increasing statistic. Broadly, patients could be classified into two distinct categories:

Aesthetics

1. Those who have been having medical aesthetic treatments on multiple occasions and, therefore, are likely to be more at ease with the clinic environment.

2. Those who may not have set foot in such a clinic previously and, consequently, could be more apprehensive.

For those who fit into the second category, a number of steps can be put in place to ease their potential anxieties: • Provide easy access to relevant treatment and product literature, such as brochures and leaflets on treatment options.

• Face the treatment room couch away from the door, so as to not immediately appear potentially intimidating.

• Position the practitioner’s desk so as not to create a barrier.

• Ensure seating is arranged to encourage positive communication – the patient could be seated at the end of a desk to help this process.

Each patient that comes through the door is different, with varied personalities, concerns and needs. The in-house marketing must therefore contain the right information to address these variations.

For instance, a potential acne patient may actually be the child of the patient sat in your waiting room, so having the right practical information for your patients on display could encourage patient retention or referral.

Conclusion In 1973, Professor Philip Kotler identified that there was a link between a physical environment and product-purchasing decisions in his study of atmospherics. He said, “In some cases, the place, more specifically the atmosphere of the place, is more influential than the product itself in the purchase decision. In some cases the atmosphere is the primary product.”3 The clinic interior is imperative for the success of any medical aesthetic clinic business. It sets the tone for patient expectations as to how they will be treated and cared for, the calibre of the team, the treatment portfolio and technology, as well as the aftercare services. In a market driven by a high degree of discretionary spend, a careful balance has to be struck between the desire to showcase products and literature to patients, and the importance of ensuring the clinic is not too much like a retail environment, overloaded with marketing material. The design process is about enhancing the patient journey and ensuring their whole experience is as comfortable, efficient and positive as possible. The aim should be to create an environment with a strong aesthetic identity, the flexibility to configure spaces and a consideration of how the clinic may evolve in the future. The correct synergy of aesthetics and functionality will provide a positive experience for both patients and clinic staff.

Miss Sherina Balaratnam is an aesthetic practitioner who has spent the last seven years of her medical career specialising in the latest non-surgical treatments. A member of the British College of Aesthetic Medicine (BCAM), she recently opened her new aesthetic clinic, S-Thetics, in Beaconsfield, Buckinghamshire.

REFERENCES 1. Münch, M., et al, ‘Effects of Prior Light Exposure on Early Evening Performance, Subjective Sleepiness, and Hormonal Secretion’, (Behavioral Neuroscience, 2011) <http://www.researchgate.net/publication/51925560_Effects_of_prior_light_exposure_on_early_ evening_performance_subjective_sleepiness_and_hormonal_secretion> [accessed 4th September 2015] 2. International Society of Aesthetic Plastic Surgery, ‘International Society of Aesthetic Plastic Surgery Releases Global Statistics on Cosmetic Procedures’, (2015), <http://www.isaps.org/Media/Default/ global-statistics/July201520ISAPSGlobalStatisticsRelease-Final.pdf)> [accessed 27th August 2015] 3. Philip Kotler, ‘Atmospherics as a Marketing Tool’, Journal of Retailing, Volume 49 (4), (1973), (p. 48)

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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The Journey from Practitioner to Entrepreneur Dr Tijion Esho shares his advice on unlocking your entrepreneurial potential Whether you have been practising aesthetics for one year or 10 years, making the transition from practitioner to business owner is likely to be a challenging experience. As medical practitioners, we are primarily geared towards helping people. Every part of our clinical training is there to improve our medical knowledge and skill, yet none of it helps us to develop our business acumen. While some practitioners may have a natural business sense, others might appreciate some guidance from those who have taken the steps themselves.

As somebody who has recently set up an aesthetic practice, I will share the six key business skills that have benefited me on my journey from practitioner to entrepreneur.

PB-1005737 PB-1138330 Rev Rev.AB

1. Identify weaknesses Recognising your weaknesses early on will help your business progression in the long run. I suggest making a list of areas for improvement and working through these one at a time. For example, if you’re unsure of the best marketing practices, talk to other business owners about their most successful marketing campaigns or invest in a learning course geared towards aesthetic clinics.

Working on your limitations will be the biggest reward to helping you in business and preparing you for the journey ahead.

From the British Medical Association (BMA) to the Medical Defence Union (MDU), there are a number of specific development courses to suit every need and they are a worthwhile investment.

2. Start simple, start small At the beginning of your journey, it is important to be realistic and have a clear, simple starting point. For many, the excitement of going alone takes over and capital can be wasted on unnecessary courses and investing in too much stock,

without conducting market research early on. When starting out, keep it simple and only offer core treatments such as botulinum toxin, dermal fillers and peels. Even when your business grows, these will most likely be the foundation of your anti-ageing practice, so you must be confident in your treatment approach and clinical expertise.

Spend time developing your injection technique and studying other practitioners’ methods for successful rejuvenation.

Attending just one conference a year could greatly support your learning potential. It is better to offer a small number of treatments with which you are able to produce excellent outcomes and, thus, happy patients, than to have a huge list of treatments that you may not be fully confident in.

3. Learn the numbers early It’s important that you identify the exact profit you make so that you can maximise your return on investment (ROI). Many people just study the cost of product minus the cost to the patient. It’s vital, however, that you also identify the cost of equipment, indemnity costs, preparation materials, and aftercare costs in order to conduct a detailed evaluation. Most startup business accounts come with software that allows you to plot all the costs incurred, in order to show the true profit that you make within your trading time. Make sure to review these at three- to six-monthly periods initially. Following a thorough assessment, you should then consider costs you should cut back on or profitable areas that could benefit from further investment.

4. Be comfortable in selling yourself The perfect platform to promote yourself will be on your clinic website and social media channels. Not only are these methods a useful tool in self-promotion, they will also act as an information point for potential or current patients. In addition to treatment information, important points to

include on your website are: • Your qualifications and professional achievements – with so many rogue practitioners out there, reassure your patients that you are certified to perform aesthetic procedures • An up-to-date, high-resolution, professional image of yourself so you are easily recognisable to patients • Testimonials from patients you’ve treated – hearing other people’s experience of procedures works wonders for referrals 5. Understand social media I am lucky that I come from a generation where ‘hashtags’, ‘likes’ and ‘shares’ are part of my everyday personal life, as well as my business life. I do understand, though, that getting to grips with online methods can be challenging for some. Don’t be overzealous, start with one site and build your confidence in using that before moving to another. I’d suggest starting with a Facebook page, which allows you to invite your email contacts to ‘like’ the page.

It’s an easy way to drum up awareness of your new business and allows you to share as much information as you wish.

Word-of-mouth will always play a crucial role in building a business and online methods provide entrepreneurs with a free tool to increase the reach of word-of-mouth testimonials. Most social media platforms allow you to view statistical information on who has engaged with you and when.

From this, you can learn how to target preceding messages effectively.

6. Find a mentor The industry as a sole practitioner can be a very lonely place – there is no-one to learn best practice techniques from and no-one to seek advice from if a complication arises.

In addition, competition in aesthetics is high, so it’s vital that you retain any new patients. While you can use the skills above to maintain a loyal patient base, I would also suggest that you find a mentor to help develop both your business and clinical skills. I continue to seek advice from a number of my aesthetic trainers; being confident to ask questions will only serve to benefit you and your business.

Dr Tijion Esho is an aesthetic practitioner with a background in plastic surgery training. He graduated with an MBChB from Leicester Medical School in 2005 and went on to attain his MRCS. He is the founder of the celebrity aesthetics and lifestyle company, Le Beau Ideal.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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“If you truly love your work, then you never work a day in your life” Dr Raj Acquilla reflects on his career in aesthetics and explains why passion for the specialty is so important to him As a self-confessed lover of art, beauty and science, it’s difficult for Dr Raj Acquilla to imagine himself in a better-suited career than medical aesthetics.

Yet it was a career he fell into simply by chance 14 years ago. “I graduated from Manchester University Medical School in 1999 and was originally involved in dermatology work, mainly performing facial surgery for skin cancers,” Dr Acquilla explains. “We’d remove a tumour and create a good aesthetic result – it was important to me that I always made a nice scar. But then we started to experiment with things like chemical peels, fillers, laser and botulinum toxin. People started to remark that their skin texture, quality and tone looked more youthful; so my interest just evolved from there.”

The aesthetic industry was in its infancy when Dr Acquilla joined a large cosmetic surgery group, where he completed his training. “The flagship clinic was a mansion house in Cheshire – downstairs we performed the non-surgical procedures and upstairs we performed the surgical procedures.” His time with the group was a happy one, but he eventually felt the need to move on. “We were like a small family, but then the industry evolved and became much more commercial. My focus has always been excellence and quality so I launched my own boutique clinic in 2003 to deliver a luxurious and personal service.” Continuing to keep up-to-date with the latest techniques and technologies, Dr Acquilla has become a UK ambassador, global Key Opinion Leader and masterclass trainer in the use of botulinum toxin and fillers. He believes it’s vital to continue learning, explaining, “Education is extremely important to me. I’ve travelled to 36 countries, in more than five continents across the world to teach my colleagues, so I’ve got to keep up with every development within the industry.”

Performing to the highest standard possible is also essential for Dr Acquilla and he is very precise in his assessment of patients for restoration and beautification. “I use a detailed geometric approach to measure facial symmetry, proportion and harmony.

I assess facial vertical fifths, horizontal thirds and PHI ratio (1:1.618) to calculate the areas of deficiency, formulate the exact injection strategy and definitive endpoints for treatment. This results in optimum aesthetic results; in other words, the patient looks the most beautiful that they possibly can in terms of balance and harmony. It’s all about the results for me. I love that balance of art and science and how you can create and restore beauty – with so many developments and new technologies being introduced, these are very exciting times for the aesthetics specialty and results have never been better!” While modest about his personal achievements, Dr Acquilla seems more excited about the developments in aesthetic treatments. “It’s a constant evolution! Where we were ten years ago is a distant memory to where we are right now. So where we will be in five to ten years from now is going to be astonishing. At present, I would say we’re now on the edge of confidently saying that, in many cases, injectables are superior to surgery to restore structure and augment soft tissue deflation and descent. Injection facelift has never been so impactful; owing to new technologies in HA, as well as practitioner techniques.”

For practitioners who want to get their foot-in-the-door, Dr Acquilla’s advice is to, “Do it for the right reason”. He explains, “My passion and motivation was all based on what I truly love, which is art, beauty, science, creativity and a quest for excellence.

Just like a musician playing live or a footballer scoring goals; if you truly love your work, then you never work a day in your life.”

What treatment do you enjoy giving the most?

I do love lifting the face; injection-based facelifting is really the cornerstone of what I do.

It gives the highest degree of satisfaction to the patient and shapes and beautifies the face.

What technological tool best compliments you as a practitioner?

Fillers. If you were to take an old-fashioned filler, it would be thick and lumpy, and give an unnatural result. Now fillers are lighter, softer, integrate into the tissue better and give a sophisticated, more natural result.

What’s the best piece of career advice you’ve ever been given?

My dear friend and mentor, Arthur Swift, always reminds me to follow my passion and dreams and never ever compromise on quality. I think this leads to happiness, fulfillment and great pleasure in what you do.

Do you have an industry pet hate?

I spend a lot of my time picking up the pieces of some of the terrible work that’s going on in the UK and correcting complications from practitioners using poor quality techniques and products – largely because of a lack of regulation here. This drives questionable aesthetic results and can distort the consumer perception of acceptable standards. For example, the increasing trend for overinflated lips posted all over social media.

What aspects do you enjoy most about the industry?

I love the creativity, the art, restoring beauty and turning people’s lives around from negative to positive. As we age the facial posture becomes sad and tired. Accurate and detailed treatment restores the perception of serenity, contentment and health. I tend to under promise and over deliver which ultimately makes my patients very happy.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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The Last Word Dr Kuldeep Minocha argues that some treatments are making patients look older and offers advice on how to avoid this issue to improve patient retention and referral There was once a time when the aesthetic community was almost solely focused on fixing lines and wrinkles. Now, however, we look more closely to the many factors that contribute to facial ageing; taking steps to also consider a patient’s loss of volume and skin quality.

Given the extensive developments and knowledge of treatments and techniques for successful rejuvenation we now have, as well as the variety of helpful tools at our fingertips, why is it, then, that we see so many patients who appear older than their years after having an aesthetic treatment? Commonly, patients will have the upper-third of the face treated with botulinum toxin but leave the lower two-thirds untouched; creating incongruences that highlight untreated areas.

The concept of this incongruence extends beyond the face into the potentially untreated neck and décolleté areas, as well as the hands, which are so often a give away of one’s true age. While this is a problem for the patient, it may also have a negative effect on the industry as a whole. Friends and family of a patient who has had a less than satisfactory aesthetic treatment may be less inclined to try it for themselves, while the patient will be unlikely to refer your services and return for future treatment. Clearly, this is an issue that needs to assessed and addressed.

What is causing treated patients to look older?

Skill base and experience One reason for the more aged appearance of some aesthetic patients may be that some practitioners work in isolation and are sometimes only able to offer a limited range of treatments. Practitioners in this position would benefit from up-skilling themselves by reading journals, attending conferences and conducting thorough research into new treatments and trends. Other practitioners seem to be easily hypnotised by their patients into ‘treating the lines’. Patients often focus on a particular line or wrinkle, which they believe is causing them to look older. We have a role in educating and explaining to our patients that fixing one wrinkle is not miraculously going to make them look more youthful; we must take a more holistic approach and address their overall health and lifestyle.

Ageing treatments Using dermal fillers and muscle-relaxing injections as the only modalities of treatment can be limiting. Continuing to volumise the midface in the hope of maintaining the ‘inverted triangle’ or ‘heart-shaped’ face, so widely associated with youth, can sometimes be less than aesthetically pleasing. In particular, treating the jowl or descent of the buccal fat pad, as well as heavy nasolabial folds, just with hyaluronic acid (HA) based fillers, can be counter-productive, as it can continue to add weight to the lower two-thirds of the face, which could create an unnatural-looking shape.

Practitioner objectivity Maintaining objectivity when assessing a patient is paramount.

Sadly, some practitioners lose objectivity when money becomes the driving-force. We have all seen patients who have lost insight during

their aesthetic journey; they compare themselves to their most recent post-treatment photographs and find a new focus that needs attention.

As a practitioner, you should be aware of possible underlying issues, such as body dysmorphia and depression. If a patient tells you they want a treatment because ‘it will make me feel better’ or ‘make people like me’, that should be the red flag. In this case, we should speak to the patient, and help them see why their reasons for treatment may not be valid. If the aesthetic practitioner complies with continued requests for treatment, the results can often metamorphosise the patient into a caricature of themselves. How often do we use our pre-treatment photographs as a tool to persuade our patients that they do not need any further treatment? It’s imperative for both practitioner and patient to see where the journey started and where they are now. It gives the chance to point out where we may need to slow things down and use alternatives such as skin peels.

Reducing the problem: The power of post-treatment care Post-treatment reviews to determine the effects of our work are essential to maintain the highest quality of clinical care. It is important to remember that patients will usually only look at themselves in the mirror with their facial muscles at rest and in 2-Dimensional proportions, rather than during expression. A detailed analysis by the practitioner following treatment, therefore, allows assessment of the patient during animation. This can highlight areas that have been over-filled with HA-based or collagen-stimulating injectables, in particular in the cheeks, but also in the nasolabial lines and forehead.

I would argue that post-treatment assessment is just as important as pre-treatment assessment, and all practitioners should strive to spend time educating themselves on recognising when a patient has had enough. We should take care to ensure patients understand why we may recommend they undergo aesthetic treatment less regularly or change their treatment approach altogether – keeping their best interests at the forefront of our minds is the key to a successful practice. In addition, we need to be judicious in our decision-making and be acutely aware of our own abilities and limits, knowing when to refer patients to more experienced practitioners or our surgical colleagues, as well as having access to a range of treatment modalities to provide a more holistic approach to skin ageing. While some practitioners may not have access to different modalities, they can benefit from further educating themselves by staying on top of the latest industry news and attending conferences and events. Many organisations hold free events, so it doesn’t necessarily have to cost the practitioner. This education will help them improve their methods, offer the best patient care and build a valuable reputation as a safe and reliable aesthetic practitioner.

Dr Kuldeep Minocha trained at Southampton University before qualifying as a GP in 1996.

He developed an interest in facial aesthetics in 2006 and has undertaken extensive post-graduate aesthetic training in Paris and London. He has now concluded his NHS commitments to take up a full-time career in aesthetics, providing his expertise at six different clinic locations UK-wide.

Reproduced from Aesthetics | Volume 2/Issue 11 - October 2015

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